如何正确把握下腔静脉滤器置放术的指征

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,如何正确把握下腔静脉滤器置放术的指征,VTE,概念的理解,静脉血栓栓塞症,(venous thromboembolism, VTE),深静脉血栓形成,(deep venous thrombosis, DVT),肺栓塞症,(pulmonary thromboembolism, PE),VTE = DVT + PE,DVT,与,PE,在发病上的一致性,同一疾病在不同阶段、不同部位的两种表现形式,在香港和新加坡， 住院病人中,VTE,的发生率,15.8 and 17.1 per 10 000,，而美国为,130 per 10 000 .,Lee LH, Gu KQ, Heng D. Deep vein thrombosis is not rare in,Asiaethe Singapore General Hospital experience. Ann Acad Med,Singap 2002 Nov;31(6):761-764.,Cheuk BL, Cheung GC, Cheng SW. Epidemiology of venous thromboembolism in a Chinese population. Br J Surg 2004 Apr;91(4):424-428.,Stien PD, Beemath A, Olson RE. Trends in the incidence of pulmonary embolism and deep venous thrombosis in hospitalized patients. Am J Cardiol 2005 June;95(12):1525e6.,Incidence of VTE per 10,000 hospital admissions,A.D. Lee, E. Stephen, S. Agarwal,et al. Venous Thrombo-embolism in India. Eur J Vasc Endovasc Surg 2009, 37, 482,485,.,在美国每年约,250 000 and 20 million cases of DVT,需要治疗,.,系统抗凝是,TVE,治疗的主要策略,然而约有,15%,的病人抗凝无效或为禁忌症对于这些病人滤器被考虑和选择,Goldhaber SZ,Tapson VF. For the DVT FREE steering Committtee.Aprospective registry of 5451 patients with ultrasound-confirmed deep vein thrombosis.Am J Cardiol,2004:93;259-262,Hanno Hoppe. Optional Vena Cava Filters. Dtsch Arztebl Int 2009; 106(24): 395402,Prevalence of pulmonary embolism (PE) and deep venous thrombosis (DVT) at autopsy,Paul D. Stein.Pulmonary Embolism. 3-4page, 2007 Published by Blackwell Publishing,Prevalence of pulmonary embolism at autopsy in general hospitals and communities,通过动物实验和对,100,例,DVT,患者与,PE,发生关系进行前瞻性研究，发现：,DVT,患者中,PE,发生率是,45%,。其中,73%,无任何临床症状，致死性,PE,为,4%.,张福先,.,肢体深静脉血栓形成与肺栓塞发生关系的研究,.,中华结核和呼吸杂志,2000,年,.9(23) ;531,533,Phl,gmatia alba dolens. In:Trousseau A.Clinique mdicale de iHtel-Dieu de Paris.3,rd,ed.Vol 3,Paris:J.B.Baillire.1868:652-695.Greenfield LJ, Michna BA.Twelve-year clinical experience with the Greenfield vena filter.Surgery 1988:104;706-712.,应用腔静脉障碍法预防,PE,是,Trousseau,早在一百四十年前,1868,年提出的,.,92,年后既,1960,年第一个滤器产生,In 400 patients Follow up At 8 years,Circulation,.2005;112:416-422.,.,各种类型滤器产生,永久型滤器,pemanent,临时型,Temporary,可选择的,optional,可回收的,Retrievable,在体内滞留最长,可达,400,天以上,可转换的,Convertible,Stein,统计美国国家医疗中心数据库内,50,个洲、地区医院资料表明：全美滤器应用量在,1979,年为,2000,个，,1999,年为,49000,个，增长了,20,倍。,2003,年报告：全世界滤器应用总量每年为,140,，,000,个。,2007,年美国报道：用了,213000,个年增长率为,16%.,Stein PD, et al,：,Twenty-one-year trends in the use of inferior vena cava filters. Arch Intern Med. 2004;164:15411545.,Rogers FB, et al,：,Practice management guidelines for the prevention of venous thromboembolism in trauma patients: The EAST practice management guidelines workgroup. J Trauma. 2002;53:142164,.,Goldhaber SZ,Tapson VF. For the DVT FREE steering Committtee.Aprospective registry of 5451 patients with ultrasound-confirmed deep vein thrombosis.Am J Cardiol,2004:93;259-262,Hanno Hoppe. Optional Vena Cava Filters. Dtsch Arztebl Int 2009; 106(24): 395402,滤器应用的现代观,J Vasc Surg 2008;47:157-65,Indications for IVC filter placement,J Vasc Surg 2008;47:157-65,Indications for IVC filter placement in 1995 and 2005,J Vasc Interv Radiol 2008; 19:393399,Distribution of indications for IVC filter placement among all providers during 2005,J Vasc Interv Radiol 2008; 19:393399,J Vasc Interv Radiol 2008; 19:393399,永久滤器与临时滤器,在美国滤器的应用量每年都在递增，而超过一半为预防性的临时滤器,Athanasoulis CA, Kaufman JA, Halpern EF, Waltman AC, Geller SC, Fan CM. Inferior vena cava,filters: review of a 26-year single-center clinical experience. Radiology 2000; 216: 54 66.,White RH, Zhou H, Kim J, Romano PS. A population-based study of the effectiveness,of inferior vena cava filter use among patients with venous thromboembolism.,Arch Intern Med 2000; 160: 20332041.,Karmy-Jones R, Jurkovich