上肢深静脉血栓课件

1、上肢深静脉血栓upper extremity deep venous thrombosis UEDVT1上肢深静脉血栓upper extremity deep 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% Cuc Mai, M.D.H.M.,Upper extremity Deep Venous Thrombosis A Review. The American Journal of Medicine, 2011. 2定义腋静脉、锁骨下静脉、桡静脉、尺静脉、肱静脉、颈内静脉、头

2、33流行病学Kroger K, Schelo C, Gocke C, et al. Colour Doppler sonographic diagnosis of upper limb venous thrombosesJ. Clin Sci (Lond),1998,94(6):657-661.Syed Mustafa, M., et al., upper extremity deep vein thrombosis. CHEST, 20034流行病学Kroger K, Schelo C, Gocke DVT中所占比例Spencer F A E C L D. Upper Extremity D

3、eep Vein Thrombosis A Community-BasedJ. Am J Med,2007,8(120):678-684. Hylton V. Joffe N K V F. Upper-Extremity Deep Vein Thrombosis A Prospective Registry of 592 PatientsJ. Circulation,2004,12(110):1605-1611.5DVT中所占比例Spencer F A E C L D. U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

4、酶原G20210A突变解剖结构异常：Paget-Schroetter综合征 Grant, J.D., et al., Diagnosis and management of upper extremity deep-vein thrombosis in adults. Thromb Haemost, 2012. 6危险因素原发性上肢深静脉血栓：6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） Munoz F J, Mism

5、etti P, Poggio R, et al. Clinical outcome of patients with upper-extremity deep vein thrombosis: results from the RIETE RegistryJ. Chest,2008,133(1):143-1487继发性上肢深静脉血栓 Munoz F J, Mismetti RIETE研究多国家、多中心 Munoz F J, Mismetti P, Poggio R, et al. Clinical outcome of patients with upper-extremity deep ve

6、in thrombosis: results from the RIETE RegistryJ. Chest,2008,133(1):143-1488 RIETE研究多国家、多中心 Munoz F J, Mi2004年美国多中心研究Hylton V. Joffe N K V F. Upper-Extremity Deep Vein Thrombosis A Prospective Registry of 592 PatientsJ. Circulation,2004,12(110):1605-161192004年美国多中心研究Hylton V. Joffe N 临床症状和体征上肢肿胀：80%患

7、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%10临床症状和体征上肢肿胀：80%10诊断 D-二聚体超声对比静脉造影：金标准 MRI、MRVCTV van M. DI NISIO, G.L.S., Accuracy of diagnostic tests for clinically suspected upper extremity deep vein thrombosis. Journal of Thrombosis and Haemostasis11诊断 D-二聚体11D-二聚体Merminodet al,2006, S

8、witzerland：500ug/L 多普勒超声确诊52例怀疑UEDVT中：1.D-dimer阳性：15/52 29%2.并发肿瘤中：8/23 34.8%3.CVC ： 6/18 33%4.无肿瘤、CVC：4/22 18%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%，12D-二聚体Merminodet al,2006, Switz超声PICC13超声PICC13 低回声 不可压缩性14 低回声 超声Di Nisio M, Van Sluis G L, Bossuyt P M, et al. Accuracy of diagnostic tests for

9、 clinically suspected upper extremity deep vein thrombosis: a systematic reviewJ. J Thromb Haemost,2010,8(4):684-69215超声Di Nisio M, Van Sluis G L, BUEDVT诊断16UEDVT诊断161717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）18急性期：确诊血栓后的前三个月治疗（参考下肢深静脉血栓形成）1治疗（参考下肢深静脉血栓形成）拔除深静

10、脉置管抗凝溶栓上腔静脉滤器手术取栓术 Grant, J.D., et al., Diagnosis and management of upper extremity deep-vein thrombosis in adults. Thromb Haemost, 201219治疗（参考下肢深静脉血栓形成）拔除深静脉置管19抗凝ACCP建议：同下肢深静脉血栓Kearon C, Kahn S R, Agnelli G, et al. Antithrombotic therapy for venous thromboembolic disease: American College of Chest

11、 Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)J. Chest,2008,133(6 Suppl):454S-545S20抗凝ACCP建议：同下肢深静脉血栓Kearon C, Kah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Kearon C, Kahn S R, Agnelli G, et al. Antithrombotic therapy for venous thromboembolic disease: A

12、merican College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)J. Chest,2008,133(6 Suppl):454S-545S21溶栓ACCP建议：仅用于：症状严重、血栓占据大部分锁骨下静脉上腔静脉滤器Owens C A, Bui J T, Knuttinen M G, et al. Pulmonary embolism from upper extremity deep vein thrombosis and the role of superior vena

13、cava filters: a review of the literatureJ. J Vasc Interv Radiol,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%22上腔静脉滤器Owens C A, Bui J T, Knut手术取栓术Kearon C, Kahn S R, Agnelli G, et al. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)J. Chest,2008,133(6 Suppl):454S-545S大块血栓形成影响肢体功能绝对抗凝、溶栓禁忌症23手术取栓术Kearon C, Kahn S R