如何正确把握下腔静脉滤器置放术的指征,北京世纪坛医院血管外科 张福先,VTE概念的理解,静脉血栓栓塞症 (venous thromboembolism, VTE) 深静脉血栓形成 (deep venous thrombosis, DVT) 肺栓塞症 (pulmonary thromboembolism, PE)VTE = DVT + PE DVT与PE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,在香港和新加坡， 住院病人中VTE 的发生率15.8 and 17.1 per 10 000，而美国为 130 per 10 000 .,Lee LH, Gu KQ, Heng D. Deep vein thrombosis is not rare in Asiaethe Singapore General Hospital experience. Ann Acad Med Singap 2002 Nov;31(6):761-764. Cheuk BL, Cheung GC, Cheng SW. Epidemiology of venous thromboembolism in a Chinese population. Br J Surg 2004 Apr;91(4):424-428. Stien PD, Beemath A, Olson RE. Trends in the incidence of pulmonary embolism and deep venous thrombosis in hospitalized patients. Am J Cardiol 2005 June;95(12):1525e6.,Incidence of VTE per 10,000 hospital admissions,A.D. Lee, E. Stephen, S. Agarwal,et al. Venous Thrombo-embolism in India. Eur J Vasc Endovasc Surg 2009, 37, 482485.,在美国每年约250 000 and 20 million cases of DVT需要治疗. 系统抗凝是TVE治疗的主要策略 然而约有15%的病人抗凝无效或为禁忌症对于这些病人滤器被考虑和选择,Goldhaber SZ,Tapson VF. For the DVT FREE steering Committtee.Aprospective registry of 5451 patients with ultrasound-confirmed deep vein thrombosis.Am J Cardiol,2004:93;259-262,Hanno Hoppe. Optional Vena Cava Filters. Dtsch Arztebl Int 2009; 106(24): 395402,Prevalence of pulmonary embolism (PE) and deep venous thrombosis (DVT) at autopsy,Paul D. Stein.Pulmonary Embolism. 3-4page, 2007 Published by Blackwell Publishing,Prevalence of pulmonary embolism at autopsy in general hospitals and communities,通过动物实验和对100例DVT患者与PE发生关系进行前瞻性研究，发现：DVT患者中PE发生率是45%。其中73%无任何临床症状，致死性PE为4%.,张福先.肢体深静脉血栓形成与肺栓塞发生关系的研究.中华结核和呼吸杂志2000年.9(23) ;531533,Phlgmatia alba dolens. In:Trousseau A.Clinique mdicale de iHtel-Dieu de Paris.3rd ed.Vol 3,Paris:J.B.Baillire.1868:652-695. Greenfield LJ, Michna BA.Twelve-year clinical experience with the Greenfield vena filter.Surgery 1988:104;706-712.,应用腔静脉障碍法预防PE是Trousseau 早在一百四十年前1868年提出的.,92年后既1960年第一个滤器产生,In 400 patients Follow up At 8 years,Circulation.2005;112:416-422,各种类型滤器产生,永久型滤器 pemanent临时型 Temporary可选择的optional,可回收的 Retrievable 在体内滞留最长 可达400天以上,可转换的Convertible,Stein 统计美国国家医疗中心数据库内50个洲、地区医院资料表明：全美滤器应用量在1979年为2000个，1999年为49000个，增长了20倍。 2003年报告：全世界滤器应用总量每年为140，000个。 2007年美国报道：用了213000个年增长率为16%.,Stein PD, et al：Twenty-one-year trends in the use of inferior vena cava filters. Arch Intern Med. 2004;164:15411545. Rogers FB, et al：Practice management guidelines for the prevention of venous thromboembolism in trauma patients: The EAST practice management guidelines workgroup. J Trauma. 2002;53:142164. Goldhaber SZ,Tapson VF. For the DVT FREE steering Committtee.Aprospective registry of 5451 patients with ultrasound-confirmed deep vein thrombosis.Am J Cardiol,2004:93;259-262,Hanno Hoppe. Optional Vena Cava Filters. Dtsch Arztebl Int 2009; 106(24): 395402,滤器应用的现代观,J Vasc Surg 2008;47:157-65,Indications for IVC filter placement,J Vasc Surg 2008;47:157-65,Indications for IVC filter placement in 1995 and 2005,J Vasc Interv Radiol 2008; 19:393399,Distribution of indications for IVC filter placement among all providers during 2005,J Vasc Interv Radiol 2008; 19:393399,J Vasc Interv Radiol 2008; 19:393399,永久滤器与临时滤器,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,Athanasoulis CA, Kaufman JA, Halpern EF, Waltman AC, Geller SC, Fan CM. Inferior vena cava filters: review of a 26-year single-center clinical experience. Radiology 2000; 216: 54 66. White RH, Zhou H, Kim J, Romano PS. A population-based study of the effectiveness of inferior vena cava filter use among patients with venous thromboembolism. Arch Intern Med 2000; 160: 20332041.Karmy-Jones R, Jurkovich GJ, Velmahos GC, et al. Practice patterns and outcomes of retrievable vena cava filters in trauma patients: an AAST multicenter study. J Trauma 2007; 62: 1724. Piano G, Ketteler ER, Prachand V, et al. Safety, feasibility, and outcome of retrievable vena cava filters in high-risk surgical patients. J Vasc Surg 2007; 45: 784788.,在没有 DVT or PE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 在明确诊断 VTE 或 PE or DVT 病人而不能耐受抗凝的病例中，腔静脉滤器应用被称为治疗性滤器,Sae Hee ,Benjamin R. Reynolds, Deidra H. Nicholas,et al. Institutional protocol improves retrievable inferior vena cava filter recovery rate. Surgery 2009;146:809-816.,近年来，在我们把注意都投在大动脉疾病治疗同时， DVT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 而在临时滤器的保护下进行的溶栓更加安全 Catheter-directed thrombolysis(CDT) 6月后与单纯性抗凝相比，血管通畅率是72 %vs 12%, P0.001，静脉瓣功能正常率为89 %vs 59%, P0.04. PTS明显减少.,滤器与DVT,滤器应用的现代观,Elsharawy M, Elzayat E .Early results of thrombolysis vs anticoagulation in iliofemoral venous thrombosis. A randomised clinical trial. Eur J Vasc Endovasc Surg 2002.24:209214,Kaufman JA, Kinney TB, Streiff MB et al.: Guidelines for the use of retrievable and convertible vena cava filters: report from the Society of Interventional Radiology multidisciplinary consensus conference. J Vasc Interv Radiol 2006; 17: 44959.,Cuschieri J, Freeman B, OKeefe G, Harbrecht BG, Bankey P, Johnson JL, et al. Inflammation and the host response to injury a large-scale collaborative project: patient-oriented research core standard operating procedure for clinical care X. Guidelines for venous thromboembolism prophylaxis in the trauma patient. J Trauma 2008;65:944-50.,