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大家有木有發(fā)現(xiàn)一個(gè)問(wèn)題，肺栓塞的教材、指南，都不提一件事：肺栓塞要不要復(fù)查肺動(dòng)脈CTA，何時(shí)復(fù)查？ 鄙人覺(jué)得，肯定有必要復(fù)查。為什么呢？看下圖： 這是肺癌合并肺栓塞的CT?？床磺?？很正常，因?yàn)閲?guó)內(nèi)的文獻(xiàn)不喜歡給圖，喜歡一大堆灰常、灰常無(wú)聊的文字描述，即使有圖，也是非常的看不清。霧里看花，水中望月，不好意思，比這個(gè)清除。 以前遇到一個(gè)病人，肺癌合并肺栓塞。肺栓塞會(huì)屎人啊，國(guó)內(nèi)醫(yī)患關(guān)系這么惡劣，急性期肺栓塞做手術(shù)很危險(xiǎn)啊。然而，患者虐我千百遍，何時(shí)妨礙我手閑？沒(méi)有擴(kuò)散的肺癌都要盡量手術(shù)啊。怎么辦？腫么辦？ 先抗凝，一月后復(fù)查肺動(dòng)脈CTA，血栓消失，趕緊手術(shù)，萬(wàn)一進(jìn)展了錯(cuò)失良機(jī)成千古恨。術(shù)后病理證實(shí)為肺癌，術(shù)后繼續(xù)抗凝，長(zhǎng)期存活。 問(wèn)題來(lái)了：不復(fù)查肺動(dòng)脈CTA，如何和諧的開(kāi)展手術(shù)？所以，肺栓塞有必要復(fù)查肺動(dòng)脈CTA。 還有，肺栓塞治療要多久？2015年中國(guó)急性肺栓塞診斷與治療專(zhuān)家共識(shí)指出：有明確危險(xiǎn)因素的急性肺栓塞，例如手術(shù)誘發(fā)的、坐飛機(jī)誘發(fā)肺栓塞，如已去除暫時(shí)性危險(xiǎn)因素，推薦抗凝治療3個(gè)月；無(wú)明確誘發(fā)危險(xiǎn)因素的急性肺栓塞：應(yīng)給予口服抗凝治療至少3個(gè)月；腫瘤患者發(fā)生急性肺栓塞后應(yīng)接受長(zhǎng)期抗凝治療。 那么，抗凝到了療程，難道就自動(dòng)停藥？你不復(fù)查怎么知道還有沒(méi)有血栓。難道就算是有血栓，療程到了，也要停藥？所以，肺栓塞肯定需要復(fù)查肺動(dòng)脈CTA，就算是不復(fù)查肺動(dòng)脈CTA，至少也要復(fù)查肺通氣灌注掃描吧！ 那么，如何復(fù)查？何時(shí)復(fù)查？很奇怪，指南不說(shuō)，教材不說(shuō)，讓你自己意會(huì)。 既然如此，各憑感覺(jué)發(fā)揮，我來(lái)查查文獻(xiàn)，和大家討論一下這個(gè)無(wú)聊而又非常有意義的話(huà)題。 先來(lái)看看國(guó)內(nèi)的文獻(xiàn)： 文獻(xiàn)1：山東大學(xué)齊魯醫(yī)院。 山東大學(xué)齊魯醫(yī)院放射科，肺栓塞42例患者，在溶栓或抗凝治療后1~3周復(fù)查螺旋CT，發(fā)現(xiàn)病灶消失24例，病灶減少18例。 文獻(xiàn)2： 王辰院士參與的一項(xiàng)研究，確診的23例肺栓塞患者，所有患者行溶栓治療，并分別于治療前、治療后24 h及14 d行CTPA檢查。肺動(dòng)脈栓塞指數(shù)在溶栓治療后逐漸減小。 復(fù)查的非?？?。 文獻(xiàn)3： 西，9例患者，所有患者均在溶栓后1~2周復(fù)查，3例復(fù)查后血栓基本消失。 文獻(xiàn)4： 中山大學(xué)附一院，14例大面積肺栓塞，8例治療24小時(shí)后復(fù)查，所有患者2周、1個(gè)月、3個(gè)月復(fù)查。8例治療24小時(shí)后復(fù)查，2例加重，2周后復(fù)查，部分血栓已經(jīng)再通、或者血栓減少。總共176支肺動(dòng)脈有血栓，1月后復(fù)查，97.2%的血管完全再通，3月后復(fù)查高達(dá)98.3%。 對(duì)于中心充盈缺損、蜂窩狀充盈缺損、內(nèi)緣隆起充盈缺損為主的血栓，多為新鮮血栓，2周復(fù)查。覆壁充盈缺損、完全充盈缺損，1~3個(gè)月復(fù)查。 文獻(xiàn)5： 廣州呼吸疾病研究所，報(bào)道一例騎跨肺栓塞，溶栓后第4天復(fù)查胸部CT造影，對(duì)比溶栓前，CT示雙側(cè)肺動(dòng)脈主干血栓消失、右下肺基底段肺動(dòng)脈栓塞較前明顯改善。 文獻(xiàn)6： .南京醫(yī)科大學(xué)的報(bào)道，以CTA隨訪(fǎng)的患者55例,隨訪(fǎng)時(shí)間為1-6周。 文獻(xiàn)7： 62例肺栓塞，43例血管造影、19例螺旋CT診斷的中央型肺栓塞，螺旋CT隨訪(fǎng)平均11月，不知道每個(gè)患者的具體隨訪(fǎng)時(shí)間。 隨訪(fǎng)中，48%的患者完全緩解，52%的患者血管內(nèi)仍有異常。 英文： To evaluate the resolution of acute central pulmonary embolism (PE). Sixty-two patients with angiographic (n = 43) or spiral computed tomographic (CT; n = 19) diagnosis of acute central PE underwent spiral CT after a mean of 11 months. At follow-up, 30 patients (group 1; 48%) had complete resolution of acute PE; 32 patients (group 2; 52%) showed endovascular abnormalities (mean follow-up in both groups, 10.5 months). 文獻(xiàn)8：
