摘要
目前对于高危急性肺栓塞(PE)患者的治疗策略均存在增加包括颅内出血等严重出血事件的风险。AngioJet机械性血栓抽吸术(ART)在高压脉冲注射溶栓药溶解、粉碎血栓的同时,允许在段级肺动脉分支上进行抽吸,对于急性PE理论上是一种有效的措施,但其安全性需进一步评估。本研究回顾3例采用ART治疗急性PE的患者的病例资料,分析ART治疗急性PE的安全性与有效性。
ART手术成功率100%,所有患者ART后收缩期肺动脉压、三尖瓣环收缩期位移、右室内径/左室内径、血氧饱和度、B型利钠肽水平均较术前得到明显改善。3例患者均出现一过性心动过缓,对症治疗后均缓解。所有患者围术期未出现严重手术相关并发症。1例患者因“冠心病、感染中毒性休克、缺血缺氧性脑病”于术后36 d死亡,2例随访3个月,期间患者肺动脉压力、右心功能均得到明显恢复。
静脉血栓栓塞症(venous thromboembolism,VTE)临床表现为深静脉血栓形成(deep vein thrombosis,DVT)和(或)肺栓塞(pulmonary embolism,PE),是全球第三大常见的急性心血管综合征,仅次于心肌梗死和脑卒
近年出现的AngioJet机械性血栓抽吸术(AngioJet rheolytic thrombectomy,ART)是一种依据伯努利原理,在高压脉冲注射溶栓药溶解、粉碎血栓的同时,导管头端负压区机械性抽吸血栓的技术,AngioJet的特殊设计允许在段级肺动脉分支上进行抽吸,对于急性PE似乎是一种有效的措施,但其安全性需进一步探
患者1 女性,62岁,因“活动后喘憋2周,加重1 h”入院。入院血压(blood pressure,BP):82/67 mmHg(1 mmHg=0.133 kPa),呼吸频率(respiratory rate,RR):23次/min,心率(heart rate,HR):110次/min,血氧饱和度:91%。化验结果:D-二聚体(D-Dimer):205 920 ng/mL(参考值:0~243 ng/mL),pH:7.483(参考值:7.35~7.45),二氧化碳分压(pCO2):31.8 mmHg(参考值:35~48 mmHg,1 mmHg=0.133 kPa),氧分压(pO2):124 mmHg(参考值:83~108 mmHg),乳酸(lactic acid,Lac):3.4 mmol/L(参考值:0.5~1.6 mmol/L),肌酸激酶-MB同工酶(creatine kinase,CK-MB):16.6 ng/mL(参考值:0.6~6.3 ng/mL),心肌肌钙蛋白I(cardiac troponin,hsTnI):1 933.1 pg/mL(参考值:0~19.8 pg/mL),乳酸脱氢酶(lactate dehydrogenase,LDH):19 404 U/L(参考值:120~250 U/L),B型利钠肽(B-type natriuretic peptide,BNP):649 pg/mL(参考值:0~100 pg/mL)。检查结果:双下肢深浅静脉彩超:双侧股浅、腘、胫后及小腿肌间静脉血栓形成,超声心动图:收缩期肺动脉压(systolic pulmonary arterial pressure,SPAP):83 mmHg,三尖瓣环收缩期位移(tricuspid annular plane systolic excursion,TAPSE):11 mm;肺动脉计算机断层血管造影术(computed tomography angiography,CTA):双侧肺动脉及叶、段分支内多发充盈缺损。