创伤性下肢骨折围手术期肺动脉血栓栓塞的临床特点分析

目的分析创伤性下肢骨折围手术期并发肺动脉血栓栓塞(肺栓塞)的临床特点,探讨早期诊断方法。方法选择2002年1月～2010年1月就诊于我院的创伤性下肢骨折手术治疗患者7352例,其中合并肺栓塞患者37例。回顾性分析围手术期肺栓塞发生的临床特点。结果 37例患者肺栓塞发病时间为创伤骨折后5～30 d,平均1 5 d。发病距离手术时间为即刻～15 d。4例(10.8%)猝死;14例(37.8%)主要临床表现为胸闷及呼吸困难。14例(37.8%)患者心电图显示典型S_ⅠQ_ⅢT_Ⅲ,22例(59.5%)患者仅出现Q_Ⅲ或S_Ⅰ心电图改变。动脉血气分析显示,9例(24.3%)PaO_260 mm Hg(1 mm Hg=0.133 kPa),1 9例(51.4%)PaCO_240 mm Hg。D-二聚体:5例(13.5%)0.5 mg/L,7例(1 8.9%)0.5～1.0 mg/L,25例(67.6%)1.0 mg/L。结论肺栓塞是创伤性下肢骨折围手术期严重的并发症之一,临床特点缺乏特异性。动脉血气分析及血浆D-二聚体是临床诊断便捷的手段。     

320层CT单容积肺动脉成像诊断老年肺动脉血栓栓塞的临床应用

目的探讨320层CT单容积肺动脉成像诊断肺动脉血栓栓塞(肺栓塞)的临床应用价值。方法应用320层CT单容积扫描模式对75例年龄60岁临床怀疑肺栓塞患者行肺动脉CT成像,采用容积再现技术、多平面重建及曲面重建等方法分析扫描数据。结果本组75例患者均成功完成扫描,图像质量均可满足诊断,41例诊断为肺栓塞,其中段级肺栓塞12例,余34例除外肺栓塞。全部病例最终诊断均经核素肺通气灌注扫描及临床溶栓治疗有效所证实。应用320层CT单容积肺动脉成像扫描时间1 s,平均射线剂量为(2.73±0.47)mSv,造影剂总量45 ml。结论 320层CT单容积肺动脉成像诊断肺栓塞是一种有效的无创检查手段,其具有低射线损伤、低对比剂用量、成像速度快等优势,尤其适用于临床急重症及老年患者。     

肺动脉栓塞的CT表现及其鉴别诊断

目的 探讨肺动脉栓塞的CT表现及其诊断价值.方法 回顾性分析20例肺动脉栓塞患者CT增强表现.结果 20例行肺动脉CT增强扫描,178条段以上肺动脉栓塞.平扫示肺动脉栓塞的间接征象为,肺纹理稀疏15例,肺动脉高压3例,胸水15例,梗死灶共30个.结论 CT肺动脉造影在诊断肺动脉栓塞方面快速、有效,对肺动脉栓塞的诊断及鉴别肺梗死和肺出血具有较高价值.     

多层螺旋CT肺动脉造影对肺动脉栓塞的诊断价值（附15例报告）

目的 评价多层螺旋CT血管造影(MSCTA)在诊断肺动脉栓塞(PE)中的价值.方法 对15例经MSCT确诊肺动脉栓塞患者进行回顾性分析.结果 多发肺动脉栓塞10例,其中双侧多发7例,左侧多发1例,右侧多发2例;单发肺动脉栓塞5例,其中肺动脉干2例,叶动脉1例,段动脉2例.肺动脉栓塞的直接征象包括肺动脉主干或其分支的充盈缺损、肺动脉段面细小及管腔内不均匀密度减低;间接征象可以有肺内"马赛克征"、楔形影或索条状影、胸腔积液或胸膜肥厚.结论 多层螺旋CT肺动脉造影是诊断肺动脉栓塞的快速、有效、无创伤的诊断方法,尤其对亚段肺动脉栓塞是一种先进的方法,可以代替肺动脉造影,成为诊断肺动脉栓塞的首选方法.     

