Download 缁忓ぇ闅愰潤鑴夊叆璺 疆绠℃憾鏍撴湳鑱斿悎鑵斿唴鎴愬舰鏈 不鐤楁

Catheter-Directed Thrombolysis via Great Saphenous Vein
for Mixed Deep Veinous Thrombosis of Lower Extremity
Xicheng Zhang1，2, Xiaoqiang Li1, Zhaolei Chen2,
Guangrui Pan2, Qingyou Meng1, Jianjie Rong1
[Abstract]
Objective:
To
explore
the
feasibility
of
catheter-directed
thrombolysis(CDT) via great saphenous vein-perforater vein to deep vein for
treatment of mixed lower extremity deep veinous thrombosis(DVT) , and to evaluate
its clinical efficacy. Methods: We performed this retrospective analysis of the clinical
data in 25 cases with acute mixed lower extremity DVT. All the patients were
punctured through ankle great saphenous vein, and the catheter were delivered
through perforater vein into deep vein for thrombolysis. The thrombolysis efficacy
was evaluated by angiography.For some patients with residual iliac vein stenosis or
occlusion, balloon-dilatation and stent placement were performed through great
saphenous vein or femoral vein. Results: In 25 patients, the catheters were
successfully delivered into deep veins through great saphenous vein-perforater vein ,
without severe complications. The thrombolysis time through catheter is 5-7 d. The
symptoms such as swollen of the lower limb and pain improved significantly after
CDT, the circumference difference of thigh and calf significantly reduced, statistically
significant (P<0.01, P<0.01). The vein patency scores are different before
（11.56±0.917） and after catheterization （2.64±2.018）, statistically significant
（P<0.01）. The improvement of vein patency was 30%～100%，averaged at
(76.66±18.10) %. The stents were delivered through great saphenous vein of lesion
side in 8 patients, through femoral vein to iliac vein in 3 patients.21 patients were
followed up for 3-12 months. One patient received intra-lumenial therapy due to
re-stenosis distal to the stent. There was no recurrence of lower extremity swollen for
the rest 20 patients. Conclusion: CDT via great saphenous vein for mixed lower
Author affiliation：Department of Vascular Surgery, Second Hospital Affiliated to Soochow
University, 215004
Department of Vascular Surgery, Clinical Medical school of Yangzhou
University, 225001
Corresponding author：Xiaoqing Li. E-mail:[email protected]
extremity DVT is a simple procedure, easy to perform, with minimal invasion and
high thrombolysis efficacy. It is an optional, safe, and practical thrombolysis in the
clinic.
[Key word]
Deep veinous thrombosis ； Catheter-directed thrombolysis; Great
saphenous vein; perforater vein
Deep venous thrombosis (DVT) is common in the clinic. Its incidence increases
every year. Acute DVT may cause fetal pulmonary embolus (PE), and affect the
quality of patient life in the late stage due to the high incidence of post-thrombosis
syndrome (PTS). In recent years, catheter-directed thrombolysis (CDT）has been used
to treat acute DVT and revealed good medium and long term efficacy, and reduced
incidence of PTS
1-2
. CDT mainly performed through popliteal vein, the small
saphenous vein and the contralateral femoral vein. We performed CDT through great
saphenous to vein perforater vein in 25 patients with acute mixed lower extremity
DVT, who were admitted in our department during Oct of 2011 to Dec of 2012, with
great success. Herein, we are reporting as follows.
Material and Method
1. General information
There were 25 patients in this group totally, 11 males and 15 females, aged at
28～68 years. The onset of the disease was 2～14d. All of cases are lateral DVT，19
at the left and 6 on the right. Clinical presentations were lateral limb swollen, pain,
dysfunctional mobility, without significant chest pain, or dyspnea, or hemoptysis or
other symptoms of pulmonary embolus. The circumference difference of thigh at
lesion side and healthy side was 5.6～11.2cm，averaged at 7.696±1.576cm；the
circumference difference of calf was 2.5～6.1cm，averaged at 4.420±1.117cm. All the
patients were confirmed for mixed DVT with color doppler or CT angiography.
2. Management
2.1 Placement of inferior vena cava filter：to prevent PE during thrombolysis,
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all the patients were placed recyclable（Optease，USA Cordis）or permanent inferior
vena cava filter（TrapEase，USA Cordis）. Puncture femoral vein of the healthy side,
perform angiography in inferior vena cava, label bilateral renal veins, and place the
filter. If the thrombus involved the inferior segment of inferior vena cava, puncture
through jugular vein, and place the filter above the thrombus.
