AngioJet在急性肠系膜上静脉-门静脉血栓治疗中的应用

Application of percutaneous AngioJet thrombectomy in patients with acute symptomatic portal and superior mesenteric venous thrombosis

目的探讨AngioJet机械性血栓清除装置在症状性急性肠系膜上静脉-门静脉血栓治疗中的临床价值。 方法回顾性分析2014年1月至2016年1月南京市第一医院介入科8例肠系膜上静脉-门静脉血栓患者，均经彩色多普勒及门静脉计算机断层扫描血管成像（CTA）明确诊断。采用超声引导下经皮经肝右侧门静脉分支穿刺，将4F造影导管植入肠系膜上静脉造影明确血栓诊断后，经交换导丝置入械性血栓抽吸导管。所有患者均在术中使用尿激酶25万U（溶解于100 ml生理盐水），通过喷射模式进行血栓内喷射，等待15 min后行血栓抽吸治疗。2例抽吸完成后进行了肠系膜上静脉-门静脉球囊扩张及支架植入，7例术后保留溶栓导管进行持续溶栓治疗24～48 h，尿激酶用量50万U/d，每天造影如果血栓基本溶解，则终止溶栓治疗并拔除溶栓导管及鞘管，48 h病例终止溶栓治疗，穿刺道采用纤毛弹簧圈或者明胶海绵条栓塞。术后1、6个月时行肠系膜上静脉-门静脉CTA复查，术后口服抗凝治疗至少6个月。血栓清除评判标准：血栓清除率〉90%为Ⅲ级；血栓清除率50%～90%为Ⅱ级；血栓清除率〈50%为Ⅰ级。 结果所有患者肠系膜上静脉-门静脉均进行了机械性血栓抽吸治疗，术后造影评估肠系膜上静脉-门静脉血栓清除3例Ⅲ级，5例Ⅱ级，其中2例予肠系膜上静脉-门静脉球囊扩张及支架植入治疗。经过24～48 h溶栓治疗，7例肠系膜上静脉-门静脉血栓清除Ⅲ级，1例Ⅱ级。1例24 h复查时肠系膜上静脉-门静脉血流恢复通畅，拔鞘后出现腹腔出血，经过输血等保守治疗患者恢复。术后6个月随访8例患者均未无血栓复发及死亡发生。 结论AngioJet机械性血栓清除装置结合溶栓治疗急性症状性肠系膜上静脉-门静脉血栓安全、有效。

ObjectiveTo evaluate the clinical value of percutaneous AngioJet thrombectomy in treatment of acute symptomatic portal and superior mesenteric venous thrombosis venous thrombosis （PVMVT） . MethodFrom January 2014 to January 2016, a total of 8 patients in Nanjing First Hospital with PVMVT verified by color Doppler ultrasound and computed tomographic angiography （CTA） were analyzed retrospectively. Under ultrasound guidance , the branch of the right portal vein（PV） was punctured with a micropuncture set and a 4-F infusion catheter was advanced to the superior mesenteric vein（SMV）. The venogram demonstrated the thrombosis in the PV/SMV and a 6-F AngioJet Xpeeedior catheter was advanced over the guidewire and positioned in the distal SMV. Percutaneous thrombectomy was performed after a mixture of 250 000 U of urokinase in 100 ml of normal saline for mechanical pulse spray of thrombus in all patients for approximately 15 minutes. 2 patients underwent PTA and stent implantation after the thrombectomy procedure, 1 of them and the others 6 patients received continuous transcatheter infusion of urokinase （500 000 U/d） for 24 or 48 hours until the thrombosis was completely dissolved confirmed by angiography at 24 and 48 hours.After procedure and the thrombolytic therapy was discontinued, removal of the infusion catheter and the sheath from the liver, the transhepatic tract was embolized with coils or gelfoam to reduce the risk of bleeding. The patency rate of PV /SMV was assessed by CTA at 1 and 6 months after the procedure. Patients were discharged with oral anticoagulation regimen for at least 6 months.The following criteria were used in evaluation of thrombolysis： grade Ⅰ〈50% thrombus removal; grade Ⅱ 50%~90% thrombus removal, and grade Ⅲ〉90% thrombus removal. ResultsAll 8 patients with PVMVT were treated by AngioJet thrombectomy. Angiography after the thrombectomy procedure showed complete thrombus removal （〉90%） was in 3 cases, substantial thrombus removal （50%~90%） in 5 cases. Grade Ⅲ （complete） thrombolysis was achieved in 7 cases and grade Ⅱ （50%~90%） lysis in 1 case post thrombolytic therapy for 24 or 48 hours. 2 patients had underwent PTA and stent implantation. Large volume intraperitoneal hemorrhage was discovered in 1 patient after removal of the catheter and sheath from the liver. The patient restored stability after a blood transfusion.Venous patency was comfirmed in all 8 patients at 1 or 6 months after the treatment. There was no patient with major complications death related to the procedure. ConclusionPercutaneous AngioJet thrombectomy with adjunctive thrombolytic therapy is an effective and safe treatment modality in patients with acute symptomatic PVMVT.