【摘要】：目的探討下肢深靜脈血栓形成并發(fā)肺動脈栓塞的診斷和治療。 方法回顧性分析我院血管外科2011.01—2012.12診治的45例下肢DVT（49條肢體）并發(fā)PTE患者的臨床資料。全組病例均由下肢深靜脈彩色多普勒超聲或深靜脈造影明確下肢DVT診斷，經(jīng)肺動脈CT血管造影明確PTE診斷，確診45例。其中經(jīng)抗凝+乆靜脈置管溶栓治療29例（30條肢體），抗凝+系統(tǒng)溶栓治療6例（8條肢體）,單純抗凝治療10例（11條肢體）。 結(jié)果本組資料中，男性21例，女性24例，年齡25-83歲，平均59.71±14.16歲，其中以40歲以上為主，占93.3%。有97.8%患者存在著致病的危險因素，其中以左髂靜脈壓迫綜合癥、外科手術(shù)、創(chuàng)傷為主要致病因素。PTE的主要癥狀表現(xiàn)為咳嗽、呼吸困難、胸悶、發(fā)熱，而具有“肺梗塞三聯(lián)征”較少，占8.8%。CTPA表現(xiàn)為肺動脈血管內(nèi)不同程度的造影缺損，以雙側(cè)肺動脈栓塞多見，右側(cè)多于左側(cè)。右下肢DVT患者并發(fā)PTE的發(fā)生率為87.5%，高于左下肢的39.1%。PTE治療方面，單純抗凝組治療的臨床有效率為80.0%，溶栓治療組總的臨床有效率為94.3%，兩者相比無統(tǒng)計(jì)學(xué)差異。經(jīng)乆靜脈導(dǎo)管溶栓治療DVT，在患肢消腫率、靜脈平均通暢率方面，近期療效較好。41例患者行下腔靜脈濾器置入術(shù)后，無再發(fā)嚴(yán)重肺動脈栓塞，攔截脫落血栓6例，9例留置下腔靜脈濾器的患者獲得隨訪，，隨訪時間3-28個月，平均（11.71±5.72）個月，無癥狀性PTE發(fā)生，復(fù)查造影未見濾器明顯移位、變形、穿孔等。 結(jié)論多種獲得性因素可導(dǎo)致VTE，其中以左髂靜脈壓迫綜合癥、外科手術(shù)、創(chuàng)傷為主要致病因素。下肢DVT栓子脫落導(dǎo)致PTE的發(fā)生率很高，特別是右下肢患者。PTE的臨床癥狀缺乏特異性，容易漏診，CTPA可以作為診斷PTE的首要檢查方法。只要及時診斷和治療，大多數(shù)VTE者經(jīng)抗凝、溶栓等治療達(dá)到較滿意的治療效果。導(dǎo)管溶栓治療下肢DVT近期療效效好，單純抗凝在PTE治療方面，可以得到很好的臨床療效，而對于大面積的PTE的患者，推薦使用溶栓治療。下腔靜脈濾器置入能有效防止脫落的血栓并再次加重PTE，降低病死率。
[Abstract]:Objective to investigate the diagnosis and treatment of deep venous thrombosis complicated with pulmonary embolism. Methods the clinical data of 45 patients with DVT (49 limbs) complicated with PTE in vascular surgery from January 2011 to December 2012 in our hospital were retrospectively analyzed. The diagnosis of lower extremity DVT was confirmed by deep vein color Doppler ultrasound or deep vein angiography in all patients, and 45 cases were diagnosed by pulmonary CT angiography (PTE). Among them, 29 cases (30 limbs) were treated with anticoagulant system, 6 cases (8 limbs) were treated with anticoagulant system, and 10 cases (11 limbs) were treated with anticoagulation alone. Results there were 21 males and 24 females, aged 25-83 years, with an average age of 59.71 鹵14.16 years. The majority of them were over 40 years old (93.3%). 97.8% of the patients had the risk factors of the disease. The main symptoms of PTE were cough, dyspnea, chest tightness, fever, and left iliac vein compression syndrome, surgery and trauma. However, there were less triple signs of pulmonary infarction, which showed different degree of angiography defect in pulmonary artery on 8.8%.CTPA. Bilateral pulmonary embolism was more common in the right side than in the left. The incidence of PTE in patients with DVT in right lower extremity was 87.5, which was higher than that in 39.1%.PTE treatment of left lower extremity. The clinical effective rate of anticoagulant group was 80.0.The total effective rate of thrombolytic treatment group was 94.3. There was no significant difference between the two groups. DVT was treated by thrombolytic therapy with intravascular catheter. In terms of deswelling rate and average patency rate of affected limbs, 41 patients received inferior vena cava filter implantation, and no serious pulmonary embolism occurred. Six cases of thrombus were intercepted and 9 cases were followed up with inferior vena cava filter. The follow-up time was 3-28 months (mean (11.71 鹵5.72) months). Asymptomatic PTE occurred. No obvious shift, deformation and perforation of filter were observed in the reexamination. Conclusion VTEs can be caused by various acquired factors, including left iliac vein compression syndrome, surgery and trauma. The incidence of PTE is very high due to the exfoliation of lower limb DVT embolus, especially the lack of specificity of clinical symptoms in patients with right lower extremity. As long as timely diagnosis and treatment, most patients with VTE through anticoagulant, thrombolysis and other treatment to achieve satisfactory results. Catheter thrombolytic therapy for lower extremity DVT is effective in the short term. Anticoagulant therapy alone can obtain a good clinical effect in the treatment of PTE. For patients with large area of PTE, thrombolytic therapy is recommended. Inferior vena cava filter (IVC) implantation can effectively prevent shedding thrombus and aggravate PTEs and reduce mortality.
【學(xué)位授予單位】：福建醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2013
【分類號】：R654.4;R563.5

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