不同治疗方法对下肢深静脉血栓发生肺栓塞影响的对比研究

目的 对比不同治疗方法对下肢深静脉血栓形成发生肺栓塞的影响.方法 回顾性分析2002年8月至2008年6月201例下肢深静脉血栓形成患者,男性97例,女性104例;年龄24～83岁,平均60.4岁.其中血栓发生于左侧肢体174例,右侧24例,双侧3例.所有患者发病≤7 d,入院时无肺栓塞,且均获得随访.按治疗方法分为:单独溶栓抗凝组,手术取栓后溶栓抗凝组及置入下腔静脉滤器后溶栓抗凝组.分别计算各组住院期间和随访期间3组肺栓塞的发生率.结果 单独溶栓抗凝组住院期间有症状肺栓塞发生率为2.8%(3/107),下腔静脉滤器组、手术组无肺栓塞发生,3组间差异无统计学意义(P=0.425).出院后随访6～72个月,平均24个月.随访期间单独溶栓抗凝治疗组及手术取栓组无肺栓塞发生,下腔静脉滤器组肺栓塞发生率为2.4%(1/42)且死于肺栓塞,3组间差异无统计学意义(P=0.656).结论 三种治疗方法对下肢深静脉血栓形成、发生有症状肺栓塞的影响并无差异,下腔静脉滤器的置入应严格掌握适应证.     

手术后下肢深静脉血栓形成的诊治

目的探讨下肢深静脉血栓形成的诊断和治疗方法。方法回顾分析下肢深静脉血栓形成106例的临床资料。结果经抗凝、溶栓等治疗后62例治愈,发展为深静脉血栓形成后综合征(PTS)39例;并发肺栓塞(PE)3例,死亡1例;脑出血2例,死亡1例。结论彩色多普勒是诊断手术后下肢深静脉血栓形成最常用的方法,一经确诊,应尽早进行抗凝、溶栓治疗,防止DVT蔓延和PE的发生,同时可以减少PTS的发生率。     

腹腔镜术后下肢深静脉血栓形成的诊治分析

目的 探讨腹腔镜围手术期下肢深静脉血栓形成(DVT)的原因、高危因素及诊治措施.方法 回顾性分析本院2005年3月至2007年1月收治的12例腹腔镜术后深静脉血栓病例的临床资料.结果 腹腔镜术后深静脉血栓占同期收治血栓患者7.3%(12/164),均经溶栓抗凝对症治疗后症状消失,4例放置下腔静脉滤器,无肺栓塞发生.随访3～15个月,无复发.结论 腹腔镜围手术期体位、麻醉等应激状态及患者高危因素均可导致下肢深静脉血栓形成,甚至肺栓塞.围手术期应积极应对,仔细观察处理高危因素,预防深静脉血栓形成.     

重症下肢深静脉血栓形成治疗的临床研究

目的 探讨综合应用下腔静脉滤器置入、手术取栓、同时处理Cockett综合征、术后抗凝及溶栓等方法 治疗重症下肢深静脉血栓(股青肿)的疗效.方法 回顾近10余年9例重症下肢深静脉血栓患者的临床资料.9例中8例行下腔静脉滤器置入、手术取栓、术后抗凝及溶栓,8例中有7例为左下肢深静脉血栓患者.均发现合并不同程度的Cockett综合征,其中2例同时处理Cockett综合征;9例中1例(左下肢深静脉血栓患者)行下肢静脉溶栓术.结果 所有患者均无肺栓塞发生,经手术的8例患者除1例(左下肢深静脉血栓患者)术后出现湿性坏疽,被迫截肢外,其余7例均取得较为满意的疗效,挽救了患肢.1例行下肢静脉溶栓的患者死亡.1个月后复查彩超,没有同时处理Cockett综合征的5例中有2例左下肢血栓患者复发血栓,但均未再次发展为股青肿.7例随访1.5～10年,均未发生严重并发症.结论 综合应用下腔静脉滤器置人、手术取栓、同时处理Cockett综合征、术后抗凝及溶栓等方法 是治疗重症下肢深静脉血栓(股青肿)的有效方法 ,Cockett综合征是左下肢DVT取栓术后复发的重要原因.     

