Department of Emergency Medicine, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, PA 19107, USA.
Ann Emerg Med. 2011 Jun;57(6):590-9. doi: 10.1016/j.annemergmed.2010.11.031. Epub 2011 Feb 8.
Recent attention to the increasing incidence of venous thromboembolism has included a call to action from the surgeon general and new guidelines from various specialty organizations. The standard of care for treatment of deep venous thrombosis in the emergency department (ED), supported by the 2008 American College of Chest Physicians (ACCP) guidelines, involves initiation of anticoagulation with low-molecular-weight heparin, pentasaccharide, or unfractionated heparin. For selected appropriate patients with extensive acute proximal deep venous thrombosis, the ACCP guidelines now recommend thrombolysis in addition to anticoagulation to reduce not only the risk of pulmonary embolism but also the risk of subsequent postthrombotic syndrome and recurrent deep venous thrombosis. Postthrombotic syndrome is a potentially debilitating chronic cluster of lower-extremity symptoms occurring in 20% to 50% of deep venous thrombosis patients subsequent to the acute insult, sometimes not until years later. A strategy of early thrombus burden reduction or frank removal might reduce the incidence of postthrombotic syndrome, as per natural history studies, venous thrombectomy data, observations after systemic and catheter-directed thrombolysis, and the still-limited number of randomized trials of catheter-directed thrombolysis (with anticoagulation) versus anticoagulation alone. Contemporary invasive (endovascular) treatments mitigate the drawbacks historically associated with thrombolytic approaches by means of intrathrombus delivery of drugs with greater fibrin specificity and lower allergenicity, followed by mechanical dispersion to accelerate lysis and then aspiration of remaining drug and clot debris. With a 2016 target completion date, the National Heart, Lung, and Blood Institute--sponsored Acute Venous Thrombosis: Thrombus Removal With Adjunctive Catheter-Directed Thrombolysis trial is comparing the safety and efficacy, in terms of both deep venous thrombosis and postthrombotic syndrome parameters, of the most evolved pharmacomechanical catheter-directed thrombolysis devices versus standard anticoagulation therapy alone. This article reviews the grounds for use of adjunctive thrombolysis in patients with acute proximal deep venous thrombosis and begins to identify types of deep venous thrombosis patients encountered in the ED who might benefit most from multidisciplinary consideration of early referral for possible endovascular therapy.
最近，人们越来越关注静脉血栓栓塞症的发病率，这包括外科医生总干事的呼吁和各个专业组织的新指南。2008 年美国胸科医师学会 (ACCP) 指南支持的急诊科（ED）深静脉血栓形成（DVT）治疗标准包括使用低分子量肝素、戊聚糖或未分级肝素开始抗凝治疗。对于有广泛急性近端深静脉血栓形成的特定合适患者，ACCP 指南现在建议除抗凝治疗外，还应进行溶栓治疗，以降低不仅肺栓塞的风险，而且还降低随后发生血栓后综合征和复发性深静脉血栓形成的风险。血栓后综合征是一种潜在的使人衰弱的慢性下肢症状群，发生在 20%至 50%的深静脉血栓形成患者的急性损伤后，有时直到几年后才会发生。根据自然病史研究、静脉血栓切除术数据、全身和导管引导溶栓后的观察结果以及导管引导溶栓（联合抗凝）与单纯抗凝治疗的随机试验数量有限，早期血栓负荷减少或直接清除血栓可能会降低血栓后综合征的发生率。当代有创（血管内）治疗通过向血栓内输送具有更高纤维蛋白特异性和更低变应原性的药物来减轻历史上与溶栓方法相关的缺点，然后进行机械分散以加速溶解，然后抽吸剩余的药物和血栓碎片。国家心肺血液研究所（NHLBI）赞助的急性静脉血栓形成：血栓切除术联合辅助导管引导溶栓试验（2016 年目标完成日期）正在比较最先进的药物机械导管引导溶栓设备与单独标准抗凝治疗在深静脉血栓形成和血栓后综合征参数方面的安全性和疗效，以确定急性近端深静脉血栓形成患者辅助溶栓的使用依据，并开始确定在 ED 遇到的可能从多学科早期转介进行可能的血管内治疗中获益最多的深静脉血栓形成患者类型。
