人工髋关节置换后深静脉血栓形成影响因素的回顾分析☆

背景：目前尚缺少严格遵照《中国骨科大手术静脉血栓栓塞症预防指南》进行血栓预防的大宗人工髋关节置换后深静脉血栓栓塞症发生情况的报道。 目的：调查人工髋关节置换患者在进行规范预防性抗凝治疗后下肢深静脉血栓的发生情况。 方法：纳入2005-01/2010-07于北京协和医院骨科接受人工髋关节置换的患者,对置换后出现下肢深静脉血栓形成者进行回顾性分析,包括高危因素、预防措施、症状特点、治疗方案及转归。 结果与结论：共纳入670例人工髋关节置换患者,其中16例发生下肢深静脉血栓,11例为人工股骨头置换患者,5例为单侧全髋关节置换患者。诊断分布为股骨颈骨折14例,股骨头无菌性坏死1例,血友病性关节炎1例。其合并症1~4个,包括高血压、糖尿病、类风湿性关节炎、慢性肾功能不全等。围手术期皆应用规范物理、药物疗法预防下肢深静脉血栓形成。14例表现为下肢肿胀、疼痛;2例以肺栓塞为首发症状。多数预后良好;1例死于与下肢深静脉血栓形成无关的肺部感染,1例抗凝治疗后并发脑出血导致植物生存状态。提示进行规范预防治疗可以降低下肢深静脉血栓形成发生率,但仍不能完全杜绝其发生。髋部骨折、长期卧床、高龄、代谢性内科疾病仍是下肢深静脉血栓形成的高危因素。     

髋部骨折后下肢深静脉血栓形成家兔模型的建立

背景：目前各种方法诱导下肢深静脉血栓的动物模型缺乏统一的标准。 目的：建立髋部骨折后下肢深静脉血栓形成兔模型。 方法：采用专用击打装置,用位于28 cm高度的击打物击打家兔后下肢左侧大腿根部;建立兔髋部骨折模型,另一侧兔后下肢不击打设为对照侧。4周后选取下肢髂静脉行彩色多普勒超声以及凝血功能的检查血栓形成情况。 结果与结论：家兔经打击后经彩色多普勒超声检查存在下肢深静脉血栓,血栓长度(124±37) mm。对照侧无下肢深静脉血栓形成。血栓形成率81.8%,死亡率为9.1%。结果证实,实验成功建立的兔髋部骨折后下肢深静脉血栓形成模型,简单可行。     

The wheelchair thrombosis syndrome

OBJECTIVE: To report a case of deep vein thrombosis (DVT) related to prolonged wheelchair use. CASE REPORT: A 48-year-old patient with spastic quadriplegia usually spent 10-12 hours daily in a wheelchair. He suddenly developed marked swelling of his right foot, leg and thigh. His plasma D-dimer level was 1,030 (normal <500) ng/ml. A duplex ultrasound revealed common femoral vein thrombosis. He was hospitalized and anticoagulated; his extremity swelling decreased considerably by day 45. Hypercoagulability work-up disclosed previously subclinical mild elevation of serum cardiolipin immunoglobulin G (antiphospholipid syndrome). This patient will receive longterm anticoagulation. CONCLUSION: Prolonged sitting in wheelchair may cause DVT. To enhance public recognition of this avoidable risk, we propose the term "wheelchair thrombosis syndrome."     

Controversial issues in the diagnosis of venous thromboembolism

Although considerable progress has been made in the diagnosis of venous thromboembolism, several issues remain that are awaiting a proper solution. Among them are: the respective role of compression ultrasound of the proximal veins and ultrasonography of the entire leg vein system in the diagnostic approach of patients with the clinical suspicion of the first episode of deep venous thrombosis (DVT) of the lower extremities; the safety of managing subgroups of patients with suspected DVT without objective tests, i.e., with the use of pre-test probability scores and D-dimer assays; the role of ultrasonography in the diagnostic approach of patients with suspected ipsilateral recurrent thrombosis; and the role of spiral CT in the diagnostic approach of patients with clinically symptomatic pulmonary embolism.     

