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DEEP VEIN THROMBOSIS SEBAGAI MANIFESTASI SINDROMA PARANEOPLASTIK DARI KANKER PARU
Keu S e a tt u g Diii maoo iOn oo i e i, ga / M FImuP n a iDaa vs He tlg- k lg M dk Ba inS l e y kt lm F Un dRS S n lhDe p s rBai K u / UP a ga n a a, l Emalk u g @ y h o o i s e a a o .c m :
ABS TRACT Th o oi e e ti p t n wi c n e i a c mmo fau e i c nrr t te p e e tt n o to oi ds r es r mb t v n n ai t t a c r s o c e h n e tr n o tay o h rs nai f h mb t io d r o c ta p r o p r n o lsi s n r mea as ll ii a s mpo o a o c l main n y Th u d ryn me h ns ta h t at f aa e pa t y d o c s oey nt l y tm f n c ut l a c . e n elig c a im h t i g a s caig b t e c n e a d tr mb ssa wela b t e c n e a d p rn o lsi s n r mei n tce ry u d rto so it n ewe n a c r n h o o i s l s ewe n a c r n aa e pa t y d o c s o lal n eso d y t On o to ec n esta fe u nl a s cae wi p rn o lsi s n r mei ln c n e. Werp re a4 y asod e. e f h s a c r h t rq e t so itd t aa e pa t y d o y h c s u g a cr e o td 6 e r l wo n ta p e e t ii al b c u eo as l n lf lg a d tn en s ao g telg Ote e a n t n wi i n r l ma h t rs ns nt l e a s f wol et e n e d r e s ln h e . h r x miai s t n o ma i y e o h fn igicu ign r l h s xry I a p o i tl ay a ltr tep t n e p re c sdsu bn c u hwi bo dsra , idn n ldn o ma c e t a . n p r xmaey e r ae,h ai t x ein e itr ig o g t lo te k e h a c mp n wi s o te so b e t. S e wa as c mpann o s ap c e tp i e p cal wh n tkn a d e b e t. c o a y t h rn s f rah h h s lo o liig f h r h s an s e il y e a ig e p rah Afe s v rle a n t n p ro me s c a b o c o c p wi b o c ilwa hn , rn to a a bo s , o o rp i su y tr e ea x miai s ef r d u h s r n h s o y t r n ha s ig ta sh rc l ip y s n g a hc td , o h e h c r ig a h , h s CT s a ,hsp t n wa fn l da n s o h vn a v n e ln main n y Hitlgcfn igwa c o ado rp y c e t c n ti ai t s ial ig o e f a ig d a c d u g l a c . soo i idn e y g s c mfr wi a e oc rio p o l dfee t td Hewa te tdu d r6 c n e uiec ce o g mztbnc mbn dwi o im t d n acn ma o ry ifrni e . h a s rae n e o c c t y ls f e i i o ie t v a h c r o lt . De pt c mpee c e tea yte t n, h b c mewo s a d de b c u eo rs iao yfi r. ab pai n s i o ltd h moh rp rame ts e e a e rt n id e a s f e prtr al e u Ke wo d :h o oi e e tp rn o lsi s n r me ln c n e y r s tr mb t v n, aa e pa t y d o ,u g a c r c c

P ENDAHULUAN DVT ( Deep Vein T romb is a aa to o i h os ) d lh r mb ss v n d lm y n tra ia ia a a y a t a ip o e e a aa a g ejd kb t d n a ki s r s s v 14 k a ua i a aaia v n y n sa i. DVT b ra o g ls p d l n e a a g tss r es ma s mad n a P ( a e g n E Pulmonary Emb meu a a s lh oli) r p k n aa s t p n e a mo tl a d n mo bdts Waa p n au e y b b rai s a t r ii . a lu u h b n a a tr to o i d n k n e s d h dk n l u u g n naa r mb ss a a k r u a ie a s jk jma d h l k l a a ttp me a imey n ea a n a uu aa k n ea i k ns ag 5, 6 me d s rn as c r p si eu dk th i Kea in n a aiy e aa a tb lm iea u. jda VTE ( Venous T romb is Ev )b r ia a tr 15 h os ent eks r naa 20 d r s lr h k n e, a k n a g albh t g i % ai eu u a k r b h a n k e i i g n 78 , dtmu a p d su i o t re ( 50 . VTE i e k n a a td p s mo tm 30 %) y n t g i a y kdh b n k nd n a k n e s lrn a g i g b n a iu u g a e g n a k r au a n 126

