急性肺栓塞危险分层的研究进展

急性肺栓塞的严重程度可从无症状偶然发现的肺动脉亚段血栓至并发心源性休克和多脏器衰竭的高危肺栓塞。因此,迅速准确危险分层对确保高质量的治疗至关重要。本文对当今临床广泛使用和正在进行研究的急性肺栓塞危险分层评估方法给予综述,并讨论危险评估策略对肺栓塞优化治疗所起的作用。     

320排CT肺减影技术对亚段肺栓塞的诊断价值

目的 探讨320排CT肺减影技术进行CTPA诊断肺栓塞同时，是否可以提供更多的诊断信息，提高亚段肺栓塞的阳性检出率。方法 98例PE患者行CT肺减影扫描获取常规CTPA图与肺减影图。两名医师独立完成常规CTPA图及肺减影图的诊断，并记录栓子的位置及类型。采用Kappa系数检验两位医师的诊断一致性，采用McNemar检验比较常规CTPA与减影CT在肺栓塞诊断中的差异。结果 两位医师在肺动脉干水平、叶肺动脉水平、段肺动脉水平和亚段肺动脉水平诊断一致性良好，Kappa值均>0.75。常规CTPA组与肺减影组在肺动脉干水平、叶肺动脉水平及段肺动脉水平栓子检出率差异不具有统计学意义，在亚段肺动脉水平差异具有统计学意义(P<0.01)。结论 320排CT肺减影技术可以为肺栓塞的诊断提供更多信息，提高亚段肺栓塞检出率及医师的诊断一致性水平。     

SPECT/CT融合显像与心脏彩超三维成像诊断肺栓塞的实验研究

目的 通过家兔自体血栓回输的方法建立急性肺动脉血栓栓塞（肺栓塞）模型,比较单光子发射计算机断层成像术（SPECT）融合显像与心脏彩超三维成像对急性肺栓塞的诊断价值.方法 30只日系大白兔采用自体血栓回输方法建立急性肺栓塞模型,栓塞后4小时后分别行SPECT/CT融合显像与心脏彩超三维成像,并与病理解剖结果进行对比分析.肺组织病例学检查：分别于栓塞显像后处死实验动物,观察栓子的分布情况.统计学采用x2检验.结果 成功建立28只兔肺栓塞模型,栓塞后4小时,SPECT/CT融合显像诊断肺栓塞阳性率为92.9％ （26/28）,其中,显示肺段及支受累11例,亚段受累15例,以肺下叶外侧段及后基底段以下亚段分支受累较多.心脏彩超三维成像阳性率为67.9％（19/28）,两者比较差异有统计学意义（P＜0.05）.结论 SPECT/CT融合显像与心脏彩超三维成像诊断肺栓塞具有较好的一致性,SPECT/CT融合显像敏感性高于心脏彩超三维成像,二者互补可提高临床肺栓塞诊断的准确率.     

高危肺栓塞高级治疗的研究进展

肺栓塞和深静脉血栓形成都是静脉血栓栓塞症的表现,其中肺栓塞是静脉血栓塞栓症较严重的表现。肺栓塞有很高的发病率和死亡率,其一旦确诊,风险分层对于治疗决策至关重要。肺栓塞根据死亡风险分为低危、中危和高危。高危肺栓塞指伴有休克、心搏骤停的肺栓塞。高危肺栓塞的治疗因其高死亡率在肺栓塞中是最具临床挑战性的,选择合适的高级治疗方式可以显著降低肺栓塞死亡率。高危肺栓塞的高级治疗包括体外膜肺氧合、全身溶栓、基于导管的干预治疗和外科取栓术。本文主要对高危肺栓塞的高级治疗方式的研究进展进行阐述和分析,为高危肺栓塞的临床诊治提供依据。     

