| BackgroundDeep venous thrombosis(DVT)is a common peripheral vascular disease,and its pulmonary embolism(PE)is a two-part of the different stages of venous thromboembolism(VTE).In recent years,the incidence and fatality rate of VTE have increased year by year,and it has become the third leading cause of death in cardiopulmonary vascular disease worldwide,second only to the heart of myocardial infarction and stroke.In addition,the occurrence of complications,especially the post-thrombosis syndrome(PTS),influencing on patients’ quality of life seriously.The target in the clinical treatment of DVT is to prevent the spread of thrombus and the occurrence of fatal PE and PTS.There are many ways to treat DVT,but the most fundamental means is anticoagulant.Anticoagulation has good effect on preventing the spread and recurrence of thrombus,but it is not possible to reduce the thrombus burden and clinical symptoms quickly.There are approximately 40%of the patients will evolve into PTS with different symptoms within two years of the onset of DVT,it has high incidence of iliac venous thrombosis and associated with iliac vein stenosis especially,and there will become refractory ulcers,venous claudication and so on in some severe cases.With the development and progress of endovascular interventional technique,various clot removal techniques have been applied to the clinic and become the most basic treatment of DVT.Catheter directed thrombolysis(CDT)and percutaneous mechanical thrombectomy(PMT)are the most common used techniques in current clinical and each has its own characteristics.There are many studies on CDT and PMT for DVT in recent years,but the existing evidence is still insufficient to support PMT or CDT which is more conducive to the treatment for DVT,and there has no evaluation to make the final conclusive statement until now.The purpose of this study was based on the accumulating evidence combined with the actual situation in our department to evaluate the efficacy and safety of PMT and CDT in the treatment of acute iliofemoral venous thrombosis,and to discuss the related problems in the process of the treatment.Most of the left lower extremity DVT have iliac vein stenosis.After PMT,if there remaining stenosis in the iliac vein more than 50%should under angioplasty,and the inferior vena cava filter can be retrieved at the same time or in the two stages if the rate of thrombus clearance is over 90%.The purpose of this study will investigate the advantages and disadvantages of multiple interventional models combined with different intravenous approaches in the treatment of left lower extremity DVT.The AngioJet system can cause hemoglobinuria due to intravascular hemolysis in the process of thrombectomy,and severe cases may suffer renal impairment.This study intends to investigate the causes and preventive measures of hemoglobinuria after PMT.Part onePercutaneous AngioJet mechanical thrombectomy in the management of acute lower extremity deep venous thrombosisObjectiveTo investigate the efficacy and safety of percutaneous AngioJet thrombectomy in the management of acute lower extremity deep venous thrombosis.MethodA total of 71 patients presenting with acute DVT were enrolled in our department from November 2015 to February 2017 and divided into group PMT(group A,n=34)and group CDT(group B,n=37)according to their own choice.All the venous thrombus were confirmed by color Doppler ultrasound and verified by DSA angiography during operation.Then the inferior vena cava filter was implanted conventional in all patients prior to the percutaneous AngioJet mechanical thrombectomy(PMT).7 cases in group A underwent local thrombolysis(100 ml of normal saline + 250000 U of urokinase)for approximately 15 minutes before PMT,and all patients treated with thrombolytic agent(60ml of normal saline + 250 000 U of urokinase by microinfusion pump in 60 min,two times a day)after surgery through the limb dorsal venous catheter or sheath for 1～3 days.In group B,the thrombolytic agent(50 ml of normal saline + 250 000 U of urokinase,manual pulse injection in 10 min)was manually injected through catheter after the CDT catheter was inserted into the thrombus for 5～7 days.We will evaluate the thrombus clearance rate every other day by DSA angiography,those patients with remaining stenosis of iliac vein more than 50%underwen balloon angioplasty or stent implantation and the inferior vena