Follow-up of circulatory changes secondary to deep venous thrombosis with special regards to radionuclide tests

The influence of circulatory changes, which are secondary to deep venous thrombosis (DVT) in the leg, on result of radionuclide tests was studied in eight patients. Strain gauge plethysmography, a radionuclide blood-pool test and phlebography were performed both in the acute phase and during recovery up to 6 months after the initial admission. Morphological and functional changes were correlated with results from repeatedly performed 99Tcm-plasmin tests, a test currently used for diagnosis of DVT. In the acute phase, the thrombotic leg showed an increase in pooled blood and, in the case of proximal thrombosis, also impaired venous outflow. During the 6-month follow-up complete recanalization was observed in three patients and partial recanalization in five. The circulatory changes were found to recover progressively and earlier than the morphological changes. The 99Tcm-plasmin test was pathological at admission in all patients. It was normalized in parallel with plethysmography and blood-pool test results, at a time when morphological recovery was still incomplete. These findings confirm that a positive 99Tcm-plasmin test reflects haemodynamic changes which are secondary to the DVT rather than a specific binding of the radiopharmaceutical to the thrombus. The 99Tcm-plasmin test was normalized from 1 to more than 26 weeks after an acute DVT. This finding is of practical importance when using radionuclide tests for evaluation of acute recurrent DVT.     

双侧全膝关节置换后下肢深静脉血栓形成与高血压的关系

背景：下肢深静脉血栓是人工全膝关节置换后的严重并发症之一,若不能及时妥当地诊断及处理会引起患者病情迁延不愈,甚至血栓脱落造成肺栓塞,危及患者生命。目前国内外研究并未确定有高血压病的患者行全膝关节置换后会增加下肢深静脉血栓的发生率。 目的：观察高血压是否会影响双侧人工全膝关节置换后患者下肢深静脉血栓的发生率。 方法：回顾性分析2010 年9月至2014年3月新疆医科大学第一附属医院关节外科因膝骨关节炎行双侧全膝关节置换患者的病历资料,根据患者是否合并有高血压,将其分为高血压组与对照组。在置换后通过彩色多普勒超声检查,诊断患者全膝关节置换后是否发生下肢深静脉血栓。比较两组间下肢深静脉血栓的发生率是否有差异,分析高血压与下肢深静脉血栓的关系。 结果与结论：共纳入525 例患者,高血压组219例,对照组306例。全膝关节置换后20例患者发生下肢深静脉血栓,发生率为3.8%,其中高血压组发生下肢深静脉血栓13例(2.5%),对照组发生下肢深静脉血栓7例(1.3%)。通过卡方检验分析,高血压组全膝关节置换后发生下肢深静脉血栓的风险是对照组患者的2.7倍,差异有显著性意义(P < 0.05)。提示术前患有高血压病患者行全膝关节置换,其置换后下肢深静脉血栓发病率高于术前血压正常患者。中国组织工程研究杂志出版内容重点：人工关节;骨植入物;脊柱;骨折;内固定;数字化骨科;组织工程全文链接：     

下肢深静脉血栓的超声诊断价值及相关诊断方法的应用

目的 研究下肢深静脉血栓的超声诊断价值及相关诊断方法的应用。方法 选取2018年5月~2019年5月在我院诊治的132例下肢深静脉血栓患者临床资料,患者均采用常规超声和多普勒超声检查,比较两种诊断方法下肢静脉血栓的检出率、不同节段下肢静脉血栓灵敏度。结果 彩色多普勒超声检查下肢深静脉血栓检出率为96.21%,高于常规超声检查的80.30%,差异有统计学意义（P＜0.05）;彩色多普勒超声检查不同节段下肢深静脉血栓（股静脉、髂总静脉、腘静脉、胫后静脉、胫前静脉）灵敏性、特异性查比较,差异有统计学意义（P＜0.05）;彩色多普勒超声对股静脉（96.66）、腘静脉（92.59）的灵敏性较高,对髂总静脉、胫后静脉、胫前静脉的灵敏性较低。结论 下肢深静脉血栓采用彩色多普勒超声检出率高,且对出不同节段深静脉血栓灵敏性存在差异,无创伤,具有良好的重复性,有一定的的诊断价值。     