下腔静脉滤器在治疗下肢深静脉血栓中的应用

目的探讨下腔静脉滤器在治疗下肢深静脉血栓中的应用价值。方法46例下肢深静脉血栓患者在其他治疗前先置入下腔静脉滤器,然后其中20例采用抗凝、溶栓等药物治疗＋气压梯度治疗,另26例实施手术治疗,并同时采取抗凝、溶栓及气压梯度治疗。观察本组患者有无出现肺栓塞的症状及体症,定期透视滤器的形态与位置。结果下腔静脉滤器置入全部成功,其中置入永久性下腔静脉滤器38例,置入临时性下腔静脉滤器8例。经治疗46例患者中44例的下肢深静脉血栓症状及体征消失或缓解,无肺栓塞发生。对置入永久性下腔静脉滤器者中的36例进行2～24个月的随访（平均13个月）,滤器无移位,未发生肺栓塞。结论下腔静脉滤器置入方法简单、安全,可有效防止肺动脉栓塞的发生,可为下肢深静脉血栓治疗提供有效保障。     

导管直接溶栓技术在急性下肢深静脉血栓形成治疗中的应用

下肢深静脉血栓(deep venous thrombosis,DVT)治疗方法虽然较多,但疗效欠佳,治疗后易留下血栓形成后综合征。急性下肢深静脉血栓形成的处理,主要是非手术治疗,只有少数病人适宜手术疗法[1]。而Greefield等[2]认为,若本病未经治疗,90%将演变成血栓形成后综合征(post-thromboticsyndrome,PTS)。Juhan等[3]认为,急性DVT行静脉取栓治疗比静脉肝素或全身溶栓治疗更有效。近年来,随着介入技术的迅猛发展,导管直接溶栓(catheter-directed thrombolysis,CDT)技术已开始应用于DVT的治疗,尽管这些技术与单纯抗凝治疗相比有一定风险,且远期疗效还有待继续长期观察,但其重要的临床价值已明显显现。1CDT概述急性下肢DVT的主要危害是发生肺栓塞造成肺动脉高压或死亡;静脉阻塞与瓣膜破坏造成远期静脉功能不全、血栓后综合征。因此,急性期正确、及时治疗可以减少肺栓塞与深静脉血栓后综合征的发生。传统单纯抗凝治疗仅6%急性下肢DVT患者10天内血栓可基本溶解,40%患者下肢血栓可能蔓延[4],5年随访显示,95%患者患肢肌肉泵功能衰竭与近段深静脉瓣...     

下腔静脉滤器植入在下肢深静脉血栓形成溶栓治疗中的应用

目的探讨下腔静脉滤器(IVCF)在下肢深静脉血栓形成(DVT)的溶栓治疗中,对预防致命性肺栓塞(PE)的有效性、安全性及手术指征。方法 10例下肢DVT患者接受IVCF植入术,术后给予溶栓及抗凝治疗。结果全组病例均获成功,疗效满意。10例均获得随访,随访时间1～23个月,随访期间无PE、严重出血性疾病及滤器相关死亡发生。结论 IVCF植入的应用不仅有效预防PE的发生,而且使溶栓治疗更为安全。     

溶栓抗凝治疗下肢深静脉血栓形成98例临床分析

目的 探讨下肢深静脉血栓形成(DVT)的药物治疗方法.方法 回顾性分析2005年12月至2010年10月间收治98例下肢DVT患者的临床资料,其中左下肢DVT60例,右下肢DVT 33例,双下肢DVT 5例,均通过下肢血管彩超确诊.患者均经足背静脉输注尿激酶7～10天溶栓治疗,25～50万U/d;同时辅以低分子肝素钠抗凝治疗10～14天,4000～6400u皮下注射、12小时一次;其中26例溶栓前放置下腔静脉滤器.出院后服用华法林和/或阿司匹林继续抗凝治疗5～26个月.结果 98例患者肢体肿胀、疼痛症状均缓解出院.药物治疗过程中发生肺栓塞6例,4例为有症状性肺栓塞,经溶栓及抗凝治疗后好转;无其他出血并发症发生.82例患者获得随访,随访时间1个月至4年,平均11.2个月.结论 尿激酶辅以低分子肝素钠在下肢DVT中的应用是安全、有效的.是否需置入下腔静脉滤器需要根据患者的具体情况而定.     