GJ, Velmahos GC, et al. Practice patterns and outcomes of retrievable vena cava filters in trauma patients: an AAST multicenter study. J Trauma 2007; 62: 1724.,Piano G, Ketteler ER, Prachand V, et al. Safety, feasibility, and outcome of retrievable,vena cava filters in high-risk surgical patients. J Vasc Surg 2007; 45: 784788.,在没有,DVT or PE,病人，但有抗凝禁忌症病例中，应用腔静脉滤器被称为预防性滤器,在明确诊断,VTE,或,PE or DVT,病人而不能耐受抗凝的病例中，腔静脉滤器应用被称为,治疗性滤器,Sae Hee ,Benjamin R. Reynolds, Deidra H. Nicholas,et al. Institutional protocol improves retrievable inferior vena cava filter recovery rate.,Surgery 2009;146:809-816.,近年来，在我们把注意都投在大动脉疾病治疗同时，,DVT,的治疗却有了重大突破,介入下血栓部位置管溶栓与球囊扩张，血管成型,而在临时滤器的保护下进行的溶栓更加安全,Catheter-directed thrombolysis(CDT) 6,月后与单纯性抗凝相比，血管通畅率是,72 %vs 12%, P0.001,，静脉瓣功能正常率为,89 %vs 59%, P0.04.,PTS,明显减少,.,滤器与,DVT,滤器应用的现代观,Elsharawy M, Elzayat E .Early results of thrombolysis vs,anticoagulation in iliofemoral venous thrombosis. A randomised,clinical trial. Eur J Vasc Endovasc Surg 2002.24:209214,Kaufman JA, Kinney TB, Streiff MB et al.: Guidelines for the use of retrievable and convertible vena cava filters: report from the Society of Interventional Radiology multidisciplinary consensus conference.J Vasc Interv Radiol 2006; 17: 44959.,Cuschieri J, Freeman B, OKeefe G, Harbrecht BG, Bankey P, Johnson JL, et al. Inflammation and the host response to injury a large-scale collaborative project: patient-oriented research core standard operating procedure for clinical care X. Guidelines for venous thromboembolism prophylaxis in the trauma patient. J Trauma 2008;65:944-50.,创伤病人在住院期间,VTE,发生率约为,58%.,尽管机械性或药物的作用是理想的预防和治疗方法，但不是所有的病人适合接受抗凝治疗另外由于担心出血和部分病人受到还需要进一步手术的约束，滤器常被认为是必要的,脊柱、脑和复合性骨外伤病人中，为了预防,DVT or PE,一些病人在围手术期选择抗凝治疗同时也选择了滤器,滤器通常在病人入院后,24h-48h,内被置入，因为研究表明：,20%-25%,的,PE,发生在病人入院第天天间,.,滤器与,创伤,滤器应用的现代观,Long-term follow-up of trauma patients with permanent prophylactic vena cava filters,.,BACKGROUND: Although permanent prophylactic Greenfield filters (PPGF) are effective, their use in young,trauma patients who may eventually return to active lifestyles is controversial due to concerns about the safety of the devices over a lifetime. This descriptive study was undertaken to provide follow-up on the long-term safety and durability of PPGF. METHODS: All patients receiving a PPGF between April 1, 1992 and March 1, 2001 were sought for follow-up. Contacted patients were interviewed regarding known filter-related complications, venous thromboembolic events, and activity levels since the time of discharge from the hospital. Patients were also offered a physical examination focusing on venous thromboembolic sequelae, a plain film of the abdomen (KUB) to assess filter integrity and location, and an ultrasound to assess caval patency. As the original level of filter placement was usually not known, migration was defined as a filter above the first lumbar vertebra (L1). RESULTS: The eligible cohort consisted of 188 patients. Ninety were unable to be located (47.8%), one refused enrollment (0.5%), and 97 patients or next of kin agreed to be interviewed by phone (51.6%) of whom 69 returned for evaluation (36.7%). No filter-related complications were self-reported. KUBs were performed in 68 patients; one filter strut fracture was found (1.5%), whereas no filter migrations above L1 were noted. No instances of caval thrombosis were found in 55 ultrasounds. Two patients suffered interim pulmonary emboli (2.1%), one of which was fatal. Of 15 interim deaths, autopsy or death certificates were available for four patients, nine had their causes of death related by next of kin, and two were unknown. Although 95.4% of nonspinal cord injury patients reported at least some ability to ambulate, only 64.6% could do so