Unclogging Qhov cuam tshuam ntawm Angiojet® Thrombectomy System Ntawm Lub raum Ua Haujlwm: Daim Ntawv Qhia Txog Cov Ntaub Ntawv
Mar 06, 2022
Yog xav paub ntxiv. hu rau:tina.xiang@wecistanche.com
Abstract
Keeb kwm: AngioJetyog ib txoj kev siv ntau zuj zus ntawm percutaneous mechanical thrombectomy rau kev kho mob ntawm cov neeg mob nrog arterial thiab venous thromboses.AngioJethas tau pom tias ua rau intravascular hemolysis universally. Peb tshaj tawm cov ntaub ntawv ntawm tus neeg mob hnub nyoog 29- xyoo uas tau txais AngioJet thrombectomy thiab tom qab txheej txheem tsim ib theem 3Mob raum raug mob(AKl.) xav tau kev kho lub raum hloov (RRT), theem nrab rau intravascular hemolysis. Peb lub hom phiaj los tshawb txog cov txheej txheem thiab cov teeb meem muaj feem cuam tshuam nrog kev tsim AKl hauv cov neeg mob no thiab qhia cov kauj ruam los txhim kho kev tswj tus neeg mob.
Case nthuav qhia: Ib tug txiv neej Caucasian uas muaj hnub nyoog 3 xyoos uas tau tsim muaj theem 3 AKl, yuav tsum tau RRT, tom qab AngioJet thrombectomy rau qhov occluded femoral leeg stent. Cov zis thiab cov kev soj ntsuam kuaj tau pom cov pov thawj ntawm intravascular hemolysis, uas yog qhov ua rau AKI. Tom qab lub sijhawm luv luv ntawm RRT, nws tau zoo tag nrholub raum ua haujlwm.
Cov lus xaus: AK yog ib qho teeb meem uas tau lees paub ntau ntxiv tom qab AngioJet thrombectomy, tab sis tseem tsis txaus ntseeg hauv kev kho mob.AKI tshwm sim los ntawm intravascular hemolysis tshwm sim los ntawm lub cuab yeej. Txog li 13 feem pua ntawm cov neeg mob xav tau RRT, tab sis tag nrho cov kev kwv yees luv luv yog qhov zoo. Cov txheej txheem ua ntej kev pheej hmoo rau kev txhim kho AKl suav nrog kev phais loj tsis ntev los no. Sodium bicarbonate yuav tsum tau muab rau cov neeg uas tsimlub raum tsis zoo. Lub raum biopsy muaj kev pheej hmoo siab thiab tsis ntxiv rau kev tswj hwm. Ntau tus kws kho mob paub txog thiab ceev faj txog AKI tom qab txheej txheem tuaj yeem tso cai rau kev lees paub ntxov thiab xa mus rau cov kev pabcuam nephrology rau kev tswj tsis tu ncua.
Ntsiab lus: Mob raum raug mob, Haemolysis, Deep vein thromboses, Arterial thromboses, Angiojet
Nyem qhov no kom paub ntau ntxiv
Keeb kwm
Arterial thiab tob venous thromboses (DVT) yog ib txwm muaj thiab tuaj yeem ua rau mob hnyav thiab tuag taus. Lub hauv paus tseem ceeb ntawm kev kho mob feem ntau suav nrog kev tswj hwm ntawm cov tshuaj antiplatelet lossis tshuaj anticoagulant, feem. Txawm li cas los xij, rau cov pob txha loj dua tuaj yeem muaj kev kho mob ntau ntxiv, txhawm rau txo qhov kev pheej hmoo ntawm cov teeb meem, suav nrog cov hlab ntsha embolization thiab post-thrombotic syndrome (PTS). Cov txheej txheem ib txwm siv rau kev tshem tawm cov ntshav nrog catheter-directed thrombolysis (CDT) tam sim no tau hloov pauv los ntawm Percutaneous mechanical thrombectomy (PMT) li, xws li AngioJet" hemolytic thrombectomy device (Pos-sis Medical, Minneapolis, Minnesota, USA) (henceforth Angio). Cov no yog ib qho kev siv ntau ntxiv ntawm kev kho mob endovascular rau ob leeg arterial thiab tob vein thromboses, vim qhov txo qis hauv lub sijhawm kho, kev saib xyuas mob hnyav, thiab tag nrho ntev ntawm kev nyob hauv tsev kho mob piv rau CDT cov tswv yim [1,2].
