1 GBUZ of the Republic of Mordovia "Republican Clinical Hospital No. 4"
2 FGBOU in the Saratov State Medical University. IN AND. Razumovsky Ministry of Health of Russia "
The article discusses the results of the sonographic diagnosis of phlebroids of the lower extremities in 334 patients. The main factors for the development of thrombosis in men were polytramic, combined surgical interventions and cardiovascular diseases; In women - cardiovascular diseases and tumors of uterus and ovaries. Color duplex scanning of veins allows you to identify the presence and level of phlebotomability, flotation of thrombotic masses, to estimate the effectiveness of anticoagulant therapy and surgical prophylaxis of pulmonary embolism. Tactical issues with fluttering thrombosis of the system of the lower vein should be solved individually taking into account both the localization and length of the proximal part of the thrombus, as well as the age of the patient and the presence of phlebotromotic factors. In the presence of embin hazardous thrombosis against the background of severe concomitant pathology and contraindications to the open operation, the Kava filter installation is a measure of TEL prevention. In young patients, it is advisable to open or endovascular installation of temporary kava filters. In 32.0?% Of patients on Kava-filter after its implantation, massive thrombosis was revealed, and in 17.0?% - Floatation of thromboms below the plugium level was found, which confirms the importance and effectiveness of urgent surgical prevention of TEL.
sonography
dopplerograph
ven. thrombosis
kava filter
vienna lower extremities
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Diagnosis and Treatment of Floating ThromBosis In The System of the Vena Cava Inferior
Ipatenko t.v. 1 DAVYDKIN V.I. 2 Shchapov v.V. 1 Savrasov T.V. 1, 2 Makhrov v.V. 1 Shirokov I.I. 2.1 State Budgetary Institution of Health of the Republic of Mordovia "Republican Clinical Hospital No. 4"
2 Saratov State Medical University. V. I. RAZUMOVSKY.
ABSTRACT:
The ARTICLE CONTAINS THE RESULTS OF ULTRASONIC DIAGNOSIS OF ACUTE VENOUS THROMBOSIS OF LOWER EXTREMITIES IN 334 PATIENTS. The Main Risk Factors Venous ThromBosis In Men Include Injury, Combined Surgery and Severe Cardiovascular Diseases; In Women - Cardiovascular Diseases and Tumors of Female Genitals. Color Duplex Scanning of the Presence and Level of the Thrombotic Process, Flotation of the Thrombotic Process, Flotation of A Blood Clot, To Evaluate The Effectiveness of Treatment and Surgical Prevention of Pulmonary Embolism. Tactical Issues with Floating Thrombus In The Inferior Vena Cava Should Be Decided Individually, Taking Into Account Both The Localization of the Proximal Part of the Thrombus and Its Extent and Age of the Patient and Factors of the Phlebothrombosis. In The Presence of this Conclusion Was Thrombosis On The Background of Severe Cava Filter Is a Vena Cava Filter Is a Measure for the prevention of Pulmonary Embolism on The Backgroundications for Open Surgery to install a vena Cava Filter Is a Measure for the Prevention of Pulmonary Embolism. In Patients of Young Age Appriate to install a Removable Vena Cava Filters, Or Perform Open Surgery With a Temporary Vena Cava Filter. From 32.0?% Patients SHOWED THROMBOSIS OF THE VENA CAVA FILTER AFTER IMPLANTATION, 17.0?% Of Patients Found to Have a Floating Thrombus Below The Level of Plaque, Which Confirms The Importance and Effectiveness Of Urgent Surgical Prevention of Pulmonary Embolism.
Keywords:
venous Thrombosis
veins of the Lower Extremities
Phlebotromombosis of the lower extremities is one of the leading problems of practical phlebology in the clinical and scientific significance. They are widespread among the adult population, and medication treatment is not effective enough. It retains a high level of disability and disability. The phlebotromboosis of the clinical picture in the first hours and days of the disease, and the first symptom is the pulmonary thromboembolism (TEL), which is the leading cause of both common and surgical mortality. In this regard, the timely and accurate diagnosis of embin hazardous venous thrombosis using informative, affordable and non-invasive methods is extremely important. Ultrasound Doppler Scanning (WSDS) has become the main method of diagnosing these phlebroids, which are a potential source of the development of pulmonary thromboembolism.
In the literature, some publications in which the ultrasound characteristics of venous thrombus embossoform are illuminated in detail. The leading criteria of the enzymology thrombus are considered the degree of its mobility and the length and echogenicity of the flotic part, the characteristic of the outer contour of the thrombus (level, uneven, fuzzy), the presence of a circular flow of blood around the thrombus in the color duplex mode in both the longitudinal and transverse scanning.
TELA prevention is an integral component of treating patients with acute venous thrombosis. Unfortunately, the use of indirect anticoagulants does not contribute to the prevention of separation and migration into the pulmonary arteries of the formed thrombus. Therefore, when detecting a long floting and emphatically, thrombosis shows a surgical intervention, aimed at preventing thromboembol migration (thromboctomy, plug, or endovascular Cava filter implantation).
The issue of surgical tactics with fluttering thrombosis of deep veins of limbs should be solved individually taking into account the localization of the proximal part of the thrombus, its length, flotation, the presence of comorbide and intercurrent pathology.
In the presence of severe intercurrent pathology and contraindications to the execution of an open operation in patients with emphasa trombosis of the main veins, the installation of a KAVA filter in absolute indications (contraindications to anticoagulant therapy, embinus-hazard thrombosis, with the impossibility of performing surgical thrombeectomy, recurrent TEL). At the same time, it is important to take into account the fact of fixing floting thrombus (thrombus length not more than 2 cm) and the possibility of conservative tactics of treatment.
The unpredictability of the flow of venous thrombosis in the system of the lower vein system is proved by the diagnostics of floting thrombosis in patients without any clinical signs of venous pathology, the detection of embin hazardous thrombosis in patients with chronic vein diseases, the facts of pulmonary artery thrombosembolism with occlusive forms of deep veins thrombosis.
Purpose of the study: Improving sonographic diagnostics and results of urgent interventions in patients with sharp phlebotoms.
Materials and research methods
We analyzed the results of physical and sonographic diagnostics of phlebombosis of the lower limbs in 334 patients who were inpatient treatment in the State Budget Institution of Health of the Republic of Mordovia "Republican Clinical Hospital No. 4". The age of patients amounted to 20-81 years; 52.4% amounted to women, 47.6% - men; 57.0% of them were able-bodied, and 19.4% of young age (Table 1).
Table 1
Paul and age of surveyed patients
table 2
Distribution of floting thrombus in the system of deep veins of the lower extremities
The biggest group of patients from 61 years and older (143 people), among men prevailed persons aged from 46 to 60 years - 66 (52.3%), in women at the age of 61 and older - respectively 89 (62 , 3%) man.
Phlebotrombosis in men under the age of 45 years have more often met in persons abusing intravenous introduction of psychoactive substances. At the age of 60 and more, the number of female patients begins to prevail over male, which is explained by the predominance of other risk factors in women: gynecological diseases (mioma of large-sized uterus, ovarian tumors), IBS, obesity, injuries, varicose veins and others. Reducing the incidence in the overall population in men at the age of 60 years and is more due to a decrease in their share in the relevant age groups, high fattyness from TEL, the development of chronic venous insufficiency and post-terromboflectic syndrome.
Ultrasonographic diagnostics and echoscopic monitoring were carried out on Ultrasonic devices VIVID 7 (General Electric, USA), Toshiba APLIO, Toshiba Xario (Japan), working in real time using convex sensors 2-5, 4-6 MHz and linear sensors with a frequency 5 -12 MHz. The study began with the projection of the femoral artery (in the inguinal region) with the assessment of blood flow in the transverse and longitudinal section with respect to the longitudinal axis of the vein. At the same time, the blood flow of the femoral artery was evaluated. When scanning, the diameter of the vein, its compressibility was estimated (by compression of veins by a sensor to the cessation of blood flow while maintaining blood flow in artery), the state of the lumen, the safety of the valve apparatus, the presence of changes on the walls, the condition of paravas tissues. The state of hemodynamic veins was evaluated using functional samples: respiratory and cough sample or sample with a fitting. At the same time, the state of the thigh, the popliteal vein, the veins of the leg, as well as the large and low subcutaneous veins, was estimated. The estimate of the hemodynamics of the lower vein, as well as the iliac, large subcutaneous, femoral veins and the ledgers in the distal department was carried out in the patient's position lying on the back. The study of the same trades, the veins of the upper third of the leg and the low subcutaneous vein was held in the patient's position lying on his stomach with a roller under the area of \u200b\u200bthe ankle joints. For the study of the main veins, and during difficulties in the study used convex, in the rest - linear sensors.
Scanning in cross section was performed to detect the mobility of the thrombus head, as evidenced by the complete contact of the venous walls with a slight compression by the sensor. In the course of the survey, the nature of phlebotromability was established: antenna, occlusive or floting.
The list of laboratory diagnostic methods included determining the level of the D-dimer, coagulogram, a study of thrombophilia markers. With suspected transferring TAL to a survey complex, computed tomography in angiopulmonography and the study of the abdominal cavity and a small pelvis was also included.
In order to surgically prophylaxis the TEL with acute phlebosis, 3 methods of operation were used: Cava filter implantation, plits of vein segment and crossctomy and / or phlebectomy. In the postoperative period, ultrasound diagnostics pursued the purpose of assessing the state of venous hemodynamics, the degree of recanalization or strengthening of the thrombotic process in the venous system, the presence or absence of fragmentation of blood cloth, the presence of flotation, thrombosis of the contralateral limb, the thrombosis of the pluggetion zone or kava filter and the linear and volumetric blood flow velocity were determined and collateral blood flow.
