经外周静脉系统溶栓与DSA引导下介入综合疗法治疗急性致死性肺栓塞的临床对比研究

发布时间：2018-08-25 18:45

【摘要】：目的:探讨DSA引导下经导管肺动脉机械碎栓、溶栓及吸栓术(CDT)与经外周静脉系统的治疗效果同时对比两种治疗方式的差异性。方法:35例急性致死性肺栓塞患者,依据家属意愿或经济情况分为两组,A组为经外周静脉给药系统治疗组(对照组),B组为行肺栓塞介入综合治疗组(研究组)。其中A组20例,B组15例。A组中男性14例,占70%,女性6例,占30%;年龄22-77岁,平均(61±12.79)岁。B组中男性8例,占53%,女性7例,占47%;年龄38-81岁,平均(64±12.81)岁。两组的所有患者均给予制动、鼻导管面罩双重吸氧及维持血液循环等支持治疗,循环不稳定患者给予必要的血管活性药物以维持生命体征的稳定性,同时严格注意控制入量以避免因维持循环的输液量过多而造成的右心负荷过重,导致心力衰竭。密切监测血压、心率、呼吸次数,经皮氧饱和度以及心电图的变化。两组患者均行入院常规理化检查、D-二聚体、心肌酶学及脑钠肽测量。A组患者经心脏彩超进行肺动脉压测量。抗凝治疗:两组患者均给予抗凝治疗,使用依诺肝素Q12h皮下注射,出院时嘱两组病人均口服利伐沙班片10mg(1/日)。两组病人均给予其他辅助药物进行降纤、祛聚、改善循环治疗,溶栓治疗:A组患者给予经外周静脉尿激酶滴注(生理盐水100ml+尿激酶40万u,2/日)。B组患者行肺动脉溶栓、碎栓及吸栓术,术后继续给予尿激酶(生理盐水100ml+尿激酶40万u,2/日)。出院时采用CTPA或dsa造影治疗前后的差异、临床症状(呼吸困难,胸痛,濒死感)有无改善及比较治疗前后的心率、血氧饱和度、肺动脉压的变化进行评判,入组的病人ctpa或dsa造影治疗后肺动脉血栓均明显减少或消失,临床症状均得到明显改善,两组疗效均显著,统计学分析比较治疗前后的心率、血氧饱和度及肺动脉压的变化。结果:所有入组病人出院前复查ctpa,与治疗前ctpa对比,肺动脉血栓均明显减少或消失。治疗20天后,35例呼吸困难患者症状均得到明显改善,12例胸痛的患者胸痛感消失,12例出现濒死感的病人均未再次出现濒死感。治疗前经外周静脉治疗组和导管溶栓碎栓治疗组两组患者血氧、心率及肺动脉压比较差异均无统计学意义(p0.05)。治疗后经外周静脉治疗组和导管溶栓碎栓治疗组两组患者血氧较治疗前均升高,心率较治疗前均降低,肺动脉压较治疗前均降低,两组治疗前后比较差异有统计学意义(p0.001)。治疗后导管溶栓碎栓治疗组患者血氧较经外周静脉治疗组患者升高明显,心率及肺动脉压较经外周静脉治疗组患者下降明显;治疗后经外周静脉治疗组和导管溶栓碎栓治疗组两组患者血氧、心率及肺动脉压比较差异均有统计学意义(p0.05)。b组15例患者均完成了肺动脉造影术,经导管肺动脉溶栓、碎栓术,其中4例因单纯碎栓溶栓效果欠佳,同时使用了导引导管吸栓治疗。技术成功率达到100%。两组患者共计放置可转换型滤器11枚(均于15日内取出),永久型滤器6例。并发症:各部位出血脐周皮下注射依诺肝素处轻度出血11例31.4%(11/35),静脉采血处皮下轻度渗血5例14.2%(5/35),均未给与特殊处置,皮下渗血自行吸收,B组穿刺点出血2例13.3%(2/15),给予穿刺点再次压迫止血,出血停止。未发生脑出血、腹腔内出血及其他重要脏器出血,未出现心脏破裂及肺动脉穿孔。B组3例患者曾发生室性心律失常,分析为术中导管通过右心室对心室壁刺激所致,避免导管接触右心室壁后症状随即消失。两组患者均未出现严重并发症。31例病人平均随访8.2个月(1-14个月),随访率达到88.5%(31/35)。所有病人均接受电话随访,病人均未能至院内行检查,只能单纯随访相关症状,无法得到如CTPA、超声心动图,肺动脉压,心率及血氧饱和度等指标。所有接受随访的病人均表示未再次出现再次出现呼吸困难、胸闷、胸痛、濒死感等症状,所有病人随访期间均生存,后续随访继续进行中。结论:1、对于急性致死性肺栓塞的治疗,无论是经外周静脉溶栓治疗亦或DSA引导下肺栓塞的介入综合治疗,均属有效的治疗手段。2、引导下肺栓塞的介入综合治疗较经外周静脉溶栓治疗更为积极、有效。
[Abstract]:Objective: To compare the therapeutic effects of DSA-guided transcatheter pulmonary artery mechanical thrombolysis, thrombolysis and thromboembolization (CDT) with those of peripheral venous system (PVS). Methods: 35 patients with acute fatal pulmonary embolism were divided into two groups according to their families'wishes or economic conditions. Group A was treated with PVS (pair). Group B was treated with interventional therapy, including 20 patients in group A and 15 patients in group B. There were 14 males (70%) and 6 females (30%) in group A, and 8 males (53%) and 7 females (47%) in group B, aged 22-77, with an average of (61 + 12.79) years. Patients with unstable circulation are given the necessary vasoactive drugs to maintain the stability of vital signs. At the same time, the intake should be strictly controlled to avoid the overload of right heart caused by excessive infusion to maintain circulation, leading to heart failure. The pulmonary arterial pressure in group A was measured by color Doppler echocardiography. Anticoagulant therapy: Both groups were given anticoagulant therapy, and the patients were given enoxaparin Q12 h subcutaneous injection. Both groups were instructed to take oral benefit at discharge. Vasa Ban tablets 10mg (1/day). Two groups of patients were