Уважаемые коллеги,
Действительно, существуют ситуации, когда идет рецидив тромбоза на фоне адекватной терапии пероральными антикоагулянтами (можно взять любое долгосрочное клин. исследование и там всегда конечные точки - % кровотечений и % тромбозов). Наиболее, на мой взгляд, частая ситуация - это антифосфолипидный синдром. Вот что об этом пишут в недавней обучалке
Relatively few data are available for those patients who sustain a recurrent thromboembolic event in the setting of therapeutic oral anticoagulation. A variety of treatment strategies have been used, including addition of antiplatelet agents to higher-intensity oral anticoagulation, conversion from oral anticoagulants to therapeutic dose low-molecular weight heparin, and addition of immunomodulatory strategies.
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В недавней статье анализируется долгосрочный прогноз постановки кава фильтров (там кстати среди имплантируемых было 15% тех, у кого были ретромбозы были на адекватной антикоагуляции), как видно прогноз у пациентов без антикоагулянтов в 2,5 раза хуже
Postgrad Med J. 2006 Feb;82(964):150-3.
Retrospective analysis of the use of inferior vena cava filters in routine hospital practice.
Dovrish Z, Hadary R, Blickstein D, Shilo L, Ellis MH.
Department of Medicine C, Meir Hospital and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
INTRODUCTION: Characteristics and outcomes of patients undergoing inferior vena cava (IVC) filter insertion are not well reported. Particularly, the role of long term anticoagulation in these patients is unclear.
AIMS: (1) To describe in a cohort of patients undergoing IVC filter insertion, underlying diseases, indications for filter insertion, complications, and survival. (2) To determine the effect of long term anticoagulant treatment on thromboembolism and patient survival.
STUDY DESIGN: A retrospective analysis of 109 consecutive patients undergoing IVC filter insertion in two university hospitals.
RESULTS: Average age was 67.4 years. Median duration of follow up was two years. Indications for IVC filter insertion were:
contraindication to anticoagulation (n = 61, 56%),
prophylactic insertion (n = 29, 27%),
thromboembolism while receiving adequate anticoagulation (n = 17, 15%),
and non-compliance with anticoagulation (n = 2, 2%).
Insertion related complications were groin haematoma in four patients (3.5%) and localised infection at the puncture site in one patient (0.9%). Fifty six patients (51.4%) died during the study period. Of these, 22 received long term anticoagulants and 34 did not. Overall and thrombosis free survival was greater in the anticoagulant treated group (median survival not reached) than in the untreated group (median survival = 12 months). Patients not receiving long term anticoagulation after IVC filter insertion were nearly 2.5-fold more likely to die or experience venous thromboembolism.
CONCLUSION: IVC filter insertion was a safe procedure and was performed for appropriate indications in the patients studied. In patients surviving for longer than 30 days, prolonged administration of oral anticoagulants was associated with improved survival with no significant increase in haemorrhagic complications.
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