儿童创伤后下肢深静脉血栓的临床分析

目的探讨儿童创伤后下肢深静脉血栓(DVT)的临床特点及治疗方法。方法对10例儿童创伤后经双下肢深静脉彩色多普勒超声确诊发生DVT后采用低分子肝素钙联合物理治疗。结果本组儿童创伤后DVT的发生率为1.28%,发生的时间于伤后1~6 d,术前发现9例,术后第2天发生1例。经治疗后随访3～15个月,均未再发生血栓及有症状的肺栓塞。结论儿童DVT的出现,打破了以往认为16岁以下儿童罕见发生DVT的理论,对于年龄偏大、创伤严重的儿童患者一定要重视下肢深静脉血栓的诊断、预防及治疗。     

可回收下腔静脉滤器在DVT治疗中的应用

目的探讨临时性下腔静脉滤器在下肢深静脉血栓(DVT)治疗中的应用。方法对28例下肢深静脉血栓(DVT)患者的临床资料进行回顾性分析。采用Seldinger技术穿刺健侧股静脉,先行下腔静脉造影,明确下腔静脉管径、有无血栓及肾静脉开口位置,换导引长鞘,将滤器送入距肾静脉下缘1.5cm处释放,再次造影,证实滤器准确无误,拔管局部加压包扎,术后抗凝治疗。除1例外,其余病例均于14～22d经原路径应用抓捕器取出下腔静脉滤器。结果 27枚滤器取出。在滤器上均可见多少不等的血栓;1例置入15d时滤器被大量血栓阻塞,经手术取栓后,置溶栓导管溶栓,好转,未取滤器。无肺栓塞发生。结论应用临时性滤器可以有效的防止肺栓塞的发生。     

下肢深静脉血栓形成的综合治疗

目的 探讨下肢深静脉血栓形成的有效治疗方法 .方法 回顾性分析近5年(2004-2009年)诊疗的411例下肢深静脉血栓形成患者的临床资料;其中8例有明显溶栓、抗凝禁忌证仅予以外敷消肿对症处理,采用常规的溶栓、抗凝、祛聚综合治疗391例,行Fograty导管取栓及综合治疗12例,置入永久性下腔静脉滤器21例.结果 382例患者临床症状和体征有明显改善,28例患者无明显疗效或出现并发症,1例患者死亡.184例(44.8%)随诊4～62个月,平均20个月;其中痊愈32例(17.4%),显效107例(58.2%),有效42例(22.8%),无效3例(1.6%).结论 溶栓、抗凝、祛聚综合治疗安全有效;早期手术取栓可明显改善患者预后;下腔静脉滤器置入能有效预防肺动脉栓塞.     

Early results of thrombolysis vs anticoagulation in iliofemoral venous thrombosis. A randomised clinical trial.

OBJECTIVE: catheter directed thrombolysis has been advocated for complete and rapid dissolution of iliofemoral deep venous thrombosis (DVT). The aim of our study is to compare, in a randomised trial, local thrombolysis and anticoagulation with anticoagulation alone in patients with iliofemoral DVT. METHODS: a consecutive series of 35 eligible patients, were randomised to either catheter directed thrombolysis followed by anticoagulation or to anticoagulation alone. Clot lysis and deep venous reflux were assessed with ultrasound duplex and plethysmography after 6 months. RESULTS: complete data were available in the 18 and 17 patients randomised to thrombolysis and anticoagulation, respectively. At 6 months, patency rate was better in cases treated with thrombolysis [13/18 (72%) vs 2/17 (12%), p < 0.001]. Venous reflux was higher in-patients treated with anticoagulant [7 patients (41%) vs 2 (11%), p = 0.04]. CONCLUSION: in the short-term patients treated with catheter directed thrombolysis obtained better patency and competence than those treated with standard anticoagulation.     

