#16
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#17
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Îêñàíà Âëàäèìèðîâíà, íó ïîíÿòíî æå, ÷òî îòñòóòñòâèå îòåêà íå ìîæåò ãàðàíòèðîâàòü íàëè÷èå ïîëíîé ðåêàíàëèçàöèè. Õî÷ó íàïîìíèòü, ÷òî êàñàòåëüíî ãëóáîêèõ âåí íåò äàæå ïðèìåðíîãî îðèåíòèðà - êàêàÿ ñòåïåíü ñòåíîçà ÿâëÿåòñÿ ãåìîäèíàìè÷åñêè çíà÷èìîé. Ýòî, êñòàòè, ñîçäàåò ïðîáëåìû â îöåíêå ðåçóëüòàòîâ ëþáîãî ìåòîäà âèçóàëèçàöèè, â òîì ÷èñëå è IVUS.
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Èëþõèí Åâãåíèé Àðêàäüåâè÷ |
#18
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Öèòàòà:
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Èëþõèí Åâãåíèé Àðêàäüåâè÷ |
#19
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Handbook of Venous Disorders Guidelines of the American Venous Forum, Third Edition. 2009. Peter Gloviczki
Öèòàòà:
Èç ACCP 9: Öèòàòà:
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Èëþõèí Åâãåíèé Àðêàäüåâè÷ |
#20
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Íå âèæó ïîêàçàíèé ó äàííîé ïàöèåíòêè òàê óãëóáëÿòüñÿ â âèçóàëèçàöèþ âåí. Êàêîé áû ó íåå ïðîöåíò ñòåíîçà íå áûë, íà ÷òî ýòî ìîæåò ïîâëèÿòü?
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#21
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Èç Âàøåé ññûëêè ñëåäóåò, ÷òî ó æåíùèí, ó êîòîðûõ Òàâîçíèê âî âðåìÿ áåðåìåííîñòè èëè ïîñëå ðîäîâ, âî âðåìÿ ñëåäóþùåé áåðåìåííîñòè íåîáõîäèìà àíòèêîàãóëÿöèÿ. Çà÷åì òîãäà èñêàòü òðîìáîôèëèþ, åñëè â ëþáîì ñëó÷àå íà âåñü ïåðèîä áåðåìåííîñòè áóäåò íàçíà÷åí ÍÌÃ?
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#22
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 ïîðÿäêå äèñêóññèè ïðèâåäó ôðàãìåíò íåäàâíî îïóáëèêîâàííîãî ýêñïåðòíîãî (àâòîð, íàïðèìåð, íåäàâíî îïóáëèêîâàë(à) â Áëàäå "Êàê ÿ ëå÷ó ÒÃÂ, âîçíèêøèé â ïåðèîä áåðåìåííîñòè") îáçîðà, êîòîðûé ñ ïîçèöèè äîêàçàòåëüíîé ìåäèöèíû ñòàâèò ïîä ñîìíåíèå òàêîå òåñòèðîâàíèå íà òðîìáîôèëèþ â ðóòèííîì ïîðÿäêå, ïîêà íå áóäóò ïîëó÷åíû óáåäèòåëüíûå äàííûå, ÷òî ïðîäëåííîå íàçíà÷åíèå ÀÊ ïàöèåíòàì ñ òðîìáîôèëèåé äåéñòâèòåëüíî äàåò ýêñöåññ áåíåôèòîâ íàä îñëîæíåíèÿìè:
In general, after a first episode of venous thrombosis, 3–6 months of anticoagulant therapy is considered to have the optimal balance between the risk of treatment (bleeding) and the benefit (prevention of an extension or recurrence of venous thrombosis) [20]. In the absence of trials that compared routine and prolonged anticoagulant treatment in patients testing positive for thrombophilia, prolonged anticoagulant therapy cannot be justified as it may cause more harm than benefit. --- Evidence-based approach to thrombophilia testing [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