Statistic analysis was performed using the Statistica program. Assessment of the differences in the results between the groups was carried out according to the Person criteria (carried out according to the criteria of Pearson) and Student (T). Differences were statistically reliable, the level of significance of which was more than 95% (p< 0,05).
Results of research and discussion
The leading sign of phlebromability was the presence of echobositive thrombotic masses in the lumen of the vessel, the density of which was intensified as the limitation of the thrombus increases. The valve sash has ceased to differentiate, the transfer pulsation from the artery was not determined, the diameter of the thrombish vein increased 2-2.5 times compared with the contralateral vessel, it is not squeezed with a sensor compression. At the beginning of the disease, when the thrombles are visually indistinguishable from the normal lumen of the veins, we consider it particularly important to carry out compression ultrasonography. On the 3-4th day of the disease, the sealing and thickening of the venous wall was observed due to the phlebitis, the perivasal tissues became "blurred".
Priest thrombosis was set in the presence of a thrombus, free blood flow in the absence of a complete contact of the walls in a compression sample, the presence of a fill and spontaneous blood flow during spectral doppler in duplex scanning.
The criteria of floting thrombosis were considered to be visualization of the thrombus in the lumen of the veins with the presence of free space and blood flow around the head, the movement of the thrombus head into cardiac battles, when conducting a sample of a straining or compression of the vein sensor, the lack of contact with the venous walls during a compression sample enhancing the type of blood flow, the presence of spontaneous blood flow With spectral dopplerography. For the final clarification of the character, the thrombus used the Waltasalver sample, which, however, is dangerous due to the additional flotation of the thrombus.
Thus, according to color duplex scanning, floting thrombus found in 118 (35.3%) cases. Most often, they were detected in the deep veins system of the pelvis and hips (in 45.3% in deep veins of the thigh, in 66.2% in the iliac veins), less often in the system of deep veins of the leg and a large subcutaneous thigh veins. Differences in the frequency of flotation of thrombus in men and women were not revealed.
The frequency of floting phlebotromability in recent years has increased, which is due to the conduct of color duplex scanning in all patients in front of surgical intervention in long-term immobilization, as well as necessarily in patients with extremities injuries and after operations on the bone-articular system. We believe that, despite the obvious clinical picture of the presence of surface varicotromibophlebit, there is always a need for a CDA to eliminate subclinical fluttering thrombosis in both superficial and deep veins.
As it is known, the coagulation processes are accompanied by the activation of the fibrinolytic system, and these processes are in parallel. For clinical practice, the fact of establishing both flotations of thrombus, the nature of the propagation of thrombus in Vienna and the probability of its fragmentation in the process of recanalization is very important.
At the CDS of the lower extremities, it is important: the nester thrombus were established in 216 (64.7%) of patients, from which occlusion thrombosis was found in 181 (83.8%) patients, non-obscison closed thrombosis - in 35 (16.2%).
Priest blood clots were detected as a fixed mass of the veins mass at a considerable distance. At the same time, the lumen of the vein was preserved between the thrombotic masses and the wall itself. In the process of anticoagulant therapy, the cloth thrombles are capable of fragmented, cause an embin hazardous state and recurrent embolism of small branches of the pulmonary artery. With mobile and fluttering blood clots, soldered with a venous wall only in its distal department, a real and high risk of tomb thrombus and pulmonary embolism is created.
Among the non-conclusion forms of thrombosis, a dome-shaped form of blood cloth can be distinguished, sonographic signs of which are a wide base equal to the diameter of veins, the lack of oscillatory movements in the blood flow and the length of the thrombus up to 4 cm. The risk of pulmonary artery embolism with this version of thrombosis is low.
Repeated colored duplex scans were carried out by all patients until the floting tip of the thrombus to the wall of the vein was further from 4 to 7 days of treatment and necessarily before the patient.
Patients with fluttering blood closures Ultrasonic angiusing of the veins of the lower extremities were carried out at mandatory per day of operation, as well as 48 hours after the Implantation of the KAVA filter or the execution of the veins (drawing). Normally, with a longitudinal scanning of the lower hollow vein, the Kava filter is visualized as a hyperheogenic structure, the form of which depends on the filter model. Typical was considered the position of the Kava filter in Vienna at the level or a little distal than the mouth of the renal veins or at the level of 1-2 lumbar vertebrae. With CDA at the place of the filter, there is usually an expansion of the lumen of the vein.
According to the color duplex scanning after the implantation of Kava filters, 8 (32.0%) from 25 patients on the filter found a fixation of massive thrombus. The segment of the veins in the area of \u200b\u200bplugium was carried out in 29 (82.9%) of 35 patients, in 4 (11.4%) was revealed by the continued thrombosis below the plight site, in 2 (5.7%) the bloodstream in the area of \u200b\u200bPlugation did not succeed Determine, and blood flow was carried out only by collateral paths.
Lower hollow vein with a sensor installed. Viden the painted blood flow (blue - flowing to the sensor, red - leakage from the sensor). On the border between them, the normally functioning Kava filter
It has been established that the Implative Cava filter contributes to the progression of the thrombotic process and increases the frequency of thrombosis recurrence, which can be explained, including not only the progression of the process, but also by finding a foreign body in a lumen of the veins and slowing down the main blood flow in this segment. The frequency of cases of thrombosis progression in patients, transferred plight and the treaty only drugs, is almost the same, but it is essentially lower in comparison with the same indicator after endovascular interventions.
conclusions
1. The main risk factors of phleburosis in men should include combined injury, the implementation of combined surgical interventions and the presence of pronounced cardiovascular diseases; In women - severe diseases of the cardiovascular system and genitals.
2. To the advantages of color duplex scanning should include the possibility of objective control over the presence and level of the thrombotic process, flotation of thrombus, assessing the effectiveness of drug therapy, monitoring over the course of phlebotomability after performing operations on TEL surgical prophylaxis. Ultrasonography allows us to solve tactical issues with fluttering thrombas individually taking into account both the localization of the proximal part of the thrombus, its length, the nature of the thrombotic process and phlebosis factors.
3. In the presence of embin hazardous thrombosis against the background of severe concomitant pathology and contraindications to the open operation, the KAVA filter installation is a measure of the prevention of TEL. In young patients, it is advisable to install removable Cava filters or execution of open operations with a temporary kava filter installation.
4. In 32.0% of patients, massive blood clots were revealed on the KAVA filter after its endovascular implantation, in 17.0% of cases below the place of paragraphs of veins detected floting thrombus. These data indicate the effectiveness of the prevention of TELE by surgical treatment of fluttering embossofer thrombosis in the system of the lower hollow vein.
Bibliographic reference
Ipatenko V.T., Davydkin V.I., Ochapov V.V., Savrasova T.V., Makhrov V.V., Shirokov I.I. Diagnosis and treatment of floting thrombosis in the system of the lower hollow vein // Scientific Review. Medical sciences. - 2017. - № 6. - P. 34-39;URL: https://science-medicine.ru/ru/article/view?id\u003d1045 (Date of handling: 27.01.2020). We bring to your attention the magazines publishing in the publishing house "Academy of Natural Science"
Acute venous thrombosis is a common and dangerous disease. According to statistical data, its frequency in the overall population is about 160 per 100,000 population. Thrombosis in the system of the lower vein (NPB) is the most frequent and dangerous variety of this pathological process and is the main source of pulmonary vessel embolism (84.5%). The system of the upper floor of the vein gives 0.4-0.7% of pulmonary artery thromboembolism (TEL), the right heart departments are 10.4%. The share of thrombosis veins of the lower extremities accounts for up to 95% of cases of all thrombosis in the NPV system. The diagnosis of acute venous thrombosis is long diagnosed in 19.2% of patients. In the long run, the deep veins thrombosis (TGV) leads to the formation of post-terrboflectric disease, manifested by chronic venous insufficiency, until the development of trophic ulcers, which significantly reduces the abilityality and quality of life of patients.
The main mechanisms of intravascular formation of thromboms known since R.VircHow are the slowdown of blood flow (stas), hypercoagulation, vessel wall injury (endothelium damage). Acute venous thrombosis quite often develops against the background of various oncological diseases (malignant tumors of the gastrointestinal tract, female sexual sphere, etc.) due to the fact that cancer intoxication causes the development of hypercoagulant changes and the oppression of fibrinolysis, as well as due to the mechanical compression of the veins, tumor and germination Its into the vascular wall. The predisposing factors of TGV are also considered obesity, pregnancy, taking oral hormonal contraceptives, hereditary thrombophilia (deficiency of antithrombin III, protein C and S, Leidenovskaya mutation, etc.), systemic diseases of connective tissue, chronic purulent infections, allergic reactions. Patients with the chronic venous insufficiency of lower extremities, as well as patients with myocardial infarction, decompensated heart failure, stroke, straggle, stroke, a stroke, proleell, gangrene, stroke, proleells, gangrene lower extremities, are subject to the greatest risk. Traumatological patients are particularly alarming, since the fractures of the femoral bone are mainly found in individuals of the elderly and senile age, the most burdened by somatic diseases. Thrombosis in traumatological patients may occur in any injury of lower extremities, since there are all the etiological factors of thrombosis (damage to the vessel, venous stagnation and changes in blood coagulation).
