肺移植术后静脉血栓栓塞症单中心分析

A single-center experience of venous thromboembolism after adult lung transplantation

目的探讨肺移植术后静脉血栓栓塞症(VTE)的发生情况.方法回顾性分析2017年3月1日至2018年9月30日在中日友好医院接受肺移植的124例终末期肺疾病患者的临床资料,统计其肺移植术后深静脉血栓形成(DVT)和肺栓塞的发生时间、可能的高危因素及治疗转归等情况.结果共124例肺移植受者,其中单肺移植78例(62.9%),双肺移植46例(37.1%);术前给予预防性抗凝52例(41.9%),术后预防性抗凝69例(55.6%);术后共32例患者发生VTE(25.8%),中位发生时间为术后22.5 d(4~295 d),其中30例(93.8%)发生DVT,病变累及1~8根静脉血管[平均(2.8±1.9)根],下肢DVT占60.0%,上肢DVT占56.7%(P>0.05).4例(4/32,12.5%)发生肺栓塞,其中2例为同时合并DVT和肺栓塞.32例肺移植术后发生VTE的受者中,体外膜式氧合(ECMO)的使用率为90.6%(29/32),明显高于未发生VTE的肺移植受者(64/92,69.6%,P=0.033).经外周置入中心静脉导管(PICC)的置入率在发生VTE(31/32,96.9%)与未发生VTE(75/92,81.5%)的两组患者间差异无统计学意义(P=0.067).30例(30/32,93.7%)患者采用低分子肝素充分抗凝,2例(2/32,6.3%)采用低分子肝素序贯华法林抗凝,均随访至充分抗凝治疗后3个月,血管完全再通率为65.6%(21/32),部分再通率为34.4%(11/32).3例发生抗凝相关出血并发症,均未导致严重后果.结论 VTE是肺移植术后常见并发症,ECMO应用为主要高危因素.VTE筛查应常规纳入肺移植围术期患者管理中,及时发现VTE并启动抗凝治疗.

Objective To investigate the incidence of venous thromboembolism (VTE) in lung transplant (LT) recipients. Methods The clinical data on 124 consecutive patients who underwent lung transplant at Lung Transplantation Center of China-Japan Friendship Hospital from March 2017 to September 2018 were retrospectively collected. Deep venous thrombosis (DVT) was ascertained by vascular ultrasound. Pulmonary embolism (PE) was diagnosed by either chest computed tomography pulmonary angiogram or ventilation/perfusion scan. The risk factors in those patients with postoperative VTE were studied. Results A total of 124 lung transplant recipients including 78 single lung transplant recipients (62.9%) and 46 bilateral lung transplant recipients(37.1%) were enrolled. Preoperative and postoperative prophylactic anticoagulant was used in 52 patients(52/124, 41.9%) and 69 patients(69/124, 55.6%) respectively. Thirty-two patients developed postoperative VTE among 124 consecutive patients. The overall incidence rate of VTE among 124 LT recipients was 25.8%. The median time to VTE episode following lung transplant was 22.5 days (range 4-295 days). The percentage of DVT in VTE was 93.8%(30/32), involving 1-8 (2.83±1.86) veins. And 60.0% of DVT was from lower extremities and 56.7% located in upper extremities (P>0.05). Four patients (4/32,12.5%) had PE episodes, and half of them suffered from only PE without DVT. The use of extracorporeal membrane oxygenation (ECMO) in 32 patients with VTE was 90.6%(29/32), which was significantly higher than that without VTE (64/92,69.6%, P=0.033). However, there was no difference in the use of peripherally inserted central catheter (PICC) between two groups (96.9% vs 81.5%, P=0.067). Resolution of VTE was successfully accomplished by anticoagulant therapy with long-term use of low molecular weight heparin in 30 patients (93.7%) and followed by oral warfarin in 2 patients (6.3%). Three months follow-up data after anticoagulant therapy showed that total and partial vascular recanalization rate was 65.6%(21/32) and 34.4%(11/32), respectively. Despite anticoagulation-related bleeding complications in three patients, no serious consequences occurred. Conclusions VTE was frequent in LT recipients. It was speculated that ECMO utilization may be a major risk factor for high incidence of VTE in LT recipients. Aggressive VTE screening/treatment protocols were suggested to be implemented in LT recipients.