简化肺栓塞严重度指数(simplified pulmonary embolism severity index,sPESI)评分2分,PE危险程度分层为高危,入院后予肝素泵入,急诊行AngioJet机械性血栓抽吸术+下腔静脉滤器置入术,手术过程顺利,术后造影可见血栓大部分清除,肺血流灌注明显改善,术中出现一过性心率过缓,停止操作后恢复。术后患者自觉喘憋症状消失,BP:143/82 mmHg,RR:23次/min,HR:102次/min,血氧饱和度100%。化验结果:D-Dimer:12 031 ng/mL,pH:7.432,pCO2:35.8 mmHg,pO2:145 mmHg,Lac:2.5 mmol/L,CK-MB:2.9 ng/mL,hsTnI:122.6 pg/mL,LDH:1 148 U/L,BNP:84 pg/mL。检查结果:超声心动图SPAP:38 mmHg,TAPSE:18 mm,后顺利出院。术后3个月复查,无喘憋症状,活动耐量可,超声心动图:SPAP:40 mmHg,TAPSE:20 mm。
患者2 男性,48岁,因“活动后胸闷、喘憋4 d”入院。入院BP:116/90 mmHg,RR:24次/分,HR:129次/min,氧饱和度:93%。化验结果:D-Dimer:2 397 ng/mL,pH:7.495,pCO2:25.5 mmHg,pO2:80.3 mmHg,Lac:2.0 mmol/L,CK-MB:5.7 ng/mL,hsTnI:70 pg/mL,LDH:264 U/L,BNP:568 pg/mL。检查结果:双下肢深浅静脉彩超:左侧股浅中远段、腘、胫后及小腿肌间静脉血栓形成,超声心动图SPAP:88 mmHg,TAPSE:14 mm;肺动脉CTA:多发肺栓塞,累及左右肺动脉主干及其分支。sPESI评分1分,肺栓塞危险程度分层为中高危,入院后予肝素泵入,效果不佳,复查D-Dimer危急值:24 139 ng/mL(0~243 ng/mL),遂行AngioJet机械性血栓抽吸术+下腔静脉滤器置入术,手术过程中血栓抽吸效果不佳,造影可见血栓未明显清除,考虑亚急性血栓,遂予局部低剂量rt-PA 18 mg溶栓,等待溶栓药局部作用30 min,再次抽吸血栓后造影可见肺血流灌注明显改善,术中出现一过性心率过缓,停止操作后恢复。术后患者自觉喘憋症状好转,BP:122/78 mmHg,RR:25次/min,HR:105次/min,血氧饱和度96%。化验结果:D-Dimer:1 043 ng/mL,pH:7.369,pCO2:35.5 mmHg,pO2:83 mmHg,Lac:1.5 mmol/L,CK-MB:0.9 ng/mL,hsTnI:2.9 pg/mL, BNP:59 pg/mL。检查结果:超声心动图:SPAP:44 mmHg,TAPSE:19 mm,后顺利出院。术后3个月复查,无喘憋症状,活动耐量可,超声心动图:无肺动脉高压,TAPSE:19 mm。
患者3 女性,47岁,冠脉搭桥术后第9天突发心率、血压下降,意识丧失,BP:53/19 mmHg,HR:39次/min,RR:15~30次/min,氧饱和度86%,化验结果:D-Dimer:7 996 ng/mL,pH:7.093,pCO2:57.6 mmHg,pO2:523 mmHg,Lac:24.0 mmol/L,CK-MB:39.4 ng/mL,hsTnI:14 043.0 pg/mL,LDH:2 474 U/L,BNP:1 113.0 pg/mL。予胸外按压复苏同时急查超声心动图:右心扩大,肺动脉主干疑似血栓形成,SPAP:89 mmHg,TAPSE:9 mm,双下肢深浅静脉彩超:双下肢静脉未见明显阻塞;体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)置入后患者恢复自主心率,但无自主呼吸,予肝素泵入,急诊行AngioJet机械性血栓抽吸术,术中明确左侧肺动脉主干栓塞,右侧肺动脉一级分支栓塞,手术过程顺利,术后造影可见血栓大部分清除,肺血流灌注明显改善,术中恢复自主呼吸,出现一过性心率过缓,停止操作后恢复。