急性人工动静脉内瘘血栓栓塞介入治疗
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摘要
目的探讨置管溶栓结合普通球囊扩张治疗急性人工动静脉内瘘血栓栓塞的安全性和有效性。方法回顾性分析2012年1月至2016年9月单中心收治的64例(84次)急性人工动静脉内瘘血栓栓塞患者临床资料。所有患者均经股动脉穿刺置管内瘘造影明确诊断。术中用普通导丝行内瘘血栓闭塞段机械碎栓术后予尿激酶12.5万~37.5万U团注,若血栓未完全溶解则保留导管,用输液泵持续泵入尿激酶至内瘘血栓完全清除;若内瘘管腔狭窄>50%或狭窄影响透析,则行普通球囊扩张术。通过KaplanMeier曲线估算首次介入治疗后一期及二期累积通畅率。结果 84例次患者中69例次(82.1%)取得技术成功。14例次患者因内瘘严重狭窄行普通球囊扩张术,成功12例次(85.7%)。总体临床成功率为78.6%(66/84)。治疗过程中共发生7例次(8.3%)出血事件,其中大出血、小出血事件分别为3例次、4例次。术后3、6、12、24个月一期/二期通畅率,分别为76.1%/81.3%、63.6%/70.8%、40.8%/47.0%、12.5%/32.5%。结论置管溶栓是治疗急性人工动静脉内瘘血栓栓塞安全有效的方法,辅助普通球囊扩张能为内瘘狭窄病变提供较为满意的治疗效果。
Objective To assess the safety and efficacy of catheter-directed thrombolysis combined with percutaneous transluminal angioplasty(PTA) in treating acute thrombo-embolism of artificial arteriovenous fistula. Methods The clinical data of 64 patients with acute thrombo-embolism of artificial arteriovenous fistula(84 events in total), who were admitted to single medical center during the period from January 2012 to September 2016, were retrospectively analyzed. The diagnosis of acute thrombo-embolism of artificial arteriovenous fistula was confirmed by angiography via femoral approach in all patients. Mechanical thrombectomy of the thrombotic occlusion segment by using common guide wire was carried out first, which was followed by bolus injection of urokinase(125,000-375,000 units); if the thrombus was not completely dissolved the catheter would be retained and the urokinase would be continuously infused with a micro-pump until the thrombus was completely dissolved. Conventional balloon dilatation would be employed when the stenosis of artificial arteriovenous fistula lumen was >50% or the stenosis impeded the performance of dialysis.Kaplan-Meier survival curve was used to estimate the primary and secondary cumulative patency rates after the first intervention. Results Of the 84 interventional procedures, technical success was achieved in 69 procedures(82.1%). A total of 14 conventional balloon dilatation procedures had to be conducted as the fistula was seriously narrowed, and up to 12 procedures(85.7%) were succeeded. The overall clinical success rate was 78.5%(66/84). During the therapeutic course, bleeding event occurred in 7 procedures(8.3%),including major bleeding(n=3) and minor bleeding(n=4). After the treatment, the 3-, 6-, 12-, 24-month primary and secondary patency rates were 76.1%, 63.6%, 40.8%, 12.5% and 81.3%, 70.8%, 47.0%, 32.5%respectively. Conclusion For the treatment of acute thrombo-embolism of artificial arteriovenous fistula,catheter-directed thrombolysis is safe and effective, it can assist conventional balloon dilatation therapy to obtain satisfactory therapeutic result for internal fistula stenosis.
