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1、如何正确把握下腔静脉滤器置放如何正确把握下腔静脉滤器置放术的指征术的指征 静脉血栓栓塞症静脉血栓栓塞症静脉血栓栓塞症静脉血栓栓塞症(venousthromboembolism,VTE)(venousthromboembolism,VTE)深静脉血栓形成深静脉血栓形成深静脉血栓形成深静脉血栓形成(deepvenousthrombosis,DVT)(deepvenousthrombosis,DVT)肺栓塞症肺栓塞症肺栓塞症肺栓塞症(pulmonarythromboembolism,PE)(pulmonarythromboembolism,PE)VTE=DVT+PEVTE=DVT+PE DVTDVT
2、与与与与PEPE在发病上的一致性在发病上的一致性在发病上的一致性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同一疾病在不同阶段、不同部位的两种表现形式同一疾病在不同阶段、不同部位的两种表现形式同一疾病在不同阶段、不同部位的两种表现形式Circulation.2005;112:416-422.各种类型滤器产生各种类型滤器产生永久型滤器永久型滤器pemanent临时型临时型Temporary可选择的可选择的optional 可回收的可回收的可回收的可回收的 RetrievableRetrievable在体内滞留最长在体内滞留最长在体内滞留最长在体内滞留最长可达可达可达可达400400
3、天以上天以上天以上天以上可转换的可转换的可转换的可转换的ConvertibleConvertibleHannoHoppe.OptionalVenaCavaFilters.DtschArzteblInt2009;106(24):395402HannoHoppe.OptionalVenaCavaFilters.DtschArzteblInt2009;106(24):395402JVascSurg2008;47:157-65JVascSurg2008;47:157-65JVascIntervRadiol2008;19:393399JVascIntervRadiol2008;19:393399JVas
4、cIntervRadiol2008;19:393399JVascIntervRadiol2008;19:393399JVascIntervRadiol2008;19:393399JVascIntervRadiol2008;19:393399在美国滤器的应用量每年都在递增，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而超过一半为预防性的临时滤器在没有在没有在没有在没有 DVTorPEDVTorPE病人，但有抗凝禁忌症病例中，应病人，但有抗凝禁忌症病例中，应病人，但有抗凝禁忌症病例中，应病人，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用腔静脉滤器被称为预防性滤器用腔静脉滤
5、器被称为预防性滤器用腔静脉滤器被称为预防性滤器在明确诊断在明确诊断在明确诊断在明确诊断 VTEVTE或或或或 PEorDVTPEorDVT病人而不能耐受抗凝病人而不能耐受抗凝病人而不能耐受抗凝病人而不能耐受抗凝的病例中，腔静脉滤器应用被称为的病例中，腔静脉滤器应用被称为的病例中，腔静脉滤器应用被称为的病例中，腔静脉滤器应用被称为治疗性滤器治疗性滤器治疗性滤器治疗性滤器近年来，在我们把注意都投在大动脉疾病治疗同时，近年来，在我们把注意都投在大动脉疾病治疗同时，近年来，在我们把注意都投在大动脉疾病治疗同时，近年来，在我们把注意都投在大动脉疾病治疗同时，DVTDVT的治疗却有了重大突破的治疗却有了重
6、大突破的治疗却有了重大突破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，血管成型介入下血栓部位置管溶栓与球囊扩张，血管成型介入下血栓部位置管溶栓与球囊扩张，血管成型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而在临时滤器的保护下进行的溶栓更加安全而在临时滤器的保护下进行的溶栓更加安全而在临时滤器的保护下进行的溶栓更加安全Catheter-directedCatheter-directedthrombolysis(CDTthrombolysis(CDT)6)6月后与单月后与单月后与单月后与单纯性抗凝相比，血管通畅率是纯性抗凝相比，血管通畅率是纯性抗凝相
7、比，血管通畅率是纯性抗凝相比，血管通畅率是72%72%vsvs12%,12%,P0.001P0.001，静脉瓣功能正常率为，静脉瓣功能正常率为，静脉瓣功能正常率为，静脉瓣功能正常率为89%89%vsvs59%,59%,P0.04.P0.04.PTSPTS明显减少明显减少明显减少明显减少.ElsharawyM,ElzayatE.EarlyresultsofthrombolysisvsElsharawyM,ElzayatE.Earlyresultsofthrombolysisvsanticoagulationinanticoagulationiniliofemoralvenousthrombosi
8、s.Arandomisediliofemoralvenousthrombosis.Arandomisedclinicaltrial.EurJVascclinicaltrial.EurJVascEndovascSurg2002.24:209214EndovascSurg2002.24:209214KaufmanJA,KinneyKaufmanJA,KinneyTB,StreiffMBetal.:TB,StreiffMBetal.:GuidelinesfortheGuidelinesfortheuseofretrievableuseofretrievableandconvertiblevenaan