目的：研究急性肺栓塞CT隨訪(fǎng)的頻率。 納入600例患者，回顧性分析。病人至少隨訪(fǎng)14月。 Records of all patients were reviewed for at least 14 months. Pulmonary embolism was diagnosed by CT angiography in 600 patients. 23.5 %的患者1年內(nèi)，至少做一次CTA。 At least one follow-up CT angiogram in 1 year was obtained in 141 of 600 (23.5 %). 6.7 %的患者1年內(nèi)，做2次CTA；三次的占2.5 %，4次的占0.5 %。 Two follow-ups in 1 year were obtained in 40 patients (6.7 %), 3 follow-ups were obtained in 15 patients (2.5 %), and 4 follow-ups were obtained in 3 patients (0.5 %). 141例患者1年內(nèi)，至少做一次CTA，這些病人第一次隨訪(fǎng)CTA，10.6 %的患者肺栓塞復(fù)發(fā)。40例1年內(nèi)，做2次CTA，這些患者中15.0 %的病人第二次隨訪(fǎng)發(fā)現(xiàn)肺栓塞復(fù)發(fā)。 Among all patients, recurrent pulmonary embolism was diagnosed in 15 of 141 (10.6 %) on the first follow-up CT angiogram and in 6 of 40 (15.0 %) on the second follow-up. 作者觀(guān)點(diǎn)：應(yīng)該尋找替代方法復(fù)查肺栓塞，減少CT輻射。 Alternative options might be considered to reduce the hazard of radiation-induced cancer, particularly in young women. 文獻(xiàn)9：
512例患者，隨訪(fǎng)肺動(dòng)脈CTA平均6月。 METHOD AND MATERIALS A follow-up CTA was performed a mean of 6 months after onset in 512 patients with previous radiological confirmed PE. 隨訪(fǎng)后，59.7%的患者血栓溶解。 RESULTS The sample was integrated by 276 men (53,9%) and 236 women (45.8%) with a mean age of 67.6 years (SD: 17.6). follow-up, 306 patients (59.7%; group 1) had resolution of the clot. 40.2%的患者血管異常。 However 206 patients showed vascular abnormalities (40.2%; group 2). 21.5%的患者CTA仍然提示急性肺栓塞，18.8%發(fā)展為慢性肺栓塞。 Of these, CTA showed persistence of acute PE in 110 patients (21.5%; group 2a) and development of chronic PE in 96 patients (18.8%; group 2b). 作者觀(guān)點(diǎn)：達(dá)到療程常規(guī)?？鼓委?，需要影像學(xué)證實(shí)血栓溶解。慢性肺栓塞需要血栓切除，這些情況都需要早期復(fù)查CTA，及時(shí)發(fā)現(xiàn)慢性肺栓塞。一句話(huà)，肺栓塞的隨訪(fǎng)，需要復(fù)查CTA。 CONCLUSION Thus, routine cessation of anticoagulant therapy in patients with PE should be aided by an image confirmation of the clot resolution.Besides, there is a significant percentage of patients that evolved to chronic PE (18,8%) and pulmonary hypertension (2.7%), whose early detection can improve management, because it has become potentially remediable by thromboendarterectomy. 文獻(xiàn)10：
19例患者，抗凝治療6月之后復(fù)查。只有32%的患者復(fù)查CT正常。 METHOD: Nineteen patients with acute PE initially identified with spiral CT scan underwent repeat CT examinations at 6 week follow-up after the start of anticoagulant therapy. RESULTS: Normalization of the pulmonary arteries at follow-up was seen in six patients (32%) only. 文獻(xiàn)11：
作者單位：Michigan State University。密歇根州立大學(xué)。 69 patients with acute PE from two hospitals were assessed。 69例急性肺栓塞納入研究。 Complete CT angiographic resolution of PE was seen in six of 15 patients (40%) 2-7 days after diagnostic imaging. 2~7天后復(fù)查，15例患者中，6例肺栓塞完全好轉(zhuǎn)。 After day 28, complete resolution occurred in 17 of 21 patients (81%). 28天時(shí)，21例中，17例完全好轉(zhuǎn)。 Most patients (81%) showed complete resolution of PE on CT angiography after 28 days .28天后，81%的患者肺栓塞完全好轉(zhuǎn)。 PEs resolved faster in the main and lobar pulmonary arteries than in the segmental branches. 相對(duì)于段肺動(dòng)脈，主肺動(dòng)脈、葉肺動(dòng)脈肺栓塞，好轉(zhuǎn)的更快。 文獻(xiàn)12：
