超声诊断下肢深静脉血栓的临床价值研究
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摘要
目的：探讨超声诊断下肢深静脉血栓的临床价值。
方法：应用超声波检查法观察下肢深静脉血栓（DVT）不同时期的声像图及血流动力学变化特点，观察对象为61例66条拟诊为急性下肢深静脉血栓的患者。用二维超声（2DUS）观察股总静脉、股浅静脉、腘静脉、胫后静脉、大隐静脉、小隐静脉的管径、管壁回声、管腔内回声及血栓形成的范围；彩色多普勒血流显像（CDFI）和脉冲多普勒（PW）观察其血流动力学改变。还分别于发病2～5周内、半年后定期对患者进行检测，并辅以探头加压试验、Valsalva试验及挤压肢体远端试验。
结果：61例急性DVT中56例单侧患者初诊时血管管径患侧较健侧明显增宽（P<0.01），血栓呈低回声，完全阻塞者管腔内未见彩色血流显示；不完全阻塞者管腔内可见彩色充盈缺损，脉冲多普勒于不完全阻塞处探及连续性低速血流频谱，随呼吸而变化较弱或不随呼吸而变化。治疗5周后复查：血栓回声稍强，患肢管腔较初诊时稍变小，但两者比较无统计学意义（P>0.05）；血栓部分出现再通，于血栓再通处可显示不规则狭窄或细小多枝状彩色血流信号，血流边缘不整齐，未见明显侧枝循环形成。半年后复查：血栓回声增强，患肢管径较初诊时明显变细（P<0.01），血管壁局限性或弥漫性增厚，再通者可见彩色血流信号显示，频谱呈低速连续性，血流通畅改善良好者，频谱可随呼吸而变化；患肢血流速较健肢低（P<0.01），此外伴有不同程度侧枝循环形成和继发性静脉瓣功能不全。
结论：血栓的不同时期声像图及血流动力学具有不同的特点，据此可判断血栓的病程，对临床疗效进行评估，进一步了解血栓后遗症，具有十分重要的意义。
Objective: To evaluate the clinical significance of ultrasound diagnosis in deep venous thrombosis of lower extremities .
Methods: To observe ultrasonic images and hemodynamic changes at each different stage of DVT by ultrasound .Sixty-one patients suspected as acute deep venous thrombosis were examined by ultrasound. 2DUS was used to detect the venous diameter, echoes, and thromboplastic scopes. CDFI and PW were used to detect blood flow, spectrum pattern, blood velocity and venous valvular function .All these cases were followed up after five weeks and half of a year . CFV, SFV, POV, etc were assessed by pressure detector examination ,Valsalva test and the action of pressing leg terminal.
Results: In the first consulting test sixty-one patients suffered vascular diameter became wider than the normal side clearly(P<0.01) .There were no color blood flow sign in vascular cavity being all blocked.In vascular cavity being partly blocked ,there was pulsing Doppler detecting successive blood flow spectrum with low velocity at the segment being thrombosis partly, which changed little according to respiration or not. After five weeks treatment, the thrombosic
echoes were enhanced and the suffered vascular diameter became smaller but not obvious (P>0.05). There was partly recanalization of some thrombi and there were abnormal strip branchful color blood flow signs at recanalization point , the blood flow margin was not tidy ,and there was no apprecibly developed collateral circulation. After six months: The thrombosic echoes were more enhanced, the suffered vascular cavity became smaller obviously than normal (p<0.01).There was locally or dispreadingly thicked at which parts.There were color blood flow signs in recanalizating venous and the spectrums were low velocity and consecutive.In the wholly recanalizating venous the spectrum could change according to following respiration, but the blood flow velocity of suffered venous was lower than the control side(P<0.05),and there were developed collateral circulation and venous valvular reflux at some degree.
Conclusion:There were characteristic ultrasonic images and hemodynamic changes at each different stage of DVT. By means of them we can recognize the course of clinical treament and know the thrombosis sequela. This is of very important clinical significance.
