1、2022-11-15.1上肢深静脉血栓上肢深静脉血栓upper extremity deep venous thrombosis UEDVT2022-11-15.2定义定义 腋静脉、锁骨下静脉、桡静脉、尺静脉、肱静脉、颈内静脉、头臂干静脉 最常见：腋静脉、锁骨下静脉 原发性：约占20%继发性：指存在危险因素的深静脉血栓形成，约占80%Cuc Mai,M.D.H.M.,UpCuc Mai,M.D.H.M.,Upper extremity Deep Venous per extremity Deep Venous Thrombosis A Review.The American Journal o
2、f Medicine,Thrombosis A Review.The American Journal of Medicine,2011.2011.2022-11-15.32022-11-15.4流行病学流行病学Kroger K,Schelo C,Gocke C,et al.Colour Doppler Kroger K,Schelo C,Gocke C,et al.Colour Doppler sonographic diagnosis of upper limb venous sonographic diagnosis of upper limb venous thrombosesJ.Cl
3、in Sci(Lond),1998,94(6):657-661.thrombosesJ.Clin Sci(Lond),1998,94(6):657-661.Syed Mustafa,M.,et al.,upper extremity deep vein Syed Mustafa,M.,et al.,upper extremity deep vein thrombosis.CHEST,2003thrombosis.CHEST,20032022-11-15.5DVT中所占比例Spencer F A E C L D.Upper Extremity Deep Vein Thrombosis A Spe
4、ncer F A E C L D.Upper Extremity Deep Vein Thrombosis A Community-BasedJ.Am J Med,2007,8(120):678-684.Community-BasedJ.Am J Med,2007,8(120):678-684.Hylton V.Joffe N K V F.Upper-Extremity Deep Vein Thrombosis A Hylton V.Joffe N K V F.Upper-Extremity Deep Vein Thrombosis A Prospective Registry of 592
5、PatientsJ.Prospective Registry of 592 PatientsJ.Circulation,2004,12(110):1605-1611.Circulation,2004,12(110):1605-1611.2022-11-15.6危险因素危险因素原发性原发性上肢深静脉血栓：遗传性血栓形成倾向：蛋白C、蛋白s或抗凝血酶、凝血因子缺乏，凝血因子VLeiden突变和凝血酶原G20210A突变 解剖结构异常：Paget-Schroetter综合征 Grant,J.D.,et al.,Diagnosis and management of upper Grant,J.D.,
6、et al.,Diagnosis and management of upper extremity deep-vein thrombosis in adults.Thromb Haemost,extremity deep-vein thrombosis in adults.Thromb Haemost,2012.2012.2022-11-15.7继发性继发性上肢深静脉血栓 CVC置入：45%与CVC有关 肿瘤：38%与恶性肿瘤有关 其他：起搏器、30天内手术史或制动史、个人或者家族深静脉血栓栓塞史、正在接受化疗、伴随疾病（高血压、糖尿病、神经系统疾病、30内肺部感染）Munoz F J,Mi
7、smetti P,Poggio R,et al.Clinical outcome of patients with Munoz F J,Mismetti P,Poggio R,et al.Clinical outcome of patients with upper-extremity deep vein thrombosis:results from the RIETE RegistryJ.upper-extremity deep vein thrombosis:results from the RIETE RegistryJ.Chest,2008,133(1):143-148Chest,2
8、008,133(1):143-1482022-11-15.8 RIETE研究多国家、多中心 Munoz F J,Mismetti P,Poggio R,et al.Clinical outcome of patients with Munoz F J,Mismetti P,Poggio R,et al.Clinical outcome of patients with upper-extremity deep vein thrombosis:results from the RIETE RegistryJ.upper-extremity deep vein thrombosis:results
9、 from the RIETE RegistryJ.Chest,2008,133(1):143-148Chest,2008,133(1):143-1482022-11-15.92004年美国多中心研究Hylton V.Joffe N K V F.Upper-Extremity Deep Vein Thrombosis A Hylton V.Joffe N K V F.Upper-Extremity Deep Vein Thrombosis A Prospective Registry of 592 PatientsJ.Prospective Registry of 592 PatientsJ.
