| The portal vein system thrombosis (abbreviation Portal Vein Thrombosis, PVT) is a form of deep venous thrombosis disease affecting the hepatic portal vein and further causes portal hypertension and reduction in the blood supply, which leads to a series of portal hypertension symptoms such as hepatosplenomegaly, hypersplenism, ascites and etc. It will jeopardize the patient's health and even life no matter whether it is chronic or acute. With the increasing cases in hepatitis, hepatic cirrhosis and external injury of and the development of diagnosis methods, there is an apparent rise in incidence rate and detection rate of this disease. Therefore, it is significant to detect this disease at its early stage and offer a systematic treatment. By analyzing thirty cases of PVT and/or its branching thrombosis patients in clinical data of our hospital during the last six years, the aim of this article is to explore the value of the new therapy which combines urokinase thrombolysis with percutaneous Transsplenic thrombolysis in treating PVT.Objective:To explore the value of the new therapy which combines urokinase thrombolysis with percutaneous Transsplenic thrombolysis in treating PVT.Methods:All the patients have been diagnosed with PVT by color Doppler sonography, contrast-enhanced computed tomography (CT), or digital subtraction angiography (DSA) examinations. Having excluded active bleeding and hematemesis recently and underwent blood routine, they are treated by hemoglutination time (BT, CT, PT APTT, TT, FIB, INR), renal function and conventional hepatic function inspection. According to the result and clinical manifestation, these patients had been treated by urokinase thrombolysis as well as anticoagulant, fibrinolytic and antiplatelet therapy. Then we observed improvement of the patients'clinical manifestation. For those cases that had not improved or failed to improve satisfactorily after these above treatments, the percutaneous transsplenic thrombolysis is applied. Eventually, the judgment on the recovery or improvement is based on the clinical manifestation and the serum test, color Doppler sonography or the DSA inspectionResults:All the 30 patients are found improved enough to leave hospital after the treatment. There is no case of mortality. According to the tracking interviews, up to now there are no complicating diseases such as upper gastrointestinal hemorrhage, hepatic encephalopathy and etc. The original symptoms such as bellyache, diarrhea, and ascites, have disappeared. 20 cases of patients have returned to their regular work and study. In 2 cases of liver cancer, the patients died because of complicating diseases. In one case the patient died of myocardial infarction one year later. In all the other cases, the patients can get back to normal life to do the daily housework. Color ultrasonic examination in their follow-up examination shows in 4 cases the thrombosis of portal vein had disappeared. In 15 cases, at least 2/3 thrombosis had disappeared. In 5 cases in which the patients without good clotting mechanism cannot be effectively applied with UK, the 1/3 thrombosis of PV have disappeared. In the other 6 cases, after the percutaneous Transsplenic thrombolysis, according to DSA examination, the thrombosis had almost disappeared and the patients'collateral circulation had returned to a good level. Conclusion:Urokinase thrombolysis combined with percutaneous Transsplenic thrombolysis is an effective way of treating PVT.Discussion:PVT has two categories: primary and secondary. The primary PVT has something to do with blood hypercoagulabale state. The secondary PVT has multiple causations, such as portal hypertension, celiac infection, Operation or external injury on abdominal region, blood hypercoagulabale state. Innocent obstruction of PVT has often been found after the lienectomy and portal hypertension. This disease is difficult to be diagnosed at its early stage. It can be easily misjudged as canker, enteritis or other diseases. Even if the diagnosis is precise, its prognosis is not effective. Thus, early diagnosis and early treatment are crucially important.In the case of an adult's portal vein, its major stem is 6 to 8cm long and its inside diameter is 1.0 to 1.25cm. The portal vein is mainly joined by superior mesenteric vein and splenic vein, which collect flood from esophagus inferior segment, gastrointestinal tract, pancreas, spleen. Gallbladder contributes its 70 to 80 percent of blood supply. The branches of the hepatic portal vein include superior mesenteric vein, splenic vein, left gastric vein, and inferior mesenteric vein. Beside those, they include right gastric vein, cystic vein, and paraumbilical veins as well. The beginning and ending of the portal vein are both capillary vessels. In the proximal end is the capillary network of stomach, intestine, pancreas, spleen; in the far end is that of lobules of liver. There is no valvula venosa in the cavity so the blood flow is extremely easy to be affected by the pressure from the far end and produces a