2 English references leg venous thrombosis
3 disease code ICD:I82.8
4 Classification of Diseases Cardiovascular Department
5 disease overview embolism refers to a circulatory disorder caused by thrombus or foreign body falling off and blocking a part of the far side of blood flow. Although this disease is quite common in arterial system, pulmonary embolism seems to be the most typical one in venous system. There was neither venous embolism nor thrombophlebitis of lower limbs. Deep venous thrombosis of lower limbs is common, and its incidence rate is about 10 of upper limbs. Time magazine.
The so-called "venous embolism of lower limbs", which is widely circulated in disease description, is fallacious. Embolism refers to the circulatory disorder caused by thrombus or foreign body falling off and blocking the far part of blood flow. Although this phenomenon is quite common in arterial system, pulmonary embolism seems to be the most typical one in venous system. There was neither venous embolism nor thrombophlebitis of lower limbs. Phlebitis caused by venous thrombosis of lower limbs is called thrombophlebitis, which is common in superficial veins of lower limbs. It can be caused by intravenous drugs, complications of varicose veins of great and small saphenous veins, vasculitis or some autoimmune diseases. Superficial venous thrombophlebitis is not easy to cause pulmonary embolism. Deep thrombophlebitis is mostly secondary to deep venous thrombosis. This disease is easy to be complicated with pulmonary embolism, which is often related to surgery, pregnancy, childbirth, long-term bed rest and previous inferior vena cava obstruction. In some parts of China, it is often related to Budd-Chiari syndrome. Clinically, the acute stage is deep venous thrombosis of lower limbs, and the subacute and chronic stage is post-thrombotic syndrome of lower limbs. The latter is also very common in clinic, with emphasis on the latter.
Symptoms and signs 1. Primary iliofemoral vein thrombosis? Thrombosis is located in iliofemoral vein, and the incidence rate is lower than that of venous thrombosis of calf muscle plexus, and it is more common on the left side, ranging from 2 to 3? Time magazine. In a group of 1432? In statistics, the left side accounts for 69.3%, the right side accounts for 26.6%, and the bilateral ratio is 4. 1%. Ilio-femoral vein is the main channel for blood return of the whole lower limb vein. Once thrombosis occurs, it will happen soon. The main clinical manifestations of this disease are: ① pain and tenderness of the affected limb; Inflammatory reaction caused by thrombus can cause local persistent pain; Distal venous blood reflux disorder leads to swelling and pain, and the symptoms are aggravated when standing. The behavior of iliofemoral vein can often touch tenderness and tenderness. ② Swelling: It is caused by severe venous reflux disorder, so it is generally quite serious. (3) The skin of the affected limb is purple, which can cause pigmentation and gangrene in severe cases. ④ In severe cases, the arterial pulsation of limbs was obviously weakened or even disappeared. ⑤ Superficial varicose veins are compensatory, but not obvious in acute stage. The outcome of primary iliofemoral vein thrombosis is: ① Fibrinolysis and recanalization. ② Limitation and systematicness. ③ Thrombodilatation: Retrograde dilatation can involve the whole deep venous system of lower limbs; Antegrade dilation may invade the inferior vena cava, and if the thrombus falls off, it may lead to fatal pulmonary embolism.
2. Secondary iliofemoral vein thrombosis? Thrombosis originates from the venous plexus of calf muscle, which can involve the whole iliofemoral venous system when it expands anterograde. This is called mixed type, which is the most common type in clinic. Its characteristics are as follows: ① the mode of onset is mostly occult; ② Symptoms were mild at first, and many patients were not found until the iliofemoral vein was involved and typical symptoms appeared, so the actual illness period was longer than the symptom period; ③ Nutritional changes in boot area, including desquamation, pigmentation, eczema-like changes and ulcers. Because the superficial communicating vein of the leg is often diseased, its change is far faster and more serious than the primary one.