抗凝溶栓治疗对急性下肢深静脉血栓形成预后的影响

目的 探讨抗凝溶栓治疗对急性下肢深静脉血栓形成的疗效及其对下肢深静脉血栓形成后综合征(PTS)的发生率及严重程度的影响.方法 回顾性选择2003年3月至2008年12月收治的急性下肢深静脉血栓形成(中央型及混合型)患者共111例(113条肢体).分别采用单纯抗凝(41条肢体)、系统溶栓(27条肢体)或导管溶栓(45条肢体)三种不同治疗方法,在随访期末收集下肢肿胀及静脉冉通情况,使用Villaha及VCSS评分表评判PTS的发生率及严重程度.结果 单纯抗凝组、系统溶栓组和导管溶栓组平均随访时间分别为(41±19)、(52±11)和(26±10)个月.三组PTS的发生率分别为58.5%(24/41)、55.6%(15/27)和35.6%(16/45),其中重度PTS的比例分别为20.8%(5/24)、3/15和1/16;导管溶栓组的PTS发生率和重度PTS比例低于其余两组(P＜0.05).三组患者双下肢周径差较治疗前均有明显改善(P＜0.05);导管溶栓组随访时的大腿周径差为(0.5 4±1.0)cm,小腿周径差为(0.7±1.0)cm,低于其余二组(P＜0.05).长期使用抗凝药物及弹力袜的患者,PTS发生率较低.结论 深静脉血栓形成急性期在抗凝基础上采用导管溶栓治疗,可降低PTS的发生率并减轻其严重程度,明显改善肢体肿胀.辅以规律抗凝及弹力袜支持,可进一步改善疗效.

Abstract：

Objective To explore the effect of anticoagulant thrombolytic therapy on acute deep venous thrombosis (DVT) and the incidence and severity of post-thrombotic syndrome (PTS). Method A total of 111 patients (113 limbs) with central or mixed types of deep venous thrombosis admitted from March 2003 to November 2008 were analyzed. The patients were divided into 3 groups by different therapies:anticoagulant group (41 limbs) , thrombolysis group (27 limbs), and catheter-directed thrombolysis group (45 limbs). In the follow-up, patients' swelling of lower extremity and recanalization of vein were found out by physical examination and venous ultrasound Duplex through following-up. The Villalta and VCSS marking scales were used in rating the incidence and severity of PTS, discussing treatments for acute phase as well as adjuvant treatment for chronic phase and the correlation between the incidence and severity of PTS. Results The average time of follow-up were (41±19) months in anticoagulant group, (52±1) months in thrombolysis group, and (26 ±10) months in catheter-directed thrombolysis group. According to the consequences from Villalta and VCSS rating scales, the incidences of PTS in the three groups were 58. 5% (24/41), 55.6% (15/27), and 35.6% (16/45), in which 20.8% (5/24), 3/15, and 1/16 were severe. The the catheter-directed thrombolysis group had a better consequence than the other two groups in reducing incidence and severity of PTS ( P ＜ 0. 05 ). The differences of circumferences of lower extremities of all patients had obvious improvement compared to that before the treatments. For patients who were treated by catheter-directed thrombolysis, the thigh circumference difference and calf circumference difference were (0. 5 ±1. 0) cm and (0. 7±1. 0) cm, which were more obvious compared to other two groups (P ＜0. 05).Most patients had their external-iliac and common-femoral veins recanalized. Using anticoagulant Pharmaceuticals and compression stockings can lead to a reduction in the incidence of PTS. Conclusions The incidences and symptoms of PTS and swelling of limbs can be significantly moderated by catheterdirected thrombolysis based on anticoagulating in the acute phase of DVT. Consequently, it would be the most efficient way in decreasing the occurrences of PTS and moderating the severities of PTS with the aids of regular anticoagulating and compression stockings.     

恶性肿瘤合并肢体深静脉血栓形成：附45例报告

目的:探讨恶性肿瘤患者合并肢体深静脉血栓形成(DVT)的临床特点及治疗方法.方法:回顾近年收治的45例合并DVT的恶性肿瘤患者的临床资料,总结、分析血栓形成的机制及防治措施.结果:38例(84.4％)患者经正规抗凝溶栓治疗后,临床症状缓解,其中1例出现皮下淤血;4例(8.9％)抗凝溶栓过程中出现肺栓塞(PE),其中3例抢救后肺栓塞症状基本缓解,1例抢救无效后死亡;3例患者因出血风险仅给予制动、对症及活血药物治疗后症状缓解.8例与外周中心静脉导管( PICC)置入有关的上肢DVT患者治疗后,根据不同情况分别拔除导管,未出现明显PE症状.结论:恶性肿瘤患者需警惕DVT形成,确诊后应积极治疗.对无明显诱因的DVT患者要高度警惕并存恶性肿瘤的可能.     

