如何正確把握下腔靜脈濾器置放術(shù)的指征-張福先

北京世紀(jì)壇醫(yī)院血管外科張福先VTE概念的理解靜脈血栓栓塞癥(venousthromboembolism,VTE)深靜脈血栓形成(deepvenousthrombosis,DVT)肺栓塞癥 (pulmonarythromboembolism,PE)VTE=DVT+PEDVT與PE在發(fā)病上的一致性——同一疾病在不同階段、不同部位的兩種表現(xiàn)形式在香港和新加坡，住院病人中VTE的發(fā)生率15.8and17.1per10000，而美國(guó)為130per10000.LeeLH,GuKQ,HengD.DeepveinthrombosisisnotrareinAsiaetheSingaporeGeneralHospitalexperience.AnnAcadMedSingap2002Nov;31(6):761-764.CheukBL,CheungGC,ChengSW.EpidemiologyofvenousthromboembolisminaChinesepopulation.BrJSurg2004Apr;91(4):424-428.StienPD,BeemathA,OlsonRE.Trendsintheincidenceofpulmonaryembolismanddeepvenousthrombosisinhospitalizedpatients.AmJCardiol2005June;95(12):1525e6.

IncidenceofVTEper10,000hospitaladmissions

A.D.Lee,E.Stephen,S.Agarwal,etal.VenousThrombo-embolisminIndia.EurJVascEndovascSurg2009,37,482－485.在美國(guó)每年約250000and20millioncasesofDVT需要治療.系統(tǒng)抗凝是TVE治療的主要策略．然而約有15%的病人抗凝無效或?yàn)榻砂Y．對(duì)于這些病人濾器被考慮和選擇．GoldhaberSZ,TapsonVF.FortheDVTFREEsteeringCommitttee.Aprospectiveregistryof5451patientswithultrasound-confirmeddeepveinthrombosis.AmJCardiol,2004:93;259-262HannoHoppe.OptionalVenaCavaFilters.DtschArzteblInt2009;106(24):395–402

Prevalenceofpulmonaryembolism(PE)anddeepvenousthrombosis(DVT)atautopsy

PaulD.Stein.PulmonaryEmbolism.3-4page,2007PublishedbyBlackwellPublishingPrevalenceofpulmonaryembolismatautopsyingeneralhospitalsandcommunities通過動(dòng)物實(shí)驗(yàn)和對(duì)100例DVT患者與PE發(fā)生關(guān)系進(jìn)行前瞻性研究，發(fā)現(xiàn)：DVT患者中PE發(fā)生率是45%。其中73%無任何臨床癥狀，致死性PE為4%.張福先.肢體深靜脈血栓形成與肺栓塞發(fā)生關(guān)系的研究.中華結(jié)核和呼吸雜志2000年.9(23);531－533Phlégmatiaalbadolens.In:TrousseauA.Cliniquemédicaledei`H?tel-DieudeParis.3rded.Vol3,Paris:J.B.Bailliére.1868:652-695.

GreenfieldLJ,MichnaBA.Twelve-yearclinicalexperiencewiththeGreenfieldvenafilter.Surgery1988:104;706-712.應(yīng)用腔靜脈障礙法預(yù)防PE是Trousseau早在一百四十年前1868年提出的.92年后既1960年第一個(gè)濾器產(chǎn)生In400patientsFollowup

At8yearsCirculation.2005;112:416-422..各種類型濾器產(chǎn)生永久型濾器pemanent臨時(shí)型Temporary可選擇的optional可回收的Retrievable在體內(nèi)滯留最長(zhǎng)可達(dá)400天以上可轉(zhuǎn)換的ConvertibleStein統(tǒng)計(jì)美國(guó)國(guó)家醫(yī)療中心數(shù)據(jù)庫(kù)內(nèi)50個(gè)洲、地區(qū)醫(yī)院資料表明：全美濾器應(yīng)用量在1979年為2000個(gè)，1999年為49000個(gè)，增長(zhǎng)了20倍。2003年報(bào)告：全世界濾器應(yīng)用總量每年為140，000個(gè)。2007年美國(guó)報(bào)道：用了213000個(gè)．年增長(zhǎng)率為16%.SteinPD,etal：Twenty-one-yeartrendsintheuseofinferiorvenacavafilters.ArchInternMed.2004;164:1541–1545.RogersFB,etal：Practicemanagementguidelinesforthepreventionofvenousthromboembolismintraumapatients:TheEASTpracticemanagementguidelinesworkgroup.JTrauma.2002;53:142–164.GoldhaberSZ,TapsonVF.FortheDVTFREEsteeringCommitttee.Aprospectiveregistryof5451patientswithultrasound-confirmeddeepveinthrombosis.AmJCardiol,2004:93;259-262HannoHoppe.OptionalVenaCavaFilters.DtschArzteblInt2009;106(24):395–402濾器應(yīng)用的現(xiàn)代觀JVascSurg2008;47:157-65IndicationsforIVCfilterplacementJVascSurg2008;47:157-65IndicationsforIVCfilterplacementin1995and2005JVascIntervRadiol2008;19:393–399DistributionofindicationsforIVCfilterplacementamongallprovidersduring2005JVascIntervRadiol2008;19:393–399JVascIntervRadiol2008;19:393–399永久濾器與臨時(shí)濾器在美國(guó)濾器的應(yīng)用量每年都在遞增，而超過一半為預(yù)防性的臨時(shí)濾器．

