nepo

作者：Alice Goodman  
出處：WebMD醫學新聞

　　November 23, 2009（紐約訊）－根據一項發表在法伊特研討會的註冊研究數據，對慢性深部靜脈栓塞（DVT）患者而言，相較於使用非超音波協助血栓溶解，以超音波協助血栓溶解的積極介入預後更好。
　　
　　美國德拉威州紐阿克克里斯汀納照護健康服務血管與介入放射學研究計畫主任、部門主任Mark J. Garcia醫師表示，過去沒有人報告以超音波協助血栓溶解治療慢性DVT這個不好治療且陳舊的血栓，許多臨床醫師不治療這些病患。這些初期研究結果顯示，以超音波協助血栓溶解可以改善整體預後，並且降低栓塞後症候群的發生率。
　　
　　每年大約有600,000位病患發生DVT，且有100,000人因此死亡。大約30% 的DVT患者會在10年再次發生DVT，治療後的頭兩年風險最高。這些病患許多無法工作或是成為社會中具有生產力的一員。目前的治療選擇包括抗凝血劑以及使用彈性襪加上抬高肢體。目前並沒有高等級的證據支持慢性DVT患者接受血管內治療。
　　
　　Garcia醫師發表的DVT註冊試驗數據，包括53位慢性DVT患者，共有59條肢體（11條上肢、48條下肢）。5位病患被排除在分析之外（數據不完整或死亡）。在48位接受治療的病患中，只有1件失敗。患者的平均年齡為52歲，大約有50%是男性。在47次成功術式中，17件是超音波協助的、另外30件是非超音波協助。
　　
　　Garcia醫師評論，我們只在1位病患身上未能穿越病灶，這顯示我們可以做些什麼來幫助這些患者。
　　
　　超音波協助組可以達到67%血栓完全溶解，非超音波協助組則是52%。表示改善很多或部分改善的病患，在超音波協助組有60%、非超音波協助組有37%。
　　
　　Garcia醫師表示，不論是否以超音波協助，我們可以穿透每個病灶，且影響血流的事實，給每位病患某些程度的改善。
　　
　　接受超音波協助的病患，有50%在術後沒有症狀，非超音波協助組則是33%；兩組中受試者中，分別有17%與56%感受到某些疼痛。
　　
　　Garcia醫師指出，這項研究顯示臨床醫師應該讓病患繼續受苦。我們在治療DVT上必須更積極。部分臨床醫師表示，你所能做得非常有限。有數百萬人罹患慢性DVT。這是改變這些病患預後與生活品質的一個確切機會。
　　
　　他表示，需針對慢性DVT患者進行大型隨機分派研究，以確認這些發現。
　　
　　【未來的治療】
　　俄亥俄州辛辛那提大學外科教授George Meier醫師表示，我和許多同事完全同意超音波導引的血栓溶解是DVT未來的治療。
　　
　　他解釋，多年來，我們已經知道血栓溶解對於DVT有效。超音波導引血栓溶解重組了血栓，且讓血栓容易被滲透、甚至是破壞，這加速了這些流程。
　　
　　Garcia醫師與Meier醫師表示已無相關資金上的往來。


Ultrasound-Assisted Thrombolysis Improves Outcomes in Chronic DVT

By Alice Goodman
Medscape Medical News

November 23, 2009 (New York) — Aggressive intervention in chronic deep vein thrombosis (DVT) using ultrasound-assisted thrombolysis shows superior outcomes compared with non-ultrasound-assisted thrombolysis, according to registry data presented here at the Veith Symposium.

"No one else has reported on treating chronic DVT — the hard, old clot — with ultrasound-assisted thrombolysis. Many physicians don't treat these patients. These early results suggest that [ultrasound]-assisted thrombolysis can improve overall outcomes and reduce the incidence of postthrombotic syndrome," said Mark J. Garcia, MD, program director of Vascular and Interventional Radiology Fellowship and section chief at Christiana Care Health Services, Newark, Delaware.

Each year, about 600,000 patients will develop DVT, and about 100,000 will die. Approximately 30% of DVT patients will have recurrent DVT within 10 years, with the greatest risk occurring in the first 2 years. Many of these patients are unable to work or be productive members of society. Current treatment options include anticoagulation and compression stockings plus extremity elevation. There is no high-level evidence to support endovascular therapy in chronic DVT, he noted.

The DVT registry Dr. Garcia presented included 53 patients with chronic DVT involving 59 limbs (11 upper limbs and 48 lower limbs). Five patients were excluded from the analysis (incomplete data or death). Of 48 treated patients, only 1 failure occurred. Mean age was 52 years, and about 50% of the patients were men. Of 47 successful procedures, 17 were ultrasound-assisted and 30 were non-ultrasound-assisted.

"We only failed to cross one lesion in one patient. This shows we can do something to help these patients," Dr. Garcia commented.

Complete lysis was achieved in 67% of the ultrasound-assisted group vs 52% of the non-ultrasound-assisted group. Sixty percent of the ultrasound-assisted group said they were "much improved" or "somewhat improved" compared with 37% of the non-ultrasound-assisted group.

"The fact that we could traverse every lesion and affect flow gave every patient some degree of improvement, either with ultrasound assistance or without it," Dr. Garcia said.

Fifty percent of the ultrasound-assisted group had no symptoms after the procedure compared with 33% in the non-ultrasound-assisted group. Some pain was experienced by 17% vs 56%, respectively.

"This study showed that physicians should not sit back and let these patients suffer. We need to be proactive about treating chronic DVT. Some physicians say there is nothing you can do, but if you can traverse the chronic hard clot, you can make a difference. There are millions of patients out there with chronic DVT. This is a real opportunity to improve outcomes and quality of life for these patients," Dr. Garcia said.

He stated that there is a need for larger randomized trials in patients with chronic DVT to confirm these findings.

Treatment of the Future

"I, and many of my colleagues, completely agree that ultrasound-guided thrombolysis is the future for treatment of DVT," said George Meier, MD, professor of surgery, University of Cincinnati, in Ohio.

"We've known for many years that thrombolysis works for DVT. Ultrasound-guided thrombolysis shakes up the clot and allows better penetration and breakdown of the clot, speeding the process up," he explained.

Dr. Garcia and Dr. Meier have disclosed no relevant financial relationships.

Veith Symposium 2009. "Aggressive Interventional Treatment of Chronic DVT: A New Method to Decrease the Symptoms of the Post-Thrombotic Syndrome: Techniques and Early Results." Presented November 20, 2009.