慢性反復性肺塞栓症に肺塞栓別除術を行い術後の再発に対しGünther下大静脈フィルターを挿入した1例

A case of chronic recurrent pulmonary embolism treated by pulmonary embolectomy and Günther vena caval filter implantation

　症例は62歳男性。1986年頃より労作性呼吸困難出現。1989年1月頃より呼吸困難増強，下肢浮腫出現。同3月8日より呼吸困難著しく悪化，15日肺塞栓の疑いのもとに入院した。動脈血ガスはO₂4　l／min経鼻下でPO₂ 51.9Torr，PCO₂ 24.7 Torr，心エコー図では右室拡大，心室中隔の左室側への変位を認めた。肺動脈圧は，90／30mmHgと肺高血圧を呈した。直ちに血栓溶解療法を行うも効果は得られなかった。肺血流シンチで左右両肺野の多発性の像欠損を確認後，緊急肺動脈塞栓剔除術を行い左右肺動脈より複数の血栓を別除した。術後病態は著しく改善，肺動脈圧も22／8mmHgへ低下したが，その後の抗凝固療法にもかかわらず塞栓再発を認めたため，より有効な予防策としてGünther filterの下大静脈への挿入を行った。慢性反復性肺塞栓症の急性増悪に対する肺動脈塞栓別除術の有効性を認識し，肺塞栓再発予防に挿入手技が極めて容易であるGünther filterを用いた症例を報告した。

A case report of chronic recurrent pulmonary embolism treated by embolectomy and Günther vena caval filter. A 62-year-old man had suffered from dyspnea on effort for 4 years, and his feeling of dyspnea had gradually increased during the past 3 months. On the day of admission he was in a pre-shock state, and his pulmonary artery pressure was very high at 90/30 mmHg. Pulmonary blood per-fusion scintigraphy showed multiple defects of iso-tope uptake. Immediately after the scintigraphy, pulmonary embolectomy was performed while using extracorporeal circulation. The operation was suc-cessful and his physical activity was markedly im-proved. After the operation, anti-coagulant and anti-platelet therapies were continued, but recur-rence of pulmonary emboli was detected by scinti-graphy, and some thrombi were found by veno-graphy in deep veins of the lower parts of both legs. To prevent recurrent pulmonary embolism, a Gunther vena caval filter was inserted into the inferior vena cava. We considered this case as an acute worsening of chronic recurrent pulmonary embolism and we had the impression that pulmonary embolectomy is a very effective therapeutic method for serious pulmonary embolism, and that insertion of the Gunther vena caval filter is a very easy and safe procedure.