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中华关节外科杂志(电子版)

中华关节外科杂志(电子版) ›› 2022, Vol. 16 ›› Issue (05) : 555 -561. doi: 10.3877/cma.j.issn.1674-134X.2022.05.005

临床论著

初次全膝置换术后孤立性小腿肌间静脉血栓的预后研究
唐一仑1, 陈媛媛1, 徐燕2, 宋金辉1, 张笑3, 孙露4, 杨佩1,†()   
  1. 1. 710061　西安交通大学第二附属医院骨科
    2. 710061　西安交通大学第二附属医院血液科
    3. 710061　西安交通大学第二附属医院手术麻醉科
    4. 710061　西安交通大学第二附属医院超声影像科
  • 收稿日期:2022-08-11 出版日期:2022-10-01
  • 通信作者: 杨佩
  • 基金资助:
    陕西省自然科学基础研究计划(2019JM-511)

Prognosis of isolated muscular calf vein thrombosis after primary knee arthroplasty

Yilun Tang1, Yuanyuan Chen1, Yan Xu2, Jinhui Song1, Xiao Zhang3, Lu Sun4, Pei Yang1,†()   

  1. 1. Department of Orthopedics, The Second Affiliated Hospital of Xi 'an Jiaotong University, Xi 'an 710061, China
    2. Department of Hematology, The Second Affiliated Hospital of Xi 'an Jiaotong University, Xi 'an 710061, China
    3. Department of surgery and anesthesiology, The Second Affiliated Hospital of Xi 'an Jiaotong University, Xi 'an 710061, China
    4. Department Ultrasound imaging, The Second Affiliated Hospital of Xi 'an Jiaotong University, Xi 'an 710061, China
  • Received:2022-08-11 Published:2022-10-01
  • Corresponding author: Pei Yang
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引用本文：

唐一仑, 陈媛媛, 徐燕, 宋金辉, 张笑, 孙露, 杨佩. 初次全膝置换术后孤立性小腿肌间静脉血栓的预后研究[J]. 中华关节外科杂志(电子版), 2022, 16(05): 555-561.

Yilun Tang, Yuanyuan Chen, Yan Xu, Jinhui Song, Xiao Zhang, Lu Sun, Pei Yang. Prognosis of isolated muscular calf vein thrombosis after primary knee arthroplasty[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2022, 16(05): 555-561.

目的

回顾性分析初次全膝关节置换术后孤立性小腿肌间静脉血栓形成患者，经两种抗凝方案处理后的预后情况及并发症情况，比较这两种抗凝方案的有效性及安全性。

方法

收集2017年1月至2021年11月在西安交通大学第二附属医院初次全膝关节置换术后诊断为孤立性小腿肌间静脉血栓形成的患者，排除既往长期使用抗凝药物、有血栓病史、术前合并血栓、术后合并下肢其他部位深静脉血栓或确诊肺栓塞、有高出血风险不能使用抗凝药物、或对利伐沙班存在使用禁忌的患者。根据抗凝药物使用时限不同分为两组：3个月抗凝组(抗凝时限3个月)和6周抗凝组(抗凝时限6周)，两组均口服利伐沙班20 mg 1次/d。所有病人均随访6个月，时间点为治疗后1、2、6、12和24周，观察血栓的转归情况、伤口及并发症情况。比较这两种抗凝方案对孤立性小腿肌间静脉血栓的有效性和安全性。计量资料两组间比较采用独立样本t检验，计数资料采用卡方检验分析。

结果

顺利完成随访患者共215例。抗凝3个月组与抗凝6周组相比，两组转归情况结局相似(P>0.05)。经抗凝治疗6周后血栓近端蔓延发生率随着时间延长而降低，血栓溶解率渐升高。6周抗凝组出血发生率低于3个月抗凝组，但两组间差异无统计学意义(均为P>0.05)；两组的不良切口发生率分别为4.1%、6.5%，差异无统计学意义(P>0.05)。

结论

初次全膝关节置换术后发生孤立性小腿肌间静脉血栓的患者，抗凝6周可能已经有足够的有效性和安全性，不需要进行3个月的抗凝。

关键词: 关节成形术，置换, 静脉血栓形成, 治疗学
Objective

To retrospectively analyze the prognosis and complications of patients with isolated calf intermuscular venous thrombosis after primary total knee arthroplasty, and to compare the efficacy and safety of the two anticoagulation regimens.