Angiojet · ntiav ntau lub dav hlau saline siab uas ua rau tawg ntawm cov hlab ntsha, thaum tib lub sijhawm xa cov tshuaj thrombolytic mus rau hauv cov ntshav. Cov nyhuv Venturi yog tsim los ntawm cov dav hlau, uas tso cai rau aspiration ntawm cov khib nyiab khib nyiab, thiab tiv thaiv cov hlab ntsha embo-lisation[3]. Txawm hais tias muaj txiaj ntsig zoo, cov txheej txheem ntawm kev ua haujlwm tau pom tias ua rau hemolysis tseem ceeb thiab niaj hnub ua rau cov txheej txheem tom qab hemoglobinuria. Qhov no nyob rau hauv lem yuav ua raumob raum raug mob(AKI), uas txawm hais tias muaj kev lees paub ntau ntxiv ntawm Angiojetremains underappreciated hauv kev kho mob. Tsib kis dhau los ntawm AKI tom qab Angiojet tau tshaj tawm hauv cov ntaub ntawv, ib qho ntawm cov menyuam yaus [4-8]. Peb tshaj tawm cov ntaub ntawv ntawm ib tug txiv neej muaj hnub nyoog 29- xyoo uas tsim ib qho mob hnyav Theem 3 AKI [9], yuav tsum tau kho lub raum hloov (RRT), tom qab AngioJet" thrombectomy ntawm occluded iliac leeg stent. qhov muaj feem cuam tshuam rau txoj kev loj hlob ntawm AKI hauv cov neeg mob uas tsis tau mus rau AngioJet", thiab qhia cov kauj ruam uas yuav tsum tau ua los txhim kho kev tswj hwm ntawm cov neeg mob no.
Case nthuav qhia
Ib tug 29-xyoo-laus tus txiv neej Caucasian uas paub sab laug flank cov tsos mob venous malformation (VM) (Daim duab 1) tau lees paub nrog 2-hnub keeb kwm ntawm sab laug ceg mob, o, thiab hloov pauv hloov mus rau DVT . Tsis muaj keeb kwm ntawm mob hauv siab, ua tsis taus pa, lossis palpitations. Ib xyoos ua ntej nws tau raug tso tseg cov leeg-iliac leeg stenting rau qhov uas tsis yog-thrombotic iliac vein lesion, kom thim rov qab venous rov qab los ntawm VM. Raws li nws tseem muaj cov tsos mob raws li cov txheej txheem no, xaiv txoj kev phais-thiab-khi ntawm lub nkoj loj pub rau VM tau ua peb lub lis piam ua ntej qhov kev nthuav qhia no. Los ntshav thaum lub sijhawm ua haujlwm no ua rau Apixaban, uas nws tau ua dhau los, raug tso tseg. Nws tsis muaj lwm yam keeb kwm kho mob yav dhau los, suav nrog tsis paub keeb kwm ntawm lub raum tsis zoo, thiab tsis muaj keeb kwm ntawm tsev neegmob raum. Thaum lub sij hawm ntawm kev nthuav qhia cardiorespiratory kuaj yog unremarkable. Kev kuaj mob ntawm lub plab tau qhia txog qhov ruaj khov, palpable loj nyob rau sab laug sab plab phab ntsa, ua raws li VM paub. Cov ceg sab laug sab laug tau o nrog mottling ntawm daim tawv nqaij tab sis txwv tsis pub muag thiab tsis muaj kev sib tw, thiab cov pulses peripheral tsis zoo.7500 units ob zaug ib hnub ntawm qhov hnyav molecular heparin (LMWH) tau pib thaum lub sijhawm nthuav tawm. Ua raws li CT venography (Fig.1) thiab duplex ultrasonography, uas tau txheeb xyuas qhov occluded venous stent, Angiojet thrombectomy thiab venoplasty tau ua raws li kev tshuaj loog dav dav los ntawm pab pawg phais vascular (Fig.2). Pre-operative clotting markers yog tag nrho nyob rau hauv ib txwm txwv (INR 1.1, APTR 1.1). Intraoperatively, 8000 units ntawm unfractionated heparin tau tswj hwm, ua raws li 15000 units ntawm LMWH ib teev tom qab txheej txheem. Ua tiav recanalization ntawm thrombosed stent tau tiav. Thaum lub sij hawm postoperative, nws tsim bradycardia thiab ntuav thiab kho nrog antiemetic thiab intravenous kua. Kev ntuav tshwm sim tom qab 36 teev. Nws tseem nyob hemodynamically ruaj khov thoob plaws. Tom qab kev phais mob ib ntus intravenous heparin infusion tau pib, txhawm rau tiv thaiv kev rov ua haujlwm ntawm stent.
Nws lub raum ua haujlwm tau pom tias poob qis tam sim tom qab, los ntawm lub hauv paus ntshav creatinine ntawm 77 μmol / L txog 168 umol / L (Fig.3). Tus neeg mob dhau cov zis liab tsaus, uas ntawm cov zis dipstick kuaj pom cov ntshav zoo. Lub raum ua haujlwm tau poob qis dua li 48 teev tom ntej (Daim duab 3). Kev tshawb nrhiav hauv chav kuaj pom pom cov ntshav lactate dehydrogenase (LDH) nce siab ntawm l148 U/L thiab haptoglobin qib qis ntawm 0.3 g/L, hemoglobin poob tom qab txheej txheem los ntawm 145 mus rau 86 g/L ( Table 1). Qhov kev kuaj ncaj qha antiglobulin tsis zoo. Kev kuaj ntshav ua ntej txheej txheem thiab hauv 72 teev tom qab txheej txheem tau qhia hauv Table 1. Kev kuaj ntshav rau lub raum thiab kab mob kis tau zoo tag nrho. Ultrasound ntawm ob lub raum thiab cov zis qhia pom qhov loj me (txoj cai 12.5 cm, sab laug 11.9 cm), tsis muaj kev cuam tshuam.lub raumob tog, nrog ib tug diffuse nce nyob rau hauv lub raum echogenicity thiab poob ntawm corticomedullary sib txawv. Incidentally, tus po tau sau tseg kom loj ntawm 13 cm. Ib tug duplex ultrasound paub tseeb patent rau lub raum vasculature thiab zoo perfusion ntawm ob lub raum.
Tus neeg mob tau raug xa mus rau lub raum ward 72 h tom qab txheej txheem vim qhov tsis tu ncua ntawm kev poob qis.lub raum ua haujlwmthiab cov zis tso zis poob (Fig. 2). Nws tau pib tswj hwm nrog 1.26 feem pua ntawm cov tshuaj sodium bicarbonate thiab 0.9 feem pua sodium chloride daws, kom tswj tau cov kua dej zoo. Txawm li cas los xij, cov zis tso zis txuas ntxiv poob thiab nws pib tsim cov pov thawj ntawm cov kua dej ntau dhau. Tom qab 48 teev ntxiv, qhov sib cuam tshuam hemodialysis (HD) tau pib ntawm txoj cai sab hauv jugular vascath. Plaub ntu ntawm HD tau ua tiav tag nrho (Fig. 3). Tom qab ntawd nws pib pom cov tsos mob ntawm lub raum rov qab nrog polyuria, dhau 3 litres ntawm cov zis ntshiab ib hnub. Kev txiav txim siab tsis ua rau lub raum biopsy vim tias muaj kev pheej hmoo siab los ntshav los ntawm kev sib xyaw heparin infusion. Nws raug tso tawm nrog creatinine poob thiab ib zaug thauj khoom ntawm warfarin. Thaum lub sijhawm sau ntawv, tus neeg mob lub raum ua haujlwm tau zoo dua qub, nrog rau cov ntshav creatinine ntawm 90 μmol / L (Fig. 3).
