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Tromboza venoasaTromboza venoasa
profundaprofunda
o provocare terapeutica
Andritoiu Alexandru*, Silosi Cristian**
Spitalul Clinic de Urgenta Militar Craiova
*Sectia Medicina Interna
** Clinica Chirurgie
TVPTVP
• The precise number of people affected by
DVT/PE is unknown, but estimates range from
300.000 to 600.000 (1 to 2 per 1000, and in
those over 80 years of age, as high as 1 in 100)
each year in the United States.
• Estimates suggest that 60.000-100.000
Americans die of DVT/PE (also called venous
thromboembolism).
• Among people who have had a DVT, one-half
will have long-term complications (post-
thrombotic syndrome)
TVP - ComplicatiileTVP - Complicatiile
tardivetardive
• Sdr. post-trombotic
• TEP recurent
Metode de diagnostic flebologicMetode de diagnostic flebologic
• Clinic
• D-dimeri
• US
• Venografie
• Isotopi
• Angio-CT/RMN
USUS
• B-mode
• Doppler color
• Doppler spectral
• Power-angio
• B-flow
• CEUS
• Elastografie
FLEBOGRAFIA – ,,gold standard,,
FlebografiaFlebografia
In cazuri selectionate!
US Doppler TVP-V. popliteeUS Doppler TVP-V. poplitee
Flux absent in vena poplitee
Flux prezent in artera homolaterala
Scorul WellsScorul Wells
TVP in situatii clinice particulareTVP in situatii clinice particulare
• Sarcina/trombofilie
• Neoplazii
• Arterite inflamatorii
• Repaus prelungit la pat (Stroke, IMA)
• Post chirurgical (pelvis, abdomen, ortopedie)
• Gonartroza
• Cateterism venos
• Droguri cu risc inalt
• Medicamente cu risc pro-trombotic
Obiectivele terapieiObiectivele terapiei
• Dizolvarea trombusului
• Prevenirea extensiei proximale
• Prevenirea recurentei TVP
• Prevenirea/tratamentul TEPA
• Prevenirea sdr. post-trombotic
Mijloace terapeuticeMijloace terapeutice
Farmacologice
• anticoagulante
• antiagregante
• trombolitice
Mecanice
• fragmentarea trombusului
• trombo-suctiunea
Hemodinamice
• Contentia in ciorap elastic
Heparina nefractionataHeparina nefractionata
LMWH/FondaparinaLMWH/Fondaparina
TVP cu TEPATVP cu TEPA
TVP in neoplaziiTVP in neoplazii
Mecanism auto-imun (asociata cu tromboza a/v 30-50% cazuri)
Agenti anticoagulanti alternativiAgenti anticoagulanti alternativi
• Fondaparina
• Danaparoid
• Lepirudin
• Argatroban
ContraindicatiiContraindicatii
Risc mai redus de sangerareRisc mai redus de sangerare
Indicatii/ContraindicatiiIndicatii/Contraindicatii
Profilaxia primara
• Preoperator • Antiagregante
• LWMH
Antiagregantele plachetareAntiagregantele plachetare
• In profilatia TVP
Direct comparisons of proportional effects of different antiplatelet
regimens on deep venous thrombosis and on pulmonary embolism
BMJ 1994;308:235-246
Proportional effects of antiplatelet therapy on numbers of patients
observed to have pulmonary embolism in trials that sought venous
thrombosis systematically after general and orthopaedic (traumatic and
elective) surgery and in high risk medical patients
BMJ 1994;308:235-246
15 April 2000;Volume 355, Issue 9212, Pages 1295 - 1302,
Aspirin reduces the risk of pulmonary embolism and
deep-vein thrombosis by at least a third throughout a
period of increased risk.
There is now good evidence for considering aspirin
routinely in a wide range of surgical and medical
groups at high risk of venous thromboembolism.
Triflusal
• selective inhibition of TxB2 and platelet cyclo-
oxygenase activity
• does not interfere significantly with endothelial
synthesis of prostacyclin via the cyclooxygen ase-2
pathway.
• increases nitric oxide synthesis by neutrophils, and
decreases the activity of nuclear transcription factor
NF-B more than aspirin does
• inactivates intraplatelet phosphodiesterase
• potentiates the antiaggregant effect of cAMP and
cGMP
• These pharmacological differences make triflusal
potentially more effective and safer than aspirin
Triflusal appears to provide prevention of thromboembolic risk to patients who have
undergone hip surgery, particularly total hip replacement
The amount of blood transfused was significantly reduced in triflusal compared with
aspirin recipients who underwent hip surgery.
