超声辅助导管溶栓在肺血栓栓塞症中的应用进展Advances in Ultrasound-assisted Catheter-directed Thrombolysis for the Treatment of Pulmonary Thromboembolism
张毅;罗勤;赵智慧;赵青;柳志红;
ZHANG Yi;LUO Qin;ZHAO Zhihui;ZHAO Qing;LIU Zhihong;Center for Respiratory and Pulmonary Vascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences &Peking Union Medical College, National Center for Cardiovascular Disease;
摘要(Abstract):
肺血栓栓塞症(pulmonary thromboembolism, PTE)是心血管疾病中导致患者死亡的第三大常见原因。在真实世界中,因担心出现大出血等风险,仅20%~30%的高危PTE患者接受了系统性溶栓治疗,虽然中危PTE患者接受系统性溶栓可降低死亡率,但出血风险远高于获益。超声辅助导管溶栓可在血栓部位直接释放溶栓药物,所需药物剂量更低,且超声波可促进血栓溶解,有望成为一种安全、有效的溶栓新手段。本文将介绍超声辅助导管溶栓的机制、所需设备与操作程序、安全性与有效性等,并对未来的研究方向提出展望。
Pulmonary thromboembolism(PTE)is the third most common cause of cardiovascular death. However, only about 20% to 30% of patients with high-risk PTE received systemic thrombolysis in real world, due to concerns about the risks such as major bleeding. Although systemic thrombolysis could decrease all-cause mortality of patients with intermediate-risk PTE,the risk of bleeding outweighs the benefits. Ultrasound-assisted catheter-directed thrombolysis(UA-CDT) could directly deliver thrombolytic drugs to the thrombus with lower doses needed. Meanwhile, ultrasound waves could also enhance thrombolysis. Therefore, UA-CDT is emerging as a new tool, with good efficacy and safety records, for the treatment of PTE. In the present review article, we introduce the mechanism, required device, common protocol, efficacy and safety of UA-CDT and discuss directions for future studies.
关键词(KeyWords):
肺血栓栓塞症;溶栓治疗;超声波
pulmonary thromboembolism;thrombolytic therapy;ultrasound wave
基金项目(Foundation): 北京市自然科学基金(7202168);; 中国医学科学院医学与健康科技创新工程(2020-I2M-C&T-B-055)~~
作者(Authors):
张毅;罗勤;赵智慧;赵青;柳志红;
ZHANG Yi;LUO Qin;ZHAO Zhihui;ZHAO Qing;LIU Zhihong;Center for Respiratory and Pulmonary Vascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences &Peking Union Medical College, National Center for Cardiovascular Disease;
参考文献(References):
- [1] 孙雪峰,施举红.肺栓塞溶栓治疗新理念[J].协和医学杂志,2020,11:135- 139.Sun XF,Shi JH.New Principles for Thrombolysis in Pulmonary Embolism[J].Xiehe Yixue Zazhi,2020,11:135- 139.
- [2] Zhang Z,Lei J,Shao X,et al.Trends in Hospitalization and In-Hospital Mortality From VTE,2007 to 2016,in China[J].Chest,2019,155:342- 353.
- [3] Keller K,Hobohm L,Ebner M,et al.Trends in thrombolytic treatment and outcomes of acute pulmonary embolism in Germany[J].Eur Heart J,2020,41:522- 529.
- [4] Jiménez D,Bikdeli B,Barrios D,et al.Epidemiology,patterns of care and mortality for patients with hemodynamically unstable acute symptomatic pulmonary embolism[J].Int J Cardiol,2018,269:327- 333.
- [5] Stein PD,Matta F.Thrombolytic therapy in unstable patients with acute pulmonary embolism:saves lives but underused[J].Am J Med,2012,125:465- 470.
- [6] Meyer G,Vicaut E,Danays T,et al.Fibrinolysis for patients with intermediate-risk pulmonary embolism[J].N Engl J Med,2014,370:1402- 1411.
- [7] Konstantinides SV,Meyer G,Becattini C,et al.2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS)[J].Eur Heart J,2020,41:543- 603.
- [8] Bader KB,Bouchoux G,Holland CK.Sonothrombolysis[J].Adv Exp Med Biol,2016,880:339- 362.
- [9] Engelberger RP,Kucher N.Ultrasound-assisted thromboly-sis for acute pulmonary embolism:a systematic review[J].Eur Heart J,2014,35:758- 764.
- [10] Chernysh IN,Everbach CE,Purohit PK,et al.Molecular mechanisms of the effect of ultrasound on the fibrinolysis of clots[J].J Thromb Haemost,2015,13:601- 609.
- [11] 钱盛友,王鸿樟,孙福成.声流现象的研究及其应用[J].应用声学,1997,16:38- 42,45.Qian SY,Wang HZ,Sun FC.Acoustic streaming and its applications[J].Yingyong Shengxue,1997,16:38- 42,45.
- [12] 夏青青,刘俐.超声联合微泡辅助溶栓的研究进展[J].心血管病学进展,2019,40:564- 568.Xia QQ,Liu L.Ultrasound Combined with Microbubble Assisted Thrombolysis[J].Xinxueguan Bingxue Jinzhan,2019,40:564- 568.
- [13] Goel L,Jiang X.Advances in Sonothrombolysis Techniques Using Piezoelectric Transducers[J].Sensors (Basel),2020,20:1288.
