医学专题一Deep-vein-thrombosis深静脉血栓.ppt

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1、 Deep vein thrombosisXiangYuCheng第一页，共四十六页。What Is Deep Vein Thrombosis?pTheearliestcaseofDVTwasdescribedaround600-900BC.pAtsomepoint,theincreasedincidenceofDVTinwomenafterchildbirthwasnoticed,andinthelate1700s,apublichealthrecommendationwasissuedtoencouragewomentobreastfeedasameanstopreventthisphen

2、omenon;theDVTwascalledmilkleg,asitwasthoughttoresultfrommilkbuildingupintheleg.第二页，共四十六页。What Is Deep Vein Thrombosis?pDeepveinthrombosis,orDVT,isabloodclotthatformsinaveindeepinthebody.Bloodclotsoccurwhenbloodthickensandclumpstogether.第三页，共四十六页。What Is Deep Vein Thrombosis?pAbloodclotinadeepveincan

3、breakoffandtravelthroughtheblood.Theemboluscouldtraveltoanarteryinthelungsandblockbloodflow.Thisconditioniscalledpulmonaryembolism,orPE.第四页，共四十六页。EpidemiologyDeep vein thrombosis*DiagnosesofDVTandPEarenotmutuallyexclusive;anestimated78,511patientsreceiveddiagnosesofbothDVTandPE.VTEestimatesincludepa

4、tientswithdiagnosesofeitherDVTorPE.第五页，共四十六页。EpidemiologyDeep vein thrombosisAccordingtothemostrecentACCPguidelines,VTEremainsthesecondmostcommoncauseofprotractedhospitalstayandthethirdmostcommoncauseofexcessmortalityamong7millionpatientsdischargedfrom944acutecarehospitalsintheUS.第六页，共四十六页。CausespGe

5、rmanpathologistRudolf Virchowpostulatedtheinterplayofthreeprocessesresultinginvenousthrombosis,nowknownasVirchowstriad:Deep vein thrombosisInkeepingwithVirchowsconcept,alterationsofthecoagulationsystemthatinduceahypercoagulablestatealsoconferanincreasedriskofDVT.第七页，共四十六页。CausespGermanpathologistRud

6、olf Virchowpostulatedtheinterplayofthreeprocessesresultinginvenousthrombosis,nowknownasVirchowstriad:Deep vein thrombosis第八页，共四十六页。CausesThebloodflowpatterninthevalvescancausehypoxemia,whichisworsenedbyvenousstasis,activatespathways-onesthatincludehypoxia-induciblefactor-1andearly-growth-responsepro

7、tein1.Hypoxia-induciblefactor-1andearly-growth-responseprotein1contributetomonocyteassociationwithendothelialproteins,suchasP-selectin,promptingmonocytestoreleasetissuefactor-filledmicrovesicles,whichpresumablybeginclottingafterbindingtotheendothelialsurface.9Deep vein thrombosis第九页，共四十六页。CausespInd

8、ependentRiskFactorsforDVTAgeisanindependentriskfactorforthromboticdisease.Themajorityofvenousthrombioccurineitherthesuperficialordeepveinsoftheleg.ADVTisstationaryclottingbloodadheredtothedeepveinofthepelvisoranextremityandusuallyoccursinthecalforthigh.VTEdenotesanobstructionarisingfromtheformationo

9、faclotinthevenouscirculationcarriedbythebloodfromthesiteoforigintopluganothervessel.Deep vein thrombosis第十页，共四十六页。CausespIndependentRiskFactorsforDVTDeep vein thrombosis第十一页，共四十六页。Signs and symptomspCommonsignsandsymptomsofDVTinclude：PainSwellingWarmthRednessordiscolorationDistentionofsurfaceveinsDe

10、ep vein thrombosis第十二页，共四十六页。Signs and symptomspCommonsignsandsymptomsofDVTinclude：PainSwellingWarmthRednessordiscolorationDistentionofsurfaceveinsDeep vein thrombosis第十三页，共四十六页。Signs and symptomspInmostsuspectedcases,DVTisruledoutafterevaluation,andsymptomsaremoreoftenduetoothercauses,suchascelluli

11、tis,Bakers cyst,musculoskeletal injury,orlymph edema.pOtherdifferentialdiagnosesincludehematoma,tumors,venousorarterialaneurysms,andconnective tissue disorders.Deep vein thrombosis第十四页，共四十六页。DiagnosispProbability:InthosewithsuspectedDVT,aclinicalassessmentofprobabilitycanbeusefultodeterminewhichtest

12、stoperform.ThemoststudiedclinicalpredictionruleistheWellsscore.Deep vein thrombosis第十五页，共四十六页。DiagnosisDeep vein thrombosis第十六页，共四十六页。DiagnosispPhysicalExam:symptomsHalfofthosewiththeconditionHAVENOSYMPTOMS.Signsandsymptomsalonearenotsufficientlysensitiveorspecifictomakeadiagnosis,butwhenconsideredi

