Вопросы коллегам

[angio]

бифуркационное стентирование ПМЖА-ДВ-1 двумя DES.

[rsp]

Сообщение от angio

бифуркационное стентирование ПМЖА-ДВ-1 двумя DES.

общий принцип, если ситуация плановая, лучше не ввязываться...А так теперь придется балансировать между потенциальными рисками ТЭЛА/кровотечения/тромбоза стента

[angio]

Общий принцип понятен.

Дело ведь в том, что у пациента нет к примеру ФП. ИМХО, пациент относится к группе низкого риска по ТЭ и среднего риска по кровотечениям. ДААТ он будет принимать не менее года.

Интересно только то, чего я нигде не смог прочитать -
а) насколько пациенты с кава-фильтром должны быть привержены к терапии антикоагулянтами?
б) нужна ли она на "неопределенно долгий срок"??
в) и можно ли ее "заменить" на ДААТ? - все-таки железка стоит не в артериальной системе, неужели она никогда не эндотелизируется???

[rsp]

Сообщение от angio

Общий принцип понятен.

Дело ведь в том, что у пациента нет к примеру ФП. ИМХО, пациент относится к группе низкого риска по ТЭ и среднего риска по кровотечениям. ДААТ он будет принимать не менее года.

Интересно только то, чего я нигде не смог прочитать -
а) насколько пациенты с кава-фильтром должны быть привержены к терапии антикоагулянтами?
б) нужна ли она на "неопределенно долгий срок"??
в) и можно ли ее "заменить" на ДААТ? - все-таки железка стоит не в артериальной системе, неужели она никогда не эндотелизируется???

Из нескольких существующих руководст по использованию кавафильтров нам близки по духу эти: Guidelines on use of vena cava filters/British Committee for Standards in Haematology: Writing group: T. P. Baglin1 J. Brush2 M. Streiff3

Vena cava filters are indicated to prevent PE in patients with
VTE who have a contraindication to anticoagulation (grade
B, level III).
1.2. Should anticoagulant treatment be started when there
is no longer a contraindication?
The most frequent complication of VC filters is recurrent
venous thrombosis. Also PE may occur. Therefore, it is
common practice to initiate anticoagulation after filter
insertion if and when there is no longer a contraindication
to anticoagulant therapy (Streiff, 2000). However, case-series
have not demonstrated a benefit from introducing anticoagulation
for the sole purpose of preventing filter-related
thrombotic events (Jones & Fink, 1994; Ortega et al, 1998).
This result may have been because of an inadequate intensity
of anticoagulation. In the long-term follow up of patients in
the PREPIC (Prevention du Risque d’Embolie Pulmonaire par
Interruption Cave) study, 43% of patients who developed
recurrent thromboembolism were on anticoagulation. The
imperfect protection afforded by anticoagulation and the
significant cumulative incidence of major (14.3%) and fatal
bleeding (4.3%) during the study period suggest that anticoagulant
therapy for patients with VC filters should be guided
by an assessment of the patient’s risk of recurrent VTE and
major bleeding, and not the presence of the filter alone (The
PREPIC Study Group, 2005).
Recommendation
Anticoagulation should be considered when a temporary
contraindication to anticoagulant therapy is no longer
present. Insufficient data exists to support a recommendation
that all filter recipients should be treated with
indefinite anticoagulation regardless of their risk of recurrent
thrombosis (grade C, level IV). The decision as to
whether or not to introduce anticoagulant therapy should
be based on the perceived underlying thrombotic risk of
the condition and the likelihood of anticoagulant therapyrelated
bleeding.

[thorn]

Сообщение от angio

Интересно только то, чего я нигде не смог прочитать
а) насколько пациенты с кава-фильтром должны быть привержены к терапии антикоагулянтами?
б) нужна ли она на "неопределенно долгий срок"??
в) и можно ли ее "заменить" на ДААТ? - все-таки железка стоит не в артериальной системе, неужели она никогда не эндотелизируется???

Обычно рекомендуют на неопределенно долгий срок, но не очень уверенно... ИМХО в данной ситуации лучше отказаться от варфарина и идти на двойной терапии минимум год, а там посмотреть...

