GENG Lin-ya, LIAO Sheng-kai, CHEN Yong-feng, ZHAN Zhao-jun, DU Xiao-ying, HONG Xiao, YU Song-tao, LI Xiao-liang. Clinical application of CTA combined with CDU-assisted anterolateral thigh flap in repairing and reconstructing defects after tongue cancer operation[J]. Chinese Journal of General Practice, 2021, 19(5): 749-752. doi: 10.16766/j.cnki.issn.1674-4152.001907
Citation: YUAN Wu-feng, JIANG Lei, ZHENG Su-jie. Effect of urokinase thrombolysis on coagulation function,D-dimer and NT-pro BNP in deep vein thrombosis patients with acute pulmonary embolism[J]. Chinese Journal of General Practice, 2017, 15(12): 2068-2070,2105. doi: 10.16766/j.cnki.issn.1674-4152.2017.12.019

Effect of urokinase thrombolysis on coagulation function,D-dimer and NT-pro BNP in deep vein thrombosis patients with acute pulmonary embolism

doi: 10.16766/j.cnki.issn.1674-4152.2017.12.019
  • Received Date: 2017-04-06
    Available Online: 2022-08-06
  • Objective To investigate the effect of urokinase thrombolysis on coagulation function,D-Dimer(D-D) and N-terminal pro-brain nitric peptide(NT-proBNP) in deep vein thrombosis patients with acute pulmonary embolism. Methods A total of 86 deep vein thrombosis patients with acute pulmonary embolism were randomly divided into observation group(43 cases) and control group(43 cases) from July,2014 to October,2016.The patients of the control group received initial low-molecular-weight heparin(LMWH) administration followed by warfarin therapy,while the patients of the observation group received additional low dose urokinase thrombolysis based on the control group.The course in both groups was 14 d.The clinical effect,coagulation function,D-D and NT-proBNP in both groups were observed. Results The effective rate of the observation group was significantly higher than that in control group(P<0.05).After the treatment,the levels of Platelet(PLT) and Fibrinogen(FIB) were not improved in both groups(P>0.05).The level of international normalized ratio (INR) increased significantly after treatment (P<0.05),however,there was no significant difference in the levels of INR,PLT and FIB between the two groups (P>0.05).After the treatment,the levels of D-D and NT-proBNP decreased significantly(P<0.05),and more significantly in the observation group(P<0.05).After the treatment,the circumference difference of knee above 20 cm and below 15 cm of the two groups decreased significantly(P<0.05),especially in the observation group (P<0.05). Conclusion Urokinase thrombolysis is effective in deep vein thrombosis patients with acute pulmonary embolism,maintaining coagulation function indexes within the normal range,and no bleeding.It can also improve the levels of D-D and NT-proBNP.

     

  • 舌癌是最常见的口腔颌面部恶性肿瘤,目前手术切除仍是治疗的第一道防线[1]。手术切除后常导致相应的组织缺陷,严重影响生存质量。因此,当舌缺损量超过一定限度时,尽可能进行修复重建。过去的40年,舌缺损的修复经历了一个从赝复体静态修复到功能性动态重建的漫长发展过程[2]。起初舌缺损修复的要求仅是关闭创面,防止并发症,当时多采用直接拉拢缝合或皮片移植,但术后功能不理想。随着游离皮瓣的应用发展,逐渐成为口腔癌术后缺损修复的主要手段。1983年自徐达传首次提出股前外侧皮瓣,次年罗力生等应用于临床并取得成功,因其血供丰富、可切取面积大、血管蒂长等优点,称为口腔颌面部修复的“万能皮瓣”[3-4]。但穿支变异限制临床应用,随着医学影像学的发展和应用,股前外侧皮瓣得到普及并在临床应用中不断改进推广。我科分别采用CT血管造影(CT angiography, CTA)联合彩色多普勒超声(color doppler ultrasonography,CDU)辅助股前外侧皮瓣设计及单独采用CTA及CDU进行术前评估及设计方法,均取得了良好的效果,报道如下。