作者：Michigan State University。 One hundred and seventy-two outpatients [102 women; mean age 56.7 ± 18.8 (SD)] with an initial CTPA that was negative for pulmonary embolism and a subsequent CTPA within 12 months of their initial study were included in our analysis. 172例初次肺動(dòng)脈CTA陰性者，12月內(nèi)復(fù)查過(guò)CTA者，納入研究。 CTPAs were negative for pulmonary embolism in 165 (96%) of 172 outpatients who returned to care within 12 months after an initial negative CTPA. 96%的患者復(fù)查也是陰性。 In the group with no risk factors none (0%) of 85 patients (P = 0.028) had pulmonary embolism at the time of repeat CTPA. 沒(méi)有危險(xiǎn)因素的那一組，復(fù)查CTA全部均無(wú)血栓。 文獻(xiàn)13：
作者：波斯尼亞熱窩大學(xué)，有意思。University Hospital of Sarajevo, Sarajevo, Bosnia。 總共83例，其中23例經(jīng)肺通氣灌注掃描診斷為肺栓塞，并隨訪(fǎng)6月。 Of 83 consecutive patients with clinically suspected PE examined with V/P SPECT, 23 patients with confirmed PE were followed by serial V/P SPECT examinations over a 6-month period. 隨訪(fǎng)2周，肺栓塞面積減少 54±26% ，3月時(shí)79±30%，6月時(shí)82±30%。 The mean relative decrease in PE extent compared with the time of diagnosis was 54±26% at 2 weeks, 79±30% at 3 months, and 82±30% at 6 months. 建議抗凝治療后三月隨訪(fǎng)復(fù)查肺通氣灌注掃描。 This study also confirms that resolution of perfusion defects after PE occurs within the first 3 months of treatment. It is therefore recommended that V/P SPECT follow-up should be considered at 3 months after diagnosis. 文獻(xiàn)14：
德國(guó)佬寫(xiě)的 Thirty-three patients (15 female, 18 male, mean age 59.4 years) with acute PE were examined initially and 1 week later using both 16-row computed tomography (CT) and MRI with magnetic resonance angiography (MRA), real-time MRI and magnetic resonance (MR) pulmonary perfusion imaging. 33例納入研究，1周后復(fù)查，采用肺血管增強(qiáng)CT與MRA（磁共振血管成像）、MR肺灌注掃描做對(duì)比。 Follow-up examinations were feasible for all patients. Diagnosis of PE was concordant between MRI and CT in all patients. 磁共振也可以隨訪(fǎng)肺栓塞。 文獻(xiàn)15：
Nineteen patients with acute PE initially identified with spiral CT scan underwent repeat CT examinations at 6 week follow-up after the start of anticoagulant therapy. 19例肺栓塞患者，抗凝6周后復(fù)查CT。 Normalization of the pulmonary arteries at follow-up was seen in six patients (32%) only. 只有6例(32%)正常。Residual abnormalities were present in 13 of 19 patients (68%). 其余血管均有異常發(fā)現(xiàn)。 肺栓塞治療后，如何判斷療效？最新專(zhuān)家共識(shí)也不說(shuō)。 2010年的中國(guó)專(zhuān)家共識(shí)這樣說(shuō)： 溶栓療效觀(guān)察指標(biāo)：(1)癥狀減輕，特別是呼吸困難好轉(zhuǎn)。(2)呼吸頻率和心率減慢，血壓升高，脈壓增寬。(3)動(dòng)脈血?dú)夥治鲋笜?biāo)好轉(zhuǎn)。(4)心電圖相關(guān)指標(biāo)好轉(zhuǎn)。(5)胸部x線(xiàn)平片顯示的肺紋理減少或稀疏區(qū)變多、肺血流分布不均改善。(6)超聲心動(dòng)圖表現(xiàn)如室間隔左移減輕、右房右室內(nèi)徑縮小、右室運(yùn)動(dòng)功能改善、肺動(dòng)脈收縮壓下降、三尖瓣反流減輕等。 也不提肺動(dòng)脈CTA。 個(gè)人觀(guān)點(diǎn)及總結(jié)： 肺栓塞何時(shí)復(fù)查肺動(dòng)脈CTA，要看病情，病情加重，及時(shí)復(fù)查，血栓增多有可能需要溶栓或改變抗凝方案。 肺肺栓塞合并肺癌，2周至一個(gè)月復(fù)查，有條件及時(shí)手術(shù)切除肺癌。 抗凝療程已到，也需要復(fù)查，仍有血栓，需要繼續(xù)治療。 參考文獻(xiàn)：
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來(lái)自： 昵稱(chēng)71917755 > 《待分類(lèi)》