ad libitum. Of those patients ambulating without limitation, 28.6% reported a complete inability to run any distance and another 23.8% could run less than one block. Follow-up for patients completing interviews was 105.3 months +/- 18.0 months, and for patients undergoing imaging was 104.6 months +/- 16.4 months. Interim deaths occurred at 48.2 months +/- 26.0 months. CONCLUSIONS: PPGF seem to be safe and effective at 105 months of follow-up; most patients report significant limitations in activity level at this same timeframe. PPGF should be the filter of choice for elderly patients in whom this time period can reasonably be expected to cover the patients remaining life expectancy.,J Trauma. 2009 Sep;67(3):485-9,肿瘤病人发生,VTE,是正常人的倍，高危险性主要来源于针对肿瘤的治疗，如：化疗、激素疗法、血管栓塞疗法以及肿瘤自身的特殊代谢等约有,20%,的病人同时伴有,VTE,，而,15%,的肿瘤病人在治疗期间会发生,VTE .,滤器与,肿瘤,滤器应用的现代观,GeertsWH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism. American College of Chest Physicians Evidence- Based Clinical Practice Guidelines (8th edition). Chest 2008; 133(suppl):381S453S.,Agnelli G, Bolis G, Capussotti L, et al.A clinical outcome-based prospective study on venous thromboembolism after cance surgery: Ann Surg 2006; 243:8995.,Heit JA, Silverstein MD, Mohr DN, et al. Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case control study. Arch Intern Med 2000; 160:809 815.,Blom JW, Doggen CJ, Osanto S, et al.Malignancies, prothrombotic mutations, and the risk of venous thrombosis. JAMA 2005; 293:715722.,Hillen HF. Thrombosis in cancer patients. Ann Oncol 2000; 11( 3):273276.,滤器与,肿瘤,滤器应用的现代观,美国哈佛大学医学院,26,年,1753,例滤器植入回顾：伴随疾病肿瘤,52.8%.,法国血栓研究协作组（,PREPIC,）,报告滤器组,(200,例,),中,:,肿瘤病人为,16%.,国际肺动脉栓塞协作中心（,ICOPER,）登记的,2284,例,non-massive PE,病人中肿瘤约为,22%,。,Athanasoulis, et al: Inferior Vena Caval Filters:Review of a 26-year Single-Center Clinical Experience. Radiology 2000 ;216(1):54-66,The PREPIC Study Group: EightYear Follow-Up of Patients With Permanent VenaCave Filters in the Prevention of Pulmonar Embolism. Circulation. 2005;112:416422.,Kucher N,et al:,Massive pulmonary embolism. Circulation. 2006 Jan 31;113(4):577-82,。,Pavic M,et al,：,Venous thromboembolism and cancer. Rev Med Interne.,2006 Apr;27(4):313-322.,滤器与外科手术,美国费城医疗中心一年中外科手术中出现的,264,例,VTE,分析,David B. Marmor, Geno J. Merli, David J. Whellan, et al. Relationship of Inferior Vena Cava Filter Usage in Post-Surgical Patients by Various Surgical and Medical Subspecialists. Am J Cardiol 2008;102:226 230,滤器应用的现代观,60%,接受了滤器,10,年间,722,例,Distribution of DVT according to specialty. General,surgery =40.3%, Orthopaedics = 20.1%, Obstetrics and gynecology = 18.5%,Neurosurgery = 14.2%, Others = 9.5%.,A.D. Lee, E. Stephen, S. Agarwal, P. Premkumar. Venous Thrombo-embolism in India.Eur J Vasc Endovasc Surg 2009 37, 482,485.,滤器与,妊娠,滤器应用的现代观,妊娠与产后期，发生,VTE,的危险性比正常高出,4-14,倍，临床评估认为：妊娠与产后期,VTE,为,1.7,1,000.,其中一半发生在妊娠期，一半发生在产后期周内,.,而造成,VTE,高发的原因是年龄超过,35,岁，黑人，既往有,VTE,和,DVT,病史口服避孕药能增加,VTE,发生的危险,3-6,倍,James AH, Jamison MG, Brancazio LR, Myers ER. Venous thromboembolism during pregnancy and the postpartum period: incidence, risk factors, and mortality. Am J Obstet Gynecol 2006; 194:13111315.,BJOG 2008;115:785788,Hanno Hoppe. Optional Vena Cava Filters. Dtsch Arztebl Int 2009; 106(24): 395402,John A. Kaufman,et al. Development of a Research Agenda for Inferior Vena Cava Filters: Proceedings from a Multidisciplinary Research Consensus Panel. J Vasc Interv Radiol 2009; 20:697707.,John A. Kaufman,et al. Development of a Research Agenda for Inferior Vena Cava Filters: Proceedings from a Multidisciplinary Research Consensus Panel. J Vasc Interv Radiol 2009; 20:697707.,在临床上不推荐常规使用滤器,提倡科学与合理的选择适应症,期待更优秀的临时滤器出现（体内停留时间长、容易取出）,伴随理想的临时滤器出现，应用指征由治疗性转为预防性,永久性滤器可能在不久的将来将完成历史使命,重视滤器后的抗凝治疗,我们提出的结论,谢谢,