如何正确把握下腔静脉滤器置放术的指征-张福先

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(venousthromboembolism,VTE)深静脉血栓形成(deepvenousthrombosis,DVT)肺栓塞症 (pulmonarythromboembolism,PE)VTE=DVT+PEDVT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15.8and17.1per10000，而美国为130per10000.LeeLH,GuKQ,HengD.DeepveinthrombosisisnotrareinAsiaetheSingaporeGeneralHospitalexperience.AnnAcadMedSingap2002Nov;31(6):761-764.CheukBL,CheungGC,ChengSW.EpidemiologyofvenousthromboembolisminaChinesepopulation.BrJSurg2004Apr;91(4):424-428.StienPD,BeemathA,OlsonRE.Trendsintheincidenceofpulmonaryembolismanddeepvenousthrombosisinhospitalizedpatients.AmJCardiol2005June;95(12):1525e6.

IncidenceofVTEper10,000hospitaladmissions

A.D.Lee,E.Stephen,S.Agarwal,etal.VenousThrombo-embolisminIndia.EurJVascEndovascSurg2009,37,482－485.在美国每年约250000and20millioncasesofDVT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．GoldhaberSZ,TapsonVF.FortheDVTFREEsteeringCommitttee.Aprospectiveregistryof5451patientswithultrasound-confirmeddeepveinthrombosis.AmJCardiol,2004:93;259-262HannoHoppe.OptionalVenaCavaFilters.DtschArzteblInt2009;106(24):395–402

Prevalenceofpulmonaryembolism(PE)anddeepvenousthrombosis(DVT)atautopsy

PaulD.Stein.PulmonaryEmbolism.3-4page,2007PublishedbyBlackwellPublishingPrevalenceofpulmonaryembolismatautopsyingeneralhospitalsandcommunities通过动物实验和对100例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);531－533Phlégmatiaalbadolens.In:TrousseauA.Cliniquemédicaledei`Hôtel-DieudeParis.3rded.Vol3,Paris:J.B.Bailliére.1868:652-695.

GreenfieldLJ,MichnaBA.Twelve-yearclinicalexperiencewiththeGreenfieldvenafilter.Surgery1988:104;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In400patientsFollowup

At8yearsCirculation.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ConvertibleStein统计美国国家医疗中心数据库内50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%.SteinPD,etal：Twenty-one-yeartrendsintheuseofinferiorvenacavafilters.ArchInternMed.2004;164:1541–1545.RogersFB,etal：Practicemanagementguidelinesforthepreventionofvenousthromboembolismintraumapatients:TheEASTpracticemanagementguidelinesworkgroup.JTrauma.2002;53:142–164.GoldhaberSZ,TapsonVF.FortheDVTFREEsteeringCommitttee.Aprospectiveregistryof5451patientswithultrasound-confirmeddeepveinthrombosis.AmJCardiol,2004:93;259-262HannoHoppe.OptionalVenaCavaFilters.DtschArzteblInt2009;106(24):395–402滤器应用的现代观JVascSurg2008;47:157-65IndicationsforIVCfilterplacementJVascSurg2008;47:157-65IndicationsforIVCfilterplacementin1995and2005JVascIntervRadiol2008;19:393–399DistributionofindicationsforIVCfilterplacementamongallprovidersduring2005JVascIntervRadiol2008;19:393–399JVascIntervRadiol2008;19:393–399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．

AthanasoulisCA,KaufmanJA,HalpernEF,WaltmanAC,GellerSC,FanCM.Inferiorvenacava

filters:reviewofa26-yearsingle-centerclinicalexperience.Radiology2000;216:54–66.WhiteRH,ZhouH,KimJ,RomanoPS.Apopulation-basedstudyoftheeffectivenessofinferiorvenacavafilteruseamongpatientswithvenousthromboembolism.ArchInternMed2000;160:2033–2041.

Karmy-JonesR,JurkovichGJ,VelmahosGC,etal.Practicepatternsandoutcomesofretrievablevenacavafiltersintraumapatients:anAASTmulticenterstudy.JTrauma2007;62:17–24.PianoG,KettelerER,PrachandV,etal.Safety,feasibility,andoutcomeofretrievablevenacavafiltersinhigh-risksurgicalpatients.JVasc

Surg2007;45:784–788.在没有

DVTorPE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

PEorDVT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．

SaeHee,BenjaminR.Reynolds,DeidraH.Nicholas,etal.Institutionalprotocolimprovesretrievableinferiorvenacavafilterrecoveryrate.Surgery2009;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．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-directedthrombolysis(CDT)6月后与单纯性抗凝相比，血管通畅率是72%vs12%,P\0.001，静脉瓣功能正常率为89%vs59%,P\0.04.

PTS明显减少.滤器与DVT滤器应用的现代观ElsharawyM,ElzayatE.Earlyresultsofthrombolysisvsanticoagulationiniliofemoralvenousthrombosis.Arandomisedclinicaltrial.EurJVascEndovascSurg2002.24:209–214

KaufmanJA,KinneyTB,StreiffMBetal.:Guidelinesfortheuseofretrievableandconvertiblevenacavafilters:reportfromtheSocietyofInterventionalRadiologymultidisciplinaryconsensusconference.

JVascIntervRadiol2006;17:449–59.

CuschieriJ,FreemanB,O’KeefeG,HarbrechtBG,BankeyP,JohnsonJL,etal.Inflammationandthehostresponsetoinjuryalarge-scalecollaborativeproject:patient-orientedresearchcorestandardoperatingprocedureforclinicalcareX.Guidelinesforvenousthromboembolismprophylaxisinthetraumapatient.JTrauma2008;65:944-50.