Methods

From January 2017 to November 2021, patients diagnosed with isolated calf intermuscular venous thrombosis after primary total knee arthroplasty in the Second Affiliated Hospital of Xi 'an Jiaotong University were collected.The patients with long-term use of anticoagulants, history of thrombosis, preoperative thrombosis, postoperative deep vein thrombosis in other parts of the lower extremities or with confirmed pulmonary embolism, the patients with high hemorrage risk but could not use anticoagulants or contraindicated to use rivaroxaban were excluded. The enrolled patients were divided into two groups according to the duration of anticoagulants: the three-month anticoagulant group, anticoagulant duration were three months; the six-week anticoagulant group, anticoagulant duration were six weeks. Both the groups were given rivaroxaban 20 mg, one time per day. All the patients were followed up for six months in one, two, six, 12 and 24 weeks after the treatment. The outcome of thrombosis, wound and complications were observed and analysed to compare the efficacy and safety of these two anticoagulant regimens for isolated calf intermuscular venous thrombosis. Independent sample t test was used for the measurement data comparison between the two groups, and chi square test was used for enumeration data.

Results

A total of 215 patients were successfully followed up. There was no statistically significant difference in the prognosis between the two groups (P>0.05). It could be seen from the outcome data of the two groups that the incidence of proximal thrombosis spread decreased with the prolongation of time after six-week anticoagulation treatment, and the thrombolysis rate increased gradually. The incidence of hemorrage in the six-week anticoagulation group was lower than that in the three-month anticoagulation group, but there was no statistically significant difference between the two groups (all P>0.05). The incidence of wound complications in the two groups was 4.1% and 6.5% respectively, yet the difference was not statistically significant (P>0.05).

Conclusion

For patients with isolated calf intermuscular venous thrombosis after primary total knee arthroplasty, six weeks of anticoagulation may be effective and safe, and three months of anticoagulation is not necessary.

