急性肺动脉栓塞及进展-心内科何国祥课件

急性肺栓塞诊疗指南及进展GuidelinesandProgressontheDiagnosisandManagementofAcutePulmonaryEmbolism

SouthwestHospital何国祥Prof.GuoxiangHE第三军医大学西南医院重庆市介入心脏病学研究所SouthwestHospitalTheThirdMilitaryMedicalUniversityChongqingInstituteofInterventionalCardiology

SouthwestHospitalUpdatein2021中国急性肺血栓栓塞症诊断治疗专家共识

GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalGuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalGuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFIG1.Venousthromboembolism(VTE)/100,000population/yearfrom1990through1999.(DatafromSteinetal.3-5)CurrProblCardiol2021;35:314-376GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFIG2.Deepvenousthrombosis(DVT)/100,000population/yearshownaccordingtoagefortheyear1999.6,7(Reprintedwithpermission.10)CurrProblCardiol2021;35:314-376GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFIG3.Pulmonaryembolism(PE)/100,000population/yearshownaccordingtoagefortheyear1999.(DatafromSteinetal.5,6)(Reprintedwithpermission.10)CurrProblCardiol2021;35:314-376GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFIG12.EstimatedcasefatalityratesforPEaccordingtodecadesofage.(Reprintedwithpermission.23)CurrProblCardiol2021;35:314-376GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFIG4.PEandDVTinchildren.(DatafromSteinetal.7)CurrProblCardiol2021;35:314-376GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospital

Majorriskfactorsforvenousthrombosis•Majorsurgery•Orthopaedicsurgerytolowerlimb/lowerlimbtrauma•Historyofpreviousvenousthrombosis•Cancer•Pregnancy/puerperium•Reducedmobility–majorillnesswithprolongedbedrest•Age>70years•Thrombophilias:antithrombindeficiencyproteinCdeficiencyproteinSdeficiencyantiphospholipidantibodiesGuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalGuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalTABLE5.Electrocardiographicmanifestations:patientswithoutpriorcardiacorpulmonarydiseaseDatafromSteinetal.29,57Reprintedwithpermission.10Somepatientshadmorethan1abnormality.CurrProblCardiol2021;35:314-376GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalTABLE6.PlainchestradiographinpatientswithacutepulmonaryembolismandnopriorcardiopulmonarydiseaseDataarefromSteinetal.29,63Reprintedwithpermission.10aAmongpatientswithapleuraleffusion,86%hadonlybluntingofthecostophrenicangle.Nonehadapleuraleffusionthatoccupiedmorethanonethirdofahemithorax.bProminentcentralpulmonaryarteryanddecreasedpulmonaryvascularity.GuidelinesandProgressontheDiagnosisandManagementofAcutePE肺实质异常肺不张/萎陷肺实变胸水

SouthwestHospitalFIGURE2.V/QSPECTforthedetectionofpulmonaryembolismV/QSPECTthermalimagingcoronalposteriorsectionsinafemalepatientshowmultiplelargepulmonary-ventilatoryareasofmismatchthatindicatepulmonaryembolithatinvolvetheupperandlowerlobesoftherightlung(whitearrows).V/QSPECT,ventilationandperfusionsinglephotonemissioncomputedtomography.GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFIG19.RelativeuseofdiagnosticimagingtestsinpatientshospitalizedwithPEfrom1979through2006.V/Q,ventilation/perfusion;ANGIOS,pulmonaryangiograms.(Reprintedwithpermission.10)CurrProblCardiol2021;35:314-376GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFIG20.CTpulmonaryangiogramshowingPEintherightpulmonaryartery.CurrProblCardiol2021;35:314-376GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFIG21.CTvenousphaseimageshowingrightpoplitealveinthrombosis(arrow).CurrProblCardiol2021;35:314-376GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospital

Threeimagesfromasinglecomputedtomographypulmonaryangiography(CTPA)studyperformedwithahighclinicalsuspicionofpulmonaryembolism(PE).Image1demonstratesalargePEintheproximalrightpulmonaryartery.Image2showsasignificantconcurrentpneumothorax.Image3demonstratesanRV/LVratio>1signifyingsignificantrightventricular(RV)dysfunction.TogethertheseimagesshowthehighutilityofCTPAindiagnosis/exclusionofPE,diagnosis/exclusionofdifferentialdiagnoses,andinriskstratifyingapatientsoastoguidetherapy.GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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CausesofaraisedD-dimer•venousthromboembolicdisease•increasingage•cancer•infection•haematoma•postsurgery•inflammation•pregnancy•peripheralvasculardisease•liverdiseaseGuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalTheThrombo-EmbolismLactateOutcomeStudy

血栓-栓塞乳酸盐转归研究

PrognosticValueofPlasmaLactateLevelsAmongPatientsWithAcutePulmonaryEmbolism

血浆乳酸盐水平在PE患者中的预后价值AnnEmergMed.2021;xx:xxxTable2.Descriptionof30-dayoutcomeofpatientsinvestigated(n=270).*GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFigure3.All-causedeathandcompositeendpointincidenceinpatientswithincreasingvaluesofplasmalactatelevel.乳酸盐水平与全因死亡和复合终点AnnEmergMed.2021;xx:xxxGuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFigure4.Coxproportionalhazardanalysisoftherelationshipbetweenplasmalactatelevelgreaterthanorequalto2mmol/Landoutcomein270patientswithacutepulmonaryembolism.AnnEmergMed.2021;xx:xxx全因死亡复合终点GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFigure5.Receiveroperatingcharacteristiccurveanalysisofplasmalactatelevel,troponinIlevel,andsPESIvaluesin270patientswithacutepulmonaryembolism.AnnEmergMed.2021;xx:xxxGuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalElevatedHeart-TypeFattyAcid-BindingProteinLevelsonAdmissionPredictanAdverseOutcomeinNormotensivePatientsWithAcutePulmonaryEmbolism

心肌脂肪酸结合蛋白水平升高预测血压正常的APE病人不良转归(JAmCollCardiol2021;55:2150–7)Figure1PrognosticSensitivityandSpecificityofH-FABP,cTnT,andNT-proBNPReceiveroperatingcharacteristiccurvesforheart-typefattyacid-bindingprotein(H-FABP),cardiactroponinT(cTnT),andN-terminalpro-brainnatriureticpeptide(NT-proBNP)levelsonadmissionwithregardtoacomplicated30-dayoutcome.AUCareaunderthecurve.GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFigure2CombinationofH-FABPWithClinicalParametersThenumberofpatientswithcomplicationsandtheoverallnumberofpatientsaregiven,alongwithpercentages,foreachcolumn.H-FABPheart-typefattyacidbindingprotein;HRheartrate;RVrightventricular.GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFigure3ProbabilityofLong-TermSurvivalinPatientsWithorWithoutElevationofH-FABP,cTnT,andNT-proBNPBiomarkerlevelsweredichotomized,andelevatedconcentrationsweredefinedasthose6ng/mlforH-FABP,0.04ng/mlforcTnT,and1,000pg/mlforNT-proBNP.Redlineselevatedvalues;bluelinesnormalvalues;pvalueswerecalculatedbythelog-ranktest.AbbreviationsasinFigure1.JACC2021;55(19):2150–7GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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Fig.1.Pathophysiologyofrightventriculardysfunctionduringacutepulmonaryembolism.

RV:Rightventricule;LV:Leftventricle;TXA2:Thromboxane-A2;ET:Endothelin;PGF2a:ProstaglandinF2a;PGI2:Prostacyclin.Greyarrowindicatesthatallconstitutedaviciouscycle.Blackarrowindicatespathophysiologychange.JMedCollPLA2021；25：235-246GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalTable2EchocardiographicriskassessmentinPE1.DiagnosticcriteriaforRVdysfunctionRV功能不全的标准

A.RVwallhypokinesis-Moderateorsevere-McConnell'ssignregionalRVhypokinesisinwhichtheapexisspared

