静脉血栓栓塞症诊治现状与展望

静脉血栓栓塞症（VTE）是血管外科领域乃至住院病人中常见病之一,临床上可表现为深静脉血栓形成（DVT）和肺栓塞（PE）。由于VTE的临床症状较为隐匿,因此给其临床诊断和治疗带来了困难。VTE的临床诊断可根据临床症状表现和实验室检查相结合进行,预防和治疗DVT目前主要还是以抗凝治疗为主。展望未来,基因分析在VTE诊断价值的不断提高、新技术应用和新药物研发必将为VTE治疗带来曙光。     

CD62p对骨折合并静脉血栓性疾病诊疗价值的临床分析

目的探讨检测CD62p在骨折合并静脉血栓性疾病（venousthromboembolism,VTE）患者预警、早期诊断及疗效评估中的临床意义。方法采用流式细胞术分别测定正常人群组、骨折患者、骨折合并VTE患者的CD62p,测定出CD62p正常水平区间,对骨折患者、骨折合并VTE患者进行动态分析,比较不同诊疗阶段CD62p水平。结果VTE患者CD62p高于骨折患者及正常对照组（P〈0．01）;骨折组CD62p高于正常对照组（P〈0．01）。骨折组及骨折合并VTE患者组在不同治疗阶段,CD62p差异有统计学意义（P〈0．01）。结论CD62p可作为骨折合并VTE早期诊断及疗效评估的有效指标。     

足踝手术患者静脉血栓栓塞的评估与预防

静脉血栓栓塞（VTE）包括深静脉血栓（DVT）和肺栓塞（PE）。创伤及手术是VTE形成的危险因素,在血栓形成后若不能及时诊断和处理,血栓形成后遗症将长时期影响患者的生活和工作质量;少数并发肺栓塞,造成严重后果。在骨科围手术期正确认识、评估和预防VTE的发生对患者的预后非常重要。     

减重手术围手术期静脉血栓栓塞症防治

静脉血栓栓塞症（VTE）是减重手术后发生并发症和病人死亡的主要因素之一。病人因肥胖及相关代谢紊乱导致VTE发病风险高，术中气腹、特殊体位，术后卧床等因素均可能诱发VTE。目前，已发布的指南中尚无预防减重及代谢手术并发VTE的理想方案，因而要求医护人员具有预防意识，与病人共同协作。建议入院后进行VTE风险分级评估，根据病情采取机械性预防（气囊加压或弹力袜）、药物预防等措施，加强多学科合作，深入贯彻加速康复外科理念，强调术后早期运动。对于术后出现VTE的病人，强调早诊断、早治疗原则，可有效降低VTE的危害。     

肝切除术围手术期症状性静脉血栓栓塞症风险评估模型的建立及验证

目的分析肝切除术患者围手术期症状性静脉血栓栓塞症（VTE）与临床特征的关系,建立风险评估模型来预测发生VTE的高危人群。 方法收集2017年1月至2020年6月接受肝切除术206例患者的临床资料。根据围手术期症状性VTE诊断标准分为VTE组（n=45例）和非VTE组（n=161例）。采用SPSS 20.0软件对VTE与临床特征之间的关系进行单因素及多因素Logistic回归分析。以P<0.05为差异有统计学意义。并构建肝切除术患者围手术期症状性VTE的风险评估模型,通过描绘受试者工作特征曲线（ROC）并计算曲线下面积（AUC）来评价模型的评估能力,并以术后实际发生结果为金标准对评估模型进行验证。 结果两组在BMI、VTE史、是否有肝脏恶性肿瘤、手术时间、术后肺部感染、术后间歇充气加压装置（IPC）使用、D-二聚体浓度之间比较差异有统计学意义（P<0.05）。多因素Logistic回归分析结果显示,VTE史、肝脏恶性肿瘤、手术时间≥3 h、术后肺部感染及D-二聚体≥0.2 mg/L是肝切除术患者围手术期发生症状性VTE的独立危险因素,术后IPC使用是肝切除术患者围手术期发生症状性VTE的保护性因素。VTE风险评估模型的AUC值为0.913（95%CI为0.869~0.974,P=0.004）;当Y的最佳临界值为2.85时对VTE发生风险具有评估价值,灵敏度为86.7%,特异度为89.4%,约登指数为0.761。以术后实际发生VTE为标准对评估模型进行验证,诊断准确度为92.7%（191/206）,灵敏度为80.0%（36/45）,特异度为96.3%（155/161）。 结论VTE史、肝脏恶性肿瘤、手术时间≥3 h、术后肺部感染及D-二聚体≥0.2 mg/L是肝切除术围手术期发生症状性VTE的独立危险因素。本研究建立的肝切除术患者围手术期症状性VTE风险评估模型对于VTE发生具有较高的预测价值,有良好的适用性。     

