如何正确把握下腔静脉滤器置放术的指征_张福先.ppt

1、如何正确把握下腔静脉滤器置放术的指征,北京世纪坛医院血管外科 张福先,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.

2、 Deep vein thrombosis is not rare inAsiaethe Singapore General Hospital experience. Ann Acad MedSingap 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

3、 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, 482485.,在美国每年约250 0

4、00 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 Filter

5、s. 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

6、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) ;531533,Phlgmatia alba dolens. In:Trousseau A.Clinique mdicale de iHtel-Dieu de Paris.3rd ed.Vol 3,Paris:J.B.Baillire.1868:652-695.Greenfield LJ, Michna BA.Twelve-year clinical experience with

7、 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

8、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 o

9、f 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,Ha

10、nno 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 fo

11、r 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-cen

12、ter 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. Pr

13、actice 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: 78478

14、8.,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

15、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 vsanticoagulation in iliofemoral venous thrombosis. A randomisedclinical tr

16、ial. 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

17、, 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

18、. 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 permanen

19、t 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

20、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

21、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 origin

22、al 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 int

23、erviewed 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 5

24、5 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 pat

25、ients 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

26、 +/- 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 time

27、frame. 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

28、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 st

29、udy 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.Malignancie

30、s, 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2

31、2%。,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. Kuche

32、r 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. Generalsurgery =40.3%, Orthopaedics = 20.1%, Obstetrics and gynecology = 18.5%,Neurosurgery