Из этой статьи вы узнаете: что такое тромбоэмболия легочной артерии (сокращенно ТЭЛА), какие причины приводят к ее развитию. Как проявляется и чем опасно это заболевание, как его лечить.
Автор статьи: Нивеличук Тарас , заведующий отделением анестезиологии и интенсивной терапии, стаж работы 8 лет. Высшее образование по специальности "Лечебное дело".
При тромбоэмболии легочной артерии происходит перекрытие тромбом артерии, несущей венозную кровь из сердца в легкие для обогащения кислородом.
Эмболия бывает разной (например, газовой – когда сосуд закупоривается пузырьком воздуха, бактериальной – закрытие просвета сосуда сгустком микроорганизмов). Обычно просвет легочной артерии блокируется тромбом, сформировавшимся в венах ног, рук, таза или в сердце. С током крови этот сгусток (эмбол) переносится в малый круг кровообращения и блокирует легочную артерию или одну из ее веток. Это нарушает кровоток в части легкого, из-за чего страдает обмен кислорода на углекислый газ.
Если тромбоэмболия легочной артерии тяжелая, то организм человека получает мало кислорода, что и вызывает клинические симптомы болезни. При критической нехватке кислорода появляется непосредственная опасность для жизни человека.
Проблемой ТЭЛА занимаются врачи различных специальностей, включая кардиологов, кардиохирургов, анестезиологов.
Причины ТЭЛА
Патология развивается вследствие тромбоза глубоких вен (ТГВ) в ногах. Тромб в этих венах может оторваться, перенестись в легочную артерию и блокировать ее. Причины образования тромбоза в сосудах описывает триада Вирхова, к которой принадлежат:
- Нарушение кровотока.
- Повреждение сосудистой стенки.
- Усиление свертываемости крови.
1. Нарушение кровотока
Основной причиной нарушений кровотока в венах ног является малоподвижность человека, которая приводит к застою крови в этих сосудах. Обычно это не является проблемой: как только человек начинает двигаться, кровоток усиливается, и тромбы не образуются. Однако длительная иммобилизация приводит к значительному ухудшению циркуляции крови и развитию тромбоза глубоких вен. Такие ситуации встречаются:
- после перенесенного инсульта;
- после операции или травмы;
- при других тяжелых заболеваниях, которые становятся причиной лежачего положения человека;
- при длительных перелетах в самолете, путешествиях в автомобиле или поезде.
2. Повреждение сосудистой стенки
При повреждении стенки сосуда его просвет может быть сужен или перекрыт, что приводит к формированию тромба. Кровеносные сосуды могут быть повреждены при травмах – при переломе костей, во время операций. Повреждать сосудистую стенку могут воспаление (васкулит) и определенные медикаменты (например, средства, применяемые для химиотерапии при раке).
3. Усиление свертываемости крови
Тромбоэмболия легочной артерии очень часто развивается у людей, имеющих заболевания, при которых кровь сворачивается легче, чем в норме. К таким болезням принадлежат:
- Злокачественные новообразования, применение химиотерапевтических препаратов, проведение лучевой терапии.
- Сердечная недостаточность.
- Тромбофилия – наследственное заболевание, при котором кровь человека имеет усиленную склонность к образованию тромбов.
- Антифосфолипидный синдром – заболевание иммунной системы, которое вызывает увеличение густоты крови, из-за чего легче образуются тромбы.
Другие факторы, увеличивающие риск ТЭЛА
Существуют другие факторы, повышающие риск развития ТЭЛА. К ним принадлежат:
- Возраст старше 60 лет.
- Ранее перенесенный тромбоз глубоких вен.
- Наличие родственника, который в прошлом имел тромбоз глубоких вен.
- Избыточный вес или ожирение.
- Беременность: риск ТЭЛА увеличен до 6 недель после родов.
- Курение.
- Прием противозачаточных таблеток или проведение гормональной терапии.
Характерные симптомы
У тромбоэмболии легочной артерии симптомы следующие:
- Боль в груди, имеющая обычно острый характер и ухудшающаяся при глубоком дыхании.
- Кашель с кровянистой мокротой (кровохарканье).