方法：应用超声波检查法观察下肢深静脉血栓（DVT）不同时期的声像图及血流动力学变化特点，观察对象为61例66条拟诊为急性下肢深静脉血栓的患者。用二维超声（2DUS）观察股总静脉、股浅静脉、腘静脉、胫后静脉、大隐静脉、小隐静脉的管径、管壁回声、管腔内回声及血栓形成的范围；彩色多普勒血流显像（CDFI）和脉冲多普勒（PW）观察其血流动力学改变。还分别于发病2～5周内、半年后定期对患者进行检测，并辅以探头加压试验、Valsalva试验及挤压肢体远端试验。
结果：61例急性DVT中56例单侧患者初诊时血管管径患侧较健侧明显增宽（P<0.01），血栓呈低回声，完全阻塞者管腔内未见彩色血流显示；不完全阻塞者管腔内可见彩色充盈缺损，脉冲多普勒于不完全阻塞处探及连续性低速血流频谱，随呼吸而变化较弱或不随呼吸而变化。治疗5周后复查：血栓回声稍强，患肢管腔较初诊时稍变小，但两者比较无统计学意义（P>0.05）；血栓部分出现再通，于血栓再通处可显示不规则狭窄或细小多枝状彩色血流信号，血流边缘不整齐，未见明显侧枝循环形成。半年后复查：血栓回声增强，患肢管径较初诊时明显变细（P<0.01），血管壁局限性或弥漫性增厚，再通者可见彩色血流信号显示，频谱呈低速连续性，血流通畅改善良好者，频谱可随呼吸而变化；患肢血流速较健肢低（P<0.01），此外伴有不同程度侧枝循环形成和继发性静脉瓣功能不全。
结论：血栓的不同时期声像图及血流动力学具有不同的特点，据此可判断血栓的病程，对临床疗效进行评估，进一步了解血栓后遗症，具有十分重要的意义。
Objective: To evaluate the clinical significance of ultrasound diagnosis in deep venous thrombosis of lower extremities .
Methods: To observe ultrasonic images and hemodynamic changes at each different stage of DVT by ultrasound .Sixty-one patients suspected as acute deep venous thrombosis were examined by ultrasound. 2DUS was used to detect the venous diameter, echoes, and thromboplastic scopes. CDFI and PW were used to detect blood flow, spectrum pattern, blood velocity and venous valvular function .All these cases were followed up after five weeks and half of a year . CFV, SFV, POV, etc were assessed by pressure detector examination ,Valsalva test and the action of pressing leg terminal.
Results: In the first consulting test sixty-one patients suffered vascular diameter became wider than the normal side clearly(P<0.01) .There were no color blood flow sign in vascular cavity being all blocked.In vascular cavity being partly blocked ,there was pulsing Doppler detecting successive blood flow spectrum with low velocity at the segment being thrombosis partly, which changed little according to respiration or not. After five weeks treatment, the thrombosic
echoes were enhanced and the suffered vascular diameter became smaller but not obvious (P>0.05). There was partly recanalization of some thrombi and there were abnormal strip branchful color blood flow signs at recanalization point , the blood flow margin was not tidy ,and there was no apprecibly developed collateral circulation. After six months: The thrombosic echoes were more enhanced, the suffered vascular cavity became smaller obviously than normal (p<0.01).There was locally or dispreadingly thicked at which parts.There were color blood flow signs in recanalizating venous and the spectrums were low velocity and consecutive.In the wholly recanalizating venous the spectrum could change according to following respiration, but the blood flow velocity of suffered venous was lower than the control side(P<0.05),and there were developed collateral circulation and venous valvular reflux at some degree.
Conclusion:There were characteristic ultrasonic images and hemodynamic changes at each different stage of DVT. By means of them we can recognize the course of clinical treament and know the thrombosis sequela. This is of very important clinical significance.
