tromboza venoasa profunda-o provocare terapeutica
DESCRIPTION
Diagnosticul si tratamentul TVP nu sunt intotdeauna usor de realizat. Din constelatia de antitrombotice, alegerea schemei si dozajului terapeutic pentru liza trombusului si/sau preventia secundara, pune serioase probleme in practica medicalaTRANSCRIPT
Tromboza venoasa Tromboza venoasa profundaprofunda
o provocare terapeutica
Andritoiu Alexandru*, Silosi Cristian**
Spitalul Clinic de Urgenta Militar Craiova*Sectia Medicina Interna
** Clinica Chirurgie
TVPTVP
• The precise number of people affected by DVT/PE is unknown, but estimates range from 300.000 to 600.000 (1 to 2 per 1000, and in those over 80 years of age, as high as 1 in 100) each year in the United States.
• Estimates suggest that 60.000-100.000 Americans die of DVT/PE (also called venous thromboembolism).
• Among people who have had a DVT, one-half will have long-term complications (post-thrombotic syndrome)
TVP - Complicatiile TVP - Complicatiile tardivetardive
• Sdr. post-trombotic
• TEP recurent
Metode de diagnostic Metode de diagnostic flebologicflebologic
• Clinic• D-dimeri• US• Venografie• Isotopi• Angio-CT/RMN
USUS• B-mode• Doppler color• Doppler spectral• Power-angio• B-flow• CEUS• Elastografie
FLEBOGRAFIA – ,,gold standard,,
FlebografiaFlebografia
In cazuri selectionate!
US Doppler TVP-V. popliteeUS Doppler TVP-V. poplitee
Flux absent in vena popliteeFlux prezent in artera homolaterala
Scorul WellsScorul Wells
TVP in situatii clinice particulareTVP in situatii clinice particulare
• Sarcina/trombofilie• Neoplazii• Arterite inflamatorii• Repaus prelungit la pat (Stroke, IMA)• Post chirurgical (pelvis, abdomen, ortopedie)• Gonartroza• Cateterism venos• Droguri cu risc inalt• Medicamente cu risc pro-trombotic
Obiectivele terapieiObiectivele terapiei
• Dizolvarea trombusului
• Prevenirea extensiei proximale
• Prevenirea recurentei TVP
• Prevenirea/tratamentul TEPA
• Prevenirea sdr. post-trombotic
Mijloace terapeuticeMijloace terapeutice
Farmacologice• anticoagulante• antiagregante• tromboliticeMecanice• fragmentarea trombusului• trombo-suctiuneaHemodinamice• Contentia in ciorap elastic
Heparina nefractionataHeparina nefractionata
LMWH/FondaparinaLMWH/Fondaparina
TVP cu TEPATVP cu TEPA
TVP in neoplaziiTVP in neoplazii
Mecanism auto-imun (asociata cu tromboza a/v 30-50% cazuri)
Agenti anticoagulanti alternativiAgenti anticoagulanti alternativi
• Fondaparina• Danaparoid• Lepirudin• Argatroban
ContraindicatiiContraindicatii
Risc mai redus de sangerareRisc mai redus de sangerare
Indicatii/ContraindicatiiIndicatii/Contraindicatii
Profilaxia primara
• Preoperator • Antiagregante • LWMH
Antiagregantele plachetareAntiagregantele plachetare
• In profilatia TVP
Direct comparisons of proportional effects of different antiplatelet regimens on deep venous thrombosis and on pulmonary embolism
BMJ 1994;308:235-246
Proportional effects of antiplatelet therapy on numbers of patients observed to have pulmonary embolism in trials that sought venous
thrombosis systematically after general and orthopaedic (traumatic and elective) surgery and in high risk medical patients
BMJ 1994;308:235-246
15 April 2000;Volume 355, Issue 9212, Pages 1295 - 1302,
Aspirin reduces the risk of pulmonary embolism and deep-vein thrombosis by at least a third throughout a period of increased risk.
There is now good evidence for considering aspirin routinely in a wide range of surgical and medical groups at high risk of venous thromboembolism.
Triflusal
• selective inhibition of TxB2 and platelet cyclo-oxygenase activity
• does not interfere significantly with endothelial synthesis of prostacyclin via the cyclooxygen ase-2 pathway.
• increases nitric oxide synthesis by neutrophils, and decreases the activity of nuclear transcription factor NF-B more than aspirin does
• inactivates intraplatelet phosphodiesterase • potentiates the antiaggregant effect of cAMP and
cGMP • These pharmacological differences make triflusal
potentially more effective and safer than aspirin
Triflusal appears to provide prevention of thromboembolic risk to patients who have undergone hip surgery, particularly total hip replacement
The amount of blood transfused was significantly reduced in triflusal compared with aspirin recipients who underwent hip surgery.
Risk of haemorrhage was also reduced in patients receiving triflusal versus aspirin.
Atentie!Atentie!
• Dovezi certe in preventia Stroke-FibA!
• Ghidurile nu recomanda Triflusal in TVP!