Reliable diagnosis of phlebotromability is one of the current clinical tasks. Physical examination methods allow you to put the correct diagnosis only in typical cases of the disease, while the frequency of diagnostic errors reaches 50%. For example, thrombosis of the veins of the calf muscles with the preserved passability of the remaining veins often proceeds asymptomatic. Due to the danger, the clinicians often put this diagnosis in each case the appearance of pain in the ion muscles in each case. Special attention deserve "traumatological" patients who have pain, edema and changes in the color of the limb can be due to the injury itself, and not TGV. Sometimes a massive tel is the first and only manifestation of such thrombosis.
The tasks of the instrumental examination include not only confirmation or refutation of the presence of thrombus, but also determining its length and degree of embology. The release of embaning thrombas into a separate group and the study of their morphological structure is of great practical importance, since without this, the development of effective prevention of the pulmonary embolism and the choice of optimal treatment tactics is impossible. Thromboembolic complications are more often observed in the presence of a floting thrombus with a heterogeneous structure, an uneven hypochogenic contour, in contrast to thrombus having a hyperheogenic circuit and a homogeneous structure. An important criterion for enzymology thrombus is the degree of its mobility in the vessel. Emumblic complications are more often noted with a pronounced and moderate mobility of thrombomass.
Venous thrombosis is a fairly dynamic process. Over time, the processes of retraction, humoral and cell lysis contribute to a decrease in the dimensions of the thrombus. At the same time, the processes of its organization and recanalization are coming. In most cases, the vessels are gradually restored, the valve vein vehicle is destroyed, and the remnants of the blood clouds deform the vascular wall in the form of cluster superplots. Diagnostic difficulties can be in the occurrence of repeated acute thrombosis against the background of partially recanalyzed veins in patients with post-tomboflicic disease. In this case, a sufficiently reliable criterion is the difference of veins in diameter: in patients with signs of the recanalization of thrombomass, a decrease in veins in diameter due to the aid of the acute process; With the development of retrose, there is a significant increase in the diameter of veins with fuzzy ("blurred") circles of the walls and the surrounding tissues. These criteria are used with the differential diagnosis of acute intricate thrombosis with post-chrombotic changes in veins.
Of all the non-invasive methods used to diagnose thrombosis, the ultrasonic scanning of the venous system is increasingly used in recent times. The Triplex Angioscaning method proposed by Barber in 1974 includes a study of vessels in in-mode, an analysis of the Doppler frequency shift in the form of classical spectral analysis and flow (in high-speed and energy modes). The use of spectral made it possible to accurately measure the bloodstream inside the lumen of the veins. The use of the method () provided the ability to quickly distinguish occlusive thrombosis from the non-cluster, identify the initial stages of the recombination of thrombus, as well as determine the location and size of venous collaterals. During studies in dynamics, the ultrasound method allows to ensure fairly accurate control over the effectiveness of thrombolytic therapy. In addition, with the help of an ultrasound study, the causes of the appearance of clinical symptoms similar to that with vessel pathology can be established, for example, to reveal a biker cyst, an intertensive hematoma or tumor. The introduction of an expert class ultrasound instruments into the practice of frequency sensors from 2.5 to 14 MHz made it possible to achieve almost 99% of diagnostic accuracy.
Material and methods
The survey included inspection of patients with clinical signs of venous thrombosis and TEL. Patients presented complaints on swelling and pain in the lower (upper) limb, pain in the calf muscle (more often sawing), "pulling" pain in the popliteal region, pain and seal along the subcutaneous veins. During the inspection, moderate cyanosis of the shin and feet, dense swelling, pain in palpation of the leg muscles, in most patients is the positive symptoms of Homans and Moshares.
The entire examined was conducted triplex scanning of the venous system on modern ultrasonic devices with a linear sensor with a frequency of 7 MHz. At the same time, the state of the thigh, the popliteal vein, the veins of the leg, as well as the large and low subcutaneous veins, was estimated. An convex sensor with a frequency of 3.5 MHz was used to visualize the iliac venues and the NPB. When scanning an NPV, iliac, large subcutaneous veins, a femoral veins and a veins of the leg in the distal section of the lower extremities, the patient was in a position lying on his back. The study of the fallen veins, the veins of the upper third of the leg and the low subcutaneous vein was carried out in the patient's position lying on his belly with a roller under the area of \u200b\u200bthe ankle joints. Diagnosis difficulties occurred when visualizing the distal surface of the femoral vein in obese patients, visualization of the veins of the shin with pronounced trophic and industrial changes in tissues. In these cases, a convex sensor was also used. The depth of scanning, the enhancement of the echo signal and other parameters of the study were selected individually for each patient and remained unchanged during the entire survey, including observations in dynamics.
Scanning began in cross section to eliminate the presence of a floting tip of the thrombus, as evidenced by the complete contact of the venous walls during a slight compression by the sensor. After convincing the absence of a free floting tipper tomb, the compression sample was performed from the segment to the segment, from the proximal departments to distal. The proposed method is the most accurate not only for the detection of thrombosis, but also to determine its length (excluding iliac veins and NPS, where the veins are determined in the CDC mode). veins confirmed the presence and characteristics of venous thrombosis. In addition, the longitudinal section was used to locate the anatomical fusion of veins. During the survey, the state of the walls, the lumen of the veins, the Localization of the thrombus, its length, degree of fixation to the vascular wall was estimated.
The ultrasound characteristic of venous thromboms was carried out in relation to the lumen of the vessel: they differed as intricate, occlusive and fluttering blood clots. The signs of the cloth thrombosis were considered the visualization of the thrombus with the presence of free blood flow in the lumen of the veins, the absence of a complete set of the walls in the compression of the vein by the sensor, the presence of a defect of filling during CDC, the presence of spontaneous blood flow during spectral dopplerography (Fig. 1).
Fig. one. Non-conclusive thrombosis of the popliteal vein. Longitudinal scan of veins. Enveling blood flow in power coding mode.
Ultrasonic criteria for floting thrombubs were considered: thrombus visualization as an echogenic structure located in the lumen of the veins with the presence of free space, the oscillatory movements of the tomb of the tomb, the absence of the veins of the veins when compression by the sensor, the presence of free space when performing breathing samples, envelope the type of blood flow under the CDC, the presence of spontaneous blood flow with spectral dopplerography. When the flushing thrombus is detected, the degree of its mobility was estimated: pronounced - in the presence of spontaneous thrombus movements with calm breathing and / or breathing delay; moderate - when the thrombus oscillatory movements are detected during the functional samples (coughing sample); Minor - with minimal thromba mobility in response to functional samples.
Results of research
From 2003 to 2006, 236 patients aged from 20 to 78 years of age were examined, of which 214 with the clinic of acute thrombosis and 22 with the tel clinic.
In the first group in 82 (38.3%) cases, the permeability of deep and superficial veins was not violated and clinical symptoms were due to other reasons (Table 1).
Table 1. States having similar symptoms with TGV.
The diagnosis of thrombosis was confirmed in 132 (61.7%) patients, while in most cases (94%) thrombosis was detected in the NPV system. The TGV was discovered in 47% of cases, the surface veins - in 39%, the defeat of both a deep and surface venous system was observed in 14%, including 5 patients with the involvement of perforate veins.
The probable causes (risk factors) of the development of venous thrombosis are presented in Table. 2.
table 2. Risk factors for the development of thrombosis.
| Risk factor | Number of patients | |
|---|---|---|
| abs. | % | |
| Injury (including long-term gypsum immobilization) | 41 | 31,0 |
| Varicose disease | 26 | 19,7 |
| Malignant neoplasms | 23 | 17,4 |
| Operations | 16 | 12,1 |
| Reception of hormonal drugs | 9 | 6,8 |
| Thrombophilia | 6 | 4,5 |
| Chronic ischemia limbs | 6 | 4,5 |
| Yatrogenic reasons | 5 | 4,0 |
In our observations, the common form of thrombosis was most often detected, as well as the defeat of the veins at the level of the detachment-beam and femoral-poned segments (Table 3).
Table 3.. Localization of the TGV.
More often (63%) there were thrombosis, fully occlusive clearance of the vessel, in second place in terms of frequency (30.2%) were intricate blood clomes. Floting thrombus are diagnosed in 6.8% of cases: in 1 patient - in saphenofemoral substitution with an upward thrombosis of the trunk of a large subcutaneous vein, in 1 - Ileofemral thrombosis with a floting top in a common iliac vein, in 5 - in the common femur vein during femur thrombosis segment and 2 - in the popliteal vein at the TGV of the shin.
The length of the non-fixed (floting) part of the thrombus, according to ultrasound data, varied from 2 to 8 cm. The moderate mobility of thrombotic masses (5 patients) was detected, in 3 cases, the thrombus mobility was minimal. In 1 patient, with a calm breath, spontaneous thrombus movements were visualized in a vessel list (high degree of mobility). In our observations, floting thrombus with an inhomogeneous echoostructure (7 people) were often detected, while the hyperheogenic component was prevailed in the distal department, and in the region of the thrombus head - hypo echogenic (Fig. 2).
Fig. 2. Floting thrombus in the common femoral vein. B-mode, longitudinal vein scanning. Thromb of heterochogenic structure with a clear hyperheogenic contour.
