经腘静脉穿刺腔内支架成形术治疗髂股静脉血栓形成后综合征的临床研究

2016-06-03 陆信武 叶开创 上海交通大学医学院附属第九人民医院

目的:探讨经皮腘静脉穿刺腔内支架成形术治疗髂股静脉血栓形成后综合征(Post-thrombotic syndrome, PTS)的技术和早期临床效果及其局限性。方法与材料:回顾性分析自2007年1月至2011年12月在我科就诊的采用经皮腘静脉穿刺腔内支架成形术治疗的髂股静脉PTS患者的一般资料、临床静脉疾病严重度评分、生活质量评分、Villalta评分、技术成功率及支架通畅率,并采用COX多因

目的:探讨经皮腘静脉穿刺腔内支架成形术治疗髂股静脉血栓形成后综合征(Post-thrombotic syndrome, PTS)的技术和早期临床效果及其局限性。

方法与材料:回顾性分析自2007年1月至2011年12月在我科就诊的采用经皮腘静脉穿刺腔内支架成形术治疗的髂股静脉PTS患者的一般资料、临床静脉疾病严重度评分、生活质量评分、Villalta评分、技术成功率及支架通畅率,并采用COX多因素和单因素分析早期支架内血栓形成和支架再狭窄的危险因素以及手术相关并发症。

结果:研究期间共纳入患者112例118条患肢,男性44例,左侧肢体102例,平均年龄51岁。经皮腘静脉穿刺腔内支架成形术治疗髂股静脉PTS技术成功率95%,平均手术时间43min(10-120min),生活质量评分、Villalta评分术后均得到显著性改善,3年一期、一期辅助及二期支架通畅率分别为70%、90%和94%。平均随访25月,严重肢体疼痛和严重肢体肿胀缓解率分别为72%(49/68)和70(64/91),累积溃疡愈合率78%(36/46)。支架成形术后有残余侧枝显影发生早期支架内血栓形成较高,而且支架跨过腹股沟韧带患者术后更易于发生支架内再狭窄。

结论:经皮腘静脉穿刺腔内支架成形术治疗髂股静脉PTS技术成功率高,安全有效,是可供选择的方法之一,但支架内再狭窄和血栓形成仍是难以忽略的难点。支架成形术后残余侧枝显影可能提示支架内或近心端残留影响血流的狭窄,而支架跨过腹股沟韧带是支架内再狭窄的主要危险因素。

1. 引言

下肢深静脉血栓形成(Deep Venous Thrombosis, DVT)仍是危及人类健康甚至生命的疾病,早期血栓堵塞深静脉系统引起肢体肿胀,栓子脱落导致肺动脉栓塞(Pulmonary Embolism, PE)危及患者生命,而后期因为血栓对静脉壁和瓣膜的损伤引起深静脉返流以及未再通的管腔出现深静脉回流障碍,进而导致一系列静脉高压的临床症候群,即深静脉血栓形成后综合征(Post-Thrombotic Syndrome, PTS),严重影响患者生活质量并消耗大量劳动力和医疗费用。DVT的治疗虽然经过一个多世纪的发展,抗凝和溶栓仍是主要治疗措施。抗凝治疗在预防血栓蔓延、降低肺动脉栓塞概率以及改善内皮细胞功能,其价值已获得学者们的认可,但无法溶解血栓,系统性溶栓治疗由于高出血风险,目前临床上较少采用,而经皮接触性导管溶栓(Catheter-Directed Thrombolysis, CDT)越来越得到学者们的重视,但是早期的CDT治疗由于各个单位在溶栓药物、剂量及时间上没有达成共识,因此所报道的结果也存在较大的差异,引起在CDT是否可以有效预防PTS的发生这一问题结论也不一致。同时,对于已经发生PTS的患者,尤其是严重PTS的患者,腔内支架成形术已经逐步在临床上使用,但腔内支架成形术是否可以改善临床症状以及支架再闭塞的危险目前也没有达成共识,各中心报道结果各有千秋,国内的临床数据更为少见。鉴于上述分析,本研究主要通过回顾性研究探讨支架成形术治疗严重PTS的临床效果及影响支架通畅率的因素。