B.RVdilatation-End-diastolicdiameter>30mminparastemalview-RVlargerthanLVinsobcostalorapicalview-Increasedtricuspidvelocity>26m/sec-ParadoxicalRVseptalsystolicmotionC.Pulmonaryarteryhypertension-Pulmonaryarterysystolicpressure>30mmHg-DilatedIVCwithlackofrespiratorycollapse2.OtherfactorsassociatedwithincreasedmortalityA.PatentforamenovaleB.Free-floatingnight-heatthrombusGuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFig.1PhysicianassessmentofpatientswithPE.GuidelinesandProgressontheDiagnosisandManagementofAcutePEPE的临床评估

SouthwestHospitalGuidelinesandProgressontheDiagnosisandManagementofAcutePE

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AssessmentofclinicalprobabilityRevisedGenevaScore

PointsAge>60years1PreviousVTE3Surgery/fracturelowerlimbinlastmonth2Activemalignancy2Unilaterallowerlimbpain3Haemoptysis2Heartrate75–943Heartrate>955Painonlowerlimbdeepvenouspalpationandunilateraloedema4ClinicalprobabilityTotalpointsLow0–3Intermediate4–10High>10GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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ModifiedWellsscore6

PointsSymptomsofaDVT3Noalternativediagnosis3Heartrate>1001.5Immobilizationorsurgeryinthepreviousmonth1.5PreviousVTE1.5Malignancy1.5Haemoptysis1.5Score4orless,PEunlikelyGuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalTABLE12.PositivepredictivevaluesofCTAandCTA/CTVinrelationtopriorclinicalassessmentOnlypatientswithareferencetestdiagnosisbyV/QscanorconventionalpulmonaryDSAwereincluded.Abbreviations:CTA,computedtomographicpulmonaryangiography;CTV,venousphasevenogram.Reprintedwithpermission.14CurrProblCardiol2021;35:314-376GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalTABLE13.NegativepredictivevaluesofCTAandCTA/CTVinrelationtopriorclinicalassessmentOnlypatientswithareferencetestdiagnosisbyV/QscanorconventionalpulmonaryDSAwereincluded.Abbreviations:CTA,computedtomographicpulmonaryangiography;CTV,venousphasevenogram.Reprintedwithpermission.14CurrProblCardiol2021;35:314-376GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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BTSscore

PointsIsaPEareasonablediagnosis?1PE的诊断合理?Isanalternativediagnosislesslikely?1可能性小?Isamajorriskfactorpresent?1存在主要危险因素?1point,lowclinicalprobability;2points,intermediateclinicalprobability;3points,highclinicalprobability.GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalGuidelinesandProgressontheDiagnosisandManagementofAcutePE

AcutePulmonaryArteryEmbolism

SouthwestHospitalFig.3PathophysiologyofRVdysfunctionanddeathinPE.

SouthwestHospitalANAESTHESIAANDINTENSIVECAREMEDICINE2021；11:12AcutePulmonaryArteryEmbolism

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Anticoagulation抗凝：有充分理由支持诊断PE：开始全剂量的LMUH治疗由影像学证实和确诊PE：停LMUH改为warfarin〔INR=2-3，目标=2.5〕为门诊病人安排监测INRAcutePulmonaryArteryEmbolism

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Suggesteddosing,heparintherapyANAESTHESIAANDINTENSIVECAREMEDICINE2021；11:12AcutePulmonaryArteryEmbolism

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Howlongtotreat?根据PE的原因而异通常6W-3M可能足够病因持续存在:抗凝持续

原发/先天性PE,一旦停止治疗,复发率4–10%/年，4年以上远期事件率20%因此,I级事件后应终身抗凝治疗,但需要权衡治疗的获益与风险严重出血(颅内出血；腹膜后出血；Hb降低需要输血者〕：≤75岁1%/年＞75岁5%/年

决策治疗疗程前与病人/家属讨论利弊是明智/必要的AcutePulmonaryArteryEmbolism

SouthwestHospitalFig.2.Percentageandsizeofresidualpulmonarythrombi.Greater,similarandsmallerocclusionmeanbigger,sameandlessersizeofpulmonarythrombirespectivelyasseeninsecondcomputedtomography.EurJIntMed2021；23：379–383EurJIntMed2021；23：379–383Residualpulmonarythromboemboliafteracutepulmonaryembolism继发于肺栓塞的剩余肺血栓AcutePulmonaryArteryEmbolism