In the dynamics, 82 patients were examined in the dynamics of the flow of the thrombotic process, of which 63 (76.8%) were noted a partial recanalization of thrombotic masses. In this group, 28 (44.4%) of patients were observed a central type of recanalization (with longitudinal and transverse scanning in the CDC mode, the reccript channel was visualized in the center of the vessel); In 23 (35%) patients were diagnosed by the cloth reconnaissance of thrombotic masses (more often the blood flow was determined along the vein wall, directly adjacent to the artery of the same name); In 13 (20.6%) patients detected incomplete recanalization with fragmentary asymmetric staining in the MDC mode. The thrombotic occlusion of the lumen of the veins was observed in 5 (6.1%) patients, in 6 (7.3%) cases noted the restoration of the lumen of the vein. Signs of retrojects persisted in 8 (9.8%) examined.
conclusions
A comprehensive ultrasound study, including angiosication using spectral, color and energy doppler regimes and soft tissue echography, is a highly informative and safe method that allows the most reliably and quickly solve the issues of differential diagnosis and therapeutic tactics in the outpatient phlebological practice. This study is advisable to conduct on an outpatient stage for earlier detection of patients who are not shown (and sometimes contraindicated) thrombolytic therapy, and their directions in profile branches; In confirming the presence of venous thrombosis, it is necessary to identify persons with a high risk of developing thromboembolic complications; Watch in dynamics over the flow of a thrombotic process and thereby adjusting the therapeutic tactics.
Literature
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- Barkagan Z.S. Hemorrhagic diseases and syndromes. Ed. 2nd, recreation. and add. M.: Medicine 1988; 525 p.
- Bergqvist D. Postoperative ThromBoembolism. // NEW YORK 1983. P. 234.
- Saveliev V.S. Phlebology. M.: Medicine 2001; 664 p.
- Kokhan E.P., Zavarina I.K. Selected lectures on angiology. M.: Science 2000. P. 210, 218.
- Hull R., Hirsh J., Sackett D.L. et al. Combined Use Of Leg Scenning and Impedance Plethysmography in Suspected Venous Thrombosis. An alternative to venography. // n.Engl.j.med. 1977. N ° 296. P. 1497-1500.
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The thrombotic damage to the venous channel of the lower extremities, primarily deep veins, is an acute state, developing as a result of a complex action of a number of factors. According to statistical reports of the Ministry of Health of the Russian Federation, our country annually registers 80,000 new cases of this disease. In the elderly and old age, the frequency of the deep vein thrombosis increases several times. In Western European countries, this pathology occurs in 3.13% of the population. Venous thrombosis is the main cause of pulmonary arterial thromboembolism. The massive thromboembolism of pulmonary arteries is developing in 32-45% of patients with acute thrombosis of the deep veins of the lower limbs and ranks third in the overall structure of sudden mortality.
Thrombosis of deep veins - This is the formation of a blood clots inside the vessel. In the formation of thrombus, an obstacle of blood outflow occurs. Venous thrombosis may occur with circulatory disorders (blood stagnation), damage to the inner wall of the vessel, an increased blood ability to form a thrombus, as well as combining these reasons. The formation of thrombus can begin on any site of the venous system, but most often - in the deep veins of the leg.
Ultrasonic compression duplex angiosication is the main method of examination with suspected venous thrombosis. The main tasks are the detection of thrombus, the description of its density (this feature is important for the diagnosis of thrombosis period), fixation to the walls of veins, length, the presence of fluttering sections (capable of separation from the vascular wall and move with blood flow), the degree of obstruction.
Also, ultrasound examination allows dynamic observation of blood cloth in the treatment process. Active search for deep veins thrombosis with duplex scanning seems appropriate in the preoperative period, as well as oncological patients. The significance of ultrasound methods in the diagnosis of thrombosis is considered sufficiently high: sensitivity ranges in the range of 64-93%, and specificity - 83-95%.
Ultrasound examination of the lower limbs is carried out using linear sensors 7 and 3.5 MHz. The study begins with the groin area in the transverse and longitudinal section in relation to the vascular beam. The mandatory scope includes inspection of subcutaneous and deep veins of both lower extremities. When obtaining an image of veins, the following parameters are estimated: diameter, compressibility (compression by the sensor until the blood flow is cessation in vein while maintaining blood flow in artery), features of the stroke of the vessel, the state of the internal lumen, the safety of the valve apparatus, changes in the walls, the condition of the surrounding tissues. Bloodstock is necessarily evaluated in a number of lying artery. The condition of venous hemodynamics is also estimated by using special functional samples: respiratory and cough sample or sample with a fitting (Valzalvy test). It is primarily used to assess the state of deep and subcutaneous vein valves. In addition, the use of functional samples facilitates visualization and assessment of veins in areas with low blood flow. Some of the functional samples may be useful to clarify the proximal boundary of venous thrombosis. The main signs of the presence of thrombosis include the presence of echoposive thrombotic masses in the lumen of the vessel, the echo absorption increases as the limitation of the thrombus increases. The valve flaps are ceased to differentiate, the transfer arterial pulsation disappears, the diameter of the thrombied vein is increased by 2-2.5 times compared with the contralateral vessel, it is not squeezed with a sensor compression.
Three types of venous thrombosis are isolated: floting thrombosis, occlusive thrombosis, tromboration (non-conducive) thrombosis.
Occlusive thrombosis is characterized by a complete fixation of the thrombomass to the venous stack, which prevents the conversion of the blood clomba to the embol. The signs of the trombic thrombosis include the presence of a thrombus with free blood flow in the absence of a complete falling off the venous walls in a compression sample. The criteria of the floting thrombub are considered to be visualization of the thrombus in the lumen of the veins with the presence of free space, the oscillatory movements of the thrombus head, the absence of contacting the walls of the vein with the sensor compression, the presence of free space when performing respiratory samples. For the final clarification of the character, the thrombus uses a special test of the waltasalver, which should be carried out with caution in view of the addition flotation.
Ultrasound examination is a diagnostic method of the first line if the thrombosis of the deep veins of the lower limbs is suspected. This contributes to the relatively low cost, availability and safety of the technique. In GBUZ "Tambov Regional Clinical Hospital named after V.D. Babenko "Ultrasonic duplex angiosication of peripheral veins is held since 2010. About 2000 studies are performed annually. High quality diagnostics allows you to save the life of a large number of people. Our institution is the only institution in the area in which there is a separation of vascular surgery, which makes it possible to determine the tactics of treatment immediately after establishing the diagnosis. Highly qualified doctors successfully use modern methods for the treatment of venous thrombosis.
E.A. Maruschka, Ph.D., A.R. Zubarev, D.M., Professor, A.K. Demidov
Russian Research Medical University. N.I. Pirogova, Moscow
Methodology of ultrasound examination of venous thrombosis
The article presents four-year experience in performing ultrasound studies of venous blood flow (12,394 outpatient and stationary patients with acute venous pathology of the Central Clinical Hospital of the Russian Academy of Sciences). On a large clinical material, the methodology of performing primary and dynamic ultrasound studies in patients in the conservative treatment of venous thrombosis and when performing various methods of surgical prevention of pulmonary arteries thromboembolism. Special attention is paid to the interpretation of the results of ultrasound research in terms of the probability of the thromboembolism of the pulmonary artery. The results of the application of the proposed ultrasound research methodology in the practice of a multidisciplinary peripheral hospital and a medical and diagnostic center are analyzed.
Keywords: ultrasound angiosication, vein, acute venous thrombosis, deep veins thrombosis, pulmonary artery thromboembolism, TEL surgical prophylaxis
About Introduction
Epidemiology of acute venous thrombosis (OVT) is characterized by disappointing data: the incidence of this pathology in the world reaches 160 people per 100 thousand population annually, and in the Russian Federation - at least 250 thousand people. According to M.T. SEVERINSEN (2010) and L.M. Lapiene1 (2012), the incidence of phlebromsis (FT) in Europe is 1: 1000 annually and reaches 5: 1000 in patients with skeletal injury. The large-scale analysis of the morbidity of deep veins (TGV), conducted in the USA in 2012, showed that 300-600 thousand Americans diagnose this pathology annually, with 60-100 thousand of them die from the pulmonary artery thromboembolism (TEL). These indicators are due to the fact that OVTs are found in patients with the most diverse pathology and are often secondary, complicating any diseases, surgical interventions.
For example, the frequency of venous blood-milk accumulations (VTEO) in stationary (including surgical profile) of patients reaches 10-40%. V.E. Bari-New et al. Specify data on the frequency of TEL in airbreivers, equal to 0.5-4.8 cases per 1 million passengers, and the fatal TEL is the cause of 18% of deaths in airplanes and airports. Tel is the cause of death in 5-10% of the hospital patients, and this indicator is growing steadily. Massive and, as a result, the lethal TEL in part of the patients is the only one, the first and last manifestation of OVT. In the study of L.A. Labo et al., Dedicated to the study of Tel in surgical patients, provides data on mortality from VTEO in Europe: their number exceeds the total mortality from breast cancer, acquired immunodeficiency syndrome and car accident and more than 25 times higher mortality from infections caused by Golden Staphylococcus .
Interesting is the fact that from 27 to 68% of all deaths from Tala potentially prevent. The high value of the ultrasound research method (ultrasound) in the diagnosis of OVT is due to non-invasiveness and approaching 100% sensitivity and specificity. Physical methods of examination of patients with suspicion of OVTs allow you to put the correct diagnosis only in typical cases of the disease, while the frequency of diagnostic errors reaches 50%. Thus, an ultrasonic diagnostic doctor has a chance to verify or eliminate OVET equal to 50/50.
The instrumental diagnosis of OVT is one of the actual tasks in the plan of visual assessment of the substrate of the disease, since the data obtained depends on the determination of angio spicy tactics, and if necessary, the surgical prophylaxis of TELE is the choice of its method. Execution of dynamic
Ultrasound is necessary both when conducting conservative treatment of OTS in order to evaluate arising changes in the affected venous vein, and in the postoperative period.