2. 方法与材料

2.1 病人选择

回顾性分析自2007年1月至2011年12月110例严重髂股静脉PTS患者(男性44例),共118条患肢,其中左侧肢体102例,右下肢16例,均采用腔内球囊扩张术+支架成形术治疗。所有患者均签署知情同意书。患者年龄32-81岁,平均年龄51。DVT病程平均8.2年(1-40年),纳入的患者均为Villalta评分大于10分,所有轻中度PTS患者(Villalta<10分)均采用药物和弹力袜治疗。所有患者术前详细记录临床症状、CEAP分级、Villalta评分及生活质量评分等。

2.2 经皮腘静脉穿刺

患者取平卧位,足背静脉穿刺成功后固定穿刺针,嘱患者取俯卧位,自足背静脉注射造影剂,待腘静脉显影后制作路图,于穿刺点利多卡因局部麻醉成功后在路图显示下经皮穿刺腘静脉,置入5F导管鞘注入普通肝素生理盐水,80IU/kg,然后行患肢深静脉造影明确病变累及范围。

2.3 支架成形术过程

明确病变累及范围后选择0.018-inch和trailblazer导管或stiff导丝和MP导管,在路图下上行通过髂股静脉闭塞段,有时候可能需要交换40或55cm长COOK导管以增加导丝导管支撑力。若出现穿孔则回退导丝导管重新寻找上行通路。导丝导管通过髂股静脉闭塞段后回撤导丝,导管内造影明确导管已经进入下腔静脉真腔。此后逐步选择直径4-16mm和长度60-220cm长球囊导管扩张髂股静脉闭塞段,髂股静脉PTS单纯球囊扩张远远不够,球囊扩张后跟进支架10-16mm和长度60-90cm长Wallstent支架,支架近远端要超过原闭塞段。由于病变长度,往往需要2枚甚至多于2枚支架,支架植入后再选择相应尺寸的球囊行后扩张,术后再次造影明确影像学治疗效果。

Wallstent支架由于输送杆较短,有时候支架近心端不足以跨过原闭塞段,此时稍微释放一小段支架再向上推送输送杆以将支架完整覆盖病变段。术后穿刺点局部加压包扎。

2.4 术后处理

术后所有患者皮下注射低分子量肝素4000IU,每12h一次,并开始重叠口服华法林,将INR控制在2-3之间,最少持续6个月,如为原发性高凝患者需要长期口服华法林抗凝。

2.5 相关定义

支架成形术后造影提示支架残存狭窄度<30%定义为技术成功,术后随访期间静脉CTA或造影发现支架狭窄度>50%定义为支架内再狭窄,1个月内支架内血栓形成定义为早期支架内血栓形成。并发症根据SIR分为严重和轻度并发症,前者往往需要住院治疗或延长住院时间,如严重大出血等,后者往往不需要住院治疗或不延长住院时间,如穿刺点小血肿等。术后溃疡的处理同术前的清创换药等,溃疡面完全上皮化称之为溃疡愈合。

2.6 随访

所有患者告知术后每3个月门诊随访一次,1年后每年随访一次,每次记录术后临床症状、CEAP分级、Villalta评分及生活质量评分等。随访方法包括问卷、体格检查、深静脉彩超,若彩超难以明确支架是否通畅则采用静脉CTA或静脉造影检查。

2.8 数据收集统计分析

所有数据采用均数+SD和比例标书,支架通畅率采用Kaplan-Meier法分析,早期支架内血栓形成和支架再闭塞的危险因素采用COX多因素和单因素法统计。统计软件为SPSS 21.0版本。P<0.05提示统计学差异有显著性。

3. 结果

3.1 一般资料

技术成功率为95%(112/118),平均手术时间43min(10-120min),6例手术失败病例系因为导丝导管难以通过闭塞段,均采用23-32mmHg压力的弹力袜治疗,症状未见明显加重。有8例患者双下肢病变,均采用双侧支架成形术治疗,7例一期手术,1例分期治疗。平局使用球囊2.33个(2-5个),平均使用支架2.06枚(1-3枚),101条患肢需要2枚支架,2条患肢使用1枚支架,9条患肢需要3枚支架。

3.2 支架通畅率

3年一期、一期辅助及二期支架通畅率分别为70%、90%和94%。随访期间,13例患者(13条患肢)失访。20例患者(21条患肢)发生再狭窄,5例患者(5条患肢)采用弹力袜辅助治疗症状无加重,另外15例患者(16条患肢)再次成功行球囊扩张术治疗。

