腔内治疗原发性主动脉血栓10例_张强.pdf

介入放射学杂志2023年4月第32卷第4期J Intervent Radiol 2023，Vol32，No4腔内治疗原发性主动脉血栓 10 例张强，李晓光，游国超，徐化静，孔祥翔，杨殿滨，刘岩【摘要】目的探讨原发性主动脉血栓腔内治疗方法，评价其临床疗效。方法回顾性分析2018年8月至2022年4月收治的10例原发性主动脉血栓患者临床资料。术前CTA检查明确主动脉血栓分型并进行抗凝治疗。对型病变行全身麻醉下支架植入术，型和+型病变行局部麻醉下取栓或支架植入术。采用双股动脉切开或穿刺入路，术中应用Fogarty球囊或Wallstent支架半释放技术预防动脉远端栓塞。周围血管栓塞治疗中仅对下肢动脉、肠系膜上动脉栓塞患者行腔内治疗，其余部位抗凝治疗。取出的血栓行病理学检查。术后继续抗凝治疗。术后1、3、6、12个月随访主动脉CTA及下肢动脉彩色超声，12个月后电话随访。结果血栓分型型5例，+型2例，b型1例，a+b型2例。取栓4例，直接裸支架治疗2例，直接覆膜支架治疗4例。4例取栓手术应用Fogarty球囊保护，术中未发生血栓异位栓塞；支架植入患者中2例行Wallstent支架保护，其中1例成功抓捕脱落的血栓。周围血管栓塞病变保守治疗4例，腔内手术6例，其中2例髂动脉支架植入，Fogarty球囊取栓3例（2例复发，共5次手术），大腔导管取栓1例。术后随访143个月，平均16.4个月，取栓患者中3例血栓消失，1例复发，二次植入覆膜支架；支架植入患者支架通畅。2例周围血管栓塞术后症状复发，末次治疗后加强健康教育，随访无复发。2例术后遗留下肢间歇性跛行，1例术后3个月因食管癌化疗诱发急性胰腺炎死亡。结论 原发性主动脉血栓少见，抗凝联合取栓或支架植入可快速清除血栓或固定血栓，降低再次栓塞风险。腔内治疗仅需股动脉切开或穿刺，创伤小、疗效确切，是治疗此疾病的有效方法。【关键词】主动脉内膜血栓；血栓栓塞；抗凝治疗；血栓切除术；血管腔内修复术中图分类号：R654.3文献标志码：A文章编号：1008-794X（2023）-04-0330-08Endovascular therapy for primary aortic mural thrombus in ten patientsZHANG Qiang，LI Xiaoguang，YOU Guochao，XU Huajing，KONG Xiangxiang，YANG Dianbin，LIU Yan.Department of InterventionalRadiology and Vascular Surgery，Anyang District Hospital，Anyang，Henan Province 455000，ChinaCorresponding author：LI Xiaoguang，E-mail：【Abstract】ObjectiveTo discuss the endovascular therapies for primary aortic mural thrombus（PAMT），and to evaluate their clinical effectiveness.MethodsThe clinical data of 10 patients with PAMT，who were admitted to authorshospital to receive endovascular therapy between August 2018 and April 2022，were retrospectively analyzed.For all patients，preoperative CTA was performed to determine the type ofPAMT and preoperative anticoagulant therapy was employed.For patients with type PAMT，stentimplantation under general anesthesia was carried out；and for patients with type or type+PAMT，thrombectomy or stenting under local anesthesia was adopted.Bilateral femoral artery incision or puncturingapproach was used，and during operation the Fogarty balloon protection technique or the Wallstent semi-release protection technique was applied so as to prevent the distal arteries from thromboembolism.Peripheralvascular therapy was used only for patients with lower limb arterial thromboembolism，endovascular therapywas used for patients with superior mesenteric arterial thromboembolism，and anticoagulant therapy was usedfor the thromboembolism located at other sites.The removed thrombus was sent for pathological examination.After operation，anticoagulation therapy was continued.The aortic CTA and the color ultrasound of lower limbartery were reexamined at 1，3，6 and 12 months after operation.One year after operation，follow-up wasconducted through telephone.ResultsType of PAMT was seen in 5 patients，type+of PAMT in 2DOI：103969jissn1008794X202304005作者单位：455000河南安阳安阳地区医院血管科/介入中心（张强、游国超、徐化静、孔祥翔、杨殿滨、刘岩）；北京医院国家老年医学中心（李晓光）通信作者：李晓光E-mail： 血管介入Vascular intervention 330介入放射学杂志2023年4月第32卷第4期J Intervent Radiol 2023，Vol32，No4图1原发性主动脉血栓分型主动脉血流速度快，原位血栓不易形成，临床遇见的主动脉血栓多与严重动脉粥样硬化、主动脉瘤或主动脉夹层相关，而原发性主动脉血栓比较少见。此病变特点为主动脉附壁血栓形成，但主动脉壁无上述典型病变；起病隐匿，多因出现周围栓塞症状确诊；病因未明，部分患者伴发易栓症，大量吸烟、饮酒、肿瘤、炎症等因素也可诱发1-3。因其为少见病，文献多为个案或少宗病例报道，最佳治疗方案仍有争议4-9。本研究总结2018年8月至2022年4月河南省安阳地区医院、南阳市第一人民医院共16例原发性主动脉血栓患者临床资料，对其中10例进行血管腔内取栓、裸支架植入及覆膜支架植入治疗，现报道如下。1材料与方法1.1定义及分型原发性主动脉血栓定义：主动脉管壁原位血栓形成，但血栓附着部位无动脉瘤、夹层、穿透性主动脉溃疡、严重动脉粥样硬化或钙化证据。分型2：型，主动脉弓部（升主动脉至左锁骨下动脉开口远心端）血栓，其中a型为升主动脉至无名动脉开口近心端血栓，b型为无名动脉开口近心端至左锁骨下动脉开口远心端血栓；型，降主动脉（左锁骨下动脉开口远心端至腹腔干开口近心端）血栓，其中a型为左锁骨下动脉开口远心端至第8胸椎（T8）水平血栓，b型为T8至腹腔干开口近心端血栓；型，腹腔干开口近心端至低位肾动脉开口远心端血栓；型，低位肾动脉开口远心端至主动脉分叉水平血栓。见图1。patients，type b in one patient，and type a+b in 2 patients.Thrombectomy was employed in 4patients，direct bare stent implantation in 2 patients，and direct covered stent implantation in 4 patients.TheFogarty balloon protection was applied in 4 patients receiving thrombectomy，and no intraoperative ectopicthromboembolism occurred.Among the patients receiving stent implantation，Wallstent semi-release protectionwas adopted in 2 patients，in one of the two patients the detached thrombus was successfully captured.In thepatients with peripheral vascular thromboembolism，anticoagulant therapy was employed in 4 patients andendovascular therapy was adopted in 6 patients，among them iliac artery stent implantation was performed in2，Fogarty balloon thrombectomy in 3（2 had postoperative recurrence，a total of five surgeries were performed），and thrombectomy by using large lumen catheter in one.The patients were followed up for a mean of 16.4months（range of 1-43 months）.In the patients receiving thrombectomy，the thrombus disappeared in 3patients，and thrombosis recurred in one patient，for whom covered stent implantation had to be carried outagain.The stent was unobstructed in all the patients receiving stent implantation.Symptoms relapse was seenin 2 patients after peripheral vascular therapy，and health education was strengthened for them after the lasttreatment and they had no recurrence at the follow-up visit.Two patients developed lower limb intermittentclaudication after treatment，and one patient died of acute pancr