Ultrasound diagnostic doctors are on an advanced visual evaluation of OVT. It is an ultrasound that is the method of choice in this category of patients, which dictates the need not only to detect OTS, but also the correct description and interpretation of all possible characteristics of this pathological condition. The purpose of this work was the standardization of the methodology for the implementation of ultrasound examinations with OVT, aimed at minimizing the likely diagnostic errors and for maximum adaptation to the needs of clinician doctors that determine therapeutic tactics.
About Materials
In the period from October 2011 to October 2015 in the Central Clinical Hospital of the Russian Academy of Sciences (CKB RAS, Moscow), 12,068 primary ultrasound of blood flow system of the lower hollow and 326 are the upper hollow system of veins (only 12 394 ultrasound). It is important to emphasize that the Central Bank of the Russian Academy of Sciences purposefully does not take acute venous pathology through the channel "Ambulance". Of the 12 394 studies, 3,181 were performed outpatient patients of therapeutic and diagnostic center, 9 213 - hospital patients with suspicion of acute venous pathology or with a prophylactic goal in patients with risk groups under venous thromboembo-lyual complications, as well as testimony as a preoperative preparation. OVTs were diagnosed in 652 hospital patients (7%) and 86 outpatient patients (2.7%)
(only 738 people, or 6%). Of these, the Localization of OVTs in the direction of the lower hollow vein was detected in 706 (95%), in line with the upper hollow vein - in 32 patients (5%). The vascular ultrasound was performed on the following devices: Voluson E8 Expert (GE HC, USA) using multi-frequency convex-th (2.0-5.5 MHz) and linear (5-3 MHz) sensors in the following modes: in-mode, color Dopple-rovin mapping, energy doppler mapping, impulse-reserved mode and the time of the unacceptable imaging of blood flow (B-FLOW); Logiq E9 Expert (GE HC, USA) with a similar set of sensors and programs plus quality ultrasonic elastography mode.
About Methodology
The first task in carrying out ultrasound is the detection of the substrate of the disease - the venous thrombosis itself. OVT is characterized by an individual and often mosaic anatomical localization in the row of hollow veins. That is why it is necessary in detail and polypositive to explore not only the surface and deep channel of both the lower (or the upper) limbs, but also the or Caval segment, including with the renal veins. Before conducting an ultrasound, it is necessary to familiarize themselves with the existing data of the history of the disease of the patient, which in some cases will help detail the search and to bring to the idea of \u200b\u200batypical sources of formation of OVT. Always need to remember the existing probability of bilateral and / or multifocal thrombotic process throughout the venous bed. The informativeness and value of the ultrasound of angiohururgov is associated not so much with the fact of verification of OVT, as with the interpretation of the results obtained and with their de
taxation. So, on the basis of the conclusion of the ultrasound, represented as "non-convened thrombosis of the common femoral vein", angiohi-rurgov, in addition to confirming the fact of OTS, does not receive any other information and, accordingly, cannot determine in detail the further tactics. Therefore, in the Ultrasound Protocol, the detected OVTs must necessarily be accompanied by all its characteristics (border, character, source, length, flotation length, attitude to anatomical orientation, etc.). In conclusion, the ultrasound should be the interpretation of the results aimed at further definition by the clinician tactics. The terms "or Caval", "orofemoral" are also clinical, and not ultrasound.
Oh primary ultrasound
The main technique for the verification of OVT with ultrasound is a compression of the sensor of the interest zone (fragment of a visualized vessel). It should be noted that the strength of the compression should be sufficient, especially in the study of the deep channel, in order to avoid obtaining false-positive information on the presence of thrombotie mass where they are not. A clean vessel that does not have pathological intravolya inclusions containing only liquid blood, with compression exposed to full compression, its lumen "disappears". In the presence in the lumen of thrombotic masses (the latter can be different structures and density) to compress the clearance completely fails, which can be confirmed by the compression of the unchanged control of the vein at the same level. The thrombown vessel has a larger diameter compared to free control, and its scoke in
tone doppler mapping (CDC) will be at least non-uniform or not available.
The study of the orObivinal segment is carried out by a low-frequency convex sensor, however, in some cases, patients with a small mass body can use high-frequency linear sensors. In obese patients with severe meteorism, as well as in the presence of adhesive disease, after surgery, the visualization of the orOrmed segment will be sharply difficult. The use of drugs, overwhelming and reduced manifestations of gas formation, as well as cleansing enema improves the conditions of visualization is insignificant, and in addition, it requires additional time or can be contraindicated in patients with suspicion of Ovt non-conclusive. The use of auxiliary modes, such as CDC, in these cases does not reduce the risk of diagnostic errors. For example, with non-conclusive local thrombosis of the outer iliac vein, the obvious patient, the magnitude of the vessel in the CDC mode can be fully scored, and the compression of the vein is not possible. To explore the veins, the pelvis and some fragments of the iliac veins in case of their poor visualization from transabdominal access, it is possible to use intra-solitary sensors (transvaginal or transrectal ultrasound). In the study of the deep venous line of the lower limbs in obese patients, as well as in the presence of lymphostasis, when the depth of the penetration of the ultrasonic beam from a linear high-frequency sensor is insufficient, it is necessary to use a low-frequency convex. In this case, you can define
the boundary of the thrombosis, but the quality of the visualization of the tomb of the tomb is in-mode will be unimportant. With poor visualization of the upper boundary and character of thrombosis or venous segment, as such, it is not necessary to give these characteristics in conclusion, remembering the main rule of the doctor of ultrasound diagnostics: not to describe what I have not seen or saw bad. In this case, it is necessary to record that obtaining this information by the Uzi method at the time of the inspection is not possible for technical reasons. It should be understood that ultrasound as a technique has its limitations and lack of a clear visualization of the upper boundary and the nature of thrombosis there is a reason for using other research methods.
In some cases, the visualization of the upper boundary and the nature of thrombosis helps the Val-Salvi sample (the patient's escape to create a retrograde blood flow in the vessel under study, in which the diameter of the vein will increase and may be visible to the thrombus flotation) and the disk compression floss (relossing the lumen of the vein Above the level of thrombosis, in which the diameter of the vessel will also increase, which will improve the visual assessment). Figure 1 shows the moment of the occurrence of retrograde blood flow in the OBA during the sample of Waltasalvi, as a result of which floting thrombus, being washed from all sides by the blood flow, took the central position in relation to the axis of the vessel. Waltasalvi sample, as well as a sample with distal compression, must be used with caution, since they can provoke TELL with emban hazardous thrombosis. In relation to the OTV, it is the largest diagnostic value. With good visualization, one can
rochemical mode for a detailed description of all characteristics of OVT. The remaining regimes (CDC, energy mapping (EC), in A ^, elastography) are auxiliary. In addition, additional modes in some extent are the artifacts that can enter a misleading doctor. Such artifacts include the phenomenon of "pouring" of the lumen in the MDC mode with non-conclusive thrombosis or, on the contrary, the complete absence of the scope of the lumen of the obviously undergoing vessel. There is little chance to diagnose thrombosis, not recognized in in mode, using only auxiliary. Also, it is also not necessary when drawing out the conclusion of ultrasound to fully rely on the data obtained only by additional modes.
It was mentioned above that to competently construct an ultrasound conclusion of one fact of detection in the lumen of veins of thrombotic masses. The conclusion should contain information on the nature of thrombosis, its source, the boundary with respect to ultrasound and anatomical benchmarks and - in the case of fluttering thrombosis, is an individual characteristic of its potential emphasis. The detailed estimate of the listed parameters makes it possible to determine the testimony for conservative treatment or to the surgical prevention of TEL, including with the choice of its type.
Occlusive OVTs and non-conclusive OVTs of an adhesive nature, being fixed to the walls of the vessel completely or on one side, respectively, have a low degree of embogenicity and are usually treated conservatively. Floting thrombus is a thrombus having a single point of fixation and flow around blood from all sides. it
Figure 1. Application of Valzalvi sample to improve the visualization of the floting head of the thrombus in in-mode (the total femoral vein in the projection of the saffe-femoral substitution)
1 - a retrograde blood flow in the common femur vein when stretching with the effect of "spontaneous contrasting"; 2 - clearance of common femoral veins; 3 - floting thrombus; 4 - Safeno-Formoral Ostope
Figure 2. Floting thrombus with varying degrees of emphasis (at the top - a tomber with a low threat of TEL, at the bottom - a tomb tomb tomb)
classical definition of FT. However, in different patients with flotation thrombosis, even with an equal flotation length, the degree of embologenicity will be different, and therefore should be determined individually in real time. So, in fluttering blood cloth with a small body length and localization in the surface femoral vein, emphasis will be quite low. In a long floting thrombus, having a kind of "worm" and located in the lumen of the common femoral vein and above, emphasis is larger (Fig. 2). Below, we will consider the characteristics of the floting head of the thrombus from the position of determining its embanoba.
The need to measure flotation length, as a rule, is no doubt, as the fact that the resulting value is greater, the worse the forecast in terms of possible fragmentation of thrombus. The thickness of the cerombus and its ratio to the fluster head, as well as the amplitude and type of oscillatory (actually fluttering) head movements in the lumen of veins characterize the elastic strength of deformation, leading to a separation. Echo-
the fancy and the Thromba structure also provide information on the probability of fragmentation: the lower the echogenicness and the less uniform structure of the thrombus, the higher the probability of its fragmentation. In addition to the characteristics of the surface of floting thrombus, the upper limit of the thrombus (zone where the vessel starts completely compressed and does not contain the thrombotic masses and its source) to determine the degree of potential ehamboity. The higher the thrombosis border, the greater there is the rate of blood flow. The more the venous segment has security, the more there are "folding" turbulent flows. The closer the localization of the thrombub head to the venues of natural flexions (groin, knee), the higher the probability of permanent compression of the lumen containing the thrombus. Characterizing the source of thrombosis, it should be remembered that the typical OVT "originates" in small muscle branches, which gives the beginning of the medial group of the sural veins, and progresses from the bottom up, extending to the popliteal (PV), further on the surface femoral (PBV), the general femoral vein (OBP ) and higher. Typical
thrombophlebitis is formed in extended large subcutaneous (BPV) and low subcutaneous (MPV) veins.