3. Bruises on the thighs? 1938? Gregoire? This paper describes a serious diffuse iliofemoral vein thrombosis involving the whole limb vein, called femoral contusion (phlegmasia? Cerulea) is not uncommon in clinic. This is the most serious type of deep venous thrombosis of lower limbs. The whole venous system of lower limbs, including potential collateral branches, is almost completely blocked, the venous pressure rises sharply, the affected limb is in severe pain accompanied by obvious swelling of the whole affected limb, the skin is shiny and cyanotic, the skin temperature drops, and the affected limb is seriously swollen, ischemic and even necrotic due to arterial spasm and/or gap syndrome. This is venous or wet gangrene. Because a large amount of body fluids enter the affected limb in a short time, sudden limb pain can lead to shock.
The cause of the disease 1. Blood stasis? Because of long-term illness in bed, trauma or fracture, major surgery, pregnancy, childbirth, long-distance car or plane ride, or long-term sitting and squatting, blood flow can be slow and stagnant, which can promote venous thrombosis of lower limbs.
2. Hypercoagulability of blood? Such as trauma, postoperative, extensive burn, pregnancy, postpartum, etc. , can increase platelets, enhance adhesion, easy to form thrombosis.
3. Vein wall injury? The vein wall is affected by any factors, such as mechanical injury, infectious injury and chemical injury, which will expose the collagen in the basement membrane and connective tissue under the vein intima. Platelets will then adhere to it and aggregate, and release many bioactive substances, such as catecholamine and serotonin. At the same time, under the action of platelet thrombin, prostaglandin PGG2 and PGH2 are formed through arachidonic acid. And other substances, which can aggravate platelet aggregation and facilitate the formation of thrombus.
4. Other factors? Such as age, obesity, anti-activating protein C? Wait a minute.
9 pathophysiology Virchow at 20? Blood stasis, venous wall injury and hypercoagulability are still the three major factors of venous thrombosis. However, since then, all the factors have been concretized, or the concept has been updated. Blood stasis promotes the adhesion, aggregation and release of platelets to the blood vessel wall, which is helpful to thrombosis. Anatomically, the left iliac vein is behind the left iliac artery, which makes the left iliac vein vulnerable to compression and makes the deep vein of the left lower limb more susceptible to illness. The damage of vein wall includes mechanical, chemical (intravenous injection), infectious and autoimmune diseases. As for the hypercoagulable state of blood, it involves infection, tumor, oral contraceptives, decreased antithrombin ⅲ activity, and C? Protein and s? Protein's abnormality and hyperphosphatemia.
10 Diagnostic examination and diagnosis: In clinical work, it is not difficult to diagnose venous thrombosis of lower limbs by inquiring about the medical history in detail, carefully examining the body and making necessary auxiliary examinations.
Laboratory examination: radioactive fibrinogen test: application of 125I? Labeled human fibrinogen can be absorbed by fresh thrombus, so after blocking the iodine absorption function of thyroid gland, intravenous injection of this agent can scan both lower limbs. If a sudden increase or concentration of radioactive agent is observed, it will be helpful for diagnosis.
Other auxiliary inspections:
1. radionuclide venography? Inject 99m radionuclide label from dorsal vein of both feet? Intravenous imaging was performed after technetium (99mTc) human albumin particles, and venous imaging of legs, thighs, pelvic cavity and abdomen was observed. "Hot spots" indicated the location of fresh thrombus.
2. Doppler blood flow and plethysmography? It is a non-invasive examination method, which is helpful to determine the blood return and blood supply of the affected limb.
3. venography? The vein can be directly developed to judge whether there is thrombus, its range, shape and collateral circulation. It not only helps to confirm the diagnosis, but also helps to directly observe the treatment results. Although this method is the most reliable, there is no need to force this examination when the condition is too serious. It must also be considered that the contrast agent itself may aggravate the lesion. Generally, a small amount of heparin is injected from the contrast department after injection of contrast agent, which is helpful to prevent the lesion from getting worse.
4. Determination of venous pressure? It is helpful to understand the condition and observe the development. It can be measured separately or during radiography.
1 1 The differential diagnosis of venous thrombosis of lower limbs is easily confused with some venous reflux disorders of lower limbs and limb ischemic diseases, so we should pay attention to differential diagnosis in clinic.
