To investigate the clinical application value of comprehensive interventional method for the treatment of lower limb deep vein thrombosis. Methods: 73 patients with lower limb deep vein thrombosis were randomly divided into two groups A and B. Group B was treated with inferior vena cava filter placement + intravascular contact thrombolysis; group A was treated with inferior vena cava filter placement + intravascular contact thrombolysis + thrombus fragmentation + PTA. Results: The total effective rate in group B was 57.89% (22/38), including 0% cure rate, 21.05% (8/38) significant rate and 36.84% (14/38) improvement rate;
The total effective rate of group B was 100% (35/35), of which the cure rate was 54.29% (19/35), the significant rate was 40% (14/35), and the improvement rate was 5.71% (2/35). There was a significant difference between the two groups, and the total effective rate in group A was significantly better than that in group A. No serious complications occurred. Conclusion: Comprehensive interventional method is a safe and effective method for the treatment of lower limb deep vein thrombosis.
Deep venous thrombosis (DVT) is a common vascular disease that seriously endangers human health, and there is still no uniform method to treat DVT of lower limbs. Interventional therapy has become one of the main treatment methods for this disease [1-3]. However, the disease is poorly treated with a single transcatheter endovascular thrombolytic therapy. We have achieved good results in 35 patients with comprehensive endovascular interventions, which are reported below.
1. Data and methods
1.1 Clinical data: 73 patients, 28 males and 45 females, aged 24-71 years. All of them were diagnosed by Doppler ultrasonography or lower limb venography before surgery (Figure 1). Among them, 39 cases had left lower extremity and 34 cases had right side. 73 patients were randomly divided into two groups A and B, 38 cases in group B and 35 cases in group A.
1.2 Methods
1.2.1 Treatment methods in groups Group B: inferior vena cava filter placement + intravascular contact thrombolysis, Group A: inferior vena cava filter placement + intravascular contact thrombolysis + thrombolysis + balloon angioplasty (PTA).
1.2.2 Inferior vena cava filter placement: 73 patients were placed with permanent inferior vena cava filters via the healthy femoral vein route before surgery.
1.2.3 Endovascular contact thrombolysis: After successful release of the filter, the filter release system was withdrawn, and the catheter was then delivered to the thrombus via a catheter sheath with a guidewire and a 5FCobra catheter. After imaging, the lesion and catheter location were clarified, 3000 U of sodium heparin was injected, and then urokinase was slowly pushed, 200,000~400,000 U dissolved in 50 ml of saline each time, for about 20 minutes, followed by imaging to observe the revascularization until the thrombus was dissolved or the total amount of urokinase reached 1.5 million U. All 73 patients underwent intravascular contact thrombolysis.
1.2.4 Thrombectomy: While thrombolysis was performed, a J-tip guidewire and catheter were pumped repeatedly through the thrombus to mash it up as much as possible. A total of 32 thrombectomies were performed.
1.2.5 Balloon angioplasty (PTA): In this group, if the thrombus is still large or the vessel is still narrow after completing the above treatment, a balloon of 8-10 mm in diameter will be introduced for PTA. 12 patients were treated with PTA in total. All patients were not treated with internal stenting.
1.2.6 Postoperative management: The catheter was removed after surgery. 1.2.7 Compression dressing was applied. All patients continued to apply urokinase via the affected foot vein for 3 days. 1.2.8 Once daily, 1.2.8 600,000 1.2.9 U each time. continue with heparin or low molecular heparin sodium for 7 days thereafter. Switch to oral 1.2.10 anticoagulant enteric aspirin (100 mg per day) for 3-6 months after discharge.
1.3 Efficacy evaluation criteria.
1.3.1 Referring to the arterial criteria
(1) Cure: complete revascularization: residual stenosis of the lumen <30%, disappearance of clinical symptoms and signs;
(2) Significant effect: partial revascularization: residual stenosis of the lumen <70%, but >30%, clinical symptoms and signs mostly disappeared;
(3) Improvement: the occluded lumen is opened but the residual stenosis is >70% or the obstructed segment is partially opened, the collateral circulation is significantly increased, and the clinical symptoms and signs are improved.
(4) Ineffective: the above criteria are not met. Effective=cured+effective+improved.