The definition and description of the ultrasound of typical OTS does not cause difficulties. The thrombus with an atypical source in some cases remains not diagnosed at all, namely, atypical thrombosis is the most embossed-mi. Sources of atypical OVTs can be: deep femoral veins (GBV), veins pelvis, the injection places of narcotic drugs (t. N. Skin-vascular fistula), the region of the venous catheter and catheter itself, renal veins, tumor invasion, gonadny veins, hepatic veins , as well as the transition of thrombosis on deep veins through the fatal and communications of the affected subcutaneous veins (Fig. 3). Most often, atypical thrombosis are fluttering with weak fixation in the neck and are located in the poor and or casual segments. Interventional OVTs (postline and post-countertop) are formed at the point of damage (alteration) of the vessel, it is the only tomb fixation point. Interventional thrombosis are often locale
or segmental, i.e. are determined only in one venous segment (as a rule, OBA), while the deep veins above and below the thrombus are passable. Another group of atypical OVTs are combined thrombosis of deep and superficial veins. Among them, according to the ultrasonic picture, 3 options can be distinguished: 1. Ascending thrombophlebitis in the BPV basin and the thrombosis of the medial group (most often) of the surshal veins (arises by the transition of the thrombus from surface veins through thrombic perforant veins).
2 Ascending thrombophlebitis in the BPV and / or MPV pool with the transition to the deep vein system in the siblonal sofa (saffe-femoral, saffen-extractive phleburombosis).
3 Different combinations of the above options, up to the thrombosis of the OBP with several flothing heads. For example, the ascending thrombophlebitis in the BPV basin with the transition to OBA in the saffe-femoral substance (SPS) plus the OBP thrombosis during the progression of thrombosis from the deep veins of the tights by transition of the thrombosis from surface veins through thrombged perforants (Fig. 4). The probability of development is combined
thrombosis of surface and deep veins systems and bilateral FT once again confirms the need to perform the complete ultrasound of venous blood flow of the system of the lower hollow vein all over both primary and dynamic studies.
The atypical thrombosis also includes OVTs, complicating the course of cancer (the thrombosis of renal veins with the transition to the lower hollow vein). Another atypical source - deep femoral veins most often affected when conducting operations at the hip joint, as well as veins of the pelvis, thrombosis in which occurs in a row of diseases of the organs of this region. The most insidious embodiment of atypical thrombosis is in situ thrombosis. This is a variant of local segmental thrombosis without a visible source. Typically, the place of thrombosis in these cases is valve sines with low blood flow rate in this zone. Often, in situ clombs are found in iliac veins or OBB and in most cases are diagnosed already on the fact of the current TEL, using second-order visualization methods (computer-tomographs
physical phlebography, angiography) or not diagnosed at all, thereby being a source of "tel without a source", completely breaking away from the vessel wall, without leaving no substrate in the lumen of the vein.
A description of the mosaic or bilateral OVT should contain detailed information on both lower limbs and in all segments of the lesion separately. Evaluation of the potential embolo hazard of floting thrombus is carried out by the total analysis of its characteristics obtained. To facilitate this process, each of the criteria chip criteria is assigned 1 or 0 conditional scores according to the scheme described below (Table 1). The resulting total score gives a more accurate picture of the potential TEL. The work in this scheme allows you to avoid passing in the assessment of one or a number of criteria and, thus, not only to standardize the ultrasound technique, but also improve its effectiveness. When diagnosing in a patient, OVT with a high threat of TEL should be understood that it is likely that it will be shown to fulfill this or that type of surgical prevention of this complication. The main operation during OWT on
Figure 3. Various sources of atypical thrombosis (projection of the saffe-femoral coolest of the common femoral vein)
1 - source - female catheter; 2 - source - skin-vascular fistula (patients of addicts); 3 - source - large subcutaneous vein; 4 - source - deep femoral vein; 5 - source - surface femoral vein
Table 1. Determination of the potential degree of embologenicity floting phlebotromability
Uz-criteria Interpretation of ultrasound criteria
Phlebhemodynamics in the localization zone of floting head active 1
Zone "Exodus" thrombus atypical thrombosis 1
Typical thrombosis 0.
The ratio of the width of the neck to the flotation length (in mm, coefficient) is less than 1.0 1
More or equal to 1.0 0
Flotation with calm breathing is 1
Spring effect when sample Waltzalvae is 1
Flotation length more than 30 mm 1
Less than 30 mm 0
The structure of the floting head is heterogeneous, reduced echogenicity, with contour defects or torn top 1
Uniform, increased echogenic 0
Thrombosis growth rate negative 1
Missing or minimal 0
Note. Evaluation of the data obtained. 0-1 score - low degree of potential embotogenicity. 2 points - the average degree of potential emphasis. 3-4 points - high degree of potential emphasis. More than 4 points are extremely high degree of potential emphasis.
the level of the lower limbs itself is the PBV bandage. A prerequisite for the implementation of this intervention is the statement of the fact of the Pentility of the GBB, as well as the upper bound of the thrombosis. So, if the floting head leaves the PBV in the OBB, then the execution of thromboectomy from OBA will be necessary. At the same time, information on the length of flotation and an anatomical benchmark of the tomb of the tomb is very important (for example, relative to the groin fold, the SPS, the TSB with distal GBV). In the case of a transition of thrombosis is significantly higher than the level of the grooves fold, it is likely to perform the dressing of the outer iliac vein (NARPV), for which it is also necessary to obtain information about the anatomical landmark of the upper boundary
thrombosis (for example, its attitude to a fatal with an internal iliac vein (HPV) or its distinguished from the groin fold) and the passability of the EIV. All this information must be contained in the descriptive part of the ultrasound protocol.
When localizing an embin hazardous OVT in the orOd segment, the Cava filter implantation is most often performed or a plug-off of the lower vein (NPV). Cava filter or plight zone must be under the mouths of the kidney
Figure 5. The upper border of the rising thrombophlebitis of a large subcutaneous vein
1 - Loss of the common femoral
2 - Trombus in the lumen of a large subcutaneous vein; Arrow - Distance to Safa-No-Formoral Foustia
veins to exclude violations of venous outflow on renal veins in the case of closing the lumen of the NPV distal than this area. In addition, it is necessary to evaluate the permeability of the renal vein itself, as well as the deep channel of the controlled side and veins of the system of the upper hollow vein, since these veins, in the case of their position, access will be available for intervention. It is necessary to indicate the distance from the tomb tomb to the nearest kidney vein closest to it, since the Kava filters are of different types and differ one from the other at least their sizes. For the same purposes, it is necessary to indicate the diameter of the NPV on the breath and exhalation. When localizing the floting head, the thrombus above the mouth of the renal veins should be indicated, where it is precisely in relation to the mouths of the renal veins, thrombosis changes its character from an occlusive or clutter to actually floting, and measure the flotation length. If the flotation begins below the mouth of the renal veins, it is possible to perform endovascular blood-bectomy from the NPI. With an upward thrombophlebitis, it is necessary to indicate the upper boundary of the thrombosis in relation to the anatomical benchmarks (for example, the distance to the SFS, Fig. 5), as well as the presence and diameter of the upper tributaries of the BPV (in some cases, with a pronounced varicose transformation of the upper tributaries, their diameter is greater than the diameter of the barrel BPV, which can lead to the dressing of the wrong vessel). It is also important to state the fact of the intact of the lumen of the discharge vessels (OBA, GBV, PBV), excluding the variant of combined thrombosis. As a rule, the testimony for surgical intervention is set at the transition of thrombosis on the thigh. It should be remembered that with the rising thrombophlebitis, the true boundary of the thrombosis
tically always higher than the clinical zone of hyperemia! With thrombophlebitis of the BPV with the transition of the thrombus into the surveillance of the OBB (combined saffe-femoral phlebotrombosis), it should be remembered whether the need for ventilation and thromback-tomy from OBA will need for which information about the length of the floting head of the thrombus in the loss of the OBB and an anatomical landmark of the localization of its tops in a deep vein . In some cases, in the presence of combined thrombosis, it will be necessary to perform simultaneously Drawing PBV and Dressing BPV, possibly in combination with thrombeectomy. In these cases, information must be made in detail in a deep and surface channel separately: for thrombophlebitis (superficial veins thrombosis with or without transition to a deep channel and with respect to anatomical landmarks) and in phlebotrombosis (deep vein thrombosis, also with respect to anatomical landmarks) According to the algorithms described above.
On repeated ultrasound
The ultrasonic dynamics of OVTs in conservative treatment is treated as positive with a decrease in flotation and / or thrombosis levels, as well as when signs of recanalysis. Also a positive point is to increase the echogenicity and homogeneity of thrombotic masses, the absence of floting movements. Negative dynamics is the registration of reverse processes. The ultrasonic dynamics of OVT in the postoperative period is interpreted as positive in the absence of the presence of three-beams above the level of dressing of deep veins and in the presence of signs of recitation of thrombotic masses below the dressing site; With preserved blood
current on the veins above the level of dressings. The ultrasound dynamics is interpreted as negative in the case of the presence of thrombotic masses above the slide of the deep vein dressing, with the lesion of the GBB or the appearance of bilateral floebo-thrombosis.
