肺栓塞的诊断与治疗进展

肺栓塞的诊断与治疗,血管外科赵克强 M.D.,2017/11/28,定义,肺栓塞（pulmonary embolism，PE）是内源性或外源性栓子(以血栓最常见)堵塞肺动脉或分支引起肺循环障碍的临床和病理生理综合征，其中发生肺出血或坏死称肺梗死。堵塞 2 个肺叶动脉以上者为大块肺栓塞。PE是发病率和死亡率较高的疾病，国内外报道约90肺栓塞栓子来源于下肢DVT，故临床上通常将DVT与PE视为同一病理过程的不同表现，统称为静脉血栓栓塞症（VTE）。统计资料表明，美国每年约有70万新发病例，其中约20%死亡，占死因第三位 ，仅次于肿瘤和心肌梗塞。阜外医院900余例心肺血管病尸检资料证实，其中肺段以上较大肺栓塞者约100例（占11%）。,2017/11/28,发病机制,1.静脉血流淤滞 下肢静脉功能不全，右心衰、肢体制动。2.血液高凝状态 手术应激、血液浓缩；高龄、肥胖、吸烟、糖尿病、肿瘤、先天性抗凝血酶III缺乏症、蛋白C、S缺乏症等，均可使机体处于一种高凝状态（易栓症）。3.血管内膜损伤 外伤、手术、血管刺激性药物,2017/11/28,PE栓子来源,肺栓塞以急性髂、股静脉血栓脱落多见，其次为腘静脉血栓形成。 小腿肌间静脉及腘静脉以远的血栓引起肺栓塞的可能性很小，除非它延伸到腘静脉； 极少数由肾静脉、髂内静脉、上肢或颈内静脉（上腔静脉系统）血栓脱落引起。,2017/11/28,PE临床表现,包括以下几种类型： (1)急性肺原性心脏病：突发呼吸困难、濒死感、惊恐、晕厥、低血压、休克、右心衰竭等，见于栓塞2个肺叶以上的患者 (2)肺梗死：胸痛、咳嗽、咯血及继发感染后出现发热、咳痰、胸膜摩擦音或胸腔积液,2017/11/28,(3) 慢性反复性肺栓塞：发病隐匿，发现晚，表现重症慢性肺动脉高压和右心功能不全。 临床典型肺栓塞三联症（呼吸困难、胸痛、咯血）不足1/3。,2017/11/28,诊断方法,1 实验室检查1.1 血常规和凝血指标 可作为评价全身状态的指标，当存在DVT 或PE 时，可出现白细胞增多、纤维蛋白原升高、凝血酶原时间和部分活化的凝血酶原时间改变等，但缺乏特异性的诊断价值。1.2 D- 二聚体 为纤维蛋白降解产物，故浓度升高提示有血栓形成，反之，浓度正常则有助于排除血栓形成的可能。因其特异性差，假阳性高，不能确诊存在VTE。因此，D-二聚体检测的临床价值在于其阴性结果。1.3 血气分析 发生PE 时，血气分析可表现为低氧血症，低碳酸血症,2017/11/28,2 心电图急性肺栓塞时70%以上的病人可出现特异性心电图改变，多在发病后立即出现，并呈动态变化。表现为电轴右偏，肺性P 波,导联S 波加深，导联出现Q 波和（或）T波倒置（SQT），V1V4 导联T 波倒置，完全性或不完全性右束支传导阻滞。,2017/11/28,3 彩色多普勒超声检查 对检查下肢深静脉血栓形成具有很高的价值，是诊断DVT 最常用的方法。对中央型DVT 敏感度达96.5。对周围型DVT （膝下腘静脉及其属支，尤其是肌间静脉血栓）的诊断敏感度较低超声心动图：肺动脉增宽，右心室扩大，同时可测肺动脉压，有时可见肺动脉内漂浮血栓。,2017/11/28,4 CT对于诊断DVT和PE 的作用越发突出，甚至在一定程度上代替了传统的DSA。可多角度显示下肢静脉血栓的部位、范围，并可同时检查腔静脉、盆腔髂内静脉以寻找PE的可能来源，还可同时行三维血管重建（CTV），使得图像更加直观。肺动脉CT成像（multislice computed tomography pulmonary angiography，CTPA）可直接发现肺动脉内的充盈缺损、远端血管不显影等直接征象，可作为确诊PE 的依据。,2017/11/28,5 数字减影血管造影术（digital substraction angiography，DSA）被视为诊断DVT和PE的“金标准”。下肢静脉造影术可以有效地判断下肢静脉血栓的位置、形态、血管闭塞的程度和侧支循环的建立情况。肺动脉DSA不仅可明确肺动脉栓塞的诊断，显示出栓塞造成血流动力学改变，还可以同时进行局部导管介入碎栓、溶栓治疗,以最大限度地挽救病人的生命。,PE的治疗,抗凝治疗肝素泵入LWMH阿加曲班新抗凝剂-利伐沙班华法林溶栓局部导管溶栓（CDT）全身溶栓（rTPA或尿激酶）局部碎栓、取栓机械碎栓术肺动脉切开血栓内膜剥脱术,导管溶栓（CDT）,血栓机械抽吸,2017/11/28,该患者肺动脉CTA,2017/11/28,2017/11/28,肺动脉置管碎栓术（例一）,女性，56岁，胸痛、憋气2小时,2017/11/28,给予急诊置管碎栓、溶栓，尿激酶50万单位泵入,碎栓前DSA,碎栓后DSA：左上肺动脉开通,2017/11/28,肺动脉置管溶栓（例二）,患者男性，65岁，咳嗽咳血、胸痛、呼吸困难4小时。,术中分别选入双侧肺动脉内，各泵入尿激酶30万IU,2017/11/28,围术期肺动脉CTA比较,肺动脉分叉部位,2017/11/28,围术期肺动脉CTA比较,右肺动脉主干,2017/11/28,围术期肺动脉CTA比较,左肺主干,VTE抗凝治疗指南,ACCP （American College of Chest Physicians） 9th-2012急性DVT患者推荐初始使用肠外抗凝治疗（1B），建议首选低分子肝素或磺达肝癸钠，优于普通肝素（2B）。对于VTE诊断不明确者，高度疑诊者推荐抗凝治疗，低度疑诊者如24h内可明确，不建议抗凝（2C）。抗凝时间选择上：有诱因（如外伤、手术等）引起DVT者，建议抗凝3个月（1B）。无诱因者，至少抗凝3月（1B），后评估风险-收益比。首次出现下肢中央型VTE，中低出血风险者建议长期抗凝（2B），高出血风险者建议3月（1B）。首次出现下肢外周型VTE，建议抗凝3月（中低出血风险者2B推荐，高风险者为1B推荐）。第二次出现VTE，建议长期抗凝（低出血风险者1B推荐，中低出血风险者2B推荐），高出血风险者建议抗凝3月（2B）。长期抗凝药选择：合并肿瘤患者低分子肝素优于VKA（2B）；不合并肿瘤患者建议选用VKA，优于低分子肝素（2C）。无症状，影像学检查偶然发现DVT，治疗建议与有症状者相同（2B）。,Management of Massive and Submassive Pulmonary Embolism,AHA（American Heart Association）-2011We propose the following definition for massive PE: Acute PE with sustained hypotension (systolic blood pressure90 mm Hg for at least 15 minutes or requiring inotropic support, not due to a cause other than PE, such as arrhythmia, hypovolemia, sepsis, or left ventricular dysfunction), pulselessness, or persistent profound bradycardia (heart rate 40 bpm with signs or symptoms of shock).We propose the following definition for submassive PE: Acute PE without systemic hypotension (systolic blood