看不見的威脅沉寂中的殺手Invisiblethreaten,silentmurderTongjiHospitalofTongjiUniversityWangLe-min同濟(jì)大學(xué)附屬同濟(jì)醫(yī)院王樂民DeepVeinThrombosis(DVT)

Pulmonaryembolism(PE)肺栓塞Character：特點(diǎn)

concealment

隱蔽性

highmorbidity:

高發(fā)病率

incidenceofDVTinDept.ofsurgeryandinternalmedicineis56％

fataloutcome

常常致命深靜脈血栓形成DVTThrombosis血栓形成Extend血栓延伸DVT深靜脈血栓栓塞Defluxion脫落Ambulation遷移PE肺栓塞Death死亡EtiologyofHeritageThrombosis

遺傳性易栓癥的病因2、Deficitoffibrolysis纖溶缺陷異常纖維蛋白原血癥纖溶酶原缺陷（PLG）T－PA缺陷PAI－1過多TAFI過多因子XⅠⅠ缺陷（FXⅠⅠ）4、Hyperfunctionofbloodclotting

凝血功能亢進(jìn)因子VⅠⅠⅠ增多因子ⅠX增多因子XⅠ增多因子VⅠⅠ增多DVT：importance問題的重要性

DVT

2000000PostthrombsyndromePE600000

Death60000

PAH30000

Low：age＜40，smallOperation，nootherriskfactorsHierarchyofriskforVEinsurgicalpatients外科病人靜脈血栓危險(xiǎn)分層

（ACCP）Medium：age＞40，bigoperation，nootherriskfactorsHigh：age＞40，bigoperation，hasanotherriskfactor

（MI,tumor,hypercoagulabalestate）Veryhigh：age＞40，operationcombiningmultiriskfactors

（Cancer,stroke,serioustrauma,spinedamage……）Precautionforthrombbefore&duringoperation,andatleast5weeksafteroperation

DVT40%－80%

（proximumdeepvein15%－50%）mortalityofPE0.3－0.5％

Lackofprecautionforhighriskpatients高危病人未作預(yù)防IncidenceofPEinhospitalizedpatientsPE在醫(yī)院病人中的發(fā)生率age（years）Annualyincidence%PE：maincauseofdeathinUS

美國死亡的主要病種MortalityofEmbolismdiseasesishigherthansumofAIDS,,breastcancerandtrafficaccidentinUS

DiseaseAnnualmortalityPE＞200000AIDS13426BC（乳腺癌）40200Trafficaccident（高速公路災(zāi)難）41800unexplainedevent（意外事件）97835CAD459841PE：AutopsyresearchofAsia

亞洲尸體解剖研究

8publishedresearches:ChineseHK3Japan3Singapore1Tailand1（1958～1994）IncidenceoffatalPE：

ChineseHK4.7％Japan6.0％closetowesterncountries（4.0％～13.0％）PE：AutopsyresearchofAsia

亞洲尸體解剖研究PE：AutopsyresearchofAsia

亞洲尸體解剖研究

Incidenceoffatalandnon-fatalPEisclosetowesterncountriesIncidenceofPEinAsiancountriestendstobehigherProblemsinChina

國內(nèi)目前存在的問題（1）1、缺乏足夠的流行病學(xué)資料2、不同醫(yī)院、科室及醫(yī)生對血栓預(yù)防的認(rèn)識存在較大差異3、醫(yī)生依靠臨床經(jīng)驗(yàn)，遠(yuǎn)多于應(yīng)用以循癥醫(yī)學(xué)為依據(jù)的指南進(jìn)行工作Strategy對策（1）提高醫(yī)生和病人對于靜脈栓塞疾病的認(rèn)識

?更多的國內(nèi)流行病學(xué)資料

?繼續(xù)教育：靜脈栓塞疾病的危險(xiǎn)性、診斷方法和血栓預(yù)防指南

?危險(xiǎn)評估：使用更簡單的方法

?預(yù)防措施：對不同危險(xiǎn)分級的病人進(jìn)行療效－利益評估Strategy對策（2）?加強(qiáng)學(xué)科間聯(lián)系和交流，建立對靜脈栓塞疾病立體化的防治網(wǎng)絡(luò)－心內(nèi)科、血管外科、呼吸內(nèi)科、急診科、監(jiān)護(hù)中心、普通外科、骨科、腫瘤科、婦產(chǎn)科、泌尿外科、老年科…Strategy對策（3）?

充分發(fā)揮多學(xué)科專家的咨詢、指導(dǎo)作用?提出觀點(diǎn)比較明確、內(nèi)容比較具體、措施比較可行的早期識別和“預(yù)防指南”，供國內(nèi)廣大醫(yī)院與醫(yī)師參與使用PEManagementafterOperation

術(shù)后發(fā)生PE如何對應(yīng)

EtiologyofAcutePE急性肺栓塞發(fā)生機(jī)制與相關(guān)臟器

Shape形狀Concentrateandreflux集中回流否DegreeofPAclog阻塞肺A程度Clinicaltype臨床類型VE靜脈血栓

Indicationofinterventionaltherapy

介入性治療的適應(yīng)癥（1）seriousandacutePE（2）unstablehomodynamic（3）thrombolytictherapyfailortaboo（4）PCPStaboo（5）skilleddoctorsforcatheteroperationCategoryofinterventionaltherapy

介入性治療方法的種類Percutemcatheterthrombolysis

經(jīng)皮導(dǎo)管溶栓術(shù)

RUpulmonaryarteryshowedBFdefectunderPulmonaryarteriography肺動脈造影可見右肺中下葉動脈血流缺損ImagingofPulmonaryarteriographyduringthrombolysisbyUK用尿激酶溶栓期間肺動脈造影圖像BFofpulmonaryarteryshowedsmoothafterthrombolysis溶栓后，右肺中、下葉動脈血流暢通

Percutemthromb-suctionoperation

經(jīng)皮導(dǎo)管吸栓術(shù)

Beforeclotsuction血栓抽吸前Afterclotsuction血栓抽吸后Clotsuckedbycatheter導(dǎo)管吸出的血栓

Thromb-crashedoperationby

percutemcatheterandguidewire經(jīng)皮導(dǎo)管、導(dǎo)絲、球囊碎栓術(shù)

SelectiveopacificationforRUCAby7FPTCAguidecatheterRUpulmonaryarteryshowedBFdefect7F右冠PTCA導(dǎo)引導(dǎo)管選擇造影，右肺上動脈血流缺損Pulmonaryarteriographyby5FpigtailcatheterRUpulmonaryarteryshowedBFdefect5F豬尾導(dǎo)管肺動脈造影，可見右肺上動脈，血流缺損Imagingafterthromb-crashedOPby7Fguidecatheterandwirecontrastagentcouldpassbypartly,Floatingclotappearedclearly（arrowmarked）7F導(dǎo)引導(dǎo)管和泥鰍導(dǎo)絲碎血栓后造影，造影劑可部分通過，浮游血栓清晰可見（箭頭所指）Imageafterthromb-smashedoperationfloatingclotinRUArteryh