Deep-vein-thrombosis深静脉血栓

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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.Theembolus could traveltoanarteryin thelungs andblockblood flow.Thisconditioniscalledpulmonaryembolism,orPE.第四页，共四十六页。EpidemiologyDeep vein thrombosis*DiagnosesofDVTandPEarenotmutuallyexclusive;anestimated78,511patientsreceiveddiagnosesofbothDVTandPE.VTEestimatesincl

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

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

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

7、seprotein1.Hypoxia-induciblefactor-1andearly-growth-responseprotein1contributetomonocyteassociationwithendothelialproteins,suchasP-selectin,promptingmonocytestoreleasetissuefactor-filledmicrovesicles,whichpresumablybeginclottingafterbindingtotheendothelialsurface.9Deep vein thrombosis第九页，共四十六页。Cause

8、spIndependentRiskFactorsforDVTAgeisanindependentriskfactorforthromboticdisease.Themajorityofvenousthrombioccurineitherthesuperficialordeepveinsoftheleg.ADVTisstationaryclottingbloodadheredtothedeepveinofthepelvisoranextremityandusuallyoccursinthecalforthigh.VTEdenotesanobstructionarisingfromtheforma

9、tionofaclotinthevenouscirculationcarriedbythebloodfromthesiteoforigintopluganothervessel.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：PainSwellingWarmthRednessordiscolorationDistentionofsurfaceve

10、insDeep 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,suchasce

11、llulitis,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,aclinicalassessmentofprobabilitycanbeusefultodeterminewhic

12、hteststoperform.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,butwhenconsid

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

14、imerresultcanruleoutadiagnosis.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,whichexclu

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

16、moderateorhighsensitivityorcompressionultrasoundoftheproximalveins.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:

17、asensitiveandspecifictoolfortheassessmentofpatientspresentingwithsymptomssuggestiveoflowerextremityDVT.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 vei

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

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

20、isofDVTClinicalpredictionrulesshouldbeusedtoestimatethepretestprobabilityofDVT.InselectedpatientswithalowpretestprobabilityofDVTorPE,anegativehigh-sensitivityD-dimertestindicatesalowlikelihoodofVTE.UltrasoundisrecommendedforpatientswithintermediatetohighpretestprobabilityofDVTinthelegs.Patientswithi

21、ntermediateorhighpretestprobabilityofPErequireadditionaldiagnosticimagingstudies.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,anticoagulationshouldbestartedimmediate

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

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

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

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

26、treatmentforaminimumof5daysanduntiltheinternationalnormalizedratioINRisatleast2.0for24hours).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。TreatmentpMedica

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

28、mentpMedicalManagement:Surgical/MechanicalinterventionPulmonaryEmbolectomyAccordingtoACCPguidelines,pulmonaryembolectomyfortheinitialtreatmentofPEisreservedforpatientswithmassivePE(documentedangiographicallyifpossible),shockdespiteheparinandresuscitationefforts,andfailureofthrombolytictherapyoracont

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

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

31、nghypercoagulablestatessuchastheantiphospholipidsyndrome,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。Preven

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

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

34、cquiredDVTis10%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

35、.pDdimerisanexcellenttesttoexcludeVTE.pDuplexultrasonographyisthenoninvasivetestofchoiceforthediagnosisofDVT.Deep vein thrombosis第四十二页，共四十六页。PreventionpComputedtomographicpulmonaryangiographyhasreplacedtheventilationperfusionscanfordiagnosingPE.pRiskstratificationisthekeytomanagementofpatientswithVT

36、E.pIndefiniteanticoagulationshouldbeconsideredforpatientswithanidiopathicorunprovokedVTE.pAppropriateprophylaxisremainsunderused.Deep vein thrombosis第四十三页，共四十六页。ReferencesDeep vein thrombosispPubmed:/ncbi.nlm.nih.gov/pubmed/pWikipedia:/en.wikipedia.org/wiki/Main_PagepGoogle:/google.hk/pTheClevelandClinic:/clevelandclinicmeded/第四十四页，共四十六页。Thank You!XiangYuChengxiangtanmail2.sysu.edu第四十五页，共四十六页。内容总结Deepveinthrombosis。Low-Molecular-Weight-Heparin。ThankYou。xiangtanmail2.sysu.edu第四十六页，共四十六页。