- Одышка – человек может иметь затрудненное дыхание даже в состоянии покоя, а при физической нагрузке одышка ухудшается.
- Увеличение температуры тела.
В зависимости от величины перекрытой артерии и количества легочной ткани, в которой нарушен кровоток, жизненные показатели (артериальное давление, частота сердечных сокращений, насыщение крови кислородом и частота дыхания) могут быть нормальными или патологическими.
Классические признаки ТЭЛА включают:
- тахикардию – повышенная частота сердечных сокращений;
- тахипноэ – увеличенная частота дыхания;
- снижение насыщения крови кислородом, которое приводит к цианозу (изменению цвета кожи и слизистых оболочек на синий);
- гипотензия – падение артериального давления.
Дальнейшее развитие болезни:
- Организм пытается компенсировать нехватку кислорода путем повышения частоты сердечных сокращений и дыхания.
- Это может стать причиной слабости и головокружения, так как органам, особенно головному мозгу, недостаточно кислорода для нормального функционирования.
- Тромб больших размеров может полностью перекрыть кровоток в легочной артерии, что приводит к немедленной смерти человека.
Так как большинство случаев легочной эмболии вызвано тромбозом сосудов в ногах, врачи обязательно обращают особое внимание на симптомы этого заболевания, к которым принадлежат:
- Боль, отек и повышенная чувствительность в одной из нижних конечностей.
- Горячая кожа и покраснение над местом тромбоза.
Диагностика
Диагноз тромбоэмболии устанавливают на основании жалоб пациента, врачебного осмотра и с помощью дополнительных методов обследования. Иногда легочную эмболию очень трудно диагностировать, так как ее клиническая картина может быть очень разнообразной и подобной другим заболеваниям.
Для уточнения диагноза проводят:
- Электрокардиографию.
- Анализ крови на Д-димер – вещество, уровень которого увеличивается при наличии тромбоза в организме. При нормальном уровне Д-димера тромбоэмболия легочной артерии отсутствует.
- Определение уровня кислорода и углекислого газа в крови.
- Рентгенографию органов грудной полости.
- Вентиляционно-перфузионное сканирование – используется для изучения газообмена и кровотока в легких.
- Ангиографию легочной артерии – рентгенологическое обследование сосудов легких с помощью контрастирования. С помощью этого обследования можно выявить эмболы в легочной артерии.
- Ангиографию легочной артерии с помощью компьютерной или магнитно-резонансной томографии.
- Ультразвуковое обследование вен нижних конечностей.
- Эхокардиоскопию – ультразвуковое исследование сердца.
Методы лечения
Выбор тактики лечения легочной эмболии осуществляет врач на основании наличия или отсутствия непосредственной опасности для жизни пациента.
При ТЭЛА лечение главным образом осуществляется с помощью антикоагулянтов – лекарственных средств, которые ослабляют сворачиваемость крови. Они предотвращают увеличение размеров тромба, благодаря чему организм медленно их рассасывает. Антикоагулянты также уменьшают риск дальнейшего образования тромбов.
В тяжелых случаях необходимо лечение, направленное на устранение тромба. Это можно сделать с помощью тромболитиков (препараты, расщепляющие тромбы) или хирургического вмешательства.
Антикоагулянты
Антикоагулянты часто называют кроверазжижающими препаратами, но они на самом деле не обладают способностью разжижать кровь. Они оказывают влияние на факторы свертываемости крови, благодаря чему предотвращают легкое образование тромбов.
Главными антикоагулянтами, которые применяются при легочной эмболии, являются гепарин и варфарин.
Гепарин вводится в организм с помощью внутривенных или подкожных инъекций. Этот препарат применяется в основном на начальных этапах лечения ТЭЛА, так как его действие развивается очень быстро. Гепарин может вызвать следующие побочные эффекты:
- повышение температуры тела;
- головные боли;
- кровотечения.
Большинству пациентов с легочной тромбоэмболией необходимо лечение гепарином в течение как минимум 5 дней. Затем им назначают пероральный прием таблеток варфарина. Действие этого препарата развивается медленнее, его назначают для длительного приема после прекращения введения гепарина. Этот препарат рекомендуют принимать не менее 3 месяцев, хотя некоторым пациентам нужно более длительное лечение.
