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大家有木有发现一个问题，肺栓塞的教材、指南，都不提一件事：肺栓塞要不要复查肺动脉CTA，何时复查？ 鄙人觉得，肯定有必要复查。为什么呢？看下图： 这是肺癌合并肺栓塞的CT。看不清？很正常，因为国内的文献不喜欢给图，喜欢一大堆灰常、灰常无聊的文字描述，即使有图，也是非常的看不清。雾里看花，水中望月，不好意思，比这个清除。 以前遇到一个病人，肺癌合并肺栓塞。肺栓塞会屎人啊，国内医患关系这么恶劣，急性期肺栓塞做手术很危险啊。然而，患者虐我千百遍，何时妨碍我手闲？没有扩散的肺癌都要尽量手术啊。怎么办？肿么办？ 先抗凝，一月后复查肺动脉CTA，血栓消失，赶紧手术，万一进展了错失良机成千古恨。术后病理证实为肺癌，术后继续抗凝，长期存活。 问题来了：不复查肺动脉CTA，如何和谐的开展手术？所以，肺栓塞有必要复查肺动脉CTA。 还有，肺栓塞治疗要多久？2015年中国急性肺栓塞诊断与治疗专家共识指出：有明确危险因素的急性肺栓塞，例如手术诱发的、坐飞机诱发肺栓塞，如已去除暂时性危险因素，推荐抗凝治疗3个月；无明确诱发危险因素的急性肺栓塞：应给予口服抗凝治疗至少3个月；肿瘤患者发生急性肺栓塞后应接受长期抗凝治疗。 那么，抗凝到了疗程，难道就自动停药？你不复查怎么知道还有没有血栓。难道就算是有血栓，疗程到了，也要停药？所以，肺栓塞肯定需要复查肺动脉CTA，就算是不复查肺动脉CTA，至少也要复查肺通气灌注扫描吧！ 那么，如何复查？何时复查？很奇怪，指南不说，教材不说，让你自己意会。 既然如此，各凭感觉发挥，我来查查文献，和大家讨论一下这个无聊而又非常有意义的话题。 先来看看国内的文献： 文献1：山东大学齐鲁医院。 山东大学齐鲁医院放射科，肺栓塞42例患者，在溶栓或抗凝治疗后1~3周复查螺旋CT，发现病灶消失24例，病灶减少18例。 文献2： 王辰院士参与的一项研究，确诊的23例肺栓塞患者，所有患者行溶栓治疗，并分别于治疗前、治疗后24 h及14 d行CTPA检查。肺动脉栓塞指数在溶栓治疗后逐渐减小。 复查的非常快。 文献3： 西，9例患者，所有患者均在溶栓后1~2周复查，3例复查后血栓基本消失。 文献4： 中山大学附一院，14例大面积肺栓塞，8例治疗24小时后复查，所有患者2周、1个月、3个月复查。8例治疗24小时后复查，2例加重，2周后复查，部分血栓已经再通、或者血栓减少。总共176支肺动脉有血栓，1月后复查，97.2%的血管完全再通，3月后复查高达98.3%。 对于中心充盈缺损、蜂窝状充盈缺损、内缘隆起充盈缺损为主的血栓，多为新鲜血栓，2周复查。覆壁充盈缺损、完全充盈缺损，1~3个月复查。 文献5： 广州呼吸疾病研究所，报道一例骑跨肺栓塞，溶栓后第4天复查胸部CT造影，对比溶栓前，CT示双侧肺动脉主干血栓消失、右下肺基底段肺动脉栓塞较前明显改善。 文献6： .南京医科大学的报道，以CTA随访的患者55例,随访时间为1-6周。 文献7： 62例肺栓塞，43例血管造影、19例螺旋CT诊断的中央型肺栓塞，螺旋CT随访平均11月，不知道每个患者的具体随访时间。 随访中，48%的患者完全缓解，52%的患者血管内仍有异常。 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). 文献8：
目的：研究急性肺栓塞CT随访的频率。 纳入600例患者，回顾性分析。病人至少随访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年内，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年内，做2次CTA；三次的占2.5 %，4次的占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年内，至少做一次CTA，这些病人第一次随访CTA，10.6 %的患者肺栓塞复发。40例1年内，做2次CTA，这些患者中15.0 %的病人第二次随访发现肺栓塞复发。 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. 作者观点：应该寻找替代方法复查肺栓塞，减少CT辐射。 Alternative options might be considered to reduce the hazard of radiation-induced cancer, particularly in young women. 文献9：
512例患者，随访肺动脉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. 随访后，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%的患者血管异常。 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%发展为慢性肺栓塞。 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). 作者观点：达到疗程常规停抗凝治疗，需要影像学证实血栓溶解。慢性肺栓塞需要血栓切除，这些情况都需要早期复查CTA，及时发现慢性肺栓塞。一句话，肺栓塞的随访，需要复查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. 文献10：
