下肢骨折术后并发深静脉血栓形成的治疗与护理

目的:探讨下肢骨折术后深静脉血栓形成患者经下腔静脉滤器置入留置导管溶栓的疗效与护理.方法:对31例下肢骨折术后患者采用彩色多普勒超声检查仪检查,在DSA引导下阻断患肢浅静脉经足背静脉留置针注入碘比醇20ml,观察深静脉阻塞的程度及血栓的范围.采用Seldiinger技术,经皮健佣股静脉穿刺置人导管鞘先行下腔静脉造影,经5F猪尾导管以20ml/s速度注入碘比醇30ml,了解双侧肾静脉开口位置,于双侧肾静脉开口下方置入下腔静脉滤器;然后经导管鞘送入溶栓导管,将溶栓导管头端置于血栓内,用肝素冒封好溶栓导管尾瑞,每8小时经溶栓导管推注10万单位尿漱酶溶液50ml(将10万单位尿激酶溶液50ml生理盐水中),常规抗凝并给予真对性护理干预.结果:31例患者治疗3～10天血栓完全溶解,血管通畅,所有患者于滤器置入第10～14天内取出.性别、年龄、骨折部位及有无合并高血压、糖尿病的骨折患者术后下肢深静脉血栓形成有显著性差异(P<0.01).结论:下腔静脉滤器置入留置溶栓导管治疗下肢深静脉血栓形成的患者,做到严密观察、细致护理,对减少并发症的发生具有积极临床意义.     

肥胖患者侧卧位微创经皮肾镜取石术导丝误入右心房及肾造瘘管误入腔静脉一例报告并文献复习

目的 探讨肥胖患者行B超引导下侧卧位微创经皮肾镜取石术(mininimally invasive percutaneous nephrolithotomy,MPCNL)中肾静脉损伤导致造瘘管置入腔静脉、导丝进入右心房的处理方法. 方法 回顾性分析2014年5月收治的1例左输尿管结石左肾积水男性患者的临床资料.年龄30岁.因反复左侧腰部疼痛5年,检查发现左肾结石伴左肾积水入院.患者有大量饮酒史3年,高血压病、糖尿病史6个月.体质指数35.9 kg/m2.查体:血压150/110 mmHg(1 mmHg=0.133 kPa).左肾区叩痛明显.B超检查:左侧肾盂输尿管连接处见约1.5 cm×1.0 cm强光团,后伴声影,左肾中度积水.CT检查:左侧输尿管上段结石伴左肾中度积水,增强扫描左肾皮质CT值100 HU.全麻下行B超引导下侧卧位MPCNL.术中建立经皮肾通道时因出血导致视野不清,留置斑马导丝及肾造瘘管准备二期行MPCNL. 结果 术后第7天复查CT发现导丝位于右心房,肾造瘘管位于腔静脉内达肝门水平.在CT引导下拔出导丝,每次约10 cm,观察5 min,患者无不良反应则再拔出10 cm,共5次将斑马导丝退入肾造瘘管内,将肾造瘘管退至肾分支静脉内距肾盂1 cm处停止,待分支肾静脉穿刺口血栓形成和愈合.术后第9天再次在CT监视下将肾造瘘管退入肾盂内,引流出清亮黄色尿液.术后第14天在全麻下经原通道行MPCNL,于肾盂输尿管连接处寻及约1.5 cm×1.0 cm结石,在输尿管镜下行气压弹道碎石术,检查各肾盏及输尿管上段无残石后,留置双J管及肾造瘘管,术中及术后无血尿,患者无不适.二次手术后3d拔除肾造瘘管.二次手术后1个月拔除双J管,患者无特殊不适. 结论 肥胖患者行B超引导下侧卧位MPCNL时经皮肾通道建立难度大,术中穿刺深度与术前CT检查测量的距离存在误差,易导致损伤.术中肾静脉损伤及肾造瘘管误入腔静脉时,可以通过夹闭造瘘管进行止血.在充分做好抢救准备的前提下,可在CT引导下分次逐步拔除导丝及造瘘管.     

