尿激酶喷射碎栓治疗动静脉内瘘血栓形成的效果分析

Effect of continuous pulse injection of urokinase on thrombosis of arteriovenous fistulas

目的评价尿激酶喷射碎栓治疗动静脉内瘘血栓形成的疗效和安全性。方法以2011年1月至2014年12月因动静脉内瘘血栓住院的40例患者为研究对象，按随机数字表法分为改良组（尿激酶喷射碎栓组）和对照组（尿激酶溶栓组），搜集两组患者的一般资料，使用16-18G静脉留置针穿刺内瘘，改良组喷射注入尿激酶20万U碎栓，对照组予等量尿激酶微泵注入，泵速为2万U／min，结束后两组均继续使用尿激酶30万U微泵注入，速度为2万U／min，同时给予低分子肝素钙4000U皮下注射，1次／d，罂粟碱注射液30mg静脉推注，1次／d，拜阿司匹林片150mg口服，1次／d，每小时记录内瘘再通情况、生命体征、出血情况和尿激酶剂量。观察终点为内瘘再通、严重出血、肺栓塞并发症，3d内重复上述方法。比较两组的溶通时间、溶通率、尿激酶剂量，以及出血和肺栓塞的发生率。结果改良组：28例次内瘘溶通，成功率为93．33％，溶通时间为（30．33±27．23）h，尿激酶剂量为（20±12）万U；对照组：22例次溶通，成功率为75．86％，溶通时间为（50．15±22．18）h，尿激酶剂量为（25±18）万u，两组在溶通成功率、溶通时间、尿激酶剂量方面差异有统计学意义（P〈0．05）。改良组出现血肿3例，对照组出现穿刺点血肿5例，两组均未出现肺栓塞，两组出血发生率差异无统计学意义（P〉0．05）。结论与传统尿激酶溶栓法相比，尿激酶喷射碎栓治疗动静脉内瘘血栓形成，溶通率高，溶通时间短，尿激酶使用剂量少，不增加出血风险，是短期内快速恢复内瘘血流的理想方法，值得临床推广。

Objective To investigate the curative effect and safety of continuous pulse injection of urokinase for the treatment of arteriovenous internal fistula thrombosis. Methods During the period from Jan. 2011 to Dec. 2014, 40 patients with arteriovenous internal fistula thrombosis were collected. They were randomly assigned to the improved group （continuous pulse urokinase injection） and control group （traditional arokinase application） according to the table of random digit. Thrombin time, prothrombin time, D-dimer, fibrinogen, hemoglobin, platelet, lipid and colored doppler ultrasonography of arteriovenous internal fistula before thrombolysis were recorded. All the patients used the 18 G venous indwelling needles. In the improved group, continuous pulse injection of urokinase （200 000 units） was performed. The same dose of urokinase were injected by micro-pump at the speed of 20 000 U/min in the control group. After that all the patients still received micro-pump injection of 300 000 units urokinase at the speed of 20 000 U/min, subcutaneous injection of low molecular heparin （4 000 U）, intravenous injection of papaverine （30 mg）, oral administration of aspirin （ 150 mg） for 3 days, respectively. We recorded the internal fistula recanaliza- tion, vital signs, bleeding, and the dose of urokinase every hour. The end points of our study were internalfistula recanalization, severe bleeding and pulmonary thromboembolism. The treatment could be repeated during the three days after admission. We compared the time and incidence of recanalization, dose of uroki- nase, incidence of bleeding and pulmonary thromboembolism between two groups. Results A total of 28 cases （93.33%） showed successful results in （30. 33 ±27. 23） hours an average, with （20 000 ± 12 000） units urokinase in the improved group. Whereas, 22 cases （75.86%） showed successful results in an aver- age of （50. 15 ±22. 18）hours, with （25 000 ± 18 000）units urokinase in the control group. There was sig- nificant difference in the time and incidence of recanalization, dose of urokinase between two groups （ P 〈 0. 05 ）. Three eases experienced puncture point hematoma in the control group, and 5 cases in the improved group, showing on statistical difference. No pulmonary thromboembolism occurred （ P 〉 0. 05 ）. Conclu- sions Compared to traditional urokinase application, continuous pulse urokinase injection achieves higher reeanalization rate, shorter recanalization time, and less dose of urokinase. It does not increase the risk of bleeding as well. For the treatment of arteriovenous internal fistula thrombosis, continuous pulse urokinase injection is an effective and safe way, with great clinical value.