13、nconjunctionwithknownriskfactorscanhelpdeterminethelikelihoodofDVT.Deep vein thrombosis第十七页，共四十六页。DiagnosispDVTdiagnosisrequirestheuseofimagingdevicessuchasultrasound.Clinicalassessments,whichpredictDVTlikelihood,canhelpdetermineifaD-dimertestisuseful.pInthosenothighlylikelytohaveDVT,anormalD-dimerr

14、esultcanruleoutadiagnosis.Deep vein thrombosis第十八页，共四十六页。DiagnosispD-dimer:Afibrindegradationproduct,andanelevatedlevelcanresultfromplasmindissolvingaclot,orotherconditions.Deep vein thrombosis第十九页，共四十六页。DiagnosisForthosewithalowormoderateprobabilityofDVT,aD-dimerlevelmightbeobtained,whichexcludesad

15、iagnosisifresultsarenormal.Anelevatedlevelrequiresfurtherinvestigationwithdiagnosticimagingtoconfirmorexcludethediagnosis.Deep vein thrombosis第二十页，共四十六页。DiagnosisForasuspectedfirstlegDVTinalow-probabilitysituation,theAmericanCollegeofChestPhysicians(ACCP)recommendstestingeitherD-dimerlevelswithmoder

16、ateorhighsensitivityorcompressionultrasoundoftheproximalveins.Deep vein thrombosis第二十一页，共四十六页。DiagnosispImaging:ImagingtestsoftheveinsareusedinthediagnosisofDVT.Ultrasound,CTscanvenography,MRIvenography,orMRIofthethrombusarealsopossibilities.Deep vein thrombosis第二十二页，共四十六页。DiagnosispUltrasound:asens

17、itiveandspecifictoolfortheassessmentofpatientspresentingwithsymptomssuggestiveoflowerextremityDVT.Deep vein thrombosis第二十三页，共四十六页。DiagnosispDoplerUltrasoundDeep vein thrombosis第二十四页，共四十六页。DiagnosispContrastVenography:Thegoldstandardmethodstorevealwhetherthevenoussupplyhasbeenobstructed.Deep vein thr

18、ombosis(a)directmanualcontrastinjectionintotheguidingcatheter(direct venography technique,DVT)and(b)occlusionofcoronarysinusbyaSwan-Ganzcatheter.第二十五页，共四十六页。DiagnosispContrastVenography:Thegoldstandardmethodstorevealwhetherthevenoussupplyhasbeenobstructed.UnilateralabovekneeDVTinapatientwitharecentr

19、ighthemispherecerebralinfarction.A19-year-oldmanwithMay-Thurnersyndromewithswellingoftheleftlowerextremity.Phlebographyinapatientwithdeepvenousthrombosis.Deep vein thrombosis第二十六页，共四十六页。DiagnosispTheAAFPandtheACPhavepublishedaclinicalpracticeguidelinethatsummarizescurrentapproachesforthediagnosisofD

20、VTClinicalpredictionrulesshouldbeusedtoestimatethepretestprobabilityofDVT.InselectedpatientswithalowpretestprobabilityofDVTorPE,anegativehigh-sensitivityD-dimertestindicatesalowlikelihoodofVTE.UltrasoundisrecommendedforpatientswithintermediatetohighpretestprobabilityofDVTinthelegs.Patientswithinterm

21、ediateorhighpretestprobabilityofPErequireadditionaldiagnosticimagingstudies.Deep vein thrombosis第二十七页，共四十六页。DiagnosisDeep vein thrombosis第二十八页，共四十六页。TreatmentpThemaingoalsoftreatmentforDVTincludepreventionofPE,VTEandrecurrentthrombosis.pOnceVTEissuspected,anticoagulationshouldbestartedimmediatelyunl

22、essthereisacontraindication.Deep vein thrombosis第二十九页，共四十六页。TreatmentpMedicalManagement:AnticoagulationUnfractionatedHeparinWeight-baseddosingofUFH(80U/kgbolusfollowedby18U/kg/hrIVinfusion)hasbeenshowntoachieveatherapeuticactivatedpartialthromboplastintime(aPTT)morerapidlythanfixed-doseregimens.Deep

23、 vein thrombosis第三十页，共四十六页。TreatmentpMedicalManagement:AnticoagulationLow-Molecular-Weight-HeparinLMWHisadministeredasaweight-basedsubcutaneousinjection.InthecurrentACCPguidelines,LMWHisrecommendedoverUFHfortheinitialtreatmentofDVTorPE.Enoxaparin,themostcommonlyusedagentintheUS,isgiveneitherasaonce-

24、dailyinjection(1.5mg/kg/day)ortwicedaily(1mg/kgevery12hr).Deep vein thrombosis第三十一页，共四十六页。TreatmentpMedicalManagement:AnticoagulationFactorXaInhibitorsFondaparinuxisanindirectfactorXainhibitorthatcanbeusedasVTEprophylaxisinmedicalpatients,thoseundergoingorthopedicprocedures(totalhipandkneearthroplas