Так как варфарин действует на сворачиваемость крови, пациентам нужно тщательно контролировать его действие с помощью регулярного определения коагулограммы (анализ крови на сворачиваемость). Эти анализы проводят амбулаторно.
В начале курса лечения варфарином может понадобиться 2–3 раза в неделю сдавать анализы, это помогает определить подходящую дозу препарата. После этого частота определения коагулограммы – примерно 1 раз в месяц.
На действие варфарина влияют различные факторы, включая питание, прием других лекарственных средств, функционирование печени.
| Во время приема варфарина необходимо | Побочные эффекты этого препарата |
|---|---|
| Поддерживать постоянство своего рациона питания | Кровотечения |
| Ограничить употребление спиртных напитков | Головные боли |
| Принимать варфарин в одно и то же время суток | Диарея |
| Избегать приема любых препаратов без консультации врача | Тошнота и рвота |
| Избегать приема любых средств растительного происхождения | Желтуха |
В настоящее время введены в клиническую практику более новые и безопасные пероральные антикоагулянты – ривароксабан, дабигатран, апиксабан. Эти препараты обладают большей безопасностью, по сравнению с варфарином, поэтому пациентам, которые их принимают, не нужно тщательно контролировать сворачиваемость крови. Их минусом является очень высокая стоимость.
Лечение, устраняющее тромб из легочной артерии
Тяжелая эмболия легочной артерии несет непосредственную опасность для жизни пациента. Поэтому в таких случаях лечение направлено на устранение тромба, перекрывающего просвет сосуда. Для этого можно использовать тромболизис или хирургические операции.
Тромболизис
Тромболизис – это расщепление тромбов с помощью определенных медикаментов. Чаще всего применяют альтеплазу, стрептокиназу или урокиназу. Однако при использовании тромболитиков существует достаточно высокий риск развития опасных кровотечений, включая кровоизлияние в мозг.
Операция
Иногда удается удалить тромб из легочной артерии хирургическим путем. Такая операция называется эмболэктомией. Это тяжелое хирургическое вмешательство, проводимое в грудной полости, около сердца. Ее выполняют кардиохирурги или торакальные хирурги только в специализированных лечебных учреждениях. Эмболэктомия считается последней надеждой для пациентов с критической легочной эмболией.
Новые методы лечения ТЭЛА
- Катетеро-направленный тромболизис – введение препарата, рассасывающего тромбы, непосредственно в блокированную легочную артерию.
- Катетерная эмболэктомия – удаление тромба или его фрагментация с помощью небольшого катетера, заведенного в легочную артерию через кровеносные сосуды.
Некоторым пациентам проводят имплантацию кава-фильтров – специальных фильтров, которые размещают в нижнюю полую вену для прекращения попадания новых тромбов из ног в легочную артерию.
Профилактика
Если у человека повышен риск появления тромбов, уменьшить его можно следующими способами:
- Применение антикоагулянтов.
- Ношение компрессионного трикотажа, который улучшает кровоток в ногах.
- Увеличение подвижности и физической активности.
- Отказ от курения.
- Здоровое питание.
- Поддержание нормального веса.
Прогноз при ТЭЛА
Тромбоэмболия легочной артерии – опасное для жизни заболевание. Прогноз у пациентов зависит от нескольких факторов – наличия сопутствующих заболеваний, своевременного установления диагноза и правильности лечения.
Примерно 10% больных с ТЭЛА умирает в течение часа от момента развития болезни, 30% – умирает позднее от повторной легочной эмболии.
Показатели смертности также зависят от типа ТЭЛА. При опасной для жизни легочной эмболии, которая характеризуется падением артериального давления, смертность достигает 30–60%.
Тромбоэмболия легочной артерии является закупоркой проходящего сосуда флотирующим тромбом. ТЭЛА, так еще называется данная патология, может проявляться в редком состоянии. Когда в артерию поступает воздух (воздушная эмболия), околоплодная жидкость вследствие патологических родов. Клетки опухолевого или жирового типа, инородные тела.