引文
姜剑军.下肢深静脉血栓形成的研究进展.山东中医杂志，1998.（3）：142-144
乙芳，龚新环.彩色多普勒对下肢深静脉血栓以及其形成以后的综合征诊断.中国超声医学杂志，1996（11）：35
杨光华主编，病理学.第5版，北京：人民卫生出版社，2001：48-50
吴阶平，裘法祖主编.黄家驷外科学.第5版，北京：人民卫生出版社，1996:956
Mohr JM,Hasselfeld KA,Byremp,Deshmukh RM,Cranley.JJ.Does the asymptomatic limb harbor deep venous thrombosis?Am J Surg. 1994 Aug;168(2):184-7.
Mohr JM,Lutter KS,Cranley RD,Sampson MG,Granley JJ.Upper extremity venous duplex imaging.J Mal Vasc. 1992;17 Suppl B:88-90.
Kerr TM,Cranley JJ,Johnson JR,Lutter KS,Riechmann GC,Cranley RD,True MA,Sampson M.Analysis of 1084 consecutive lower extremities involved with acute venous thrombosis diagnosed by duplex scanning. Surgery. 1990 Sep;108(3):520-7.
吴阶平，裘法祖主编.黄家驷外科学.第5版，北京：人民卫生出版社，
Lindhagen A.Bergqvist D.Hallbook T.et al Venous function five to eight years after clinically suspected deep Venous thrombosis[J].Acta Med Scand,1985.217:329-341
Redman HC.Deep venous thrombsis:Is contrast venography still the diagnosis gold standard[J].Radiology,1998.168(1):277-278
王纯正主编.1993.超声学。北京：人民生出版社，133-145
董国祥.实用血管外科学及护理学[M].北京：中国医药科技出版社，1995
Baxter GM,Mcechine.Duffy P, Colour Doppler Ultrasound in deep Venous thrombosis:a companrision with Venography,Clinical Radiology 1990,42:32
Cronan JJ,Dorfman GS,Scola FH,et al.DeepVenous thrombosis:US assessment using vein compression.Radiology,1987.162:191
O’Leary DH.Kane KA,Chase BM.A prospective study of the efficacy of B-Scan sonography in the detection of deep Venous thrombosis in the lower extremities J Clin Ultrasound,1988.16:1
Grigg MJ,Nicolaides AN.Wolfe JHN.1998.Detection and grading of femoro distal vein graft stenoses duplex measuremates compared with angiography.J Vasc Surg,8:661-666
Buth J,Disselhoff B,Sommeling C et al.1991,Color-flow duplex criteria for grading sreaosis in infrainguinal vein grafts,J Vasc Surg,14:716-728
Shionogs S.Thrombectomy for acute deep venous thrombosis:Provention of Post-thrombotic Syndrome Cardiovasc surg.1989.30(5):484
Caps.MT.Manzo RA.Bergelin RO.et al.Venous vavular reflux in veins not involved at the time of acute deep venous thrombosis.J Vasc Surg.1995,22(5)524-531
Koopman MMW.Beck EJR.Cate JW:Diagnosis of deep Venous thrombosis.Progress in cardiovascular diseases.1994.1:1
查长松，赵玉华，林荣莉等.下肢深静脉血栓形成不同方法的对比研究.中国超声医学杂志，1996.14（7）：53
Cronan JJ,Dorfman GS,Scola FH,et al. Deep Venous thrombosis:US assessment using vein compression.Radiology,1987.162:191
Murphy TP,Cronan JJ.Evolution of deep venous thrombosis:a prospective evalution with US.radiology.1990,177:543-548
Markel A,Manzo RA,Bergelin Ro.Pattern and distribution of thrombi in acute venous thrombosis.Arch Surg,1992,127:305-309
Netzer P,Binek J,Hammer B,et al..Vtility of abdominal sonography in patients with idiopathic deep vein thrombosis.J Clin ultrasound.1999,27:177-181
唐杰主编.1992.腹部及外周血管彩色多普勒诊断学.北京：人民生出版社
李建初等。血管及浅表器官彩色多普勒诊断学[M].北京医科大学中国协和医科大学联合出版社，1999
查长松，赵玉华，黄晓云等.二维彩色多普勒显像检测下肢慢性静脉瓣功能不全. 中国超声医学杂志，1998.14（6）：35-37
查长松，赵玉华. 彩色多普勒显像检测下肢静脉瓣功能不全的临床应用. 中国超声医学杂志，1998.14（5）：61-63
年楠楠，梁春香.彩色多普勒显像检测下肢深静脉瓣功能不全的应用价值[J]. 中医学影像技术，2001.17（10）.1001-1002
Clagett GP,Reisch JS Prevention of venous thromboembolism in general surgical patients. Results of meta-analysis.Ann Surg. 1988 Aug;208(2):227-40. Review.