c r a p r , o aim. Dia ig jns k n en a en , au v ru s mpn e i a k r y , b b rp k n ii y n me y ra s p ri t d k n e ea a o ds a g n eti e et i a a n o ea i p mb ra k moea i trp h r n ld n p rs, e ein e trp, ea i o mo a a t d k np ma a g na s s if sk ttrv n s nrl i a a e s n a k e (n u , aee, e a e ta) n jg a a me ig ak n k jda to o i.6,u a k n nn k ta ea in r mb ss 9 11 Waa p n VTE meu a a lu u r p k n ma ie ts nfsa i kii y n u m djmp ip d s o a g p n ei l k a g mu i n u a a a e rn e d rt a k n e,a ns b l n a dtmu a a a y k jda a k r mu e ai y i n k e k n d n a ea in VTE, tr tma DVT y n mu c ly me d h li eua ag n un a n a uu t un a k n e p i r y meu a a k s s y n i ly a k r rmen a r p k n a u a g mb jrn . Ap bl diui d lm wa t y n c k p aa g a i i t aa a k ku a g u u lma a a d p t dtmu a a a y k n e y n a kn aa i e kn dn a akr ag me d s rn a Kea in DVT y n me d h li n a aiy . jda ag n a uu mu c ly s b a k n e dtmu a b r ia a tr n un a e u h a k r i e k n eks r naa
J Peny Dalam, Volume 12 Nomor 2 Mei 2011

7 26%, i n a g aiia a ma i t g ia a i dma a n k n k n kn i g p bl n a DVT n a dka iia ia s b g i DVT iip t y ilsfk sk n e a a do ai k ( rov edDVT) a dd p ta p d u i lnu.11unp ok d n ia ak n a a sa a jt 14 DVT y n me d h lit un as au k n e a g n a uu i ly u t a k r mb p i r me y r p i k jda s au sn r ma p r rme n eu a ea in u t id o aa n o lsi, i n sn r maii r p k nk mp ln e pa t dma a id o n meu a a u ua k d r tn a d n g jl a ia k r s k n o g n aa ai a d a eaa kb t eu a a r a tu jrn a y n ltk y ju d r k n e p n e a n a aig n a g ea n a a h ai a k r e y b b y . Keu a a ii iame g n i a i s mu o g nd n r s k n n bs n e a h mpr e a r a a jrn a tb h S n r maii iame c p i 15% aig n u u . id o n bs n a a 10 d r s mu k g n s n S n r ma iime jd p nig ai e a e a a a . id o n na i e t n k rn bs meu a a s t-au y g jl d r s b a ae a ia r p k n au s tn a eaa ai e u h k n e d n b h a bs s b g itn aa ld r s au a k r a a k n ia e a a a d wa ai u t k n e,n mu k rn g jl d n tn a y n s n a a k r a n ae a eaa a a d a g a g t b r ais, id o ii eigt a tr ee s d n a ev ra i sn r ma n s rn i k ed tk i e g n d b i.15ak 17 Vais kii d r b r c m- c m k g n s n ra i l k ai ema a ma a e a a a n d n k i n y d n a k jda to o i b i y n a at n a e g n ea in r mb ss ak a g a meu a a a ia k n en aaa p ny n me d h li r p k n kb t a k r y tu u a g n a uu mu c ly s b a k n e, dd g a ia itrk i n un a e u h a k r iu a kb t nea s a tr b r a a jns p oen boo i d r s b a naa eb g i e i r ti ilgk ai e u h k n e d n a p oenk a ua iu u s hn g tra i a k r e g n r ti o g ls tb h e ig a ejd a t a ip o e k a ua id n tr e tk y to o i. ki s r s s o g ls a eb nu n a r mb ss v P n ei k n e d n a VTE a a me u y i e d rt a k r e g n a kn mp n a

