腔静脉滤器在创伤后深静脉血栓中的临床应用

Application of vena cava filters for treating deep venous thrombosis secondary to trauma

目的分析创伤后深静脉血栓形成(DVT)的临床特点和诊疗方法,研究选择性下腔静脉滤器置入术的利与弊,并思考滤器植入的适应人群。方法回顾性分析2009年1月～2012年1月收治的80例创伤后DVT患者临床资料、相关DVT的临床特点以及不同类型处置及结果。结果 80例创伤后DVT患者治愈79例,死亡1例[ISS 29分,死亡原因为多脏器功能衰竭(MODS)]。其中35例采取了选择性下腔静脉滤器置入术,可回收滤器11例,永久滤器24例。适应证:(1)高龄者;(2)为中央型和混合型血栓者;(3)既往有DVT病史者;(4)抗凝禁忌证者;(5)ISS评分>16分者;(6)有发生肺栓塞高风险者。非手术治疗45例,主要采用肝素或低分子肝素、蕲蛇酶等药物进行抗凝治疗,其中有2例在治疗中发生肺栓塞(PE),经永久滤器植入后治愈。结论创伤患者中ISS评分>16分,制动卧床或长期卧床,有吸烟史、合并糖尿病、高血压、冠心病、出血倾向者是发生DVT的高危人群。早期监护和预防措施是避免DVT发生的关键。急性DVT采取滤器置入术应严格掌握适应证,不宜作为常规治疗手段,且尽可能选择临时或可回收滤器,这对预后有重要意义。

Objective To explore the indicators of vena cava filters （ VCFs ） implementation for treating deep venous thrombosis（DVT）secondary to trauma and how to select among different types of VCFs. Methods A retrospective review was applied on 80 DVT patients secondary to trauma in trauma center, Daping Hospital of Third Military Medical University from Jan. 2009 to Jan. 2012. Results In 80 DVT patients secondary to trauma,79 cases were cured, 1 case died （ ISS 29, due to MODS）. Totally 35 patients took selective insertion of inferior vena cava filter （ recyclable filter in 11 cases, permanent filter in 24 cases }. The indications were ： （ 1 ） elder; （ 2 ） the central type and mixed type DVT patients ; （ 3 ） a previous history of DVT; （4） antieoagulation contraindieations ; （ 5 ） the ISS 〉 16 ; （ 6 ） pulmonary embolism in high-risk patients. Conservative treatment was conducted in 45 cases, mainly by heparin or low molecular weight heparin and other anticoagulant therapies, there were 2 cases of pulmonary embolism （PE） , and permanent filter implantation was taken and cured. Conclusion ISS 〉 16,prolonged bed rest,history of smoking, diabetes, hypertension,coronary heart disease,bleeding are high risk factors of DVT. In spite of the risk of thromboembelism in trauma patients is transient, temporary VCFs is not the first choice. Early care and prevention measures are keys to manage DVT. Acute DVT which requires filter implantation should strictly grasp the indications, and try applying the temporary or reeyelable fiher,which has important significance for prognosis.