双源螺旋CT对肺栓塞患者栓塞血管分布特点的评价

目的采用双源螺旋CT的方法分析评价肺动脉栓塞患者栓塞血管分布特点,为临床诊断肺栓塞提供影像学的依据。方法收集中国医科大学附属第一医院2009年1月至2010年9月心内科等其他科室怀疑肺栓塞的患者,行双源螺旋CT检查确诊171例肺动脉栓塞,并对其栓塞血管分布特点进行分析。结果 171例经双源螺旋CT确诊肺动脉栓塞患者中累及主肺动脉111例(64.91%),累及叶动脉84例(49.12%),累及段动脉42例(24.56%),累及孤立亚段动脉5例(2.92%)。其中主肺动脉及其分支均有累及为85例(49.71%),仅主肺动脉累及为26例(15.20%),叶动脉及其分支均有累及为51例(29.82%),仅叶动脉累及为33例(19.30%),段动脉及其分支累及为8例(4.68%),仅段动脉累及为34例(19.88%),孤立亚段动脉累及为5例(2.92%)。其中多发部位栓塞144例(59.5%),单发栓塞部位为98例(40.5%)。结论经双源螺旋CT确诊肺栓塞患者的栓塞血管,主肺动脉和叶动脉所占比例较大,段动脉及亚段动脉也有累及。     

双源CT肺动脉造影与双能量肺灌注成像诊断急性肺栓塞的对比研究

目的探讨双源CT扫描时双能量肺灌注成像(DEPI)结合CT肺动脉造影(CTPA)对急性肺栓塞患者的诊断价值。方法选取我院2008年10月至2010年3月急性肺栓塞患者12例,应用双源CT进行平扫加增强扫描,先行CTPA,再用双能量扫描模式行肺灌注扫描,得出肺灌注图像及两种能量状态的融合图像,将CTPA上所示段及亚段肺血管内充盈缺损的位置、数目、类型与DEPI中肺灌注位置、数目、形态进行对比。结果当段、亚段肺血管为完全充盈缺损时,相应的肺灌注图像主要是肺段或亚段分布的灌注缺损,分别占84.4%(16支血管,7例)和63.6%(7支血管,5例)。而当部分充盈缺损时,肺灌注图像以不均匀灌注缺损为主,16%表现为无灌注缺损;相反,4个肺段区显示灌注缺损,而CTPA未见异常。结论双源CT肺灌注成像表现与CTPA上肺动脉栓塞程度、部位有关,两者联合有助于提高急性肺栓塞诊断率。     

肺栓塞在基层医院诊疗中的经验（附30例报告）

目的分析急性肺栓塞的临床特点、早期诊断的无创检查手段、溶栓及抗凝治疗的疗效,以期降低漏诊率和误诊率,并探讨早期诊断及治疗方法。方法分析2006年至2010年我院住院30例肺栓塞的临床特点、辅助检查和治疗方案等临床资料。结果肺栓塞临床表现以呼吸困难最为常见;D二聚体对肺栓塞具有高度敏感性;CTPA＋心脏彩超检查可明确诊断。积极予以溶栓、抗凝、呼吸支持等治疗可降低误诊率和死亡率。结论在基层医院,提高肺栓塞的诊断意识,提高肺栓塞的诊断率和治愈率。     

肺栓塞临床及预后影响因素分析

目的 :探讨肺栓塞的临床特点、诊断程序、治疗措施和预后的影响因素。方法 :对我院1995～ 2 0 0 3年确诊的 38例肺栓塞病例的资料进行回顾性分析。结果 :肺栓塞患者以 4 0～ 6 0岁年龄段所占比例最高。肺栓塞易患因素居前 2位的分别为心血管疾病和静脉血管病。肺栓塞的常见症状有呼吸困难、咳嗽、心悸、胸痛、咯血、晕厥等。实验室检查 ,D -二聚体阳性者占 77.8% ,肺核素扫描显示肺段灌注缺损的敏感性为 10 0 %。接受溶栓治疗的患者 ,死亡率为 2 3.1% ,接受抗凝治疗的患者 ,死亡率为 38.5 %。发现收缩压 <90mmHg、PaO2 <6 5mmHg、PaCO2 <2 5mmHg、P(A-a)O2 较高及受累肺段数较多等是肺栓塞预后不良的影响因素。结论 :肺栓塞的临床表现多样 ,对于有心血管疾病的中老年患者 ,当出现呼吸系统症状时要警惕肺栓塞的可能 ,应根据病情的轻重缓急制定相关的检查和治疗方案。对于存在预后不良影响因素的肺栓塞患者 ,要高度警惕 ,加强监测 ,积极治疗 ,争取降低死亡率。     