Risk of haemorrhage was also reduced in patients receiving triflusal versus aspirin.
Atentie!Atentie!
• Dovezi certe in preventia Stroke-
FibA!
• Ghidurile nu recomanda Triflusal
in TVP!
Profilaxia recurenteiProfilaxia recurentei
TVP/EPTVP/EP
• Antiagregante
• LWHM
• Anticoagulante dicumarinice
• NOAC
Risk-Assessment Model for Venous Thromboembolism
According to the Khorana Score
Connors JM. N Engl J Med 2014;370:2515-2519
Comparison of Recommendations
regarding Prophylaxis against Venous Thromboembolism
Connors JM. N Engl J Med 2014;370:2515-2519
Profilaxia secundaraProfilaxia secundara
(dicumarinicele)(dicumarinicele)
Long-term therapy
• Coumadin
(warfarina)
• Acenocumarol
(sintrom, trombostop)
• Reduce riscul de
recurenta >90%
• INR optim 2-3
• Risc de sangerare
3% /an
Profilaxia secundaraProfilaxia secundara
NOACNOAC
Trombofilia / Riscul de recurentaTrombofilia / Riscul de recurenta
Durata proxilaxiei secundareDurata proxilaxiei secundare
Raportul risc de recidiva/risc de sangerare
Experienta noastra
• Peste 50 cazuri TVP- dupa 2010
• Prima cauza de deces in Sp. Militar Cva!
• TEPA masiv – cauza de deces
• Dupa interv. chirurgicale
- abdomniale/pelvine
- ortopedie
- neoplazii
• +/- Asociate cu obezitatea
1. Case report1. Case report
T. Maria, 48 ani
• Fibrom uterin
• Tratament: Orgametril
• Edem masiv m. inf. stg.
Fibromatoza uterin
Tromb masiv ocluziv in v. iliaca comuna stg
US DopplerUS Doppler
TVP - V. iliaca com. stgTVP - V. iliaca com. stg
Confirmare Angio-RMN
Ex. BiologiceEx. Biologice
• VSH 56-41 mm/h
• Fibrinogen 440 mg/dL
• CRP 4mg/dL
• Hb 7.5 g/dL
• Sideremie 7 microgr/dL
• Tb 635.000 /mmc
• CEA - negativ
• CA 125 - negativ
Coagulograma
• INR 2.5
• TQ 35 sec
• AP 20%
• APTT 44 sec
Rezolutia trombozeiRezolutia trombozei
• Clexane 1mg/Kgc
• Sintrom 2 mg
• Aflen 300 mg
• Detralex
• Contentie elastica
Dupa 20 zile
Profilaxia recidivei/TEPAProfilaxia recidivei/TEPA
• Sintrom ¼ cp
• Aflen 300 mg x 2
• Detralex 2 x1 cp
• Contentie elastica
Reevaluare la 3 luni
• Fara tromboza US
• Fara TEPA
• INR 2.2-2.9
2. Case Report2. Case Report
S. Filofteia, 50 yr
• 2009 TVP Fem-Popl stg
• Repetate episoade EP
• APP: hipercolesterolemie
TRATAMENT
• Sintrom 4mg
• Aflen 1 cp/zi
• Detralex 2 x 1 cp/zi
• Endolex 2 x 1 cp/zi
• Lioton gel – local
• Sortis 20 mg/zi
• VSH 21-50-125-60-37
• D-dimeri pozitivi
• Colesterol 325
• LDL-Col178 mg/dL
• HDL-Col 56 mg/dl
• CRP pozitiva
• Proteina S 31% (55-140)
• Proteina C 57% (70-130)
• AT III122% (>80)
3. Case report3. Case report
A. Emil, 42 yrA. Emil, 42 yr
• Iulie 2008- TVP-V. popl stg.
• Febr. 2010: TVP Fem-Popl dr. TEPA
masiv
• ECG: RS, Ax QRS la dreapta, T neg
anterior
• Doppler: tromboza profunda ax
venos femuro-popliteu dr
• D-dimeri pozitivi
• Angio CT: coronare permeabile
Tromb rezidual non-ocluziv A
pulmonara dr
• Tratament
• Sintrom 2 mg/zi
• Aflen 1 cp/zi
• Detralex 2 x 1 cp/zi
• Venoruton, gel-local
• Rezolutia trombului -6
luni
• Fara recidiva TEPA
• A sistat tratam.
antitrombotic dupa 12
luni!