Key words: Arthroplasty, Venous thrombosis, Therapeutics
表1 初次TKA患者一般资料
分组 例数 年龄[岁，(±s)] 性别[例(%)] BMI[kg/m2，(±s)] 合并糖尿病[例(%)]
男 女
3个月组 93 69±17 44(47.3) 49(52.7) 24±5 14(15.1)
6周组 122 68±14 60(49.2) 62(50.8) 23±3 20(16.4)
统计值   t＝1.112 χ2＝0.074 t＝1.182 χ2＝0.071
P值   >0.05 >0.05 >0.05 >0.05
分组 例数 合并高血压[例(%)] 合并高血脂[例(%)] 长期卧床[例(%)] 伴下肢症状[例(%)]
3个月组 93 16(17.2) 17(18.3) 29(31.2) 33(35.5)
6周组 122 22(18.0) 23(18.9) 41(33.6) 47(38.5)
统计值   χ2＝0.025 χ2＝0.011 χ2＝0.141 χ2＝0.209
P值   >0.05 >0.05 >0.05 >0.05
表2 两组患者IMCVT预后随访结果比较[例(%)]
随访时间 分组 IMCVT预后 肺栓塞
溶解吸收 稳定 近端蔓延
1周 3个月组 10(10.8) 61(65.6) 22(23.6) 0
6周组 15(12.3) 76(62.3) 31(25.4) 0
χ2值 0.264 －
P值 >0.05 －
随访时间 分组 IMCVT预后 肺栓塞
溶解吸收 稳定 近端蔓延
2周 3个月组 19(20.4) 55(59.1) 19(20.4) 1(1.1)
6周组 28(23.0) 68(55.7) 26(21.3) 2(1.6)
χ2值 0.280 0.122
P值 >0.05 >0.05
随访时间 分组 IMCVT预后 肺栓塞
溶解吸收 稳定 近端蔓延
6周 3个月组 46(49.5) 40(43.0) 7(7.5) 1(1.1)
6周组 53(43.4) 57(46.7) 12(9.8) 3(2.5)
χ2值 0.895 0.553
P值 >0.05 >0.05
随访时间 分组 IMCVT预后 肺栓塞
溶解吸收 稳定 近端蔓延
12周 3个月组 66(71.0) 25(26.9) 2(2.1) 0
6周组 84(68.9) 34(27.9) 4(3.2) 0
χ2值 0.293 －
P值 0.864 －
随访时间 分组 IMCVT预后 肺栓塞
溶解吸收 稳定 近端蔓延
24周 3个月组 68(73.1) 24(25.8) 1(1.1) 0
6周组 90(73.8) 29(23.8) 3(2.4) 0
χ2值 0.635 －
P值 >0.05 －
表3 两组出血及伤口情况比较
分组 例数 大出血事件1[例(%)] 大出血事件2[例(%)] 其他出血事件[例(%)] 术后引流量[ml，(±s)] 拆线时间[d，(±s)] 不良切口发生率[例(%)]
3个月组 93 9(9.7 ) 5(5.4) 15(16.1) 159.1±137.9 12.5±2.0 6(6.5)
6周组 122 12(9.8) 4(3.3) 12(9.8) 147.4±166.0 12.0±1.5 5(4.1)
统计值   χ2＝0.002 χ2＝0.579 χ2＝1.903 t＝1.378 t＝1.189 χ2＝0.602
P值   >0.05 >0.05 >0.05 >0.05 >0.05 >0.05
[1]
Heit JA, Spencer FA, White RH. The epidemiology of venous thromboembolism[J]. J Thromb Thrombolysis, 2016, 41(1):3-14.
[2]
中华医学会骨科学分会．中国骨科大手术静脉血栓栓塞症预防指南[J]．中华骨科杂志，2016，36(2):65-71.
[3]
李星鑫，丁炎，吴鹏西，等．高频超声对诊断孤立性小腿肌间静脉血栓的临床效果分析[J]. 影像研究与医学应用，2021，5(10):87-88.
[4]
谢锦伟，岳辰，马俊，等．初次髋膝关节置换术后静脉血栓发生情况的观察比较[J]．中国骨伤，2016，29(8):708-712.
[5]
Wang CJ, Wang JW, Weng LH, et al. Clinical significance of muscular deep vein thrombosis after total knee arthroplasty[J]. Chang Gung Med J, 2007, 30(1): 41-46.
[6]
Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST Guideline and Expert Panel Report [J]. Chest, 2016, 149(2):315-352.
[7]
Stevens SM, Woller SC, Kreuziger LB, et al. Antithrombotic therapy for VTE disease: second update of the CHEST Guideline and Expert Panel Report[J]. Chest，2021，160(6): e545-e608.
[8]
Kakkos SK, Gohel M, Baekgaard N, et al. Editor's choice-European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis[J]. Eur J Vasc Endovasc Surg, 2021, 61(1):9-82.
[9]
Kuczmik W, Wysokinski WE, Hesley GK, et al. Calf vein thrombosis comparison of outcomes for axial and muscular venous thrombosis[J]. Thromb Haemost. 2021，121(2):216-223.
[10]
Schulman S, Kearon C, Subcommittee on Control of Anticoagulation of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients[J]. J Thromb Haemost, 2005, 3(4):692-694.
[11]
Kuczmik W, Wysokinski WE, Macedo T, et al. Calf vein thrombosis outcomes comparing anticoagulation and serial ultrasound imaging management strategies[J]. Mayo Clin Proc, 2021, 96(5):1184-1192.
[12]
Kret MR, Liem TK, Mitchell EL, et al. Isolated calf muscular vein thrombosis is associated with pulmonary embolism and a high incidence of additional ipsilateral and contralateral deep venous thrombosis[J]. J Vasc Surg Venous Lymphat Disord, 2013, 1(1):33-38.
[13]
Ohgi S, Tachibana M, Ikebuchi M, et al. Pulmonary embolism in patients with isolated soleal vein thrombosis[J]. Angiology, 1998, 49(9):759-764.
[14]
Gillet JL, Perrin MR, Allaert FA. Short-term and mid-term outcome of isolated symptomatic muscular calf vein thrombosis[J]. J Vasc Surg, 2007, 46(3):513-519.
[15]
Guias B, Simoni G, Oger E, et al. Calf muscle venous thrombosis and pulmonary embolism[J]. J Mal Vasc, 1999, 24(2):132-134.
[16]
Hollerweger A, Macheiner P, Rettenbacher T, et al. Sonographische diagnose von muskelvenenthrombosen des unterschenkels und deren bedeutung als emboliequelle [Sonographic diagnosis of thrombosis of the calf muscle veins and the risk of pulmonary embolism][J]. Ultraschall Med, 2000, 21(2):66-72.