Kev sib tham thiab xaus
Haemolysis yog cov ntaub ntawv ua tau zoo ntawm AKI hauv ntau yam mob, suav nrog autoimmune hemolysis, paroxysmal nocturnal hemoglobinuria, thiab hemolysis theem nrab rau cov hlab plawv plawv [10]. AngioJet ~ yav dhau los tau pom tias muaj kev cuam tshuam thoob ntiaj teb hauv cov txheej txheem tom qab tag nrho cov haematuria, tom qab intravascular hemolysis tshwm sim los ntawm cov dav hlau saline siab [1]. Tsis tas li ntawd, cov xwm txheej dhau los ntawm AKI thib ob rau AngioJet--induced intravascular hemolysis kuj tseem muaj.
tau tshaj tawm [4-8]. Qhov tshwm sim ntawm hemolysis nyob rau hauv cov ntaub ntawv nthuav tawm, raws li muaj pov thawj los ntawm kev tso zis tsaus liab liab tom qab txheej txheem, poob hauv hemoglobin thiab haptoglobin, thiab nce hauv cov ntshav LDH yog qhov xav tau ntawm cov txheej txheem. Muab tus neeg mob lub hnub nyoog hluas thiab tsis muaj lwm yam kev pheej hmoo, kev ua haujlwm ntawm lub raum tsis zoo mus txog qhov xav tau RRT (Fig. 3), tsis tau xav txog. Tus neeg mob muaj qhov sib txawv me me ntawm qhov sib txawv hauv qhov ua haujlwm thiab ntuav tseem ceeb tom qab kev phais, ob qho tib si tuaj yeem ua rau AKI. Qhov hnyav ntawm AKI nrog rau qhov xav tau ntawm RRT, txawm hais tias muaj kev hloov pauv hloov pauv, qhia tias qhov ua rau lub raum tsis ua haujlwm zoo li hemolysis, raws li yav dhau los tau tshaj tawm.
Cov ntawv tshaj tawm dhau los tau pom tias muaj kev pheej hmoo ntxiv ntawm cov teeb meem tom qab lub raum biopsy hauv tsev kho mob hauv cov neeg mob uas tsim AKI, piv rau cov neeg mob sab nraud [12]. Muab qhov no thiab concomitant Heparin infusion, peb tus neeg mob tau pib tom qab AngioJet, qhov kev txiav txim siab tsis ua rau lub raum biopsy txhawm rau tshawb xyuas qhov ua rau AKI. Nws tau xav tias muaj pov thawj txaus ntawm hemolysis (raws li tau tham yav dhau los) ua rau AKI thiab qhov kev kuaj ntshav biopsy yuav ntxiv me ntsis los qhia kev tswj xyuas ntxiv. Ib qho kev tshawb fawb yav dhau los qhia txog kev tshawb pom ntawm lub raum biopsy hauv tus neeg mob uas tsim AKI post-AngioJet degree. Qhov kev tshawb fawb no tau tshaj tawm cov kev tshawb pom suav nrog kev raug mob ntawm tubular mob, cov ntshav liab cov khib nyiab hauv tubules,
thiab tubular epithelial hlwb thiab podocytes staining rau ferritin thiab haemo-oxygenase-1 (HO-1)[7]. Cov kev tshawb pom no qiv kev txhawb nqa rau ntau cov kev tshawb fawb uas qhia txog cov txheej txheem ntawm AKI tom qab hemolysis yuav muaj feem cuam tshuam nrog kev sib cuam tshuam ntawm cytotoxic inflammatory media-tors, qhib rau hauv cov lus teb rau cov hlau thiab hemoprotein ntau ntxiv los ntawm cov qe ntshav liab lysed. Lim hemoproteins induce tso tawm ferritin thiab HO-1, uas tiv thaiv oxidative kev nyuaj siab los ntawm scavenging dawb haem thiab hlau. Thaum cov txheej txheem tiv thaiv no dhau los, txawm li cas los xij, haem thiab hlau tuaj yeem muaj kev cuam tshuam ncaj qha rau glomeruli thiab tubular hlwb, ua rau lub raum tsis ua haujlwm [13].
