住院患者下肢深静脉血栓形成位置与肺栓塞发生部位的特点分析

Analysis of characteristics of the location of lower extremity deep vein thrombosis and the site of pulmonary embolism in hospitalized patients

目的探讨住院患者下肢深静脉血栓(DVT)形成位置与肺栓塞发生部位的特点及其潜在关联。方法回顾分析2017年12月至2021年12月通过超声诊断为下肢DVT,同时经CT肺动脉造影诊断为肺栓塞患者的临床资料。根据下肢DVT形成位置分为混合型DVT、近端DVT、远端DVT,远端DVT进一步分为胫前/后静脉和腓静脉血栓及小腿肌间静脉血栓,混合型DVT指同时存在近端和远端DVT。根据肺动脉受累部位将肺栓塞分为肺动脉主干或左/右肺动脉干栓塞、肺叶动脉栓塞和肺段动脉栓塞。观察住院患者DVT形成位置、肺栓塞发生部位、静脉血栓栓塞症(VTE)的临床表现(气短、胸闷、胸痛、咯血、咳嗽、下肢肿胀、下肢疼痛、晕厥、发热)和危险因素(骨折/创伤、肿瘤、糖尿病、高血压、心房颤动、感染、手术、自身免疫性疾病、瘫痪、妊娠),以及D-二聚体水平。结果最终共209例患者纳入分析,其中左下肢DVT 127例(占60.8%),右下肢DVT 82例(占39.2%);混合型DVT占39.2%,近端DVT占17.3%,远端DVT占43.5%(胫前/后静脉和腓静脉血栓占14.8%、小腿肌间静脉血栓占28.7%)。混合型DVT及近端DVT患者肺动脉主干或左/右肺动脉干栓塞发生率明显高于胫前/后静脉和腓静脉血栓与小腿肌间静脉血栓患者〔41.5%(34/82)、38.8%(14/36)比16.2%(5/31)、10.0%(6/60)〕,差异有统计学意义(均P<0.05)。胫前/后静脉和腓静脉血栓患者肺段动脉栓塞发生率高于混合型DVT及近端DVT患者〔41.9%(13/31)比26.8%(22/82)、30.6%(11/36)〕,但差异无统计学意义(均P>0.05);小腿肌间静脉血栓患者肺段动脉栓塞发生率明显高于混合型DVT和近端DVT患者〔66.7%(40/60)比26.8%(22/82)、30.6%(11/36)〕,差异均有统计学意义(均P<0.05)。小腿肌间静脉血栓合并肺动脉主干或左/右肺动脉干栓塞患者D-二聚体水平明显高于合并肺段动脉栓塞者(mg/L:6.08±3.12比3.66±2.66,P<0.05);而下肢其他DVT形成位置合并不同部位肺栓塞患者D-二聚体水平差异均无统计学意义。在VTE临床表现方面,除混合型DVT患者下肢肿胀发生率明显高于胫前/后静脉和腓静脉血栓及小腿肌间静脉血栓患者〔54.9%(45/82)比29.0%(9/31)、15.0%(9/60),均P<0.05〕、近端DVT患者下肢肿胀发生率明显高于小腿肌间静脉血栓患者外〔41.7%(15/63)比15.0%(9/60),P<0.05〕,下肢DVT不同形成位置患者其他VTE临床表现无明显差异,且各组VTE危险因素差异亦无统计学意义。结论住院患者DVT大多发生于左下肢,且远端DVT发生率高于近端DVT;混合型DVT及近端DVT患者合并肺栓塞大多发生在肺动脉主干或左/右肺动脉干,远端DVT患者合并肺栓塞多发生在肺段动脉;下肢DVT合并肺动脉主干或左/右肺动脉干患者D-二聚体水平高于合并肺叶和肺段动脉栓塞者;混合型DVT和近端DVT患者下肢肿胀发生率高于远端DVT患者。