术后患者昏迷状态,BP:118/89 mmHg,RR:15次/min,HR:75次/min,血氧饱和度95%。化验结果:D-Dimer:1 837 ng/mL,pH:7.566,pCO2:38.1 mmHg,pO2:63 mmHg,Lac:4.8 mmol/L,CK-MB:12 ng/mL,hsTnI:2 587.7 pg/mL,BNP:509 pg/mL。检查结果:超声心动图SPAP:33 mmHg,TAPSE:16 mm。术后第36天,患者因“冠心病、感染中毒性休克、缺血缺氧性脑病”死亡。
2例患者行非插管全麻,1例患者行气管插管全麻,麻醉满意后,穿刺右侧颈内静脉,置入6-F鞘管,经鞘引入MPA导管配合超滑导丝至下腔静脉下段,于肾静脉开口下方下腔静脉内放置Cordis滤器,造影可见滤器位置良好(患者1及患者2);改为8-F长鞘管送入右心室,MPA导管配合超滑导丝选择入主肺动脉内,根据造影及术前肺动脉CTA结果定位于栓塞部位,送入Boston AngioJet 6-F血栓抽吸导管,调节抽栓模式同一位置抽吸3次后造影,若血栓清除不佳,可调节为喷药模式,于同侧肺动脉主干局部喷洒rtPA后等待30 min(患者2),再次调节为抽吸模式在血栓处反复抽吸,每次抽吸时间<10 s,抽吸完成后再次行造影观察肺动脉情况,压迫穿刺点止血。所有患者围术期未出现严重手术相关并发症(无法控制心动过缓、停搏、急性肾功能不全、高钾血症等);随访3个月结果提示2例患者肺动脉压力、右心功能均得到明显恢复。
PE具有起病隐匿、发展迅速、病死率高等特点,已成为全球第三大致死性心血管疾病,新近国际注册登记研
外科肺动脉血栓切除术是一种有效的措施,但有研究显示其病死率高达19
在一项对接受ART治疗的PE患者进行的早期荟萃分
本研究3例患者术前BNP、hsTnI、肺动脉压力均显著升高,提示右心功能受损严重,影像学提示肺动脉栓塞,从而导致肺动脉压力增高,右心后负荷增加,导致功能受损,2例患者同时出现左心功能受限,心排血量降低,体循环低血压的情况,因此,迅速减少血栓负荷、降低肺动脉压力、恢复肺循环及体循环灌注是降低病死率、改善预后的关键。3例患者中,患者1及患者3属于急性高危PE,患者2属于急性中高危PE抗凝效果不佳,3例患者ART技术成功率100%,术后肺动脉压力、右左心室内径比值、血氧饱和度均得到有效改善,肺循环及体循环灌注恢复,生命体征平稳。2例患者术前下肢静脉彩超提示血栓形成,术中放置下腔静脉滤器。所有患者术后血流动力学和呼吸状态方面取得了明显改善,心率、血压和氧合恢复正常,且手术耐受性良好,无严重并发症,虽然出现手术相关的缓慢性心律失常,但这些心律失常是自限性的,不需要特殊治疗。同时3个月随访结果提示无CTEPH发生。
ART常见并发症包括心动过缓、血管损伤、高钾血症、血红蛋白尿
本研究有一定的局限性,此为单中心回顾性研究,且样本量较少,可能会造成偏倚,且随访时间较短,无法证实其远期疗效,也未与其他治疗方式效果进行比较。在未来的研究中,应进行前瞻性研究,扩大样本量且延长随访周期,与CDT等其他急性PE介入治疗手段进行对比,以期证实ART治疗急性PE的安全性及有效性。
综上所述,ART对于急性高危和中高危PE来说可能是安全有效的,为了减少ART相关并发症,应在术中动作轻柔,严格把控抽吸时间,操作过程中密切关注患者血压心率变化,必要时吸栓后追加使用低剂量溶栓药物,同时围术期充分水化,减少造影剂应用,以减少肾脏负担,避免急性肾功能不全发生。
利益冲突
所有作者均声明不存在利益冲突。
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