Greenfield LJ, Proctor MC. Recurrent thromboembolism in patients with vena cava filters.J Vasc Surg. 2001 Mar;33(3):510-4.
Source
Department of Surgery, University of Michigan Hospital, Ann Arbor 48109, USA. [Ссылки доступны только зарегистрированным пользователям ]
Abstract
BACKGROUND:
Patients with venous thromboembolic disease are treated with anticoagulation or vena cava filter placement to prevent pulmonary embolism. A recent report suggested that filter placement may increase the risk of recurrent deep venous thrombosis (DVT) and prompted a review of our experience.
METHODS: Prospectively collected data on 2109 consecutive patients receiving filters were evaluated for recurrent thromboembolism, vena cava occlusion, or venous stasis ulceration. Outcomes were stratified and analyzed according to the use of anticoagulants at the time of insertion and at follow-up. Incidence rates were also compared with reports in the literature.
RESULTS: Of 1191 patients with DVT at filter placement, complete follow-up data at a mean of 9 years were available for 465. Recurrent DVT was found in 12% of the 241 patients who were given anticoagulants and 15% of the 224 who were not (P >.05). We also failed to find a significant association between the use of anticoagulation and the incidence of pulmonary embolism (2%), stasis ulceration (2%), and vena cava occlusion (0.0).
CONCLUSIONS: Recurrent DVT in patients with existing thromboembolic disease is not an unexpected event, which, in our experience, is not associated with anticoagulant or filter use. Anticoagulation should be used when possible to treat existing DVT to reduce thrombus progression and potentially to reduce subsequent complications but does not seem to reduce the rate of recurrent DVT. Rates of recurrent thromboembolism were consistently less than the 20% to 50% reported in the literature.

Poletti PA, Becker CD, Prina L, Ruijs P, Bounameaux H, Didier D, Schneider PA, Terrier F. Long-term results of the Simon nitinol inferior vena cava filter. Eur Radiol. 1998;8(2):289-94.
Source
Department of Radiology, Division of Diagnostic and Interventional Radiology, Geneva University Hospital, 24 Rue Micheli-du Crest, CH-1211 Geneva 14, Switzerland.
Abstract
The aim of this study was to evaluate the clinical efficacy, mechanical stability, and safety of the Simon nitinol inferior vena cava filter (SNF). The SNF was inserted in 114 consecutive patients at two institutions for prophylaxis of pulmonary embolism (PE). Clinical follow-up data were obtained retrospectively on all patients, and 38 patients underwent a dedicated radiologic follow-up protocol consisting of abdominal radiography, Doppler sonography, and CT. There was no immediate complication following filter insertion. Fifty patients died, on average, 5.6 (1-23) months after filter insertion, and 64 patients were alive, on average, 27 (3-62) months after filter insertion. Recurrent pulmonary embolism was documented in 5 patients (4.4 %) but originated distal to the filter in 1 patient. Deep venous thrombosis (DVT) was documented in 5.3 %, thrombosis at the access site in 3.5 %, and thrombosis of the inferior vena cava in 3.5 %. The rate of thromboembolic complications was similar in patients who did receive long-term anticoagulation and in those who did not. Radiologic follow-up showed no filter migration after, on average, 32 (5-62) months. A CT examination showed that struts of the SNF had penetrated the vena cava in 95 %, and were in contact with adjacent organs in 76 %; however, there were no clinical symptoms attributable to the filter. Filters were in an eccentric position in 63 % and partial filter disruption was found in 16 %; however, this did not affect filter function. The rate of recurrent pulmonary embolism after insertion of the SNF is 2.4 % per patient per year. Regardless of long-term anticoagulation, the rate of caval thrombosis is acceptably low. Except for occasional access-site thrombosis, no other filter-related morbidity was observed.

[angio]

Всем огромное спасибо за обсуждение!!!

Хотя я еще раз запутался во всех рекомендациях, но чувствую себя несколько менее озадаченным.

