
6 курс / Кардиология / Джон_Кэмм_Болезни_сердца_и_сосудов_2011
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ГЛАВА 37. ВЕНОЗНАЯ ТРОМБОЭМБОЛИЯ
Sebastian M. Schellong, Henri Bounameaux
и Harry R. Büller
РЕЗЮМЕ
В этой главе тромбоз глубоких вен (ТГВ) и ТЭЛА рассматриваются как проявления одного патологического процесса. Несмотря на растущее использование препаратов для профилактики тромбообразования, ТЭЛА занимает третье место среди наиболее частых причин смерти при заболеваниях сердечно-сосудистой системы.
Согласно современным представлениям, венозная тромбоэмболия (ВТЭ) - многофакторное заболевание. Помимо возраста, существует несколько временных и постоянных факторов риска. Наиболее значимые в прежней группе - хирургические операции и травмы, тогда как в нынешней - онкологические заболевания и тромбофилия. Однако существенная часть случаев ВТЭ протекает без идентифицируемого фактора риска и потому классифицируется как "идиопатические" или "неспровоцированные" эпизоды. У таких пациентов, а также при наличии постоянных факторов риска ВТЭ носит характер хронического рецидивирующего заболевания.
Диагноз каждого конкретного эпизода заболевания необходимо устанавливать на основании визуализирующих методов исследования. За последние 10 лет компрессионное УЗИ и МСКТ показали себя как наиболее мощные диаг-ностические инструменты. Однако на этапе до инструментальных исследований, основываясь только на клинической вероятности и
изолированном определении уровня D-димеров, можно достоверно исключить диагноз в одной трети всех подозреваемых случаев.
Для большинства пациентов в острый период возможна только антикоагулянтная терапия. П/к введение низкомолекулярных гепаринов или фондапаринукса - в настоящее время стандарт лечения. Посттромбоэмболический синдром как отдаленное осложнение ТГВ можно эффективно предотвратить баротерапией. В случае гемодинамической нестабильности при ТЭЛА необходим системный тромболизис из-за риска смерти вследствие правожелудочко-
вой СН. Стандартным средством поддерживающей терапии служат антагонисты витамина K (антикоагулянты для приема внутрь), длительность применения которых определяется риском рецидива, с одной стороны, и обширного кровотечения, с другой.
ТЕЧЕНИЕ ЗАБОЛЕВАНИЯ
Венозный тромбоз возникает вследствие формирования сгустка крови (тромба) в венозной системе. Признаки и симптомы заболевания вызываются тромбозом соответствующей вены и/или эмболизации частями тромба сосудов легких. Это определение относится только к венам нижних и верхних конечностей. Тромбоз церебральных и висцеральных вен не рассматривается в этой главе.
ТЭЛА - нередкое осложнение, обычно встречаемое у пациентов с ТГВ. При детальном исследовании признаки бессимптомной ТЭЛА могут быть найдены приблизительно у 70% пациентов с проксимальным тромбозом глубоких вен. По этой причине ТГВ и ТЭЛА рассматривают как две манифестации одного заболевания: венозной тромбоэмболической болезни или ВТЭ. Поскольку течение болезни, диагноз и лечение тромбоза глубоких вен и ТЭЛА сходны во многих аспектах, эти заболевания будут обсуждаться вместе.
ЭТИОЛОГИЯ
Причина образования тромбов - дисбаланс между местными и системными про- и антикоагулянтами, а также профибринолитической и антифибринолитической активностью. Согласно теории Вирхова, все патогенные факторы, отвечающие за этот дисбаланс, можно разделить на три категории: нарушения венозного кровотока, изменения сосудистой стенки и нарушения состава крови. В табл. 37.1 представлены примеры патогенных факторов каждой категории.
Таблица 37.1. Патофизиологические механизмы венозных тромбоэмболий в соответствии с триадой Вирхова
Нарушение |
Нарушение венозной стенки |
Нарушение состава крови |
|
кровотока |
|
|
|
(венозный стаз) |
|
|
|
|
|
|
|
Наружная |
Злокачественная инфильтрация |
Дегидратация |
|
компрессия |
Воспалительная инфильтрация |
Полиглобулинемия |
|
проксимальных вен |
|||
|
|
||
Солидные опухоли |
Хирургия |
Полицитоз |
|
|
|
||
Артериальные |
Пункция вен |
Гиперфибриногенемия |
|
|
|
||
аневризмы |
Другие травмы |
Наследственная тромбофилия |
|
Турникет |
Гипергомоцистеинемия |
Антифосфолипидные антитела / |
|
Лимфоцеле |
Антифосфолипидные |
волчаночноподобные |
|
антикоагулянты |
|||
|
антитела/волчаночноподобные |
||
Кисты Бейкера |
|
||
антикоагулянты |
Гепарин-индуцированная |
||
|
|||
Беременность |
Гепарин-индуцированная |
тромбоцитопения |
|
|
|
||
Внутренняя |
тромбоцитопения |
Опухолевые прокоагулянты |
|
обструкция |
Остаточный тромбоз после |
Беременность, послеродовый |
|
|
|||
Остаточный тромбоз |
предыдущего ТГВ |
период |
|
после ТГВ |
|
ЛС |
|
|
|
||
Катетер |
|
Гипофибринолиз |
|
|
|
||
|
|
|