25、ty),andthoseundergoingabdominalsurgery.Deep vein thrombosis第三十二页，共四十六页。TreatmentpMedicalManagement:AnticoagulationWarfarinWarfarinremainsthemainstayoftherapyforlong-termtreatmentofVTE.ItmaybeinitiatedonceanticoagulationwithUFH,LWMH,orfondaparinuxhasbeenstarted(andwhichshouldbecontinuedasoverlaptreat

26、mentforaminimumof5daysanduntiltheinternationalnormalizedratioINRisatleast2.0for24hours).Deep vein thrombosis第三十三页，共四十六页。TreatmentpMedicalManagement:AnticoagulationNewOralAnticoagulantsDabigatran：directthrombininhibitorRivaroxaban：factorXainhibitorDeep vein thrombosis第三十四页，共四十六页。TreatmentpMedicalMana

27、gement:AnticoagulationThrombolyticTherapyThrombolytictherapyforDVTmaybebeneficialinselectedpatients,andalthoughitcanbeadministeredsystemically.ThrombolytictherapyforacutePEremainscontroversialbecausetherehasbeennoclearlyestablishedshort-termmortalitybenefit.Deep vein thrombosis第三十五页，共四十六页。Treatmentp

28、MedicalManagement:Surgical/MechanicalinterventionPulmonaryEmbolectomyAccordingtoACCPguidelines,pulmonaryembolectomyfortheinitialtreatmentofPEisreservedforpatientswithmassivePE(documentedangiographicallyifpossible),shockdespiteheparinandresuscitationefforts,andfailureofthrombolytictherapyoracontraind

29、icationtoitsDeep vein thrombosis第三十六页，共四十六页。TreatmentpMedicalManagement:Surgical/MechanicalinterventionVenaCavalInterruptionCurrentguidelinesrecommendagainsttheroutineuseofinferiorvenacava(IVC)filtersforthetreatmentofVTE.IndicationsfortheplacementofIVCfiltersincludeacontraindicationtoanticoagulation

30、,complicationsofanticoagulation,recurrentthromboembolismdespiteadequateanticoagulanttherapy,andpatientsundergoingpulmonaryembolectomy.Deep vein thrombosis第三十七页，共四十六页。TreatmentpThedurationoftreatmentfollowingthediagnosisofDVTdependsontheriskofrecurrence,includingidiopathicDVTorPE,certainunderlyinghyp

31、ercoagulablestatessuchastheantiphospholipidsyndrome,andunderlyingmalignancy.Deep vein thrombosis第三十八页，共四十六页。TreatmentpAlthoughtheriskofrecurrencedecreaseswithlongerdurationsofanticoagulation,cliniciansmustweightheriskofbleedingagainsttheriskofnewthrombosis.Deep vein thrombosis第三十九页，共四十六页。Preventionp

32、Approximatelytwo-thirdsofallDVTeventsresultfromhospitalization,yetonlyonethirdofallhospitalizedpatientsatriskreceiveadequateprophylaxis.pPEisthemostcommonpreventablecauseofhospitaldeathintheUS.Withoutprophylaxis,theincidenceofhospital-acquiredDVTis10%to20%amongmedicalpatientsandhigher(15%to40%)among

33、surgicalpatients.Deep vein thrombosis第四十页，共四十六页。PreventionpApproximatelytwo-thirdsofallDVTeventsresultfromhospitalization,yetonlyonethirdofallhospitalizedpatientsatriskreceiveadequateprophylaxis.pPEisthemostcommonpreventablecauseofhospitaldeathintheUS.Withoutprophylaxis,theincidenceofhospital-acquir

34、edDVTis10%to20%amongmedicalpatientsandhigher(15%to40%)amongsurgicalpatients.Deep vein thrombosis第四十一页，共四十六页。PreventionpLong-termcomplicationsincluderecurrentVTE,CTPH,andthePTS.pTherecurrencerateforidiopathicVTEapproaches30%after10years,theincidenceofCTPHis4%at2years,andtherateofPTSis30%at8years.pDdi

35、merisanexcellenttesttoexcludeVTE.pDuplexultrasonographyisthenoninvasivetestofchoiceforthediagnosisofDVT.Deep vein thrombosis第四十二页，共四十六页。PreventionpComputedtomographicpulmonaryangiographyhasreplacedtheventilationperfusionscanfordiagnosingPE.pRiskstratificationisthekeytomanagementofpatientswithVTE.pIn

36、definiteanticoagulationshouldbeconsideredforpatientswithanidiopathicorunprovokedVTE.pAppropriateprophylaxisremainsunderused.Deep vein thrombosis第四十三页，共四十六页。ReferencesDeep vein thrombosispPubmed:pWikipedia:pGoogle:pTheClevelandClinic:第四十四页，共四十六页。Thank You!XiangYuCheng第四十五页，共四十六页。内容(nirng)总结第四十六页，共四十六页。