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（王建安）
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内科学新进展 第二章 呼吸系统疾病
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第一节 肺血栓栓塞症（PTE）的诊断和治疗进展
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摘 要 肺血栓栓塞症（PTE）的发病率、病死率高，误诊、漏诊率高。本章综述了肺血栓栓塞症的危险因素，诊断方法，包括通气／灌注扫描（ventilation-perfusion scanning, V/Q)、CT肺动脉造影（CT arteriography, CTPA)、磁共振肺动脉造影（magnetic resonance pulmonary angiography, MRPA)、肺动脉造影（pulmonary arteriography, PAG）和诊断思路。同时探讨肺血栓栓塞症的内科学治疗，主要包括溶栓和抗凝治疗。其中，抗凝为肺血栓栓塞症患者所必需，而溶栓适用于大块和次大块肺栓塞。
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Abstract Pulmonary thromboembolism（PTE）has high morbidity, case fatality as well as high rate of misdiagnosis. The state of risk factors, the art of diagnostic evaluation and treatment of PET was reviewed. Recent advances in imaging and pharmacotherapeutics have tremendously improved the diagnosis and treatment of pulmonary thromboembolism. Nuclear lung scan（V/Q scan), CT pulmonary angiography（CTPA), magnetic resonance pulmonary angiography（MRPA）and pulmonary arteriography（PAG）have revolutionized the diagnostic methodology and risk assessment criteria. While all patients of pulmonary embolism require anticoagulation, systemic thrombolytic therapy is the mainstay of initial treatment in massive and submassive pulmonary embolism.
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一、基本概念
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肺栓塞（pulmonary embolism, PE）是以各种栓子阻塞肺动脉系统为其发病原因的一组疾病或临床综合征的总称，包括肺血栓栓塞症（pulmonary thromboembolism, PTE)、脂肪栓塞综合征、羊水栓塞、空气栓塞等。PTE是PE的常见类型，是临床常见的危重病症，为继冠状动脉粥样硬化性心脏病和脑卒中后的第3大死因。深静脉血栓形成（deep venous thrombosis, DVT）是PTE的主要病因，约有70％～90％的PTE的血栓来源于下腔静脉系统，以股静脉及髂静脉多见。
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二、PTE和（或）DVT危险因素
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DVT和PTE是同一疾病过程的不同部位、不同阶段的两种表现形式，DVT、PTE共属于静脉血栓栓塞症（venous thromboembolism, VTE)。PTE的危险因素同VTE, 即Virchow的三大经典风险因子——静脉血液淤滞、静脉系统内皮损伤和血液高凝状态，并往往有一个以上因素叠加参与血栓的形成。
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（一）获得性危险因素
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某些危险因素增加了DVT和PTE的风险。包括：年龄≥40岁；肥胖；有VTE病史；恶性肿瘤；卧床≥5d; 外科手术，尤其术后制动的手术，如髋或膝关节置换；充血性心力衰竭或心肌梗死；静脉曲张；下肢骨折；雌激素治疗；脑卒中；多发性创伤尤其如脊髓损伤；分娩；中心静脉置管；长途旅行。
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