滤器与创伤滤器应用的现代观Long-termfollow-upoftraumapatientswithpermanentprophylacticvenacavafilters.BACKGROUND:AlthoughpermanentprophylacticGreenfieldfilters(PPGF)areeffective,theiruseinyoung

traumapatientswhomayeventuallyreturntoactivelifestylesiscontroversialduetoconcernsaboutthesafetyofthedevicesoveralifetime.Thisdescriptivestudywasundertakentoprovidefollow-uponthelong-termsafetyanddurabilityofPPGF.METHODS:AllpatientsreceivingaPPGFbetweenApril1,1992andMarch1,2001weresoughtforfollow-up.Contactedpatientswereinterviewedregardingknownfilter-relatedcomplications,venousthromboembolicevents,andactivitylevelssincethetimeofdischargefromthehospital.Patientswerealsoofferedaphysicalexaminationfocusingonvenousthromboembolicsequelae,aplainfilmoftheabdomen(KUB)toassessfilterintegrityandlocation,andanultrasoundtoassesscavalpatency.Astheoriginalleveloffilterplacementwasusuallynotknown,migrationwasdefinedasafilterabovethefirstlumbarvertebra(L1).RESULTS:Theeligiblecohortconsistedof188patients.Ninetywereunabletobelocated(47.8%),onerefusedenrollment(0.5%),and97patientsornextofkinagreedtobeinterviewedbyphone(51.6%)ofwhom69returnedforevaluation(36.7%).Nofilter-relatedcomplicationswereself-reported.KUBswereperformedin68patients;onefilterstrutfracturewasfound(1.5%),whereasnofiltermigrationsaboveL1werenoted.Noinstancesofcavalthrombosiswerefoundin55ultrasounds.Twopatientssufferedinterimpulmonaryemboli(2.1%),oneofwhichwasfatal.Of15interimdeaths,autopsyordeathcertificateswereavailableforfourpatients,ninehadtheircausesofdeathrelatedbynextofkin,andtwowereunknown.Although95.4%ofnonspinalcordinjurypatientsreportedatleastsomeabilitytoambulate,only64.6%coulddosoadlibitum.Ofthosepatientsambulatingwithoutlimitation,28.6%reportedacompleteinabilitytorunanydistanceandanother23.8%couldrunlessthanoneblock.Follow-upforpatientscompletinginterviewswas105.3months+/-18.0months,andforpatientsundergoingimagingwas104.6months+/-16.4months.Interimdeathsoccurredat48.2months+/-26.0months.CONCLUSIONS:PPGFseemtobesafeandeffectiveat105monthsoffollow-up;mostpatientsreportsignificantlimitationsinactivitylevelatthissametimeframe.PPGFshouldbethefilterofchoiceforelderlypatientsinwhomthistimeperiodcanreasonablybeexpectedtocoverthepatient'sremaininglifeexpectancy.JTrauma.2009Sep;67(3):485-9

肿瘤病人发生VTE是正常人的７倍，高危险性主要来源于针对肿瘤的治疗，如：化疗、激素疗法、血管栓塞疗法以及肿瘤自身的特殊代谢等．约有20%的病人同时伴有VTE，而15%的肿瘤病人在治疗期间会发生VTE.

滤器与肿瘤滤器应用的现代观GeertsWH,BergqvistD,PineoGF,etal.Preventionofvenousthromboembolism.AmericanCollegeofChestPhysiciansEvidence-BasedClinicalPracticeGuidelines(8thedition).Chest2008;133(suppl):381S–453S.AgnelliG,BolisG,CapussottiL,etal.Aclinicaloutcome-basedprospectivestudyonvenousthromboembolismaftercancesurgery:AnnSurg2006;243:89–95.HeitJA,SilversteinMD,MohrDN,etal.Riskfactorsfordeepveinthrombosisandpulmonaryembolism:apopulation-basedcase–controlstudy.ArchInternMed2000;160:809–815.BlomJW,DoggenCJ,OsantoS,etal.Malignancies,prothromboticmutations,andtheriskofvenousthrombosis.JAMA2005;293:715–722.HillenHF.Thrombosisincancerpatients.AnnOncol2000;11(3):273–276.

滤器与肿瘤滤器应用的现代观美国哈佛大学医学院26年1753例滤器植入回顾：伴随疾病肿瘤52.8%.法国血栓研究协作组（PREPIC）报告滤器组(200例)中:肿瘤病人为16%.国际肺动脉栓塞协作中心（ICOPER）登记的2284例non-massivePE病人中肿瘤约为22%。Athanasoulis,etal:InferiorVenaCavalFilters:Reviewofa26-yearSingle-CenterClinicalExperience.Radiology2000;216(1):54-66ThePREPICStudyGroup:Eight—YearFollow-UpofPatientsWithPermanentVenaCaveFiltersinthePreventionofPulmonarEmbolism.Circulation.2005;112:416422.KucherN,etal:Massivepulmonaryembolism.Circulation.2006Jan31;113(4):577-82。PavicM

etal：Venousthromboembolismandcancer.

RevMedInterne.2006Apr;27(4):313-322.

DavidB.Marmor,GenoJ.Merli,DavidJ.Whellan,etal.RelationshipofInferiorVenaCavaFilterUsageinPost-SurgicalPatientsbyVariousSurgicalandMedicalSubspecialists.AmJCardiol2008;102:226–230滤器应用的现代观60%接受了滤器10年间722例DistributionofDVTaccordingtospecialty.Generalsurgery=40.3%,Orthopaedics=20.1%,Obstetricsandgynecology=18.5%,Neurosurgery=14.2%,Others=9.5%.A.D.Lee,E