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1、PulmonaryEmbolism:LatestDiagnostic&ManagementStrategiesMichaelD.McGoon,MDTheVTEContinuumandGoalsofInterventionProximalDVTRiskofVTEDistal(calf)DVTPulmonaryEmbolismDeathRecurrencePost-thromboticsyndromeCTEPH25%50%3.8%after2yearsPengo,NEJM20047%in6months
2、17%in1year;28%in5yearsSeealsoKearonCl:NaturalHistoryofVenousThromboembolism;Circulation2003;107:I-22-I-30VenousThromboembolism:PE-TheScopeoftheProblem(2004)30%mortalityifuntreated(vs2-8%)10-15%ofdeathsinacutecarehospitals100-200,000deathsyearly(US)>50
3、%areundiagnosed<30%offatalPEcaseshavepriorDVTsuspicionVenousThromboembolism:RiskFactors(RelativeRisk)Obesity,smoking,hypertension(2-3)Oralcontraceptives,estrogenmodulators(5)Cancer,acuteillnessinhospital(5-10)ThrombophiliaAntithrombinIIIdeficiency(5-5
4、0)HomozygousfactorVLeidenmutation(80)Majortraumaorsurgery(200)VenousThromboembolism:DemographicsofRisk(2004)BrestDistrict,FranceOlmstedCounty,MNUSHospitalSurvey(2004)AfrAm,WhitesPopulationVTEIncidence1.22–1.83/1000DVT0.48–1.24PE0.34–0.69USHospitalSurv
5、ey(2004)AJC2004;93:1194-1197Asians,PI’sHongKong20040.23/1000DVT0.17-0.20PE0.039–0.05LowerprevalenceofFactorVLeidenandotherthrombophiliasinAsiansDeepVeinThrombosisEvaluationofSuspectedDVT(2004)ClinicalProbabilityLowHighD-dimerNoDVTDVTDuplexUSDuplexUSD-
6、dimerNoDVTSerialUSBasedonCirculation2004,109,I-9posnegposnegnegposnegposnegposPulmonaryEmbolismDiagnosis-VentilationPerfusionScintigraphyNormalscanessentiallyrulesoutPESensitivityof“high-probability”scanis41%EverythinginbetweenisindeterminateBy2001,le
7、ssusedthanCTangioIdentifiesPEin14-44%ofindeterminateVQscansAccuratetothesegmentallevelCandiagnoseotherintrathoracicdiseases;canbecombinedwithlegCTvenographyExcellentoutcomewithoutanticoagulationafternegativeCTangioSwensonetal,MayoClinicProceedings77:1
8、30-138,2002Faster,cheaper,lessinvasive,morewidelyavailablethanpulmonaryangioPulmonaryEmbolismDiagnosis-CTAngiographyPulmonaryEmbolismDiagnosis-MRAngiographyNoneedforIViodinatedcontrastmaterialPulmonaryvascularimagingmaybecombinedwithMRvenograp