下肢静脉血栓的彩色多普勒超声诊断

目的 探讨下肢静脉血栓的彩色多普勒超声声像图特点。方法 回顾性分析71例下肢静脉血栓形成患者的彩色多普勒声像图特点。结果 左下肢的发病率明显高于右下肢，常累及股静脉、股浅静脉、股深静脉、月国静脉等。声像图特点为管腔内探及实性高或低回声团块CDFI血流信号变细或无血流信号；脉冲多普勒血流速度减慢且不受呼吸影响。结论 彩色多普勒超声诊断下肢静脉血栓具有直观性、可靠性。     

髋关节置换后利伐沙班与低分子肝素预防下肢深静脉血栓的比较

背景：低分子肝素可显著降低髋关节置换后下肢深静脉血栓的发生率,但其因需皮下注射而存在局限性。 目的：比较全髋关节置换后应用利伐沙班与低分子肝素预防下肢深静脉血栓疗效和安全性的差异。 方法：58例全髋关节置换患者按随机数字表法分为2组,利伐沙班组28例,低分子肝素组(达肝素)30例。置换后行双下肢彩色多普勒检查评估DVT形成情况,并观察治疗期间出血情况。 结果与结论：利伐沙班组与达肝素组患者在预防下肢深静脉血栓疗效上差异无显著性意义(P > 0.05)。两组在治疗期间均无严重出血,置换后非严重出血差异也无显著性意义(P > 0.05)。提示利伐沙班在预防全髋置换后下肢深静脉血栓的疗效与安全性上与低分子肝素作用相当。     

Diagnostic value of fibrinopeptide A and beta-thromboglobulin in acute deep venous thrombosis and pulmonary embolism

The purpose of this study was to assess the predictive values of the assays of fibrinopeptide A (FPA), beta-thromboglobulin (BTG) and their combination in patients suspected of having acute deep venous thrombosis (DVT) or pulmonary embolism (PE). In 80 controls the mean (+/- SD) plasma concentrations of FPA and BTG were 0.72 +/- 0.47 and 28.2 +/- 10.1 ng/ml, respectively. In 26 patients in whom DVT was confirmed by phlebography and Doppler ultrasound, clearly raised mean FPA (5.62 ng/ml) and BTG (70.6 ng/ml) concentrations were measured compared to those in 13 patients in whom this disorder was excluded (1.00 and 33.6 ng/ml, respectively). Also in 25 patients, in whom PE was established by perfusion lung scanning, clearly increased mean FPA (6.28 ng/ml) and BTG (82.4 ng/ml) concentrations were measured compared to those in 12 patients without this disease (1.03 and 32.5 ng/ml, respectively). Raised FPA and BTG concentrations were also found in 20 patients with inflammatory disorders and in 10 with various types of malignancy. The mean FPA and BTG concentrations did not differ between patients with renal failure or diabetes mellitus and patients without these diseases. From the predictive values of these assays and their combination it can be concluded that raised FPA and BTG concentrations are not specific for thrombosis. However, when normal FPA and BTG concentrations are present, acute DVT or PE can safely be excluded in symptomatic patients. In the group with confirmed DVT/PE, anticoagulant treatment (heparin and phenprocoumon) brought down the mean FPA concentration to levels within the normal range in less than 1 hour while the mean BTG concentration remained elevated throughout the 10-day study period.     