成人腹股沟疝修补术后静脉血栓栓塞症调查及影响因素分析

目的 分析成人腹股沟疝修补术后静脉血栓栓塞症（VTE）的发生情况,并探讨其防治方法。方法 回顾性分析2018年1-12月复旦大学附属中山医院和复旦大学附属华东医院收治入院的行手术治疗的1002例腹股沟疝病人的临床资料。随访1年,观察VTE的发生情况并分析其相关因素。结果 病人年龄为（68.7±13.8）岁;男性950例,女性52例;BMI为22.8±3.1。急诊手术60例,平诊手术942例;手术时间为（72.7±31.1）min。开放手术745例,腹腔镜手术257例。术后在院期间发生VTE共6例,出院后2~48 d另有6例确诊VTE,总发生率为1.2%,除1例肺栓塞（PE）病人死亡外,其他病人经过治疗均好转或痊愈。VTE的发生与疝的临床分型、急诊手术具有相关性（P<0.05）。结论 更严重的临床类型和急诊手术可显著增高成人腹股沟疝术后VTE的发生率,应尽早给予治疗,并在术后适当延长随访时间。     

2013年中国骨科静脉血栓栓塞症预防高峰论坛（西部行）即将在宁夏银川举行

静脉血栓栓塞症（VTE）是骨科大手术术后引起并发症和死亡的一个重要原因,而早期对患者危险因素进行积极评估及采取正确的预防策略可以明显降低其致残率和致死率。随着我国老龄人口的不断增多,VTE发病率呈现了上升的趋势,提高对VTE致病因素与临床特点的认识,有利于及早诊治,对于临床工作实践意义重大。为了进一步提高我国尤其是西部地区的骨科临床医师对骨科大手术VTE预防重要性的认识,提高VTE预防的临床水平,《中华关节外科杂志（电子版）》编委会拟从2012年起每年和我国西部各省区当地骨科学会一起举办“中国骨科大手术静脉血栓栓塞症防治高峰论坛（西部行）”系列高峰论坛,届时我们将组织国内优秀的骨、关节外科专家组成强大的讲师团,进行专场专题演讲和学术互动等;以促进西部（包括陕西、甘肃、青海、四川、新疆、云南、贵州、西藏等）地区骨科医师对骨科大手术VTE预防的临床交流,提高临床实践水平,更好地服务患者。     

妇产科侵袭性真菌感染患者的诊断和治疗探讨

目的 总结侵袭性真菌感染（IFI）在北京协和医院妇产科手术及肿瘤患者中的诊断和治疗特点,主要关注其分布、病原学特点、高危因素和治疗效果.方法 对2003年1月至2009年12月间北京协和医院细菌室及病案科记录的IFI资料行回顾性分析,按诊断标准分为确诊、临床诊断和拟诊病例,按治疗性质分为手术、化疗和恶性肿瘤终末期患者.分析不同IFI患者的分布、病原学特点、高危因素和治疗效果.结果 总计220例妇科IFI病例入选,其中确诊、临床诊断和拟诊病例分别为52例、11例和157例.妇产科IFI患者泌尿生殖系感染显著高于全院水平（46.2% vs 18.7%,P＜0.001）;可能的高危因素包括低白蛋白血症（87.3%）、中性粒细胞减少（52.4%）和放化疗（50.8%）;手术、化疗和恶性肿瘤终末期患者的总体治疗有效率分别为100.0%（108/108）、91.6%（87/95）和52.9%（9/17）,存在显著差异（P＜0.001）.结论 妇产科侵袭性真菌感染重症患者多,感染部位分布特殊,易感因素多样,手术及化疗患者中的治疗效果好.     

