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外伤后肺栓塞可能并非来源于深静脉血栓

Post-Trauma Pulmonary Embolism May Not Derive From Deep-Vein Thrombosis

By Mary Ann Moon  |   2009-10-19
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Pulmonary embolism may not originate as deep vein thrombosis in trauma patients, according to a report in the October issue of the Archives of Surgery.

In a study of 46 patients treated over a 3-year period at a single trauma center who developed pulmonary embolism (PE), only 7 (15%) were found to have deep vein thrombosis (DVT) of the pelvic and proximal veins on computed tomographic venography, said Dr. George C. Velmahos of the division of trauma, emergency surgery, and surgical critical care at Massachusetts General Hospital, Boston, and his associates (Arch. Surg. 2009;144:928-32).

“This study is the first to [cast] doubt [on] the traditional belief that PE originates from pelvic and proximal lower extremity veins. We propose that many PEs form primarily in the lungs and that the risk-benefit ratio of vena cava filters should be reconsidered,” they noted.

The prevailing belief is that PE develops when a clot in the leg or pelvic veins breaks apart and part of the clot travels to the pulmonary circulation. Filters for the inferior vena cava were developed to catch those traveling clots before they could lodge in the lungs.

Numerous studies have failed to demonstrate the culprit DVT in patients with PE, but all have relied on ultrasonography or other limited technologies to diagnose DVT. It has been assumed that these techniques are not sensitive enough to detect most DVT, especially when it is located in the pelvis.

Dr. Velmahos and his colleagues reviewed the records of all 247 trauma patients who underwent computed tomographic (CT) pulmonary angiography at their center from 2004 to 2007 and identified 46 found to have PE. There were 18 central PE cases (39%) involving the main or lobar pulmonary arteries and 28 peripheral PE cases (61%) involving the segmental or subsegmental branches.

When the 46 patients were simultaneously examined using CT venography, a much more sensitive detector of DVT than ultrasonography, only 7 were found to have DVT.

Moreover, there were no differences between patients who had DVT and those who did not in age, sex, injury type, length of hospital stay, overall injury severity score, chest injury severity score, use of appropriate anticoagulation therapy, or use of vena cava filters.

The findings demonstrate that PE does not originate from DVT, the authors said, which explains why vena cava filters have not been successful in preventing PE.

In addition, “It can no longer be argued that almost two-thirds of DVT episodes are missed in patients with proven PE solely because the diagnostic tools are inaccurate,” the investigators said.

The researchers’ conclusions are “intriguing,” but the study alone could not establish them as definitive, noted Dr. Raul Coimbra of the division of trauma, surgical critical care, and burns at the University of California San Diego, in an invited critique of the report.

“The lack of a control comparison for CT venography is a significant limitation of the study,” Dr. Coimbra said, and the authors’ attempts to diagnose both DVT and PE concurrently “may lead to erroneous conclusions” if the two are in fact sequential (Arch. Surg. 2009;144:932).

��Perhaps a more consistent screening protocol implemented early after admission would have resulted in more diagnoses of DVTs,” he added. Also, “Velmahos et al. offered no mechanistic explanation for their hypothesis that clots may form de novo in the lungs.”

Neither Dr. Velmahos nor Dr. Coimbra reported any financial conflicts of interest.

Copyright (c) 2009 Elsevier Global Medical News. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

根据发表于10月份的《外科学纪要》(Archives of Surgery)的一项研究报告,外伤患者的肺栓塞(PE)可能并非来源于深静脉血栓(DVT)。

波士顿麻省总医院创伤科、急诊外科及外科重症监护病房的George C. Velmahos博士及其同事将3年中在单一创伤中心接受治疗并出现PE的46例患者纳入研究。经计算机断层扫描(CT)检查发现,仅7例(15%)患者盆腔静脉和近端静脉有DVT(Arch. Surg. 2009;144:928-32)。
 
研究者指出,“本研究首次对PE来源于盆腔和近端下肢静脉的传统观点提出质疑。我们认为许多PEs的形成主要是在肺内,因此应重新考虑腔静脉过滤器的风险-效益比。”
 
主流观点认为,当腿部或盆腔静脉中的血凝块破裂分离,部分血块游走进入肺循环,从而形成PE。依据上述观点开发出的下腔静脉过滤器则试图在这些游走血块流至肺部前捕捉到它们。
 
大量研究未能证实DVT是导致PE患者发病的元凶,不过这些研究均依靠超声检查或其他有局限性的技术来诊断DVT。对于探查大多数DVT,特别是位于盆腔静脉的DVT,这些技术可能不够敏感。
 
Velmahos博士及其同事分析了其中心2004~2007年间所有接受CT肺血管造影的247例外伤患者的医疗记录,确认其中46例患者患有PE。有18例(39%)中心型PE患者,病变累及肺动脉主干或肺叶动脉。其他28例(61%)为周围型PE患者,病变累及段或亚段肺动脉。
 
当这46例患者同时应用较超声检查更为敏感的CT静脉造影检查DVT时,仅发现7例有DVT。
 
此外,患有和未患DVT的患者之间在年龄、性别、外伤类型、住院时间、全身损伤严重程度评分、胸部损伤严重程度评分、应用适当的抗凝治疗或应用腔静脉过滤器方面无差异。
 
研究者称,研究结果显示PE并非源于DVT,这也解释了腔静脉过滤器为何不能有效预防PE。
 
另外,研究者认为:“研究结果还可结束有关仅因为诊断工具不准确而造成PE确诊患者中近2/3者未检出DVT的观点。”
 
加州大学圣地亚哥分校创伤科、外科重症监护病房及烧伤科的Raul Coimbra博士在应邀对上述研究进行评论时强调,研究者所得出的结论是“吸引人的”,但仅依据该项研究尚不能最终确立其结论。
 
Coimbra博士指出,“该研究的一个重要局限性在于没有与CT静脉造影进行对照比较。”且研究者试图诊断的是DVT和PE并存的情况,可如果二者事实上是相继发生的,那么他们“可能得到的是错误的结论。”(Arch. Surg. 2009;144:932)
 
他补充说:“也许在患者入院早期即应用更一致的筛选方案可能会有更多的DVT得以确诊。并且对于血块可能在肺内形成的假设,Velmahos等并未说明机制。”
 
Velmahos博士及Coimbra博士均声明无任何经济利益冲突。
 
爱思唯尔   版权所有

Subjects:
pulmonology, surgery, surgery, emergency_trauma
学科代码:
呼吸病学, 普通外科学, 胸部外科学, 急诊医学
关键词:
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