9、dconvertiblevenacavafilters:reportcavafilters:reportfromtheSocietyoffromtheSocietyofInterventionalInterventionalRadiologyRadiologymultidisciplinarymultidisciplinaryconsensusconsensusconference.conference.JVascIntervRadiolJVascIntervRadiol2006;17:44959.2006;17:44959.CuschieriJ,FreemanB,OKeefeG,Harbre
10、chtBG,BankeyP,JohnsonJL,etal.InflammationCuschieriJ,FreemanB,OKeefeG,HarbrechtBG,BankeyP,JohnsonJL,etal.Inflammationandthehostresponsetoinjuryalarge-scalecollaborativeproject:patient-orientedresearchandthehostresponsetoinjuryalarge-scalecollaborativeproject:patient-orientedresearchcorestandardoperat
11、ingprocedureforclinicalcareX.GuidelinesforvenousthromboembolismcorestandardoperatingprocedureforclinicalcareX.Guidelinesforvenousthromboembolismprophylaxisinthetraumapatient.JTrauma2008;65:944-50prophylaxisinthetraumapatient.JTrauma2008;65:944-50.创伤病人在住院期间创伤病人在住院期间创伤病人在住院期间创伤病人在住院期间VTEVTE发生率约为发生率约为发
12、生率约为发生率约为58%.58%.尽管机械性尽管机械性尽管机械性尽管机械性或药物的作用是理想的预防和治疗方法，但不是所有的或药物的作用是理想的预防和治疗方法，但不是所有的或药物的作用是理想的预防和治疗方法，但不是所有的或药物的作用是理想的预防和治疗方法，但不是所有的病人适合接受抗凝治疗另外由于担心出血和部分病人病人适合接受抗凝治疗另外由于担心出血和部分病人病人适合接受抗凝治疗另外由于担心出血和部分病人病人适合接受抗凝治疗另外由于担心出血和部分病人受到还需要进一步手术的约束，滤器常被认为是必要的受到还需要进一步手术的约束，滤器常被认为是必要的受到还需要进一步手术的约束，滤器常被认为是必要的受到还
13、需要进一步手术的约束，滤器常被认为是必要的 脊柱、脑和复合性骨外伤病人中，为了预防脊柱、脑和复合性骨外伤病人中，为了预防脊柱、脑和复合性骨外伤病人中，为了预防脊柱、脑和复合性骨外伤病人中，为了预防DVTorPE,DVTorPE,一些病人在围手术期选择抗凝治疗同时也选择了滤器一些病人在围手术期选择抗凝治疗同时也选择了滤器一些病人在围手术期选择抗凝治疗同时也选择了滤器一些病人在围手术期选择抗凝治疗同时也选择了滤器 滤器通常在病人入院后滤器通常在病人入院后滤器通常在病人入院后滤器通常在病人入院后24h-48h24h-48h内被置入，因为研究表内被置入，因为研究表内被置入，因为研究表内被置入，因为研究
14、表明：明：明：明：20%-25%20%-25%的的的的PEPE发生在病人入院第天天间发生在病人入院第天天间发生在病人入院第天天间发生在病人入院第天天间.Long-termfollow-upoftraumapatientswithpermanentprophylacticvenacavafilters.BACKGROUND:AlthoughpermanentprophylacticGreenfieldfilters(PPGF)areeffective,theiruseinyoung traumapatientswhomayeventuallyreturntoactivelifestylesisc
15、ontroversialduetoconcernsaboutthetraumapatientswhomayeventuallyreturntoactivelifestylesiscontroversialduetoconcernsaboutthesafetyofthedevicesoveralifetime.Thisdescriptivestudywasundertakentoprovidefollow-uponthelong-safetyofthedevicesoveralifetime.Thisdescriptivestudywasundertakentoprovidefollow-upo
16、nthelong-termsafetyanddurabilityofPPGF.METHODS:termsafetyanddurabilityofPPGF.METHODS:AllpatientsreceivingaPPGFbetweenApril1,1992andAllpatientsreceivingaPPGFbetweenApril1,1992andMarch1,2001weresoughtforfollow-up.March1,2001weresoughtforfollow-up.Contactedpatientswereinterviewedregardingknownfilter-re
17、latedContactedpatientswereinterviewedregardingknownfilter-relatedcomplications,venousthromboembolicevents,andactivitylevelssincethetimeofdischargefromthecomplications,venousthromboembolicevents,andactivitylevelssincethetimeofdischargefromthehospital.Patientswerealsoofferedaphysicalexaminationfocusin
