Catheter-directed Intrathrombus Thrombolysisが著効した深部静脈血栓合併アンチトロンビン欠損妊婦の1例

A Female Patient with Antithrombin Deficiency whose Deep Vein Thrombosis was Well Dissolved using Catheter Directed Thrombolysis

要旨　27歳，女性，妊娠9週2日．右下肢の腫脹，しびれにて来院．下肢超音波検査にて右外腸骨静脈から膝窩静脈にかけて静脈血栓を認めた．心エコー図検査にて右心負荷所見はなかったが，肺塞栓症予防，妊娠継続のため腎静脈上部に下大静脈フィルターを留置のうえヘパリンによる治療を開始した．入院後，アンチトロンビン欠損症と診断．アンチトロンビン補充，ヘパリン点滴を開始したが，血栓症の増悪を認め，右下肢の疼痛も増悪したためフィルター抜去は行わず永久留置とし，人工妊娠中絶のうえ，膝窩静脈からカテーテルの挿入を行いウロキナーゼの持続注入，間歇的空気圧迫法を行った．外腸骨静脈の血栓はほぼ消失し，下肢の浮腫は消失した．ワルファリンによる抗凝固療法，弾性ストッキング着用にて退院となった．深部静脈血栓症に対し，血栓溶解療法は広く行われているものの，全身投与または患肢の末梢静脈投与では，中枢性の深部静脈血栓に対し有効な血栓溶解効果が得られないことが多い．本症例では短期間に自覚症状と下肢腫脹を改善するためにカテーテル併用による血栓溶解療法が極めて有効であったと考えられた．

　A 27-year-old pregnant woman(9 weeks 2 days) consulted our hospital due to right leg swelling and numbness. We found widespread DVT from the iliac to the popliteal vein on ultrasonography. We started anti-coagulation therapy using, heparin after implantation of an IVC filter at the upper part of the renal vein to prevent pulmonary embolism and allow continuation of pregnancy. We initially found decreased AT antigen level and activity and replenished her antithrombin. However thrombosis worsened and she became unable to bend her leg due to pain and edema.

　Because of our concern about the progression of venous necrosis due to her acute perfusion disorder, we inserted an infusion catheter from the popliteal vein and continuously injected urokinase with intermittent pneumatic compression after abortion. Two days later, thrombus in the iliac vein along with leg edema had almost disappeared. Thrombolysis is available for deep vein thrombosis, but we often experience difficulty in dissolving thrombus by systemic infusion or peripheral venous infusion. In this case, catheter directed thrombolysis was very effective for quickly improving symptoms and leg edema. Antithrombin antigen levels of the patient's mother, brother and daughter were also decreased by about 50%. Thus we later diagnosised both siblings as having congenital antithrombin deficiency.