Rao Atul S, Konig Gerhardt, Leers Steven A, Cho Jae, Rhee Robert Y, Makaroun Michel S, Chaer Rabih A
Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
J Vasc Surg. 2009 Nov;50(5):1092-8. doi: 10.1016/j.jvs.2009.06.050. Epub 2009 Sep 26.
Venous lysis is usually reserved for symptomatic patients with acute deep vein thrombosis (DVT) and low risk for bleeding. This study reports the use of pharmacomechanical thrombectomy (PMT) in patients with contraindications to thrombolysis.
A retrospective review of all patients with symptomatic DVT treated between 2007 and 2008 with PMT was performed. All patients were treated by a combination of local tissue plasminogen activator (tPA) with the Angiojet (Possis Medical, Minneapolis, Minn) or Trellis device (Bacchus Vascular, Santa Clara, Calif). Catheter-directed lysis was used sparingly.
Forty-three patients (mean age, 48.4 +/- 16.6 years) presented with symptoms averaging 13.6 +/- 9.6 days in duration. Nineteen (44%) had symptoms for >14 days, and 15 (35%) had a high risk for bleeding. Symptomatic subclavian thrombosis occurred in eight (19%), and 35 (81%) presented with disabling lower extremity DVT (4 phlegmasia) despite anticoagulation. Fifteen patients had a thrombosed indwelling permanent filter. Sixty-three percent were treated in one session, but 16 patients required a lytic infusion after suboptimal PMT. Iliac stenting was required in 35% of limbs treated. Successful lysis (>50%) was achieved in 95% of patients and symptom resolution in 93%. All patients became ambulatory with no or minimal limitation. There were no major systemic bleeding complications, but access site hematoma occurred in two patients and worsening of pre-existing rectus sheath hematoma requiring transfusion occurred in another two. Limb salvage was maintained in 100% of patients who presented with phlegmasia. Mean follow-up was 5.0 +/- 4.8 months. Freedom from DVT recurrence and reintervention was 95% at 9 months by life-table analysis.
PMT can be safely and effectively used for subacute iliocaval and iliofemoral DVT and in patients with contraindications for lytic therapy, resulting in improved functional outcomes relative to their debilitated state before the procedure.
静脉溶栓通常用于有症状的急性深静脉血栓形成（DVT）且出血风险低的患者。本研究报告了在有溶栓禁忌证的患者中使用药物机械性血栓切除术（PMT）的情况。
对2007年至2008年间接受PMT治疗的所有有症状DVT患者进行回顾性分析。所有患者均采用局部组织纤溶酶原激活剂（tPA）联合Angiojet（Possis Medical，明尼阿波利斯，明尼苏达州）或Trellis装置（Bacchus Vascular，圣克拉拉，加利福尼亚州）进行治疗。导管定向溶栓使用较少。
43例患者（平均年龄48.4±16.6岁），症状持续时间平均为13.6±9.6天。19例（44%）症状持续时间>14天，15例（35%）出血风险高。8例（19%）出现有症状的锁骨下血栓形成，35例（81%）尽管接受了抗凝治疗仍出现导致功能障碍的下肢DVT（4例股青肿）。15例患者有留置的永久性滤器血栓形成。63%的患者在一次治疗中完成，16例患者在PMT效果欠佳后需要进行溶栓输注。35%接受治疗的肢体需要进行髂静脉支架置入术。95%的患者实现了成功溶栓（>50%），93%的患者症状得到缓解。所有患者均可自由活动，无或仅有轻微活动受限。无严重全身性出血并发症，但2例患者出现穿刺部位血肿，另2例患者原有腹直肌鞘血肿加重，需要输血。100%出现股青肿的患者肢体得以保留。平均随访时间为5.0±4.8个月。通过生命表分析，9个月时DVT复发和再次干预的自由度为95%。
PMT可安全有效地用于亚急性髂股静脉和髂总静脉DVT以及有溶栓治疗禁忌证的患者，相对于术前虚弱状态，可改善功能结局。