4. Case report4. Case report
D. Adriana, 43 yr
• Edem masiv m. inf.dr.
• Internare Chir. Sp. Jud
• Tratatment: Sintrom - INR 2.8!
• 2 sapt.- Recidiva edemului!
• Reinternare Sp. Mil.
• D-dimeri pozitivi
Doppler-Elastografia TVPDoppler-Elastografia TVP
TVP F-P dr. – la 2 sapt. de la debut (recidiva sub Sintrom)
QUIZ
Care este cea mai buna solutie
terapeutica?
• Pastrarea Sintrom (INR optim) si
expectativa
• Adaugare anti-agregant
• Inlocuirea Sintrom cu NOAC
• Tratament interventional
Tratament
In spital
• Heparina nefractionata 1000 UI/h (25.000 Ui/zi)-72 h
• Clexane s.c -5 zile
• Clexane+Sintrom 3 zile
• Externare: edem redus
Tratament la domiciliu
• Sintrom 2mg/z
• Aflen 300 mg/z
• Detralex
• Contentie elastica
• INR la 1 L
• Reevaluare Doppler-Elasto+D-dimeri+INR la 1-3 luni
Concluzii
• TVP – ramane o provocare terapeutica
• Multiple optiuni terapeutice antitrombotice
Important:
• Localizarea trombusului
• Vechimea trombusului
• Atingerea raportului Risc/Beneficiu optim (la limita
sangerarii!)
• Raport cost-eficienta (tratament 6L-24 L)
Combinatia ACO+Antiagregant
• Potenteaza efectul antitrombotic
• Permite reducerea dozelor de ACO
• Dupa 3 luni - doar antiagregant
• Fara recidiva trombotica
• Fara recidiva embolica
• Fara risc major de sangerare

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Tromboza venoasa profunda-o provocare terapeutica

  • 1. Tromboza venoasaTromboza venoasa profundaprofunda o provocare terapeutica Andritoiu Alexandru*, Silosi Cristian** Spitalul Clinic de Urgenta Militar Craiova *Sectia Medicina Interna ** Clinica Chirurgie
  • 3. • The precise number of people affected by DVT/PE is unknown, but estimates range from 300.000 to 600.000 (1 to 2 per 1000, and in those over 80 years of age, as high as 1 in 100) each year in the United States. • Estimates suggest that 60.000-100.000 Americans die of DVT/PE (also called venous thromboembolism). • Among people who have had a DVT, one-half will have long-term complications (post- thrombotic syndrome)
  • 4. TVP - ComplicatiileTVP - Complicatiile tardivetardive • Sdr. post-trombotic • TEP recurent
  • 5. Metode de diagnostic flebologicMetode de diagnostic flebologic • Clinic • D-dimeri • US • Venografie • Isotopi • Angio-CT/RMN USUS • B-mode • Doppler color • Doppler spectral • Power-angio • B-flow • CEUS • Elastografie FLEBOGRAFIA – ,,gold standard,,
  • 7. US Doppler TVP-V. popliteeUS Doppler TVP-V. poplitee Flux absent in vena poplitee Flux prezent in artera homolaterala
  • 8.
  • 10. TVP in situatii clinice particulareTVP in situatii clinice particulare • Sarcina/trombofilie • Neoplazii • Arterite inflamatorii • Repaus prelungit la pat (Stroke, IMA) • Post chirurgical (pelvis, abdomen, ortopedie) • Gonartroza • Cateterism venos • Droguri cu risc inalt • Medicamente cu risc pro-trombotic
  • 11. Obiectivele terapieiObiectivele terapiei • Dizolvarea trombusului • Prevenirea extensiei proximale • Prevenirea recurentei TVP • Prevenirea/tratamentul TEPA • Prevenirea sdr. post-trombotic
  • 12. Mijloace terapeuticeMijloace terapeutice Farmacologice • anticoagulante • antiagregante • trombolitice Mecanice • fragmentarea trombusului • trombo-suctiunea Hemodinamice • Contentia in ciorap elastic
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  • 15.
