下肢动脉硬化闭塞腔内治疗前行抗凝及抗血小板治疗对临床预后的影响

Effect of Anticoagulant and Antiplatelet Therapy Before the Intracavitary Therapy of Lower Limb Atherosclerosis Occlusion on Clinical Outcomes

目的探讨术前行低分子肝素抗凝及阿司匹林抗血小板对下肢动脉硬化闭塞介入治疗患者无复流现象及疗效的影响。方法选择126例126条肢体行介入治疗的下肢动脉硬化闭塞患者将其随机分成三组:阿司匹林组(44例):术前3天口服阿司匹林100 mg qd;低分子肝素组(40例):术前3天皮下注射低分子肝素4100 U q12h;对照组(42例):完善相关检查后即行手术。分别于入院时、术前、术后0 h、术后24 h测定血浆凝血酶调节蛋白(PTM)、可溶性纤维蛋白单体复合物(sFMC)、血小板α-颗粒膜糖蛋白140(GMP-140)、D-二聚体(DD)及血浆黏度测定,术前及术后第3天测踝臂指数(ABI),比较两组内不同时间点各项指标的变化及两组间的差异。同时记录三组术后发生患肢无复流、急性动脉血栓形成或栓塞、穿刺部位出血或血肿的例数。结果①对照组sFMC、GMP-140、DD和血浆黏度在术后0 h显著升高(P<0.05或0.01)并达峰值,术后24 h较术后0 h有所下降,但仍明显高于术前(P<0.05或0.01)。②与对照组比较,两治疗组术前sFMC、GMP-140、DD和血浆黏度显著降低(P<0.05)。③两治疗组sFMC和血浆黏度在术后0 h、术后24 h与术前比较无明显升高(P>0.05),而DD有显著增高(P<0.01),但与对照组同一时间点比较升高的幅度明显降低(P<0.01)。低分子肝素组术后0 h、术后24 h GMP-140、DD较阿司匹林组明显增高(P<0.05)。④两治疗组术后ABI与对照组同时间点比较升高幅度明显增加(P<0.05)。⑤三组患者PTM术后同术前均无明显变化(P>0.05)。⑥阿司匹林组术后发生患肢无复流及急性动脉血栓形成或栓塞率明显低于低分子肝素组及对照组(P<0.05),三组穿刺部位出血或血肿并发症的发生率无差异。结论动脉硬化闭塞介入治疗前行抗血小板或抗凝治疗明显降低血栓前状态,有效降低无复流及急性动脉血栓形成率,同时不增加出血并发症的发生率,抗血小板优于抗凝。

Aim To detect the influence of pretreatment with preoperative low molecular heparin anticoagulation and aspirin antiplatelet on the patients' no-reflow phenomenon and efficacy after interventional therapy of lower limb atherosclerosis occlusion. Methods 126 patients( 126 limbs) with lower limb atherosclerosis occlusion undergoing interventional therapy were randomly divided into aspirin group( 44 patients) with aspirin for 3 ~ 5 days prior to interventional therapy,low molecular heparin group( 40 patients) with low molecular heparin for 3 ~ 5 days prior to interventional therapy and control group( 42 patients) without aspirin and low molecular heparin before interventional therapy. Plasma thrombomodulin( PTM),soluble fibrin monomer complex( sFMC),platelet α-granule membrane glycoprotein 140( GMP-140),Ddimer( DD) and plasma viscosity levels of plasma were measured at four different time points: on admission,before percutaneous transluminal angioplasty( PTA),immediately after the last PTA and at 24 hours after PTA,while the ankle brachial index( ABI) were detected at two different time points: on admission and at 3 days after PTA. The changes in groups at different time points and the differences between groups at the same time points were compared. The number of postoperative cases of no-reflow occurred limbs,puncture site bleeding or hematoma,acute arterial thrombosis or embolism were recorded at the same time. Results ① In control group,sFMC,GMP-140,DD and plasma viscosity levels was increased( P < 0. 05 or 0. 01) immediately after the last PTA and rose to peak values,and slightly decreased at 24 hours after PTA,which were still higher than the values before PTA( P < 0. 05 or 0. 01). ②Compared with control group, sFMC,GMP-140,DD and plasma viscosity of the two treatments group decreased significantly before PTA( P < 0. 05). ③In the two treatment groups,there were no remarkable elevation in the levels of sFMC and plasma viscosity at different time points,compared with the values before PTA( P > 0. 05). However,DD still elevated( P < 0. 01) compared with the values before PTA,which were much lower than the values at the same time points in control group( P < 0. 01). Compared with aspirin group,GMP-140 and DD of the low molecular heparin group increased greatly immediately after the last PTA and at 24 hours after PTA. ④In the two treatment groups,postoperative ankle-brachial index( ABI) increased significantly,compared with the values at the same time points in control group( P < 0. 05). ⑤The levels of plasma PTM had no significant change in different time points of all groups compared with that before PTA( P > 0. 05). ⑥In the aspirin group,postoperative limb no-reflow rate and acute arterial thrombosis or embolism rate were significantly lower than that in low molecular heparin group and the control group( P < 0. 05). There were no remarkable difference in the incidence of complications of puncture site bleeding or hematoma. Conclusion Anticoagulant therapy or antiplatelet therapy before the intracavitary therapy of lower limb atherosclerosis occlusion reduced prothrombotic state,the rate of no-reflow and acute arterial thrombosis effectively,and didn't increase the incidence of bleeding complications. The antiplatelet was better than anticoagulant.