老年肺栓塞的螺旋CT肺动脉造影诊断研究

目的探讨螺旋CT肺动脉造影在老年肺动脉栓塞(PE)诊断中的临床应用价值。方法采用螺旋CT对66例老年PE患者行肺动脉增强扫描,其中多层、单层螺旋CT(MSCT,SCT)肺动脉造影检查者各为21和45例。结果分析66例老年PE患者的2728支肺动脉,MSCT、SCT肺动脉造影共显示926支肺动脉受累。直接征象为中心型充盈缺损、部分型充盈缺损、完全性阻塞、附壁性充盈缺损,约占33.9%;1206支段以上肺动脉中,依据直接征象MSCT、SCT分别检出240支/384支(62.5%)和481支/822支(58.5%),共721支/1206支,两者检出率无明显差别(P=0.037);1522支亚段肺动脉中,MSCT、SCT分别检出121支/484支(25.0%)和84支/1038支(8.1%),共205支/1522支,前者检出率明显高于后者(P=0.632)。平扫示间接征象共125例次。结论MSCT、SCT对段以上PE的诊断二者均有较高的准确度,MSCT对亚段PE的诊断有其优势。     

CT肺动脉造影在老年急性肺栓塞疗效评估中的价值

目的探讨CT肺动脉造影(CTPA)在老年急性肺栓塞(PE)疗效评估中的价值。方法入选2009年1月至2016年1月期间在复旦太学附属华东医院诊断及治疗的急性PE患者75例,分为老年组(≥60岁,n=41)和非老年组(60岁,n=34)。对41例老年组患者进行亚组分析:(1)休克组(n=21)和非休克组(n=20);(2)溶栓组(n=28)、介入取栓组(n=8)和手术取栓组(n=5)。比较不同分组模式下患者治疗前后右/左心室最大短轴径比(RV/LV)、肺主动脉最大直径(MPA)和左、右肺动脉主干直径(LPA、RPA)、上腔静脉直径(SVC)以及栓塞指数。结果在治疗前,老年组与非老年组患者的MPA、LPA和RPA值间,以及休克组与非休克组患者的RV/LV、MPA、LPA、RPA、SVC和栓塞指数间差异均具有统计学意义(P0.05)。与治疗前相比:老年组患者治疗后肺动脉栓塞指数显著降低(P0.05);非休克组患者治疗后的MPA和栓塞指数显著降低(P0.05);非老年组、休克组、溶栓组、介入取栓组和手术取栓组患者治疗后的RV/LV、MPA、LPA、RPA、SVC以及栓塞指数均显著降低(P0.05)。Pearson相关性分析结果显示脑钠肽和肌钙蛋白I与RV/LV呈显著正相关(P0.05),栓塞指数和RV/IV与PaO_2呈显著负相关(P0.05)。结论 CTPA可以对老年急性PE的疗效做出准确评估。     

老年肺动脉栓塞多层螺旋CT血管造影的诊断价值

多层螺旋CT(MSCT)的临床应用使得肺动脉栓塞(pulmo-naryembolism,PE)的影像诊断研究进入一个新阶段.快速的容积扫描和较高的空间和时间分辨率,使肺动脉的显示更直观、准确[1].可以清楚显示血栓部位、形态、与血管关系及内腔受损情况,可以鉴别胸肺病变,及评价溶栓和手术效果,所以螺旋CT在老年PE的诊断中非常重要[2].本研究回顾性分析本院39例PE患者的临床资料及MSCT肺血管成像表现,并结合文献探讨MSCT血管成像对PE诊断价值.     

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.     

16排螺旋CT肺血管造影及重建技术在老年人肺动脉栓塞诊断中的应用

目的 研究16层螺旋CT肺血管造影及重建技术在老年人肺动脉栓塞(肺栓塞)诊断中的应用.方法 24例疑为肺栓塞的老年患者应用16层螺旋CT行肺动脉成像.CT后重建技术包括最大密度投影(MIP)、多平面重建(MPR)及容积再现(VR).结果 24例老年患者共发现肺动脉栓子161个,肺栓塞的直接CT征象:完全闭塞27支(占16.8%),不规则的充盈缺损109支(67.7%),中心性充盈缺损(轨道征)25支(15.5%).横断面图像共检出栓子161个,MPR像共检出153个(95.0%),MIP像检出113个(70.2%),VR像检出69个(42.9%).MIP和VR图像对栓子的显示效果相对较差,尤其是对肺叶及其以下肺动脉分支内栓子的显示效果明显低于横断面组(x2值分别为235.36和243.4l,均P＜0.05).结论 16层螺旋CT肺血管造影无创、快速、敏感性高,应当作为老年人肺栓塞的首选检查方法.