SouthwestHospitalEurJIntMed2021；23：379–383Residualpulmonarythromboemboliafteracutepulmonaryembolism继发于肺栓塞的剩余肺血栓AcutePulmonaryArteryEmbolism

SouthwestHospitalTable1Causesofnon-repeatedCTangiographyCausesN(%)Cognitiveimpairment5(11)Mobilityimpairment17(37)Renalfailure4(9)Death9(19)Livingoutofourcommunity6(13)Pregnancy1(2)Rejection4(9)EurJIntMed2021；23：379–383Residualpulmonarythromboemboliafteracutepulmonaryembolism继发于肺栓塞的剩余肺血栓AcutePulmonaryArteryEmbolism

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Lifelongtreatmentisappropriateif:TheinitialPEwaslifethreateningPE威胁生存Thepatienthassignificantcardiorespiratorydisease患者有显著的心肺疾病Wherebyafurther,evensmall,PEcouldhavefatalconsequences;orthepatienthasasecond,unprovokedeventPE可能有致命性后果，或有再次无缘无故的事件AcutePulmonaryArteryEmbolism

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INR达标:PE的复发是罕见的如果复发：增加warfarin、增大目标INR癌症患者〔复发更常见〕：转换为LMWH在抗凝治疗中仍存在DVT，或抗凝禁忌：腔静脉滤器〔可回收式〕

GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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抗凝：严重出血并发症<3%漏诊PE：死亡风险30%提示：确诊的PE、临床高度PE风险者均应抗凝，除非有明确禁忌症ANAESTHESIAANDINTENSIVECAREMEDICINE2021；11:12GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalNewDrugReviewDabigatranEtexilate:AnOralDirectThrombinInhibitorfortheManagementofThromboembolicDisorders

达比加群：口服的直接凝血酶抑制剂ClinTher.2021;34:766–787TableI.PertinentdruginteractionswithdabigatranGuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalTableII.Pertinentclinicalstudiesontheuseofdabigatran.GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalBISTROIBoehringerIngelheimStudyinThrombosisI;DEdabigatranetexilate;DVTdeepveinthrombosis;PEpulmonaryembolism;QDdaily;RE-NOVATEPreventionofVenousThromboembolismAfterTotalHipReplacement;VTEvenousthromboembolism;RE-MODELThromboembolismPreventionAfterKneeSurgery;RE-MOBILIZEDabigatranVersusEnoxaparininPreventingVenousThromboembolismFollowingTotalKneeArthroplasty;RE-COVERDabigatranVersusWarfarinintheTreatmentofAcuteVenousThromboembolism;INRinternationalnormalizedratio;PETROPreventionofEmbolicandThromboticEventsinPatientsWithPersistentAtrialFibrillation;AFatrialfibrillation;RE-LYRandomizedEvaluationofLong-termAnticoagulationTherapy;Postoppostoperation.*P0.05forenoxaparin.†P0.05indicatingnon-inferiortoenoxoparin.‡P0.0001indicatingnon-inferiortowarfarin.§P0.05significantlydifferentfromwarfarin.P0.001indicatingnon-inferiortowarfarin.¶P0.001indicatingsuperiortowarfarin.GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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Thrombolysis溶栓巨大PE：常伴心血管病，有或无紫绀、静脉怒张、搏动，P2亢进虽然确诊应该基于影象结果，因为大的PE危急，通常难以转送至放射科进行CTPA床旁UCG可提供有价值的信息：急性右心负荷过重不能解释的心肺衰竭病人，因为病情太不稳定，无法CTPA、甚至床旁UCG，假定基于危险评估和临床表现而拟诊PE：alteplase〔阿替普酶〕50mg巨大PE，显著或进行性血动力学不稳定〔溶栓可能戏剧性改善血动力学和氧合状态病死率和PE复发率低于肝素疗法，但几天内血凝块的解析度那么不如，缺乏头对头研究结果，meta-analysis倾向溶栓疗法，因为显著降低了病死率submassivePE患者，溶栓后显著减少了进CCU的需求程度