Profilaxia recurentei Profilaxia recurentei TVP/EPTVP/EP
• Antiagregante
• LWHM
• Anticoagulante dicumarinice
• NOAC
Risk-Assessment Model for Venous Thromboembolism According to the Khorana Score
Connors JM. N Engl J Med 2014;370:2515-2519
Comparison of Recommendations regarding Prophylaxis against Venous Thromboembolism
Connors JM. N Engl J Med 2014;370:2515-2519
Profilaxia secundaraProfilaxia secundara (dicumarinicele)(dicumarinicele)
Long-term therapy• Coumadin
(warfarina)• Acenocumarol
(sintrom, trombostop)
• Reduce riscul de recurenta >90%
• INR optim 2-3• Risc de sangerare
3% /an
Profilaxia secundara Profilaxia secundara NOACNOAC
Trombofilia / Riscul de recurentaTrombofilia / Riscul de recurenta
Durata proxilaxiei secundareDurata proxilaxiei secundare
Raportul risc de recidiva/risc de sangerare
Experienta noastra
• Peste 50 cazuri TVP- dupa 2010• Prima cauza de deces in Sp. Militar Cva!• TEPA masiv – cauza de deces• Dupa interv. chirurgicale - abdomniale/pelvine - ortopedie - neoplazii
• +/- Asociate cu obezitatea
1. Case report1. Case report
T. Maria, 48 ani• Fibrom uterin• Tratament: Orgametril• Edem masiv m. inf. stg.
Fibromatoza uterin
Tromb masiv ocluziv in v. iliaca comuna stg
US DopplerUS Doppler
TVP - V. iliaca com. stgTVP - V. iliaca com. stg
Confirmare Angio-RMN
Ex. BiologiceEx. Biologice
• VSH 56-41 mm/h• Fibrinogen 440 mg/dL• CRP 4mg/dL• Hb 7.5 g/dL• Sideremie 7 microgr/dL• Tb 635.000 /mmc• CEA - negativ• CA 125 - negativ
Coagulograma• INR 2.5• TQ 35 sec• AP 20%• APTT 44 sec
Rezolutia trombozeiRezolutia trombozei
• Clexane 1mg/Kgc• Sintrom 2 mg• Aflen 300 mg• Detralex• Contentie elastica
Dupa 20 zile
Profilaxia recidivei/TEPAProfilaxia recidivei/TEPA
• Sintrom ¼ cp• Aflen 300 mg x 2• Detralex 2 x1 cp• Contentie elastica
Reevaluare la 3 luni• Fara tromboza US• Fara TEPA• INR 2.2-2.9
2. Case Report2. Case Report
S. Filofteia, 50 yr• 2009 TVP Fem-Popl stg• Repetate episoade EP• APP: hipercolesterolemie TRATAMENT• Sintrom 4mg• Aflen 1 cp/zi• Detralex 2 x 1 cp/zi• Endolex 2 x 1 cp/zi• Lioton gel – local• Sortis 20 mg/zi
• VSH 21-50-125-60-37• D-dimeri pozitivi• Colesterol 325• LDL-Col178 mg/dL• HDL-Col 56 mg/dl• CRP pozitiva• Proteina S 31% (55-140)• Proteina C 57% (70-130)• AT III122% (>80)
3. Case report3. Case report
A. Emil, 42 yrA. Emil, 42 yr• Iulie 2008- TVP-V. popl stg.• Febr. 2010: TVP Fem-Popl dr. TEPA
masiv• ECG: RS, Ax QRS la dreapta, T neg
anterior• Doppler: tromboza profunda ax
venos femuro-popliteu dr• D-dimeri pozitivi• Angio CT: coronare permeabile Tromb rezidual non-ocluziv A
pulmonara dr
• Tratament• Sintrom 2 mg/zi• Aflen 1 cp/zi• Detralex 2 x 1 cp/zi• Venoruton, gel-local
• Rezolutia trombului -6 luni
• Fara recidiva TEPA• A sistat tratam.
antitrombotic dupa 12 luni!
4. Case report4. Case report
D. Adriana, 43 yr
• Edem masiv m. inf.dr.
• Internare Chir. Sp. Jud
• Tratatment: Sintrom - INR 2.8!
• 2 sapt.- Recidiva edemului!
• Reinternare Sp. Mil.
• D-dimeri pozitivi
Doppler-Elastografia TVPDoppler-Elastografia TVP
TVP F-P dr. – la 2 sapt. de la debut (recidiva sub Sintrom)
QUIZ
Care este cea mai buna solutie terapeutica?
• Pastrarea Sintrom (INR optim) si expectativa
• Adaugare anti-agregant
• Inlocuirea Sintrom cu NOAC
• Tratament interventional
Tratament
In spital• Heparina nefractionata 1000 UI/h (25.000 Ui/zi)-72 h• Clexane s.c -5 zile• Clexane+Sintrom 3 zile• Externare: edem redus Tratament la domiciliu• Sintrom 2mg/z• Aflen 300 mg/z• Detralex• Contentie elastica• INR la 1 L• Reevaluare Doppler-Elasto+D-dimeri+INR la 1-3 luni
Concluzii
• TVP – ramane o provocare terapeutica• Multiple optiuni terapeutice antitromboticeImportant:• Localizarea trombusului• Vechimea trombusului• Atingerea raportului Risc/Beneficiu optim (la limita
sangerarii!)• Raport cost-eficienta (tratament 6L-24 L)
Combinatia ACO+Antiagregant
• Potenteaza efectul antitrombotic
• Permite reducerea dozelor de ACO
• Dupa 3 luni - doar antiagregant• Fara recidiva trombotica• Fara recidiva embolica• Fara risc major de sangerare