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#23
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Öèòàòà:
Ïðè ÷åì òóò ïðîöåíò ñòåíîçà? ß èìåë ââèäó, ÷òî äàæå âûðàæåííûé ñòåíîç ìîæåò áûòü ãåìîäèíàìè÷åñêè íåçíà÷èìûì - çíà÷èò íå ïðèâîäèòü ê îòåêàì. Çíà÷èò ïî îòñóòñòâèþ îòåêà íåëüçÿ ñóäèòü î íàëè÷èè èëè îòñóòñòâèè òðîìáîòè÷åñêèõ ìàññ â âåíå, à îíè ÿâëÿþòñÿ ôàêòîðàìè ðèñêà ðåöèäèâà ÒÃÂ. Ïîýòîìó áîëåå "ïðîçðà÷íîå" îïèñàíèå ñîñòîÿíèÿ âåí áûëî áû óìåñòíî, íà ìîé âçãëÿä. Ïî òðîìáîôèëèè. Ôàêò ïåðåíåñåííîãî òðîìáîçà, àññîöèèðîâàííîãî ñ áåðåìåííîñòüþ, íå ÿâëÿåòñÿ áåçóñëîâíûì ïîêàçàíèåì ê àíòèêîàãóëÿöèè â òå÷åíèå âñåé ñëåäóþùåé áåðåìåííîñòè. Îíà öåëåñîîáðàçíà (we suggest), íî, êàê ÿ ïîíèìàþ, ýòî òî ïîëîæåíèå, íà ðàâíîâåñèå êîòîðîãî ìîãóò ïîâëèÿòü äîïîëíèòåëüíûå ôàêòîðû. Ïîñåìó òàêè ñ÷èòàþ, ÷òî îáñëåäîâàíèå íà òðîìáîôèëèþ ïîêàçàíî. Ïðè÷åì, â ýòîì âîïðîñå ïðîñòî íå ìîæåò áûòü îäíîçíà÷íîãî êàòåãîðè÷íîãî îòâåòà è ðåêîìåíäàöèè - âñå áóäåò îêîí÷àòåëüíî ðåøàòüñÿ êîíêðåòíûì ñïåöèàëèñòîì íà ìåñòàõ. Öèòàòà:
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Èëþõèí Åâãåíèé Àðêàäüåâè÷ |
#24
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Èíòåðåñíûé ìîìåíò: ïðè ñðàâíåíèè ðåêîìåíäàöèé ACCP (ãäå àâòîð ó÷àñòâîâàëà êàê îäèí èç ýêñïåðòîâ):
9.2.1. For pregnant women with no prior history of VTE who are known to be homozygous for factor V Leiden or the prothrombin 20210A mutation and have a positive family history for VTE, we suggest antepartum prophylaxis with prophylactic- or intermediate-dose LMWH and postpartum prophylaxis for 6 weeks with prophylactic- or intermediate-dose LMWH or vitamin K antagonists targeted at INR 2.0 to 3.0 rather than no prophylaxis (Grade 2B). òîãäà êàê äëÿ âñåõ îñòàëüíûõ òðîìáîôèëèé (à çíà÷èò è äåôèöèò íàòóðàëüíûõ àíòèêîàãóëÿíòîâ) - 9.2.2. For pregnant women with all other thrombophilias and no prior VTE who have a positive family history for VTE, we suggest antepartum clinical vigilance... è ôðàãìåíò èç åå ïóáëèêàöèè Evidence-based approach to thrombophilia testing Only for women with antithrombin, protein C or protein S deficiency, or those who are homozygous for factor V Leiden, the risks during pregnancy may outweigh the nuisance of daily subcutaneous low-molecular-weight heparin injections and skin reactions, and the very small risk for severe complications of anticoagulant therapy during pregnancy [40–42].