1. Primary deep venous valve insufficiency of lower limbs? Because the free edge of the deep venous valve of the lower limb is slack and drooping, the valve leaves can't be closed tightly, and venous blood completely flows back to the distal end of the limb, resulting in high blood pressure and congestion of the deep vein, destroying the communicating branch venous valve, leading to swelling of the lower limb and obvious superficial varicose veins. More common in people who have been engaged in standing work for a long time. The onset is hidden and relatively slow. These are not exactly the same as venous thrombosis of lower limbs. Pay attention to identification.
2. Simple varicose veins of lower limbs? It is more common in young and middle-aged men, mainly manifested as varicose veins of great saphenous vein and small saphenous vein of lower limbs. There is a feeling of heaviness and fatigue in the lower limbs, and there is little swelling. After standing or exercising for a long time, the calf and ankle appear slight swelling and disappear after rest. The venous thrombosis of lower limbs leads to extensive swelling, obvious swelling pain or severe pain of lower limbs, and the secondary superficial veins are also obvious and extensive. If necessary, the diagnosis can be made by ultrasonic Doppler examination and venography of lower limbs.
3. Acute arterial embolism of lower extremity? More common in rheumatic heart disease, coronary heart disease, atrial fibrillation and so on. Sudden and severe limb pain, especially finger tip, cold, pale face, loss of sensation, limb atrophy, superficial vein collapse, and arterial pulsation below the embolization plane disappeared. Large-scale gangrene of limbs can occur. Pay attention to identification.
12 treatment plan 198 1 ~ 1986? Yes, the author is 15? A patient with femoral contusion underwent venous thrombectomy. Although there was no serious pulmonary embolism during and after operation, the treatment effect was good, but since 1986? A few years later, one case of the same operation was not performed, suggesting that non-surgical methods were very effective, almost replacing the operation of late cases including embolectomy and muscle space decompression. Acute iliofemoral vein thrombosis is undoubtedly a rapid onset and development, and should be treated with the most effective method. Intravenous heparin, although it can immediately exert anticoagulant effect and thus exert thrombolytic effect by mobilizing endogenous plasmodium, seems to be more passive than direct thrombolytic agent. Therefore, the author regards fibrinolytic preparation as the first choice for acute cases. Because streptokinase has antigenicity and often causes pyrogen reaction after intravenous administration, urokinase is advocated. Commonly used every day 10? Ten thousand to twenty? Ten thousand u, soluble in 250 ~ 500 ml? Intravenous infusion of low molecular dextran, twice? The second vote. It is required to monitor fibrinogen above 200mg% and euglobulin time above 80 minutes. Plus raising the affected limb, often in 1 ~ 3? Within a few days, the swelling of the affected limb was obviously reduced. Until the curative effect is obvious or the total amount reaches 654.38+00,000 ~ 200? Wan u? Stop taking drugs and switch to intravenous heparin 3 ~ 5? Days, divided into continuous intravenous drip method or divided administration method, the total amount is about 200mg per day, and the coagulation time of maintaining activated coagulation (ACT) or test tube method is prolonged by 2 ~ 3 times. After oral anticoagulation (warfarin or coumarin acetate tablets) 2 ~ 3? Keep prothrombin activity at 30% for several months. ~? 40%? Tissue plasminogen activator (tissue? The application of plasminogen activator and continuous infusion of fibrinolytic drugs through head-end microporous catheter can further improve the therapeutic effect. The indication of venous embolectomy is that the condition is still developing rapidly during the above treatment, especially the pulse of dorsal foot or posterior tibial artery is weakened sharply, but it is too late to take embolectomy for patients with venous gangrene. The main problem of venous embolectomy is pulmonary embolism during embolectomy. Therefore, it is best to insert the vena cava filter through the internal jugular vein before removing the thrombus, so as to reliably prevent pulmonary embolism caused by thrombus shedding during operation. As for the method introduced in the literature, I have used a balloon catheter inserted from the contralateral femoral vein to block the bifurcation of the inferior vena cava. This method is not reliable, because the balloon still needs to be removed after the thrombus is removed, and the residual or temporarily blocked thrombus can still fall off. Even so, the author used F5 to cut the femoral vein from the affected side. Or F6? Fogarty? When the thrombus is removed by balloon catheter, the assistant still presses the abdomen. 