可回收下腔静脉滤器在DVT治疗中的应用

目的探讨临时性下腔静脉滤器在下肢深静脉血栓(DVT)治疗中的应用。方法对28例下肢深静脉血栓(DVT)患者的临床资料进行回顾性分析。采用Seldinger技术穿刺健侧股静脉,先行下腔静脉造影,明确下腔静脉管径、有无血栓及肾静脉开口位置,换导引长鞘,将滤器送入距肾静脉下缘1.5cm处释放,再次造影,证实滤器准确无误,拔管局部加压包扎,术后抗凝治疗。除1例外,其余病例均于14～22d经原路径应用抓捕器取出下腔静脉滤器。结果 27枚滤器取出。在滤器上均可见多少不等的血栓;1例置入15d时滤器被大量血栓阻塞,经手术取栓后,置溶栓导管溶栓,好转,未取滤器。无肺栓塞发生。结论应用临时性滤器可以有效的防止肺栓塞的发生。     

经皮肾手术肾造瘘管误入静脉系统的诊治分析

目的探讨经皮肾手术肾造瘘管误入静脉系统的诊治特点。方法回顾性分析2006年1月至2020年12月湖南省郴州市第一人民医院和湖南省郴州市第四人民医院共收治的6例肾造瘘管误入静脉系统患者的临床资料。男4例, 女2例;中位年龄41.0(38.5, 53.0)岁;有对侧上尿路手术史3例, 同侧上尿路手术史1例, 无上尿路手术史2例;孤立肾2例;铸形肾结石2例(合并轻度肾积水1例, 中度肾积水1例), 输尿管结石4例(合并轻度肾积水2例, 中度肾积水1例, 重度肾积水1例)。6例均行经皮肾镜取石术(PCNL), 术中在筋膜扩张器扩张后, 拔出扩张器内芯时血液由工作鞘涌出, 立即留置肾造瘘管并夹闭, 结束手术。5例术后返回病房后行CT检查明确诊断, 1例术中经肾造瘘管注入造影剂肾静脉显影, 早期明确诊断。6例中行左侧手术5例, 右侧1例;肾造瘘管末端位于同侧肾静脉内3例(均为行左侧手术), 经同侧肾静脉至下腔静脉2例(均为左侧手术), 经同侧肾静脉、下腔静脉至对侧肾静脉1例(行右侧手术)。6例均无合并肾静脉或下腔静脉血栓。监测患者生命体征, 严格卧床, 予抗感染治疗;保持造瘘管夹闭状态, 采用一步...     

导管溶栓及置入下腔静脉滤器预防肺栓塞的临床应用

目的评价导管溶栓治疗下肢深静脉血栓形成的效果及置入下腔静脉滤器预防下肢深静脉血栓脱落引起肺栓塞的价值。方法48例下肢深静脉血栓患者分别经股静脉（40例）、右颈静脉（8例）置入下腔静脉滤器，滤器位于双。肾静脉水平以下的下腔静脉内，下腔静脉滤器植入后将溶栓导管插入血栓之髂股静脉进行溶栓。药物：尿激酶80-100万u，肝素1mg／kg。结果下腔静脉滤器置入全部成功，术中导管溶栓32例完全再通及部分再通，余16例术后溶栓成功。结论经导管术中溶栓成功率高，效果好，置入下腔静脉滤器防止肺栓塞是安全有效的方法。     