18、gonvenousthromboembolicsequelae,ahospital.Patientswerealsoofferedaphysicalexaminationfocusingonvenousthromboembolicsequelae,aplainfilmoftheabdomen(KUB)toassessfilterintegrityandlocation,andanultrasoundtoassesscavalplainfilmoftheabdomen(KUB)toassessfilterintegrityandlocation,andanultrasoundtoassessca
19、valpatency.Astheoriginalleveloffilterplacementwasusuallynotknown,migrationwasdefinedasafilterpatency.Astheoriginalleveloffilterplacementwasusuallynotknown,migrationwasdefinedasafilterabovethefirstlumbarvertebra(L1).RESULTS:abovethefirstlumbarvertebra(L1).RESULTS:Theeligiblecohortconsistedof188patien
20、tsTheeligiblecohortconsistedof188patients.Ninetywere.Ninetywereunabletobelocated(47.8%),onerefusedenrollment(0.5%),and97patientsornextofkinagreedtobeunabletobelocated(47.8%),onerefusedenrollment(0.5%),and97patientsornextofkinagreedtobeinterviewedbyphone(51.6%)ofwhom69returnedforevaluation(36.7%).Nof
21、ilter-relatedcomplicationsinterviewedbyphone(51.6%)ofwhom69returnedforevaluation(36.7%).Nofilter-relatedcomplicationswereself-reported.KUBswereperformedin68patients;onefilterstrutfracturewasfound(1.5%),whereaswereself-reported.KUBswereperformedin68patients;onefilterstrutfracturewasfound(1.5%),wherea
22、snofiltermigrationsaboveL1werenoted.Noinstancesofcavalthrombosiswerefoundin55ultrasounds.nofiltermigrationsaboveL1werenoted.Noinstancesofcavalthrombosiswerefoundin55ultrasounds.Twopatientssufferedinterimpulmonaryemboli(2.1%),oneofwhichwasfatal.Of15interimdeaths,autopsyTwopatientssufferedinterimpulmo
23、naryemboli(2.1%),oneofwhichwasfatal.Of15interimdeaths,autopsyordeathcertificateswereavailableforfourpatients,ninehadtheircausesofdeathrelatedbynextofkin,ordeathcertificateswereavailableforfourpatients,ninehadtheircausesofdeathrelatedbynextofkin,andtwowereunknown.Although95.4%ofnonspinalcordinjurypat
24、ientsreportedatleastsomeabilitytoandtwowereunknown.Although95.4%ofnonspinalcordinjurypatientsreportedatleastsomeabilitytoambulate,only64.6%coulddosoadlibitum.Ofthosepatientsambulatingwithoutlimitation,28.6%reportedambulate,only64.6%coulddosoadlibitum.Ofthosepatientsambulatingwithoutlimitation,28.6%r
25、eportedacompleteinabilitytorunanydistanceandanother23.8%couldrunlessthanoneblock.Follow-upforacompleteinabilitytorunanydistanceandanother23.8%couldrunlessthanoneblock.Follow-upforpatientscompletinginterviewswas105.3months+/-18.0months,andforpatientsundergoingimagingwaspatientscompletinginterviewswas
26、105.3months+/-18.0months,andforpatientsundergoingimagingwas104.6months+/-16.4months.Interimdeathsoccurredat48.2months+/-26.0months.CONCLUSIONS:104.6months+/-16.4months.Interimdeathsoccurredat48.2months+/-26.0months.CONCLUSIONS:PPGFseemtobesafeandeffectiveat105monthsoffollow-up;mostpatientsreportsign
