分期递增式球囊扩张技术在布加综合征合并下腔静脉血栓形成腔内治疗中的应用效果及安全性

The application of staged incremental balloon dilatation technique in the interventional treatment of Budd-Chiari syndrome with inferior vena cava thrombosis

目的探讨分期递增式球囊扩张技术在布加综合征(BCS)合并下腔静脉血栓形成腔内治疗中的应用效果及安全性。方法回顾性分析2016年1月—2018年12月蚌埠医学院第一附属医院血管外科收治的34例BCS合并下腔静脉血栓患者临床资料,其中男18例、女16例,年龄32~53岁。均采用分期递增式球囊扩张技术治疗,即无论新鲜或陈旧性血栓,病变部位导丝开通后行小球囊(8 mm)第1次扩张并予抗凝治疗,1周后采用小球囊(12 mm)第2次扩张,1个月后行大球囊(18~25 mm)扩张治疗。观察手术成功率、围术期并发症、近期通畅率及实验室相关指标。结果最终手术成功开通33例,成功率97.06%(33/34);其中新鲜血栓14例(14/34)均行经导管溶栓后下腔静脉血栓清除,血流恢复,病变段开通。1例未开通者为下腔静脉长段闭塞,在第1次扩张时反复尝试均无法通过闭塞段,改行下腔静脉-右心房转流手术。33例在1周后行12 mm球囊扩张和1个月后大球囊扩张时导丝均能顺利通过病变段,顺利实施球囊扩张术。33例扩张成功患者在小球囊第1次扩张前碱性磷酸酶、胆红素和血小板水平分别是(111.91±22.38)U/L、(20.76±1.82)U/L和(103.85±21.98)×109/L,在大球囊扩张术前分别是(78.88±10.04)U/L、(19.79±2.03)U/L和(137.27±17.68)×109/L,差异均有统计学意义(t=7.741、2.039、6.802,P值均<0.05);但红细胞、白细胞及丙氨酸氨基转移酶、天冬氨酸氨基转移酶等指标变化不明显。大球囊开通术后6个月患者门脉高压症状得到明显的改善,腹水消减、肝脾缩小、肝功能好转。住院及随访期间均无患者死亡。围术期未发生致死性肺栓塞、下腔静脉破裂、心包填塞等严重并发症;溶栓期间未发生症状性肺栓塞和致死性肺拴塞。33例患者术后6个月、1年经彩超复查显示下腔静脉通畅率分别是96.97%(32/33)、90.91%(30/33)。结论分期递增式球囊扩张技术,应用于BCS合并下腔静脉血栓形成腔内治疗过程中安全有效,近期疗效满意。

Objective To investigate the effect and safety of staged incremental balloon dilatation in the interventional treatment of Budd-Chiari syndrome(BCS)with inferior vena cava thrombosis.Methods From January 2016 to December 2018,the clinical data of 34 BCS patients with inferior vena cava thrombosis(18 males and 16 females aged 32-53 years)admitted to vascular surgery of the First Affiliated Hospital of Bengbu Medical College were analyzed retrospectively.All patients were treated by staged incremental balloon dilatation,namely whether the thrombus was fresh or not,the small balloon(8 mm)was dilated for the first time and anticoagulant treatment was given after the guide wire was opened,the small balloon(12 mm)was dilated for the second time after one week,and the large balloon(18-25 mm)was dilated after one month.The success rate,perioperative complications,short-term patency rate and laboratory related indexes were observed.Results Thirty-three cases were successfully opened,the total success rate was 97.06%(33/34).The other patient was a long segment occlusion of the inferior vena cava.Repeated attempts at the first dilation failed to pass the occlusion segment,and the operation of the inferior vena cava-right atrial bypass was performed instead;among them,14 cases(14/34)of fresh thrombus underwent transcatheter thrombolysis followed by removal of inferior vena cava thrombus,recovery of blood flow and opening of lesion segment.Thirty-three cases underwent 12 mm balloon dilatation after 1 week and 1 month,respectively,the large balloon dilatation was successfully performed,and the guide wire could pass through the lesion.The levels of alkaline phosphatase,bilirubin and platelet were(111.91±22.38)U/L,(20.76±1.82)U/L and(103.85±21.98)×109/L before the first dilation of the small balloon in 33 patients with successful dilation,and(78.88±10.04)U/L,(19.79±2.03)U/L and(137.27±17.68)×109/L before the first dilation of the large balloon,respectively.The differences were statistically significant(t=7.741,2.039,6.802,all P values<0.05);but the changes of red blood cells,white blood cells,alanine aminotransferase and aspartate aminotransferase were not obvious.Six months after the operation,the symptoms of portal hypertension were significantly improved,such as the reduction of ascites,the reduction of liver and spleen,and the reduction of liver function score.No patient died during hospitalization and follow-up.There were no serious complications such as fatal pulmonary embolism,inferior vena cava rupture and pericardial tamponade in the perioperative period,and no symptomatic pulmonary embolism and fatal pulmonary embolism in the thrombolysis period.The results showed that the patency rates of inferior vena cava were 96.97%(32/33)and 90.91%(30/33),when 33 patients were rechecked by color ultrasound 6 months and 1 year after operation.Conclusions Staged incremental balloon dilatation is a safe and effective technique in the treatment of BCS with inferior vena cava thrombus.