AthanasoulisCA,KaufmanJA,HalpernEF,WaltmanAC,GellerSC,FanCM.Inferiorvenacava

filters:reviewofa26-yearsingle-centerclinicalexperience.Radiology2000;216:54–66.WhiteRH,ZhouH,KimJ,RomanoPS.Apopulation-basedstudyoftheeffectivenessofinferiorvenacavafilteruseamongpatientswithvenousthromboembolism.ArchInternMed2000;160:2033–2041.

Karmy-JonesR,JurkovichGJ,VelmahosGC,etal.Practicepatternsandoutcomesofretrievablevenacavafiltersintraumapatients:anAASTmulticenterstudy.JTrauma2007;62:17–24.PianoG,KettelerER,PrachandV,etal.Safety,feasibility,andoutcomeofretrievablevenacavafiltersinhigh-risksurgicalpatients.JVasc

Surg2007;45:784–788.在沒有

DVTorPE病人，但有抗凝禁忌癥病例中，應(yīng)用腔靜脈濾器被稱為預(yù)防性濾器．在明確診斷

VTE或

PEorDVT病人而不能耐受抗凝的病例中，腔靜脈濾器應(yīng)用被稱為治療性濾器．

SaeHee,BenjaminR.Reynolds,DeidraH.Nicholas,etal.Institutionalprotocolimprovesretrievableinferiorvenacavafilterrecoveryrate.Surgery2009;146:809-816.

近年來，在我們把注意都投在大動(dòng)脈疾病治療同時(shí)，DVT的治療卻有了重大突破．介入下血栓部位置管溶栓與球囊擴(kuò)張，血管成型．而在臨時(shí)濾器的保護(hù)下進(jìn)行的溶栓更加安全．Catheter-directedthrombolysis(CDT)6月后與單純性抗凝相比，血管通暢率是72%vs12%,P\0.001，靜脈瓣功能正常率為89%vs59%,P\0.04.

PTS明顯減少.濾器與DVT濾器應(yīng)用的現(xiàn)代觀ElsharawyM,ElzayatE.Earlyresultsofthrombolysisvsanticoagulationiniliofemoralvenousthrombosis.Arandomisedclinicaltrial.EurJVascEndovascSurg2002.24:209–214

KaufmanJA,KinneyTB,StreiffMBetal.:Guidelinesfortheuseofretrievableandconvertiblevenacavafilters:reportfromtheSocietyofInterventionalRadiologymultidisciplinaryconsensusconference.

JVascIntervRadiol2006;17:449–59.

CuschieriJ,FreemanB,O’KeefeG,HarbrechtBG,BankeyP,JohnsonJL,etal.Inflammationandthehostresponsetoinjuryalarge-scalecollaborativeproject:patient-orientedresearchcorestandardoperatingprocedureforclinicalcareX.Guidelinesforvenousthromboembolismprophylaxisinthetraumapatient.JTrauma2008;65:944-50.

濾器與創(chuàng)傷濾器應(yīng)用的現(xiàn)代觀Long-termfollow-upoftraumapatientswithpermanentprophylacticvenacavafilters.BACKGROUND:AlthoughpermanentprophylacticGreenfieldfilters(PPGF)areeffective,theiruseinyoung

