上肢深靜脈血栓課件

1、上肢深靜脈血栓upper extremity deep venous thrombosis UEDVT1上肢深靜脈血栓upper extremity deep 定義腋靜脈、鎖骨下靜脈、橈靜脈、尺靜脈、肱靜脈、頸內靜脈、頭臂干靜脈最常見：腋靜脈、鎖骨下靜脈原發(fā)性：約占20%繼發(fā)性：指存在危險因素的深靜脈血栓形成，約占80% Cuc Mai, M.D.H.M.,Upper extremity Deep Venous Thrombosis A Review. The American Journal of Medicine, 2011. 2定義腋靜脈、鎖骨下靜脈、橈靜脈、尺靜脈、肱靜脈、頸內靜脈、頭

2、33流行病學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流行病學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危險因素原發(fā)性上肢深靜脈血栓：遺傳性血栓形成傾向：蛋白C、蛋白s或抗凝血酶、凝血因子缺乏，凝血因子VLeiden突變和凝血

4、酶原G20210A突變解剖結構異常：Paget-Schroetter綜合征 Grant, J.D., et al., Diagnosis and management of upper extremity deep-vein thrombosis in adults. Thromb Haemost, 2012. 6危險因素原發(fā)性上肢深靜脈血栓：6繼發(fā)性上肢深靜脈血栓 CVC置入：45%與CVC有關 腫瘤：38%與惡性腫瘤有關其他：起搏器、30天內手術史或制動史、個人或者家族深靜脈血栓栓塞史、正在接受化療、伴隨疾病（高血壓、糖尿病、神經(jīng)系統(tǒng)疾病、 30內肺部感染） 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繼發(fā)性上肢深靜脈血栓 Munoz F J, Mismetti RIETE研究多國家、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研究多國家、多中心 Munoz F J, Mi2004年美國多中心研究Hylton V. Joffe N K V F. Upper-Extremity Deep Vein Thrombosis A Prospective Registry of 592 PatientsJ. Circulation,2004,12(110):1605-161192004年美國多中心研究Hylton V. Joffe N 臨床癥狀和體征上肢腫脹：80%患

7、側肢體疼痛：3050%較少出現(xiàn)的：患側肢體紅斑、淺表靜脈曲張、肢體功能障礙、胸痛、呼吸困難、頸部腫脹無癥狀：約5%10臨床癥狀和體征上肢腫脹：80%10診斷 D-二聚體超聲對比靜脈造影：金標準 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診斷 D-二聚體11D-二聚體Merminodet al,2006, S

8、witzerland：500ug/L 多普勒超聲確診52例懷疑UEDVT中：1.D-dimer陽性：15/52 29%2.并發(fā)腫瘤中：8/23 34.8%3.CVC ： 6/18 33%4.無腫瘤、CVC：4/22 18%診斷的敏感性為100%，特異性為14%，陽性預測價值為32%，陰性排除價值為100%，12D-二聚體Merminodet al,2006, Switz超聲PICC13超聲PICC13 低回聲 不可壓縮性14 低回聲 超聲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超聲Di Nisio M, Van Sluis G L, BUEDVT診斷16UEDVT診斷161717急性期：確診血栓后的前三個月 可以降低血栓后綜合征、血栓復發(fā)的發(fā)生率。預防期：急性期治療后的階段 目的是控制血栓形成的危險因素 治療（參考下肢深靜脈血栓形成）18急性期：確診血栓后的前三個月治療（參考下肢深靜脈血栓形成）1治療（參考下肢深靜脈血栓形成）拔除深靜

10、脈置管抗凝溶栓上腔靜脈濾器手術取栓術 Grant, J.D., et al., Diagnosis and management of upper extremity deep-vein thrombosis in adults. Thromb Haemost, 201219治療（參考下肢深靜脈血栓形成）拔除深靜脈置管19抗凝ACCP建議：同下肢深靜脈血栓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建議：同下肢深靜脈血栓Kearon C, Kah溶栓ACCP建議：僅用于：癥狀嚴重、血栓占據(jù)大部分鎖骨下靜脈和腋靜脈、血栓形成14天內、肢體功能良好、預期壽命長于一年、低出血風險者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建議：僅用于：癥狀嚴重、血栓占據(jù)大部分鎖骨下靜脈上腔靜脈濾器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上腔靜脈短，放置困難致死性并發(fā)癥發(fā)生率為3.8%22上腔靜脈濾器Owens C A, Bui J T, Knut手術取栓術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大塊血栓形成影響肢體功能絕對抗凝、溶栓禁忌癥23手術取栓術Kearon C, Kahn S R