中图分类号 R969.3;R973+.2 文献标志码A 文章编号 1001-0408（2025）20-2582-06

DOI 10.6039/j.issn.1001-0408.2025.20.17

Analysis of causes for initial antithrombotic therapy failureand the establishment of an antithrombotic pathway in arterial and venous thrombosis complicated with antiphospholipid syndrome

GUAN Yu，SHEN Zhu，ZHU Zhu（Dept. of Pharmacy，the Second Afiliated Hospital of Soochow University Jiangsu Suzhou 215004，China）

ABSTRACTOBJECTIVEToinvestigatethepotentialcausesof initialantithrombotictherapyfailureandestablishan antithromboticpathwayinarterialandvenous thrombosiscomplicatedwithantiphospholipidsyndrome（APS），aimingtooptimize clinical treatment.METHODSAretrospectiveanalysiswasconductedonthree patientswitharterialandvenous thrombosis accompaniedbyAPS；byintegrating clinicaldata，laboratorytests，imaging findings，andtreatmentprocesses，keyfactors contributingtoinitialantithrombotictherapyfailuresweresummarized.Theantithromboticpathwayinarterialandvenous thrombosis complicated with APS was established through areview of relevant literature.RESULTSamp;CONCLUSIONS The causesofinitialantithrombotictreatmentfailurein3patientsincludedselectingdirectoralanticoagulantsastefirstchoicefor antithrombotictherapy，using antiplateletdrugssuchasaspirinalone，andappying standardantithromboticregimenstopatients withrefractoryAPScomplicatedbyimmune diseaseslikesystemic lupuserythematosus.Thecopingstrategiesintheestablished antithromboticpathwayareasfollows：forvenous thromboembolicevents，secondarypreventionofthrombosisisthecoreand warfarinisthefirstchoice；forarterialthromboembolicevents，singleuseofantiplateletdrugshaslimitedeficacyandvitamin K antagonistsshouldbeusedincombinationforanticoagulation；forpatientswithcombinedvascularriskfactorsbutwithouthigh bleedingrisk，warfarincombinedwithantiplateletdrugsisprefered；forrefractoryAPS，asteppedtreatmentregimenshouldbe adopted，whichinvolvesfrstoptimizing warfarin，thenswitchingtothrapeutic-doselow-molecular-weightheparin，andswitching tofondaparinux if the treatment is ineffctiveorthe patient iscomplicatedby heparin-induced thrombocytopenia.

KEYWORDSarterialandvenous thrombosis；antiphospholipidsyndrome;antithrombosis；initial treatment failure；pathway

不明原因血栓是指在没有明确诱因（如手术、创伤、长期卧床等）的情况下发生的血栓事件。临床实践表明，部分不明原因血栓患者的抗栓治疗效果不佳，甚至出现初始治疗失败的情况[]。研究指出，在不明原因静脉血栓患者中，抗磷脂抗体（antiphospholipidantibody，aPL）的检出率约为 25% ，提示抗磷脂综合征（antiphos-pholipidsyndrome，APS）可能是引起不明原因血栓形成的重要因素2]。APS作为自身免疫性疾病，以持续aPL阳性、动静脉血栓形成及妊娠并发症为特征，可累及单一或多血管系统；同时，APS重症患者可在1周内发生多器官血栓栓塞，死亡率较高[。尽管抗栓、调节免疫是APS治疗的核心策略[4，但仍有 20%～30% 的产科APS患者和 30% 以上的血栓性APS患者对常规抗栓治疗反应不佳，其中难治性APS患者的治疗面临更大挑战[。这种治疗困境既源于APS的异质性（如患者血栓类型不同），也与临床认知不足（如部分患者因症状非典型，易被临床误诊为特发性血栓，故而错失早期干预时机）密切相关。本文以3例初始抗栓治疗失败的动静脉血栓伴APS患者为例，探讨治疗失败的可能原因，并提出应对策略，为该类患者的抗栓治疗提供参考。

1临床资料

1.1 病例1

男性患者，37岁，体重为 75kg ，体重指数（bodymassindex，BMI）为 25.35kg/m² ;既往无高血压、糖尿病等慢性病史，否认吸烟、饮酒史。2022年1月，患者因“双下肢肿胀\"就诊，超声检查示股静脉血栓形成，计算机体层成像（CT）静脉造影检查示下腔静脉狭窄伴侧支循环开放。患者行下腔静脉滤器置入术 + 置管溶栓术 + 下腔静脉球囊扩张成形术，术后予依诺肝素钠注射液4000AXaIU，q8h 抗凝。……