血栓形成与肿瘤201227.pptVIP

静脉血栓栓塞症Venous Thrombo-embolism 2012.2.2 静脉血栓栓塞症的分类 深静脉血栓（DVT，deep venous thrombosis） 肺栓塞（PE，pulmonary embolism） 弥散性血管内凝血（DIC） 门静脉血栓（PVT） 动脉血栓栓塞（AT） 游走性浅表血栓性静脉炎等 其中以下肢DVT及PE最为常见。 静脉血栓栓塞症 DVT（deep venous thrombosis）血液在深静脉内不正常凝结引起的病症 多发生在下肢 血栓脱落可引起肺栓塞（pulmonary embolism，PE） 静脉血栓栓塞症与肿瘤 cancer body thrombosis 静脉血栓栓塞症的流行病学 静脉血栓栓塞症与肿瘤 发生原因 高凝状态 血管壁损伤 静脉血液淤滞 血小板异常 纤溶系统功能异常 补液量不足 解剖因素 肿瘤细胞侵袭静脉系统 静脉血栓栓塞症与肿瘤 高凝状态 TF和CP TNF、IL-1 凝血酵素 高凝状态 血小板的黏着和聚集 单核 和内皮细胞产生TF 活化凝血因子VIIa 和 Xa 血栓形成的原因之血管壁损伤 临床显示：易引起血管壁损伤的化疗药物有顺铂、氟尿嘧啶及甲氨蝶呤等。而EPO、他莫昔芬、激素、反应停、贝伐单抗都可以导致癌症病人血栓形成。 高危人群 腺癌；手术；卧床 静脉导管；化疗 DVT 的诊断 DVT 的诊断 In 2006, Scarvelis and Wells overviewed a set of clinical prediction rules for DVT on the heels of a widely adopted set of clinical criteria for pulmonary embolism. Wells score or criteria: (Possible score -2 to 9) Active cancer (treatment within last 6 months or palliative) +1 point Calf swelling 3 cm compared to other calf (measured 10 cm below tibial tuberosity) +1 point Collateral superficial veins (non-varicose) +1 point Pitting edema (confined to symptomatic leg) +1 point Previous documented DVT +1 point. Swelling of entire leg +1 point Localized pain along distribution of deep venous system +1 point Paralysis, paresis, or recent cast immobilization of lower extremities +1 point Recently bedridden 3 days, or major surgery requiring regional or general anesthetic in past 4 weeks +1 point Alternative diagnosis at least as likely -2 points Interpretation: Score of 2 or higher — deep vein thrombosis is likely. Consider imaging the leg veins. Score of less than 2 — deep vein thrombosis is unlikely. Consider blood test such as d-dimer test to further rule out deep vein thrombosis. DVT 的治疗 PE的诊断 PE的诊断 PE的治疗 注意 DVT治疗的重点是 缓解症状 使栓子局限 减少肺栓塞的风险 预防复发 PE治疗的重点是 缓解症状 抗凝溶栓 预防复发 抗凝治疗的监测 普通肝素：血小板计数50×109／L时停用肝素或输注血小板，抗凝血酶活性(AT：A)测定维持在80％以上； LMWH：APTT、PT、抗凝血酶复合物(TAT)等试验与LMWH无明显相关性