急性非大面积肺栓塞13例诊治分析

目的对急性非大面积肺栓塞进行临床分析,评价诊断方法和治疗效果。方法 2009年1月至2010年2月收治例13例急性非大面积肺栓塞病例进行回顾性分析。结果本组肺栓塞患者通过D-二聚体、心电图、心脏彩超、血气分析、双下肢静脉彩超、CTPA最终确诊,误诊率23%,予以抗凝治疗疗效显著。结论肺栓塞的临床症状、体征不典型,误诊率高,发病与易患因素密切相关,对于急性非大面积肺栓塞患者提倡抗凝治疗,临床医师提高对此病的认识和诊断水平是当务之急。     

冠状动脉CT成像意外检出住院患者肺栓塞的临床分析

目的量化临床疑似冠心病住院患者冠状动脉CT成像(CCTA)图像上肺栓塞的意外检出率,并初步探讨意外检出肺栓塞的特征及原因。方法选择临床疑似冠心病并接受CCTA检查的住院患者4609例,最后入选4177例,其中年龄<60岁患者1730例,≥60岁患者2447例。观察图像并记录每个患者的肺动脉强化程度和有无肺栓塞。结果意外检出肺栓塞56例(1.3%)。肺栓塞意外检出率随着年龄增长而升高,年龄<60岁检出率为0.6%,≥60岁检出率增至1.8%(P<0.05)。56例肺栓塞中,37例(66.1%)仅累及肺段和肺亚段动脉,阵发性心房颤动(房颤)包括有房颤病史和心功能不全患者,其肺栓塞意外检出率(3.9%、4.9%)虽高于未合并房颤和心功能不全患者(1.1%,1.1%)的检出率,但差异无统计学意义(P>0.05)。50例肺栓塞患者中,下肢静脉血栓7例(14.0%),53例肺栓塞患者中,10例D-二聚体水平>0.50mg/L(18.9%)。结论住院患者CCTA图像上肺栓塞的意外检出率较低,并具有与"典型"肺栓塞不同的特征。每一个影像医师都应常规利用CCTA图像评价是否存在肺栓塞,尤其是合并房颤包括有房颤病史或心功能不全的老年住院患者。     

Pulmonary tumor embolism: a critical review of clinical, imaging, and hemodynamic features

Pulmonary tumor embolism is a common finding at autopsy but is generally perceived as a difficult diagnosis to make ante mortem. After a retrospective review of 164 reported cases of pulmonary tumor embolism, we identified a typical profile of clinical, laboratory, and imaging features that may permit confident clinical diagnosis in most patients with this condition. The clinical features include a documented or suspected underlying malignancy, acute to subacute onset of dyspnea, and signs of cor pulmonale. Supportive laboratory features are hypoxemia or increased alveolar-arterial oxygen gradient, and invasive or noninvasive evidence of pulmonary artery hypertension. Typical imaging findings are normal chest radiographs; multiple, subsegmental, peripheral perfusion defects on ventilation-perfusion lung scans; and delayed filling with or without subsegmental filling defects but without a thrombus on pulmonary angiogram. Radiolabeled monoclonal antibody imaging and pulmonary microvascular cytology sampling techniques are promising diagnostic tests for early diagnosis of pulmonary tumor embolism.     

Should we treat subsegmental pulmonary embolism?

The expanded use of multi-detector computed tomography has increased the proportion of diagnosed subsegmental pulmonary embolism. The clinical significance and prognosis of these embolisms remain unknown and the benefit of anticoagulation is not yet proven. Several previously validated diagnostic strategies for pulmonary embolism exclusion (based on single-detector computed tomography and ventilation-perfusion lung scan) were unable to detect most of these subsegmental pulmonary embolisms. However, these strategies have been proven safe, with very few thromboembolic events at 3 months. Furthermore, the comparison between studies using single-detector and multi-detector computed tomography suggests increased rates of PE diagnosis and increased rates of anticoagulated patients without improvement of the three-month followup. Subsegmental pulmonary embolisms seem to have less clinical impact than proximal pulmonary embolisms and a better long-term prognosis. In some patients with isolated subsegmental pulmonary embolism, the bleeding risk related to anticoagulation might outweigh the benefit of preventing recurrent thromboembolic event.     

Helical computed tomography and magnet resonance imaging: diagnosis of pulmonary embolism in symptomatic patients

The diagnosis of pulmonary embolism is challenging because lung scanning is nondiagnostic in most patients and because pulmonary angiography is invasive. Advancements in computed tomography and magnetic resonance imaging have enabled visualization of pulmonary emboli. Studies using each of these modalities have demonstrated high sensitivity for lobar and segmental emboli and lower sensitivity for subsegmental emboli. A recent study of a management approach using spiral computed tomography combined with testing for deep vein thrombosis using compression ultrasonography was found to have high clinical validity. A number of different magnetic resonance imaging techniques have been used to identify pulmonary emboli, and no single technique has been shown to be superior. Further studies are needed to delineate the role of magnetic resonance imaging in the management of patients with suspected pulmonary embolism.     

