肺栓塞需要複查CTA嗎？何時複查？指南不說，咱讓文獻來說。

06-06

大家有木有發現一個問題，肺栓塞的教材、指南，都不提一件事：肺栓塞要不要複查肺動脈CTA，何時複查？

鄙人覺得，肯定有必要複查。為什麼呢？看下圖：

這是肺癌合併肺栓塞的CT。看不清？很正常，因為國內的文獻不喜歡給圖，喜歡一大堆灰常、灰常無聊的文字描述，即使有圖，也是非常的看不清。霧裡看花，水中望月，不好意思，比這個清除。

以前遇到一個病人，肺癌合併肺栓塞。肺栓塞會屎人啊，國內醫患關係這麼惡劣，急性期肺栓塞做手術很危險啊。然而，患者虐我千百遍，何時妨礙我手閑？沒有擴散的肺癌都要盡量手術啊。怎麼辦？腫么辦？

先抗凝，一月後複查肺動脈CTA，血栓消失，趕緊手術，萬一進展了錯失良機成千古恨。術後病理證實為肺癌，術後繼續抗凝，長期存活。

問題來了：不複查肺動脈CTA，如何和諧的開展手術？所以，肺栓塞有必要複查肺動脈CTA。

還有，肺栓塞治療要多久？2015年中國急性肺栓塞診斷與治療專家共識指出：有明確危險因素的急性肺栓塞，例如手術誘發的、坐飛機誘發肺栓塞，如已去除暫時性危險因素，推薦抗凝治療3個月；無明確誘發危險因素的急性肺栓塞：應給予口服抗凝治療至少3個月；腫瘤患者發生急性肺栓塞後應接受長期抗凝治療。

那麼，抗凝到了療程，難道就自動停葯？你不複查怎麼知道還有沒有血栓。難道就算是有血栓，療程到了，也要停葯？所以，肺栓塞肯定需要複查肺動脈CTA，就算是不複查肺動脈CTA，至少也要複查肺通氣灌注掃描吧！

那麼，如何複查？何時複查？很奇怪，指南不說，教材不說，讓你自己意會。

既然如此，各憑感覺發揮，我來查查文獻，和大家討論一下這個無聊而又非常有意義的話題。

先來看看國內的文獻：

文獻1：山東大學齊魯醫院。

山東大學齊魯醫院放射科，肺栓塞42例患者，在溶栓或抗凝治療後1~3周複查螺旋CT，發現病灶消失24例，病灶減少18例。

文獻2：

王辰院士參與的一項研究，確診的23例肺栓塞患者，所有患者行溶栓治療，並分別於治療前、治療後24 h及14 d行CTPA檢查。肺動脈栓塞指數在溶栓治療後逐漸減小。

複查的非常快。

文獻3：

第四軍醫大學西京醫院，9例患者，所有患者均在溶栓後1~2周複查，3例複查後血栓基本消失。

文獻4：

中山大學附一院，14例大面積肺栓塞，8例治療24小時後複查，所有患者2周、1個月、3個月複查。8例治療24小時後複查，2例加重，2周後複查，部分血栓已經再通、或者血栓減少。總共176支肺動脈有血栓，1月後複查，97.2%的血管完全再通，3月後複查高達98.3%。

對於中心充盈缺損、蜂窩狀充盈缺損、內緣隆起充盈缺損為主的血栓，多為新鮮血栓，2周複查。覆壁充盈缺損、完全充盈缺損，1~3個月複查。

文獻5：

廣州呼吸疾病研究所，報道一例騎跨肺栓塞，溶栓後第4天複查胸部CT造影，對比溶栓前，CT示雙側肺動脈主幹血栓消失、右下肺基底段肺動脈栓塞較前明顯改善。

文獻6：

.南京醫科大學的報道，以CTA隨訪的患者55例,隨訪時間為1-6周。

文獻7：

62例肺栓塞，43例血管造影、19例螺旋CT診斷的中央型肺栓塞，螺旋CT隨訪平均11月，不知道每個患者的具體隨訪時間。

隨訪中，48%的患者完全緩解，52%的患者血管內仍有異常。

英文：

To evaluate the resolution of acute central pulmonary embolism (PE). Sixty-two patients with angiographic (n = 43) or spiral computed tomographic (CT; n = 19) diagnosis of acute central PE underwent spiral CT after a mean of 11 months.

At follow-up, 30 patients (group 1; 48%) had complete resolution of acute PE; 32 patients (group 2; 52%) showed endovascular abnormalities (mean follow-up in both groups, 10.5 months).

文獻8：

目的：研究急性肺栓塞CT隨訪的頻率。

納入600例患者，回顧性分析。病人至少隨訪14月。

Records of all patients were reviewed for at least 14 months. Pulmonary embolism was diagnosed by CT angiography in 600 patients.

23.5 %的患者1年內，至少做一次CTA。

At least one follow-up CT angiogram in 1 year was obtained in 141 of 600 (23.5 %).