ANAESTHESIAANDINTENSIVECAREMEDICINE2021；11:12GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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溶栓剂和方案〔Thrombolyticagentsandregimens〕

Streptokinase

250,000Uasaloadingdoseover30min,链激酶

followedby100,000Uperhourover12–24h

Acceleratedregimen:1.5millionIUover2hUrokinase

4400Uperkilogramofbodyweightasaloadingdoseover10min,

尿激酶

followedby4400U/kg/hover12–24h

Acceleratedregimen:3millionUover2hAlteplase

100mgover2h阿替普酶

Acceleratedregimen:0.6mg/kgover15minReteplase

Twobolusinjectionsof10U30minapart瑞替普酶Tenecteplase

30–50mgbolusover5–10s替奈普酶adjustedforbodyweight:<60kg:30mg60–<70kg:35mg70–<80kg:40mg80–<90kg:45mg90kg:50mg

SouthwestHospital

Nostudyhasshownasignificantdifferenceintheefficacyofdifferentthrombolyticagents尚无研究说明不同溶栓剂效果有显著差异Asuggestedprotocoloftwo10unitdosesofReteplase,separatedby30minutes,iseffectiveandsimple建议2个10u瑞替普酶，间隔30minThereisnoevidencethatusingacentralvenousorpulmonaryartery(PA)catheterforadministeringthrombolyticsconfersatreatmentadvantageoranyreductioninbleedingcomplications，mayresultinarterialinjury，pneumothorax没有证据说明使用CV/PA导管给药具有治疗优势和减少出血并发症，而可致动脉损伤、气胸Majorbleeding：10%vs.<3%withheparininfusionalone,Intracerebralhaemorrhage：<0.5%严重出血并发症10%，颅内出血<0.5%GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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Massivepulmonaryembolism巨大PEPEcausingsustained(>15minutes)hypotension(systolicBP<90mmHg)orasustainedsignificantdropinsystolicbloodpressure(>40mmHg)持续低BP〔>15min〕，或SBP持续显著下降(>40mmHg〕Mortalityexceeding25%(65%ifcardiopulmonaryresuscitationisrequired)65%需要CPR者，病死率超过25%AcuteRVfailureisaverycommonfeature急性RVF十分常见Theremayonlybeabriefwindowofopportunitytoidentifyandaddressthecondition可供识别和处理的时间窗很短Patientsremainatsignificantriskofdeathforseveraldaysafteranevent几天内死亡风险仍很高GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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SubmassivePE次大PETypicallydescribesotheracutePEs典型的急性PE病症Normalbloodpressure血压正常PatientsmayhaveevidenceofRVdysfunction(bestconfirmedwithechocardiography,butalsopossiblyshownonCT)右心室功能不全的病症〔UCG，CT〕Thissubgrouphasuptofourtimesthemortalityriskandincreasedratesofrecurrence,mayalsogoontodevelopshockorRVthrombus也可发生休克或RV血栓，那么死亡增加4倍、复发风险增加Removeclotsuchasthrombolysismayhavearoleinthisgroup溶栓可能有作用Preventionofrecurrenceisapriority预防复发优先GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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AllotherpatientswithPE其他PE者Haemodynamicallystable血动力血稳定NormalRVfunction,RV功能正常Majoritytendtofollowanuneventfulcourse(<2%mortality)unlessfurtherPEoccurs病死率<2%，除非进一步的PE发生GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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Aim：preventionoffurtherembolizationandthrombosis目的：预防进一步血栓形成和栓塞Method:anticoagulationinferiorvenacavafiltersremovalofestablishedclot(thrombolysisandembolectomy)方法：抗凝下腔静脉滤器祛除血凝块：溶栓和血栓切除GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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BestPractice&ResearchClinicalHaematology2021(25):379–389

