1、上肢深静脉血栓上肢深静脉血栓upper extremity deep venous thrombosis UEDVT1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.,Upper extremity Deep Venous Thrombosis A Review.The American Journal of Medicine,2011.23流行病学流行病学Kroger K,Schelo C,Gocke C,et al.Colour Dop
2、pler sonographic diagnosis of upper limb venous thrombosesJ.Clin Sci(Lond),1998,94(6):657-661.Syed Mustafa,M.,et al.,upper extremity deep vein thrombosis.CHEST,20034DVT中所占比例Spencer F A E C L D.Upper Extremity Deep Vein Thrombosis A Community-BasedJ.Am J Med,2007,8(120):678-684.Hylton V.Joffe N K V F
3、.Upper-Extremity Deep Vein Thrombosis A Prospective Registry of 592 PatientsJ.Circulation,2004,12(110):1605-1611.5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 extremity deep-vein thrombo
4、sis in adults.Thromb Haemost,2012.6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,Mismetti P,Poggio R,et al.Clinical outcome of patients with upper-extremity deep vein thrombosis:results from the RIETE RegistryJ.Chest,2008,1
5、33(1):143-1487 RIETE研究多国家、多中心 Munoz F J,Mismetti P,Poggio R,et al.Clinical outcome of patients with upper-extremity deep vein thrombosis:results from the RIETE RegistryJ.Chest,2008,133(1):143-14882004年美国多中心研究Hylton V.Joffe N K V F.Upper-Extremity Deep Vein Thrombosis A Prospective Registry of 592 Pa
6、tientsJ.Circulation,2004,12(110):1605-16119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%10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 for clinically suspected upper extremity deep vein thrombosis.Journal of Thrombosis a
7、nd Haemostasis11D-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-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%，特异性为，特异性为14%，阳性预测价值为阳性预测价值为32%，阴性排除价值为，阴性排除价值为100%，12超声超声PICC13 低回声低回声 不可压缩性不可压缩性14超声超声Di Nisio M,Van Sluis G L,Bossuyt P M,et
8、 al.Accuracy of diagnostic tests for clinically suspected upper extremity deep vein thrombosis:a systematic reviewJ.J Thromb Haemost,2010,8(4):684-69215UEDVT诊断1617 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）18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
9、.,et al.,Diagnosis and management of upper extremity deep-vein thrombosis in adults.Thromb Haemost,201219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 venous thromboembolic disease:American College of Chest Physicians Evidence-Based Clinical Practice Guidelines(8th
10、Edition)J.Chest,2008,133(6 Suppl):454S-545S20溶栓溶栓ACCP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 venous thromboembolic disease:American College of Chest Physicians Evidence-Based Clinical Practice Guidelines(8th Edition)J.C
11、hest,2008,133(6 Suppl):454S-545S21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 upper extremity deep vein thrombosis and the role of superior vena cava filters:a review of the literatureJ.J Vasc Interv Radiol,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%22手术取栓术手术取栓术Kearon
12、C,Kahn S R,Agnelli G,et al.Antithrombotic therapy for venous thromboembolic disease:American College of Chest Physicians Evidence-Based Clinical Practice Guidelines(8th Edition)J.Chest,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23治疗策略比较治疗策略比较24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%25PE26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）2728