妇科肿瘤围手术期并发下肢深静脉血栓28例诊疗体会

目的探讨妇科肿瘤围手术期并发下肢深静脉血栓的诊断及治疗。方法回顾性分析28例妇科肿瘤围手术期并发下肢深静脉血栓患者的临床资料。结果本组28例患者中恶性肿瘤患者25例，良性肿瘤患者3例，平均年龄51．6岁。经静脉彩色多普勒超声检查并结合D-二聚体监测，确诊后采用全身及局部抗凝、溶栓及活血化淤药物治疗；术前并发中央型、混合型下肢深静脉血栓，及术前或术后并发肺动脉栓塞患者均放置临时性下腔静脉滤器。28例患者均达好转出院，无死亡病例。结论1．妇科肿瘤尤其恶性肿瘤患者围手术期应充分重视LDVT的诊断及治疗。2．下腔静脉滤器可有效预防妇科肿瘤围手术期致命性肺动脉栓塞的发生。     

下肢深静脉血栓形成药物治疗150例疗效分析

目的探讨下肢深静脉血栓形成药物治疗的方法、疗效。方法回顾分析2005年5月至2010年7月对150例LDVT患者药物治疗资料，发病时间1d～1个月，均为单肢发病，周围型60例，髂股型85例，混合型5例，全部病例经下肢血管彩超及静脉造影检查证实。治疗期间均未置放下腔静脉滤器，予抗凝、溶栓等治疗，时间10～14d。结果130例患者治疗期间患者水肿完全消退，2周后复查Doppler超声基本全程通畅；20例患者患肢轻度肿胀，Doppler超声复查存在髂股静脉短段闭塞，给予华法林维持治疗及弹力袜保护治疗6个月至1年。所有病例均获随访12-18个月，患肢肿胀明显消退，均无肺栓塞并发症。结论下肢深静脉血栓形成药物治疗安全、效果肯定。     

Thrombosis associated with right internal jugular central venous catheters: A prospective observational study

Background and Aims:

Central venous catheters (CVC) are essential in a critical care setting. Thrombosis is one of the very important associated complications that can lead to increased morbidity and mortality. The aim of this study was to find out the incidence of thrombosis in right-sided internal jugular vein (IJV) CVC with the help of color Doppler duplex sonography, its extent, risk factors and clinical impact.

Materials and Methods:

One hundred consecutive patients having right-sided IJV CVC were included in the study. Color Doppler sonography was performed on the 3^rd and 6^th days after CVC insertion. The size of the thrombus was noted. Presence of diabetes mellitus, hypertension or smoking was noted. Presence of any hypertonic solution and thromboprophylaxis for Deep vein thrombosis (DVT) were also noted.

Results:

Thrombus was detected in 33 of 100 (33.0%) patients. The incidence in males was 32.86% and in females was 33.33%. Males had a significantly higher incidence of small thrombus (P = 0.05), whereas females had a significantly higher incidence of large thrombus (P = 0.05). DVT thromboprophylaxis was not effective for CVC-related thrombosis. Hypertonic solution, presence of diabetes, hypertension or history of smoking did not increase the risk of thrombosis.

Conclusion:

CVC-related thrombosis is common and has the potential for serious complications. Females appear to be at a higher risk for larger thrombus formation. DVT thromboprophylaxis does not confer protection for CVC-related thrombosis. Color Doppler duplex sonography provides with an easily available, noninvasive means of detecting a thrombus. More studies are needed to establish a consensus for prophylaxis and treatment of asymptomatic CVC-related thrombosis.     

The ultrasound examination of the deep vein thrombosis

Ultrasonography is very useful for detection of deep vein thrombosis. The purpose of this paper is to show a method for detecting them efficiently by high resolution transducer and color Doppler system. We examined patients in the supine and prone positions. To detect the venous flow easily and differentiate thrombi from simple venous dilatation, some maneuvers are useful; one is pushing the vein area using the transducer on examination, the second is breathing overload, and the last is so-called milking. We can find throombi in the external iliac or femoral veins of patients who have symptoms of lower leg swelling, however, we need to better detect venous thrombi in the lower leg in patients with a history of pulmonary embolism. Because deep venous thrombi are increasing, the role of ultrasound will expand in the future.     