B超定位下经皮肾造瘘术并发肾静脉损伤三例报告

目的 总结经皮肾造瘘术(PCN)中肾静脉损伤的处理方法.方法 PCN术中发生肾静脉损伤3例.男2例,女1例.年龄分别为43、55及72岁.例1因左肾鹿角形铸型结石行左肾经皮肾镜取石术(PCNL),术中穿刺扩张后出现大出血,留置肾造瘘管并夹闭.CT检查提示肾造瘘管进入下腔静脉,并通过右心房进入右颈内静脉.例2因右肾下盏结石行右肾PCNL,B超定位穿刺成功后有少量出血,扩张至16 F鞘后出现大出血,KUB示肾造瘘管进入肾静脉.例3因胃癌晚期肿瘤侵犯双侧输尿管,导致双肾积水、肾衰竭,行右肾PCN术弓l流尿液.穿刺后出现静脉性出血,放置肾造瘘管并夹闭,KUB示肾造瘘管部分进入下腔静脉.3例患者术后48h内在X线监视下逐次将肾造瘘管退至肾静脉破口处,24～48h后再退至集合系统.每次退管3～4cm.结果 3例出血均控制,血液动力学状态稳定.拔管后均未出现再出血,未行外科手术干预,未出现肾功能进一步损害.结论 PCN术中肾静脉损伤及其导致的严重静脉性出血可以通过留置并夹闭肾造瘘管,分次逐渐退出肾造瘘管而愈合.该方法可以避免外科手术干预,不会对患肾功能造成进一步损害.     

经皮肾镜取石术并发乳糜尿的诊治:附1例报告并文献复习

目的探讨经皮肾镜取石术(PCNL)并发乳糜尿的临床特点及治疗方法。方法回顾性分析2011年5月收治的1例PCNL并发乳糜尿的临床资料,并进行文献复习。患者,女,64岁,因"左肾盂肾下盏结石"行"左侧微通道PCNL",术后当天发现左肾造瘘管和尿管均引出乳白色尿液,尿乳糜尿试验(+++),左肾造瘘管造影显示左肾周丰富的淋巴管显影。通过逆行插入肾盂输尿管连接部封堵器堵塞左输尿管上段,经左肾造瘘管注入2%硝酸银溶液15ml,每次留置10min,共3次。结果术后左肾造瘘管引流尿液变清,尿乳糜尿试验(-),随访9个月未见乳糜尿复发。结论经皮肾镜取石术并发乳糜尿较罕见,确诊依靠其临床表现、乳糜尿试验及相关影像学检查,低脂饮食、肾盂内硬化剂灌注和肾蒂淋巴管结扎术为其可选的治疗方法。     

复杂可回收下腔静脉滤器回收的方法和技巧：附29例分析

目的:探讨复杂可回收下腔静脉滤器回收的方法和技巧。方法:回顾性分析29例复杂滤器回收的下肢深静脉血栓形成患者资料。所有患者均先行造影了解滤器情况;对回收钩贴壁患者,分别采用猪尾管支撑技术、导丝成攀及搅拌技术、双向导丝技术、鹅颈抓捕器与成攀导丝结合技术等回收;对下腔静脉继发血栓患者,必要时再次新置滤器1枚,经溶栓、吸栓处理后,将滤器回收。结果:成功回收24例,1例患者滤器未能成功回收,4例放弃,回收率83.9%。术中无下腔静脉破裂出血、肺栓塞并发症,取出滤器完整、无折断现象。至少随访半年,下腔静脉血流通畅、无血栓形成,腹腔无明显积液。结论:导管、导丝及鹅颈抓捕器辅助,溶栓、吸栓等方法可增加复杂可回收下腔静脉滤器回收率,可减少长期留置引起相关并发症。     

B超引导经皮肾造瘘术中并发肾静脉损伤3例临床分析

目的总结经皮肾造瘘术中肾静脉损伤的原因及处理策略。方法回顾分析2009~2014年间经皮肾造瘘及经皮肾镜取石术发生的3例肾静脉损伤患者的临床资料。男性1例,女性2例;均在建立经皮肾通道过程中发生导丝穿入肾静脉,肾造瘘管沿导丝误入肾静脉及腔静脉,术后经CT检查明确。3例患者术后均在彩超监测下分次逐步拔除肾造瘘管。结果 3例患者拔除肾造瘘管后,未发生肾静脉瘘口出血,未行外科手术干预,未出现肾功能损害。结论经皮肾造瘘术中发生肾造瘘管误入肾静脉后,采用留置并夹闭肾造瘘管、分次逐步拔除肾造瘘管是安全可靠的,可以避免外科手术干预。     