Lub 'Peripheral Siv AngioJet Rheolytic Thrombec-tomy nrog ntau yam ntawm Catheter Lengths' (PEARL) kev sau npe tsuas yog luv luv hais txog kev koom tes ntawm AngioJet" thiab kev txhim kho ntawm AKI. PEARL tsis tau hais txog qhov xwm txheej ntawm AKI tsis xav tau RRT thiab hais tias. 5 feem pua ntawm cov neeg mob xav tau RRT tom qab 12 lub hlis tom qab txheej txheem, txawm li cas los xij, lawv tsis tau nthuav dav ntawm qhov qhia txog RRT, thiab tsis muaj kev daws teeb meem thiab tiv thaiv AKI hauv pawg no [14]. Morrow et al. tau soj ntsuam qhov tshwm sim ntawm AKI hauv cov neeg mob uas muaj cov hlab ntsha thiab cov hlab ntsha, ua rau PMT nrog Angio-Jet. }} feem pua (p=0.033), feem. Tsis muaj tus neeg mob PMT txawm li cas los xij xav tau RRT [15]. Ib yam li ntawd, Escobar li al. pom AngioJet" los ua ib qho kev pheej hmoo ywj pheej rau kev txhim kho ntawm AKI (qhov txawv txav. piv 8.22, p{{14 }}.004)[16]. Shen et al. kuj tau tshaj tawm tias muaj kev pheej hmoo ntau ntxiv ntawm AKI hauv cov neeg mob uas tau txais AngioJet rau iliofemoral DVT piv rau CDT, 22.8 feem pua thiab 9.2 feem pua (p=0.013), raws li. Tsis tas li ntawd, lawv tau pom qhov kev phais loj nyob rau hauv 3 lub hlis ua ntej kev cuam tshuam ntawm vascular, los ua ib qho kev pheej hmoo rau kev loj hlob hauv AKI post-AngioJet ~ (qhov txawv ntawm qhov sib txawv 8.51,p<0.01)[11]. our="" patient="" underwent="" excision-and-tie="" of="" the="" vm="" within="" 3="" months="" prior="" to="" angiojet,="" potentially="" placing="" him="">
nce kev pheej hmoo ntawm kev tsim AKI. Lwm yam tshaj li qhov kev phais loj tau ua nyob rau hauv 3 lub hlis ntawm kev cuam tshuam vascular [11], tsis muaj ib qho ntawm cov kev tshawb fawb tau txheeb xyuas ib qho kev pheej hmoo ua ntej rau kev txhim kho AKI, suav nrog cov xwm txheej pheej hmoo rau AKI. Ob leeg Escobar et al. thiab Shen li al.reported 2 cov neeg mob xav tau ib lub sij hawm ntawm RRT, 11 feem pua thiab 13 feem pua, feem [ll, 16].