抗凝治疗对低风险组下肢骨折患者深静脉血栓形成的影响

目的研究静脉血栓形成危险度评分量表(RAPT)评分≤5分的低风险组下肢骨折患者下肢深静脉血栓形成(DVT)发生率及预防性应用抗凝药物的安全性和必要性。方法回顾性分析自2014-09—2016-10诊治的348例RAPT评分≤5分的低风险组下肢骨折患者的临床资料,根据是否应用抗凝药物分为抗凝组和对照组,抗凝组每日皮下注射低分子肝素钙(4 100 IU qd),术前12 h停药,术后12 h伤口无明显出血,拔除引流管时再次给药,对照组则不应用抗凝药物,2组均给予足底静脉泵物理治疗;术后2、30 d行双下肢静脉彩色多普勒超声检查,根据超声检查结果统计血栓发生率、分布及转归情况。结果术后发生DVT 17例(4.89%),抗凝组7例,对照组10例。术后2组DVT发生率比较差异无统计学意义(χ~2=0.753,P=0.385);2组术后在DVT分布、累及肢体和静脉差异均无统计学意义(χ~2=0.843,P=0.656;χ~2=2.205,P=0.364;χ~2=0.957,P=0.916)。所有患者获得30 d随访,2例仍存在远端肌间静脉血栓,但无临床症状;复查超声显示血栓未向近端蔓延,均未出现致死性肺栓塞(PE)。结论低风险组下肢骨折患者术后DVT发生率较低,给予基本预防和物理预防即可,临床上应结合RAPT评分充分评估患者并发VTE的危险程度,避免盲目进行抗凝治疗。     

Risk of deep vein thrombosis following laparoscopic rectosigmoid cancer resection in chinese patients

OBJECTIVE: The aim of this study was to evaluate the incidence of postoperative deep vein thrombosis (DVT) in Chinese patients who underwent laparoscopic resection of rectal or sigmoid cancer in the absence of thromboprophylaxis. METHODS: Patients with adenocarcinoma of the sigmoid colon or rectum scheduled for laparoscopic resection were recruited. Neither chemoprophylaxis nor mechanical methods against DVT were employed. They were scheduled to have routine duplex ultrasound of both lower limbs perioperatively. RESULTS: In a 12-month period, 50 patients were recruited. Postoperative DVT occurred in 19 (38%) patients. None needed anticoagulation. Complete resolution of the thrombus was noted in 10 (53%) patients 12 weeks after operation, and in six patients 36 weeks after operation. Female sex was identified as being associated with a higher incidence of DVT. Age, smoking, preoperative neoadjuvant chemoirradiation, preoperative metastasis, duration of operation, conversion and postoperative complications did not appear to be risk factors for DVT. CONCLUSION: The incidence of asymptomatic calf vein DVT is relatively high after laparoscopic resection for rectosigmoid cancers in the Chinese population. However, complete resolution occurred without the use of anticoagulant therapy in the majority of cases. It is thus difficult to advocate the routine use of anticoagulant prophylaxis.     

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??Current situation and trend of treatment of deep vein thrombosis LI Wen-dong??LI Xiao-qiang??XIAO Lun. Department of Vascular Surgery, the Second Affiliated Hospital of Soochow University, Suzhou 215000, China
Corresponding author: LI Xiao-qiang, E-mail??flytsg@126.com
Abstract Deep vein thrombosis ??DVT???? which can complicate with pulmonary embolism ??PE?? and develop into postthrombotic syndrome ??PTS???? is a troublesome problem in clinic. Thus?? the treatment of DVT mainly includes two aspects?? ??1??protection from symptomatic PE and sprawled thrombus????2??protection from PTS. Sufficient and effective anticoagulation is the fundamental treatment for acute DVT. New oral anticoagulation drugs facilitate the treatment of anticoagulation by avoiding monitor of coagulation function. But in some patients with contraindications for anticoagulation?? inferior vena cava filter is necessary for preventing fatal PE. Retrieval filter with a wide duration of withdrawal is attractive in clinic. Removing thrombi by embolectomy??catheter-directed thrombolysis and pharmacomechanical thrombolysis can facilitate to restore the blood flow. But the methods of removal thrombi tend to invasive and efficient. Patients with DVT are always complicated with iliac vein compression. Stenting to solve the obstructive iliac vein is necessary when thrombi are removed. Long-term anticoagulation for prevention of recurrent DVT is necessary for protecting from PTS. Compression including stocking compression and intermittent pneumatic compression contributes to reducing the symptoms of DVT.     

