肺血栓栓塞症(肺栓塞)并发矛盾性栓塞并不常见,而且临床医师对其认识不足,故其误诊和漏诊率颇高,矛盾性栓塞的病例报道国内少见。

例1

　患者,男,60岁,因胸闷、气短1个月,左上肢无力1周入院。患者1个月前无明显诱因出现活动后胸闷、气短,无咯血和胸痛。当地医院超声心动图检查发现肺动脉高压,右心扩大,肺动脉增强CT显示双肺多发性肺动脉栓塞(图26-1),给予链激酶溶栓治疗,气短明显好转,在溶栓过程中突感左上肢无力,左桡动脉脉搏消失,左上肢动脉测不出。血管多普勒超声显示左锁骨下动脉血栓形成,左上肢动脉血流明显减少,血流减少。血管CT显示左锁骨下动脉血栓。下肢血管超声提示左下肢深静脉血栓形成。患者既往有高血压和糖尿病史。

图26-1　双肺动脉多发性肺栓塞

查体:R　20次/分,右上肢BP　140/90mmHg,左上肢血压测不到,肺部呼吸音清晰,HR　75次/分,律齐,各瓣膜听诊区未闻及杂音,肝脾未触及,下肢不肿。

心电图:完全性右束支传导阻滞。

超声心动图:左心房轻大,左心房内未见血栓,未见卵圆孔开放。诊断:急性肺栓塞,左下肢深静脉血栓形成,矛盾性左锁骨下动脉栓塞。

入院后行大动脉造影(图26-2):左侧锁骨下动脉大量血栓,血流慢,左尺动脉远端、左小指和无名指间动脉闭塞,其余动脉分支未见异常。随后行经皮左锁骨下动脉球囊扩张(图26-3),并经导管注入尿激酶50万U溶栓治疗,再复查动脉造影显示左锁骨下动脉内血栓消失,血流通畅,血流正常(图26-4)。针对急性肺栓塞继续给予低分子量肝素和华法林治疗,根据INR调整华法林剂量,使INR维持在2～3之间。

图26-2　动脉造影显示左锁骨下动脉大量血栓,血流缓慢

图26-3　经皮左锁骨下动脉内球囊扩张

图26-4　经过球囊扩张和血管内溶栓后左锁骨下动脉血流通畅,血栓消失,血流正常

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