上肢深静脉血栓课件

上肢深静脉血栓

upperextremitydeepvenousthrombosis

UEDVT

1上肢深静脉血栓

upperextremitydeep定义腋静脉、锁骨下静脉、桡静脉、尺静脉、肱静脉、颈内静脉、头臂干静脉最常见：腋静脉、锁骨下静脉原发性：约占20%继发性：指存在危险因素的深静脉血栓形成，约占80%

CucMai,M.D.H.M.,UpperextremityDeepVenousThrombosisAReview.TheAmericanJournalofMedicine,2011.2定义腋静脉、锁骨下静脉、桡静脉、尺静脉、肱静脉、颈内静脉、头33流行病学KrogerK,ScheloC,GockeC,etal.ColourDopplersonographicdiagnosisofupperlimbvenousthromboses[J].ClinSci(Lond),1998,94(6):657-661.SyedMustafa,M.,etal.,upperextremitydeepveinthrombosis.CHEST,20034流行病学KrogerK,ScheloC,GockeDVT中所占比例SpencerFAECLD.UpperExtremityDeepVeinThrombosisACommunity-Based[J].AmJMed,2007,8(120):678-684.HyltonV.JoffeNKVF.Upper-ExtremityDeepVeinThrombosisAProspectiveRegistryof592Patients[J].Circulation,2004,12(110):1605-1611.5DVT中所占比例SpencerFAECLD.U危险因素原发性上肢深静脉血栓：遗传性血栓形成倾向：蛋白C、蛋白s或抗凝血酶、凝血因子Ⅲ缺乏，凝血因子VLeiden突变和凝血酶原G20210A突变解剖结构异常：Paget-Schroetter综合征

Grant,J.D.,etal.,Diagnosisandmanagementofupperextremitydeep-veinthrombosisinadults.ThrombHaemost,2012.6危险因素原发性上肢深静脉血栓：6继发性上肢深静脉血栓

CVC置入：45%与CVC有关肿瘤：38%与恶性肿瘤有关其他：起搏器、30天内手术史或制动史、个人或者家族深静脉血栓栓塞史、正在接受化疗、伴随疾病（高血压、糖尿病、神经系统疾病、

30内肺部感染）MunozFJ,MismettiP,PoggioR,etal.Clinicaloutcomeofpatientswithupper-extremitydeepveinthrombosis:resultsfromtheRIETERegistry[J].Chest,2008,133(1):143-1487继发性上肢深静脉血栓MunozFJ,Mismetti

RIETE研究

多国家、多中心MunozFJ,MismettiP,PoggioR,etal.Clinicaloutcomeofpatientswithupper-extremitydeepveinthrombosis:resultsfromtheRIETERegistry[J].Chest,2008,133(1):143-1488RIETE研究

多国家、多中心MunozFJ,Mi2004年美国多中心研究HyltonV.JoffeNKVF.Upper-ExtremityDeepVeinThrombosisAProspectiveRegistryof592Patients[J].Circulation,2004,12(110):1605-161192004年美国多中心研究HyltonV.JoffeN临床症状和体征上肢肿胀：80%患侧肢体疼痛：30—50%较少出现的：患侧肢体红斑、浅表静脉曲张、肢体功能障碍、胸痛、呼吸困难、颈部肿胀无症状：约5%10临床症状和体征上肢肿胀：80%10诊断

D-二聚体超声对比静脉造影：金标准MRI、MRVCTV……

vanM.DINISIO,G.L.S.,Accuracyofdiagnostictestsforclinicallysuspectedupperextremitydeepveinthrombosis.JournalofThrombosisandHaemostasis11诊断D-二聚体11D-二聚体Merminodetal,2006,Switzerland：500ug/L多普勒超声确诊52例怀疑UEDVT中：1.D-dimer阳性：15/5229%2.并发肿瘤中：8/2334.8%3.CVC：6/1833%4.无肿瘤、CVC：4/2218%诊断的敏感性为100%，特异性为14%，阳性预测价值为32%，阴性排除价值为100%，12D-二聚体Merminodetal,2006,Switz超声PICC13超声PICC13

低回声不可压缩性14低回声超声DiNisioM,VanSluisGL,BossuytPM,etal.Accuracyofdiagnostictestsforclinicallysuspectedupperextremitydeepveinthrombosis:asystematicreview[J].JThrombHaemost,2010,8(4):684-69215超声DiNisioM,VanSluisGL,BUEDVT诊断16UEDVT诊断161717急性期：确诊血栓后的前三个月