    选取蚌埠医学院第一附属医院口腔科从2017年7月—2020年9月因舌癌需行手术修复的患者。纳入标准: (1)需行皮瓣修复舌缺损且不可直接拉拢缝者;(2)经检查后无全身转移患者。排除标准:(1)各种代谢类疾病及各种既往史无法行手术治疗患者;(2)碘造影剂过敏患者。研究经蚌埠医学院伦理委员会批准,所有患者及家属均知情同意。共选取40例患者,采用随机数字表法随机分为3组,A组20例为CTA联合CDU辅助股前外侧皮瓣进行术前规划;B组10例为利用CTA进行规划;C组10例为利用CDU进行规划。其中男性27例,女性13例,年龄29~76岁,平均约57岁。依据AJCC第八版TNM分类,Ⅱ期11例,Ⅲ期15例,Ⅳ期14例。3组患者的年龄、性别和临床分期相比,差异均无统计学意义(均P > 0.05),具有可比性,见表 1

    表  1  3组舌癌患者一般资料比较[例(%)]
    组别 例数 年龄(x ±s,岁) 性别 临床分期
    男性 女性
    A组 20 55.05±11.22 14(70.0) 6(30.0) 4(20.0) 8(40.0) 8(40.0)
    B组 10 55.70±14.15 6(60.0) 4(40.0) 4(40.0) 3(30.0) 3(30.0)
    C组 10 60.10±8.39 7(70.0) 3(30.0) 3(30.0) 4(40.0) 3(30.0)
    统计量 0.682a 0.342b 1.027b
    P 0.512 0.843 0.599
    注:aF值,bχ2值。
    下载: 导出CSV 
    | 显示表格

    术前1周,均获得40例患者同意后,分别予以40例患者完善术前检查。A组20例患者在GE256排Revolution CT机器下对其行双下肢动脉增强CT扫描(髂前上棘至髌骨)后进行体表标记[5-6]。并辅以LOGIQ S8型彩色多普勒超声(CDU)对CTA已定位的穿支血管进行复核,标记血流信号最强的2~3个穿支[7]。B组10例患者为单独利用CTA进行穿支定位;C组10例患者标记髂前上棘至髌骨中点,在超声探头下探查旋骨外侧动脉处穿支点并进行体表标记。

    A组术前通过CTA联合CDU成像来评估和追踪穿支的位置和特征。扫描完成后,将获得的DICOM数据导入MIMICS软件中,利用软件对旋股外侧动脉、骨骼及周围组织进行三维重建,创建供区三维可视化模型[8],见图 1。B组患者术前将CTA数据导入工作站进行三维重建后观察穿支及周围解剖特点,通过建立坐标进行皮肤定位。C组患者在体表皮肤之间标记超声探头下路径短信号强2~3个穿支,见图 2。3组患者分别结合舌癌术后预计组织缺损部位、大小、外形来设计个性化皮瓣。3组患者根据穿支点的位置,及舌癌术后缺损的情况来设计皮瓣。

    图  1  CTA进行三维重建
    图  2  CDU寻找适宜穿支

    沿画好的标志线先切开内侧缘,依次分离各层组织后小心将瓣翻起,寻得穿支血管后,记录穿支点的实际位置及穿支类型,与术前3组测量结果对比。受区处理完成后将皮瓣断蒂,将旋股外动脉降支于颌面部动静脉端端吻合,进行超引流,勒血试验正常,将皮瓣修剪后分层缝于创面[9]

    予以患者常规行生命体征监测,并予以抗凝、抗感染、补液吸氧等对症处理同时嘱以患者头部制动。尤其是术后72 h,对皮瓣进行严密监测,观察皮瓣的颜色、弹性等,提示有血管危象及时进行处理和探查。

    观察术中解剖穿支点与术前影像定位是否符合,术中实际穿支位置与术前定位点距离在1 cm以内都视认为定位穿支点符合;术前利用影像资料预判穿支类型与术中解剖时发现是否一致,若一致视为穿支类型符合;同时对制取皮瓣的时间及术后住院天数进行记录。