p o n ssy n lbhjlkk ludb n ig a d n a r g o i a g e i ee aa ia dn k n e g n 914 k n e y n s may n t a ds ra d n a VTE.5,, akr ag a a g i k ieti e g n d Beiu iik milp r a s b a k s sk n e rk t n a a o k n e u h a u a k r p r y n b r dk th i eea s ktr ea u , i n au a g au iea u s tlh e i s th n dma a a s b lmn ap n ei y n b ra g ua d tn h n a e eu y e d rt a g es n k tn aa g a y a d n a k lh na l d n ak k b n k k( e g n eu a wa a a y a i e g a DVT) . KAS US S o a g p n ei wa i 4 th n p g wa e rn e d rt a nt 6 a u , e a i a n g r spl t a meo o ,d n a rwa a p n a i e ei ii i k r k k e g n i y t e y kt , d s p ri eiu. S ktr ua d s mb r 0 , e d rt e etb rk t e i b ln e e e 20 8 p n ei a a me g lh n ei b h k n n y n hln t u, n eu y r a u a a a g i g i l a mb tn a ds ra p n s d n k lh n lin a P d s a a p ieti a a a eu a an y . a a a t tre u dlk k n e au s kii, lb rtru es b t i u a a v la i l k a o ao im n d n r ng n lgs Dai p meis a r ng n b h a o te oo i. r e rk a n o te a u dd p ta h sl a gn r l a d rp meis a f t ia ak n a iy n o ma d n ai e rk a n oo d d ,ia dtmu a a a y k lia p d jnu gd n a at k i d e k n d n a ean n a a a tn a p r ( mb r2a. T d kdd p ta a a y g mb rn au Ga a ) ia ia ak n d n a a aa ma s p d p r . Ha i d r lb rtru Hb 12, sa a a au sl ai a o ao im: 7 g /l W BC 5,8 10 u;paee 265.10 u;S rd; 8 . 3/l ltlt 3/l GOT 10 ul GP 9 ul GDP 8 mgd;GD 2j P 121 mg /S T / ; ; 4 /l P / d;Lii p o i d lm b tsn r l BUN 25 mgd; l pd r fl aa aa o ma. e /l s r m k e t i 07 mgd. Be ea ab ln b rea g eu rai n , n /l b rp ua es ln ,

Ga a 1. P meis a Do pe Ul a o o rp yp d e srmi sb wa . mb r e rk a n p lr t s n g a h a a k te t a h r a
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M e 20 9 p n ei me g lh k k kr trs b rt i 0 e d rt a n eu a i ii ea a ea b n k k p n s d n k d n - a a g trs n ei e g a , a a a a a g k d n ea a y r. P n ei b r b tk d ke d n dda n ss s b g i e d rt eo a e o tr a iig o i e a a a DVT s rado aid n a e o a ai (nio g ln . et ib t e g n n x p rn a t a ua ) k S tlhs ktr b lnd n a p n o aa a t o g ln eea e i 2 ua e g n e g b tn ni a ua a k p n ei d tn k RS S n lhu tkk lh nk k e d rt aa g e UP a ga nu eu a a i a b n k k y y n ma i b lm b r u a g s lr h y . e g a n a a g sh eu ek rn eu u n a Di k k n p meis a ua g d n a US Do pe. l u a e rk a n ln e g n G a p lr Ha i p meis a US Do pe tn g l22// 0 sl e rk a n G p lr a g a 820 9 p d e srmi s b wa kr ( mb r 1) dtmu a a a k te t a h ii Ga a a i e kn a a y h mb tn aia p d v n p pi a t il d n a a aa l n a a e a o l e i ai r t b s a tro d n fb lrssnsr,c rg s au tr mb s neir a iuai iita u ia u t h o u p d v n p pi a snsr. P meis a D dme a a e a o l e iita e rk a n t i r 44 5 n / ( o to < 50 n / ) F b io e 367 ,8 gml k nr l 0 gml, irn g n mgml( aa b tsn r l P T 203 d t ( o to / d lm aa o ma, P , ei k nr l k 13, d t )AP T 285 d t ( o to 32, d t ) I 8 ei , P k , ei k nr l 5 ei , NR k k 1, d t ( o to < 09d t ) P d s a ii e d rt 36 ei k nr l , ei . a a a tn p n ei k k a drwa h n a d n a DVT y n b lm s mb h ia t a y e g n a g eu e u s hn g o a- b tnu tkDVT n adtr s a . e ig a b to aa nu y i uk n e S lnun ap d b lnDe e e 20 9p n ei ea jty a a ua s mb r 0 e d rt a d tn lg d n a k lh nn ei u g u gkr. Ny r aa g a i e g n eu a y r p n g n ii ei ds ra d n a p rs a oo s ktr y n trai, ieti e g n ea a n tt e i a a g etrk s p na g h r d n me ea . J g ds ra d n a e a jn ai a n tp u a ieti e g n b tk b tk y n hln t u d n a ra k d n au - au a g i g i l e g n ik a a g a mb ds ra d n a b ra d rh S s k n fs drs k n ieti e g n ec k aa . e a aa ia a a

me ea d nb ra a b rt lu u p n ei t a n tp a etmb h ea waa p n e d rt i k a d mea u a a t i sfsk y n b rt Bau d n s s k lk k n ki t ii a g ea. tk a e a va ds ra d n a n eid d y n me u u tr tma ieti e g n y r a a a g n s k eua p d d d s b lh k n n tmb sk p n g n . P d a a a a e ea a a e u e u g u g a a s a iip n ei mea a lbh lma ,n fu ma a a t n e d rt a rs e i e h as kn d n miu ju b r u a d n p n ei mea albh a n m a h ek rn a e d rt a rs a i k r s M u l a jg drs k nn mu h n ak d n uu . a mu l u a ia a a a n a y a a g k d n s j ds ra d n a mu th Bu n arb s r a a g aa ieti e g n na . a g i ea d n b a g ark clma i n r l P d p meis a a u n i e i sh o ma. a a e rk a n fsk dtmu a p n ei d n a k s n s ktb rt ii i e k n e d rt e g n e a a i ea, a k s d rn ma i c mp sme t d n lma . T k n n e a aa sh o o ni a e h e a a s d rh 1108 mmHg RR 28 xmn,n d 9 xmn aa /2 , / t ai 4 / t d ntmp ra r372C. p meis a k p l d nlh r a e etu , e rk a n e aa a e e h n adtmu a k n u giay n a a a e s P d ay i e k n o y n t a g g k n mi. a a v p meis a d d dd p ta v c l fe ts y n e rk a n a a ia ak n o a rmi u ag me u u d k n n n eitk n p d p n g n k n n n rn i a a , y r e a a a u g u g a a . J nu g d lm b ts n r l t a dd p ta s aa a tn aa aa o ma, i k ia ak n u r d mu mu aa g l p P d e srmi st a dtmu a r r tu al . a a k te t i k i o a d e kn a a y p mb n k k n p d k k p n ei . Dai d n a e e g a a a a a i e d rt a r p meis a lb rtru bl u i ttl 063 mg e rk a n a o ao im: i r bn oa , i / d,i r bn idrk 034 mgd, 61 I l GOT 20 l l u i n ie , bi /l AP U/S , I lS T17I lab mi 3, g /lBUN 12, mgd, U/ GP , U/ lu n 2 rd, , 0 /l s r m k e t i 065 mgd, eu rai n , n /lGDP8 mgd, 08mg 5 /lHB , / 3 d, BC 3,1.10/lpaee 215.10/lM CV 7 3 f, lW 7 3 u, ltlt u, 6, l M CH 22, p , CHC 31 gd. Di k k np meis a 3 gM /l l u a e rk a n a

mb r . sa i au a a e g n f s Ga a 2a F t trk d n a d n a k s n p r Ga a 2b M a s d p r k n nd n a eu i mb r . oo o a s e g n e g n e a au d njnu gd lm b tsn r l a a tn aa aa o ma