可以降低血栓后综合征、血栓复发的发生率。预防期：急性期治疗后的阶段

目的是控制血栓形成的危险因素

治疗（参考下肢深静脉血栓形成）18急性期：确诊血栓后的前三个月治疗（参考下肢深静脉血栓形成）1治疗（参考下肢深静脉血栓形成）拔除深静脉置管抗凝溶栓上腔静脉滤器手术取栓术

Grant,J.D.,etal.,Diagnosisandmanagementofupperextremitydeep-veinthrombosisinadults.ThrombHaemost,201219治疗（参考下肢深静脉血栓形成）拔除深静脉置管19抗凝ACCP建议：同下肢深静脉血栓KearonC,KahnSR,AgnelliG,etal.Antithrombotictherapyforvenousthromboembolicdisease:AmericanCollegeofChestPhysiciansEvidence-BasedClinicalPracticeGuidelines(8thEdition)[J].Chest,2008,133(6Suppl):454S-545S20抗凝ACCP建议：同下肢深静脉血栓KearonC,Kah溶栓ACCP建议：仅用于：症状严重、血栓占据大部分锁骨下静脉和腋静脉、血栓形成14天内、肢体功能良好、预期寿命长于一年、低出血风险者KearonC,KahnSR,AgnelliG,etal.Antithrombotictherapyforvenousthromboembolicdisease:AmericanCollegeofChestPhysiciansEvidence-BasedClinicalPracticeGuidelines(8thEdition)[J].Chest,2008,133(6Suppl):454S-545S21溶栓ACCP建议：仅用于：症状严重、血栓占据大部分锁骨下静脉上腔静脉滤器OwensCA,BuiJT,KnuttinenMG,etal.Pulmonaryembolismfromupperextremitydeepveinthrombosisandtheroleofsuperiorvenacavafilters:areviewoftheliterature[J].JVascIntervRadiol,2010,21(6):779-787上腔静脉短，放置困难致死性并发症发生率为3.8%22上腔静脉滤器OwensCA,BuiJT,Knut手术取栓术KearonC,KahnSR,AgnelliG,etal.Antithrombotictherapyforvenousthromboembolicdisease:AmericanCollegeofChestPhysiciansEvidence-BasedClinicalPracticeGuidelines(8thEdition)[J].Chest,2008,133(6Suppl):454S-545S大块血栓形成影响肢体功能绝对抗凝、溶栓禁忌症23手术取栓术KearonC,KahnSR,Agnel治疗策略比较24治疗策略比较24并发症肺栓塞：发生率约为5%；抗凝深静脉血栓复发：高复发、早复发血栓后综合征（Post-thromboticSyndrome,PTS）发生率为20—40%25并发症肺栓塞：发生率约为5%；抗凝25PE26PE26预防合理的选择CVC置入小剂量低分子肝素、小剂量华法林、维生素K拮抗剂（继发性）27预防合理的选择CVC置入27ThankYou！28ThankYou！28上肢深静脉血栓

upperextremitydeepvenousthrombosis

UEDVT

29上肢深静脉血栓

upperextremitydeep定义腋静脉、锁骨下静脉、桡静脉、尺静脉、肱静脉、颈内静脉、头臂干静脉最常见：腋静脉、锁骨下静脉原发性：约占20%继发性：指存在危险因素的深静脉血栓形成，约占80%

CucMai,M.D.H.M.,UpperextremityDeepVenousThrombosisAReview.TheAmericanJournalofMedicine,2011.30定义腋静脉、锁骨下静脉、桡静脉、尺静脉、肱静脉、颈内静脉、头313流行病学KrogerK,ScheloC,GockeC,etal.ColourDopplersonographicdiagnosisofupperlimbvenousthromboses[J].ClinSci(Lond),1998,94(6):657-661.SyedMustafa,M.,etal.,upperextremitydeepveinthrombosis.CHEST,200332流行病学KrogerK,ScheloC,GockeDVT中所占比例SpencerFAECLD.UpperExtremityDeepVeinThrombosisACommunity-Based[J].AmJMed,2007,8(120):678-684.HyltonV.JoffeNKVF.Upper-ExtremityDeepVeinThrombosisAProspectiveRegistryof592Patients[J].Circulation,2004,12(110):1605-1611.33DVT中所占比例SpencerFAECLD.U危险因素原发性上肢深静脉血栓：遗传性血栓形成倾向：蛋白C、蛋白s或抗凝血酶、凝血因子Ⅲ缺乏，凝血因子VLeiden突变和凝血酶原G20210A突变解剖结构异常：Paget-Schroetter综合征

