Xue Guan-hua, Huang Xiao-zhong, Ye Meng, Liang Wei, Zhang Hao, Zhang Ji-wei, Zhang Bai-gen
Department of Vascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China.
Department of Vascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China.
Ann Vasc Surg. 2014 May;28(4):957-63. doi: 10.1016/j.avsg.2013.11.012. Epub 2014 Jan 16.
The purpose of this study was to evaluate the safety and effectiveness of catheter-directed thrombolysis (CDT) and stenting in the treatment of iliac vein compression syndrome (IVCS) with acute iliofemoral deep vein thrombosis (DVT).
A retrospective analysis was conducted in 61 patients (36 women, 25 men, age range 32-90 years, mean 64 years) who had IVCS with acute iliofemoral thrmobosis (≤10 days) and were treated by CDT and stenting between June 2006 and August 2011. All patients presented with IVCS with a median duration of 4.1 days and were treated with CDT (urokinase: initial dose of 125,000-250,000 U followed by 20,000-60,000 U/hr) followed by stent placement. Filters were implanted in those patients with existing pulmonary embolism (PE), inferior caval vein thrombosis, or in accordance with the patients' request. The patency, the pressure gradient crossing the stenosis of the iliac vein, both thigh and calf limb circumferences, and complications were assessed before and after CDT and stenting. A Duplex ultrasound was used to perform follow-up examinations at 1 month, 6 months, 1 year, 2 years, 3 years, 4 years, and 5 years after the operation.
Three patients had PE before CDT as assessed by the computed tomography angiography. A total of 28 patients had a filter implanted (25 patients had a Cordis permanent filter and 3 patients had a Braun temporary filter). A total of 68 stents were implanted in 61 patients. Overall, the 1-month, 6-month, 1-year, 2-year, 3-year, and 5-year primary patency rates were 96.7%, 95.1%, 91.8%, 90.2%, 88.5%, and 85.2%, respectively. The pressure gradient crossing the stenosis of the iliac vein decreased significantly after CDT and stenting (7.22 ± 4.64 vs. 1.82 ± 2.78 cm H2O, P < 0.001). The reductions of thigh and calf circumferences were 66.7% (6.19 ± 2.67 vs. 1.98 ± 1.43 cm) and 61.6% (4.36 ± 2.10 vs. 1.46 ± 1.10 cm), respectively. Reocclusion occurred in 7 patients within 1-27 months. Four patients (7%) experienced minor bleeding and were treated successfully with sandbag compression. One patient felt light pain on the left waist after 3 months of stenting. No large hematoma, stent migration, or acute thrombosis complications occurred during the procedure. Two patients died from nonvascular causes during a follow-up of 2-62 months (mean, 31.0 months). Four patients were found with limb swelling and three patients felt heaviness. The incidence rate of postthrombotic syndrome was 11.5% (7/61).
Treatment with CDT for IVCS with acute DVT achieves good patency and vein function after 5 years of follow-up in this study. However, further evidence is required to establish longer term benefits.
本研究旨在评估导管定向溶栓（CDT）及支架置入术治疗伴有急性髂股深静脉血栓形成（DVT）的髂静脉受压综合征（IVCS）的安全性和有效性。
对2006年6月至2011年8月期间接受CDT及支架置入术治疗的61例患者（36例女性，25例男性，年龄范围32 - 90岁，平均64岁）进行回顾性分析。所有患者均患有IVCS，中位病程为4.1天，先接受CDT治疗（尿激酶：初始剂量125,000 - 250,000 U，随后以20,000 - 60,000 U/小时持续给药），之后进行支架置入。对于存在肺栓塞（PE）、下腔静脉血栓形成的患者或根据患者要求植入滤器。在CDT及支架置入前后评估髂静脉通畅情况、跨狭窄段的压力梯度、双侧大腿及小腿周径以及并发症情况。术后1个月、6个月、1年、2年、3年、4年和5年采用双功超声进行随访检查。
计算机断层血管造影评估显示，3例患者在CDT治疗前存在PE。共有28例患者植入了滤器（25例患者植入了Cordis永久性滤器，3例患者植入了Braun临时性滤器）。61例患者共植入了68枚支架。总体而言，1个月、6个月、1年、2年、3年和5年的原发性通畅率分别为96.7%、95.1%、91.8%、90.2%、88.5%和85.2%。CDT及支架置入后，跨髂静脉狭窄段的压力梯度显著降低（7.22±4.64 vs. 1.82±2.78 cm H₂O，P < 0.001）。大腿和小腿周径分别减小了66.7%（6.19±2.67 vs. 1.98±1.43 cm）和61.6%（4.36±2.10 vs. 1.46±1.10 cm）。7例患者在1 - 27个月内发生再闭塞。4例患者（7%）出现轻微出血，经沙袋压迫成功治疗。1例患者在支架置入3个月后左侧腰部出现轻度疼痛。术中未发生大出血、支架移位或急性血栓形成并发症。2例患者在2 - 62个月（平均31.0个月）的随访期间死于非血管性原因。4例患者出现肢体肿胀，3例患者感觉沉重。血栓形成后综合征的发生率为11.5%（7/61）。
本研究中，采用CDT治疗伴有急性DVT的IVCS，随访5年后获得了良好的通畅率及静脉功能。然而，需要更多证据来证实其长期获益情况。
