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1、下肢深靜脈血栓形成Deepveinthrombosisinthelowerextremity蘇州大學(xué)附屬瑞華骨科醫(yī)院脊柱下肢外科劉德俊Introduction下肢深靜脈血栓形成DeepveinthrombosisDVT發(fā)生率32-88%(無預(yù)防措施)15-30%(有預(yù)防措施)治療效果不夠理想常遺留下肢深靜脈阻塞或靜脈瓣膜功能不全嚴(yán)重者可發(fā)生肺動脈栓塞(PulmonaryembolismPE)PathologyofDVTVirchow三聯(lián)定律(virchowtriad,1946~1956)靜脈血流滯緩靜脈壁損傷血液高凝狀態(tài)Patholog
2、yofDVTClassificationofDVT(1)周圍型?。?)中央型 (3)混合型ClinicalmanifestationofDVT腫脹明顯,股青腫小腿部疼痛或脹感,腓腸肌有壓痛Homans征陽性淺靜脈擴(kuò)張發(fā)燒,但一般不超過38.5℃RiskFactorsforDVT以前有DVT史或家族史長時間制動如:長期臥床,坐飛機(jī),火車等近期手術(shù),尤其下肢骨科手術(shù)年齡大于40激素治療或口服避孕藥懷孕或產(chǎn)后惡性腫瘤慢性肺病肥胖凝血異常手術(shù)時間過長(>4h)DiagnosisofDVT高危因素臨床表現(xiàn)輔助檢查彩色DopplarMRI靜脈造影(
3、金標(biāo)準(zhǔn))UltrasonographyforDVTVenographyforDVTPreventionforDVT機(jī)械預(yù)防方法早期活動、抬高床腳,盡早下床活動多作深呼吸及咳嗽動作下肢按摩穿長腿彈力襪(elasticstocking)靜脈脈沖泵(venousimpulsepump)充氣褲(pneumaticcompressiontrouses)PreventionforDVTDesignedtooffergraduatedcompressionofthefoot,ankleandcalfmuscle.Helpsreduceswelling
4、,achingandtheriskofDeepVeinThrombosis-DVT.CombinesthecomfortofCottonwithahighpercentageofLycratoproducegraduatedcompression.Looksandfeelslikeaneverydaysock.Areavailablein3sizesforaperfectfit.flightsocksPreventionforDVTPreventionforDVT藥物預(yù)防口服華法令:起效慢阿斯匹林與低右(Dextran):作用不確實(shí)普通
5、肝素(UFHs):副作用大低分子量肝素(LMWHs)作用確實(shí),廣泛應(yīng)用?a拮抗劑:fondaparinux作用確實(shí),未廣泛應(yīng)用DVTpreventionafterjointarthroplastyComplicationRatesbyAgentAuthorsAgentNBleedingComplications(%)HeitandBerkowiteetal.[29]Warfarin2794.4Ardeparin2777.9HullandRaskob[30]Warfarin3242.4Logiparin3174.4LeClercandGe
6、ntetal.[10]Warfarin3341.8Enoxaparin8422.4*LiebermanandSungetal.[23]Warfarin8152.5?PaiementandWessingeretal.[31]Warfarin2684.0AuthorsAgentNBleedingComplications(%)HeitandBerkowiteetal.Warfarin2794.4Ardeparin2777.9HullandRaskobWarfarin3242.4Logiparin3174.4LeClercandGenteta
7、l.Warfarin3341.8Enoxaparin8422.4*LiebermanandSungetal.Warfarin8152.5?PaiementandWessingeretal.[Warfarin2684.0PreventionforDVTPreventionforDVT(LMWHs)enoxaparin,fondaparinux,ximelagatran開始時間:術(shù)前一天(歐洲)術(shù)后12-24小時(北美)持續(xù)時間:7d-21d檢測凝血指標(biāo)減少DVT發(fā)生率40-70%PreventionforDVTOREF一致認(rèn)為Orthop
8、edicresearcheducationfoundation2002,CA,USADVT要進(jìn)行預(yù)防PreventionforDVTOREFOralwarfarin(18.7%)Aspirin(18.2%)