27、ificantlimitationsPPGFseemtobesafeandeffectiveat105monthsoffollow-up;mostpatientsreportsignificantlimitationsinactivitylevelatthissametimeframe.PPGFshouldbethefilterofchoiceforelderlypatientsinwhomthisinactivitylevelatthissametimeframe.PPGFshouldbethefilterofchoiceforelderlypatientsinwhomthistimeper
28、iodcanreasonablybeexpectedtocoverthepatientsremaininglifeexpectancy.timeperiodcanreasonablybeexpectedtocoverthepatientsremaininglifeexpectancy.J Trauma.2009 Sep;67(3):485-9肿瘤病人发生肿瘤病人发生肿瘤病人发生肿瘤病人发生VTEVTE是正常人的倍，高危险是正常人的倍，高危险是正常人的倍，高危险是正常人的倍，高危险性主要来源于针对肿瘤的治疗，如：化疗、性主要来源于针对肿瘤的治疗，如：化疗、性主要来源于针对肿瘤的治疗，如：化疗、性
29、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激素疗法、血管栓塞疗法以及肿瘤自身的特激素疗法、血管栓塞疗法以及肿瘤自身的特激素疗法、血管栓塞疗法以及肿瘤自身的特殊代谢等约有殊代谢等约有殊代谢等约有殊代谢等约有20%20%的病人同时伴有的病人同时伴有的病人同时伴有的病人同时伴有VTEVTE，而而而而15%15%的肿瘤病人在治疗期间会发生的肿瘤病人在治疗期间会发生的肿瘤病人在治疗期间会发生的肿瘤病人在治疗期间会发生VTE.VTE.GeertsWH,BergqvistD,PineoGF,etal.Preventionofvenousthromboembolism.Amer
30、icanCollegeofChestGeertsWH,BergqvistD,PineoGF,etal.Preventionofvenousthromboembolism.AmericanCollegeofChestPhysiciansEvidence-BasedClinicalPracticeGuidelines(8thedition).Chest2008;133(suppl):381S453S.PhysiciansEvidence-BasedClinicalPracticeGuidelines(8thedition).Chest2008;133(suppl):381S453S.Agnelli
31、G,BolisG,CapussottiL,etal.Aclinicaloutcome-basedprospectivestudyonvenousAgnelliG,BolisG,CapussottiL,etal.Aclinicaloutcome-basedprospectivestudyonvenousthromboembolismaftercancesurgery:AnnSurg2006;243:8995.thromboembolismaftercancesurgery:AnnSurg2006;243:8995.HeitJA,SilversteinMD,MohrDN,etal.Riskfact
32、orsfordeepveinthrombosisandpulmonaryembolism:aHeitJA,SilversteinMD,MohrDN,etal.Riskfactorsfordeepveinthrombosisandpulmonaryembolism:apopulation-basedcasecontrolstudy.ArchInternMed2000;160:809815.population-basedcasecontrolstudy.ArchInternMed2000;160:809815.BlomJW,DoggenCJ,OsantoS,etal.Malignancies,p
33、rothromboticmutations,andtheriskofvenousBlomJW,DoggenCJ,OsantoS,etal.Malignancies,prothromboticmutations,andtheriskofvenousthrombosis.JAMA2005;293:715722.thrombosis.JAMA2005;293:715722.HillenHF.Thrombosisincancerpatients.AnnOncol2000;11(3):273276.HillenHF.Thrombosisincancerpatients.AnnOncol2000;11(3
34、):273276.美国哈佛大学医学院美国哈佛大学医学院美国哈佛大学医学院美国哈佛大学医学院2626年年年年17531753例滤器植入回顾：例滤器植入回顾：例滤器植入回顾：例滤器植入回顾：伴随疾病肿瘤伴随疾病肿瘤伴随疾病肿瘤伴随疾病肿瘤52.8%.52.8%.法国血栓研究协作组（法国血栓研究协作组（法国血栓研究协作组（法国血栓研究协作组（PREPICPREPIC）报告滤器组报告滤器组报告滤器组报告滤器组(200(200例例例例)中中中中:肿瘤病人为肿瘤病人为肿瘤病人为肿瘤病人为16%.16%.国际肺动脉栓塞协作中心（国际肺动脉栓塞协作中心（国际肺动脉栓塞协作中心（国际肺动脉栓塞协作中心（ICOP
35、ERICOPER）登记的）登记的）登记的）登记的22842284例例例例non-massivePEnon-massivePE病人中肿瘤约为病人中肿瘤约为病人中肿瘤约为病人中肿瘤约为22%22%。Athanasoulis,etal:InferiorVenaCavalFilters:Reviewofa26-yearSingle-CenterClinicalAthanasoulis,etal:InferiorVenaCavalFilters:Reviewofa26-yearSingle-CenterClinicalExperience.Radiology2000;216(1):54-66Experi
