可取回型下腔静脉滤器预防下肢骨折合并深静脉血栓形成患者围术期肺动脉栓塞的价值研究

doi:10.12114/j.issn.1007-9572.2018.00.367

摘要/Abstract

摘要： 背景　下肢骨折合并深静脉血栓形成（DVT）患者围术期死亡的主要危险因素为肺动脉栓塞（PE），而对于这类高危人群置入可取回型下腔静脉（IVC）滤器既能预防PE的发生，又可在不需要时进行收回。目的　探讨下肢骨折合并DVT患者置入IVC滤器预防围术期PE的临床价值。方法　收集2001年1月—2007年12月六盘水市人民医院收治的下肢骨折合并DVT未置入IVC滤器（因本院2008年之前未开展该类技术）的患者1 062例定义为对照组2，均经下肢血管多普勒超声检查证实。2008年1月—2017年1月明确诊断为下肢骨折合并DVT患者1 711例，其中843例患者置入可取回型IVC滤器，定义为滤器组；排除231例置入永久型IVC滤器患者，未置入IVC滤器患者637例，定义为对照组1。比较患者PE发生率、病死率，IVC滤器置入、抗凝治疗情况，IVC滤器置入后相关并发症。结果　对照组1、对照组2 PE发生率、接受抗凝治疗患者PE发生率、有抗凝治疗禁忌证患者PE发生率、病死率高于滤器组（P<0.05）。滤器组患者均成功置入IVC滤器，滤器均放置在正确位置，其中244例（28.94%）发生滤器倾斜，700例（83.04%）无抗凝治疗禁忌证，置入滤器后行低分子肝素（LMWH）治疗。对照组1中25例（3.92%）因有抗凝治疗禁忌证并拒绝放置滤器，围术期未给予抗凝治疗。对照组2中接受抗凝治疗共924例（87.01%）。发生与手术相关气胸1例，发生穿刺点血肿2例，未发现动静脉瘘形成，发生滤器向心脏方向移位6例，其中在取出滤器过程中出现腔静脉损伤3例，对腔静脉局部切割长度<2 cm 2例，出现IVC穿孔1例，出现直径约3 cm的造影剂外溢区域，滤器取出过程未发生PE。251例（29.77%）患者在滤器取出前发现捕获栓子，其中122例（14.47%）捕获栓子较大（直径>1 cm），129例（15.30%）捕获栓子较小；19例患者IVC被捕获的大量栓子堵塞。Optease?滤器除了1例因腔静脉造影发现滤器上有较大栓子外，其余滤器（n=218）均按照疗程取出。滤器置入时间10~17 d，平均（13.9±4.8）d。Celcet滤器共放置625例，其中578例进行了滤器取出，566例（97.92%）成功取出，滤器体内留存时间12~52 d，平均（15.8±12.1）d。结论　下肢骨折合并DVT患者置入可取回型IVC滤器可能是预防其围术期发生症状性或致死性PE安全而有效的方法。

关键词: 静脉血栓形成, 骨折, 下肢, 肺栓塞, 腔静脉滤器

Abstract: Background　Pulmonary embolism （PE）is the main risk factor for perioperative mortality in patients with lower limb fracture complicated with deep vein thrombosis（DVT）. For such high-risk population，retrievable inferior vena cava（IVC） filter can prevent the occurrence of pulmonary embolism and recover it when not needed.Objective　To investigate the clinical value of retrievable IVC filter replacement for the prevention of perioperative PE in patients with DVT following lower extremity fracture.Methods　We conducted this study among the patients with DVT following lower extremity fracture who received treatment in Liupanshui People's Hospital from January 2001 to December 2007.All were confirmed by Doppler ultrasonography of the lower extremity arteries.Among them，of the 1 711 cases treated during January 2008 to January 2017，after excluding 231 with permanent IVC filter replacement，we assigned 843 receiving retrievable IVC filter replacement to the retrievable IVC filter replacement group，and other 637 without IVC filter replacement to No. 1 control group，respectively.Furthermore，all the 1 062 cases who were treated but were not given IVC filter replacement during January 2001 to January 2017（because this treatment has been carried out in this hospital since 2008） were assigned to No. 2 control group.The incidence of PE，mortality，and anticoagulant therapy were compared between the 3 groups.And IVC filter placement and complications secondary to this treatment were compared between the retrievable IVC filter replacement group and No. 1 control group.Results　Compared with the two control groups，the retrievable IVC filter replacement group had lower overall incidence of PE，lower incidence of PE in those receiving anticoagulant therapy，lower incidence of PE in those with contraindications for anticoagulation therapy，and lower overall mortality（P<0.05）．Retrievable IVC filter replacement was implemented successfully in the 843 cases，and the filters were placed in the correct position.The prevalence of filter tilt was 28.94%（244/843） in the follow-up period.700 patients（83.04%） who had no contraindications to anticoagulant therapy were treated with LMWH after surgery.25 patients（3.92%） in No.1 control group refused to place the filter because of contraindications to anticoagulation therapy，and no anticoagulant therapy was given to them during the perioperative period.In No. 2 control group，924 patients （87.01%） received anticoagulant therapy.In the retrievable IVC filter replacement group，1 case had pneumothorax associated with surgery，2 cases had puncture site haematoma，and no arteriovenous fistula occurred.For 6 cases had retrievable IVC filters tilting towards the heart，the filters were removed.During the removal process，3 had vena cava injuries，2 of them had a incision less than 2 cm in the vena cava，other 1 had IVC perforation with an area about 3 cm in diameter with leaked contrast media，and no PE occurred.In 251 patients（29.8%），the embolus was found before the removable filter was removed.Among them，122（14.47%） had large emboli（diameter>1 cm） and 129（15.30%） had smaller emboli；19 patients had IVC blocked by a large number of emboli.Of the 219 cases using Optease? filters，except for one case，a large embolus was found on the filter by vena cava angiography，the filters of other cases were removed according to the course of treatment.The filter was placed for 10 to 17 days with an average of（13.9±4.8） days.Of the 625 cases using Celcet filters，the filters of 578 were removed，and the removal was successfully implemented in 566 cases（97.92%）．The retention time of the retrievable filters was 12 to 52 days，with an average of（15.8±12.1） days.Conclusion　Retrievable IVC filter replacement may be a safe and effective treatment for preventing perioperative symptomatic or fatal PE in lower extremity fracture patients with DVT.

Key words: Venous thrombosis；Fractures, bone；Lower extremity；Pulmonary embolism；Vena cava filters

解银立,张大春,支兴兴,等. 可取回型下腔静脉滤器预防下肢骨折合并深静脉血栓形成患者围术期肺动脉栓塞的价值研究[J]. 中国全科医学, 2019, 22(6): 715-719. DOI: 10.12114/j.issn.1007-9572.2018.00.367.
XIE Yinli,ZHANG Dachun,ZHI Xingxing, et al. Retrievable Inferior Vena Cava Filter Placement for the Prevention of Perioperative Pulmonary Embolism in Patients with Deep Venous Thrombosis after Lower Extremity Fracture[J]. Chinese General Practice, 2019, 22(6): 715-719. DOI: 10.12114/j.issn.1007-9572.2018.00.367.

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