[17]
Kret MR, Liem TK, Mitchell EL, et al. Isolated calf muscular vein thrombosis is associated with pulmonary embolism and a high incidence of additional ipsilateral and contralateral deep venous thrombosis[J]. J Vasc Surg Venous Lymphat Disord, 2013, 1(1):33-38.
[18]
Lautz TB, Abbas F, Walsh SJ, et al. Isolated gastrocnemius and soleal vein thrombosis: should these patients receive therapeutic anticoagulation? [J]. Ann Surg, 2010, 251(4):735-742.
[19]
Macdonald PS, Kahn SR, Miller N, et al. Short-term natural history of isolated gastrocnemius and soleal vein thrombosis[J]. J Vasc Surg, 2003, 37(3):523-527.
[20]
Schommer K, Nussbaumer P. Submassive pulmonary embolism and muscular calf vein thrombosis after complicated hip fracture[J]. Vasa, 2007, 36(3):215-216.
[21]
Galanaud JP, Sevestre MA, Genty C, et al. Comparison of the clinical history of symptomatic isolated muscular calf vein thrombosis versus deep calf vein thrombosis[J]. J Vasc Surg, 2010, 52(4):932-938.e9382.
[22]
Schwarz T, Schmidt B, Beyer J, Schellong SM. Therapy of isolated calf muscle vein thrombosis with low-molecular-weight heparin[J]. Blood Coagul Fibrinolysis, 2001, 12(7):597-599.
[23]
Singh K, Yakoub D, Giangola P, et al. Early follow-up and treatment recommendations for isolated calf deep venous thrombosis[J]. J Vasc Surg, 2012, 55(1): 136-140.
[24]
Masuda EM, Kistner RL, Musikasinthorn C, et al. The controversy of managing calf vein thrombosis[J]. J Vasc Surg, 2012, 55(2):550-561.
[25]
De Martino RR, Wallaert JB, Rossi AP, et al. A meta-analysis of anticoagulation for calf deep venous thrombosis[J]. J Vasc Surg, 2012, 56(1):228-237.
[26]
Huang XC, Hu XH, Wang XR, et al. Efficacy and safety of therapeutic anticoagulation for the treatment of isolated calf muscle vein thrombosis-a systematic review and meta-analysis[J]. Vasa, 2016, 45(6): 478-485.
[27]
凌端强，杨涛，郝斌．小腿肌间静脉丛血栓形成认识及诊治进展[J]．血管与腔内血管外科杂志，2015，1(2): 185-189.
[28]
Sales CM, Haq F, Bustami R, et al. Management of isolated soleal and gastrocnemius vein thrombosis[J]. J Vasc Surg, 2010, 52(5):1251-1254.
[29]
Schwarz T, Buschmann L, Beyer J, et al. Therapy of isolated calf muscle vein thrombosis: a randomized, controlled study[J]. J Vasc Surg，2010, 52(5): 1246-1250.
[30]
哈承志，王大伟，王凯，等．利伐沙班治疗髋膝关节置换术后下肢肌间静脉血栓的有效性与安全性研究[J/CD]．中华老年骨科与康复电子杂志，2019, 5(4): 184-189.
[31]
龚恒，黄斌，付立功，等. 全膝关节置换术后小腿肌间静脉血栓临床研究[J]．中国运动医学杂志，2020, 39(11): 863-869.
[32]
王剑锋，黄小强，李辉，等. 全膝关节置换术后下肢肌间静脉血栓的转归及影响因素[J]．骨科，2021, 12(2): 137-142.
[33]
Robert-Ebadi H, Righini M. Management of distal deep vein thrombosis[J]. Thromb Res, 2017, 149: 48-55.
[34]
Utter GH, Dhillon TS, Salcedo ES, et al. Therapeutic anticoagulation for isolated calf deep vein thrombosis. [J/OL]. JAMA Surg, 2016, 151(9):e161770. DOI：10.1001/jamasurg.2016.1770.
[35]
Palareti G, Sartori M. Treatment of isolated below the knee feep vein thrombosis[J/OL]. Curr Atheroscler Rep, 2016, 18(7):37. DOI：10.1007/s11883-016-0594-1.
[36]
Baglin T, Douketis J, Tosetto A, et al. Does the clinical presentation and extent of venous thrombosis predict likelihood and type of recurrence? A patient-level meta-analysis[J]. J Thromb Haemost, 2010, 8(11):2436-2442.
[37]
杨逸成，熊长明．小腿肌间静脉血栓的抗凝治疗进展[J]．中国医学科学院学报，2021, 43(5): 822-826.
[38]
唐兴华. 小腿肌间静脉血栓与肺栓塞发生相关性及小腿肌间静脉血栓形成危险因素的研究[D]．山东大学，2017.
[39]
郭媛媛，李敏，郭丰勇，等．急性孤立性小腿肌间静脉血栓不同抗凝治疗时限的中、短期疗效观察[J]．中国普通外科杂志，2013, 22(12): 1605-1608.
[40]
白冰．利伐沙班，伊诺肝素和低相对分子质量肝素钙治疗脊柱融合术后下肢肌间静脉血栓的效果[J]．血栓与止血学，2016，22(1):34-37.
[41]
中国医药教育协会急诊医学分化．中国急性血栓性疾病抗栓治疗共识[J]．中国急救医学，2019，39(6):501-532.
[42]
Yi YH, Gong S, Gong TL, et al. New Oral Anticoagulants for venous thromboembolism prophylaxis in total hip and knee arthroplasty: a systematic review and network meta-analysis[J/OL]. Front Pharmacol, 2022, 12: 775126. DOI：10.3389/fphar.2021.775126.
[43]
Ray WA, Chung CP, Murray KT, et al. Association of oral anticoagulants and proton pump inhibitor cotherapy with hospitalization for upper gastrointestinal tract bleeding [J]. JAMA, 2018, 320(21): 2221-2230.
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