下腔静脉滤器在急性下肢深静脉血栓形成导管溶栓治疗中的必要性探讨

目的 探讨急性下肢深静脉血栓形成(deep venous thrombosis,DVT)患者行导管溶栓治疗(catheter direct thrombolysis,CDT)时,置入下腔静脉滤器的必要性.方法 回顾性总结2006年11月至2008年12月在仁济医院(东院)血管外科,经CDT及后续腔内治疗的急性下肢DVT患者临床资料.全组93例(93侧肢体),其中男35例,女58例;左下肢80例,右下肢13例;年龄28～88岁,平均60±29岁.病程5 h至15 d,平均(6.28±7.08)d.结果 93例患者中,置入滤器者30例,未置滤器者63例(67.7%,63/93).左下肢DVT未置滤器者占93.6%(59/63).溶栓后复查数字减影造影(digital subtraction angiography,DSA),77例髂-股静脉血栓完全溶解,其中70例于患肢髂静脉检出狭窄或闭塞性病变,57例接受了后续腔内治疗.全组未发生症状性肺栓塞(pulmonary embolism,PE).术后肺CTA检查:3例PE,均为置入下腔静脉滤器者;1例可疑PE,系未置入滤器者.结论 对于左下肢DVT且血栓未累及下腔静脉者,行CDT治疗时不必常规置入腔静脉滤器.     

Comparing Short-Term Outcomes of Femoral-Popliteal and Iliofemoral Deep Venous Thrombosis: Early Lysis and Development of Reflux

This study compares the development of reflux, recanalization, and clinical outcomes of patients with femoral-popliteal and iliofemoral deep venous thrombosis (DVT). Emphasis is placed on the relationship between early lysis of clot through thrombolysis and the development of reflux and post-thrombotic syndrome (PTS) for iliofemoral patients. A retrospective chart review was conducted of 27 femoral-popliteal DVT limbs and 11 iliofemoral DVT limbs with average follow-up of 2.3 and 2.1 years, respectively. Rates of recanalization, development of reflux, and post-thrombotic syndrome were recorded through review of duplex scans and physical examinations. All femoral-popliteal patients received anticoagulant therapy. Nine of 11 iliofemoral patients (82%) received thrombolytic therapy in addition to anticoagulants. Statistical analysis included Kaplan-Meier estimation to take into account dropout in follow-up times, and chi-squared analysis to compare final outcomes. A significantly greater proportion of iliofemoral patients (73%) than femoral patients (31%) remained asymptomatic at the end of their follow-up (p < 0.025). Because of thrombolytic therapy, 82% of iliofemoral limbs showed partial or complete lysis 4 weeks after diagnosis of clot. As expected, only 22% of femoral-popliteal limbs developed some recanalization 4 weeks after diagnosis (p < 0.005). Interestingly, no significant difference in reflux development was observed between the two groups. After an average of 2.1 years, 60% of femoral-popliteal limbs developed reflux in the deep veins vs. 64% for iliofemoral limbs. The iliofemoral DVT patients showed improved clinical outcomes in the short term compared to that of femoral-popliteal patients in this pilot study. The improved clinical outcomes could be attributed to the early lysis of clot via thrombolytic therapy for the iliofemoral group. Although the extent of reflux development was similar in both groups, iliofemoral patients still showed fewer clinical symptoms after follow-up. This may suggest that the presence of both residual obstruction and reflux, rather than either one alone, significantly increases the chances for development of PTS. Since thrombolytics eliminates at least one of these factors, residual obstruction, it may aid in decreasing development of PTS in the short term. The data in this retrospective study warrant further long-term prospective analysis of thrombolysis and its relationship with PTS.