  • 17. TVP cu TEPATVP cu TEPA
  • 18. TVP in neoplaziiTVP in neoplazii
  • 19. Mecanism auto-imun (asociata cu tromboza a/v 30-50% cazuri)
  • 20. Agenti anticoagulanti alternativiAgenti anticoagulanti alternativi • Fondaparina • Danaparoid • Lepirudin • Argatroban
  • 22.
  • 23.
  • 24.
  • 25. Risc mai redus de sangerareRisc mai redus de sangerare
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  • 40. Profilaxia primara • Preoperator • Antiagregante • LWMH
  • 42. Direct comparisons of proportional effects of different antiplatelet regimens on deep venous thrombosis and on pulmonary embolism BMJ 1994;308:235-246
  • 43. Proportional effects of antiplatelet therapy on numbers of patients observed to have pulmonary embolism in trials that sought venous thrombosis systematically after general and orthopaedic (traumatic and elective) surgery and in high risk medical patients BMJ 1994;308:235-246
  • 44. 15 April 2000;Volume 355, Issue 9212, Pages 1295 - 1302, Aspirin reduces the risk of pulmonary embolism and deep-vein thrombosis by at least a third throughout a period of increased risk. There is now good evidence for considering aspirin routinely in a wide range of surgical and medical groups at high risk of venous thromboembolism.
  • 45. Triflusal • selective inhibition of TxB2 and platelet cyclo- oxygenase activity • does not interfere significantly with endothelial synthesis of prostacyclin via the cyclooxygen ase-2 pathway. • increases nitric oxide synthesis by neutrophils, and decreases the activity of nuclear transcription factor NF-B more than aspirin does • inactivates intraplatelet phosphodiesterase • potentiates the antiaggregant effect of cAMP and cGMP • These pharmacological differences make triflusal potentially more effective and safer than aspirin
  • 46. Triflusal appears to provide prevention of thromboembolic risk to patients who have undergone hip surgery, particularly total hip replacement The amount of blood transfused was significantly reduced in triflusal compared with aspirin recipients who underwent hip surgery. Risk of haemorrhage was also reduced in patients receiving triflusal versus aspirin.
  • 47.
  • 48. Atentie!Atentie! • Dovezi certe in preventia Stroke- FibA! • Ghidurile nu recomanda Triflusal in TVP!
  • 49.
  • 50. Profilaxia recurenteiProfilaxia recurentei TVP/EPTVP/EP • Antiagregante • LWHM • Anticoagulante dicumarinice • NOAC
  • 51.
  • 52.
  • 53. Risk-Assessment Model for Venous Thromboembolism According to the Khorana Score Connors JM. N Engl J Med 2014;370:2515-2519
  • 54. Comparison of Recommendations regarding Prophylaxis against Venous Thromboembolism Connors JM. N Engl J Med 2014;370:2515-2519
  • 55. Profilaxia secundaraProfilaxia secundara (dicumarinicele)(dicumarinicele) Long-term therapy • Coumadin (warfarina) • Acenocumarol (sintrom, trombostop) • Reduce riscul de recurenta >90% • INR optim 2-3 • Risc de sangerare 3% /an
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  • 66. Trombofilia / Riscul de recurentaTrombofilia / Riscul de recurenta
  • 67. Durata proxilaxiei secundareDurata proxilaxiei secundare Raportul risc de recidiva/risc de sangerare
  • 68.
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  • 73. Experienta noastra • Peste 50 cazuri TVP- dupa 2010 • Prima cauza de deces in Sp. Militar Cva! • TEPA masiv – cauza de deces • Dupa interv. chirurgicale - abdomniale/pelvine - ortopedie - neoplazii • +/- Asociate cu obezitatea
  • 74. 1. Case report1. Case report T. Maria, 48 ani • Fibrom uterin • Tratament: Orgametril • Edem masiv m. inf. stg. Fibromatoza uterin
  • 75. Tromb masiv ocluziv in v. iliaca comuna stg US DopplerUS Doppler
  • 76. TVP - V. iliaca com. stgTVP - V. iliaca com. stg Confirmare Angio-RMN
  • 77. Ex. BiologiceEx. Biologice • VSH 56-41 mm/h • Fibrinogen 440 mg/dL • CRP 4mg/dL • Hb 7.5 g/dL • Sideremie 7 microgr/dL • Tb 635.000 /mmc • CEA - negativ • CA 125 - negativ Coagulograma • INR 2.5 • TQ 35 sec • AP 20% • APTT 44 sec
  • 78.