Objective To investigate the characteristics and relationship between the location of lower extremity deep vein thrombosis(DVT)and the site of pulmonary embolism in hospitalized patients.Methods The data of patients with lower extremity DVT diagnosed by ultrasound examination and pulmonary embolism diagnosed by CT pulmonary angiography from December 2017 to December 2021 were analyzed retrospectively.According to the location of lower extremity DVT,the patients were divided into mixed DVT,proximal DVT,and distal DVT which was further divided into anterior/posterior tibial vein or peroneal vein thrombosis and calf muscular venous thrombosis.Mixed DVT was referred to the presence of both proximal and distal DVT.According to the involved site of pulmonary artery,pulmonary embolism was divided into three types:main pulmonary artery,left or right pulmonary artery trunk embolism,lobar pulmonary artery embolism and segmental pulmonary artery embolism.The location of lower extremity DVT,the site of pulmonary embolism,the clinical manifestation(shortness of breath,chest tightness,chest pain,hemoptysis,cough,lower limb swelling,lower limb pain,syncope,fever)and risk factors(fracture/trauma,tumor,diabetes,hypertension,atrial fibrillation,infection,surgery,autoimmune diseases,paralysis,pregnancy)of venous thromboembolism(VTE),and the level of D-dimer were analyzed.Results A total of 209 patients were enrolled finally,including 127 patients with left lower extremity DVT(60.8%)and 82 with right lower extremity DVT(39.2%).Mixed DVT accounted for 39.2%,proximal DVT accounted for 17.3%,and distal DVT accounted for 43.5%(anterior/posterior tibial vein and peroneal vein thrombosis accounted for 14.8%,calf muscular venous thrombosis accounted for 28.7%).The incidences of main pulmonary artery embolism,left or right pulmonary artery trunk embolism in the mixed DVT and proximal DVT were significantly higher than those in the anterior/posterior tibial vein or peroneal vein thrombosis and calf muscular venous thrombosis[41.5%(34/82),38.8%(14/36)vs.16.2%(5/31),10.0%(6/60)],with statistically significant differences(all P<0.05).The incidences of pulmonary segmental artery embolism in the anterior/posterior tibial vein or peroneal vein thrombosis were higher than those in the mixed DVT and proximal DVT[41.9%(13/31)vs.26.8%(22/82),30.6%(11/36)],but the difference was not statistically significant(both P>0.05).The incidences of pulmonary segmental artery embolism in the calf muscular venous thrombosis were significantly higher than those in the mixed DVT and the proximal DVT[66.7%(40/60)vs.26.8%(22/82),30.6%(11/36)],and the difference was statistically significant(both P<0.05).The levels of D-dimer in patients with calf muscular venous thrombosis combined with main pulmonary artery embolism,left or right pulmonary artery trunk embolism were significantly higher than those in patients with calf muscular venous thrombosis combined pulmonary segmental artery embolism(mg/L:6.08±3.12 vs.3.66±2.66,P<0.05).There were no significant differences in D-dimer levels in other patients with DVT combined with pulmonary embolism in different sites.In terms of the clinical manifestations of VTE,the incidences of lower limb swelling in the mixed DVT and proximal DVT were significantly higher than those in the anterior/posterior tibial vein or peroneal vein thrombosis and calf muscular venous thrombosis[54.9%(45/82),vs.29.0%(9/31),15.0%(9/60),both P<0.05],the incidences of lower limb swelling in the proximal DVT were significantly higher than those in the calf muscular venous thrombosis[41.7%(15/63)vs.15.0%(9/60),P<0.05],there were no significant difference in the other clinical manifestations among the DVT groups.There was no significant difference in the incidence of VTE risk factors among the groups.Conclusions The DVT of inpatients mostly occurred in the left lower limb,and the incidence of distal DVT was higher than that of proximal DVT.Mixed DVT and proximal DVT combined with pulmonary embolism mostly occurred in the main pulmonary artery,left or right pulmonary artery trunk,while distal DVT combined with pulmonary embolism mostly occurred in the pulmonary segmental artery.The levels of D-dimer in patients with lower extremity DVT combined with main pulmonary artery or left and right pulmonary artery trunk embolism were higher than those in patients with pulmonary lobe and segmental artery embolism.The incidence of lower extremity swelling in patients with mixed DVT and proximal DVT was higher than that in patients with distal DVT.