如何正确把握下腔静脉滤器置放术指征

如何正确把握下腔静脉滤器置放术指征VTE概念的理解静脉血栓栓塞症(venousthromboembolism,VTE)深静脉血栓形成(deepvenousthrombosis,DVT)肺栓塞症 (pulmonarythromboembolism,PE)VTE=DVT+PEDVT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如何正确把握下腔静脉滤器置放术指征在香港和新加坡，住院病人中VTE的发生率15.8and17.1per10000，而美国为130per10000.LeeLH,GuKQ,HengD.Deepveinthrombosisisnotrarein

AsiaetheSingaporeGeneralHospitalexperience.AnnAcadMed

Singap2002Nov;31(6):761-764.CheukBL,CheungGC,ChengSW.EpidemiologyofvenousthromboembolisminaChinesepopulation.BrJSurg2004Apr;91(4):424-428.StienPD,BeemathA,OlsonRE.Trendsintheincidenceofpulmonaryembolismanddeepvenousthrombosisinhospitalizedpatients.AmJCardiol2005June;95(12):1525e6.如何正确把握下腔静脉滤器置放术指征

IncidenceofVTEper10,000hospitaladmissions

A.D.Lee,E.Stephen,S.Agarwal,etal.VenousThrombo-embolisminIndia.EurJVascEndovascSurg2009,37,482－485.如何正确把握下腔静脉滤器置放术指征在美国每年约250000and20millioncasesofDVT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．GoldhaberSZ,TapsonVF.FortheDVTFREEsteeringCommitttee.Aprospectiveregistryof5451patientswithultrasound-confirmeddeepveinthrombosis.AmJCardiol,2004:93;259-262HannoHoppe.OptionalVenaCavaFilters.DtschArzteblInt2009;106(24):395–402如何正确把握下腔静脉滤器置放术指征

Prevalenceofpulmonaryembolism(PE)anddeepvenousthrombosis(DVT)atautopsy

PaulD.Stein.PulmonaryEmbolism.3-4page,2007PublishedbyBlackwellPublishing如何正确把握下腔静脉滤器置放术指征Prevalenceofpulmonaryembolismatautopsyingeneralhospitalsandcommunities如何正确把握下腔静脉滤器置放术指征通过动物实验和对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如何正确把握下腔静脉滤器置放术指征Phlrded.Vol3,Paris:J.B.Bailliére.1868:652-695.

GreenfieldLJ,MichnaBA.Twelve-yearclinicalexperiencewiththeGreenfieldvenafilter.Surgery1988:104;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年第一个滤器产生如何正确把握下腔静脉滤器置放术指征In400patientsFollowup

At8yearsCirculation.2005;112:416-422..如何正确把握下腔静脉滤器置放术指征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如何正确把握下腔静脉滤器置放术指征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%.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滤器应用的现代观如何正确把握下腔静脉滤器置放术指征JVascSurg2008;47:157-65如何正确把握下腔静脉滤器置放术指征IndicationsforIVCfilterplacementJVascSurg2008;47:157-65如何正确把握下腔静脉滤器置放术指征IndicationsforIVCfilterplacementin1995and2005JVascIntervRadiol2008;19:393–399如何正确把握下腔静脉滤器置放术指征DistributionofindicationsforIVCfilterplacementamongallprovidersduring2005JVascIntervRadiol2008;19:393–399如何正确把握下腔静脉滤器置放术指征JVascIntervRadiol2008;19:393–399永久滤器与临时滤器如何正确把握下腔静脉滤器置放术指征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．

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.JVascSurg2007;45:784–788.如何正确把握下腔静脉滤器置放术指征在没有DVTorPE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PEorDVT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．

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

如何正确把握下腔静脉滤器置放术指征近年来，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-directedthrombolysis(CDT)6月后与单纯性抗凝相比，血管通畅率是，静脉瓣功能正常率为89%vs59%,P\0.04.

PTS明显减少.滤器与DVT滤器应用的现代观ElsharawyM,ElzayatE.Earlyresultsofthrombolysisvs

anticoagulationiniliofemoralvenousthrombosis.Arandomised

clinicaltrial.EurJVascEndovascSurg2002.24:209–214如何正确把握下腔静脉滤器置放术指征如何正确把握下腔静脉滤器置放术指征

KaufmanJA,KinneyTB,StreiffMBetal.:Guidelinesfortheuseofretrievableandconvertiblevenacavafilters:reportfromtheSocietyofInterventionalRadiologymultidisciplinaryconsensusconference.

JVascIntervRadiol2006;17:449–59.

如何正确把握下腔静脉滤器置放术指征

CuschieriJ,FreemanB,O’KeefeG,HarbrechtBG,BankeyP,JohnsonJL,etal.Inflammationandthehostresponsetoinjuryalarge-scalecollaborativeproject:patient-orientedresearchcorestandardoperatingprocedureforclinicalcareX.Guidelinesforvenousthromboembolismprophylaxisinthetraumapatient.JTrauma2008;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DVTorPE,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３天－７天间.滤器与创伤滤器应用的现代观如何正确把握下腔静脉滤器置放术指征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

如何正确把握下腔静脉滤器置放术指征肿瘤病人发生VTE是正常人的７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,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.如何正确把握下腔静脉滤器置放术指征

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-massivePE病人中肿瘤约为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.

如何正确把握下腔静脉滤器置放术指征

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DavidB.Marmor,GenoJ.Merli,DavidJ.Whellan,etal.RelationshipofInferiorVenaCavaFilterUsageinPost-SurgicalPatientsbyVariousSurgicalandMedicalSubspecialists.AmJCardiol2008;102:226–230滤器应用的现代观60%接受了滤器如何正确把握下腔静脉滤器置放术指征10年间722例DistributionofDVTaccordingtospecialty.Ge