多层螺旋CT肺动脉造影在诊断周围型动脉栓塞中的应用

目的探讨多层螺旋CT肺动脉造影(MSCTPA)对周围型肺栓塞(PPE)的诊断价值。方法回顾性分析417例MSCTPA的患者资料,结合多层面曲面重组成像(CPR)、最大密度投影(MPR)、曲面重组(MIP)等图像后处理手段,分析PPE的MSCTPA的表现。结果检出的188例周围型动脉肺栓塞患者中,孤立性PPE 1例,PPE合并中心型肺动脉栓塞187例。188例患者共检出PPE 1583支,其中,累及亚段1012支,亚亚段PE 473支,亚亚段以远分支PE 98支。结论 MSCTPA能够准确显示PPE的范围及影像表现特征,对诊断PPE及病情评估具有重要的影像学参考价值,是诊断PPE的首选影像学检查手段。     

The rehabilitation of clinical assessment for the diagnosis of pulmonary embolism

Pulmonary angiography is the gold standard for diagnosis of segmental pulmonary embolism, but no longer for subsegmental pulmonary embolism because the inter-observer agreement for angiographically documented subsegmental pulmonary embolism is only 60%. A normal rapid ELISA VIDAS D-dimer test result and a normal perfusion scan exclude pulmonary embolism with a negative predictive value of >99%, irrespective of clinical score. The positive predictive value for pulmonary embolism of a high probability VP-scan compared to pulmonary angiography is 87% indicating that 13% of patients with a high probability VP-scan do not have pulmonary embolism. The combination of a negative CUS, a low clinical score, and a non-diagnostic VP-scan safely excludes pulmonary embolism. Patients with a non-diagnostic VP-scan, a negative CUS, but a moderate to high clinical score are candidates for pulmonary angiography. The positive predictive value of helical spiral CT is >95 to 99%. The combination of a negative CUS, a low clinical score, and the presence of a clear alternative diagnosis is predicted to safely exclude pulmonary embolism. Helical spiral CT detects all clinical relevant pulmonary emboli and a large number of alternative diagnoses in symptomatic patients with a non-diagnostic or a high-probability VP-scan. The negative predictive value during 3 months followup after a negative spiral CT for pulmonary embolism in 4 retrospective studies and 1 prospective management study was >99%. Only a small group of patients (1-2%) with a non-diagnostic spiral CT are candidates for pulmonary angiography. Therefore, it is predicted that the spiral CT will replace both VP-scanning and pulmonary angiography to safely exclude or diagnose pulmonary emboli in patients with suspected pulmonary embolism.     

Multidetector computed tomography for the diagnosis of acute pulmonary embolism

PURPOSE OF REVIEW: This review describes the accuracy of multidetector contrast-enhanced computed tomography (CT) for the diagnosis of acute pulmonary embolism, the role of clinical assessment and of venous phase imaging in combination with it, and the approach to the diagnosis. RECENT FINDINGS: The sensitivity of CT angiography was 83%, specificity 96% and positive predictive value 86%. Positive predictive values were 97% for pulmonary embolism in a main or lobar artery, 68% for a segmental vessel, and 25% for a subsegmental branch. A CT angiogram with concordant clinical probability assessment resulted in high predictive values, but with a discordant clinical probability, predictive value was low. The sensitivity for pulmonary embolism increased to 90% by using CT venography in combination with CT angiography.A negative D-dimer by the rapid enzyme-linked immunosorbent assay method with a low or moderate probability clinical assessment can safely exclude pulmonary embolism. Clinical probability assessment and D-dimer are recommended. In general, CT angiography in combination with CT venography is recommended, but the choice of diagnostic tests depends on the clinical situation. SUMMARY: The reliability of multislice CT angiography is enhanced by clinical assessment and CT venography used with it. Clinical assessment and D-dimer are recommended before imaging.     