According to dynamic ultrasound, including the degree of recitation of thrombotic masses in the postoperative period (as well as in conservative treatment), the effectiveness of the conduct of anticoagulant therapy is estimated, doses correction is carried out. Performing an ultrasound after surgery should be remembered about the possibility of progressive-rigors. The greatest risk of this complication occurs in a situation when, in addition to the Drawing of the PBV, running the batter-tomiya from OBA. When progressing, thrombosis is locked by "fresh" thrombotic masses above the vein dressing area. The source can be a GBB, directly the dressing place or the location of the thrombectomy. The reason for the progression of thrombosis may be inadequate antico-adult therapy and / or technical errors of operational intervention (for example, when the veins are lining above the ignition with the GBV - this situation is interpreted not as a PBV bandage, but as an OBL dressing).
With ascending thrombophlebitis, the BPV can be carried out by the BPV's bastard in fatty with the OBB or the interconnection of the BPV. A possible find in the technical errors of the operation may be a residual BPV culture, often with the upper tributaries or the presence of cultural thrombosis. In the presence of a residual cult, t. N. "Second Ear Mickey Mouse", i.e., 3 lumens are defined in the transverse scanning in the projection of the groin
Table 2. Decreased mortality from Tel
2009 2010 2011 2012 2013 2014 2015
Passed 13 153 1 4229 14 728 15 932 14 949 14 749 10 626
119 132 110 128 143 105 61 died
Died from Tel B 12 11 0 4 3 3
a vessel: common femoral artery, OBB and the BPV cult opened in it. The BPV cult, especially while maintaining the upper tributaries flowing into it, can serve as a source of progression of thrombosis with the transition to OBL. Another finding may be the statement of the actual non-compliance of the operation. This is possible in the event of a dressing or resection of not the BPV barrel itself, but one of its large varicose transformed tributaries. This ultrasound picture should be differentiated from the upper tributary separately in the OBB or from doubling the BPV barrel. With the simultaneous implementation of the assurance resection of the BPV and Dressing PBV (with thrombeectomy from OBB or without) for combined thrombosis during the postoperative ultrasound, the blood flow on the OBB is locked, energized only from the GBB. The presence of additional streams in this case may indicate technical errors of the operation.
Cava filter is bulging in the form of clear hyperheogenic signals, different in shape, depending on the type of filter: by type umbrella or spiral. The presence of clear blood flow in the projection of the Kava filter, which occupies the entire lumen of the Vienna at the CDC, indicates its full passability. In-mode, the complete patency of the filter is characterized by the absence of thrombotic masses in it, having a form of echo positive fragments.
There are 3 types of thrombotic lesions of Kava filter. 1. The filter embolusion due to the separation of the floting head of the thrombus (depending on the size of the occlusive head, it can be complete or incomplete, with a complete overlap of the lumen or with the presence of clutch blood flow).
2. The germination of the filter due to the progression of or phhemo-rally thrombosis. At the same time, it is also necessary to estimate the safety or absence of blood flow in the lower vein.
3. Filter thrombosis as a new source of thrombosis (KAVA filter is a foreign body and in itself can serve as an in-trauma matrix for thrombotic education).
Extremely rare, single observations are cases of Cava filter migration above the established position and the progression of thrombosis above the level of renal veins through the filter (the latter prevents the bloodstream from the renal veins). In the latter case, it is necessary to establish the anatomical benchmarks of the upper limit of thrombosis already above the level of the filter, set its character, the presence or absence of flotation and measure its length, i.e., describe all the characteristics that are described in the primary study.
In patients with implanted Cava filter or Plug, NPV should pay attention to the presence or absence of retroperitone hematoma, as well as free fluid in the abdominal cavity.
If the patient was implanted by the Kava filter of the removable design, then a prerequisite for its removal will be a combination of two factors defined in the ultrasound: the lack of fragments of thrombotic masses and the absence in line with the lower hollow veins of Embolo-dangerous thrombones. May have
a hundred the flow of fluttering FT, when the embolism does not occur in the filter: the head does not leave, and for several days it continues to remain at its level, keeping the threat of separation; At the same time, over time, under the action of anticoagulant therapy, it occurs its lysis "on the spot." This is the very case when Kava filter is deleted without performing his direct destination.
0 Ultrasound with the OWT system of the upper hollow vein
In most cases, OVTs of the upper limbs are occlusive and are not Embo-lobs. The authors did not meet the floting character of the FT bed of the upper hollow vein in no patient. The row of the upper floor of the vein is well available for ultrasound, difficulties may occur only when some fragments of the connector veins are visualized. Here, as in the study of the orObavinal segment, it is possible to use a convex low-frequency sensor, as well as the use of auxiliary modes. The main information that is required from the ultrasonic diagnostic physician is to verify the OVT surface or deep channel, or their combined lesion, as well as in the description of the occlusive or intricate character of thrombosis, since the thrombosis of the surface and deep channel has various conservative treatment. Especially important ultrasound becomes
in case of suspected OWT channels of the upper hollow vein in patients with the presence of intra-delicious catheters (cubital, connectible). With occlusive thrombosis of the venous segment carrying a catheter, it is shown to remove it, and with atypical non-conclusive catheter thrombosis, when the thrombotic mass, localizing on the catheter, flotation in the lumen, is likely to perform vetomy with thrombe-ktomy and the removal of the catheter. The very fact of diagnosing catheter thrombosis as a likely source of angosepsis can give additional information in
wearing the severity of the patient's condition and further tactics of its maintenance.
About conclusion
The ultrasound of venous blood flow is a mandatory study of both the primary diagnosis of OTS and throughout the hospital phase of the patient's treatment. The wider implementation of an ultrasound with a preventive purpose, which takes into account the risks of venous thrombotic embolocal complications in the relevant categories of patients, minimizes the offensive as
my Tala and, respectively, the fatal outcome from it. The methodology presented in the article by the implementation of the ultrasound of venous blood flow in aggregate with a high frequency of destination of the study itself, as well as with the active introduction of endovascular methods of surgical prevention of TELA (applied to the Central Bank of the Russian Academy of Sciences since 2012) led to a significant decrease in death from TELA, which is reflected in Table 2 (2015 - data at the time of delivery of the article as a statement as of the beginning of October).
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Parkina M. I., Makhrov V. V., Schapov V. V., Vedochkin O. S.
Ultrasonic diagnosis of sharp venous thrombosis
Lower extremities abstract. The article discusses the results of ultrasonic diagnostics of acute venous thrombosis of the lower limbs in 334 patients. In 32% of patients, massive blood clots are revealed on the KAVA filter after its implantation, 17% of patients found fluttering thrombus below the venon plight site, which confirms the need for urgent surgical prevention of TELE and its high efficiency.
Keywords: sonography, doppler, vein thrombosis, thrombus, kava filter, veins of lower extremities.
Parkin M. I., Makhrov V. V., Shchapov V. V., VedyashKina O. S.
Ultrasound Diagnosis of Acute Venous Thrombosis of the Lower Extremities
ABSTRACT. The Article Considers The Results of Ultrasonic Diagnosis of The Lower Extremities in 334 Patients. 32% of Patients SHOWED MASSIVE BLOOD CLOTS ON THE CAVA FILTER AFTER IMPLANTATION. 17% of Patients SHOWED FLOATING CLOTS BELOW THE VEIN PLICATION. The Ultrasound Diagnosis Confirms The Need for An Urgent Surgical Prophylaxis of Pulmonary Embolism, and Its High Efficiency.
Keywords: Ultrasound, Doppler, Blood Clot, Venous Thrombosis, Cava-Filter, Veins of the Lower Extremities.
Introduction Acute venous thrombosis of the lower extremities is one of the most important problems of clinical phlebology problems in the practical and scientific importance. Phleburombosis is extremely common among the population, conservative treatment is not effective enough, high levels of temporary and resistant disability. Often the clinic erased, and the first symptom of venous thrombosis becomes the thromboembolism of the pulmonary artery (TEL), which is one of the leading causes of postoperative mortality. In this regard, the timely diagnosis of embossofic states using available and non-invasive methods is very important. The CDS of the lower limbs is responsible for these criteria, although there are not many works devoted to the study of echosemyatics of floting thrombus. Until now, there is no single point of view in determining ultrasound criteria for embossogenic thrombov. The insufficient level of information on the embinogenic properties of floting thrombus explains the absence of these
The purpose of the study is to improve the diagnosis and results of the treatment of patients with acute venous thrombosis of the lower extremities.
Material and research methods. The results of the clinical and ultrasonic diagnosis of acute venous thrombosis of the lower limbs in 334 patients for 2011-2012 were analyzed. Inpatient treatment in the separation of vascular surgery of the State Budgetary Institution of the Republic of Mordovia "Republican Clinical Hospital №4".
The age of patients hesitated from 20 to 81 years; 52.4% amounted to women, 47.6% - made; 57% of them were able-bodied, and 19.5% - young age. Basic information on the distribution of patients by sex and age is presented in Table 1.
Table 1
Distribution of patients on the floor and age_
Up to 45 years 45-60 years 60 years and older
Abs. Number of% abs. Number of% abs. Number of% abs. quantity %
Men 39 60.0 66 52.3 54 37,7 159 47.6
Women 26 40.0 60 47,6 89 62.3 175 52,4
TOTAL 65 19.4 126 37.7 143 42.8 334 100
The most numerous cohort patients was a group of 60 years and older (143 people), among men prevailed persons aged 45 to 60 years - 66 people (52.3%), in women at age 60 and older - respectively 89 (62 , 3%) man.