given other adjuvant drugs for defibrillation, depolymerization, improvement of circulatory therapy, thrombolytic therapy: Group A was given by peripheral intravenous urokinase drip (saline 100ml + urokinase 400,000 u, 2/day). Group B was given pulmonary artery thrombolysis, thrombolysis and thromboembolization, and continued to give urokinase (saline 100ml + urokinase). The difference of clinical symptoms (dyspnea, chest pain, near-death) before and after treatment and the changes of heart rate, oxygen saturation and pulmonary artery pressure before and after treatment were compared. The pulmonary artery thrombosis of the patients in the study group was significantly reduced or disappeared after treatment with CTPA or DSa. The symptoms were significantly improved in both groups, and the changes of heart rate, oxygen saturation and pulmonary artery pressure before and after treatment were statistically analyzed and compared. There was no significant difference in oxygen, heart rate and pulmonary artery pressure between the two groups before treatment (p0.05). There was no significant difference between the two groups after treatment (p0.05). After treatment, the blood oxygen in the catheter thrombolytic therapy group was significantly higher than that in the peripheral vein treatment group, and the heart rate and pulmonary artery pressure were significantly higher than those in the peripheral vein treatment group. There were significant differences in blood oxygen, heart rate and pulmonary artery pressure between the two groups (p0.05). All the 15 patients in group B completed pulmonary angiography, pulmonary artery thrombolysis through catheter, and thrombolysis through catheter, 4 of them were not effective because of simple thrombolysis. The successful rate of the technique was 100%. A total of 11 convertible filters were placed (all removed within 15 days) and 6 permanent filters were placed in the two groups. In group B, 3 patients had ventricular arrhythmias, which were analyzed as intraoperative catheters. No serious complications were found in either group. 31 patients were followed up for an average of 8.2 months (1-14 months) with a follow-up rate of 88.5% (31/35). All patients received telephone follow-up. All patients were unable to go to hospital for examination, and only follow-up was related. Symptoms, such as CTPA, echocardiography, pulmonary artery pressure, heart rate and oxygen saturation, could not be obtained. All patients who were followed up showed no recurrence of dyspnea, chest tightness, chest pain, Near-Death and other symptoms. All patients survived during the follow-up period. Follow-up continued. Conclusion: 1. The treatment of pulmonary embolism, whether through peripheral vein thrombolysis or DSA-guided interventional therapy, is an effective means of treatment. 2. The interventional therapy of guided pulmonary embolism is more active and effective than peripheral vein thrombolysis.
【学位授予单位】：吉林大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R563.5

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