急性下肢深静脉血栓形成伴髂静脉重度狭窄血栓清除术中髂静脉支架置入时机的选择

doi:10.3760/cma.j.cn101202-20230811-00038

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摘要目的探讨急性下肢深静脉血栓形成（DVT）伴髂静脉重度狭窄患者血栓清除术中髂静脉支架置入时机的选择。方法回顾性队列研究。纳入苏州大学附属第一医院2020年1月—2021年12月急性下肢DVT伴髂静脉重度狭窄患者68例,其中男24例、女44例,年龄27~87（62.6±11.6）岁,均接受AngioJet血栓清除术+髂静脉支架置入术治疗。按照置入支架时期不同分为2组：同期组35例,接受AngioJet血栓清除术,同期髂静脉支架置入后行置管溶栓治疗;分期组33例,一期行AngioJet血栓清除术+置管溶栓治疗,二期行髂静脉支架置入治疗。观察指标：（1）比较2组患者的年龄、性别、患肢侧别、合并肺栓塞情况、血栓分型、病程、术前肢体周径差、近期手术/外伤、恶性肿瘤、自身免疫性疾病等基线资料;（2）比较2组治疗期间溶栓剂用量、溶栓时间、住院时间、血栓清除率、并发症发生情况;（3）比较2组术后12个月时的支架累积通畅率、肢体周径差、下肢血栓形成后综合征（PTS）发生率及静脉临床严重程度评分（VCSS）情况。结果（1）2组基线资料比较,差异均无统计学意义（P值均>0.05）。（2）68例患者手术均取得成功。同期组患者治疗期间尿激酶用量、溶栓时间、住院时间分别为（85.7±32.0）万U、（3.3±1.6）d、（6.7±1.7）d,分期组分别为（117.6±19.8）万U、（4.9±1.0）d、（8.6±2.0）d,差异均有统计学意义（t=-4.96、-4.95、-4.03,P值均<0.001）;2组AngioJet抽吸时间、血栓清除率情况,差异均无统计学意义（P值均>0.05）;同期组和分期组患者并发症发生率分别为45.7%（16/35）和51.5%（17/33）,差异无统计学意义（χ²=0.23,P=0.632）,均未发生出血、症状性肺栓塞等严重并发症。（3）68例患者术后均获随访,随访时间12~24（17.3±3.5）个月。术后12个月时,2组患者支架累积通畅率、肢体周径差、PTS发生率及VCSS评分比较,差异均无统计学意义（P值均>0.05）。结论对于合并髂静脉重度狭窄的急性下肢DVT患者,选择同期或分期行髂静脉支架置入均可行,两者具有相似的近中期疗效及风险;同期置入支架相比于分期置入支架的优势在于,患者溶栓药物用量更小、住院时间更短。

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	周文杰
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	段鹏飞

关键词 ：静脉血栓形成, 髂静脉重度狭窄, 经皮机械血栓清除术, 溶栓治疗, 髂静脉支架, 手术时机

Abstract：Objective This study aimed to investigate the timing of iliac vein stenting during thrombectomy for acute lower extremity deep vein thrombosis (DVT) with severe iliac vein stenosis. Methods A total of 68 patients with acute lower extremity DVT and severe iliac vein stenosis who underwent surgery in the First Affiliated Hospital of Soochow University from January 2020, to December 2021, were enrolled, including 24 males and 44 females aged 27-87 (62.6±11.6) years. All patients received AngioJet thrombectomy and iliac vein stent placement. The patients were divided into groups in accordance with the period of stent placement: 35 cases received AngioJet thrombectomy and catheter-directed thrombolysis after iliac vein stenting during the same period (the concurrent group), and 33 cases received AngioJet thrombectomy followed by catheter-directed thrombolysis and iliac vein stenting during the staged period (the staged group). Observation indices: (1) The baseline data, such as age, gender, side of the affected limb, combined pulmonary embolism, thrombus type, disease duration, preoperative limb circumference difference and recent surgery/trauma, malignant tumor, and autoimmune disease of the two groups were compared. (2) The dose of thrombolytic agent, thrombolytic time, thrombus clearance rate, hospital stay, and occurrence of complications during the treatment period of the two groups were compared. (3) The cumulative stent patency rate, limb circumference difference, and incidence of post-thrombotic syndrome (PTS) and venous clinical severity score (VCSS) in the two groups at 12 months after the procedure were compared. Results (1) The difference between the baseline data of the two groups was not statistically significant (all P values >0.05). (2) The procedure was technically successful in all 68 patients. The urokinase dosage, thrombolysis time, and hospital stay during treatment were (0.857±0.320) ×10⁶ units, (3.3±1.6) days, and (6.7±1.7) days, respectively, in the concurrent group, and (1.176±0.198)×10⁶ units, (4.9±1.0) days, and (8.6±2.0) days, respectively, in the staged group. The differences were statistically significant (t=-4.96, -4.95, -4.03; all P values <0.001). The differences in AngioJet aspiration time and thrombus clearance rate between the two groups were not statistically significant (all P values >0.05). The complication rates of patients in the concurrent group and the staged group were 45.7% (16/35) and 51.5% (17/33), respectively, and the difference was not statistically significant (χ²=0.23, P=0.632). All patients did not suffer from bleeding, symptomatic pulmonary embolism, and other serious complications. (3) All 68 patients were followed up for 12-24(17.3±3.5) months after the procedure. At 12 months after the procedure, the cumulative patency rate of stent, limb circumference difference, PTS incidence, and VCSS score of the two groups were compared, and the differences were not statistically significant (all P values >0.05). Conclusion For patients with acute lower limb DVT combined with severe stenosis of the iliac vein, either contemporaneous or staged iliac vein stenting can be an option, and the two groups have similar risks and near- and mid-term efficacy. Patients undergoing simultaneous stent implantation use less thrombolytic drugs and have shorter hospital stay than patients undergoing staged stent implantation.

Key words： Venous thrombosis Severe iliac vein stenosis Percutaneous mechanical thrombectomy Thrombolytic therapy Iliac vein stent Operation timing

收稿日期: 2023-08-11

基金资助:江苏省医学会科研专项资金（SYH-3201140-0046、2022003）

通讯作者: 段鹏飞,Email：dpf621@126.com

引用本文:

周文杰, 杨超, 王孝运, 朱晓黎, 吕朋华, 段鹏飞. 急性下肢深静脉血栓形成伴髂静脉重度狭窄血栓清除术中髂静脉支架置入时机的选择[J]. 中华解剖与临床杂志, 2024, 29(4): 222-227.
Zhou Wenjie, Yang Chao, Wang Xiaoyun, Zhu Xiaoli, Lyu Penghua, Duan Pengfei. Timing of iliac vein stenting in acute lower extremity deep vein thrombosis with severe stenosis of the iliac vein thrombectomy. Chinese Journal of Anatomy and Clinics, 2024, 29(4): 222-227.

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http://www.cjac.com.cn/CN/10.3760/cma.j.cn101202-20230811-00038 或 http://www.cjac.com.cn/CN/Y2024/V29/I4/222

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