手术治疗导致肺栓塞的静脉曲张疾病后停用抗凝剂是否安全?

T. G. Kipiani, V. V. Kozlova, K. Lobastov
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引用次数: 0

摘要

浅静脉血栓大多由下肢静脉曲张疾病引起,可并发肺栓塞。同时,对于静脉曲张血栓引起的肺栓塞,抗凝治疗的最佳持续时间仍存在争议。一方面,静脉曲张的存在被认为是发生静脉血栓栓塞事件的一个小风险因素,而静脉曲张的持续存在决定了复发风险的增加,需要长时间的抗凝治疗。另一方面,静脉曲张的消除与随后发生静脉血栓栓塞事件的风险降低有关。文章描述了一例因手术治疗静脉曲张疾病而导致原发性肺栓塞后复发肺栓塞的临床病例。一名 45 岁的患者患有左下肢静脉曲张疾病 5 年,因怀疑肺栓塞被送入重症监护室。进一步检查发现,双侧肺动脉节段和节段下分支以及右肺动脉中叶分支均有血栓闭塞的迹象,同时还有右侧心脏负荷过重的迹象。在该病例中,发现肺栓塞源于左下肢大隐静脉主干的血栓形成,其近端边界位于小腿水平。没有发现深静脉受累的迹象。在医院开始接受肠外抗凝治疗后,转为服用治疗剂量的利伐沙班。治疗 6 个月后,发现受累静脉有再通迹象,于是决定对大隐静脉主干进行静脉腔内激光凝固术,并在持续口服抗凝药的基础上对曲张支流进行小静脉切除术。利伐沙班治疗在介入治疗一个月后结束。然而,7 天后,患者被诊断为反复出现症状性肺栓塞,源于左侧腘静脉血栓形成。建议恢复无限期抗凝治疗。文章讨论了浅静脉曲张血栓形成所致肺栓塞的最佳治疗时间问题,以及介入治疗后完成抗凝治疗的可能时机。
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Is it safe to discontinue anticoagulant after surgical treatment of varicose vein disease, which caused pulmonary embolism?
Superficial vein thrombosis, which is mostly caused by lower extremity varicose vein disease, can be complicated by pulmonary embolism. At the same time, the optimal duration of anticoagulant therapy for pulmonary embolism originated from varicose vein thrombosis is still under debate. On the one hand, the presence of varicose veins is considered a small risk factor for the development of venous thromboembolic events, which persistence determines an increased risk of relapse and requires prolonged anticoagulant therapy. On the other hand, elimination of varicose veins is associated with reduced risk of subsequent venous thromboembolic events. The article describes a clinical case of recurrent pulmonary embolism after surgical treatment of varicose vein disease, which caused primary pulmonary embolism. A 45-year-old patient suffering from left lower extremity varicose vein disease for 5 years was admitted to the intensive care unit with suspected pulmonary embolism. The further examination revealed signs of thrombotic occlusion of the segmental and subsegmental branches of the pulmonary arteries bilaterally and the middle lobe branch of the right pulmonary artery, as well as signs of the right-sided heart overload. In this case, pulmonary embolism was found to originate from thrombosis of the trunk of the great saphenous vein ofthe left lower extremity with a proximal border at the level of the lower leg. No signs of deep vein involvement were detected. The parenteral anticoagulant therapy initiated in the hospital was followed by switching to therapeutic doses of rivaroxaban. The signs of recanalization of involved veins were identified after 6 months of treatment, and it was decided to perform endovenous laser coagulation of the trunk of the great saphenous vein combined with mini-phlebectomy of varicose tributaries on continuous oral anticoagulant therapy. The rivaroxaban therapy was completed a month after intervention. However, 7 days later the patient was diagnosed with repeated symptomatic pulmonary embolism, which originated from thrombosis of the left popliteal vein. It was recommended to resume anticoagulant therapy of indefinite duration. The article discusses the issues of optimal duration of treatment for pulmonary embolism originated from thrombosis of superficial varicose veins, as well as the possible timing of completion of anticoagulant therapy after the intervention.
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