Перекрытие в большинстве случаев происходит из-за оторвавшихся и блуждающих по кровотоку тромбов. Тяжесть симптомов и исход болезни напрямую зависит от количества сгустков и их размеров.
Одни пациенты даже не замечают слабовыраженных предвестников ТЭЛА. Другие же оказываются в тяжелом состоянии в реанимации, возможен летальный исход.
Причины
Разобравшись, что это такое ТЭЛА, стоит рассмотреть факторы, провоцирующие болезнь. Ее пусковой механизм основан на таких состояниях как:
- тромбозы или тромбофлебиты сосудов на нижних конечностях;
- онкология;
- порок сердца в любом проявлении.
Патология обычно представляет собой осложнение уже имеющихся нарушений со стороны сосудистой системы. Развивается на фоне онкологии. Но в некоторых случаях она обнаруживается и у здоровых людей. Например из-за частых авиаперелетов.
Так, при наличии здоровых сосудов длительное нахождение на высоте со значительными перепадами давления негативно сказывается на кровообращении в ногах и малом тазу. А именно происходит сгущение, застой кровяных масс.
Высокий риск развития тромбоэмболии наблюдается у людей. Которые перенесли инфаркты, инсульты, серьезные травмы в виде перелома шейки бедра. И которым показан строгий постельный режим.
Обстановка усугубляется при недостаточном уходе, т.к. при обездвиживании происходит сбой кровотока и образуются сосудистые тромбы. Появление ТЭЛА повышается в случае кесарева сечения, проводимого по экстренным показателям.
В случае дегидратации, которая развивается из-за сильной рвоты, приема медикаментов, отравления. Происходит сгущение крови, как следствие – формирование опасных тромбов.
Классификация
Приступая к лечению тромбоэмболии необходимо знать особенности закупорки легочной артерии.
Ее, а также ответвляющиеся вены, перекрывают сгустки в единичном или множественном количестве, отличающиеся диаметром.
Самыми опасными являются образования, которые закрепляются внутри сосуда только с одной стороны.
Отделение тромба происходит при сильном кашле, резком движении, чрезмерных натуживаниях.
Освободившись, он поступает в полую вену, далее переходит в предсердие справа, правый сердечный желудочек. Останавливается в легочной артерии. В этом месте сгусток останавливается, может разделяться на мелкие вкрапления. Провоцируя тромбоэмболию мелких веток, отходящих от легочной артерии.
Сгустки в большом количестве закупоривают артерию, из-за чего в сосудах повышается давление.
Прогрессирует в таком случае сердечная недостаточность. Которая квалифицируется в медицине как легочное острое — сердце явный признак ТЭЛА.
Патологию принято делить на следующие степени:
- малая – поражение не более 1/3 сосудов легкого;
- субмассивная – страдает около половины вен, причем как мелких, так и крупных;
- массивная – патология поразила большую часть сосудистой сетки легких.
Основные проявления патологии
Неотложная помощь понадобится в следующих случаях:
- загрудинная боль;
- одышка;
- кашель с кровью;
- тахикардия;
- поднятие температуры;
- синие губы;
- кашель с влажным хрипом;
- снижение АД.
Предвестники болезни совмещаются и создают устойчивые синдромы. Которые проявляются при той или иной стадии тромбоэмболии. Если говорить про субмиссивный или малый подвид заболевания легочных сосудов. Он проявляется плеврально-легочным синдромом с одышкой, отхождением мокроты.
Что касается массивной эмболии, для нее свойственный кардиальный синдром с болями. Напоминающими стенокардию, снижением кровяного давления с частым наступлением коллапса. На шее при этом вздуваются вены.
Медики бригады скорой помощи обычно констатируют у таких больных повышенное давление. Именно в правом предсердии, сердечные усиленные толчки, венный пульс положительного характера. У пожилых людей ТЭЛА прогрессирует параллельно с церебральным синдромом (судороги, паралич, потеря сознания).
Диагностические меры
Если имеет место малейшее подозрение на тромбоэмболию вен в легких, проводится максимально быстрая и срочная диагностика, которая поможет принять экстренные правильные меры, снижающие тяжесть приступа.