术前血小板/淋巴细胞比值与胰十二指肠切除术后静脉血栓栓塞症的发生及预后的关系

目的 探讨术前血小板/淋巴细胞比值（PLR）与胰十二指肠切除（PD）术后静脉血栓栓塞症（VTE）的发生及预后的关系。方法 回顾性分析2014年1月至2018年12月在新疆医科大学附属第一、第五医院行PD术的206例患者资料,比较VTE组及非VTE组患者在术前资料、手术因素、血常规、PLR方面的差异,绘制术前PLR预测术后VTE的受试者工作特征（ROC）曲线。根据PLR临界值进一步将VTE组分为高PLR亚组和低PLR亚组,分析两亚组在VTE血栓形成部位、术后生存时间方面有无差异。结果 PD术后发生VTE组（63例）和非VTE组（143例）在PLR上具有统计学差异（t=5.324,P<0.001）。PLR预测术后VTE的ROC曲线下面积（AUC）为0.853（95%CI 0.784~0.928）,敏感性为90.3%,特异性为75.0%,PLR临界值为244.54。高PLR亚组（n=30）术后双侧静脉血栓（BVT）12例、肺栓塞（PTE）13例,低PLR亚组（n=33）BVT 5例、PTE 6例,两亚组存在统计学差异（BVT：χ²=4.925,P=0.026;PTE：χ²=4.720,P=0.030）。高PLR亚组术后中位生存时间11个月（95%CI 10.238~11.762）,低PLR亚组为12个月（95%CI 10.530~13.470）,差异有统计学意义（χ²=5.909,P=0.015）。结论 术前PLR是PD术后发生VTE的独立危险因素,PLR值越大,术后发生静脉栓塞的风险越高,患者术后生存时间越短。根据术前PLR值早期干预具有VTE高风险的患者,可以延长患者PD术后生存时间。     

2012年中国骨科大手术围手术期静脉血栓栓塞症预防高峰论坛（西部行）即将在新疆伊犁举行

静脉血栓栓塞症（VTE）是骨科大手术术后引起并发症和死亡的一个重要原因,而早期对患者危险因素进行积极评估及采取正确的预防策略可以明显降低其致残率和致死率。随着我国老龄人口的不断增多,VTE发病率呈现了上升的趋势,提高对VTE致病因素与临床特点的认识,有利于及早诊治,对于临床工作实践意义重大。     

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??The present situation and forecast of venous thromboembolism WANG Shen-ming. Department of Vascular Surgery, the First Affiliated Hospital, Sun Yat-sen University, Guangzhou 510080, China
Abstract Venous thromboembolism (VTE) is a common disease in the field of vascular surgery and even found in the crowd of hospitalized patients. The clinical manifestations of VTE are classified as deep vein thrombosis (DVT) and pulmonary embolism (PE). Most of the VTE patients are asymptomatic, which brings dilemma to the VTE diagnosis and therapeutics. VTE clinical diagnosis according to clinical symptoms and laboratory examination. Clinical prevention and treatment DVT mainly based on anticoagulant therapy.Here we reviewed the recent studies concerning VTE mechanism, and the current situation of diagnosis and treatment, foreseeing the value of genetic analysis in VTE diagnosis, the new pattern of clinical technique and new drugs research/development for the treatment.     

Postoperative right atrial and pulmonary embolism after prolonged spinal surgery

Perioperative pulmonary thromboembolism can proceed rapidly with grave prognosis, in which immediate or accurate diagnosis and management is not easy. According to the literatures, patients receiving spinal surgery are at relatively lower risk of developing thromboembolism. We would like to present a case of postoperative pulmonary thromboembolism which developed after a prolonged lumbar spinal surgery. Tachycardia and unstable hemodynamics were noted postoperatively. Pulmonary and right atrial thrombi were disclosed by transesophageal echocardiography. Although cardiotomy and thrombectomy were immediately performed, the patient finally died 3 days after the operation. The pathogenesis of venous thromboembolism (VTE) in the surgical patients, the risk factors which predispose a patient to VTE, diagnosis, and treatment as well as the prophylactic measures of VTE are herein reviewed and discussed.     

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??The diagnosis value of D-dimer in acute venous thromboembolism ZHAO Yu??ZHANG Mao. Department of Vascular Surgery?? the First Hospital Affiliated Chongqing Medical University , Chongqing 400016, China
Corresponding author ??ZHAO Yu??E-mail??zhaoyu1@medmail.com.cn
Abstract D-dimer is the end products derived from cross-linked fibrin acted on by plasmin. As long as there is activated intravascular thrombosis and fibrinolytic activity in the body, the lever of D-dimer would rise. D-dimer negative can exclude diagnosis of acute venous thromboembolism (VTE)??D-dimer positive combined with clinical manifestations can diagnose acute VTE in special cases. In addition, monitoring D-dimer can reflect the effects of anticoagulant and thrombolytic drugs treating acute VTE??and can evaluating the risk factor of recurrence and prognosis of VTE. The lever of D-dimer in old people, patients with cancer, pregnant women and other specific groups are generally high, therefore, cutoff value of D-dimer for diagnosis VTE should be appropriately adjusted in order to increase diagnostic efficiency of D-dimer.     