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f t trk d n a h sltmp k a a y k n oia i oo o a s e g n a i a a d n a o s l s d rdo p k p d d ea lb sb wa a tro k n n a io a s a a a rh o u a h neir a a , tp muu . S n s k so rnk s k n n tmp l d n e i ls iu o tfe iu a a u u a treu u g Ke a :tmo p r k n n d n a eu i es lb n . s n u r au a a e g n f s pe r k n n DB ( a n ss Ba dn ) p e mo i lu a a a Dig o i n ig : n u na lb sme is( mb r2b . ou du Ga a ) P d s a ii p n ei drwa d n a a a at n e d rt ia t e g n a k c rg a s au tmo p r d n a eu i pe r e u ia n u t u r au e g n f s lu a s hn g a du uk n p meis a lbh lnu s p ri e ig g is la e rk a n e i a jt e et b o k s o id n s a d d ,ds mpn p meis a r n o k p a c n a a ia ig e rk a n stlg c ia eu i P d p meis a b o k s o i i o i arn f s. a a e rk a n r n o k p o d n a b o c il r s igd ndlk k np meis a e g n r n ha b u hn a i u a e rk a n a hsoo i dtmu in a a y g mb rn b o k g nk itlgs i e ka d n a a aa r n o e i k rio asn ma s s a d n a a e o k rio . Ha ii e u i e g n d n asn ma ln dd k n p l oe h slF iu u g ua lh a i NAB p d tmu d n a aa u r egn t d k n ta so a a bo s dma a dtmu a jg i a a rn trk l ip i i n i n e kn u a g mb rn mo f lg s s a d n a a e o asn ma a aa roo i e u i e g n d n k rio . P d s a d d d n a iia a iltn ad n d n a a a c n a a e g n rs n xa a p a e g n k nrs dtmu a a a y ma s d c r ip e iu o ta i e k n d n a sa i ado rnk s k n n y n me gn i rs h miifa ma k n n d n a a a g n ifl a i e darg t aa a ma u k p rn i l e,lb ltd d n a a a y s k e ae sm i r o uae e g n d n a v p nn k tn p d p mb ra k nrs Uk rn ma a e ig aa a a e ein o ta . ua s 76 x6, x6 c me d s karu k n nd nds ra , 7 m, n e a tim a a a ieti d n a l d n p t p r a ra trk l . Daih sl e g n i e o ai aa o t o a ai ma s r ai e o k r ig ai dtmu a k tp k tp n r l k c ado rf i e k n au - au o ma, dme s r a g jnu g n r l n r kn t d n L i n i u n a tn o ma, o mo iei a V k ssoi f n s n r l itl u g i o ma. k Bed s r a p meis a US h p r t a r a ak n e rk a n G ea i k d dtmu a a a y tn atn amea ts . P meis a i e k n d n a a d -a d tsa e e rk a n tmb h nliy y i CEA 78 mgmlk nr l 5,0 a a a an a at u ,7 / ( o to < 0 mgmlAF 1, UIml k nr l ,0Ui ) d r d t / , P 63 / ( o to 80 / . ai aa ml y n a a p n ei dda n ss d n a k n e p r a g d e d rt iig o i e g n a k r au a (d n k rio ) sa im II d n a eu i pe r a e o asn ma tdu Ib e g n f s lu a d n rwa a a a y DVT P n ei dtrp d n a a i yt dn a . e d rt i a i e g n a e rgme t k moea i k mbn s g mstbn d n a e i n e trp o ia i e i i e g n a c r o lt s lma6 k l sku a a ttp t a a a ab pai ea n ai ils k n ea i i k d d p r ak n y n sg iia . Ko ds p n ei ttp eb ia a g infk n n ii e d rt ea a me u u ma i lma d n s s k n fsy n ma i mb r k kn e h a e a aa a g kn b rtd n a hr y p n ei me ig a d n a k u a ea a k in a e d rt nn g l e g n a s a k maina ia g g l aa . e t kb t a a n fs a

