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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. D
2、eep vein thrombosis is not rare in Asiaethe Singapore General Hospital experience. Ann Acad Med Singap 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 wit
7、h 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内5
8、0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 of
9、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,Hann
10、o 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 for
11、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-cente
12、r 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. Pract
13、ice 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: 784788.,
14、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的治疗却有了重大突破
15、 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 vs anticoagulation in iliofemoral venous thrombosis. A randomised clinical 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
17、J, 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. J Trauma 2008;65:944-50.,