- [14] Hobohm L,Keller K,Münzel T,et al.EkoSonic? endovascular system and other catheter-directed treatment reperfusion strategies for acute pulmonary embolism:overview of efficacy and safety outcomes[J].Expert Rev Med Devices,2020,17:739- 749.
- [15] Engelberger RP,Fahrni J,Willenberg T,et al.Fixed low-dose ultrasound-assisted catheter-directed thrombolysis followed by routine stenting of residual stenosis for acute ilio-femoral deep-vein thrombosis[J].Thromb Haemost,2014,111:1153- 1160.
- [16] Herriott B,Mion LC.Nursing Care Practices for Patients With Pulmonary Embolism Undergoing Treatment With Ultrasound-Assisted Thrombolysis:An Integrative Review[J].J Cardiovasc Nurs,2020,35:386- 399.
- [17] Kucher N,Boekstegers P,Müller OJ,et al.Randomized,controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism[J].Circulation,2014,129:479- 486.
- [18] Piazza G,Hohlfelder B,Jaff MR,et al.A Prospective,Single-Arm,Multicenter Trial of Ultrasound-Facilitated,Catheter-Directed,Low-Dose Fibrinolysis for Acute Massive and Submassive Pulmonary Embolism:The SEATTLE Ⅱ Study[J].JACC Cardiovasc Interv,2015,8:1382- 1392.
- [19] Tapson VF,Sterling K,Jones N,et al.A Randomized Trial of the Optimum Duration of Acoustic Pulse Thromboly-sis Procedure in Acute Intermediate-Risk Pulmonary Embolism:the OPTALYSE PE Trial[J].JACC Cardiovasc Interv,2018,11:1401- 1410.
- [20] Sardar P,Piazza G,Goldhaber SZ,et al.Predictors of Treatment Response Following Ultrasound-Facilitated Catheter-Directed Thrombolysis for Submassive and Massive Pulmonary Embolism:A SEATTLE Ⅱ Substudy[J].Circ Cardiovasc Interv,2020,13:e008747.
- [21] Piazza G,Sterling KM,Tapson VF,et al.One-Year Echocardiographic,Functional,and Quality of Life Outcomes After Ultrasound-Facilitated Catheter-Based Fibrinolysis for Pulmonary Embolism[J].Circ Cardiovasc Interv,2020,13:e009012.
- [22] Avgerinos ED,Saadeddin Z,Abou Ali AN,et al.A meta-analysis of outcomes of catheter-directed thrombolysis for high- and intermediate-risk pulmonary embolism[J].J Vasc Surg Venous Lymphat Disord,2018,6:530- 540.
- [23] Kaymaz C,Akbal OY,Tanboga IH,et al.Ultrasound-Assisted Catheter-Directed Thrombolysis in High-Risk and Intermediate-High-Risk Pulmonary Embolism:A Meta-Analysis[J].Curr Vasc Pharmacol,2018,16:179- 189.
- [24] Wu J,Chen H,Yu Y,et al.Feasibility of ultrasound-assisted catheter-directed thrombolysis for submassive pulmonary embolism:A meta-analysis of case series[J].Clin Respir J,2020,14:430- 439.
- [25] Lin PH,Annambhotla S,Bechara CF,et al.Comparison of percutaneous ultrasound-accelerated thrombolysis versus catheter-directed thrombolysis in patients with acute massive pulmonary embolism[J].Vascular,2009,17:S137- S147.
- [26] Rao G,Xu H,Wang JJ,et al.Ultrasound-assisted versus conventional catheter-directed thrombolysis for acute pulmonary embolism:A multicenter comparison of patient-centered outcomes[J].Vasc Med,2019,24:241- 247.
- [27] Rothschild DP,Goldstein JA,Ciacci J,et al.Ultrasound-accelerated thrombolysis (USAT) versus standard catheter-directed thrombolysis (CDT) for treatment of pulmonary embolism:A retrospective analysis[J].Vasc Med,2019,24:234- 240.
- [28] 朱琼,高顺记,郭梦娇,等.血栓内微泡联合尿激酶介导的超声溶栓体外实验[J].中国介入影像与治疗学,2017,14:242- 246.Zhu Q,Gao SJ,Guo MJ,et al.Intraclot microbubble combined with urokinase mediated ultrasound thrombolysis:Experiment in vitro[J].Zhongguo Jieru Yingxiang Yu Zhiliaoxue,2017,14:242- 246.
- [29] 张冰,王浩.超声溶栓临床应用的研究进展[J].中华医学超声杂志(电子版),2019,16:785- 789.
- [30] Mathias W Jr,Tsutsui JM,Tavares BG,et al.Diagnostic Ultrasound Impulses Improve Microvascular Flow in Patients With STEMI Receiving Intravenous Microbubbles[J].J Am Coll Cardiol,2016,67:2506- 2515.
- 张毅
- 罗勤
- 赵智慧
- 赵青
- 柳志红
ZHANG Yi- LUO Qin
- ZHAO Zhihui
- ZHAO Qing
- LIU Zhihong
- Center for Respiratory and Pulmonary Vascular Disease
- Fuwai Hospital
- Chinese Academy of Medical Sciences &Peking Union Medical College
- National Center for Cardiovascular Disease
- 张毅
- 罗勤
- 赵智慧
- 赵青
- 柳志红
ZHANG Yi- LUO Qin
- ZHAO Zhihui
- ZHAO Qing
- LIU Zhihong
- Center for Respiratory and Pulmonary Vascular Disease
- Fuwai Hospital
- Chinese Academy of Medical Sciences &Peking Union Medical College
- National Center for Cardiovascular Disease