Nurmohamed MT,Rosendaal FR,Buller HR,et al.Low-molecular-weight heparin versus standard heparin in general and orthopaedic surgery: a meta-analysis.Lancet. 1992 Jul 18;340(8812):152-6.
Ramaswami G,Nicolaides AN Principles of angioplasty guidance using ultrasound. Cardiovasc Surg (Torino). 1996 Jun;37(3 Suppl 1):27-31.
殷志泉，张强.静脉血栓形成.实用血管外科学 沈阳：辽宁科学技术出版社，1999，543-544
Hoyt DB,Swegle JR Deep venous thrombosis in the surgical intensive care unit.Surg Clin North Am. 1991 Aug;71(4):811-30. Review.
吴阶平，裘法祖主编.黄家驷外科学.第6版，北京：人民卫生出版社，2002，890-895
吴在德主编.外科学.第5版，北京：人民卫生出版社，2001，689-692
Color D Jolly BT,Massarin E,Pigman ECoppler ultrasonography by emergency physicians for the diagnosis of acute deep venous thrombosis.Acad Emerg Med. 1997 Feb;4(2):129-32
Meissner MH,Caps MT,Zierler BK，Polissar N,Bergelin RO,Manzo RA,Strandness DE Jr. Determinants of chronic venous disease after acute deep venous thrombosis.J Vasc Surg. 1998 Nov;28(5):826-33.
陆恩祥，任卫东.血管超声诊断图谱.辽宁科技出版社，1999：3
陆恩祥，任卫东.血管超声诊断图谱.辽宁科技出版社，1999：86-115
裴玉昆主编.周围血管病学.第1版，北京：北京科技出版社，1993，308-317
Jolly BT-Massarin E.Pigman EC.color Doppler ultrasonography hy emergency physicians for the diagnosis of acute deep venous thrombosis,Acad Emerg Med,1997,4(2):129-132
Van Bemmelen PS.Bedford G,Beech KW,et al Quantitative segmental evalution of venous valvular reflux with duplex ultrasound scanning.J Vasc Surg.1998,10:425-431
Thibault PK. Duplex examination-Dermatol Surg,1995,21:77
孙建民，张培华，秦月琴.下肢静脉瓣膜的解剖和组织观察及其临床意义.中华实验外科学杂志，1989，6（1）：1
Masude EM.Kistner RL.Eklof B.Prospective study of duplex scanning venous reflux,comparison of valsalva and pneumatic cuff techniques in the reverse Trendelenburg and standing positions.J.Vasc Surg,1994.20:711
Masude EM.Kistner RL.Prospective comparison of duplex scanning and descending venography in the assessment of venous insufficiency .AM J Surg 1992,164:254
徐秋华，燕山.下肢静脉血栓血流动力学的研究.中国医学影像技术，2001（6）：578-580
Lindhagen A.Bergqvist D.Hallbook T.et al Venous function five to eight years after clinically suspected deep Venous thrombosis[J].Acta Med Scand,1985.217:329-341
Ramshorsr BC.Van Bemmelen PS.Eikelboom BC,The development of
valvular incompetence after deep Venous thrombosis:afollow-up study with duplex scanning[J].Vasc Surg,1994,20:1058-1066
Masuda EM,Kistner RL.Long-term result of venous valve reconsomtion :a four-to twenty-one-year follow-up[J].J Vase Surg,1994,19:391-403
Milne AA ,Stonebridge PA,Bradbury AW.et al.venous function and clinical outcome following deep vein thrombosis[J].Br J Surg.1994,81:847-849
徐秋华，燕山等.下肢深静脉功能的彩超诊断[J].中国超声医学杂志，1998.14（5）：59-60
Killewich LA, Sandager GP,Nguyen AH,et al.venous hemodynemics during impulse foot pumping [J],J Vasc Surg.1995.22(5):596-605
乙芳，龚新环.彩色多普勒对下肢深静脉血栓以及其形成以后的综合征诊断.中国超声医学杂志，1996（11）：35
杨光华主编，病理学.第5版，北京：人民卫生出版社，2001：48-50
吴阶平，裘法祖主编.黄家驷外科学.第5版，北京：人民卫生出版社，1996:956
Mohr JM,Hasselfeld KA,Byremp,Deshmukh RM,Cranley.JJ.Does the asymptomatic limb harbor deep venous thrombosis?Am J Surg. 1994 Aug;168(2):184-7.