2.2 Thrombolysis via great saphenous vein: Puncture great saphenous vein at
the ankle of the lesion side. First, place tourniquet at the upper middle segment of the
calf. Dorsalis pedis superficial vein was punctured for injection of contrast. Take a
look at the perforater vein between the shallow vein and deep vein. If this perforater
vein is good for catheter, pass through it; or else, go through small saphenous vein.
After great saphenous vein is filled up, puncture great saphenous vein at the ankle,
place a 5F sheath, and then deliver the tubing through the sheath, inject some contrast.
Under the vision of “road map” track, select calf perforater vein, match the guide wire
with the tubing, and then deliver the guide wire into calf deep vein via perforater vein,
and then deliver the guide wire via DVT into inferior vena cava. Withdraw the guide
wire; deliver Unifuse-catheter with 50cm of thrombolysis segment (AngioDynmics
inc. USA)，with the tip close to the proximal side of the thrombus. Fix the exterior
catheter.
2.3 Thrombolysis and anti-coagulation: First, iv. push urokinase 200 thousand
u into Unifuse catheter as the initial dosage, and then continues infuse urokinase
through mini-pump at 200～400 thousand U/h, and exam the thrombolysis every 24
hr by angiography. Use low molecular heparin subcutaneously for anti-coagulation,
4000U/12h. Monitor coagulation regularly.
2.4 Management after thrombolysis: for those with complete dissolved
thrombus with CDT, those with severe residual iliac vein stenosis or occlusion were
treated with intra-lumenal therapy via great saphenous vein or femoral vein of the
lesion side, suggesting with balloon-dilatation and stent placement. All patients with
CDT should take warfarin orally for at least 3～6 months, and followed up for
coagulation parameters regularly, wear elastic stockings, and take oral flavonoids.
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3. Efficacy evaluation
3.1
Clinical efficacy evaluation: Observe the symptom improvement of the
limb with lesion, including swollen of the lower limb, soar and pain etc.
Measure the circumference 10cm above and under the knee, calculate the
circumference difference of thigh and calf between the lesion side and
healthy side.
3.2
Patency of vein：By using vein patency score, evaluate the outcome of
thrombolysis
3
as follows: Divide the lesion limb deep veins into inferior
vena cava, iliac general vein, iliac external vein, common femoral vein,
superficial femoral vein upper segment, superficial femoral vein lower
segment and popliteal vein, totally 7 segments. According to the results of
angiography, score the vein patency of the above 7 segments and add up.
Complete patency was scored as 0, partial for 1, and no patency for 2. Vein
patency improvement rate=( vein patency score before thrombolysis－vein
patency score after thrombolysis) / vein patency score before thrombolysis
×100%. Improvement rate of vein patency＜50% was regarded as thrombus
dissolve grade I; Improvement rate of vein patency 50% ～ 90% was
regarded as thrombus dissolve grade II；Improvement rate of vein patency＞
90% was regarded as thrombus dissolve grade III4.
4. Statistical analysis
SPSS19.0 software was used for statistical analysis; quantitative data were
presented as X±S. The circumference difference of bilateral limbs and the score value
of vein patency were examined with paired t test；P＜0.05 was regarded statistically
significant.
Results
1. Clinical efficacy: These 25 patients were successfully placed catheter
thrombolysis via great saphenous vein. After the therapy, the symptoms such as
swollen of the lower limb and pain improved significantly. The circumference
difference between the lesion side and healthy side reduced dramatically. The
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circumference difference of the thigh reduced from 7.696±1.576 cm to
2.032±0.824cm，statistically significant（T=17.081，P＜0.01）；The circumference
difference of the calf dropped from 4.420±1.117cm to 1.304±0.662cm ，
statistically significant（T=12.045，P＜0.01）.
2. Medications and complications：The treatment time of CDT for these patients
was about 3 ～7d，averaged at 4.80±1.38d，the total dosage of urokinase was
150×104 ～525×104U，averaged at (322.8±110.28）×104U. There were four cases
with complications （16%），including one case of oozing blood at the puncture
site, 2 cases of hematuria, and one case of mild hemoptysis. There was no
symptomatic PE or other severe complications.
3. Angiography Comparison before and after CDT：Before CDT, perform deep
vein angiography to evaluate the vein patency score. Before CDT, the vein
patency score was 10～13, averaged at 11.56±0.917. After CDT, the score was
0～8, averaged at 2.64±2.018. There was significant difference for the score
before and after CDT（T=19.029，P＜0.01）. The patency improvement rate was
30%～100%，averaged at（76.66±18.11）%. Among those, the vein patency
improvement rate in 3 cases reached thrombus dissolve grade （
I 12%），14 reached
grade II（56%），and 8 reached grade III（32%）.