双下腔静脉合并双下肢深静脉血栓形成及肺动脉栓塞一例

患者女,51岁,主因双下肢肿胀伴心悸及胸闷3d.经下肢静脉超声及胸部强化CT诊断为急性双下肢深静脉血栓形成、肺动脉栓塞,拟行下腔静脉滤器置入术.术中经左股静脉行下腔静脉造影,发现下腔静脉沿椎体左侧上行,于肾静脉开口上方水平转向脊柱右侧.于是行右股静脉穿刺,经双侧股静脉穿刺处鞘管同时行下腔静脉造影,发现双下腔静脉.右肾静脉在L1椎体水平、左肾静脉在L2椎体水平分别汇入右侧下腔静脉和左侧下腔静脉,双侧下腔静脉在L1椎体上缘水平汇合成总下腔静脉,在总下腔静脉放置滤器1枚.术后给予抗凝等治疗.术后3年随访,患者长时间活动或站立后双下肢轻度肿胀,余无明显不适.     

Percutaneous insertion of the Greenfield inferior vena cava filter: experience with ninety-six patients

This article evaluates the ease, safety, and convenience of percutaneous Greenfield filter placement and compares percutaneous with surgical placement. Greenfield filters were inserted percutaneously into the inferior vena cava in 96 patients. Ninety filters were placed via the femoral route and 12 were placed from the right internal jugular vein. Six patients had two filters inserted. An inferior venacavogram was performed before filter insertion in all patients. Cavography provided vital information concerning diameter of the inferior vena cava, the level of the renal veins, and the presence and location of thrombus. Filter placement was accomplished in all patients in whom it was attempted. There were four minor complications and one periprocedural death. The incidence of documented femoral vein thrombosis that could be related to percutaneous placement via the femoral veins was 33%; however, none of these patients had permanent venous stasis sequelae. Percutaneous insertion of the Greenfield filter is a safe and convenient procedure and is superior to surgical placement in terms of time, logistics, and the accuracy of filter positioning.     

Temporary inferior vena cava filter applied to 4 patients with urological disease

A temporary inferior vena cava (IVC) filter was placed in 4 patients. Patient 1 had an advanced testicular germ cell tumor with IVC tumor thrombosis, patient 2 presented with a large adrenal tumor with IVC tumor thrombosis, patient 3 was found to have deep vein thrombosis following grade 3b renal injury, and patient 4 was suffering severe SLE with renal vein thrombosis. The temporary inferior vena cava filter prevented pulmonary thromboembolism in all cases, and no adverse reaction was observed. Temporary inferior vena cava filter is safe and useful to prevent pulmonary thromboembolism associated with urological disorders.     

永久性下腔静脉滤器在下肢深静脉血栓治疗中的中长期疗效及应用价值

目的 总结永久性下腔静脉滤器在下肢深静脉血栓治疗中的中长期疗效并评估其应用价值.方法 回顾性分析上海交通大学医学院附属仁济医院血管外科2010年1月-2015年10月置入永久性下腔静脉滤器的86例下肢深静脉血栓的病例资料,其中男性41例,女性45例,年龄50 ～ 94岁,平均年龄71.8岁.深静脉血栓位于左下肢51例,右下肢25例,双下肢10例,合并肺栓塞6例.滤器置入后,无溶栓禁忌者行导管溶栓,必要时行髂股静脉球囊扩张及支架置入.术后除抗凝禁忌者外,均采用抗凝治疗.结果 所有患者均一次性放置滤器成功.置入贝朗Vena Tech LP滤器76例,强生TrapEase滤器10例.单纯滤器置入65例,滤器置入+导管溶栓7例,滤器置入+导管溶栓+球囊扩张/支架置入14例.随访12～81个月,平均51个月,死亡27例,均非滤器相关性,其中恶性肿瘤17例,其他死因10例.深静脉血栓复发3例,支架狭窄伴血栓形成2例.滤器倾斜6例,倾斜角度＜15°,滤器下方血栓形成3例,滤器明显移位2例,无滤器断裂、下腔静脉穿孔及出血等发生,无症状性肺栓塞新发或者复发.结论 永久性滤器可以有效预防下肢深静脉血栓导致的肺栓塞,但长期留置可能导致相关并发症,对于高龄或者合并晚期肿瘤等、预期寿命有限的患者,永久性滤器仍是不错的选择.     