3.3 危险因素分析

研究中同时分析了早期支架内血栓形成和再狭窄的危险因素,性别、年龄、血栓病程、支架长度、手术时间、早期支架内血栓形成及左右侧患肢等因素对支架内再狭窄均无明显影响,支架跨过腹股沟韧带现在提高1年内支架内狭窄的风险。40条患肢支架成形术后仍有侧枝显影,有9条患肢出现早期支架内血栓形成(22.5%),另82条患肢支架成形术后未见侧枝显影,仅有5条患肢出现早期支架内血栓形成(6.1%),因此支架术后残存侧枝显影可能是早期支架内血栓形成的危险因素(22.5% VS 6.1%, P=0.007)。

3.4 临床治疗效果

平均随访25个月(1-52个月),有74例患者完成了完整的术前术后生活质量评分结果,生活治疗评分改善情况术后较术前具有显著性差异。有87例患者完成了完整的术前术后Villalta评分结果,由术前的22.0分降低到术后9.3(P=0.001)。术前共有46条患肢存在活动性溃疡,随访期间累积溃疡愈合率为78%。术前分别有91条患肢和68条患肢存在重度肢体肿胀(肿胀程度为3级)和患肢疼痛(疼痛指数>5分),缓解率分别为70%和72%。

3.5 并发症

所有患者均能耐受手术,均没有严重并发症的发生,无肺动脉栓塞及死亡病例,无手术相关的出血,无需要干预处理的穿刺点并发症。57例患者术后主诉腰酸腰疼,术后自行缓解,31例患者术中出现静脉穿孔,经回撤导丝导管重新寻找通路,在支架成形术后静脉穿孔自行消失。

4. 讨论

本部分回顾性分析表明,经皮腘静脉穿刺腔内支架成形术治疗髂股静脉PTS具有较高的技术成功率,临床症状能够得到显著性缓解,短中期支架通畅率也可以接受。Rosales等学者曾报道了32例患者采用支架成形术治疗髂股静脉PTS,其2年一期、一期辅助及二期支架通畅率分别为67%、76%和90%;Raju等学者也报道了285例髂股静脉PTS患者的腔内支架成形术治疗,5年二期支架通畅率高达82%。本研究结果显示3年一期、一期辅助及二期支架通畅率分别为70%、90%和94%,也上述学者报道的结果类似。

部分学者报道可以通过颈内静脉、大腿中段股静脉穿刺等入路成功治疗髂股静脉。我们常规采用在路图导引下经皮穿刺腘静脉腔内治疗髂股静脉PTS。类似于Neglen等学者的报道,经颈内静脉穿刺治疗有时候很难从下腔静脉通过髂股静脉闭塞进入远心端真腔,尤其是部分患者同时合并下腔静脉病变者。本部分研究中经腘静脉穿刺治疗髂股静脉PTS的技术成功率高达95%,也没有患者因为难以耐受手术过程而需要终止手术。而且,手术平均时间仅有43min,和Raju等学者报道的经大腿中段股静脉穿刺入路支架成形术手术时间30-40min也相差无几。

根据我们的经验,经大腿中段股静脉穿刺需要在超声引导下且需要由经验丰富的手术者操作,由于大腿段股静脉较深,单纯压迫困难,术后往往需要静脉缝合器闭合穿刺点,而且,相当部分髂股静脉PTS患者病变同时也累及股静脉,更为增加了穿刺的难度。相比经腘静脉穿刺,可以在路图或超声引导下穿刺,术后易于压迫,不需要静脉缝合器闭合穿刺点。本研究中所有患者也没有出现穿刺点血肿、动静脉瘘及出血的发生。但同样腘静脉穿刺尤其缺点,如偶尔Wallstent支架输送杆偏短,此时可以通过先释放一小段支架后再将输送杆向上推送至指定位置后再全部释放支架来解决。所以腘静脉穿刺腔内治疗髂股静脉PTS也是可供选择的穿刺入路。

与既往其他学者报道的结果一样,支架远心端跨过腹股沟韧带是支架内再狭窄的危险因素,但是,对于病变累及腹股沟韧带及其以远的股静脉,若支架不跨过腹股沟韧带将会引起早期支架血栓形成。本部分研究同时发现,早期支架内血栓形成患者往往在支架成形术后仍存在残留的侧枝显影,这往往提示支架扩张不够充分,支架内或支架近心端存在限制血流的残余狭窄。早期支架内血栓形成虽然可以通过经皮导管接触性溶栓来处理,但首次支架成形术中尽可能充分扩张支架以解除限制血流的狭窄是关键措施。

