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目的实验性比较经导管机械祛栓、经导管肺动脉内局部溶栓和经导管机械祛栓联合局部溶栓治疗急性肺动脉栓塞疗效和安全性。方法28只杂种犬经数字法随机分为4组,机械祛栓治疗组、局部溶栓治疗组、机械祛栓联合局部溶栓治疗组和对照组(CTL组)各7只。用犬的自体血栓建立急性肺动脉栓塞模型,分别采用经导管予机械祛栓(helix thrombectomy device,HTD)、尿激酶(UK)局部溶栓、机械祛栓联合尿激酶及生理盐水治疗。监测肺动脉平均压(PAMP)、主动脉收缩压(SBP)、血气及肺动脉造影情况。术后取动物肺组织行病理检查。结果在各组中,治疗后PAMP在30min时,CTL组为(33.5±3.38)mm Hg(1mm Hg=0.133kPa),UK组为(29.00±3.96)mm Hg,HTD组为(29.39±3.17)mm Hg,HTD+UK组为(25.24±3.04)mm Hg(q=6.88,P=0.002);60min时,CTL组为(33.19±3.54)mm Hg,UK组为(28.79±3.96)mm Hg,HTD组为(24.44±3.70)mm Hg,HTD+UK组为(23.57±4.57)mm Hg(q=8.73,P=0.000);120min时,CTL组为(31.50±3.75)mm Hg,UK组为(26.43±4.04)mm Hg,HTD组为(22.00±3.62)mm Hg,HTD+UK组为(17.86±3.26)mm Hg(q=17.78,P=0.000)。治疗后30、60和120min与对照组同时相的PAMP相比均明显降低,差异有统计学意义(P<0.05)。HTD组于治疗后120min与UK组同时相PAMP相比差异有统计学意义(P<0.05)。HTD+UK组治疗后30min和120min较UK组和HTD组同时相的PAMP降低更为明显(P<0.05);治疗60min与UK组差异有统计学意义(P<0.05)。治疗后的肺动脉造影表现为阻塞的肺动脉血流完全或不完全再通;充盈缺损减小;相应肺组织血流完全或不完全恢复。病理检查:(1)对照组:所见栓塞部位与肺动脉造影结果一致。光学显微镜下,肺动脉血管内可见血栓,肺组织大片出血灶,部分肺泡腔内大量红细胞。(2)治疗组:肺出血轻,肺泡腔内少量红细胞。HTD操作的相应肺动脉内膜轻微损伤。结论HTD消融器祛栓联合局部溶栓的疗效明显优于单独经导管肺动脉内局部溶栓或HTD消融器祛栓治疗,具较高的安全性。
Objective To compare the curative effect and safety of mechanical embolectomy, local thrombolysis in catheter pulmonary artery and mechanical thrombectomy combined with local thrombolysis in the treatment of acute pulmonary embolism. Methods 28 dogs were randomly divided into 4 groups: mechanical thrombectomy group, local thrombolysis group, mechanical thrombectomy combined with local thrombolysis group and control group (CTL group). Acute pulmonary embolism model was established by using autologous thrombus in dogs. Thrombolytic therapy with local thrombolysis, mechanical thrombectomy combined with urokinase and normal saline were used respectively. Monitoring of pulmonary artery mean pressure (PAMP), aortic systolic blood pressure (SBP), blood gas and pulmonary angiography. After taking the animal lung tissue pathological examination. Results In each group, PAMP was (33.5 ± 3.38) mm Hg (1 mm Hg = 0.133 kPa) in CTL group and (29.00 ± 3.96) mm Hg in UK group and (29.39 ± 3.17) mmHg in the HTD + UK group was (25.24 ± 3.04) mm Hg (q = 6.88, P = 0.002); the CTL group was (33.19 ± 3.54) mm Hg at 60min and (28.79 ± 3.96) mm Hg in the UK group (24.44 ± 3.70) mm Hg in HTD group and (23.57 ± 4.57) mm Hg in HTD + UK group (q = 8.73, P = 0.000) (26.43 ± 4.04) mm Hg in HTD group and (22.00 ± 3.62) mm Hg in HTD group and 17.86 ± 3.26 mm Hg in HTD + UK group (q = 17.78, P = 0.000). The levels of PAMP in the control group at 30, 60 and 120 min after treatment were significantly lower than those in the control group (P <0.05). The difference of PAMP in HTD group at 120min after treatment was statistically significant (P <0.05). Compared with UK group and HTD group, PAMP decreased more significantly in HTD + UK group 30min and 120min after treatment (P <0.05). There was a significant difference between UKD and HTD + UK group (P <0.05). Pulmonary angiography after treatment showed complete or incomplete recanalization of obstructed pulmonary blood flow; filling deficits were reduced; and the corresponding pulmonary blood flow was completely or incompletely recovered. Pathological examination: (1) control group: the embolization site and pulmonary angiography findings. Under light microscope, thrombus was found in pulmonary artery, massive hemorrhage in lung tissue and a large number of red blood cells in part of alveolar space. (2) treatment group: light pulmonary hemorrhage, a small amount of red blood cells in the alveolar cavity. Corresponding pulmonary arterial intima minor injury in HTD procedures. Conclusion The curative effect of combination of thrombus ablation and local thrombolysis in HTD ablator is better than that of local thrombolysis with local catheterization of pulmonary artery or ablation of HTD ablator, which has high safety.