Objective To assess the safety and efficacy of catheter-directed thrombolysis combined with percutaneous transluminal angioplasty(PTA) in treating acute thrombo-embolism of artificial arteriovenous fistula. Methods The clinical data of 64 patients with acute thrombo-embolism of artificial arteriovenous fistula(84 events in total), who were admitted to single medical center during the period from January 2012 to September 2016, were retrospectively analyzed. The diagnosis of acute thrombo-embolism of artificial arteriovenous fistula was confirmed by angiography via femoral approach in all patients. Mechanical thrombectomy of the thrombotic occlusion segment by using common guide wire was carried out first, which was followed by bolus injection of urokinase(125,000-375,000 units); if the thrombus was not completely dissolved the catheter would be retained and the urokinase would be continuously infused with a micro-pump until the thrombus was completely dissolved. Conventional balloon dilatation would be employed when the stenosis of artificial arteriovenous fistula lumen was >50% or the stenosis impeded the performance of dialysis.Kaplan-Meier survival curve was used to estimate the primary and secondary cumulative patency rates after the first intervention. Results Of the 84 interventional procedures, technical success was achieved in 69 procedures(82.1%). A total of 14 conventional balloon dilatation procedures had to be conducted as the fistula was seriously narrowed, and up to 12 procedures(85.7%) were succeeded. The overall clinical success rate was 78.5%(66/84). During the therapeutic course, bleeding event occurred in 7 procedures(8.3%),including major bleeding(n=3) and minor bleeding(n=4). After the treatment, the 3-, 6-, 12-, 24-month primary and secondary patency rates were 76.1%, 63.6%, 40.8%, 12.5% and 81.3%, 70.8%, 47.0%, 32.5%respectively. Conclusion For the treatment of acute thrombo-embolism of artificial arteriovenous fistula,catheter-directed thrombolysis is safe and effective, it can assist conventional balloon dilatation therapy to obtain satisfactory therapeutic result for internal fistula stenosis.
引文
[1]Ravani P,Palmer SC,Oliver MJ,et al.Associations between hemodialysis access type and clinical outcomes:a systematic review[J].J Am Soc Nephrol,2013,24:465-473.
[2]Vascular Access Work Group.Clinical prac tice guidelines for vascular access[J].Am J Kidney Dis,2006,48:S248-S273.
[3]Brahmbhatt A,Misra S.The biology of hemodialysis vascular access failure[J].Semin Intervent Radiol,2016,33:15-20.
[4]Milburn JA,Ford I,Mutch NJ,et al.Thrombin-anti-thrombin levels and patency of arterio-venous fistula in patients undergoing haemodialysis compared to healthy volunteers:a prospective analysis[J].PLo S One,2013,8:e67799.
[5]Bermudez P,Fontsere N,Mestres G,et al.Endovascular revascularization of hemodialysis thrombosed grafts with the hydrodynamic thrombectomy catheter.Our 7-year experience[J].Cardiovasc Intervent Radiol,2017,40:252-259.
[6]宋进华,顾建平,楼文胜,等.急性动静脉内瘘血栓形成的置管溶栓治疗[J].介入放射学杂志,2012,21:284-287.
[7]Bittl JA.Catheter interventions for hemodialysis fistulas and grafts[J].JACC Cardiovasc Interv,2010,3:1-11.
[8]朱光宇,滕皋军,郭金和,等.血液透析动静脉内瘘急性血栓形成的溶栓治疗[J].介入放射学杂志,2002,11:339-341.
[9]Maleux G,De Coster B,Laenen A,et al.Percutaneous rheolytic thrombectomy of thrombosed autogenous dialysis fistulas:technical results,clinical outcome,and factors influencing patency[J].J Endovasc Ther,2015,22:80-86.
[10]Petronis JD,Regan F,Briefel G,et al.Ventilation-perfusion scintigraphic evaluation of pulmonary clot burden after percutaneous thrombolysis of clotted hemodialysis access grafts[J].Am J Kidney Dis,1999,34:207-211.
[11]Sabovic M,Salobir B,Zupan IP,et al.The influence of the haemodialysis procedure on platelets,coagulation and fibrinolysis[J].Pathophysiol Haemost Thromb,2005,34:274-278.
[12]Rajan DK,Sidhu A,Noel-Lamy M,et al.Elastic recoil after balloon angioplasty in hemodialysis accesses:does it actually occur and is it clinically relevant[J].Radiology,2016,279:961-967.
[13]Khawaja AZ,Cassidy DB,Al Shakarchi J,et al.Systematic review of drug eluting balloon angioplasty for arteriovenous haemodialysis access stenosis[J].J Vasc Access,2016,17:103-110.