Acute venous thrombosis occur under the age of 45 years more often in men, which is associated with the abuse of intravenous administration of psychoactive substances, and at the age of 60 years and the more female patients begin to prevail over male. It is possible to explain this by the fact that other risk factors are beginning to prevail: gynecological diseases, corporation, obesity, injury, varicose veins, etc. Reducing the incidence in the general population in men aged 60 years and is more due to a decrease in their share in the relevant age groups , low lifespan, high fatness from TEL, the development of chronic venous insufficiency and post-bitfambic syndrome.
Ultrasonographic diagnosis and dynamic echoscopy was carried out on
ultrasonic devices Sonoace Pico (Korea), Vivid 7 (General Electric, USA), Toshiba
Xario SSA-660A (Toshiba, Japan) operating in real time using sensors 7 and 3.5 MHz. The study began with the groin area in the transverse and longitudinal section in relation to the vascular beam. Estimated blood flow near the lying artery. When obtaining the image of the veins, the following parameters were estimated: diameter, compression (compression by a sensor to stopping blood flow in Vienna while maintaining blood flow in artery), features of the stroke, the state of the internal lumen, the safety of the valve apparatus, changes in the walls, the condition of the surrounding tissues, the bloodstream is evaluated by a number of lying artery. The state of venous hemodynamics was also evaluated when using functional samples: a respiratory and cough sample or a sample with a fitting. At the same time, the state of the thigh, the popliteal vein, the veins of the leg, as well as the large and low subcutaneous veins, was estimated. When scanning an NPV, iliac, large subcutaneous veins, a femoral veins and a veins of the leg in the distal section of the lower extremities, the patient was in a position lying on his back. The study of the fallen veins, the veins of the upper third of the leg and the low subcutaneous vein was carried out in the patient's position lying on his belly with a roller under the area of \u200b\u200bthe ankle joints. For the study of the main veins and convex, in the rest - linear sensors were used in the study.
Scanning began in cross section to eliminate the presence of a floting tip of the thrombus, as evidenced by the complete contact of the venous walls during a slight compression by the sensor. In the course of the survey, the nature of the venous thrombus was established: closed, occlusive and fluttering thrombus.
In order to surgically prophylaxis the TEL in acute phlebosis, 3 methods of operation were used: installation of the CAVA filter, the plugle of the vein segment and crossctomy and / or phlebectomy. In the postoperative period, ultrasound diagnostics pursued the purpose of assessing the state of venous hemodynamics, the degree of recanalization or strengthening of the thrombotic process in the venous system, the presence or absence of fragmentation of blood cloth, the presence of flotation, thrombosis of the contralateral limb, the thrombosis of the pluggetion zone or kava filter and the linear and volumetric blood flow velocity were determined and collateral blood flow. Statistical processing of the obtained digital data was performed using Microsoft Office 2007 software package.
Research results. The main features of thrombosis were the presence of echoposive thrombotic masses in the space of the vessel, the echo absorption increases as the limitation of the thrombus increases. The valve sash has ceased to differentiate, the transfer arterial ripple disappeared, the diameter increased
thrombned veins 2-2.5 times compared to the contralateral vessel, with a sensor compression, it is not squeezed. In the first days of the disease, we consider particularly important compression ultrasonography when the thrombus is visually indistinguishable from the normal lumen of the vein. For 3-4 days of the disease, a seal arose and thickening the walls of the veins due to the phlebitis, the perivasal structures became "blurred".
The signs of the cloth thrombosis were considered the presence of a thrombus with free blood flow in the absence of a complete set of walls in compression ultrasonography, the presence of a defect of filling in duplex scanning and spontaneous blood flow during spectral doppler.
The criteria of floting thrombub considered the visualization of the thrombus aspect a vein with the presence of free space, the oscillatory movements of the thrombus head, the absence of contacting the walls of the veins during compression by the sensor, the presence of a free space when performing breathing samples, enveling the type of blood flow, the presence of spontaneous blood flow during spectral doppler. For the final clarification of the character, the thrombus used the Waltasalvy sample, which is a danger in view of the additional flotation of thrombus.
Thus, according to ultrasonic diagnostics, floting thrombus found in 118 (35.3%) of patients (Fig. 1).
60 -50 -40 -30 -20 -10 -0 -
Figure 1. Frequency floting thromboms in the system of surface and deep veins of limbs
It has been established that the most frequent floting thrombus according to color duplex scans is detected in the deep vein system (especially in the Ilequoral segment - 42.0%), less frequently in the deep veins system and large
ileofemoral segment
deep veins of hips
podlond Vienna and Bearing Vienna
subcutaneous vein hips
subcutaneous veins of hips. The difference in the frequency thrombus frequency in the system of the deep system in men and women was not revealed.
In 2011, the frequency of fluttering thrombosis was 29.1% of all examined, which is 1.5 times less than in 2012 (Table 2). This is due to the implementation of ultrasound diagnostics in all patients entering the clinic, as well as with suspicion of the acute pathology of the venous system. This fact is confirmed by the fact that in 2012, the proportion of patients in which flotizing blood clots in the surface system was identified only according to the CDA data. In this regard, the presence of surface varicotromibophlebitis, despite a clear clinical picture, dictates the need for a CDA to detect a subclinical fluttering thrombosis of both superficial and deep veins.
Table 2
Distribution of floting thrombus in the system of deep veins of the lower extremities
Localization 2011 2012 Total
Number of floting-phloting-
dear sens of dimensional blood clots
Ileofemoral 39 23 (59.0%) 35 27 (55.2%) 74 50 (67.6%)
Deep veins of hips 31 12 (38.7%) 33 15 (45.5%) 64 27 (42.2%)
Page Vienna and 36 6 (16.7%) 31 10 (32.3%) 67 16 (23.9%)
veins of the heads
Subcutaneous elements of hips 69 10 (14.5%) 60 15 (25.0%) 129 25 (19.4%)
Total 175 51 (29.2%) 159 67 (42.2%) 334 118 (35.3%)
As is known, the coagulation processes are accompanied by activation of the fibrinolytic system, these processes are in parallel. For clinical practice, the fact is very important to establish not only flotation of thrombus, but also the nature of the spread of thrombus in Vienna, the possibility of its fragmentation in the process of recanalization.
Under the CDS of the lower extremities, the neglesting blood clods were mounted in 216 patients (64.7%): occlusion thrombosis was found in 183 patients (54.8%), neoplylusive tromboosis - in 33 (9.9%).
The onset clomes were most often fixed to the walls of the vein throughout and were characterized by the preservation of the lumen between the thrombotic masses and the venous wall. However, they can be fragmented and migrated into a small circle of blood circulation. With fluttering tombach, soldered with the vascular wall only in the distal part of the affected vein, a real high risk of pulmonary artery embolism is created.
Among the non-compound forms of thrombosis, you can highlight a domed form
thrombus, the morphological signs of which are a wide base equal
vienna diameter, lack of oscillatory movements in the blood flow and length of up to 4 cm.
The control color duplex scanning was performed by all patients until the floting tip of the blood clouds to the vein wall and subsequently from 4 to 7 days of treatment and before the patient's discharge.
The ultrasonic angiosication of the lower limbs with fluttering clocks is mandatory before the operation, as well as 48 hours after the Implantation of the KAVA filter or the veins plight (Fig. 2). Normally, with longitudinal scanning, the KAVA filter is visualized in the lumen of the lower hollow vein in the form of a hyperheogenic structure, the form of which depends on the filter modification. The most typical position of Kava filter in Vienna is at the level or immediately distal as the mouth of the renal vein or at the level of 1-2 lumbar vertebrae. Typically, there is an expansion of the lumen of the vein in the field of the filter.
Figure 2. Lower hollow vein with a sensor installed. Viden the painted stream of blood (blue flowing to the sensor, red - leaving the sensor). On the border between them, the normally functioning Kava filter.
According to color duplex scanning after installing Kava filters, 8 (32%) from 25 patients, a fixation on the filter of massive thrombov was observed. The segment of the vein after pricing was carried out in 29 (82.9%) of 35 patients, in 4 (11.4%) - the ascending thrombosis was revealed below the plugle site, in 2 (5.7%) - the bloodstream in the area of \u200b\u200bPlugation could not visualize.
It should be noted that the frequency of the progression of the thrombotic process and the recurrences of thrombosis is highest in patients who have undergone the implantation of Cava
filter, which can be explained by finding in the lumen of the NPV of the foreign body, changing the nature of blood flow in the segment. The frequency of thrombosis recurrences in patients undergoing plugistics or conservatively conservatively, almost the same and at the same time significantly lower in comparison with the same indicator after endovascular interventions.
Conclusions. The leading risk factors for the risk of thrombosis in men should include injuries and combined surgical interventions, severe cardiovascular diseases; In women - cardiovascular diseases and diseases of female genital organs. Color duplex scanning allows you to establish the presence and level of thrombotic process in Vienna, flotation of thrombus, evaluate the effectiveness of drug therapy, monitor over the flow of phlebotromability after TEL surgical prevention. After endovascular implantation, 32% of patients identified massive thrombus on the KAVA filter, after the plight of the veins in 17% of patients were detected by floting thrombus below the operation site, which confirms the feasibility and high efficiency of urgent surgical prevention of fatal pulmonary artery embolism.
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