36、ence.Radiology2000;216(1):54-66 ThePREPICStudyGroup:EightYearFollow-UpofPatientsWithPermanentVenaCaveFiltersinThePREPICStudyGroup:EightYearFollow-UpofPatientsWithPermanentVenaCaveFiltersinthePreventionofPulmonarEmbolism.Circulation.2005;112:416422.thePreventionofPulmonarEmbolism.Circulation.2005;112
37、:416422.KucherN,etal:Massivepulmonaryembolism.Circulation.2006Jan31;113(4):577-82KucherN,etal:Massivepulmonaryembolism.Circulation.2006Jan31;113(4):577-82。PavicMPavicM et alet al：Venousthromboembolismandcancer.RevMedInterne.Venousthromboembolismandcancer.RevMedInterne.2006Apr;27(4):313-322.2006Apr;2
38、7(4):313-322.DavidB.Marmor,GenoJ.Merli,DavidJ.Whellan,etal.RelationshipofDavidB.Marmor,GenoJ.Merli,DavidJ.Whellan,etal.RelationshipofInferiorVenaCavaFilterUsageinPost-SurgicalPatientsbyVariousInferiorVenaCavaFilterUsageinPost-SurgicalPatientsbyVariousSurgicalandMedicalSubspecialists.AmJCardiol2008;1
39、02:226230SurgicalandMedicalSubspecialists.AmJCardiol2008;102:22623060%60%接受了滤器接受了滤器接受了滤器接受了滤器 A.D.Lee,E.Stephen,S.Agarwal,P.Premkumar.VenousThrombo-A.D.Lee,E.Stephen,S.Agarwal,P.Premkumar.VenousThrombo-embolisminIndia.EurJVascEndovascSurg200937,482embolisminIndia.EurJVascEndovascSurg200937,482485.48
40、5.JamesAH,JamisonMG,BrancazioLR,MyersER.Venousthromboembolismduringpregnancyandthepostpartumperiod:incidence,riskfactors,andmortality.AmJObstetGynecol2006;194:13111315.BJOG2008;115:785788BJOG2008;115:785788HannoHoppe.OptionalVenaCavaFilters.DtschArzteblInt2009;106(24):395402HannoHoppe.OptionalVenaCa
41、vaFilters.DtschArzteblInt2009;106(24):395402 JohnA.Kaufman,etal.DevelopmentofaResearchAgendaforJohnA.Kaufman,etal.DevelopmentofaResearchAgendaforInferiorVenaCavaFilters:ProceedingsfromaMultidisciplinaryInferiorVenaCavaFilters:ProceedingsfromaMultidisciplinaryResearchConsensusPanel.JVascIntervRadiol2
42、009;20:697707.ResearchConsensusPanel.JVascIntervRadiol2009;20:697707.JohnA.Kaufman,etal.DevelopmentofaResearchAgendaforJohnA.Kaufman,etal.DevelopmentofaResearchAgendaforInferiorVenaCavaFilters:ProceedingsfromaMultidisciplinaryInferiorVenaCavaFilters:ProceedingsfromaMultidisciplinaryResearchConsensus
43、Panel.JVascIntervRadiol2009;20:697707.ResearchConsensusPanel.JVascIntervRadiol2009;20:697707.在临床上不推荐常规使用滤器在临床上不推荐常规使用滤器在临床上不推荐常规使用滤器在临床上不推荐常规使用滤器提倡科学与合理的选择适应症提倡科学与合理的选择适应症提倡科学与合理的选择适应症提倡科学与合理的选择适应症期待更优秀的临时滤器出现（体内停留时间长、容期待更优秀的临时滤器出现（体内停留时间长、容期待更优秀的临时滤器出现（体内停留时间长、容期待更优秀的临时滤器出现（体内停留时间长、容易取出）易取出）易取出）易取出）伴随理想的临时滤器出现，应用指征由治疗性转为伴随理想的临时滤器出现，应用指征由治疗性转为伴随理想的临时滤器出现，应用指征由治疗性转为伴随理想的临时滤器出现，应用指征由治疗性转为预防性预防性预防性预防性永久性滤器可能在不久的将来将完成历史使命永久性滤器可能在不久的将来将完成历史使命永久性滤器可能在不久的将来将完成历史使命永久性滤器可能在不久的将来将完成历史使命重视滤器后的抗凝治疗重视滤器后的抗凝治疗重视滤器后的抗凝治疗重视滤器后的抗凝治疗