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#25
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Åùå äåòàëü: â çíàìåíèòîì èññëåäîâàíèè
Blood. 2011 Aug 25;118(8):2055-61 Thrombotic risk during oral contraceptive use and pregnancy in women with factor V Leiden or prothrombin mutation: a rational approach to contraception. ãäå îöåíèâàëàñü ÷àñòîòà âîçíèêíîâåíèÿ ïåðâîãî òðîìáîçà ó æåíùèí-ðîäñòâåííèêîâ òðîìáîôèëèêîâ âî âðåìÿ áåðåìåííîñòè (÷àñòîòà òðîìáîçà 7.65% â ãîä ïðè íàëè÷èè êîìáèíèðîâàííîãî äåôåêòà) áûëî ïðîñëåæåíî 50 æåíùèí â òå÷åíèå 24 ëåò â ñðåäíåì, èç êîòîðûõ: 14 homozygote carriers of factor V Leiden, of whom 3 were also heterozygous for prothrombin G20210A, and 4 homozygote carriers of the prothrombin G20210A mutation... à çíà÷èò îñòàëüíûå 50 - 14 - 4 = 32 (64%) áûëè äâîéíûå ãåòåðîçèãîòû ïî ýòèì ìóòàöèÿì... òî åñòü åñëè ãîâîðèòü î ðåêîìåíäàöèÿõ ACCP, èçëîæåííûõ âûøå: "be homozygous for factor V Leiden or the prothrombin 20210A mutation", òî îíè äîëæíû íà÷èíàòüñÿ ñ äâîéíûõ ãåòåðîçèãîò, à ïîòîì òîëüêî ãîìîçîãîòû ïî äð. ìóòàöèÿì, òàê êàê ãîìîçèãîòíûå ìóòàöèè êðàéíå ðåäêè (îñîáåííî ïðîòðîìáèíîâàÿ) è áîëüøèíñòâîì ìàòåðèàëà äëÿ îöåíêè ðèñêà òðîìáîçà ïîñëóæèëè èìåííî äâîéíûå ãåòåðîçèãîòû...
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#26
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#27
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Ïðåäëàãàþ ïîñìîòðåòü â Ïàáìåäå.
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Èëþõèí Åâãåíèé Àðêàäüåâè÷ |
#28
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#29
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Óâàæàåìàÿ Îêñàíà Âëàäèìèðîâíà,
 ñâîåì îáçîðå "Natural History of Venous Thromboembolism" Clive Kearon äàåò 2 ññûëêè íà ïîäîáíûå èññëåäîâàíèÿ: The cumulative incidence of normal results on ultrasonography was 38.8% at 6 months, 58.1% at 12 months, 69.3% at 24 months, and 73.8% at 36 months. Of 58 recurrent episodes, 41 occurred while the patient had residual thrombosis. The hazard ratio for recurrent thromboembolism was 2.4 (95% CI, 1.3 to 4.4; P = 0.004) for patients with persistent residual thrombosis versus those with early vein recanalization. --- Ann Intern Med. 2002 Dec 17;137(12):955-60. Residual venous thrombosis as a predictive factor of recurrent venous thromboembolism. ïëþñ The absence of previous C-US normalization was the only predictor of recurrence or new thrombosis occurring after 3 and 6 months from the index DVT (OR 5.26, p 0.027). INTERPRETATION AND CONCLUSIONS: Absence of C-US normalization after a first episode of DVT appears to be a factor favoring recurrence or new thrombosis and may be relevant to the optimal duration of oral anticoagulant treatment. Normalization rates of compression ultrasonography in patients with a first episode of deep vein thrombosis of the lower limbs: association with recurrence and new thrombosis [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] âî âòîðîé ïóáëèêàöèè åñòü ñïèñîê ðàáîò, ãäå ïðîöèòèðîâàíà äàííàÿ ðàáîòà ïî ïîõîæåé òåìàòèêå, íàïð.: Residual vein thrombosis to establish duration of anticoagulation after a first episode of deep vein thrombosis: the Duration of Anticoagulation based on Compression UltraSonography (DACUS) study Residual thrombosis was detected in 180 (69.8%) of 258 patients; recurrent events occurred in 27.2% of those who discontinued (25/92; 15.2% person-years) and 19.3% of those who continued OAT (17/88; 10.1% person-years). The relative adjusted hazard ratio (HR) was 1.58 (95% confidence interval [CI], 0.85-2.93; P = .145). Of the 78 (30.2%) patients without RVT, only 1 (1.3%; 0.63% person-years) had a recurrence. The adjusted HR of patients with RVT versus those without was 24.9 (95% CI, 3.4-183.6; P = .002). [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
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Ýòè è äð. ïóáëèêàöèè ñóììèðîâàíû â îáçîðå, îïóáëèêîâàííîì â ATVB 2009 â ãëàâå Residual Venous Thrombosis (ñòð. 11)
Venous Thromboembolism: Risk Factors for Recurrence [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |