尿激酶经导管溶栓治疗下肢深静脉血栓失败后介入补救方案的探讨
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摘要
目的探讨尿激酶经导管溶栓(UK-CDT)治疗髂股静脉血栓形成(LEDVT)失败后的介入补救方案。方法搜集采用UK-CDT治疗的LEDVT患者343例,其中UK-CDT治疗成功和失败分别为281例和62例,对可能影响治疗效果的因素进行分析。UK-CDT治疗失败62例患者分别采用了替换抗凝药物、增加溶栓剂量、替换溶栓剂、血栓减负荷或开通流出道补救措施。结果血栓溶解率(<50%与≥50%)在发病时间、溶栓时间、UK用量及是否合并HIT等有相关性(P <0. 05)。UK-CDT失败患者介入补救治疗血栓溶解率(≥50%)为77. 4%(48/62),替换抗凝药物、增加溶栓剂量、替换溶栓剂、血栓减负荷或开通流出道血栓补救治疗的溶解率(≥50%)分别为92. 3%(12/13)、45. 5%(5/11)、81. 3%(13/16)、83. 3%(10/12)和80. 0%(8/10),患肢肿胀症状、体征均有改善。补救期间均未发生大出血事件,小出血并发症发生率8. 6%(5/62)。结论 UK-CDT溶栓失败后立即行补救性介入治疗有助于提高血栓溶解率,改善症状、体征,不失为一种安全、积极有效的策略选择。
Objective To explore rescue strategies for treatment of lower extremity deep venous thrombosis( LEDVT)after ineffective catheter-directed thrombosis( CDT) with urokinase( UK). Methods From January 2014 to January2017,a total of 343 cases of LEDVT patients who were treated with UK-CDT were collected,including 281 and 62 of patients who underwent effective and ineffective CDT respectively. In the study we analyzed the factors that might affect the therapeutic effect in two groups. For patients who underwent ineffective UK-CDT,we made the different rescue strategies of replacement of anticoagulant drugs,increasing the dosage and time of thrombolytic agents,adjusting the thrombolytic agents,removing the thrombus burden,or opening the out-flow tract. Results Thrombolytic rate( < 50% or ≥50%) had statistical significance with the time of symptom onset,thrombolytic time,UK dosage and whether combined heparin-induced thrombocytopenia( HIT)( P < 0. 05). The efficacy thrombolytic rate( ≥50%) of rescue strategies was 77. 4%( 48/62),and for replacement of anticoagulant drugs,increasing the dosage and time of thrombolytic agents,adjusting the thrombolytic agents,removing the thrombus burden,or opening the out-flow tract were 92. 3%( 12/13),45. 5%( 5/11),81. 3%( 13/16),83. 3%( 10/12) and 80. 0%( 8/10),respectively. The symptoms and signs were both relieved. No major bleeding occurred during the rescue procedure,minor bleeding complications rate was 8. 6%( 5/62). Conclusion Treatment of rescue strategies for LEDVT patients who underwent ineffective UK-CDT can improve the thrombolytic rate and relieve the symptoms and signs,and may be a safe and effective alternative.
Objective To explore rescue strategies for treatment of lower extremity deep venous thrombosis( LEDVT)after ineffective catheter-directed thrombosis( CDT) with urokinase( UK). Methods From January 2014 to January2017,a total of 343 cases of LEDVT patients who were treated with UK-CDT were collected,including 281 and 62 of patients who underwent effective and ineffective CDT respectively. In the study we analyzed the factors that might affect the therapeutic effect in two groups. For patients who underwent ineffective UK-CDT,we made the different rescue strategies of replacement of anticoagulant drugs,increasing the dosage and time of thrombolytic agents,adjusting the thrombolytic agents,removing the thrombus burden,or opening the out-flow tract. Results Thrombolytic rate( < 50% or ≥50%) had statistical significance with the time of symptom onset,thrombolytic time,UK dosage and whether combined heparin-induced thrombocytopenia( HIT)( P < 0. 05). The efficacy thrombolytic rate( ≥50%) of rescue strategies was 77. 4%( 48/62),and for replacement of anticoagulant drugs,increasing the dosage and time of thrombolytic agents,adjusting the thrombolytic agents,removing the thrombus burden,or opening the out-flow tract were 92. 3%( 12/13),45. 5%( 5/11),81. 3%( 13/16),83. 3%( 10/12) and 80. 0%( 8/10),respectively. The symptoms and signs were both relieved. No major bleeding occurred during the rescue procedure,minor bleeding complications rate was 8. 6%( 5/62). Conclusion Treatment of rescue strategies for LEDVT patients who underwent ineffective UK-CDT can improve the thrombolytic rate and relieve the symptoms and signs,and may be a safe and effective alternative.
引文
1 Vedantham S,Sista AK,Klein SJ,et al.Quality improvement guidelines for the treatment of lower-extremity deep vein thrombosis with use of endovascular thrombus removal[J].J Vasc Interv Radiol,2014,25:1317-1325.
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3 Gurman P,Miranda O,Nathan A,et al.Recombinant tissue plasminogen activators(rt PA):A review[J].Clin Pharmacol Ther,2015,97:274-285.
4陈国平,顾建平,何旭,等.低剂量尿激酶较长时间经导管直接溶栓术治疗急性髂-股静脉血栓形成的安全性和临床疗效[J].中华放射学杂志,2012,12:1119-1125.
5陈国平,顾建平,何旭,等.双向联合溶栓治疗急性混合型下肢深静脉血栓形成的临床疗效[J].临床放射学杂志,2014,33:421-425.
6苏浩波,楼文胜,顾建平,等.急性下肢深静脉血栓形成合并Ⅱ型肝素诱导血小板减少症的临床特征及介入综合治疗效果[J].中华放射学杂志,2015,49:380-385.
7 Mewissen MW,Seabrook GR,Meissner MH,et al.Catheter-directed thrombolysis for lower extremity deep venous thrombosis:report of a national multicenter registry[J].Radiology,1999,211:29:39-49.
8 Lee GM,Arepally GM.Diagnosis and management of heparin-induced thrombocytopenia[J].Hematol Oncol Clin North Am,2013,27:541-563.
9 Meyerovitz MF.Drug variables in thrombolytic therapy[J].J Vasc Interv Radiol,1995,6:62-65.
10 Oguzkurt L,Ozkan U,Gulcan O,et al.Endovascular treatment of acute and subacute iliofemoral deep venous thrombosis by using manual aspiration thrombectomy:long-term results of 139 patients in a single center[J].Diagn Interv Radiol,2012,18:410-416.
11 Garcia MJ,Lookstein R,Malhotra R,et al.Endovascular management of deep vein thrombosis with rheolytic thrombectomy:final report of the prospective multicenter PEARL(Peripheral Use of Angio Jet Rheolytic Thrombectomy with a Variety of Catheter Lengths)registry[J].J Vasc Interv Radiol,2015,26:777-785.
12 Delis KT,Bountouroglou D,Mansfield AO.Venous claudication in iliofemoral thrombosis:long-term effects on venous hemodynamics,clinical status,and quality of life[J].Ann Surg,2004,239:118-126.
13刘凯,段鹏飞,倪才方.髂静脉支架置入后行置管溶栓治疗急性下肢深静脉血栓形成八例[J].中华普通外科杂志,2016,31:339-340.
2 Haig Y,Enden T,Grotta O,et al.Post-thrombotic syndrome after catheter-directed thrombolysis for deep vein thrombosis(CaVenT):5-year follow-up results of an open-label,randomised controlled trial[J].Lancet Haematol,2016,3:64-71.
3 Gurman P,Miranda O,Nathan A,et al.Recombinant tissue plasminogen activators(rt PA):A review[J].Clin Pharmacol Ther,2015,97:274-285.
4陈国平,顾建平,何旭,等.低剂量尿激酶较长时间经导管直接溶栓术治疗急性髂-股静脉血栓形成的安全性和临床疗效[J].中华放射学杂志,2012,12:1119-1125.
5陈国平,顾建平,何旭,等.双向联合溶栓治疗急性混合型下肢深静脉血栓形成的临床疗效[J].临床放射学杂志,2014,33:421-425.
6苏浩波,楼文胜,顾建平,等.急性下肢深静脉血栓形成合并Ⅱ型肝素诱导血小板减少症的临床特征及介入综合治疗效果[J].中华放射学杂志,2015,49:380-385.
7 Mewissen MW,Seabrook GR,Meissner MH,et al.Catheter-directed thrombolysis for lower extremity deep venous thrombosis:report of a national multicenter registry[J].Radiology,1999,211:29:39-49.
8 Lee GM,Arepally GM.Diagnosis and management of heparin-induced thrombocytopenia[J].Hematol Oncol Clin North Am,2013,27:541-563.
9 Meyerovitz MF.Drug variables in thrombolytic therapy[J].J Vasc Interv Radiol,1995,6:62-65.
10 Oguzkurt L,Ozkan U,Gulcan O,et al.Endovascular treatment of acute and subacute iliofemoral deep venous thrombosis by using manual aspiration thrombectomy:long-term results of 139 patients in a single center[J].Diagn Interv Radiol,2012,18:410-416.
11 Garcia MJ,Lookstein R,Malhotra R,et al.Endovascular management of deep vein thrombosis with rheolytic thrombectomy:final report of the prospective multicenter PEARL(Peripheral Use of Angio Jet Rheolytic Thrombectomy with a Variety of Catheter Lengths)registry[J].J Vasc Interv Radiol,2015,26:777-785.
12 Delis KT,Bountouroglou D,Mansfield AO.Venous claudication in iliofemoral thrombosis:long-term effects on venous hemodynamics,clinical status,and quality of life[J].Ann Surg,2004,239:118-126.
13刘凯,段鹏飞,倪才方.髂静脉支架置入后行置管溶栓治疗急性下肢深静脉血栓形成八例[J].中华普通外科杂志,2016,31:339-340.
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