cava filter retrieved at the same operation time if the thrombus was confirmed to be dissolved more than 90%or within half a month.The patency rate of iliofemoral venous was assessed by color Doppler ultrasound at least the first,third,sixth and twelfth month after discharge.After the year,the patients should be reviewed every six months or set up the appointments by call.All patients should take oral anticoagulant therapy for at least half a year,and return to the hospital every month during the period of taking anticoagulant.The patients with stent implantation should take oral Bayaspirin for at least a year.Result1.In group A,34 patients were successfully treated by percutaneous AngioJet mechanical thrombectomy.Angiography after the thrombectomy procedure showed the thrombus clearance rates reached grade Ⅲ in 23 patients,grade Ⅱ in 9 patients and grade I in 2 patients.A total of 26 patients who had iliac vein compression syndrome(IVCS)underwent PTA and 22 of which performed stent implantation.The swelling symptoms of the 27 patients were significantly relieved while 7 patients had mild swelling after those procedures.One patient had edema recurrence on the third day after the operation due to the severe iliac vein stenosis had not angioplasty and the angiography showed iliac vein completely occluded.One stent thrombosis occurred within 5 days after implantation that the stent had not completely covered the stricture iliofemoral vein.One patient with mild stenosis of the iliac vein suffered from limb swelling recurrence owing to take warfarin anticoagulation was not sufficient,and the symptom disappeared after stent implantation during the sixth-month follow-up period.No thrombus recurrences were found in the previously affected vessels of other patients.All the patients were followed up(13.71 ± 3.66)months.22 patients had no affected limbs swelling,11 patients had mild swelling and 1 patient had severe swelling during follow-up.2.In group B,18 limbs fulfilled grade Ⅲ thrombus clearance criteria while 13 limbs reached grade Ⅱ and 6 limbs reached grade Ⅰ.16 patients who had IVCS underwent PTA and stent implantation.The swelling symptoms of the 23 patients were significantly relieved while 14 patients had mild swelling after those procedures.Three patients were found iliac vein total occlusion by angiography within 2 weeks that the stenosis was more than 50%and did not perform angioplasty after thrombolysis.Six patients suffered from limb swelling recurrence during the follow-up,color ultrasound indicated that the iliac vein were incomplete obstruction and only a small amount of collateral circulation was found,and the symptom in two of them disappeared after stent implantation.The remaining patients had satisfactory results.All patients were followed up(15.05±3.10)months.17 patients had no swelling of the affected limbs,16 patients had mild swelling and 4 patients had severe swelling during follow-up.3.The thrombus clearance rates[(87.09±19.00)%vs(74.77±24.30)%]and the swelling ratio[(74.14±15.15)%vs(63.58±17.75)%and(67.87±17.19)%vs(50.69±24.69)%,in thigh and calf respectively]in group A were significantly higher than that in group B(P<0.05).At the last follow-up of the two groups,the Villalta PTS scale were(4.62±2.02)and(7.32±2.63)in PMT and CDT groups respectively(P<0.05).The inferior vena cava filter of all the patients exclude three were successfully retrieved,and the filter persist in the body with a mean time of 9.25±2.78 days(range:3 to 14 days)after surgery.The time of filters remains in the body in PMT group was significantly shorter than the CDT group[(7.65±3.26)days vs(10.54 ±1.77)days,P<0.05].The total amount of urokinase with a mean dosage of 945 600±461 900 U(range:250 000 to 1 700 000 U)and 2 837 800±421 700 U(range:2 250 000 to 2 500 000 U)in PMT and CDT groups respectively(P<0.001).The thrombolysis time on average 1.97 ± 0.83 days(range:1 to 3 days)and 5.86±0.82 days(range:5 to 7 days)in PMT and CDT groups respectively(P<0.001).The total hospital stay with a mean time of 8.85±3.13 days(range:4 to 15 days)and 12.43±1.74 days(range:9 to 15 days)in grop A and group B respectively(P<0.05).The total cost in group A with a mean 88 300±15 300 yuan(range:55 000 to 100 000 yuan)and 58 900±17 500 yuan(range:33 000 to 78 000 yuan)in grop A and group B respectively(P>0.05).There were no major hemorrhage,death,serious PE and other complications