Venous thromboembolism: application and effectiveness of the American College of Chest Physicians 2001 guidelines for prophylaxis

CONTEXT: Guidelines on the use of prophylaxis in venous thromboembolism (VTE) are poorly implemented in clinical practice. OBJECTIVE: To evaluate the extent to which the American College of Chest Physicians (ACCP) 2001 guidelines on VTE prophylaxis are adhered to in clinical practice by determining whether patients admitted to a medical center with an objective diagnosis of VTE had received adequate prophylaxis. METHODS: The medical records of medical and surgery patients with an objective diagnosis of VTE were reviewed. Patients were classified as having either preventable or nonpreventable VTE according to indication for prophylaxis, VTE risk, and adequacy of prophylaxis if administered. Adequacy was determined by adherence to the ACCP 2001 guidelines. RESULTS: Of 44 patients, 17 (38.6%) had not received adequate prophylaxis and were classified as having potentially preventable VTE. Venous thromboembolism developed in the remaining 27 (61.4%) patients despite adequate prophylaxis. In general, adequate prophylaxis rates were lower among surgery patients compared with medical patients. Four (80%) of the very-high-risk surgery patients received inadequate prophylaxis. The most common VTE risk factor in both categories was immobility. CONCLUSIONS: Adherence to the ACCP guidelines is suboptimal, with a substantial proportion of patients with VTE receiving inadequate prophylaxis. The additional finding that the incidence of VTE is high despite adequate prophylaxis indicates that the guidelines may need to be reevaluated.     

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??Value and clinic significance of detecting the hemostatic and coagulation function for the perioperaitive venous thromboembolism MEN Jian-long. Tianjin Medical University General Hospital, Tianjin 300052,China
Abstract There is the important value with hemostasis and coagulation function tests in excluding diagnosis of venous thromboembolism (VTE), assisting diagnosis with thrombophilia, estimating risk of VTE and antithrombotics monitoring. The clinician should consider fully about population characteristics and drug influence before implementing the tests, and should understand with the major application rules of thrombosis tests, including (1) excluding diagnosis of VTE, to understand the diagnostic sensitivity with the D-dimer in the medical institution and ensuring safety and effectiveness; (2) the clinician should use different cut-off values for different population and aim of diagnosis and treatment; (3) it should understand the medical history and family history detailed before laboratory screening for patients with suspected genetic defects; (4) it should use the risk assessment model and pre-test probability to screen the patients which accord with test indications before lupus anticoagulant and heparin-induced thrombocytopenia antibody test performance.     

重视普通外科围手术期静脉血栓栓塞症规范化防治

普通外科围手术期病人是静脉血栓栓塞症(VTE)的高发人群,近年来国内外已经日益重视普通外科围手术期VTE的预防,但是在开展预防的前提下普通外科围手术期VTE仍时有发生,目前国内围手术期的风险评估和预防实施率仍不高,因此有必要重视普通外科围手术期VTE的规范化防治。规范化预防包括采用Caprini评分进行VTE风险评估以及在此基础上结合出血评估采用相应的机械预防和药物预防措施。规范化治疗主要是请血管外科和呼吸科专科医师协助根据指南对深静脉血栓形成(DVT)和肺动脉栓塞(PE)进行及时的诊断和治疗。治疗首选抗凝,其次根据病人病情和危险分层可进行溶栓、腔内治疗。同时植入滤器应严格按照指征。     

Thoracic surgery for patients with deep vein thrombosis

Deep vein thrombosis (DVT) is a main cause of pulmonary thromboembolism (PTE), and therefore both diseases are categorized as a serial pathophysiology of venous thromboembolism (VTE). Treatment goals for DVT include stopping clot propagation and preventing the recurrence of thrombus, the occurrence of PTE, and the development of pulmonary hypertension, which can be a complication of multiple recurrent pulmonary emboli. Clinical guidelines stratify the risk of VTE to 4 levels and recommend the treatment options. In high or extremely high risk patients for VTE, the use of low-dose heparin is recommended. The prevention against VTE, such as elastic compression stockings and intermittent sequential pneumatic leg compression( ISPC), is the most important prophylactic treatment against perioperative PTE by reducing thrombotic risk in low or moderate high risk patients for VET. Since there is no clear evidence that screening all or even selected patients for thrombophilias improves long-term outcomes, the physician's clinical judgment, and consultation with appropriate subspecialists should guide management perioperatively. Once PTE is suspected, immediate and accurate diagnosis and appropriate treatment are mandatory.     

抗凝药物治疗静脉血栓栓塞症争议与共识

静脉血栓栓塞症（VTE）包括深静脉血栓形成（DVT）和肺动脉栓塞（PE）,是同一疾病在不同阶段和身体不同部位的两种表现形式。VTE是仅次于心脏病和中风后的第三大常见心血管疾病死亡原因。美国每年＞900 000例病人发生症状性VTE,除带来巨大的医疗负担外,其中300 000例病人死于PE。1949年,抗凝被作为首选治疗方法引入我国后,至今仍占据VTE一线治疗地位。然而,虽然到目前为止我国已经在VTE的诊治中积累了丰富经验,但依然存在一些问题尚待研究和解决。