С одной стороны "all filter recipients should be treated with indefinite anticoagulation regardless of their risk of recurrent thrombosis" - только не очень понятно что обозначает "(grade C, level IV)" - необязательность гипокоагуляции или относительная независимость от риска ТЭ?

С другой стороны: "The rate of thromboembolic complications was similar in patients who did receive long-term anticoagulation and in those who did not"

_________________________________________

Можно ли сделать такой вывод, что пациентам с низким риском кровотечений лучше поддерживать гипокоагуляцию (на неопределенном уровне), а пациентам со средним и высоким риском кровотечений можно обойтись ДААТ?
____________________________________________

Сообщение от shok

лучше не менее 1,5

можете не сомневаться.

[rsp]

Сообщение от angio

С одной стороны "all filter recipients should be treated with indefinite anticoagulation regardless of their risk of recurrent thrombosis" - только не очень понятно что обозначает "(grade C, level IV)" - необязательность гипокоагуляции или относительная независимость от риска ТЭ?

в этом документе используется другая шкала уровня доказательности:

Classification of Evidence Levels

Ia Evidence obtained from meta-analysis of randomised controlled trials.

Ib Evidence obtained from at least one randomised controlled trial.

IIa Evidence obtained from at least one well-designed controlled study without randomisation.

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study (refers to a situation in which implementation of an intervention is without the control of the investigators, but an opportunity exists to evaluate its effect).

III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.

IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.

Classification of Grades of Recommendations

Grade A Requires at least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing specific recommendation (Evidence levels Ia, Ib).

Grade B Requires the availability of well conducted clinical studies but no randomised clinical trials on the topic of recommendation (Evidence levels IIa, IIb, III).

Grade C Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates an absence of directly applicable clinical studies of good quality (Evidence level IV).

[rsp]

Относительно данного случая, поддержу коллегу thorn'a. Я тоже склонился бы отменить антикоагулянты на период 2ААТ, если сейчас по данным УЗИ вен ног и глубоких вен таза нет признаков тромбоза, кава-фильтр в нижней полой вене располагается ниже устьев почечных вен и также без признаков тромбоза, по сцинти легких нет данных о множественных дефектах перфузии. После 2ААТ, рекомендовал бы аспирин+варфарин (мно=2-2.5).

[Gilarov]

Если у пациента ТГВ и флотирующий тромб, то это относительное показание к имплантации кава-фильтра и пациенту нужны антикоагулянты. Само по себе устройство в вене антикоагулянтов не требует, ибо его имплантируют в тех случаях, когда прием антикоагулянтов невозможен и их, соответственно, не принимают. Риск кровотечений на фоне тройной терапии представляется куда более серьезной угрозой, чем тромбоз кава-фильтра.

[Gilarov]

Вдогонку...
Int Angiol. 2006 Mar;25(1):60-6.
Recurrent venous thromboembolism in patients with and without anticoagulation after inferior vena caval filter placement.
Yale SH, Mazza JJ, Glurich I, Peters T, Mukesh BN.
AIM:
The aim of this study was to compare the rate of recurrent venothromboembolic (VTE) events and factors contributing to VTE events in patients with inferior vena caval (IVC) filters on chronic anticoagulation to those in whom anticoagulation was discontinued.

METHODS:
Retrospective cohort study of 353 patients who received IVC filters between 1986 and 2002.

RESULTS:
Anticoagulation status was available for 304 patients (132 on coumadin anticoagulation therapy and 172 who did not receive any anticoagulation therapy) whose IVC filters were placed within 30 days of their qualifying thromboembolic event. Two-year event-free survival for the anticoagulated group was 80.6% (95% confidence interval--CI--76.9, 84.3] and was 67.8% (95% CI 63.2, 72.3) for the non-anticoagulated group. Patients who had Greenfield filter had a higher, but not statistically significant different, rate of recurrence compared to those with other types of filters (hazard ratio 1.4; 95% CI 0.9, 2). The rate of recurrent VTE events was independent of age, gender, smoking status, or underlying medical condition.

CONCLUSIONS:
Among those with IVC filters, long-term anticoagulation therapy prolonged event-free survival for up to 2 years but did not prevent recurrent VTE events.