associated with surgery in both groups.Conclusion1.Whether CDT or PMT are effective for removing fresh thrombus,it is as much as possible to choose the acute phase thrombus within 14 days,but PMT is obviously better than CDT in the primary outcome.2.If the iliac vein with CDT or PMT treatment remaining stenosis>50%after PTA,we should implant stent at the same operation phase or the second phase in the hospitalization time.3.It is more efficiency if rheolytic AngioJet mechanical thrombectomy combine with CDT or local thrombolysis than PMT alone.4.Rheolytic AngioJet mechanical thrombectomy is safe and effective for acute DVT,this technique can significantly shorter the thrombolytic time,the time of inferior vena cava filter remain in the body,treatment duration and lower lytic doses.and has good short outcomes.Part TwoAnalysis of different intravenous approach of PMT combined with multiple interventional models in treatment of acute left deep venous thrombosisObjectiveTo investigate the advantages and disadvantages and the value of AngioJet thrombectomy combined with multiple interventional models in treating acute left deep venous thrombosis(DVT).MethodsThe clinical data and the imaging materials of 28 patients suffering from acute DVT in the left extremity were analyzed,and the interventional treatment strategies were discussed,the efficacy and complications of three different venous ways of the femoral vein,the popliteal vein and the anterior tibial vein were observed.ResultsTen patients were treated with PMT through the anterior tibial vein,12 patients by popliteal vein and 6 patients by the healthy side femoral vein.There was no significant difference in the rate of thrombus clearance(χ2=0.253,P=0.881),the swelling ratio(χ2=2.406,P=0.300 and χ2=0.757,P=0.685,in thigh and calf respectively)and complications(χ2=2.000,P=0.368)between three kinds of venous access,but the perimeter margin of the affected and nomoal extremities were statistically significant difference between postoperative and preoperative among three approachs in thigh and calf respectively(P<0.05).The length of hospital stay were[(11.00±3.52)vs(9.75±2.60)vs(6.0010.94),χ2=10.213,P=0.001]respectively,and the anterior tibial vein was significantly shorten the hospitalization time than the other two routes.ConclusionThe three vein approaches for DVT treated with AngioJet system is effective and can achieve better thrombus clearance,combined with multiple interventional models can shorten the overall treatment time.All of the three punctured ways have their own characteristics,so we should accord to the situations of the patients to choose the befitting vein approach.Part ThreeCauses of hemoglobinuria in Patients with deep vein thrombosis underwent rheolytic thrombectomyObjectiveThe objective of this study was to investigate factors influencing the occurrence of hemoglobinuria in patients with deep vein thrombosis(DVT)during percutaneous mechanical thrombectomy(PMT)and to explore corresponding preventive measures.MethodsThe present study analyzed the clinical data of 30 patients with DVT who underwent PMT in our hospital.In addition,the study examined the differences in duration of thromboaspiration and thrombus load between the group of patients who experienced hemoglobinuria(group A)and the group of patients who did not suffer hemoglobinuria(group B).ResultsMacroscopic hemoglobinuria occurred in 18 of the 30 patients during PMT.The incidence of hemoglobinuria was 60.00%(18/30).In all cases of intraoperative hemoglobinuria,the color of the urine returned to normal within 24 h after the PMT.None of the patients suffered renal impairment.Moreover,no statistically significant differences were found between the group that experienced intraoperative hemoglobinuria and the group that did not suffer hemoglobinuria in duration of thromboaspiration[(325.22± 113.98)s vs(308.92±104.89)s,t=0.396,P=0.695]or thrombus load(χ2=0.023,P=0.880).ConclusionThe factors that influenced the occurrence of hemoglobinuria during rheolytic thrombectomy mainly duration of thromboaspiration,thrombus load.However,the occurrence of hemoglobinuria was also affected by the interaction between these factors.Furthermore,we speculate that control of thromboaspiration duration and administration of perioperative symptomatic treatment may reduce the incidence of hemoglobinuria. |
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