Mohr JM,Lutter KS,Cranley RD,Sampson MG,Granley JJ.Upper extremity venous duplex imaging.J Mal Vasc. 1992;17 Suppl B:88-90.
Kerr TM,Cranley JJ,Johnson JR,Lutter KS,Riechmann GC,Cranley RD,True MA,Sampson M.Analysis of 1084 consecutive lower extremities involved with acute venous thrombosis diagnosed by duplex scanning. Surgery. 1990 Sep;108(3):520-7.
吴阶平，裘法祖主编.黄家驷外科学.第5版，北京：人民卫生出版社，
Lindhagen A.Bergqvist D.Hallbook T.et al Venous function five to eight years after clinically suspected deep Venous thrombosis[J].Acta Med Scand,1985.217:329-341
Redman HC.Deep venous thrombsis:Is contrast venography still the diagnosis gold standard[J].Radiology,1998.168(1):277-278
王纯正主编.1993.超声学。北京：人民生出版社，133-145
董国祥.实用血管外科学及护理学[M].北京：中国医药科技出版社，1995
Baxter GM,Mcechine.Duffy P, Colour Doppler Ultrasound in deep Venous thrombosis:a companrision with Venography,Clinical Radiology 1990,42:32
Cronan JJ,Dorfman GS,Scola FH,et al.DeepVenous thrombosis:US assessment using vein compression.Radiology,1987.162:191
O’Leary DH.Kane KA,Chase BM.A prospective study of the efficacy of B-Scan sonography in the detection of deep Venous thrombosis in the lower extremities J Clin Ultrasound,1988.16:1
Grigg MJ,Nicolaides AN.Wolfe JHN.1998.Detection and grading of femoro distal vein graft stenoses duplex measuremates compared with angiography.J Vasc Surg,8:661-666
Buth J,Disselhoff B,Sommeling C et al.1991,Color-flow duplex criteria for grading sreaosis in infrainguinal vein grafts,J Vasc Surg,14:716-728
Shionogs S.Thrombectomy for acute deep venous thrombosis:Provention of Post-thrombotic Syndrome Cardiovasc surg.1989.30(5):484
Caps.MT.Manzo RA.Bergelin RO.et al.Venous vavular reflux in veins not involved at the time of acute deep venous thrombosis.J Vasc Surg.1995,22(5)524-531
Koopman MMW.Beck EJR.Cate JW:Diagnosis of deep Venous thrombosis.Progress in cardiovascular diseases.1994.1:1
查长松，赵玉华，林荣莉等.下肢深静脉血栓形成不同方法的对比研究.中国超声医学杂志，1996.14（7）：53
Cronan JJ,Dorfman GS,Scola FH,et al. Deep Venous thrombosis:US assessment using vein compression.Radiology,1987.162:191
Murphy TP,Cronan JJ.Evolution of deep venous thrombosis:a prospective evalution with US.radiology.1990,177:543-548
Markel A,Manzo RA,Bergelin Ro.Pattern and distribution of thrombi in acute venous thrombosis.Arch Surg,1992,127:305-309
Netzer P,Binek J,Hammer B,et al..Vtility of abdominal sonography in patients with idiopathic deep vein thrombosis.J Clin ultrasound.1999,27:177-181