SouthwestHospital

Relative相对禁忌症Transientischemicattackinprevious6months6个月内TIA史Oralanticoagulation口服抗凝剂Pregnancyorfirstpostpartumweek妊娠或产后1周Non-compressiblepuncturesites不可压迫的穿刺部位Traumaticresuscitation外伤性复苏Refractoryhypertension(systolicbloodpressure>180mmHg)顽固性高血压〔SBP>180mmHg)Advancedliverdisease肝病晚期Infectiveendocarditis感染性心内膜炎Activepepticulcer活动性消化道溃疡

SouthwestHospitalTable1ContraindicationstofibrinolyticuseinPECardiacarrest:1.Absolutecontraindications-None2.Relativecontraindications-Activeinternalbleeding-RecentintracranialbleedingMassivePE:1.Absolutecontraindications-Activeinternalbleeding-Recentintracranialbleeding2.Relativecontraindications-Intracranialtumororseizurehistory-Ischemicstokeuntil2months-Neurosurgerywithinpastmonth-Recentsurgerywithin10days-Punctureofnoncompressiblevesselwithin10days-Traumawithin15days-Uncontrolledhypertension(SBP>180mmHg,DBP>110mmHg)-Hemorrhagicdisorderofthrombocytopenia(<100,000)-Impairedhepaticorrenalfunction-GIbleedingwithin10days-PregnancyGuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalSubmassivePE:1.Absolutecontraindications-Intracranialprocessorseizurehistory-Ischemicstrokewithin2months-Neurosurgerywithinpastmonths-Recentsurgerywithin10days-Punctureofnon-compressiblevesselwithin10days-Traumawithin15days-Uncontrolledhypertension(SBP>180mmHg,DBP>110mmHg)-Hemorrhagicdisorderorthrombocytopenia(<100,000)-Impairedhepaticorrenalfunction-GIbleedingwithin10days-Pregnancy2.Relativecontraindications-Age>65GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalTable4FibrinolyticdosingregimensinPECardiacarrest:1.UK、SK、r-tpA(任一种)2.Alteplase(FDA-appointed)阿替普酶〔FDA指定〕a.50-mgIVbolus50mg弹丸式IVb.Mayrepeat50-mgIVbolusin15minifnoROSC15min内如未恢复，可重复1次3.Reteplase瑞替普酶a.20-UIVbolus20-UIV弹丸式IV3.Tenecteplase替奈普酶a.0.5-mg/kgIVbolus(max50mg)MassiveandsubmassivePE:1.Alteplase(FDAapproved)a.10-mgIVbolusb.Followedby90-mgIVillusionover2h2.Reteplasea.10-UIVbolus,b.Followedin30minbyanother10-UIVbolus3.Tenecteplasea.0.5-mg/kgIVbolus(max50mg)1次GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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Inferiorvenacava(IVC)filters：下腔静脉滤器RetrievableDecreasetherateofrecurrentPEandlower90-daymortalitybutincreasetherateofDVTANAESTHESIAANDINTENSIVECAREMEDICINE2021；11:12GuidelinesandProgressontheDiagnosisandManagementofAcutePE

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Suggestedindicationsforinsertionofinferiorvenacava(IVC)filterANAESTHESIAANDINTENSIVECAREMEDICINE2021；11:12GuidelinesandProgressontheDiagnosisandManagementofAcutePE

SouthwestHospitalFig.2.Thesamepatientonthe10thdayaftercaesareandelivery.(A)Follow-upcavographyjustbeforeextractionofthefilter.Nolargethrombiareseen.Moderatetiltingofthefilterafterthedelivery.(B)Filterhookengagementbyretrievalloop.(C)Follow-upcavographyafterfilterextraction,noextravasation,IVCstenosisorveinwallinjuryisvisible.RetrievableGuntherTulipVenaCavaFilterinthepreventionofpulmonaryembolisminpatientswithacutedeepvenousthrombosisinperinatalperiod

下腔静脉滤器预防围产期深静脉血栓患者PEEurJRadio2021；70：165–169GuidelinesandProgressontheDiagnosisandManagemento