Cov ntaub ntawv nthuav tawm zoo li zoo li piv rau lwm qhov xwm txheej ntawm AKI tseem ceeb tom qab Angio-Jet[4-8]. Peb tus neeg mob tau tsim AKI tam sim ntawd tom qab txheej txheem nrog hemolysis thiab cov pov thawj ntawm hemolysis, txawm tias muaj kev kub ntxhov hauv cov hlab ntsha. Tom qab lub sijhawm luv luv ntawm HD, muaj pov thawj ntawm lub raum rov zoo nrog cov zis tso zis ntau ntxiv thiab txhim kho cov ntshav creatinine (Daim duab 3). Nws tseem tsis tau paub meej txog seb puas muaj VM pab txhawb kev txhim kho AKI hauv peb cov neeg mob. Lub xub ntiag ntawm VM txhais tau tias muaj lub nra hnyav dua ntawm thrombus tam sim no, uas nyob rau hauv lem yuav xav tau cov txheej txheem ntev dua kom tshem tau. Nws yog ntseeg hais tias lub nra hnyav ntxiv tau tso cai rau qib siab dua ntawm hemolysis thiab yog li muaj kev pheej hmoo siab ntawm AKI hauv tus neeg mob no. Kev tiv thaiv thiab kev tswj hwm ntawm AKI cuam tshuam nrog hemolysis yog thaj chaw uas tseem tab tom tshawb nrhiav. Muaj qee cov pov thawj los qhia tias kev siv sodium bicarbonate tuaj yeem muaj txiaj ntsig los ntawm cov txiaj ntsig ntawm alkalinization, txo cov dawb radical tiam, thiab txo qis ntawm cov teebmeem ntawm oxidative kev nyuaj siab ntawm lub raum tubules [13](Table 2). Hauv qee tus neeg, txawm li cas los xij, cov kev ntsuas kev saib xyuas no ua tsis tiav thiab qhov kev xav tau rau RRT tej zaum yuav raug zam. Kev xa mus raws sijhawm rau cov kev pabcuam nephrology tso cai rau cov lus qhia txog kev kho cov kua dej thiab pib ntawm RRT, uas tsis tas yuav nkag mus rau chav saib xyuas mob hnyav. Cov ntaub ntawv no, nrog rau cov ntawv tshaj tawm dhau los, yuav qhia tias qhov kev cia siab luv luv hauv cov neeg mob uas tsim AKI tom qab AngioJet yog qhov zoo, nrog rau kev rov zoo ntawm lub raum ua haujlwm feem ntau. Cov kev tshawb fawb ntxiv yog xav tau txawm li cas los xij los txiav txim siab qhov cuam tshuam ntev ntev ntawm AKI tom qab AngioJet", suav nrog kev pheej hmoo ntev ntawm kev xav tau RRT.
AKI yog ib qho teeb meem ntau ntxiv tom qab AngioJet" thrombectomy tab sis tseem tsis txaus siab nyob rau hauv kev kho mob txhua hnub. Kev loj hlob ntawm AKI hauv cov neeg mob hauv tsev kho mob tsis cuam tshuam nrog AngioJet³ Kev phais loj hauv 3 lub hlis ntawm Angio-Jet9 yog tib qho kev pheej hmoo ua ntej tau tshaj tawm tias cuam tshuam nrog kev txhim kho ntawm AKI. Kev ntsuas los tiv thaiv AKI tom qab haemolysis tseem tab tom tshawb nrhiav, txawm li cas los xij, kev tswj hwm ntawm sodium bicarbonate tej zaum yuav muaj txiaj ntsig. Cov kws kho mob yuav tsum nco ntsoov txog kev pheej hmoo ntawm AKI cuam tshuam nrog AngioJet thrombectomy txhawm rau tso cai; kev tawm tswv yim tsim nyog thiab pom zoo t pre-procedure; post-procedural vigilance rau deterioration nyob rau hauv lub raum muaj nuj nqi; thiab xa mus rau cov kev pabcuam nephrology raws sijhawm thaum tsim AKI (Table 2).
Cov ntawv luv
AKI: mob raum mob;
CDT: Catheter-directed thrombolysis;
DVT: sib sib zog nqus hlab ntsha thromboses; HD: Hemodialysis;
LDH: Lactate dehydrogenase;
LMWH: Tsawg molecular hnyav heparin;
PEARL: Peripheral Siv AngioJet Rheolytic Thrombectomy nrog ntau yam ntawm Catheter Lengths;
PTS: Post-thrombotic syndrome; RRT: Kev kho lub raum hloov; VM: Venous malformation.
Cov ntaub ntawv
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