支架成形术治疗髂股静脉PTS最常见的并发症是术中术后腰背部疼痛,本研究中有51.8%(57/110)患者在球囊扩张或支架植入后主诉腰背部疼痛,和我们既往的研究相比,髂股静脉PTS患者腰背部疼痛的发病率要高于单纯的非血栓性髂股静脉病变,可能的原因是前者闭塞的程度更为严重所致。Raju等学者报道的发病率更低,可能的原因是其他学者往往在全身麻醉下手术,而本研究患者均在局部麻醉下手术。静脉穿孔是另一个常见的并发症,往往是经过盆腔侧枝或机化的血栓下方刺破静脉,回撤导丝导管重新寻找开通通道在支架成形术后穿刺均能够自行消退,并不会引起严重后果。但是需要注意的是,在未确定导管已经进入真腔前,切记不可贸然行球囊扩张甚至支架植入,可能会引起致命的后腹膜出血。

本研究存在的局限性。首先,本研究为回顾性研究,纳入的研究对象数量较少且随访时间较短,尚不足以形成临床一级推荐等级依据。其次,不同型号的球囊和支架的效果之间没有比较,哪种支架更为有效尚不得而知。第三,腔内支架成形术治疗髂股静脉PTS有多种穿刺入路,哪种技术成功率最理想术后效果最高也是未来研究的方向之一。最后,也是目前腔内支架成形术治疗静脉性基本的最大局限性,没有一个可以获得学者们认可和共识的客观的诊断和随访检查方法。

总之,腔内支架成形术治疗髂股静脉PTS可行性强,且安全有效,但是髂股静脉PTS这一严重影响患者生活质量的病变并没有彻底解决,例如,支架成形术后支架再闭塞是一个难以忽视的难点,术后部分患者症状能够得到一定的缓解,但仍然是影响患者生活质量的重要因素,而且,对于股腘静脉段PTS,根据我们的临床实践,支架成形术后6个月内几乎全部闭塞。不仅如此,由于深静脉血栓及其后期机化的过程长期对静脉瓣膜和功能的损伤,即使是支架成形术仍不能改善深静脉返流。因此,下肢静脉PTS仍然是血管外科难点之一,很多领域都需要进一步深入研究。3