6.7 %的患者1年內，做2次CTA；三次的佔2.5 %，4次的佔0.5 %。

Two follow-ups in 1 year were obtained in 40 patients (6.7 %), 3 follow-ups were obtained in 15 patients (2.5 %), and 4 follow-ups were obtained in 3 patients (0.5 %).

141例患者1年內，至少做一次CTA，這些病人第一次隨訪CTA，10.6 %的患者肺栓塞複發。40例1年內，做2次CTA，這些患者中15.0 %的病人第二次隨訪發現肺栓塞複發。

Among all patients, recurrent pulmonary embolism was diagnosed in 15 of 141 (10.6 %) on the first follow-up CT angiogram and in 6 of 40 (15.0 %) on the second follow-up.

作者觀點：應該尋找替代方法複查肺栓塞，減少CT輻射。 Alternative options might be considered to reduce the hazard of radiation-induced cancer, particularly in young women.

文獻9：

512例患者，隨訪肺動脈CTA平均6月。

METHOD AND MATERIALS A follow-up CTA was performed a mean of 6 months after onset in 512 patients with previous radiological confirmed PE.

隨訪後，59.7%的患者血栓溶解。

RESULTS The sample was integrated by 276 men (53,9%) and 236 women (45.8%) with a mean age of 67.6 years (SD: 17.6). follow-up, 306 patients (59.7%; group 1) had resolution of the clot.

40.2%的患者血管異常。

However 206 patients showed vascular abnormalities (40.2%; group 2).

21.5%的患者CTA仍然提示急性肺栓塞，18.8%發展為慢性肺栓塞。

Of these, CTA showed persistence of acute PE in 110 patients (21.5%; group 2a) and development of chronic PE in 96 patients (18.8%; group 2b).

作者觀點：達到療程常規停抗凝治療，需要影像學證實血栓溶解。慢性肺栓塞需要血栓切除，這些情況都需要早期複查CTA，及時發現慢性肺栓塞。一句話，肺栓塞的隨訪，需要複查CTA。

CONCLUSION Thus, routine cessation of anticoagulant therapy in patients with PE should be aided by an image confirmation of the clot resolution.Besides, there is a significant percentage of patients that evolved to chronic PE (18,8%) and pulmonary hypertension (2.7%), whose early detection can improve management, because it has become potentially remediable by thromboendarterectomy.

文獻10：

19例患者，抗凝治療6月之後複查。只有32%的患者複查CT正常。

METHOD: Nineteen patients with acute PE initially identified with spiral CT scan underwent repeat CT examinations at 6 week follow-up after the start of anticoagulant therapy.

RESULTS: Normalization of the pulmonary arteries at follow-up was seen in six patients (32%) only.

文獻11：

作者單位：Michigan State University。密歇根州立大學。

69 patients with acute PE from two hospitals were assessed。

69例急性肺栓塞納入研究。

Complete CT angiographic resolution of PE was seen in six of 15 patients (40%) 2-7 days after diagnostic imaging.

2~7天後複查，15例患者中，6例肺栓塞完全好轉。

After day 28, complete resolution occurred in 17 of 21 patients (81%).

28天時，21例中，17例完全好轉。

Most patients (81%) showed complete resolution of PE on CT angiography after 28 days

.28天後，81%的患者肺栓塞完全好轉。

PEs resolved faster in the main and lobar pulmonary arteries than in the segmental branches.

相對於段肺動脈，主肺動脈、葉肺動脈肺栓塞，好轉的更快。

文獻12：

作者：Michigan State University。

One hundred and seventy-two outpatients [102 women; mean age 56.7 ± 18.8 (SD)] with an initial CTPA that was negative for pulmonary embolism and a subsequent CTPA within 12 months of their initial study were included in our analysis.

172例初次肺動脈CTA陰性者，12月內複查過CTA者，納入研究。

CTPAs were negative for pulmonary embolism in 165 (96%) of 172 outpatients who returned to care within 12 months after an initial negative CTPA.

96%的患者複查也是陰性。

In the group with no risk factors none (0%) of 85 patients (P = 0.028) had pulmonary embolism at the time of repeat CTPA.

沒有危險因素的那一組，複查CTA全部均無血栓。

文獻13：

作者：波斯尼亞熱窩大學，有意思。University Hospital of Sarajevo, Sarajevo, Bosnia。

總共83例，其中23例經肺通氣灌注掃描診斷為肺栓塞，並隨訪6月。

Of 83 consecutive patients with clinically suspected PE examined with V/P SPECT, 23 patients with confirmed PE were followed by serial V/P SPECT examinations over a 6-month period.

隨訪2周，肺栓塞面積減少 54±26% ，3月時79±30%，6月時82±30%。

The mean relative decrease in PE extent compared with the time of diagnosis was 54±26% at 2 weeks, 79±30% at 3 months, and 82±30% at 6 months.

建議抗凝治療後三月隨訪複查肺通氣灌注掃描。

This study also confirms that resolution of perfusion defects after PE occurs within the first 3 months of treatment. It is therefore recommended that V/P SPECT follow-up should be considered at 3 months after diagnosis.