Популярные аппаратные методы:
- сцинтиграфия перфузионного типа;
- КТ;
- селективная ангиография.
Что касается рентгенографии и ЭКГ при описываемой патологии. Они проявляют незначительный потенциал, следовательно, и данные, полученные при их проведении, учитываются ограничено.
Во время проведения КТ дополнительно может обнаруживаться инфаркт легкого, что является самым сложным осложнением. Беременным обычно назначается МРТ, процедура точно определяет наличие болезни. При этом отсутствует опасное для ребенка излучение.
Самым доступным по стоимости методом обнаружения эмболии легких является перфузионная сцинтиграфия. Ангиография селективная быстро определяет характерные признаки, обнаруживает место нахождения тромба. Обеспечивает мониторинг перемещения кровяных масс по малому кругу кровотока.
Ангиография позволяет бужировать блуждающий сгусток катетером, после чего уже проводится терапия.
Лечение
Терапия патологии основана на оказании экстренных мер. Которые направлены на спасение человека и обеспечение нормальной проходимости пораженных сосудов. В ход идут оперативные и консервативные мероприятия.
Оперативное вмешательство
ТЭЛА – коварная болезнь, успех лечения которой во многом зависит от степени закупорки и общего состояния пациента.
Что касается операции Тренделенбурга по устранению эмболов. Они на практике задействуется редко из-за высоких показателей смертности.
Большое распространение нашла катетерная эмболэктомия внутрисосудистого типа. При которой через сосуды и сердечные камеры выводится проблемный тромб.
Консервативное лечение
Подобная терапия направлена на обеспечение лизиса тромбов с последующим восстановлением тока крови в пораженных венах. Специалистом назначаются:
- фибринолитики, разжижающие опасные сгустки;
- антикоагулянты – не допускающие сгущение кровяных масс, повторный тромбоз в сосудах легких.
Лечение комбинированного типа при ТЭЛА предполагает активное устранение спазмов, стабилизацию сердечной функции, корректирование обменных процессов.
Лечащим врачом назначается прием отхаркивающих, противошоковых медикаментов, средств, оказывающих мощное противовоспалительное действие, анальгетиков.
При консервативной терапии медикаменты обычно водятся посредством катетера через носовые проходы, задействуется капельная внутривенная методика. Для некоторых лекарств предусмотрено введение через катетер, соединенный с артерией.
Полезное видео: Особенности тромбоэмболии легочной артерии
Многие люди не слышали о существовании такого заболевания, как тромбоэмболия легочной артерии (ТЭЛА). Однако эта патология встречается почти так же часто, как острый коронарный синдром. Она служит третьей по частоте причиной смертности от болезней сердца и сосудов.
У трети пациентов ТЭЛА вызывает внезапную сердечную смерть. Правильный диагноз при жизни больного ставится лишь у 7% больных. Это вызвано отсутствием характерных симптомов тромбоэмболии легочной артерии, а также трудностями ее диагностики.
Определение и патогенез
Сердце человека состоит из четырех отделов. В правые камеры (предсердие и желудочек) приносится венозная кровь, бедная кислородом. Оттуда она по легочной артерии ( легочному стволу) направляется в малый круг кровообращения. Он представлен сетью сосудов, тесно оплетающих дыхательные мешочки – альвеолы. В малом круге кровь обогащается кислородом, который проникает сквозь стенки альвеол. Затем она собирается в легочные вены, попадает в левые предсердие и желудочек, и оттуда по аорте поступает в остальные артерии.
Если из венозной системы через правые камеры сердца в легочную артерию попадет сгусток крови, возникнет ее закупорка – тромбоэмболия. Если тромб небольшой, он может продвинуться глубже и вызвать тромбоэмболию ветвей легочной артерии.
Кровь поступает в легочную артерию под нарастающим давлением. Правые камеры сердца перестают справляться с нагрузкой, и развивается острая недостаточность функции правого желудочка. При хроническом течении болезни формируется легочное сердце.
Одновременно развивается рефлекторный спазм бронхов, резко снижается артериальное давление, ухудшается кровоснабжение сердца. Возникает дыхательная недостаточность.