多层螺旋CT肺血管造影在肺动脉栓塞中的诊断价值

目的 研究多层螺旋CT肺血管造影在肺动脉栓塞诊断中的诊断价值.方法 对18例经16层螺旋CT确诊的肺栓塞患者进行回顾性分析.结果 18例患者共累及224支肺动脉及其分支,其中肺动脉干1支,左、右肺动脉共9支,叶动脉45支,段动脉78支,亚段动脉及以下动脉分支91支.肺栓塞的CT表现:①直接征象:中心型充盈缺损、偏心型充盈缺损、附壁血栓、完全阻塞型充盈缺损.②间接征象:肺野透过度增高,肺纹理稀疏、细小,肺动脉高压,肺梗死,主、肺动脉增宽,右心室增大,心包积液、胸腔积液等.结论 多层螺旋CT肺血管造影是诊断肺动脉栓塞的一种快捷、无创、安全、可靠的影像诊断方法,对及时诊断和治疗肺动脉栓塞有重要的临床意义.     

超声心动图诊断急性肺动脉栓塞的价值

目的 :分析评价床旁超声心动图 (ECHO)在急性肺动脉栓塞 (APE)诊断中的实用价值。方法 :采用经胸ECHO对临床怀疑APE的 5 8例患者在 4～ 6h内行床旁ECHO检查。结果 :超声直接检出主肺动脉及左右肺动脉主干近端血栓者 4例 ,均被外科手术或肺动脉造影证实。本组具有典型右心负荷过重超声征象者 15例 (其中包括具有超声直接征象的 4例 ) ,核素肺灌注 通气扫描提示为双肺多发性大面积栓塞。仅右房、右室轻度增大或肺动脉轻度增宽者 19例 ,ECHO无改变者 2 4例 ,但核素肺灌注 通气扫描均提示为肺段或亚段栓塞。结论 :ECHO能够发现主肺动脉、左右肺动脉干内附壁血栓直接提示肺动脉栓塞 ,或根据右室负荷过重表现间接提示肺栓塞的可能 ,但对肺段或亚段栓塞者超声不能作出或排除诊断。     

Diagnosis and management of isolated subsegmental pulmonary embolism: review and assessment of the options

We assessed the potential safety of withholding treatment of pulmonary embolism (PE) limited to subsegmental branches. Literature review showed that untreated patients with mostly subsegmental PE had no fatal recurrences in 1 to 3 months and no nonfatal recurrences of PE in 3 months. Patients with suspected PE who had nondiagnostic ventilation/perfusion lung scans, adequate cardiorespiratory reserve or low or moderate clinical probability, and negative serial noninvasive leg tests were shown not to require treatment. It appears safe, therefore, to withhold treatment of subsegmental PE providing (1) pulmonary-respiratory reserve is good; (2) no evidence of deep venous thrombosis (DVT) on serial testing; (3) major risk factor for PE was transient and no longer present; (4) no history of central venous catheterization or atrial fibrillation; and (5) willingness to return for serial venous ultrasound. After fully informing patients, some may choose to be treated and some may choose not to be treated.     

Association of right ventricular dilatation with bilateral pulmonary embolism, pulmonary embolism in a main pulmonary artery and lobar, segmental and subsegmental pulmonary embolism in 190 patients with acute pulmonary embolism

BACKGROUND: Acute pulmonary embolism (PE) may result in right ventricular (RV) pressure overload with a dilated RV which can be diagnosed by two-dimensional echocardiography. METHODS: A retrospective analysis was performed in 190 unselected patients who had acute PE documented by contrast-enhanced spiral computed tomographic scanning. The 190 patients included 104 women and 86 men, mean age 58 +/- 15 years. RESULTS: RV dilatation was present in 45 of 70 patients (64%) with bilateral PE, in 19 of 120 patients (16%) without bilateral PE, in 42 of 47 patients (89%) with main pulmonary artery embolism, in 34 of 84 patients (40%) with lobar PE, in 16 of 70 patients (23%) with segmental PE and in 6 of 36 patients (17%) with subsegmental PE; p < 0.001 comparing bilateral with no bilateral PE and main pulmonary artery embolism with no main pulmonary artery embolism, with lobar, segmental and subsegmental PE; p < 0.025 comparing lobar with segmental PE, and p < 0.02 comparing lobar with subsegmental PE. CONCLUSION: The prevalence of RV dilatation is highest in patients with main pulmonary artery embolism or bilateral pulmonary artery embolism; furthermore, the prevalence of RV dilatation is higher in patients with lobar PE than in patients with segmental or subsegmental PE.