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  1. [GetPortalCommentsPageByObjectIdResponse(id=1697323, encodeId=3db3169e32396, content=<a href='/topic/show?id=f2399910109' target=_blank style='color:#2F92EE;'>#静脉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=99101, encryptionId=f2399910109, topicName=静脉)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0bc129907796, createdName=fusion, createdTime=Thu Apr 27 03:12:00 CST 2017, time=2017-04-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1955236, encodeId=2f9b1955236ca, content=<a href='/topic/show?id=0aeb991e44c' target=_blank style='color:#2F92EE;'>#静脉血#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=99174, encryptionId=0aeb991e44c, topicName=静脉血)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d139492, createdName=xue8602, createdTime=Fri Jul 15 13:12:00 CST 2016, time=2016-07-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2004644, encodeId=aeaf2004644b3, content=<a href='/topic/show?id=4e8a5400816' target=_blank style='color:#2F92EE;'>#成形术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=54008, encryptionId=4e8a5400816, topicName=成形术)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7fb6449, createdName=ZGMFX24A, createdTime=Thu Aug 04 23:12:00 CST 2016, time=2016-08-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1311874, encodeId=b8bd13118e49b, content=<a href='/topic/show?id=21a6e54280e' target=_blank style='color:#2F92EE;'>#穿刺#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=18, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=75428, encryptionId=21a6e54280e, topicName=穿刺)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8b48400, createdName=rgjl, createdTime=Sun Jun 05 00:12:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1430625, encodeId=fd3214306259e, content=<a href='/topic/show?id=f9b9e9124a8' target=_blank style='color:#2F92EE;'>#综合征#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79124, encryptionId=f9b9e9124a8, topicName=综合征)], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyheQLjPSX3OUs5GmkyBlcCOwTPIeq3why9NGibxxUqYo6hcx8qZLHZFgNPnBK1yzWeOFpyg2OnWOt0/0, createdBy=fa4716, createdName=zhouqu_8, createdTime=Sun Jun 05 00:12:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1483242, encodeId=128f1483242a3, content=<a href='/topic/show?id=c82e991e71b' target=_blank style='color:#2F92EE;'>#静脉血栓形成#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=99177, encryptionId=c82e991e71b, topicName=静脉血栓形成)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1d387907505, createdName=ms5187542471278033, createdTime=Sun Jun 05 00:12:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1581683, encodeId=71781581683a8, content=<a href='/topic/show?id=c3049916553' target=_blank style='color:#2F92EE;'>#静脉穿刺#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=99165, encryptionId=c3049916553, topicName=静脉穿刺)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=00b816859588, createdName=ms1467340776200723, createdTime=Sun Jun 05 00:12:00 CST 2016, time=2016-06-05, status=1, ipAttribution=)]
    2017-04-27 fusion
  2. [GetPortalCommentsPageByObjectIdResponse(id=1697323, encodeId=3db3169e32396, content=<a href='/topic/show?id=f2399910109' target=_blank style='color:#2F92EE;'>#静脉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=99101, encryptionId=f2399910109, topicName=静脉)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0bc129907796, createdName=fusion, createdTime=Thu Apr 27 03:12:00 CST 2017, time=2017-04-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1955236, encodeId=2f9b1955236ca, content=<a href='/topic/show?id=0aeb991e44c' target=_blank style='color:#2F92EE;'>#静脉血#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=99174, encryptionId=0aeb991e44c, topicName=静脉血)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d139492, createdName=xue8602, createdTime=Fri Jul 15 13:12:00 CST 2016, time=2016-07-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2004644, encodeId=aeaf2004644b3, content=<a href='/topic/show?id=4e8a5400816' target=_blank style='color:#2F92EE;'>#成形术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=54008, encryptionId=4e8a5400816, topicName=成形术)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7fb6449, createdName=ZGMFX24A, createdTime=Thu Aug 04 23:12:00 CST 2016, time=2016-08-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1311874, encodeId=b8bd13118e49b, content=<a href='/topic/show?id=21a6e54280e' target=_blank style='color:#2F92EE;'>#穿刺#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=18, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=75428, encryptionId=21a6e54280e, topicName=穿刺)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8b48400, createdName=rgjl, createdTime=Sun Jun 05 00:12:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1430625, encodeId=fd3214306259e, content=<a href='/topic/show?id=f9b9e9124a8' target=_blank style='color:#2F92EE;'>#综合征#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79124, encryptionId=f9b9e9124a8, topicName=综合征)], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyheQLjPSX3OUs5GmkyBlcCOwTPIeq3why9NGibxxUqYo6hcx8qZLHZFgNPnBK1yzWeOFpyg2OnWOt0/0, createdBy=fa4716, createdName=zhouqu_8, createdTime=Sun Jun 05 00:12:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1483242, encodeId=128f1483242a3, content=<a href='/topic/show?id=c82e991e71b' target=_blank style='color:#2F92EE;'>#静脉血栓形成#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=99177, encryptionId=c82e991e71b, topicName=静脉血栓形成)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1d387907505, createdName=ms5187542471278033, createdTime=Sun Jun 05 00:12:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1581683, encodeId=71781581683a8, content=<a href='/topic/show?id=c3049916553' target=_blank style='color:#2F92EE;'>#静脉穿刺#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=99165, encryptionId=c3049916553, topicName=静脉穿刺)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=00b816859588, createdName=ms1467340776200723, createdTime=Sun Jun 05 00:12:00 CST 2016, time=2016-06-05, status=1, ipAttribution=)]
    2016-07-15 xue8602