pressure 90 mm Hg) but with either RV dysfunction or myocardial necrosis.,Recommendations for Initial Anticoagulation for Acute PE同ACCP9,1. Therapeutic anticoagulation with subcutaneous LMWH, intravenous or subcutaneous UFH with monitoring, unmonitored weight-based subcutaneous UFH, or subcutaneous fondaparinux should be given to patients with objectively confirmed PE and no contraindications to anticoagulation (Class I; Level A).2. Therapeutic anticoagulation during the diagnostic workup should be given to patients with intermediate or high clinical probability of PE and no contraindications to anticoagulation (Class I; LevelC).,Recommendations for Fibrinolysis for Acute PE,1. Fibrinolysis is reasonable for patients with massive acute PE and acceptable risk of bleeding complications (Class IIa; Level B).2. Fibrinolysis may be considered for patients with submassive acute PE judged to have clinical evidence of adverse prognosis (new emodynamic instability, worsening respiratory insufficiency, severe RV dysfunction, or major myocardial necrosis) and low risk of bleeding complications (Class IIb; LevelC).3. Fibrinolysis is not recommended for patients with low-risk PE (Class III; Level of Evidence B) or submassive acute PE with minor RV dysfunction, minor myocardial necrosis, and no clinical worsening (Class III; Level of Evidence B).4. Fibrinolysis is not recommended for undifferentiated cardiac arrest (Class III; Level of Evidence B).,Recommendations for Catheter Embolectomyand Fragmentation,1. Depending on local expertise, either catheter embolectomy and fragmentation or surgical embolectomy is reasonable for patients with massive PE and contraindications to fibrinolysis (Class IIa; Level of Evidence C).2. Catheter embolectomy and fragmentation or surgical embolectomy is reasonable for patients with massive PE who remain unstable after receiving fibrinolysis (Class IIa; Level of Evidence C).3. Either catheter embolectomy or surgical embolectomy may be considered for patients with submassive acute PE judged to have clinical evidence of adverse prognosis (new hemodynamic instability, worsening respiratory failure, severe RV dysfunction, or major myocardial necrosis) (Class IIb; Level of Evidence C).4. Catheter embolectomy and surgical thrombectomy are not recommended for patients with low-risk PE or submassive acute PE with minor RV dysfunction, minor myocardial necrosis, and no clinical worsening (Class III; Level of Evidence C).,Recommendations on IVC Filters in the Setting of Acute PE,1. Adult patients with any confirmed acute PE (or proximal DVT) with contraindications to anticoagulation or with active bleeding complication should receive an IVC filter (Class I; Level of Evidence B).2. Anticoagulation should be resumed in patients with an IVC filter once contraindications to anticoagulation or active bleeding complications have resolved (Class I; Level of Evidence B).3. Patients who receive retrievable IVC filters should be evaluated periodically for filter retrieval within the specific filters retrieval window (Class I; Level of Evidence C).,Recommendations on IVC Filters,4. For patients with recurrent acute PE despite therapeutic anticoagulati