主动脉原发性血栓的诊断及治疗

Diagnosis and therapy for primary aorticmural thrombus

目的探讨主动脉原发性血栓的诊断及治疗方法。方法回顾性分析2018年8月至2021年11月河南省安阳地区医院血管科/介入中心收治的14例患者的临床资料,其中下肢疼痛11例,腹痛2例,同时伴有腹痛及下肢疼痛1例;Ⅱa+Ⅱb型1例,Ⅱb型2例,Ⅲ+Ⅳ型3例,Ⅳ型8例。主动脉血栓广基底附壁患者采取单纯抗凝治疗,窄基底附壁或漂浮患者采取抗凝+取栓或支架植入。术中应用Fogarty球囊或Wallstent支架半释放技术预防远端动脉栓塞。下肢动脉及肠系膜上动脉累及者采取介入手术治疗,余部位抗凝治疗。遗传性高危因素患者术后终身抗凝;可控高危因素患者基础病治疗后抗凝治疗1年,余患者抗凝治疗半年。术后1、3、6、12月复查主动脉CTA和下肢动脉彩超。结果对于主动脉血栓的治疗,14例患者中,单纯抗凝6例;手术治疗8例,其中取栓3例,裸支架治疗2例,直接覆膜支架治疗3例。对于周围血管栓塞的治疗,2例抗凝治疗,余12例手术治疗。中位随访时间18.5个月。随访期间,6例主动脉血栓抗凝治疗患者血栓消失1例,血栓明显减少5例。3例主动脉取栓患者,2例血栓消失,1例2个月后复发,予以覆膜支架植入。主动脉支架血流通畅。周围血管栓塞复发4例,足趾截趾1例,间歇性跛行症状3例,1例术后3个月因急性胰腺炎死亡。结论原发性主动脉血栓发病率低,抗凝需贯穿治疗全程;对于外科手术风险大或脱落风险低的患者,可采用单纯抗凝治疗;对于血栓脱落风险较大的患者,抗凝同时可联合取栓或支架植入;高危因素治疗及术后健康教育有利于预防术后复发。

Objective To discuss the diagnosis and therapy for primary aortic mural thrombus.Methods From August 2018 to November 2021,the clinical data of 14 patients with primary aortic mural thrombus in the Department of Vascular and Interventional Radiology in Henan Anyang District Hospital were retrospectively analyzed.Among them,11 patients were admitted to the hospital for lower limb pain,2 cases for abdominal pain,and 1 case for abdominal and lower limb pain.There was 1 case of typeⅡa+Ⅱb,2 cases of typeⅡb,3 cases of typeⅢ+Ⅳ,and 8 cases of typeⅣ.Anticoagulant therapy was used for patients with broad basal wall thrombosis and anticoagulant therapy combined with thrombectomy or stent implantation was used for patients with narrow basal wall thrombosis or floating thrombus.Fogarty balloon catheters or Wallstent stents were applied to prevent distal arterial embolism.The interventional operation was used in patients with lower limb artery embolization and superior mesenteric artery embolization,and anticoagulation therapy was performed in the remaining parts.Life-long anticoagulant therapy was used for patients with genetic high-risk factors,patients with controllable high-risk factors were treated with anticoagulant therapy for 1 year after the treatment of basic diseases and the remaining patients were treated with anticoagulant therapy for 6 months.The aorta was followed up by CTA at 1,3,6,and 12 months postoperatively,at the same period,the lower limb arteries were followed up by color Doppler ultrasonography.Results For the treatment of aortic thrombosis,6 patients were treated with anticoagulant therapy and 8 cases underwent surgery,including 3 cases of thrombectomy,2 cases of bare stents therapy,and 3 cases of directly covered stents therapy.For the therapy of peripheral vascular embolism,2 patients were treated with anticoagulant therapy and 12 patients underwent surgery.The median follow-up time was 18.5 months.Among 6 patients treated with anticoagulant therapy,thrombus disappearance occurred in 1 case and a significant reduction occurred in 5 cases during the follow-up.Among patients treated with thrombectomy,thrombus disappearance occurred in 2 cases,recurrence occurred in 1 case after 2 months,and then implanted with a covered stent.There was no obstruction during the follow-up.Peripheral vascular embolization recurrence occurred in 4 cases,toe amputation occurred in 1 case,intermittent claudication occurred in 3 cases,and death occurred in 1 patient 3 months after the operation for acute pancreatitis.Conclusions Primary aortic mural thrombus has a characteristic of low incidence and anticoagulant therapy should be used throughout the whole treatment process.Anticoagulant therapy could be used in patients with a higher risk of surgical operation or patients with a lower risk of thrombus detachment.Anticoagulant therapy combined with thrombectomy or stent implantation could be used in patients with a higher risk of thrombus detachment.Treating high-risk factors and postoperative patient education is very important for preventing postoperative recurrence.