  3. [GetPortalCommentsPageByObjectIdResponse(id=1697323, encodeId=3db3169e32396, content=<a href='/topic/show?id=f2399910109' target=_blank style='color:#2F92EE;'>#静脉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=99101, encryptionId=f2399910109, topicName=静脉)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0bc129907796, createdName=fusion, createdTime=Thu Apr 27 03:12:00 CST 2017, time=2017-04-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1955236, encodeId=2f9b1955236ca, content=<a href='/topic/show?id=0aeb991e44c' target=_blank style='color:#2F92EE;'>#静脉血#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=99174, encryptionId=0aeb991e44c, topicName=静脉血)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d139492, createdName=xue8602, createdTime=Fri Jul 15 13:12:00 CST 2016, time=2016-07-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2004644, encodeId=aeaf2004644b3, content=<a href='/topic/show?id=4e8a5400816' target=_blank style='color:#2F92EE;'>#成形术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=54008, encryptionId=4e8a5400816, topicName=成形术)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7fb6449, createdName=ZGMFX24A, createdTime=Thu Aug 04 23:12:00 CST 2016, time=2016-08-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1311874, encodeId=b8bd13118e49b, content=<a href='/topic/show?id=21a6e54280e' target=_blank style='color:#2F92EE;'>#穿刺#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=18, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=75428, encryptionId=21a6e54280e, topicName=穿刺)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8b48400, createdName=rgjl, createdTime=Sun Jun 05 00:12:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1430625, encodeId=fd3214306259e, content=<a href='/topic/show?id=f9b9e9124a8' target=_blank style='color:#2F92EE;'>#综合征#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79124, encryptionId=f9b9e9124a8, topicName=综合征)], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyheQLjPSX3OUs5GmkyBlcCOwTPIeq3why9NGibxxUqYo6hcx8qZLHZFgNPnBK1yzWeOFpyg2OnWOt0/0, createdBy=fa4716, createdName=zhouqu_8, createdTime=Sun Jun 05 00:12:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1483242, encodeId=128f1483242a3, content=<a href='/topic/show?id=c82e991e71b' target=_blank style='color:#2F92EE;'>#静脉血栓形成#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=99177, encryptionId=c82e991e71b, topicName=静脉血栓形成)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1d387907505, createdName=ms5187542471278033, createdTime=Sun Jun 05 00:12:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1581683, encodeId=71781581683a8, content=<a href='/topic/show?id=c3049916553' target=_blank style='color:#2F92EE;'>#静脉穿刺#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=99165, encryptionId=c3049916553, topicName=静脉穿刺)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=00b816859588, createdName=ms1467340776200723, createdTime=Sun Jun 05 00:12:00 CST 2016, time=2016-06-05, status=1, ipAttribution=)]
  4. [GetPortalCommentsPageByObjectIdResponse(id=1697323, encodeId=3db3169e32396, content=<a href='/topic/show?id=f2399910109' target=_blank style='color:#2F92EE;'>#静脉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=99101, encryptionId=f2399910109, topicName=静脉)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0bc129907796, createdName=fusion, createdTime=Thu Apr 27 03:12:00 CST 2017, time=2017-04-27, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1955236, encodeId=2f9b1955236ca, content=<a href='/topic/show?id=0aeb991e44c' target=_blank style='color:#2F92EE;'>#静脉血#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=99174, encryptionId=0aeb991e44c, topicName=静脉血)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d139492, createdName=xue8602, createdTime=Fri Jul 15 13:12:00 CST 2016, time=2016-07-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2004644, encodeId=aeaf2004644b3, content=<a href='/topic/show?id=4e8a5400816' target=_blank style='color:#2F92EE;'>#成形术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=54008, encryptionId=4e8a5400816, topicName=成形术)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7fb6449, createdName=ZGMFX24A, createdTime=Thu Aug 04 23:12:00 CST 2016, time=2016-08-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1311874, encodeId=b8bd13118e49b, content=<a href='/topic/show?id=21a6e54280e' target=_blank style='color:#2F92EE;'>#穿刺#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=18, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=75428, encryptionId=21a6e54280e, topicName=穿刺)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8b48400, createdName=rgjl, createdTime=Sun Jun 05 00:12:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1430625, encodeId=fd3214306259e, content=<a href='/topic/show?id=f9b9e9124a8' target=_blank style='color:#2F92EE;'>#综合征#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=24, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79124, encryptionId=f9b9e9124a8, topicName=综合征)], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyheQLjPSX3OUs5GmkyBlcCOwTPIeq3why9NGibxxUqYo6hcx8qZLHZFgNPnBK1yzWeOFpyg2OnWOt0/0, createdBy=fa4716, createdName=zhouqu_8, createdTime=Sun Jun 05 00:12:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1483242, encodeId=128f1483242a3, content=<a href='/topic/show?id=c82e991e71b' target=_blank style='color:#2F92EE;'>#静脉血栓形成#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=99177, encryptionId=c82e991e71b, topicName=静脉血栓形成)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=1d387907505, createdName=ms5187542471278033, createdTime=Sun Jun 05 00:12:00 CST 2016, time=2016-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1581683, encodeId=71781581683a8, content=<a href='/topic/show?id=c3049916553' target=_blank style='color:#2F92EE;'>#静脉穿刺#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=33, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=99165, encryptionId=c3049916553, topicName=静脉穿刺)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=00b816859588, createdName=ms1467340776200723, createdTime=Sun Jun 05 00:12:00 CST 2016, time=2016-06-05, status=1, ipAttribution=)]
    2016-06-05 rgjl
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