counter-flow. There is a very ditissimus collateral circulation between the systems of portal vein and caval vein. Precisely based on the above anatomic structure, When the PVT is formed and only after it affects vena mesenterica and its arcus venosus, there are only apparent symptoms. However, the physical signs are still obscure. Meanwhile, the above anatomic analysis offers a possibility for us to apply percutaneous transsplenic thrombolysis to treat PVT. Thrombolytic therapy has a history over thirty years and has definitely curative effect. In clinical practice, one should strive for the early time to dissolve the primary thrombus completely, for it is the best chance to treat fresh thrombus or incompletely formative thrombus within 3 days (especially within the first 24h)Currently in clinical practice, the common thrombolytic medicine are staphylokinase(SK), urokinase(UK), and(rt-PA). We choose UK as the thrombolytic medicine since it is relatively cheap and without obvious antigenicity. Under the strict control of indication, we keep a close observation to make sure if there is a symptom of haemorrhage (such as if there is mucocutaneous hemorrhage or gingiva hamorrhage). Based on the actual situation, we at times review the hemoglutination time. Under the normal circumstances, the review of hemoglutination time and blood routine will be undertaken each three days, which should control the arrange of Fib of the patients between 0.7 to 1.0 g/L, PT between 15 to 20 seconds, APTT between 1.5 to 2.0 times of the normal value,(INR)at round 2.0, and Pltstay in the normal range. Although these examinations cannon predict whether or not the treatment is successful or whether or not there will be a haemorrhage, when all these values reach beyond these ranges, according to my years of experience of curing thrombolytic therapy, the haemorrhage rate will greatly rise. Therefore, we should correspondingly adjust the dosage. After the thrombolytic therapy, the anticoagulation treatment should continue at least half a year and stay within the INR at around 2.0.For those patients that have an unsatisfactory result after the urokinase thrombolysis treatment, we will use percutaneous Transsplenic thrombolysis. By injecting catheter from femoral artery into splenic artery to mark a signal, we follow this mark and use this filament as a guide in order to inject catheter into splenic vein percutaneous transsplenic pathway. By using the fluoroscopy to mark the signal filament in the splenic artery, we can make sure that the splenic puncture is safe and precise. According to the previous analysis of the anatomic characteristics of portal vein, it is not directly involved into systemic circulation, and its two ends are both capillary networks as well. Therefore, it is safe to break up thrombus with catheter. We will use multiple side-hoes catheter directly to penetrate deeply into the thrombus and to fragment thrombosis mechanically that will increase the contact area of thrombus to the thrombolytic medicine. To the reliquus thrombus and the thrombus attached in venule, we will sequentially use UK to dissolve thrombosis. Because of the direct thrombolysis in the portal vein the density of medicine has been raised dramatically, which correspondingly enhance the effect of thrombolysis. The dosage in the specific part is small, which is safer. The retained vessel can be used to dynamically observe the effect of thromolysis. Due to the short half-life of UK, With the help of the catheter we can consistently instill UK by which the density in the area can be maintained and the better result can be reached. Also, this method has not a high requirement on equipments. It is easy to apply and takes less time if combined with urokinase thrombolysis, which is more suitable for average-level hospitals to apply. Its shortcomings include that during the process of centesis, there might be side effects such as vice-damage, intraperitoneal hemorrhage and so on. Moreover, this treatment is not applicable to the patients who have lienectomy.It will depend on the number of fibrin combined by fibrinolysinum in thrombus whether or not the final result of thrombolysis is successful, which is partially caused by when thrombus is formulated. We believe, for the patient with chronic thrombus, that we should base our treatment mainly on anticoagulant therapy. On the one hand, this method has effect on eliminating the thrombus; on the other hand, it can prevent the new thrombus from forming. Meanwhile, we should be aware that the dosage of UK should gradually decease in order to prevent the thrombus from rebounding. Under the close observation as well as avoiding massive haemorrhage, thrombolysis and anticoagulation should be applied simultaneously. As a result of that, the application will enhance the effect of thrombolysis.All in all, in terms of the treatment of PVT patients, it will have a relatively high value in clinical practice to integrate these above methods.
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