| ObjectiveThis study observes the impact and the corresponding safety of the thrombolytic effect on different courses of disease,as well as varying dosages and modes of urokinase administration in catheter-directed thrombolysis(CDT)treatment.And the second section evaluates the benefit of stenting the iliac vein in patients with residual iliac vein stenosis treated with CDT for acute iliofemoral deep venous thrombosis(DVT).MethodsPatients admitted with acute deep vein thrombosis(DVT)to our department from January 2014 to January 2018 were included in this prospective clinical study.Urokinase CDT treatment was conducted,and patient grouping was determined according to thrombolytic dosages administered and modes of urokinase administration.Patients with varying dosages were randomly enrolled in groups A,B,C,D.Groups A were administered urokinase 600,000 U/d,groups B were administered 800,000 U/d,Groups C were administered 800,000 U/d,groups D were administered 1000,000 U/d.Each group was divided into two subgroups according to the modes of administration of urokinase.Rapid injection was used in Groups A1,B1,C1,and D1;24-hour continuous pumping was used in Groups A2,B2,C2 and D2.Comparison of the thrombolysis rate among each group at postoperative day 2,3,and 4,the time of the clearance of trunk thrombus,Grade classification,limb edema reduction rate,and the incidence of complications after thrombosis dissolution are evaluated in this paper.The second part is the midterm follow-up of the deep venous patency rate of the affected limbs and the improvement of clinical symptoms after stenting or not in the treatment of residual iliac vein stenosis(>50%)after acute lower extremity DVT treated with CDT.From Dec.2008 to Dec.2012,patients with a first-time acute lower extremity deep venous thrombosis were treated with catheter-directed thrombolysis.After the fresh thrombolysis was performed,patients with residual iliac vein stenosis(>50%)were randomly divided into two groups.One group was treated with pereutaneous transluminal angioplasty(PTA)and stent implantation(CDT+Stent group),and the other group was not treated(CDT Alone Group).After that both groups received strict anticoagulant therapy.The treatment plan was based on the "Guide to the diagnosis and treatment of deep vein formation"(the third edition)recommended by the Chinese Medical Association’s Vascular Surgery Group.Follow-up telephone and out-patient follow-up visits were conducted at the 6th,12th,24th,and 36th month after discharge.Deep venous ultrasonography and digital subtraction angiography(DSA)were used to evaluate the fluency of deep venous blood in affected limbs.The CEAP classification,VCSS,and CIVIQ scores were used to assess the improvement of clinical symptoms(including observation of lower limb edema,skin pigmentation,and presence or absence of superficial varices and ulcers).ResultsThe first part of the study showed that 220 patients with acute lower extremity DVT were treated with CDT.All of them underwent CDT treatment successfully.There were 88 male cases and 132 female cases with an average age of 53.69 years.There were 157 cases of left lower limbs,61 cases of right lower extremity,2 cases of double lower limbs,56 cases of central thrombus and 164 cases of mixed type.The thrombolysis rates,main thrombectomy time,and swelling rate of the main limbs on the second,third,and fourth days after CDT were compared according to the dose of urokinase.The difference was statistically significant(p<0.05)between the groups(A vs B,B vs C,A vs C,A vs D,B vs D).The difference between group C and group D was not significant(P>0.05),but the results in group C were better than those in group D.In accordance with the urokinase pumping method(A1 vs A2,B1 vs.B2,C1 vs C2,D1 vs D2),there was no significant difference(p>0.05).Compared with Grade classification results,group C was superior to group D,followed by group B and group A.No serious bleeding complications occurred in this group.There were 16 cases(7.3%)with minor bleeding complications.The incidence in group A was 3.8%.In group B and group C were 5.4%.In group D it was 14.3%.The incidence of bleeding in group D was significantly higher than in other groups.Six patients(2.7%)developed mild pulmonary embolism(PE)symptoms and no fatal PE occurred.There was no significant difference between groups A and B.Both in group C and D it was 3.6%.It’s higher than that in groups A and B.The occurrence of catheter-related infection occurred in 4 patients(1.8%).There was no significant difference between groups A,B,C,and D.After thrombolytic therapy and reduction of anticoagulant doses,these complications were cured.The second part of the study shows that from Dec.2008 to Dec.2012,66 patients met the follow-up conditions,including 26 males and 40 females.The average age was 50.85 years.27 patients were treated with iliac vein stents(CDT+stent group),and 39 patients in the control group were not placed iliac vein stents(simple CDT group).The results of two groups of deep venous patency in the mid-term follow-up showed:74.07%in the CDT+stent group and 46.59%in the control group.The comparison of CEAP grades and VCSS scores showed a significant difference between the CDT+ stent group and the simple CDT group.The CIVIQ score after discharge in the CDT+ Stent group was sigiificantly higher than the CDT Alone group.ConclusionThe thrombolytic effect in CDT treatment is closely related to the dose of urokinase,and group B is superior to group A.Group C is superior to group A,group B and group D,and the incidence of complications is not significantly improved.The results of group D were superior to that of group A and group B,but the incidence of bleeding complications was significantly higher than that in the three groups of A,B and C.Therefore,the thrombolytic effect of the group C is the best,and this dose can be recommended in the treatment of CDT.The two modes of urokinase administration were not statistically significant in the efficiency of thromboclasis,the time of the clearance of trunk thrombus,and the limb edema reduction rate.Placement of an iliac vein stent in patients with residual iliac vein stenosis after CDT for acute lower extremity DVT increases iliac vein patency and improves clinical symptoms,health-related quality of life at mid-term follow-up compared to patients treated with CDT alone. |
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