1 Department of Radiology, Division of Interventional Radiology, University of Illinois Hospital and Health Sciences System, 1740 W Taylor St, MC 931, Chicago, IL 60612.
AJR Am J Roentgenol. 2014 Jun;202(6):1355-60. doi: 10.2214/AJR.13.11366.
The purpose of this study was to assess the efficacy and safety of flow-directed catheter thrombolysis for treatment of submassive pulmonary embolism (PE).
In this single-institution retrospective study, 19 patients (nine men and 10 women; mean age [± SD], 54 ± 13 years) with submassive PE underwent catheter-directed thrombolysis between 2009 and 2013. Presenting symptoms included dyspnea in 18 of 19 (95%) cases. Submassive PE was diagnosed by pulmonary CT arteriography and right ventricular strain. PE was bilateral in 17 of 19 (89%) and unilateral in two of 19 (11%) cases. Thrombolysis was performed via a pulmonary artery (PA) catheter infusing 0.5- 1.0 mg alteplase per hour and was continued to complete or near complete clot dissolution with reduction in PA pressure. IV systemic heparin was administered. Measured outcomes included procedural success, PA pressure reduction, clinical success, survival, and adverse events.
Procedural success, defined as successful PA catheter placement, fibrinolytic agent delivery, PA pressure reduction, and achievement of complete or near complete clot dissolution, was achieved in 18 of 19 (95%) cases. Thrombolysis required 57 ± 31 mg of alteplase administered over 89 ± 32 hours. Initial and final PA pressures were 30 ± 10 mm Hg and 20 ± 8 mm Hg (p < 0.001). All 18 (100%) technically successful cases achieved clinical success because all patients experienced symptomatic improvement. Eighteen of 19 (95%) patients survived to hospital discharge; 18 of 19 (95%) and 15 of 16 (94%) patients had documented 1-month and 3-month survival. One fatal case of intracranial hemorrhage was attributed to supratherapeutic anticoagulation because normal fibrinogen levels did not suggest remote fibrinolysis; procedural success was not achieved in this case because of early thrombolysis termination. No other complications were encountered.
Among a small patient cohort, flow-directed catheter thrombolysis with alteplase effectively dissolved submassive PE and reduced PA pressure. Postprocedure short-term survival was high, and patients undergoing thrombolysis required close observation for bleeding events.
本研究旨在评估血流导向导管溶栓治疗亚大块肺栓塞（PE）的疗效和安全性。
本研究为单中心回顾性研究，2009 年至 2013 年期间，19 例（9 例男性，10 例女性；平均年龄[±标准差]，54±13 岁）亚大块 PE 患者接受了导管定向溶栓治疗。19 例患者均存在呼吸困难（18/19，95%）的表现。通过肺动脉 CT 血管造影和右心室应变诊断为亚大块 PE。19 例患者中 17 例为双侧病变（17/19，89%），2 例为单侧病变（2/19，11%）。通过肺动脉（PA）导管输注 0.5-1.0mg 阿替普酶/小时进行溶栓，持续溶栓直至 PA 压力降低并完全或接近完全溶解血栓。静脉内给予全身肝素。观察指标包括手术成功率、PA 压力降低、临床成功率、生存率和不良事件。
19 例患者中，18 例（95%）成功完成手术，包括 PA 导管放置、纤维蛋白溶解剂输送、PA 压力降低以及达到完全或接近完全血栓溶解。18 例患者接受了 57±31mg 的阿替普酶溶栓治疗，时间为 89±32 小时。初始和最终的 PA 压力分别为 30±10mmHg 和 20±8mmHg（p<0.001）。所有 18 例（100%）技术成功的患者均获得了临床成功，因为所有患者的症状均得到改善。19 例患者中，18 例（95%）存活至出院，19 例患者中 18 例（95%）和 16 例患者中的 15 例（94%）在 1 个月和 3 个月时的生存率均有记录。1 例颅内出血死亡病例归因于抗凝过度治疗，因为正常的纤维蛋白原水平并未提示有远处纤维蛋白溶解；由于早期溶栓终止，该例患者未达到手术成功。未发生其他并发症。
在小样本患者队列中，阿替普酶血流导向导管溶栓有效溶解了亚大块 PE 并降低了 PA 压力。术后短期生存率较高，接受溶栓治疗的患者需要密切观察出血事件。