Причины и факторы риска
Главные причины тромбоэмболии легочной артерии (точнее, состояния, увеличивающие ее вероятность):
- перелом шейки бедра или другой кости нижних конечностей;
- госпитализация по поводу мерцательной аритмии (фибрилляции, трепетания предсердий) или сердечной недостаточности III – IV функциональных классов за последние 3 месяца;
- состояние после эндопротезирования (замены на искусственный) коленного или тазобедренного сустава;
- любая тяжелая травма, в частности, повреждение спинного мозга;
- перенесенный за последние 3 месяца инфаркт миокарда;
- венозная тромбоэмболия, перенесенная больным ранее.
Средняя степень риска ТЭЛА возникает при таких состояниях:
- артроскопия коленного сустава;
- любые аутоиммунные болезни;
- гемотрансфузия (переливание крови);
- установленный в центральную вену катетер (например, подключичный);
- лечение химиопрепаратами по поводу онкологического заболевания;
- тяжелая сердечная или дыхательная недостаточность;
- прием эритропоэтинов;
- применение оральных контрацептивов или заместительная гормонотерапия у женщин;
- экстракорпоральное оплодотворение;
- пневмония, колит, пиелонефрит;
- ВИЧ-инфекция;
- метастазирующие злокачественные опухоли;
- послеродовый период;
- тромбоз поверхностных вен;
- тромбофилия.
Факторы, незначительно увеличивающие риск тромбоэмболии легочной артерии:
- постельный режим продолжительностью более трех дней;
- беременность;
- сахарный диабет;
- гипертония;
- продолжительный перелет в самолете или автомобильная поездка;
- ожирение;
- пожилой возраст;
- лапароскопическое хирургическое вмешательство;
- варикозная болезнь.
В зависимости от степени риска ТЭЛА используются разные меры ее профилактики.
Клинические признаки
Симптомы тромбоэмболии легочной артерии часто не позволяют с уверенностью поставить этот диагноз.
Основные признаки заболевания:
- внезапная острая боль за грудиной;
- частое сердцебиение;
- боль в груди, усиливающаяся при дыхании;
- одышка;
- головокружение;
- кашель с примесью крови в мокроте;
- синюшность кожи;
- снижение давления, холодный пот, бледность.
Может возникать поражение нервной системы: рвота, судороги, потеря сознания, временное нарушение движений в конечностях. У части больных увеличивается печень, появляются боли в правом подреберье, горечь во рту, Многие пациенты отмечают умеренное повышение температуры, которое сохраняется от 2 до 12 дней.
Заподозрить ТЭЛА необходимо при наличии 4-х и более из перечисленных ниже симптомов:
- возраст больше 65 лет;
- перенесенный ранее тромбоз глубоких вен или ТЭЛА;
- операция или переломы за последний месяц;
- наличие злокачественной опухоли;
- боль в одной ноге;
- кровохарканье;
- частота пульса более 75 в минуту;
- отек одной ноги.
Заболевание может протекать по одному из следующих вариантов:
- Острейший: закупорен главный ствол артерии. Развивается потеря сознания, резко снижается АД, дыхание останавливается. Через несколько минут наступает летальный исход.
- Острый: наблюдается почти у трети больных, возникает при закупорке крупных ветвей артерии. Быстро начинается и усиливается, приводя к одышке, учащению пульса, снижению АД, боли в груди и нарушениям со стороны нервной системы.
- Подострый: характерен для половины пациентов, сопровождается инфарктом легкого. Постепенно нарастают признаки недостаточности дыхания, а также правожелудочковая сердечная недостаточность, отеки, нарушения ритма. Вероятны рецидивы ТЭЛА.
- Хроническое рецидивирующее течение наблюдается у 20% пациентов. Клинические признаки – прогрессирующая правожелудочковая недостаточность, отеки, двусторонние плевриты.
Диагностика
При тяжелом состоянии пациента (шок, падение АД) показана немедленная эхокардиография (УЗИ сердца). При ТЭЛА на ЭхоКГ определяются признаки избыточной нагрузки на правый желудочек вследствие повышения давления в легочной артерии. Это служит основанием для назначения тромболитической терапии.