Abstract：

Objective To study the application of pulmonary angiography and reconstruction techniques with 16-detector row spiral CT in the diagnosis of pulmonary embolism (PE) in the elderly.Methods Twenty-four elderly patients with suspected pulmonary thromboembolism received detection of CT and pulmonary artery angiography ( CTPA ) on 16-detector MSCT.Post-reconstruction techniques included maximum intensity projection (MIP), volume rendering (VR)and multiple planar reformation (MPR). Results A total of 161 pulmonary artery thrombi were detected in 24 elderly patients. The direct signs of pulmonary embolism included total occlusion (16.8%, 27/161), partial filling defect (67.7%, 109/161) and central filling defect or track sign (15.5%, 25/161). A total of 161 pieces of pulmonary thrombi were detected in transect image, 153 (95.0%) in MPR, 113 (70.2%) in MIP and 69 (42.9%) in VR. The transect image excelled evidently MIP and VR image in displaying pulmonary thrombi, especially the thrombi in pulmonary lobe and pulmonary artery branch (χ2 =235.36 and 243.41, P＜0.05). Conclusions The 16-detector row spiral CT pulmonary angiography is non-invasive, fast and high sensitive, it should be the first choice for the diagnosis of PE in the elderly.     

16层螺旋CT在肺动脉栓塞诊断中的临床应用

肺动脉栓塞（pulmonary embolism，PE）是常见的肺血管疾病，是指内源性或外源性栓子栓塞肺动脉引起肺循环障碍的综合征，病死率高达20％～30％，但若能及时诊断和有效治疗病死率可降至8％。近年来，多层螺旋CT肺动脉造影（MSCTPA）在PE的诊断中发挥了越来越重要的作用。现将我院近年来20例PE患者的MSCTPA的影像资料总结报道如下。     

Optimization of the diagnostic management of clinically suspected pulmonary embolism in hospitalized patients

Identical diagnostic algorithms for suspected pulmonary embolism (PE) are used for hospitalized patients and outpatients, while D‐dimer levels, risk factors and pre‐test probability for PE differ, and the percentage of patients managed without computerized tomography pulmonary angiography (CTPA) is lower in hospitalized patients. We aimed to improve the efficiency of the diagnostic algorithm by increasing the threshold of the D‐dimer, the threshold of the Wells rule and by adjustments of the Wells rule. Six‐hundred and twenty‐four hospitalized patients from two previously performed management studies with a PE prevalence of 26% were studied. Adjustments were considered to be safe when the failure rate remained <2%. By applying standard management, 8% (49/624) were managed without CTPA with a failure rate of 0·0% (0/49; 95% confidence interval [CI] 0·0–7·3), and it was 1·7% (8/465; 95%CI 0·8–3·4) for all patients in whom PE was excluded at baseline. All evaluated adjustments resulted in an increase of the failure rate with very small improvements of the efficiency. Given these potentially small improvements and the increasing complexity of clinical practice if adjusted diagnostic algorithms for specific patient categories were introduced, we do not recommend further evaluation of any of the adjustments; we recommend that the standard diagnostic algorithm should continue to be applied.     

中老年急性肺血栓栓塞症的诊治分析

目的探讨1996～2010年江苏省人民医院确诊为急性肺血栓栓塞症（APTE）中老年病例的危险因素、易患因素以及诊断和治疗方法的变迁。方法对我院1996～2010年间280例确诊为APTE的中老年病例的发病特点、诊治及其转归进行临床回顾性评估分析。结果 APTE好发年龄为50～80岁,占发病的77.5%,以冬春季节为多。APTE临床表现仍以胸闷气急、呼吸困难为主要临床表现,占60.7%。D二聚体〉0.5μg/L占88.5%,仍是高敏感性检查指标。结论 APTE发病与易发因素有关,对其认识加深,重视高敏感性检查指标的筛选,结合快速有效的影像学检查,可提高APTE的诊断率。     

急性大块血栓性肺栓塞15例临床分析

目的总结急性大块血栓性肺栓塞的临床特征及治疗效果,并分析预后相关因素。方法对我院15例急性大块血栓性肺栓塞患者进行回顾性分析,包括临床表现、诊断、治疗及转归。结果本组常见临床表现依次为:心动过速100%,呼吸困难93.3%,一过性或持续性低血压53.3%,休克53.5%,晕厥40.0%,咯血40.0%。首诊准确率为46.7%。15例患者中死亡8例,病死率为53.3%。结论急性大块血栓性肺栓塞的误诊率、死亡率高;预后与右心室/左心室(RV/LV)比值、治疗方法以及是否合并其他疾病,特别是与脑卒中密切相关。紧急肺动脉内导管治疗是降低病死率的有效方法。     