Grant,J.D.,etal.,Diagnosisandmanagementofupperextremitydeep-veinthrombosisinadults.ThrombHaemost,2012.34危险因素原发性上肢深静脉血栓：6继发性上肢深静脉血栓

CVC置入：45%与CVC有关肿瘤：38%与恶性肿瘤有关其他：起搏器、30天内手术史或制动史、个人或者家族深静脉血栓栓塞史、正在接受化疗、伴随疾病（高血压、糖尿病、神经系统疾病、

30内肺部感染）MunozFJ,MismettiP,PoggioR,etal.Clinicaloutcomeofpatientswithupper-extremitydeepveinthrombosis:resultsfromtheRIETERegistry[J].Chest,2008,133(1):143-14835继发性上肢深静脉血栓MunozFJ,Mismetti

RIETE研究

多国家、多中心MunozFJ,MismettiP,PoggioR,etal.Clinicaloutcomeofpatientswithupper-extremitydeepveinthrombosis:resultsfromtheRIETERegistry[J].Chest,2008,133(1):143-14836RIETE研究

多国家、多中心MunozFJ,Mi2004年美国多中心研究HyltonV.JoffeNKVF.Upper-ExtremityDeepVeinThrombosisAProspectiveRegistryof592Patients[J].Circulation,2004,12(110):1605-1611372004年美国多中心研究HyltonV.JoffeN临床症状和体征上肢肿胀：80%患侧肢体疼痛：30—50%较少出现的：患侧肢体红斑、浅表静脉曲张、肢体功能障碍、胸痛、呼吸困难、颈部肿胀无症状：约5%38临床症状和体征上肢肿胀：80%10诊断

D-二聚体超声对比静脉造影：金标准MRI、MRVCTV……

vanM.DINISIO,G.L.S.,Accuracyofdiagnostictestsforclinicallysuspectedupperextremitydeepveinthrombosis.JournalofThrombosisandHaemostasis39诊断D-二聚体11D-二聚体Merminodetal,2006,Switzerland：500ug/L多普勒超声确诊52例怀疑UEDVT中：1.D-dimer阳性：15/5229%2.并发肿瘤中：8/2334.8%3.CVC：6/1833%4.无肿瘤、CVC：4/2218%诊断的敏感性为100%，特异性为14%，阳性预测价值为32%，阴性排除价值为100%，40D-二聚体Merminodetal,2006,Switz超声PICC41超声PICC13

低回声不可压缩性42低回声超声DiNisioM,VanSluisGL,BossuytPM,etal.Accuracyofdiagnostictestsforclinicallysuspectedupperextremitydeepveinthrombosis:asystematicreview[J].JThrombHaemost,2010,8(4):684-69243超声DiNisioM,VanSluisGL,BUEDVT诊断44UEDVT诊断164517急性期：确诊血栓后的前三个月

可以降低血栓后综合征、血栓复发的发生率。预防期：急性期治疗后的阶段

目的是控制血栓形成的危险因素

治疗（参考下肢深静脉血栓形成）46急性期：确诊血栓后的前三个月治疗（参考下肢深静脉血栓形成）1治疗（参考下肢深静脉血栓形成）拔除深静脉置管抗凝溶栓上腔静脉滤器手术取栓术

Grant,J.D.,etal.,Diagnosisandmanagementofupperextremitydeep-veinthrombosisinadults.ThrombHaemost,201247治疗（参考下肢深静脉血栓形成）拔除深静脉置管19抗凝ACCP建议：同下肢深静脉血栓KearonC,KahnSR,AgnelliG,etal.Antithrombotictherapyforvenousthromboembolicdisease:AmericanCollegeofChestPhysiciansEvidence-BasedClinicalPracticeGuidelines(8thEdition)[J].Chest,2008,133(6Suppl):454S-545S48抗凝ACCP建议：同下肢深静脉血栓KearonC,Kah溶栓ACCP建议：仅用于：症状严重、血栓占据大部分锁骨下静脉和腋静脉、血栓形成14天内、肢体功能良好、预期寿命长于一年、低出血风险者KearonC,KahnSR,AgnelliG,etal.Antithrombotictherapyforvenousthromboembolicdisease:AmericanCollegeofChestPhysician