Sule Ashish Anil, Chin Tay Jam, Handa Pankaj, Earnest Arul
Department of General Medicine;
Int J Angiol. 2009 Summer;18(2):83-7. doi: 10.1055/s-0031-1278332.
During the past two decades, the diagnosis of deep venous thrombosis (DVT) has made considerable progress. The term distal or calf vein thrombosis includes thrombosis in infrapopliteal veins, including the posterior tibial, peroneal, anterior tibial and muscular calf veins. The necessity of treating of distal DVT is debatable.
To determine whether treatment of isolated, distal DVT with anticoagulation versus no treatment affects patient outcome.
All patients discharged with a diagnosis of distal DVT from Tan Tock Seng Hospital, Singapore, between January 1, 2006, and December 31, 2007, were identified by the medical records office of the hospital. Compression of the intraluminal thrombus by duplex scan was used to diagnose distal DVT. Excluded were patients who either had both distal and proximal DVT, or had distal DVT along with pulmonary embolism (PE) at presentation. Complete resolution of distal DVT on repeat duplex scan was used to measure the primary outcome. Repeat follow-up scans were performed at two weeks, one month, three months and six months, or on subsequent follow-up until the distal DVT had resolved completely. Secondary outcome measures were complete improvement of symptoms, progression of thrombosis, or PE or death during the follow-up period. The study included 68 patients with distal DVT; however, 17 patients with PE, two of whom had proximal DVT (in the iliac and common femoral veins) at the first presentation along with distal DVT, were excluded from the study. In total, 51 patients were included for analysis. The follow-up scan was available in 35 patients; therefore, the primary analysis was performed in 35 patients (47 incidences of distal DVT). However, the secondary analysis was available in all 51 patients. Of the 35 patients available for follow-up scans, 17 patients (25 incidences of distal DVT) received anticoagulation and 18 patients (22 incidences of distal DVT) received no anticoagulation. Of the 17 patients who were treated with anticoagulation, nine patients (13 incidences of distal DVT) received enoxaparin at a dose of 1 mg/kg twice a day for two weeks and eight patients (12 incidences of distal DVT) received warfarin for a period of three months with initial overlap of enoxaparin 1 mg/kg twice a day for three to five days. Once the prothrombin time international normalized ratio of a patient on warfarin was between 2 and 3, enoxaparin was discontinued. The 18 patients who did not receive anticoagulation received follow-up with regular duplex scan.
There were no statistically significant differences among the groups in the resolution of distal DVT or symptom improvement with or without treatment. In the group that received no treatment, one death occurred. Proximal extension and PE were not recorded in any of the patients.
Distal DVT may not require treatment with anticoagulation. If leg symptoms worsen, or if there is an extension of distal DVT on the follow-up scan, treatment with anticoagulation is recommended.
在过去二十年中，深静脉血栓形成（DVT）的诊断取得了显著进展。术语远端或小腿静脉血栓形成包括腘静脉以下静脉的血栓形成，包括胫后静脉、腓静脉、胫前静脉和小腿肌肉静脉。治疗远端DVT的必要性存在争议。
确定抗凝治疗孤立性远端DVT与不治疗对患者预后的影响。
新加坡丹戎巴葛医院医疗记录办公室确定了2006年1月1日至2007年12月31日期间出院诊断为远端DVT的所有患者。通过双功扫描腔内血栓受压情况来诊断远端DVT。排除同时患有远端和近端DVT或就诊时伴有肺栓塞（PE）的远端DVT患者。通过重复双功扫描远端DVT完全消退来衡量主要结局。在两周、一个月、三个月和六个月或随后的随访中进行重复随访扫描，直到远端DVT完全消退。次要结局指标为症状完全改善、血栓进展、随访期间发生PE或死亡。该研究纳入了68例远端DVT患者；然而，17例患有PE的患者被排除在研究之外，其中2例在首次就诊时除远端DVT外还患有近端DVT（髂静脉和股总静脉）。总共51例患者纳入分析。35例患者有随访扫描结果；因此，对35例患者进行了主要分析（47例远端DVT病例）。然而，所有51例患者都有次要分析结果。在35例可进行随访扫描的患者中，17例患者（25例远端DVT病例）接受了抗凝治疗，18例患者（22例远端DVT病例）未接受抗凝治疗。在17例接受抗凝治疗的患者中，9例患者（13例远端DVT病例）接受了依诺肝素治疗，剂量为1mg/kg，每日两次，共两周，8例患者（12例远端DVT病例）接受了华法林治疗，为期三个月，最初重叠使用依诺肝素1mg/kg，每日两次，持续三至五天。一旦服用华法林的患者凝血酶原时间国际标准化比值在2至3之间，就停用依诺肝素。18例未接受抗凝治疗的患者通过定期双功扫描进行随访。
在远端DVT消退或症状改善方面，治疗组与未治疗组之间无统计学显著差异。在未治疗组中，发生1例死亡。所有患者均未记录到近端血栓扩展和PE。
远端DVT可能无需抗凝治疗。如果腿部症状恶化，或随访扫描显示远端DVT有扩展，建议进行抗凝治疗。