Successful treatment of acute inferior vena cava and unilateral renal vein thrombosis by local infusion of recombinant tissue plasminogen activator

Renal vein thrombosis can occur as a complication of nephrotic syndrome. We present the case of a young man with nephrotic syndrome caused by minimal change disease who developed acute inferior vena cava and left renal vein thrombosis. He was treated initially with intravenous heparin. Because of the persistence of severe left flank pain and gross hematuria, local infusion of recombinant tissue plasminogen activator was tried, with resolution of thrombi and subsidence of symptoms. Functional preservation of the involved kidney is good, as indicated by Tc-99m DMSA scan (involved kidney, 47.4%; uninvolved kidney, 52.6%). Anticoagulation is usually recommended as the treatment of choice in renal vein thrombosis. We believe that in cases with critical presentations, such as bilateral involvement, extension into inferior vena cava, acute renal failure, pulmonary embolism or severe flank pain, thrombolytic therapy should be considered as a second-line treatment if good response is not obtained with heparin.     

Insertion of the inferior vena cava filter followed by iliofemoral venous thrombectomy for ischemic venous thrombosis

An elderly man, with ischemic venous thrombosis of the left lower extremity, underwent insertion of the inferior vena cava filter through the right internal jugular vein, followed by left iliofemoral venous thrombectomy with the Fogarty balloon catheter, both with fluoroscopic guidance. The inferior vena cava filter was inserted before venous thrombectomy to prevent pulmonary embolism from dislodged clots during the latter procedure.     

Deep venous thrombosis during neoadjuvant chemotherapy in a patient with osteosarcoma: a case report

A 29-year-old man with an osteosarcoma of the left distal femur developed asymptomatic deep venous thrombosis (DVT) during neoadjuvant chemotherapy. The thrombotic event occurred in the left common iliac vein and was revealed by pelvic computed tomography (CT). We successfully performed a limb salvage operation with placement of a permanent inferior vena cava filter. The thrombus spontaneously regressed without thrombolytic therapy after surgery. We should consider DVT in patients with musculoskeletal sarcomas who are under long-term hospitalization and immobilization associated with not only surgery but also chemotherapy. To screen for both metastasis and DVT, we recommend contrast-enhanced whole-body CT, including scans of the pelvis.     

Transatrial interruption of the inferior vena cava

Transatrial placement of a Greenfield filter at the time of cardiac surgery was performed on three patients with recent femoral venous thrombosis and unstable angina, and at the time of pulmonary embolectomy on four others. The filter carrier was passed through the right atrial cannulation site under fluoroscopic guidance into the inferior vena cava. A preliminary venacavogram was performed through the carrier or a previously placed angiographic catheter. Two complications were encountered: the first was misplacement of a filter in the right renal vein before routine venacavography was employed; the second was caudal displacement of a filter by a right atrial venous drainage cannula that projected into the inferior vena cava. The latter complication can be prevented by the use of a right atrial "sump" drain that does not protrude into the inferior vena cava.     