文獻14：

德國佬寫的

Thirty-three patients (15 female, 18 male, mean age 59.4 years) with acute PE were examined initially and 1 week later using both 16-row computed tomography (CT) and MRI with magnetic resonance angiography (MRA), real-time MRI and magnetic resonance (MR) pulmonary perfusion imaging.

33例納入研究，1周後複查，採用肺血管增強CT與MRA（磁共振血管成像）、MR肺灌注掃描做對比。

Follow-up examinations were feasible for all patients. Diagnosis of PE was concordant between MRI and CT in all patients.

磁共振也可以隨訪肺栓塞。

文獻15：

Nineteen patients with acute PE initially identified with spiral CT scan underwent repeat CT examinations at 6 week follow-up after the start of anticoagulant therapy.

19例肺栓塞患者，抗凝6周後複查CT。

Normalization of the pulmonary arteries at follow-up was seen in six patients (32%) only.

只有6例(32%)正常。Residual abnormalities were present in 13 of 19 patients (68%). 其餘血管均有異常發現。

肺栓塞治療後，如何判斷療效？最新專家共識也不說。

2010年的中國專家共識這樣說：

溶栓療效觀察指標：(1)癥狀減輕，特別是呼吸困難好轉。(2)呼吸頻率和心率減慢，血壓升高，脈壓增寬。(3)動脈血氣分析指標好轉。(4)心電圖相關指標好轉。(5)胸部x線平片顯示的肺紋理減少或稀疏區變多、肺血流分布不均改善。(6)超聲心動圖表現如室間隔左移減輕、右房右室內徑縮小、右室運動功能改善、肺動脈收縮壓下降、三尖瓣反流減輕等。

也不提肺動脈CTA。

個人觀點及總結：

肺栓塞何時複查肺動脈CTA，要看病情，病情加重，及時複查，血栓增多有可能需要溶栓或改變抗凝方案。

肺肺栓塞合併肺癌，2周至一個月複查，有條件及時手術切除肺癌。

抗凝療程已到，也需要複查，仍有血栓，需要繼續治療。

參考文獻：

王青, 馬祥興, 李傳福,等. 16層螺旋CT肺血管造影在肺動脈栓塞診斷中的應用[J]. 中華放射學雜誌, 2004, 38(7):711-713.
王建國, 郭佑民,朱力,等. CT肺血管成像對急性大面積肺栓塞患者的動態分析價值[J]. 中華放射學雜誌, 2008, 42(7):729-733.
鄭敏文, 宦怡, 葛雅麗,等. 電子束CT在急性肺動脈栓塞治療中的應用價值[J]. 實用放射學雜誌, 2004, 20(8):698-700.
周旭輝, 李子平, 譚國勝,等. 急性大面積肺動脈血栓栓塞症溶栓治療的動態CT觀察[J]. 中華放射學雜誌, 2005, 39(3):256-261.
洪城, 張挪富, 李時悅,等. 騎跨型肺動脈栓塞溶栓治療後繼發肺梗死一例[J]. 中華結核和呼吸雜誌, 2016, 39(8):646-648.
袁梅, 劉許慧, 俞同福. CT肺動脈阻塞指數對肺栓塞治療效果的定量評估[J]. 臨床放射學雜誌, 2011, 30(4):504-507.
Remy-Jardin M, Louvegny S, Remy J, et al. Acute central thromboembolic disease: posttherapeutic follow-up with spiral CT angiography.Radiology,1997,203(1):173-80.
Stein P D, Matta F, Hughes P G, et al. Follow-up CT pulmonary angiograms in patients with acute pulmonary embolism[J]. Emergency Radiology, 2016:1-5.
Gallardo G, Torres I, Fernandez-Capitan C, et al. Follow-up in Pulmonary Embolism with CT Angiography: Is It Necessary?[C]// Radiological Society of North America 2008 Scientific Assembly and Meeting. 2008.
Van Rossum A B, Pattynama P M, Tjin A T E, et al. Spiral CT appearance of resolving clots at 6 week follow-up after acute pulmonary embolism.[J]. Journal of Computer Assisted Tomography, 1998, 22(3):413.
Stein P D, Yaekoub A Y, Matta F, et al. Resolution of pulmonary embolism on CT pulmonary angiography.[J]. Ajr American Journal of Roentgenology, 2010, 194(5):1263.
Boldt B M, Cox C W, Dedekam E A, et al. Pulmonary embolism at follow-up outpatient CT pulmonary angiography: implications on patient risk stratification.[J]. Blood Coagulation & Fibrinolysis, 2013, 24(6):633-637.
Begic A , J?gi J , Hadziredzepovic A , et al.Tomographic ventilation/perfusion lung scintigraphy in the monitoring of the effect of treatment in pulmonary embolism: serial follow-up over a 6-month period. Nucl Med Commun,2011,32 (6): 508-14.
Kluge A , Gerriets T , Lange U , Bachman G .MRI for short-term follow-up of acute pulmonary embolism. Assessment of thrombus appearance and pulmonary perfusion: a feasibility study.Eur Radiol，2005，15 (9):1969-77.