  • 79. Rezolutia trombozeiRezolutia trombozei • Clexane 1mg/Kgc • Sintrom 2 mg • Aflen 300 mg • Detralex • Contentie elastica Dupa 20 zile
  • 80. Profilaxia recidivei/TEPAProfilaxia recidivei/TEPA • Sintrom ¼ cp • Aflen 300 mg x 2 • Detralex 2 x1 cp • Contentie elastica Reevaluare la 3 luni • Fara tromboza US • Fara TEPA • INR 2.2-2.9
  • 81. 2. Case Report2. Case Report S. Filofteia, 50 yr • 2009 TVP Fem-Popl stg • Repetate episoade EP • APP: hipercolesterolemie TRATAMENT • Sintrom 4mg • Aflen 1 cp/zi • Detralex 2 x 1 cp/zi • Endolex 2 x 1 cp/zi • Lioton gel – local • Sortis 20 mg/zi • VSH 21-50-125-60-37 • D-dimeri pozitivi • Colesterol 325 • LDL-Col178 mg/dL • HDL-Col 56 mg/dl • CRP pozitiva • Proteina S 31% (55-140) • Proteina C 57% (70-130) • AT III122% (>80)
  • 82. 3. Case report3. Case report A. Emil, 42 yrA. Emil, 42 yr • Iulie 2008- TVP-V. popl stg. • Febr. 2010: TVP Fem-Popl dr. TEPA masiv • ECG: RS, Ax QRS la dreapta, T neg anterior • Doppler: tromboza profunda ax venos femuro-popliteu dr • D-dimeri pozitivi • Angio CT: coronare permeabile Tromb rezidual non-ocluziv A pulmonara dr • Tratament • Sintrom 2 mg/zi • Aflen 1 cp/zi • Detralex 2 x 1 cp/zi • Venoruton, gel-local • Rezolutia trombului -6 luni • Fara recidiva TEPA • A sistat tratam. antitrombotic dupa 12 luni!
  • 83. 4. Case report4. Case report D. Adriana, 43 yr • Edem masiv m. inf.dr. • Internare Chir. Sp. Jud • Tratatment: Sintrom - INR 2.8! • 2 sapt.- Recidiva edemului! • Reinternare Sp. Mil. • D-dimeri pozitivi
  • 84. Doppler-Elastografia TVPDoppler-Elastografia TVP TVP F-P dr. – la 2 sapt. de la debut (recidiva sub Sintrom)
  • 85. QUIZ Care este cea mai buna solutie terapeutica? • Pastrarea Sintrom (INR optim) si expectativa • Adaugare anti-agregant • Inlocuirea Sintrom cu NOAC • Tratament interventional
  • 86. Tratament In spital • Heparina nefractionata 1000 UI/h (25.000 Ui/zi)-72 h • Clexane s.c -5 zile • Clexane+Sintrom 3 zile • Externare: edem redus Tratament la domiciliu • Sintrom 2mg/z • Aflen 300 mg/z • Detralex • Contentie elastica • INR la 1 L • Reevaluare Doppler-Elasto+D-dimeri+INR la 1-3 luni
  • 87. Concluzii • TVP – ramane o provocare terapeutica • Multiple optiuni terapeutice antitrombotice Important: • Localizarea trombusului • Vechimea trombusului • Atingerea raportului Risc/Beneficiu optim (la limita sangerarii!) • Raport cost-eficienta (tratament 6L-24 L)
  • 88. Combinatia ACO+Antiagregant • Potenteaza efectul antitrombotic • Permite reducerea dozelor de ACO • Dupa 3 luni - doar antiagregant • Fara recidiva trombotica • Fara recidiva embolica • Fara risc major de sangerare

Editor's Notes

  1. Direct comparisons of proportional effects of different antiplatelet regimens on deep venous thrombosis and on pulmonary embolism. Symbols and conventions as in figure 1. Asp=Aspirin. Dip=Dipyridamole. Hydroxy=Hydroxychloroquine
  2. Proportional effects of antiplatelet therapy on numbers of patients observed to have pulmonary embolism in trials that sought venous thrombosis systematically after general and orthopaedic (traumatic and elective) surgery and in high risk medical patients. Symbols and conventions as in figure 1
  3. Table 1 Risk-Assessment Model for Venous Thromboembolism, According to the Khorana Score.
  4. Table 2 Comparison of Recommendations Regarding Prophylaxis against Venous Thromboembolism.