1.3.2 Statistical treatment: t-test was used for comparison between the two groups, and the significance level was taken as p<0.01
2. Results
The clinical results are shown in Table 1. the revascularization rate of group B was 57.89% (22/38), and group B was 100%. Among them, complete revascularization was 0 in group B and 54.29% in group A (19/35); partial revascularization was 21.05% in group B (8/38) and 40% in group A (14/35). No serious complications such as intracranial hemorrhage and pulmonary embolism occurred in both groups, except for some patients with hematoma at the puncture site.
Table 1 Comparison of the different outcomes of DVT in the lower extremities of the two groups in AB
Group Total Cure (%) Apparent effect (%) Improvement (%) Effective (%) Ineffective (%)
A 35 19(54.29) 14(40) 2(5.71) 35(100) 0
B 38 0 8(21.05) 14(36.84) 22(57.89) 16(42.11)
Comparison of efficiency rate between two groups in AB p<0.01
3.Discussion
The danger of lower extremity deep vein thrombosis (DVT) is increasingly recognized. In addition to causing pulmonary embolism, the long-term prognosis of DVT of the lower extremity itself is also worrying, which seriously affects the daily life and labor of patients. Therefore, effective treatment of DVT in the lower extremities is necessary. With the widespread use of interventional techniques, direct catheter-contact thrombolysis has gradually been accepted, and its efficacy is significantly better than that of systemic intravenous thrombolytic therapy.
Mewissen et al. reported that direct catheter thrombolysis for lower extremity DVT was effective, and Grossman et al. reported that the efficiency of direct catheter contact thrombolysis for lower extremity DVT of >4 weeks was 60%. However, how to further improve the therapeutic effect is still the goal pursued by doctors and patients. It is generally believed that in the natural course of disease, mechanization begins after 2-3d of fresh thrombus formation and is completed after about 10-12d.
The site of thrombus causing vascular occlusion is not formed once, but repeatedly at different times and in different states, which is a chronic process. Therefore, these thrombi are mostly mixed thrombi, consisting of fresh, unmachined, and fully machined thrombi together. In these thrombosed individuals, the overall effect of single intravascular thrombolysis is not ideal for long obstructed segments of lesions.
Tang Dukuan et al. used thrombolysis + thrombus aspiration + PTA + stenting to achieve satisfactory results. We adopted a comprehensive interventional therapy to treat 35 patients, and the overall efficiency reached 100%, which was significantly higher than that of the thrombolysis group alone. From the results of this group, it can be seen that adding thrombolysis and PTA to endovascular thrombolysis significantly increased the rate of revascularization, and the difference between the groups was significant (P<0.01.), indicating that the integrated interventional method can significantly improve the therapeutic effect in the treatment of lower limb deep vein thrombosis.
3.2 Sequential issues of the integrated interventional method for the treatment of lower limb deep vein thrombosis
The treatment of lower extremity deep vein thrombosis can achieve satisfactory efficacy by the integrated interventional method, but the sequence of various treatment methods is also very important. Our experience is that the following sequence is used.a First is filter placement. Most scholars believe that for acute or chronic exacerbation of thrombosis, and long, free lower limb deep vein thrombosis diagnosed by imaging, inferior vena cava filter should be placed as soon as possible to prevent the occurrence of lethal pulmonary embolism.
In our group, 73 patients were placed with inferior vena cava filters before treatment, and none of them had pulmonary embolism. The placement of an inferior vena cava filter can effectively prevent thrombus dislodged during thrombolysis and thrombus mashed during fragmentation from entering the heart with blood flow, so preoperative placement of an inferior vena cava filter is necessary. b Thrombolytic therapy. Thrombolysis is performed immediately after placement of the inferior vena cava filter. c Thrombolysis. Thrombolysis is performed at the same time as thrombolysis to accelerate the dissolution and rupture of the thrombus and recanalize the blocked vessel.
d Endovascular angioplasty (PTA). PTA is performed for those patients whose revascularization is still unsatisfactory after thrombolysis and thrombolysis, which can further revascularize the vessel.
3.3 Continue thrombolysis and anticoagulation therapy. After the patient returns to the ward, with the coagulation index 3.4 standard 3.5 detected, 3.6 continue thrombolysis for 3 days and anticoagulation for 3 to 6 months. This promotes further dissolution of the thrombus, prevents thrombus re-formation at the same time as 3.7, and 3.8 improves the long-term outcome.
In conclusion, the integrated interventional treatment of lower extremity deep vein thrombosis using inferior vena cava filter placement, endovascular thrombolysis, thrombus fragmentation, and endovascular molding is a safe and effective method. As for the long-term efficacy and recurrence, we did not observe the follow-up, and further study is needed.