10、Circulation,2004,12(110):1605-1611Circulation,2004,12(110):1605-16112022-11-15.10临床症状和体征临床症状和体征 上肢肿胀：80%患侧肢体疼痛：3050%较少出现的：患侧肢体红斑、浅表静脉曲张、肢体功能障碍、胸痛、呼吸困难、颈部肿胀 无症状：约5%2022-11-15.11诊断诊断 D-二聚体 超声 对比静脉造影：金标准 MRI、MRV CTV van M.DI NISIO,G.L.S.,Accuracy of diagnostic tests forvan M.DI NISIO,G.L.S.,Accuracy of
11、 diagnostic tests for clinically suspected upper extremity deep vein clinically suspected upper extremity deep vein thrombosis.Journal of Thrombosis and Haemostasis thrombosis.Journal of Thrombosis and Haemostasis2022-11-15.12D-D-二聚体二聚体 Merminodet al,2006,Switzerland：500ug/L 多普勒超声确诊 52例怀疑UEDVT中：1.D-
12、dimer阳性：15/52 29%2.并发肿瘤中：8/23 34.8%3.CVC：6/18 33%4.无肿瘤、CVC：4/22 18%诊断的敏感性为诊断的敏感性为100%100%，特异性为，特异性为14%14%，阳性预测价值为阳性预测价值为32%32%，阴性排除价值为，阴性排除价值为100%100%，2022-11-15.13超声超声PICCPICC2022-11-15.14 低回声低回声 不可压缩性不可压缩性2022-11-15.15超声超声Di Nisio M,Van Sluis G L,Bossuyt P M,et al.Accuracy of diagnostic tests Di N
13、isio M,Van Sluis G L,Bossuyt P M,et al.Accuracy of diagnostic tests for clinically suspected upper extremity deep vein thrombosis:a for clinically suspected upper extremity deep vein thrombosis:a systematic reviewJ.J Thromb Haemost,2010,8(4):684-692systematic reviewJ.J Thromb Haemost,2010,8(4):684-6
14、922022-11-15.16UEDVT诊断2022-11-15.172022-11-15.18 急性期：确诊血栓后的前三个月 可以降低血栓后综合征、血栓复发的发生率。预防期：急性期治疗后的阶段 目的是控制血栓形成的危险因素 治疗治疗（参考下肢深静脉血栓形成）2022-11-15.19治疗治疗（参考下肢深静脉血栓形成）拔除深静脉置管 抗凝 溶栓 上腔静脉滤器 手术取栓术 Grant,J.D.,et al.,Diagnosis and management of upper extremity deep-Grant,J.D.,et al.,Diagnosis and management of
15、upper extremity deep-vein thrombosis in adults.Thromb Haemost,2012vein thrombosis in adults.Thromb Haemost,20122022-11-15.20抗凝抗凝ACCP建议：同下肢深静脉血栓Kearon C,Kahn S R,Agnelli G,et al.Antithrombotic therapy for Kearon C,Kahn S R,Agnelli G,et al.Antithrombotic therapy for venous thromboembolic disease:Ameri
16、can College of Chest venous thromboembolic disease:American College of Chest Physicians Evidence-Based Clinical Practice Guidelines(8th Edition)J.Physicians Evidence-Based Clinical Practice Guidelines(8th Edition)J.Chest,2008,133(6 Suppl):454S-545SChest,2008,133(6 Suppl):454S-545S2022-11-15.21溶栓溶栓AC
17、CP建议：仅用于：症状严重、血栓占据大部分锁骨下静脉和腋静脉、血栓形成14天内、肢体功能良好、预期寿命长于一年、低出血风险者Kearon C,Kahn S R,Agnelli G,et al.Antithrombotic therapy for Kearon C,Kahn S R,Agnelli G,et al.Antithrombotic therapy for venous thromboembolic disease:American College of Chest venous thromboembolic disease:American College of Chest Phys
18、icians Evidence-Based Clinical Practice Guidelines(8th Edition)J.Physicians Evidence-Based Clinical Practice Guidelines(8th Edition)J.Chest,2008,133(6 Suppl):454S-545SChest,2008,133(6 Suppl):454S-545S2022-11-15.22上腔静脉滤器上腔静脉滤器Owens C A,Bui J T,Knuttinen M G,et al.Pulmonary embolism from Owens C A,Bui
19、 J T,Knuttinen M G,et al.Pulmonary embolism from upper extremity deep vein thrombosis and the role of superior vena upper extremity deep vein thrombosis and the role of superior vena cava filters:a review of the literatureJ.J Vasc Interv cava filters:a review of the literatureJ.J Vasc Interv Radiol,
20、2010,21(6):779-787Radiol,2010,21(6):779-787 上腔静脉短，放置困难 致死性并发症发生率为3.8%2022-11-15.23手术取栓术手术取栓术Kearon C,Kahn S R,Agnelli G,et al.Antithrombotic therapy for Kearon C,Kahn S R,Agnelli G,et al.Antithrombotic therapy for venous thromboembolic disease:American College of Chest venous thromboembolic disease:
21、American College of Chest Physicians Evidence-Based Clinical Practice Guidelines(8th Edition)J.Physicians Evidence-Based Clinical Practice Guidelines(8th Edition)J.Chest,2008,133(6 Suppl):454S-545SChest,2008,133(6 Suppl):454S-545S 大块血栓形成影响肢体功能 绝对抗凝、溶栓禁忌症2022-11-15.24治疗策略比较治疗策略比较2022-11-15.25并发症并发症 肺栓塞：发生率约为5%；抗凝 深静脉血栓复发：高复发、早复发 血栓后综合征（Post-thrombotic Syndrome,PTS）发生率为2040%2022-11-15.26PE2022-11-15.27预防预防 合理的选择CVC置入 小剂量低分子肝素、小剂量华法林、维生素K拮抗剂（继发性）2022-11-15.28/10/29.29NoImage