Risk factors of recurrent venous thromboembolism: the role of residual vein thrombosis

In 313 consecutive symptomatic outpatients with proximal deep vein thrombosis (DVT) who had a conventional anticoagulation, an ultrasound assessment of the common femoral and the popliteal vein was performed three months after the acute episode, and then at 6, 12, 24, and 36 months. Veins were considered as recanalized in case of a vein diameter < 2.0 mm in a single determination, or < 3.0 mm in two consecutive determinations. Of the 58 patients who experienced recurrent episodes, 41 occurred while the patient still had residual thrombosis. The hazard ratio of recurrent thromboembolism was 2.4 (95% CI, 1.3 to 4.4; p =0.004) for persistent residual thrombosis versus early vein recanalization. In conclusion, residual venous thrombosis should be regarded as an important risk factor of recurrent thromboembolism.     

Deep venous thrombosis, inflammatory bowel disease, and protein S deficiency

The authors observed a patient with severe inflammatory bowel disease (IBD) complicated by ten episodes of deep venous thrombosis (DVT). Her unusual thrombotic tendency prompted further investigation for primary hypercoagulability. A nonfamilial deficiency of Protein S was documented suggesting the deficiency was acquired. This occurrence suggests that low Protein S levels should be considered as a potential etiologic factor in patients with IBD and recurrent DVT.     

组织蛋白酶L/G对创伤性深静脉血栓模型大鼠静脉壁的影响

背景：目前,深静脉血栓的分子病因学机制及其形成的核心调控网络仍未完全阐明,对于深静脉血栓的早期诊断预测也无理想的方法。 目的：研究组织蛋白酶L/G与创伤性深静脉血栓的预测。 方法：采用蚊式钳夹闭50只SD大鼠双侧股静脉的3个不同部位3 s随后予以模具制动制备大鼠创伤性深静脉血栓模型,根据股静脉血栓形成的不同阶段和生物学特征,将模型大鼠分为血栓形成前组、血栓形成组和无血栓形成组,另取10只正常大鼠作为对照组。在相应时间点取大鼠创伤静脉,提取总RNA,经过基因芯片技术筛选差异表达基因,并进一步应用real-time PCR进行验证。 结果与结论：基因芯片杂交结果发现组织蛋白酶L/G基因在各组间差异表达明显,其中血栓形成组最高,无血栓形成组和血栓形成前组次之,均明显高于对照组(P < 0.05);real-time PCR分析结果与基因芯片杂交分析结果相一致。说明局部静脉血管壁中组织蛋白酶L/G表达水平升高与创伤性深静脉血栓形成有关,可作为深静脉血栓形成早期诊断、预测的候选分子标志。     

Venous thromboembolism associated with long-term use of central venous catheters in cancer patients

Increased incidence of cancers and the development of totally implanted venous access devices that contain their own port to deliver chemotherapy will lead to a greater than before numbers of central venous catheter-related thrombosis (CVCT). Medical consequences include catheter dysfunction and pulmonary embolism. Vessel injury caused by the procedure of CVC insertion is the most important risk factor for development of CVCT. This event could cause the formation of a fresh thrombus, which is reversible in the large majority of patients. In some cases, thrombus formation is not related to catheter insertion. The incidence of CVC-related DVT assessed by venography has been reported to vary from 30 to 60% but catheter-related DVT in adult patients is symptomatic in only 5% of cases. The majority of patients with CVC-related DVT is asymptomatic or has nonspecific symptoms: arm or neck swelling or pain, distal paresthesias, headache, congestion of subcutaneous collateral veins. In the case of clinical suspicion of CVC-related deep venous thrombosis (DVT), compressive ultrasonography (US), especially with doppler and color imaging, currently is first used to confirm the diagnosis. Consequently, contrast venography is reserved for clinical trials and difficult diagnostic situations. There is no consensus on the optimal management of patients with CVC-related DVT. Treatment of CVC-related VTE requires a five- to seven-day course of adjusted-dose unfractionated heparin or low molecular weight heparin (LMWH) followed by oral anticoagulants. Long-term LMWH that has been shown to be more effective than oral anticoagulant in cancer patients with lower limb DVT, could be used in these patients. The efficacy and safety of pharmacologic prophylaxis for CVC related thrombosis is not established and the last recommendations suggest that clinicians not routinely use prophylaxis to try to prevent thrombosis related to long-term indwelling CVCs in cancer patients. Additional studies performed in high risk populations with appropriate dosage and timing will help to define which patients could benefit from prophylaxis.     

