Urokinaseの肺動脈内直接注入療法が奏効したと考えられる反復性肺塞栓症の一治験例

A case of recurrent pulmonary thromboembolism that could be saved by direct infusion of urokinase into pulmonary artery in severe acute phase

　肺塞栓症は，静脈血栓症の最も重大な合併症であり，致死的な疾患である。しかし，本邦では欧米にくらべその発生頻度は低く，欧米の1／10〜1／5と考えられている^1,2）。肺シンチグラムの出現以来，本症に対する関心も高まり，近年増加傾向が認められているが^3），その報告例は少ない^4）。今回，5カ月という短期間に少なくとも3回の肺塞栓症をくりかえし，肺動脈内へのウロキナーゼ（U．K．）の直接大量投与が奏効し，救命しえた症例を経験したので報告する。

A 45-year-old woman with total uterectomy 4 months ago, was admitted to our hospital because of dyspnea and precordial pain. Cardiomegaly with cardiothoracic ratio 0.54 and slightly enlarged pulmonary conus on the chest x-ray, and inverted T in lead V₁ to V₃, deep S in lead V₆ and so called S_IQ_III pattern with right axis deviation in ECG were found. Echocardiogram showed dilated right ventricle and the signs of pulmonary hyper-tension. Multiple defects were observed on lung perfusion scan. All these findings pointed strongly to a diagnosis of pulmonary thromboembolism.

Although initially she was treated successfully with heparin and urokinase, two months after that she complained of precordial pain and showed severe hypotension. Further treatment using dopamine and increased doses of heparin and urokinase brought her gradual improvement. But, 5 days later, she complained suddenly of precordial pain, showing cyanosis and fell into a seemingly incurable state of shock. After intubation, Swan-Ganz catheter was inserted into pulmonary artery, through which large dose of urokinase was injected with bolus. About 2 hours after injection, she showed remarkable improvement, and subsequently lung perfusion scan confirmed revascularization of pulmonary artery.

This case was considered to be rare because recurrent and massive pulmonary thromboembolism occurred during short interval after operation and yet the patient was saved.

This suggest that direct infusion of large dose of urokinase into pulmonary artery is an effective treatment for pulmonary thromboembolism, es-pecially in acute phase.