[thorn]

Сообщение от rsp

После 2ААТ, рекомендовал бы аспирин+варфарин (мно=2-2.5).

Аспирин особенно бонусов варфарину не добавляет. В европейских гайдах по фибрилляции предсердий - таблица 11 - четко прописано после тройной и потом двойной терапии: "Lifelong: VKA (INR 2.0–3.0) alone". Варфарина вполне будет достаточно одного имхо...

[rsp]

Сообщение от thorn

Аспирин особенно бонусов варфарину не добавляет. В европейских гайдах по фибрилляции предсердий - таблица 11 - четко прописано после тройной и потом двойной терапии: "Lifelong: VKA (INR 2.0–3.0) alone". Варфарина вполне будет достаточно одного имхо...

аспирин данному пациенту я бы все-таки оставил "на форева" из-за железной бифуркации в системе ПМЖА.

После отмены клопи в будущем, варфарин мне видится разумным не с целью предупреждения легочных эмболий в упомянутом Михаилом Юрьевичем исследовании, а скорее из-за

Two-year event-free survival for the anticoagulated group was 80.6% (95% confidence interval--CI--76.9, 84.3] and was 67.8% (95% CI 63.2, 72.3) for the non-anticoagulated group

Известно, что на кава-фильтрах достоверно чаще происходит тромбоз глубоких вен таза в отдаленном периоде, возможно хронический прием снизит эту вероятность:

In the randomised study by Decousus et al (1998), 400 patients
with proximal deep vein thrombosis (DVT) who were
considered to be at high risk of PE were randomised to filter
placement or not. Patients had ventilation–perfusion lung (V/
Q) scans at baseline and between days 8 and 12. All patients
were also treated with anticoagulant therapy:
• At day 12 there were fewer new PEs demonstrated by V/Q
in the filter group but there was no significant difference in
symptomatic PE (filter 1.1% vs. no filter 2.6%, odds ratio
0.40, 95% CI 0.08–2.1, P = 0.25).
• At 2 years, recurrent DVT was significantly more frequent
in the filter group (20.8% vs. 11.8%, odds ratio 1.87, 95%
CI 1.10–3.20, P = 0.02). Symptomatic PE was not signifi-
cantly less in the filter group (3.4% vs. 6.3%, odds ratio
0.50, 95% CI 0.19–1.33, P = 0.16) and mortality and
bleeding were not different.
• After 8 years of follow up, the filter group had suffered
fewer PE (6.2% vs. 15.1%, P = 0.01) but had a high
incidence of DVT (36.7% vs. 27.5%, P = 0.042). No
difference in mortality was noted (48.1% vs. 51.0%). Less
than 50% of patients were on anticoagulation for more than
1 year and only 35% of patients in both groups received
vitamin K antagonists over the entire 8-year period. These
results indicate that VC filters provide greater protection
against PE than a limited course of anticoagulation but are
associated with a greater risk of DVT and provide no
mortality benefit (The PREPIC Study Group, 2005).

[shok]

Имхо: тромбоз (даже если он случиться) НПВ - менее "смертельное" заболевание, чем возможное кровотечение! Я за ДААТ, года на 2, потом за аспирин only.

[Shahla]

Уважаемые кардиологи! Является ли описание ЭХОкг в данном случае нормой?
http://forums.rusmedserv.com/showthr...14#post1527614

[totla_proval]

Добрый вечер, Уважаемые Коллеги!
Я врач-педиатр, столкнувшийся с проблемой легочной гипертензии у детей с бронхолегочной дисплазией. В литературе описаны критерии диагностики легочной гипертензии по данным катетеризации правых отделов (среднее давление в легочной артерии более 25 мм.рт.ст. в покое и более 30 при нагрузке). Подскажите, пожалуйста, а существуют ли четкие критерии диагностики легочной гипертензии по данным ДЭХО-КГ и какие? Как можно рассчитать среднее давление в легочной артерии, зная систолическое и диастолическое давление в правом желудочке?
Заранее, большое спасибо!