    采用SPSS 26.0统计学软件进行统计学分析,符合正态分布的计量资料以x ±s表示,2组间比较采用独立样本t检验,3组间比较采用方差分析,两两比较采用LSD-t检验;计数资料采用例(%)进行描述,组间比较采用χ2检验;病例数小且有理论数小于1,均采用Fisher精确概率法;等级资料采用Kruskal-Wallis H检验。P < 0.05为差异有统计学意义。

    40例皮瓣成活率为92.5%,平均皮瓣面积为(5.0 cm×6.0 cm)~(5.0 cm×12.0 cm),其股前外侧肌皮瓣8例,股前外侧皮瓣27例,修薄皮瓣5例;肌皮穿支20例,肌间隔穿支14例,直接皮穿支6例,供受区伤口一期愈合,均无明显并发症。A组1例肌皮瓣术后72 h出现静脉危象予以及时探查抢救后皮瓣部分坏死,肌瓣存活,B组及C组患者各有1例患者出现静脉危象抢救后仍坏死。

    A、B、C三组在定位穿支点符合率上及术后住院天数方面差异无统计学意义(P > 0.05);A、C 2组在穿支类型符合率上差异有统计学意义(P=0.002);A组与B、C 2组在皮瓣制备时间方面差异有统计学意义(A组与B比较,P=0.016;A组与C比较,P=0.002),见表 2

    表  2  3组舌癌患者手术情况比较
    组别 例数 穿支点符合率[例(%)] 穿支类型符合率[例(%)] 皮瓣制备时间(x ±s,min) 术后住院天数(x ±s,d)
    A组 20 20(100.0) 20(100.0) 39.75±6.29 9.25±2.04
    B组 10 9(90.0) 9(90.0) 46.20±4.29c 9.70±2.21
    C组 10 9(90.0) 5(50.0)b 48.10±8.66c 9.50±1.90
    统计量 6.564d 0.169d
    P 0.244a 0.001a 0.004 0.845
    注:a为采用Fisher精确检验;与A组比较,bP < 0.017(采用卡方分割,检验水准α校正=0.017),cP < 0.05;dF值。
    下载: 导出CSV 
    | 显示表格

    舌癌作为口腔颌面部最常见的恶性肿瘤之一,术后缺损往往会导致舌畸形与功能障碍,舌缺损的修复方案主要是依据舌体缺损的部位和范围而定。舌癌术后常以穿支皮瓣作为修复缺损的主要手段。其中股前外侧穿支皮瓣又因具有不牺牲主要血管、可直接缝合宽度小于9 cm的伤口、术后对供区形态功能影响小等诸多优点,并且修复范围广包括头颈、躯干和四肢,切取面积大,被称为“万能皮瓣”[10]。但其在切取应用中的最主要困难是血管解剖变异较大,术前确定股前外侧皮瓣的穿支对外科医生来说仍然是一个挑战。有学者研究穿支血管发现,每侧股部存在1~3支穿支血管, 大多数穿支血管位于髂前上棘与髌骨外侧缘连线中点上下5.0 cm范围内[11]。然而,又由于血管解剖是可变的,包括不确定的穿支起源、路线等,并且穿支可变性是术前皮瓣设计一项尤为关键的限制。一些研究描述解剖时发现接近5.4%~16.0%的患者缺乏可用于手术的最佳皮肤穿支[12]。所以仅通过手术医师的经验及解剖学研究定位穿支血管存在一定的盲目性且难以进行合理的术前规划,从而易导致皮瓣制备失败或供区创伤过大。因此,皮瓣的术前设计尤为关键。术前对穿支动脉的分析可以准确识别其位置和方向,从而选择最佳动脉,改善皮瓣设计,减少手术时间和供区损伤[13]

    近年来,多种血管影像学技术被研究与应用,其中最为广泛应用的是CDU及CTA。起初CTA的使用主要是针对腹壁下动脉穿支皮瓣进行检查,后期有众多学者在研究中描述了CTA在股前外侧皮瓣术前成像中的重要价值[14-15]。笔者在术前予以患者采用Philips 256排螺旋CT扫描双下肢髂前上棘至髌骨平面,利用软件工具对旋股外侧动脉及周围软硬组织进行三维重建,创建供区三维可视化模型,从而定位皮瓣的穿支血管。CTA结合三维重建技术,可清晰明确血管走行、管径粗细及与周围毗邻组织的关系,从而实现CTA对体表投影定位[16]。术前对路径和穿支类型认识可缩减获取皮瓣所需的时间,特别是在一些有难度的贯穿型病例中,术前可以更好规划设计不同类型的股前外侧皮瓣,从而减少操作难度[17]。CTA之所以被大多数研究认为是“金标准”,它的预期效用是毋庸置疑的,但CTA检测小的穿支的灵敏度不如直径大于1 mm的穿支,并且CTA无法判断穿支的血流动态信息。本研究结果发现CTA联合CDU组与CTA组虽在定位穿支符合率方面差异无统计学意义(P > 0.05),但是CTA组定位穿支符合率仅为90.0%,与体表定位存在偏差,在临床实践中发现可能因为CTA技术在终末支及阔筋膜浅层的显影缺陷造成测量偏差。而且,笔者发现利用MIMICS进行三维重建时,也仍存在一些不足,比如过于细小的穿支血管重建困难,体表定位与术中实际略有偏差,一方面考虑患者行CT检查时体位与手术体位不同,另一方面软组织可牵拉形变造成[18]

    目前CDU仍是手术医生确定穿支最常用的辅助手段之一,但是大多数学者已经证明CDU会产生相当多的假阳性和假阴性。因为它既不能识别穿支全部走行,也不能清晰识别穿支和主要血管蒂之间的信号,导致某些血流信号可能被误读,可能耽误手术医生术前进行最佳穿支的选择。但是其提供了精确的血流动力学变化的信息[19],可动态地检测血管峰值流速(PSV),这种技术在识别适宜穿支中具有一定优势[20],并且对于鉴别动静脉具有很高的准确性,它成本低,无创性和在大多数医院的可用性且易于操作,所以CDU仍作为术前定位常用手段。本研究结果显示, CTA与CDU 2组在几个方面相比,差异均无统计学意义。可见CTA和CDU都可以在术前有效进行穿支定位,但他们都存在各自的优缺点。联合应用CTA及CDU组中,二者协同预估穿支类型和行径进行术前皮瓣规划和设计明显优于单独使用组,同时使用2种方法可为外科医生提供精确的穿支定位信息,增加其在手术过程中的信心、提高手术成功率。

    CTA是静态地图,而CDU是动态导航[21],具体来看,CTA三维可视化重建并结合CDU有以下优点: (1)CTA结合数字软件可以更客观、准确、直观地显示穿支血管及其周围组织的三维空间图像,术者可以自由选择观察角度,多方面观察和评估血管,从而获取血管蒂长度、直径等解剖信息,弥补了CDU反映穿支源动脉解剖信息的不足。(2)便于根据不同患者的实际临床需要进行手术方案的设计,穿支血管的选择,组织瓣的制备等。如患者舌缺损范围较小,仅需制备单纯的皮瓣,重建图像中尽量选取肌间隔穿支,若涉及舌和口底或其他部位软组织的大面积缺损,则需制备肌皮瓣或双叶瓣,尽量选取肌皮穿支血管或来源于同一源动脉的两个穿支血管,简化了肌肉部分穿支血管的解剖,排除来源于非同一源动脉的两条穿支血管,从而降低手术难度,缩短手术时间,减轻手术创伤[22]。(3)利用CTA识别穿支血管同时辅以CDU复核穿支血管,弥补CTA在终末支及阔筋膜浅层的显影缺陷,优化皮瓣术前设计[17]

    本次研究通过CTA联合CDU辅助股前外侧皮瓣在舌癌术后缺损修复重建中的应用,发现各组在穿支类型符合率及制备时间方面存在明显差异(均P < 0.05)。两者协同可更好地指导临床实践,详细了解穿支变化,选择优势穿支,利于皮瓣设计,减少术后并发症。认为在条件许可的情况下应用CTA联合CDU辅助设计个性化的股前外侧穿支皮瓣,有助于降低手术风险,确保皮瓣移植的成功率。

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