唐杰主编.1992.腹部及外周血管彩色多普勒诊断学.北京：人民生出版社
李建初等。血管及浅表器官彩色多普勒诊断学[M].北京医科大学中国协和医科大学联合出版社，1999
查长松，赵玉华，黄晓云等.二维彩色多普勒显像检测下肢慢性静脉瓣功能不全. 中国超声医学杂志，1998.14（6）：35-37
查长松，赵玉华. 彩色多普勒显像检测下肢静脉瓣功能不全的临床应用. 中国超声医学杂志，1998.14（5）：61-63
年楠楠，梁春香.彩色多普勒显像检测下肢深静脉瓣功能不全的应用价值[J]. 中医学影像技术，2001.17（10）.1001-1002
Clagett GP,Reisch JS Prevention of venous thromboembolism in general surgical patients. Results of meta-analysis.Ann Surg. 1988 Aug;208(2):227-40. Review.
Nurmohamed MT,Rosendaal FR,Buller HR,et al.Low-molecular-weight heparin versus standard heparin in general and orthopaedic surgery: a meta-analysis.Lancet. 1992 Jul 18;340(8812):152-6.
Ramaswami G,Nicolaides AN Principles of angioplasty guidance using ultrasound. Cardiovasc Surg (Torino). 1996 Jun;37(3 Suppl 1):27-31.
殷志泉，张强.静脉血栓形成.实用血管外科学 沈阳：辽宁科学技术出版社，1999，543-544
Hoyt DB,Swegle JR Deep venous thrombosis in the surgical intensive care unit.Surg Clin North Am. 1991 Aug;71(4):811-30. Review.
吴阶平，裘法祖主编.黄家驷外科学.第6版，北京：人民卫生出版社，2002，890-895
吴在德主编.外科学.第5版，北京：人民卫生出版社，2001，689-692
Color D Jolly BT,Massarin E,Pigman ECoppler ultrasonography by emergency physicians for the diagnosis of acute deep venous thrombosis.Acad Emerg Med. 1997 Feb;4(2):129-32
Meissner MH,Caps MT,Zierler BK，Polissar N,Bergelin RO,Manzo RA,Strandness DE Jr. Determinants of chronic venous disease after acute deep venous thrombosis.J Vasc Surg. 1998 Nov;28(5):826-33.
陆恩祥，任卫东.血管超声诊断图谱.辽宁科技出版社，1999：3
陆恩祥，任卫东.血管超声诊断图谱.辽宁科技出版社，1999：86-115
裴玉昆主编.周围血管病学.第1版，北京：北京科技出版社，1993，308-317
Jolly BT-Massarin E.Pigman EC.color Doppler ultrasonography hy emergency physicians for the diagnosis of acute deep venous thrombosis,Acad Emerg Med,1997,4(2):129-132
Van Bemmelen PS.Bedford G,Beech KW,et al Quantitative segmental evalution of venous valvular reflux with duplex ultrasound scanning.J Vasc Surg.1998,10:425-431
Thibault PK. Duplex examination-Dermatol Surg,1995,21:77
孙建民，张培华，秦月琴.下肢静脉瓣膜的解剖和组织观察及其临床意义.中华实验外科学杂志，1989，6（1）：1
Masude EM.Kistner RL.Eklof B.Prospective study of duplex scanning venous reflux,comparison of valsalva and pneumatic cuff techniques in the reverse Trendelenburg and standing positions.J.Vasc Surg,1994.20:711
Masude EM.Kistner RL.Prospective comparison of duplex scanning and descending venography in the assessment of venous insufficiency .AM J Surg 1992,164:254
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