10? In the remaining cases, there was no serious pulmonary embolism, but there were 3? Postoperative dyspnea cases 1 ~ 3? Jesus Christ. After the proximal embolectomy, the distal femoral vein valve blocked Fogarty? Balloon catheter is often unable to enter in the opposite direction, so it is squeezed from the far side to the near side with a blood drive belt, that is, milking? At this time, the thrombus is extruded from the femoral vein incision. The iliofemoral vein embolism is not entirely mainly in the left common iliac vein, because it may have been more or less compressed by the left iliac artery, making it difficult to relieve the local stenosis. Secondly, it is difficult to completely remove the thrombus in the small vein of the distal limb. It is natural to put the patient in heparinization state before cutting off the femoral vein. After embolectomy, the femoral vein should be sutured directly or temporary distal femoral arteriovenous fistula should be added to improve the surgical effect. After operation, heparin should be used for intravenous anticoagulation for 3 ~ 5? Oh, my god, change it to oral method 2 ~ 3? Last month. Once the femoral contusion develops to the necrotic stage, extensive myotomy can only be performed to fully drain the necrotic tissue. Raising the affected limb and changing the dressing frequently may be the only treatment. The author uses near 1? Years, has been cured 1? Like this serious case. If it cannot be relieved in the acute stage, it will develop into post-thrombotic syndrome of lower limbs.
Complications of 13 may lead to thromboembolism (pulmonary embolism, cerebral embolism, etc. ); Chronic ulcer of lower limbs, etc. In severe cases, it can cause acute pulmonary embolism and sudden death.
14 prognosis and preventive prognosis: it is generally believed that acute deep vein thrombosis is 3 ~ 6? After a few months, it entered the sequela period. Deep vein thrombosis undergoes absorption and polarization and slow recanalization. The closer the thrombus is to the proximal end, the less likely it is to recanalize. According to Dell? It is reported that the recanalization rate of iliofemoral vein thrombosis is about 65438 0% ~ 2%. In addition, in the process of thrombus recanalization, the valve can be destroyed, thus causing reflux disease. In addition to obvious limb swelling, due to long-term deep venous reflux disorder, deep venous hypertension of lower limbs and involvement of communicating branches, the varicosity of superficial veins of lower limbs is becoming more and more obvious. Due to skin malnutrition, chronic eczema, pigmentation and even stagnant ulcers may appear in the feet and boots.
Prevention:
1. Mechanical method? Aiming at promoting venous return of lower limbs. Electrogastrocnemius, circulatory driver or rhythmic positive or negative pressure driver can effectively promote limb circulation. It is also important to encourage patients to do ankle and quadriceps activities as soon as possible after operation, take more deep breaths and cough, and get out of bed as soon as possible. Wearing medical elastic socks with pressure difference after operation, such as calf 4.0kPa(30mmHg) and thigh 2.67kPa(20mmHg), also plays the role of circulation drive.
2. Drug Prevention Law? The first is low-dose subcutaneous heparin therapy. Comprehensive data showed that subcutaneous heparin treatment reduced the incidence of postoperative deep vein thrombosis from 25% to 7%. The incidence of massive pulmonary embolism decreased from 6% to 0.6%. The preventive mechanism of low-dose heparin is not completely clear. The main reason may be that subcutaneous route slows down the absorption of drugs and keeps the body at a certain heparin concentration. How to use it is usually 2 hours before surgery. 50mg subcutaneous injection per 12? How many hours? 1? Time, 50 mg each time. Antiplatelet therapy mainly includes enteric aspirin and dipyridamole. The function of low molecular dextran is to reduce blood viscosity, and 500 ~ 1000 ml can be injected intravenously every day as appropriate.
15 deep venous thrombosis is common in lower limbs, and its incidence rate is about 10 times that of upper limbs. At present, there is no exact statistical data about the incidence rate in China, but it is increasing year by year.
16 specially suggests that it is also important to encourage patients to do ankle and quadriceps activities as soon as possible after operation, take more deep breaths and cough, and get out of bed as soon as possible. Wearing medical elastic socks with pressure difference after operation, such as calf 4.0kPa(30mmHg) and thigh 2.67kPa(20mmHg), also plays the role of circulation drive.
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