人工髋关节置换术前近端血栓不置入滤器的可行性研究

The feasibility of management with acute proximal deep vein thrombosis without insertion of inferior vena cava filter before hip arthroplasty

目的 探讨高龄股骨颈骨折患者行人工髋关节置换术前急性近端血栓形成,在未置入滤器仅接受抗凝治疗后待近端血栓溶解或稳定后再接受髋关节置换的可行性。方法 回顾性分析2013年1月至2017年8月,9例股骨颈骨折行人工髋关节置换术前近端出现急性血栓,经抗凝治疗后再行髋关节置换患者资料,男3例,女6例;年龄69~83岁,平均（76.44±5.39）岁;9例患者均未在行髋关节置换术前置入下腔静脉滤器,其中4例口服拜瑞妥10 mg,2次/d;2例皮下注射克赛0.4 ml,2次/d;3例静脉滴注东菱迪芙0.5 ml/次,隔天一次,同时加用克赛0.4 ml或拜瑞妥10 mg,1次/d。分别记录治疗前、后近端血栓长度、凝血指标的改变,术前、术中、术后及末次随访时血栓转归以及并发症发生情况。结果 9例患者受伤至入院时间（4.00±4.06） d;血栓均位于近端,其中8例合并远端血栓。近端血栓发现的平均时间为入院后（3.89±3.01） d。术前近端血栓平均长度（10.78±6.10） cm（范围,4.0~20.0 cm）;平均治疗（14.22±7.03） d后,5例近端血栓完全消失,3例好转,1例无变化但血栓转为稳定。治疗后近端血栓长度显著比治疗前减小[（10.77±6.10） cm vs. （4.39±6.50） cm],两组比较差异有统计学意义（t=3.429,P=0.009）。治疗前后血液学指标比较中, D-二聚体在治疗后显著降低[（10.47±4.87） μg/ml vs. （2.59±1.60） μg/ml],两者比较差异有统计学意义（t=4.970,P=0.001）;血浆凝血酶原时间、国际标准化比值、活化部分凝血活酶时间、凝血酶时间、纤维蛋白原比较无统计学差异。术后1例出现伤口渗液较多,停抗凝药后2 d血栓复发,后继续予以抗凝治疗。9例患者均获得随访,随访时间1.5~24个月,平均（8.3±7.6）个月。末次随访时,4例近端及远端血栓均溶解;3例仍见部分肌间静脉血栓残留;1例近端血栓较出院时好转,但仍有部分血栓残留;1例出院后血栓加重,继续抗凝治疗。无一例患者出现死亡、症状性肺栓塞以及大出血等不良事件。结论 股骨颈骨折行髋关节置换术前出现急性近端静脉血栓时,可先不置入滤器,采用药物抗凝方法 治疗血栓,待近端血栓完全溶解或稳定后再行手术治疗。

Objective To evaluate the feasibility of anticoagulant therapy for acute proximal deep vein thrombosis without inferior vena cava filter placement for femoral neck patients before hip arthroplasty. Methods From January 2013 to August 2017, 9 femoral neck fractures patients with acute proximal deep vein thrombosis before hip arthroplasty were enrolled into this study. There were 3 men and 6 women. The average age was 76.44±5.39 years old （range, 69 to 83 years old）. The average injured time before admission was 4.00±4.06 days. All patients received anticoagulant therapy without placement of inferior vena cava filter before hip arthroplasty. Four patients received Rivaroxaban 10mg, two times per day, while two patients received Enoxaparin 0.4 ml, two times per day; 3 cases received Batroxobin 0.5 ml, every other day combined with Rivaroxaban 10 mg one time per day or Enoxaparin 0.4 ml, one time per day. The size of thrombus before and after treatment, changes of coagulation markers, the outcome of thrombosis before surgery, during surgery, postoperatively and during follow-up, the related complications were recorded. Results The diagnosis time for proximal DVT was 3.89±3.01 days after admission. 8 patients showed proximal DVT combined with distal thrombus and 1 patient showed isolated proximal DVT. The average length of proximal thrombus was 10.78±6.10 cm （range, 4.0-20.0 cm）. The mean duration of treatment was 14.22±7.03 days. The Results showed 5 proximal DVTs have complete disappeared, 3 cases significantly improved, and 1 case had no change but showed stable. After treatment, the length of the proximal thrombus was significantly decreased （10.77±6.10 cm vs. 4.39±6.50 cm）, there were statistically significant between two groups （t=3.429, P=0.009）; D-dimer was significantly lower after treatment （10.47±4.87 μg/ml vs. 2.59±1.60 μg/ml） with statistical difference （t=4.970, P=0.001）. However, no statistical significance was found in other coagulation parameters such as plasma prothrombin time, the international normalized ratio, activated partial thromboplastin time, thrombin time, fibrinogen. Incision exudate occurred in one patient and anticoagulant therapy was paused, however, two days later, DVT recurred and then the patient received continuous therapy with drug anticoagulation. The average time for postoperative follow-up was 8.3±7.6 months. At the latest follow-up, 4 cases had thoroughly recovered with the thrombi fully resolved; 4 cases had significantly improved including three thrombi partly locating in the muscular veins and one partly locating in the infra-popliteal vein. One case became more severe after discharge and received continuous anticoagulant therapy. No death, symptomatic pulmonary embolism, bleeding and other adverse events occurred. Conclusion Inferior vena cava filter placement for femoral neck fracture patients with acute proximal venous thrombosis before hip arthroplasty may not be potent. Anticoagulant therapy which make the proximal thrombus completely dissolved or stabilized before surgery may be effective.