上肢深静脉血栓研究进展.ppt

上肢深静脉血栓upperextremitydeepvenousthrombosisUEDVT,定义,腋静脉、锁骨下静脉、桡静脉、尺静脉、肱静脉、颈内静脉、头臂干静脉最常见：腋静脉、锁骨下静脉原发性：约占20%继发性：指存在危险因素的深静脉血栓形成，约占80%CucMai,M.D.H.M.,UpperextremityDeepVenousThrombosisAReview.TheAmericanJournalofMedicine,2011.,流行病学,KrogerK,ScheloC,GockeC,etal.ColourDopplersonographicdiagnosisofupperlimbvenousthrombosesJ.ClinSci(Lond),1998,94(6):657-661.SyedMustafa,M.,etal.,upperextremitydeepveinthrombosis.CHEST,2003,DVT中所占比例,SpencerFAECLD.UpperExtremityDeepVeinThrombosisACommunity-BasedJ.AmJMed,2007,8(120):678-684.HyltonV.JoffeNKVF.Upper-ExtremityDeepVeinThrombosisAProspectiveRegistryof592PatientsJ.Circulation,2004,12(110):1605-1611.,危险因素,原发性上肢深静脉血栓：遗传性血栓形成倾向：蛋白C、蛋白s或抗凝血酶、凝血因子缺乏，凝血因子VLeiden突变和凝血酶原G20210A突变解剖结构异常：Paget-Schroetter综合征Grant,J.D.,etal.,Diagnosisandmanagementofupperextremitydeep-veinthrombosisinadults.ThrombHaemost,2012.,继发性上肢深静脉血栓CVC置入：45%与CVC有关肿瘤：38%与恶性肿瘤有关其他：起搏器、30天内手术史或制动史、个人或者家族深静脉血栓栓塞史、正在接受化疗、伴随疾病（高血压、糖尿病、神经系统疾病、30内肺部感染）,MunozFJ,MismettiP,PoggioR,etal.Clinicaloutcomeofpatientswithupper-extremitydeepveinthrombosis:resultsfromtheRIETERegistryJ.Chest,2008,133(1):143-148,RIETE研究多国家、多中心,MunozFJ,MismettiP,PoggioR,etal.Clinicaloutcomeofpatientswithupper-extremitydeepveinthrombosis:resultsfromtheRIETERegistryJ.Chest,2008,133(1):143-148,2004年美国多中心研究,HyltonV.JoffeNKVF.Upper-ExtremityDeepVeinThrombosisAProspectiveRegistryof592PatientsJ.Circulation,2004,12(110):1605-1611,临床症状和体征,上肢肿胀：80%患侧肢体疼痛：3050%较少出现的：患侧肢体红斑、浅表静脉曲张、肢体功能障碍、胸痛、呼吸困难、颈部肿胀无症状：约5%,诊断,D-二聚体超声对比静脉造影：金标准MRI、MRVCTVvanM.DINISIO,G.L.S.,Accuracyofdiagnostictestsforclinicallysuspectedupperextremitydeepveinthrombosis.JournalofThrombosisandHaemostasis,D-二聚体,Merminodetal,2006,Switzerland：500ug/L多普勒超声确诊52例怀疑UEDVT中：1.D-dimer阳性：15/5229%2.并发肿瘤中：8/2334.8%3.CVC：6/1833%4.无肿瘤、CVC：4/2218%诊断的敏感性为100%，特异性为14%，阳性预测价值为32%，阴性排除价值为100%，,超声,PICC,低回声不可压缩性,超声,DiNisioM,VanSluisGL,BossuytPM,etal.Accuracyofdiagnostictestsforclinicallysuspectedupperextremitydeepveinthrombosis:asystematicreviewJ.JThrombHaemost,2010,8(4):684-692,UEDVT诊断,急性期：确诊血栓后的前三个月可以降低血栓后综合征、血栓复发的发生率。预防期：急性期治疗后的阶段目的是控制血栓形成的危险因素,治疗（参考下肢深静脉血栓形成）,治疗（参考下肢深静脉血栓形成）,拔除深静脉置管抗凝溶栓上腔静脉滤器手术取栓术Grant,J.D.,etal.,Diagnosisandmanagementofupperextremitydeep-veinthrombosisinadults.ThrombHaemost,2012,抗凝,ACCP建议：同下肢深静脉血栓,KearonC,KahnSR,AgnelliG,etal.Antithrombotictherapyforvenousthromboembolicdisease:AmericanCollegeofChestPhysiciansEvidence-BasedClinicalPracticeGuidelines(8thEdition)J.Chest,2008,133(6Suppl):454S-545S,溶栓,ACCP建议：仅用于：症状严重、血栓占据大部分锁骨下静脉和腋静脉、血栓形成14天内、肢体功能良好、预期寿命长于一年、低出血风险者,KearonC,KahnSR,AgnelliG,etal.Antithrombotictherapyforvenousthromboembolicdisease:AmericanCollegeofChestPhysiciansEvidence-BasedClinicalPracticeGuidelines(8thEdition)J.Chest,2008,133(6Suppl):454S-545S,上腔静脉滤器,OwensCA,BuiJT,KnuttinenMG,etal.Pulmonaryembolismfromupperextremitydeepveinthrombosisandtheroleofsuperiorvenacavafilters:areviewoftheliteratureJ.JVascIntervRadiol,2010,21(6):779-787,上腔静脉短，放置困难致死性并发症发生率为3.8%,手术取栓术,KearonC,KahnSR,AgnelliG,etal.Antithrombotictherapyforvenousthromboembolicdisease:AmericanCollegeofChestPhysiciansEvidence-BasedClinicalPracticeGuidelines(8thEdition)J.Chest,2008,133(6Suppl):454S-545S