Thrombosed aneurysm of the infrarenal vena cava: diagnosis and treatment

Aneurysms of the inferior vena cava are rare. Usually they are diagnosed incidentally or due to the patient having suffered thromboembolic complications. We report one case of a patient admitted due to deep vein thrombosis of his left lower limb in whom a thrombosed mass of the infrarenal vena cava and of both proximal common iliac veins was detected by duplex, CT scan and MRI. The additional information obtained by the phlebography showed abundant collateral circulation via ascending lumbar veins, suggesting gradual occlusion rather than sudden thrombosis. Guided biopsy was not contemplated and the patient underwent surgery with a diagnosis of thrombosis of the infrarenal vena cava due to suspected malignancy versus aneurysm. Intraoperative anatomopathological examination revealed no evidence of malignancy and partial resection with infrarenal vena cava ligation was performed. After six months the patient remains well under oral anticoagulation. On the basis of the literature and taking into account this case, the management of aneurysms of the inferior vena cava when they have already suffered thrombosis should include open surgery which allows us to make the diagnosis with certainty and treatment of the patient.     

Extensive Inferior Vena Cava Thrombosis in a Liver Transplant Patient: A Case Report

Thrombosis of the inferior vena cava is a clinical condition with very diverse presentations, ranging from asymptomatic patients to others with severe edema in the legs and lower torso. We report the case of a 27-year-old female patient, previously diagnosed with autoimmune hepatitis, with asymptomatic extensive thrombosis of the inferior vena cava. The thrombus extended from the renal veins up to the emergence of the hepatic veins, causing post-sinusoidal portal hypertension (Budd-Chiari syndrome). The patient underwent an orthotopic cadaveric liver transplant with removal of the retrohepatic vena cava and thrombectomy of blood clots from the infrahepatic vena cava. She initially recovered well from surgery, but on the 8 postoperative day she had a significant increase in hepatic injury markers and was diagnosed with rethrombosis of the inferior vena cava and hepatic veins. A surgical thrombectomy was performed, with an intraoperative finding of chronic thrombus in both renal veins, previously undiagnosed. The thrombectomy was successful, but the patient's hepatic function continued to worsen and a second liver transplant was performed. After the second transplant she underwent several imaging exams that showed no signs of rethrombosis. She was kept on postoperative anticoagulation indefinitely, first with intravenous heparin then with rivaroxaban. An extensive investigation failed to identify any causes of thrombophilia associated with this vast thrombosis. She is currently alive and with good graft function 1 year and 4 months after the second transplant.     

Cauterization of access tract for nephrostomy tube-free percutaneous nephrolithotomy

BACKGROUND AND PURPOSE: Percutaneous nephrolithotomy (PCNL) is now a popular method for removal of renal and ureteral stones. Placement of a nephrostomy tube after the completion of PCNL has been considered a standard procedure by most urologists, but some authors have recently challenged this practice. Bleeding is one of the most prevalent problems after nephrostomy tube-free percutaneous renal surgery. To diminish the possibility of postoperative bleeding, we cauterized the PCNL tract to make it bloodless. The efficacy and safety of this procedure were reviewed in this study. PATIENTS AND METHODS: From March 2001 to March 2003, 51 patients underwent PCNL with a one-stage procedure and a single access tract. The stone size ranged from 1.0 to 7.0 cm (mean 2.7 +/- 1.4 cm). A holmium:YAG laser and pneumatic lithotripter were used. After stone extraction, a 6F double-J catheter was inserted antegrade. The access tract was checked, and the bleeding points were cauterized. No nephrostomy tube was inserted, but a Penrose drain was left overnight. Perforation of the collecting system was not a contraindication to tubeless PCNL. RESULTS: The stone-free rate was 80.4%, including five patients with complete staghorn stones. Twenty-one patients required postoperative analgesics. Only one patient had urine leakage for longer than 24 hours. Transient low fever was noted in five patients, but no patient experienced severe urinary tract infection. Delayed hemorrhage (1 week after the operation) secondary to irritation by the double-J ureteral stent was noted in one patient. The average postoperative hospital stay was 2.2 days (range 1-3 days). No patient required a blood transfusion. No urinoma was noted on the postoperative ultrasound follow-up. CONCLUSION: Nephrostomy tube-free percutaneous renal surgery is a safe and effective procedure for selected patients with minimal hemorrhage after PCNL. Cauterization of tract bleeding points may make this modification a more secure procedure and make it suitable for more patients.