После стабилизации состояния больного проводят мультиспиральную компьютерную ангиографию (МСКТ-ангио). Это исследование дает возможность увидеть, на каком уровне произошел тромбоз сосуда, и оценить размеры поражения легких.
У части пациентов, направленных на МСКТ-ангио, тромбоэмболия мелких ветвей обнаруживается случайно. При этом пациенту рекомендуется пройти УЗИ вен нижних конечностей. При необходимости (наличие онкопатологии, поражение долевых и более крупных ветвей) назначаются антикоагулянты.
Если показатели кровообращения стабильны, а риск ТЭЛА у больного средний или низкий, первое исследование при подозрении на это заболевание – определение так называемого D-димера. У людей младше 50 лет его максимально нормальное значение – 500 нг/мл. У пациентов в возрасте 50 лет и старше верхняя граница нормы определяется как возраст в годах х 10 (нг/мл).
При нормальном содержании D-димера и низком или среднем риске ТЭЛА этот диагноз исключают. В других случаях назначают МСКТ-ангио. Ее отрицательные результаты также позволяют исключить патологию. Дополнительно пациенту проводится УЗИ вен нижних конечностей.
При невозможности выполнения этих исследований диагностика тромбоэмболии легочной артерии включает рентгенографию легких и ЭКГ.
Лечение
Если у пациента развился шок и снизилось АД, ему необходимо проведение тромболизиса – растворения тромба в легочной артерии с помощью специальных лекарственных препаратов. Одновременно проводится дыхательная поддержка – подается кислород или проводится искусственная вентиляция легких.
При вероятности ТЭЛА и тяжелом состоянии больного назначаются гепарин и варфарин. Гепарин вводится 5 дней и более. Его отменяют только тогда, когда показатель МНО составляет более 2,0 в течение двух дней.
Препараты, используемые для тромболизиса: стрептокиназа, альтеплаза, урокиназа. Их эффективность примерно одинакова. Эти лекарственные средства можно вводить за два часа, но тогда повышается вероятность кровотечений. Применяется и 12-часовой протокол тромболизиса.
Если тромболизис противопоказан, или состояние пациента настолько тяжелое, что он может не дожить до развития эффекта лекарств, проводят экстренную операцию – хирургическое удаление эмбола из сосуда или чрескожное катетерное вмешательство. Необходимо выполнить такое вмешательство в первые часы заболевания. Желательно использование искусственного кровообращения. Такие операции сопровождаются высокой летальностью.
При невысоком риске смерти больного лечение тромбоэмболии легочной артерии включает назначение гепарина и варфарина. В последние годы на смену этим двум препаратам приходит новый антикоагулянт ривароксабан (Ксарелто), принимаемый в форме таблеток. Кроме того, варфарин можно заменить на дабигатран. Ривароксабан сейчас рекомендован для длительной терапии и профилактики рецидивов ТЭЛА, так как он значительно безопаснее варфарина, и при его использовании не нужно постоянно контролировать свертываемость крови.
При невозможности использования антикоагулянтов используются кава-фильтры – устройства, помещаемые в просвет полой вены и предотвращающие проникновение тромбов в правые отделы сердца. Сейчас показания к их использованию сужаются, предпочтение отдается временным кава-фильтрам.
Профилактика
Предотвращение ТЭЛА у прооперированных, малоподвижных, онкологических больных и других групп пациентов с высоким риском патологии проводится по общепринятым правилам. Профилактика включает эластическое бинтование конечностей, раннюю активизацию больного, лечебную гимнастику. Многим больным после операции назначается профилактическое введение препаратов низкомолекулярного гепарина (Фраксипарин и другие).
После ТЭЛА антикоагулянты принимаются не менее 3 месяцев. Более длительные сроки приема устанавливаются для больных с онкозаболеваниями, антифосфолипидным синдромом, наследственной тромбофилией, рецидивом ТЭЛА.
Обычно сначала назначается варфарин, а после снижения риска ТЭЛА осуществляется переход на ривароксабан.
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