traumapatientswhomayeventuallyreturntoactivelifestylesiscontroversialduetoconcernsaboutthesafetyofthedevicesoveralifetime.Thisdescriptivestudywasundertakentoprovidefollow-uponthelong-termsafetyanddurabilityofPPGF.METHODS:AllpatientsreceivingaPPGFbetweenApril1,1992andMarch1,2001weresoughtforfollow-up.Contactedpatientswereinterviewedregardingknownfilter-relatedcomplications,venousthromboembolicevents,andactivitylevelssincethetimeofdischargefromthehospital.Patientswerealsoofferedaphysicalexaminationfocusingonvenousthromboembolicsequelae,aplainfilmoftheabdomen(KUB)toassessfilterintegrityandlocation,andanultrasoundtoassesscavalpatency.Astheoriginalleveloffilterplacementwasusuallynotknown,migrationwasdefinedasafilterabovethefirstlumbarvertebra(L1).RESULTS:Theeligiblecohortconsistedof188patients.Ninetywereunabletobelocated(47.8%),onerefusedenrollment(0.5%),and97patientsornextofkinagreedtobeinterviewedbyphone(51.6%)ofwhom69returnedforevaluation(36.7%).Nofilter-relatedcomplicationswereself-reported.KUBswereperformedin68patients;onefilterstrutfracturewasfound(1.5%),whereasnofiltermigrationsaboveL1werenoted.Noinstancesofcavalthrombosiswerefoundin55ultrasounds.Twopatientssufferedinterimpulmonaryemboli(2.1%),oneofwhichwasfatal.Of15interimdeaths,autopsyordeathcertificateswereavailableforfourpatients,ninehadtheircausesofdeathrelatedbynextofkin,andtwowereunknown.Although95.4%ofnonspinalcordinjurypatientsreportedatleastsomeabilitytoambulate,only64.6%coulddosoadlibitum.Ofthosepatientsambulatingwithoutlimitation,28.6%reportedacompleteinabilitytorunanydistanceandanother23.8%couldrunlessthanoneblock.Follow-upforpatientscompletinginterviewswas105.3months+/-18.0months,andforpatientsundergoingimagingwas104.6months+/-16.4months.Interimdeathsoccurredat48.2months+/-26.0months.CONCLUSIONS:PPGFseemtobesafeandeffectiveat105monthsoffollow-up;mostpatientsreportsignificantlimitationsinactivitylevelatthissametimeframe.PPGFshouldbethefilterofchoiceforelderlypatientsinwhomthistimeperiodcanreasonablybeexpectedtocoverthepatient'sremaininglifeexpectancy.JTrauma.2009Sep;67(3):485-9

腫瘤病人發(fā)生VTE是正常人的７倍，高危險(xiǎn)性主要來源于針對(duì)腫瘤的治療，如：化療、激素療法、血管栓塞療法以及腫瘤自身的特殊代謝等．約有20%的病人同時(shí)伴有VTE，而15%的腫瘤病人在治療期間會(huì)發(fā)生VTE.

濾器與腫瘤濾器應(yīng)用的現(xiàn)代觀GeertsWH,BergqvistD,PineoGF,etal.Preventionofvenousthromboembolism.AmericanCollegeofChestPhysiciansEvidence-BasedClinicalPracticeGuidelines(8thedition).Chest2008;133(suppl):381S–453S.AgnelliG,BolisG,CapussottiL,etal.Aclinicaloutcome-basedprospectivestudyonvenousthromboembolismaftercancesurgery:AnnSurg2006;243:89–95.HeitJA,SilversteinMD,MohrDN,etal.Riskfactorsfordeepveinthrombosisandpulmonaryembolism:apopulation-basedcase–controlstudy.ArchInternMed2000;160:809–815.BlomJW,DoggenCJ,OsantoS,etal.Malignancies,prothromboticmutations,andtheriskofvenousthrombosis.JAMA2005;293:715–722.HillenHF.Thrombosisincancerpatients.AnnOncol2000;11(3):273–276.

濾器與腫瘤濾器應(yīng)用的現(xiàn)代觀美國(guó)哈佛大學(xué)醫(yī)學(xué)院26年1753例濾器植入回顧：伴隨疾病腫瘤52.8%.法國(guó)血栓研究協(xié)作組（PREPIC）報(bào)告濾器組(200例)中:腫瘤病人為16%.國(guó)際肺動(dòng)脈栓塞協(xié)作中心（ICOPER）登記的2284例non-massivePE病人中腫瘤約為22%。Athanasoulis,etal:InferiorVenaCavalFilters:Reviewofa26-yearSingle-CenterClinicalExperience.Radiology2000;216(1):54-66ThePREPICStudyGroup:Eight—YearFollow-UpofPatientsWithPermanentVenaCaveFiltersinthePreventionofPulmonarEmbolism.Circulation.2005;112:416422.KucherN,etal:Massivepulmonaryembolism.Circulation.2006Jan31;113(4):577-82。PavicM

etal：Venousthromboembolismandcancer.

RevMedInterne.2006Apr;27(4):313-322.

DavidB.Marmor,GenoJ.Merli,DavidJ.Whellan,etal.RelationshipofInferiorVenaCavaFilterUsageinPost-SurgicalPatientsbyVariousSurgicalandMedicalSubspecialists.AmJCardiol2008;102:226–230濾器應(yīng)用的現(xiàn)代觀60%接受了濾器10年間722例DistributionofDVTaccordingtospecialty.Generalsurgery=40.3%,Orthopaedics=20.1%,Obstetricsandgynecology=18.5%,Neurosurgery=14.2%,Others=9.5%.A.D.Lee,E