多层螺旋CT在老年急性肺栓塞诊断及疗效评估中的价值

目的 探讨CT肺动脉造影（CTPA）对老年急性肺栓塞（PE）的诊断及疗效评估价值。方法 入选2009年1月至2015年1月在复旦大学附属华东医院心内科住院的老年急性PE患者55例,分为严重组（n＝24）和非严重组（n＝31）。比较两组患者在溶栓治疗前后右/左心室短轴最大径比（RV/LV）、上腔静脉最大径、肺动脉最大径及栓塞指数等指标。结果 与溶栓治疗前相比,严重组患者的RV/LV、上腔静脉最大径、肺动脉最大径及栓塞指数在治疗后均显著降低,差异均具有统计学意义（P＜0.05）;非严重组患者的肺动脉最大径和栓塞指数在治疗后显著降低,差异均具有统计学意义（P＜0.05）。结论 CTPA可用于PE的诊断,并能对溶栓后疗效进行评价,具有快速、有效、无创的优势。     

CT肺栓塞指数在肺栓塞患者中的临床应用研究

目的:探讨肺栓塞指数(CTI)在肺栓塞(PE)患者中的临床应用价值。方法:入选通过双源CT肺动脉造影确诊的187例PE患者,132例为急性PE,55例为慢性PE;急性PE中,低危组46例,中危组86例,高危组0例。通过CT影像计算CTI,结合PE危险分层绘制两者的受试者工作曲线(ROC曲线)并得到最佳诊断阈值,按对应的CTI将急、慢性PE患者分别划分为2组,对比分析2组的临床病例资料。结果:1急性PE中,低危组平均CTI为(37.5±27.4)%,中危组平均CTI为(50.8±23.9)%,差异具有统计学意义(P0.05);慢性PE平均CTI为(23.1±21.9)%。2CTI与危险分层的ROC曲线下面积为0.653(P=0.004),最佳诊断阈值对应的CTI为60%。3急、慢性PE患者CTI在性别、年龄分布上的差异均无统计学意义。4急性PE中,与CTI60%组相比,CTI≥60%组出现呼吸困难及晕厥症状比例更多,心率更快,PaO_2、SaO_2、PaCO_2降低,P(A-a)O_2增高,WBC、NEUT、Hs CRP增高,cTnI、BNP、D-二聚体增高,RA、RV、RV/LV增高(均P0.05)。2组在收缩压、舒张压方面差异无统计学意义。5慢性PE中,与CTI60%组相比,CTI≥60%组出现呼吸困难症状比例更多,PaO_2、SaO_2、PaCO_2降低,P(A-a)O_2增高,HsCRP、D-二聚体增高,RA、RV、RV/LV增高。急性、慢性PE中,CTI≥60%组的肺栓塞严重指数(PESI)评分均高于CTI60%组(P0.05)。结论:CTI与PE危险分层具有显著的相关性,两者ROC曲线的最佳诊断阈值所对应的CTI为60%。以60%为界,CTI可良好区分急、慢性PE患者的病情严重程度及预后,说明CTI在急、慢性PE患者中均具有一定的临床应用价值。     

Diagnostic yield of CT pulmonary angiography for pulmonary embolism in clinically suspected patients

Pulmonary embolism (PE) is a common medical problem. Its diagnostic criteria must be reviewed to determine the need for confirmatory testing. Computed tomography pulmonary angiography (CTPA) is the current standard of care, which provides accurate diagnosis with rapid turnaround. This study aimed to estimate the diagnostic yield of CTPA in clinically suspected PE patients in a tertiary care hospital in Saudi Arabia.Radiology records of all patients with clinically suspected PE who underwent CTPA between January 1, 2012 and September 30, 2018 were reviewed retrospectively. A radiologist with 10 years of professional experience interpreted and reported all cases. The Wells score with 2 tiers (likely and unlikely) was used to raise the clinical suspicion of PE.Positive results for PE were reported in 177 out of 534 clinically suspected cases (33%). Among the positive PE cases, 143 were acute (81%) and 34 (19%) were chronic. Bilateral, right-sided, and left-sided PE were found in 115 (65%), 37 (21%), and 25 (14%) cases, respectively. Involvement of the segmental branches, subsegmental branches, and the pulmonary trunk were noted in 152 (86%), 70 (40%), and 9 cases (5%), respectively. Saddle PE was found in (4%) of the cases. The lower lobe branches (right 55%, left 53%) and the upper lobe branches (right 47%, left 41%) were the most common sites of involvement.CTPA had a higher positive detection rate for PE among clinically suspected cases than its published diagnostic yield. Adequate clinical evaluation when selecting patients for CTPA is emphasized to minimize unjustified exposure of the patients to radiation and intravenous contrast administration. It is crucial for radiologists to provide detailed reports commenting on all relevant findings, including pertinent negatives. A template for reporting radiological findings for CTPA can be recommended for this purpose.