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NEJM:严重创伤预防性放置下腔静脉滤器的意义

2019-08-07 杨中华 脑血管病及重症文献导读

静脉血栓栓塞(Venous thromboembolism,VTE)是严重创生后常见的并发症。一项前瞻性监测研究纳入了349例连续的严重损伤患者,显示不采取预防性抗凝治疗,其近端深静脉血栓形成(deep-vein thrombosis,DVT)发生率为18%,肺栓塞发生率为11%。

静脉血栓栓塞(Venous thromboembolism,VTE)是严重创生后常见的并发症。一项前瞻性监测研究纳入了349例连续的严重损伤患者,显示不采取预防性抗凝治疗,其近端深静脉血栓形成(deep-vein thrombosis,DVT)发生率为18%,肺栓塞发生率为11%。更为重要的是,该研究还发现高达37%的所有症状性肺栓塞发生在创伤后前4天以内。致死性肺栓塞比较少见(0.4-4.2%);不过,它占严重创伤后所有死亡的12%,并且一半的死亡被认为是可以预防的。因此,有效的血栓预防是至关重要的。

观察性研究已经发现对于严重创伤的患者,预防血栓延迟超过1-3天会增加3倍 VTE 风险,还可能会增加死亡率。不过,同时发现对于创伤性脑损伤的患者来讲,预防性抗凝会导致进展性血肿扩大的 OR 值超过13。最近一项随机对照试验评价了创伤性脑损伤后给予促红细胞生成素的疗效,他们发现创伤入院后7天内高达43%的患者未给予预防性抗凝治疗。为了解决这个有挑战性的问题,人们开发出了可回收下腔静脉滤器,并被广泛用于许多创伤中心所为预防肺栓塞的主要方法。这个方法受到缺乏高质量证据的数据用于指导如何使用这些设备,包括选择合适的患者、植入的时机和移除的时机。预防性使用下腔静脉滤网最具争议。已经发表了大量观察性研究,但是这些滤器的长期并发症仍倍受关注,包括人们对大量滤器未被移除的认识。另外,对医疗资源也具有重要意义。2017年美国下腔静脉滤器市值不到200百万美元,全球估计为435百万美元(2016年)。

对于预防性抗凝禁忌的患者,需要RCT 试验高质量证据支持继续使用下腔静脉滤器。2019年7月来自澳大利亚的Kwok M. Ho等在 NEJM 上公布了他们的研究结果,目的在于探讨对于预防性抗凝禁忌的严重创伤患者,创伤入院后72h 内植入可回收下腔静脉滤器是否能够降低肺栓塞的风险。

在这项多中心、随机对照研究中,共纳入了240例严重创伤患者(创伤严重评分>15),并且这些患者存在抗凝治疗的禁忌症。这些患者与入院72h 内随机植入下腔静脉滤器或不植入滤器。主要复合终点包括90天症状性肺栓塞或全因死亡。

这些患者的平均年龄为39岁,损伤严重得分平均为27分。结果发现,早期植入下腔静脉滤器并未显着降低90天症状性肺栓塞或全因死亡(vs 未植入滤器)(下腔静脉滤器组13.9%,对照组14.4%;HR,0.99;95% CI,0.51 - 1.94;P = 0.98)。对于创伤后7天内未接受预防性抗凝治疗的80例患者(下腔静脉滤器组46例,对照组34例),下腔静脉滤器组和对照组肺栓塞发生率分别为0%和14.7%(5例),包括1例死亡(肺栓塞相对风险,0;95% CI,0 - 0.55)。下腔静脉滤器组6例检测到网内血栓(entrapped thrombus)。

最终作者认为严重创伤后早期预防性放置下腔静脉滤器未能显着降低90天症状性肺栓塞或死亡。

原始出处:Ho KM1, Rao S1, Honeybul S1, et al. A Multicenter Trial of Vena Cava Filters in Severely Injured Patients. N Engl J Med. 2019 Jul 25;

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    2019-08-08 旺医

    顶刊就是顶刊,谢谢梅斯带来这么高水平的研究报道,我们科里同事经常看梅斯,分享梅斯上的信息

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