4. Subsequent therapy：Among these 25 patients，16 were discovered with severe
stenosis or occlusion of iliac vein after CDT treatment with vein angiography,
among which, 11 were treated with further iliac intra-lumenial therapy, with 8 via
great saphenous vein and 3 via ipsilateral femoral vein and performed iliac vein
angioplasty and stent placement. The patients took oral warfarin regularly after
being discharged and followed up with coagulation parameters regularly.
Twenty-one patients were followed up, for about 3～12 months. 8 months after
surgery, one patient presented with left lower limb bulge discomfort after long
standing, and was found with imaging examination that there was severe stenosis
at the distal of iliac vein stent. The patient was treated with intralumenal therapy
and the symptoms were relieved. There was no other recurrence of lower limb
swollen.
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Discussion
Compared with systemic anti-coagulation, thrombolysis, CDT for lower limb
DVT delivers the thrombolytic drugs directly into the thrombus via tubing. Not only it
has a high thrombolytic rate, it also protects vein valve function, and reduces the
incidence of thrombus sequela 1，5-6. In china, in the second edition of the guideline for
diagnosis and treatment of lower limb DVT in 2012, it was recommended CDT as the
first choice of treatment for DVT7.
In the commonly used CDT road, different centers use different roads for
cathetering with different experiences. The common used roads include via ipsilateral
popliteal vein, small saphenous vein, contralateral femoral vein, and jugular vein etc.
Among them, popliteal vein and small saphenous vein were often used 8. Popliteal
vein puncture has the following flaws: the patient should be supine when performed,
which made it difficult for the old, weak and after trauma; it is easy to injure popliteal
artery and tibia nerve during puncture. Furthermore, the thrombolysis catheter were
delivered via popliteal vein to deep vein, making it difficult for the thrombus in deep
vein distal to popliteal vein dissolved, unable to supply good entrance, and reduce the
rate of thrombolysis. Moreover, due to the injury to popliteal vein and catheter
placement, it may cause subsequent thrombus worse
9-10
. The path via small
saphenous vein can solve this problem very well, which makes it a good path. But
small saphenous vein has many variances, the locations vary, the successful rate of
puncture was low, and it often requires a minor incision for cathetering, and it often
requires the patients adduct and internal rotate the lesion limb, and it is difficult to be
exposed, the incision for cathetering is easy to ooze blood and it is very inconvenient
for nursing.
Cragg or Armon et al9-10 had reported successful cases with catheter-directed
thrombolysis punctured shallow vein of calf and catheter delivered via perforater vein
between superficial and deep vein of calf. In our practice, we found that puncturing
great saphenous vein at ankle via perforater vein can be used as routine road. This is
because that the location of great saphenous vein at the ankle is rather stable, often
had compensated dilatation after DVT, it is easy to puncture, and with a high
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successful rate. Furthermore, there is no important structure along with great
saphenous vein, there is not many complication for puncture, there is little oozing of
blood after the procedure and it is convenient for nursing. The patient can move
without specific limitation after the procedure. There are many perforater veins to the
deep vein for great saphenous vein above ankle and below the knee. Injection of
contrast into dorsalis pedis superficial vein before the procedure, and evaluate the
feasibility of placement of catheter in perforater vein. Generally speaking, the
perforater vein will compensate and dilate after DVT. The mixed DVT is the most
common 11. Therefore, it improved the successful rate of cathetering in perforater vein
via great saphenous vein. Those with up-sloping inserted into perforater vein to deep
vein without curve had a high successful rate. If there are several perforater veins,
those with low surface branch veins should be chosen for getting into deep vein, to
increase the dissolving range of deep vein thrombus of the calf.
For those without
parforater vein displayed with angiography or those tiny, downsloping or curvedly
into deep vein, the successful rate was low. The puncture path should be given up.
Choose small saphenous vein to catheter. Although cathetering via great saphenous
vein perforater vein has many advantages, there are shortcomings. Not every patient
can be placed successfully. According to our experience, mixed DVT patients can be
cathetered via great saphenous vein, with a successful rate of 70%.
Puncture via great saphenous vein at the ankle and go through perforater vein for
CDT to treat lower limb acute mixed DVT made the catheter directly into deep vein
below knee which improved the dissolved area of thrombus. Medication thrombolysis
can set up good vein entrance and improve thrombolytic rate. This is a simple
procedure with few complications, and easy for nursing afterword. It is a worthy
option for good cathetering.
References
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