19例患者，抗凝治疗6月之后复查。只有32%的患者复查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. 文献11：
作者单位：Michigan State University。密歇根州立大学。 69 patients with acute PE from two hospitals were assessed。 69例急性肺栓塞纳入研究。 Complete CT angiographic resolution of PE was seen in six of 15 patients (40%) 2-7 days after diagnostic imaging. 2~7天后复查，15例患者中，6例肺栓塞完全好转。 After day 28, complete resolution occurred in 17 of 21 patients (81%). 28天时，21例中，17例完全好转。 Most patients (81%) showed complete resolution of PE on CT angiography after 28 days .28天后，81%的患者肺栓塞完全好转。 PEs resolved faster in the main and lobar pulmonary arteries than in the segmental branches. 相对于段肺动脉，主肺动脉、叶肺动脉肺栓塞，好转的更快。 文献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例初次肺动脉CTA阴性者，12月内复查过CTA者，纳入研究。 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%的患者复查也是阴性。 In the group with no risk factors none (0%) of 85 patients (P = 0.028) had pulmonary embolism at the time of repeat CTPA. 没有危险因素的那一组，复查CTA全部均无血栓。 文献13：
作者：波斯尼亚热窝大学，有意思。University Hospital of Sarajevo, Sarajevo, Bosnia。 总共83例，其中23例经肺通气灌注扫描诊断为肺栓塞，并随访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. 随访2周，肺栓塞面积减少 54±26% ，3月时79±30%，6月时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. 建议抗凝治疗后三月随访复查肺通气灌注扫描。 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. 文献14：
德国佬写的 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例纳入研究，1周后复查，采用肺血管增强CT与MRA（磁共振血管成像）、MR肺灌注扫描做对比。 Follow-up examinations were feasible for all patients. Diagnosis of PE was concordant between MRI and CT in all patients. 磁共振也可以随访肺栓塞。 文献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周后复查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%). 其余血管均有异常发现。 肺栓塞治疗后，如何判断疗效？最新专家共识也不说。 2010年的中国专家共识这样说： 溶栓疗效观察指标：(1)症状减轻，特别是呼吸困难好转。(2)呼吸频率和心率减慢，血压升高，脉压增宽。(3)动脉血气分析指标好转。(4)心电图相关指标好转。(5)胸部x线平片显示的肺纹理减少或稀疏区变多、肺血流分布不均改善。(6)超声心动图表现如室间隔左移减轻、右房右室内径缩小、右室运动功能改善、肺动脉收缩压下降、三尖瓣反流减轻等。 也不提肺动脉CTA。 个人观点及总结： 肺栓塞何时复查肺动脉CTA，要看病情，病情加重，及时复查，血栓增多有可能需要溶栓或改变抗凝方案。 肺肺栓塞合并肺癌，2周至一个月复查，有条件及时手术切除肺癌。 抗凝疗程已到，也需要复查，仍有血栓，需要继续治疗。 参考文献：
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