选择性导管溶栓治疗急性大面积肺动脉血栓栓塞症  

Acute massive pulmonary thromboembolism treated by selective catheter-directed thrombolysis

作　　者：冯海[1] 陈学明[1] 张志文[1] 李晨宇[1] 房杰[1] 张喆[1] 朱仁明[1] 于宏志[1] 

机构地区：[1]首都医科大学附属北京友谊医院血管外科,100029

出　　处：《心肺血管病杂志》2015年第12期894-898,共5页Journal of Cardiovascular and Pulmonary Diseases

摘　　要：目的:探讨应用溶栓导管进行选择性肺动脉置管溶栓,治疗急性大面积肺动脉血栓栓塞症的安全性及有效性。方法:选取自2010年3月至2013年3月间,符合标准的26例患者;将溶栓导管(Uni Fuse-infusion system)选择性置入肺动脉血栓主体中,导管前端置放于目标肺段动脉。溶栓方案为术中推注尿激酶25万U。术后以输液泵连接溶栓导管泵入尿激酶25^-50万U/24小时(溶解于1 000m L0.9%氯化钠液)进行持续溶栓72小时;每间隔4小时推注溶栓液20m L。术后第4天再次行肺动脉造影及测量肺动脉压(s PAP),并拔除溶栓导管。评价比较溶栓前后临床症状及客观指标;指标包括休克指数(shock index,SI)、s PAP、外周动脉氧分压(Pa O2)和米勒指数(miller index,MI)。结果:此组男性16例,女性10例;年龄19~82岁,平均年龄(49.9±18.8)岁;发病时间4小时~8天。病变累及左肺动脉8例,右肺动脉10例,双肺动脉8例。26例均获得技术成功;置管途径经股静脉22例/次,经右锁骨下静脉12例/次;8例双肺动脉栓塞者同期分别向左右肺动脉置入溶栓导管各1根。溶栓后呼吸困难、咳嗽不同程度缓解,胸痛、喀血及晕厥均消失,无呼吸困难一过性加重者,临床成功率为100%。SI由[术前(1.74±0.38)降至术后(0.71±0.09),P<0.01],Pa O2由[术前(52.78±6.92)%升至术后(85.98±5.91)%,P<0.01],s PAP由[术前(65.19±8.22)mm Hg(1mm Hg=0.133k Pa)降至术后(34.42±4.05)mm Hg,P<0.01],MI由[术前(0.69±0.09)降至术后(0.33±0.06),P<0.01]。平均每例尿激酶用量(129.81±22.38)万U。术中有2例在导丝通过右心室时出现一过性室性期前收缩,其前端到达肺动脉后早搏消失;术后并发症包括穿刺部位血肿2例,拔除鞘管后加压包扎而愈;消化道出血1例,均经保守治疗而愈,未予以输血。结论:选择性肺动脉置管溶栓对于急性大面积肺动脉血栓栓塞症提供了一种安全有效的治疗选择。Objective： To explore the safety and efficacy of selective catheter-directed thrombolysis in treating acute massive pulmonary thromboembolism（ AMPTE）. Methods： Twenty-six AMPTE patients were enrolled between March 2010 and March 2013. A Uni＊ Fuse infusion system was inserted into the main pulmonary artery thrombus. The thrombolytic regimen included an intraoperative bolus injection of 250,000 IU urokinase,followed by continuous thrombolytic infusion of 250,000-500,000 IU /24 h urokinase for 72 h postoperatively. Clinical symptoms,shock index（ SI）,systolic pulmonary artery pressure（ s PAP）,peripheral arterial partial pressure of oxygen（ Pa O2）,and Miller index（ MI） were assessed before and after treatment. Results：The patients included sixteen men and ten women（ 49. 9 ± 18. 8） years old; time to onset of（ 50. 2 ± 28. 5h）.After thrombolysis,dyspnea and cough were relieved to varying degrees; chest pain,hemoptysis,and syncope disappeared. Importantly,a clinical success rate of 100% was achieved. All objective indices were improved：SI decreased from（ 1. 74 ± 0. 38） before operation to（ 0. 71 ± 0. 09） postoperatively（ P 0. 01）; Pa O2 increased from（ 52. 78 ± 6. 92） mm Hg to（ 85. 98 ± 5. 91） mm Hg（ P 0. 01）; s PAP was reduced from（ 65. 19± 8. 22） mm Hg to（ 34. 42 ± 4. 05） mm Hg（ P 0. 01）; MI dropped from（ 0. 69 ± 0. 09） to（ 0. 33 ± 0. 06）（ P 0. 01）. Mean total urokinase amounts were 1,298,000 IU for each patient. Postoperative complications included 2 cases of puncture site hematoma（ cured by pressure bandage） and 1 case of gastrointestinal hemorrhage（ healed by conservative treatment without blood transfusion）. Conclusion： Selective catheter-directed thrombolysis may serve as a safe and efficacious therapeutic approach for acute massive pulmonary thromboembolism.

关 键 词：肺动血栓栓塞症 休克 导管介入治疗 溶栓 尿激酶 

分 类 号：R56[医药卫生—呼吸系统]