[14]Haskal ZJ,Saad TF,Hoggard JG,et al.Prospective,randomized,concurrently-controlled study of a stent graft versus balloon angioplasty for treatment of arteriovenous access graft stenosis:2-year results of the RENOVA study[J].J Vasc Interv Radiol,2016,27:1105-1114.
[15]宋岩,李冀军,张壹言,等.局部尿激酶溶栓治疗血液透析患者动静脉内瘘血栓疗效及治疗方案探讨[J].中国血液净化,2007,6:597-600.
[16]Vashchenko N,Korzets A,Neiman C,et al.Retrospective comparison of mechanical percutaneous thrombectomy of hemodialysis arteriovenous grafts with the Arrow-Trerotola device and the Lyse and wait technique[J].AJR Am J Roentgenol,2010,194:1626-1629.
[2]Vascular Access Work Group.Clinical prac tice guidelines for vascular access[J].Am J Kidney Dis,2006,48:S248-S273.
[3]Brahmbhatt A,Misra S.The biology of hemodialysis vascular access failure[J].Semin Intervent Radiol,2016,33:15-20.
[4]Milburn JA,Ford I,Mutch NJ,et al.Thrombin-anti-thrombin levels and patency of arterio-venous fistula in patients undergoing haemodialysis compared to healthy volunteers:a prospective analysis[J].PLo S One,2013,8:e67799.
[5]Bermudez P,Fontsere N,Mestres G,et al.Endovascular revascularization of hemodialysis thrombosed grafts with the hydrodynamic thrombectomy catheter.Our 7-year experience[J].Cardiovasc Intervent Radiol,2017,40:252-259.
[6]宋进华,顾建平,楼文胜,等.急性动静脉内瘘血栓形成的置管溶栓治疗[J].介入放射学杂志,2012,21:284-287.
[7]Bittl JA.Catheter interventions for hemodialysis fistulas and grafts[J].JACC Cardiovasc Interv,2010,3:1-11.
[8]朱光宇,滕皋军,郭金和,等.血液透析动静脉内瘘急性血栓形成的溶栓治疗[J].介入放射学杂志,2002,11:339-341.
[9]Maleux G,De Coster B,Laenen A,et al.Percutaneous rheolytic thrombectomy of thrombosed autogenous dialysis fistulas:technical results,clinical outcome,and factors influencing patency[J].J Endovasc Ther,2015,22:80-86.
[10]Petronis JD,Regan F,Briefel G,et al.Ventilation-perfusion scintigraphic evaluation of pulmonary clot burden after percutaneous thrombolysis of clotted hemodialysis access grafts[J].Am J Kidney Dis,1999,34:207-211.
[11]Sabovic M,Salobir B,Zupan IP,et al.The influence of the haemodialysis procedure on platelets,coagulation and fibrinolysis[J].Pathophysiol Haemost Thromb,2005,34:274-278.
[12]Rajan DK,Sidhu A,Noel-Lamy M,et al.Elastic recoil after balloon angioplasty in hemodialysis accesses:does it actually occur and is it clinically relevant[J].Radiology,2016,279:961-967.
[13]Khawaja AZ,Cassidy DB,Al Shakarchi J,et al.Systematic review of drug eluting balloon angioplasty for arteriovenous haemodialysis access stenosis[J].J Vasc Access,2016,17:103-110.
[14]Haskal ZJ,Saad TF,Hoggard JG,et al.Prospective,randomized,concurrently-controlled study of a stent graft versus balloon angioplasty for treatment of arteriovenous access graft stenosis:2-year results of the RENOVA study[J].J Vasc Interv Radiol,2016,27:1105-1114.
[15]宋岩,李冀军,张壹言,等.局部尿激酶溶栓治疗血液透析患者动静脉内瘘血栓疗效及治疗方案探讨[J].中国血液净化,2007,6:597-600.
[16]Vashchenko N,Korzets A,Neiman C,et al.Retrospective comparison of mechanical percutaneous thrombectomy of hemodialysis arteriovenous grafts with the Arrow-Trerotola device and the Lyse and wait technique[J].AJR Am J Roentgenol,2010,194:1626-1629.