Association of C46T genetic polymorphism of coagulation factor XII with deep venous thrombosis: a cohort study on Egyptian patients

Deep vein thrombosis (DVT) is a common multi-factorial disease, with serious short- and long-term complications, and a potential fatal outcome. Many genes are involved in determining the interindividual variation in traits that define the onset and progression of disease, as well as the response to treatment. Several association studies have designed the relationship between factor XII C46T polymorphism and the risk of arterial and venous thrombosis. Some studies reported that FXII gene polymorphism is not associated with venous thrombosis, whereas other studies found an increased risk of venous thrombosis in carriers of a FXII-T variant. We constructed an age–gender–ethnic–matched case–control study including 52 DVT patients and 100 healthy volunteers. C46T polymorphism of the coagulation factor XII was carried out using allelic discrimination assay by real-time polymerase chain reaction for patients and controls, while plasma factor XII activity was detected by one-step clotting assay. FXII C46T genotyping in DVT patients revealed that 34.6% were heterozygous harboring the FXII-CT heterotype and 3.85% were homozygous; FXII-TT homotype, with no statistically significant difference in the distribution of the mutant genotypes between DVT patients and the control group. FXII activity was significantly reduced in DVT patients harboring the mutant genotypes. In the present study, FXII C46T gene polymorphism was not associated with increased risk of deep venous thrombosis.     

Arrive: A retrospective registry of Indian patients with venous thromboembolism

Background and Aim:

There is lack of substantial Indian data on venous thromboembolism (VTE). The aim of this study was to provide real-world information on patient characteristics, management strategies, clinical outcomes, and temporal trends in VTE.

Subjects and Methods:

Multicentre retrospective registry involving 549 medical records of patients with confirmed diagnosis of VTE (deep vein thrombosis [DVT] confirmed by Doppler ultrasonography; pulmonary embolism [PE] by computed tomography, pulmonary angiography and/or V/Q scan) from 2006 to 2010 at three Indian tertiary care hospitals.

Results:

Acute DVT without PE, acute DVT with PE, and PE alone were reported in 64% (352/549), 23% (124/549), and 13% (73/549) patients, respectively. Mean age was 47 (±16) years, and 70% were males. H/o DVT (34%), surgery including orthopedic surgery (28%), trauma (16%), and immobilization >3 days (14%) were the most common risk factors for VTE. Hypertension (25%), diabetes (19%), and neurological disease (other than stroke) (8%) were the most common co-morbidities. Most (94%) were treated with heparin alone (82%) or fondaparinux (2%) for initial anticoagulation; low molecular weight heparin alone (5%) or warfarin/acenocoumarol (76%) for long-term anticoagulation. Anticoagulant treatment was stopped because of bleeding in 2% (9/515) patients. Mortality was 7% among patients diagnosed with VTE during hospital stay versus 1% in those hospitalized with diagnosed VTE. The annual incidence of DVT (±PE) increased from 2006 to 2010.

Conclusion:

Acute DVT alone was responsible for the substantial burden of VTE in Indian patients. Bleeding was not the limiting factor for anticoagulant treatment in most patients.