Dai p raa a p n a i p n ei daa r ejln n e y kt e d rt its a dsmp la b h p n ei daa me g lmiDVT ii uk n a wa e d rt its n aa a y n meu a a s au sn r ma p rn o lsi d n a g r p k n u t id o aa e pa t a k meu a a b ga d r s au tmo p r d lm h l r p k n a in ai u t u r au aa a iia e o asn ma p r sa im II d n a eu i n d n k rio au tdu IB e g n f s pe r. lu a P BAHAS EM AN P se d n a DVT mu g i h n ame u y i a in e g n n kn a y mp n a g jl y n mii l aa aiia d n g jl aa eaa a g nma tu t k l a eaa tu p tn atn a y n me y r p i s au DVT s rn a d -a d a g n eu a u t eig dtmu a p d k lia n nto o i. Ha y s ktr i e k n a a ean n o r mb ss n a e i a 25% p n ei DVT mu c ld n a k lia y n e d rt a n u e g n ean n a g s s a. P se d n a DVT ba a y d tn d n a e u i a in e g n is n a aa g e g n k lh n n ei b n k k tr en s s p na g aia eu a y r, e g a , ed r e s e a jn l n r v n d lm,a a y k mea a ,a a p lb rn v n . e a aa d n a e rh n d ee aa e a Dig o i DVTdtg k a d n a c resiv v a n ss i a k n e g n omp s e enous e ult onog h d n p meis a D dme. S a d r ras rap y a e rk a n i r tn a b k u tkda n ssDVT a aa v a u nu ig o i d lh enog h 1- , 18 rap y.412, P n ei ii aa gd n a k lh nb n k kp d e d rt n d tn e g n eu a e g a a a a k k, y r d nk k trs b rtd nd r p meis a a in ei a a i ea a ea, a ai e rk a n Do pe s n g a idtmu a a a y tn as mb tn o lr o o rp i e k n d n a a d u aa aia v n p d v n p pi a s ra dd k n oe l n e a a a e a o l e et iu u g lh r t D dme y n t g i( 4 0 u / )ma a da n ss i r a g i g > 0 0 gml k ig o i n DVT s n a mu g i dtg k a . P d s a ii p d a g t n kn i a k n a a a t n , a a e p meis a f t trk p r d n jnu g d lm b ts e rk a n oo o a au a a tn aa aa n r l t a dtmu a tn atn a k g n s np r . o ma, i k i d e k n a d -a d e a a a au Ak n ttp b rea g s th n k mu in p n ei a ea i es ln ea u e da e d rt a a hr y dda n ssme d rt k n e p r sa im II k in a iig o i n ei a k r au tdu I a B (d n k rio ) d n a eu ipe r. Diea u a e o asn ma e g n f s lu a k th i b h k n e p r meu a a s lhs t jnsk n e a wa a k r au r p k n aa au e i a k r y n s rn ds ra d n a ma ie ts sn r ma a g eig ieti e g n nfsa i id o p rn o lsi. Dii uk n b h ma ie ts DVT aa e pa t k smp la a wa nfsa i p d k n e p r ii r p k nma ie ts a l at a a a k r au n meu a a nfsa i wa y i u s ausn r map rn o lt d r s b a k n e p r . u t id o aa e pai ai e u h a k r au k Waa p n t un a k jda VTE p d lu u i ly mb ea in aa p n ei k n e meu a a g jl y n u m, e d rt a k r a r p k n eaa a g mu a a ttp s b l n a DVT/ k n ea i e ai y k VTE y n me d h li a g n a uu d n meu a a g jl a ld r s au k n e y n a r p k n eaa wa ai u t a k r a g

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tre u y ( c malig es mb n ioc ult nanc meu a a k s s a g y) r p k n a u y n jrn . S au su imea o k n a g aa tr 7 26% aa g u t td lp r a n k naa dtmu a a a y oc ultmalig i e kn dn a c nanc p d p n ei y a a e d rt a d n a to o i ( e g n r mb ss DVT) Bu t li d n a su i . ki an e g n td k h r d nsu i a ap p ls u m me u jk a 10 o o t a td p d o ua i mu n nu k n 15% d r p n ei y n d tn d n a DVT y n ai e d rt a g aa g e g n a ag iip t ( rov ed DVT)a a me d rt k n e do ai unp ok k k n n ei a k r a d lm b b rp th ns tlhk jda tr mb ss11, aa e ea a a u eea ea in h o o i. 19 An k iss e a a me ig a 2 4 l a p d g a n id n k n nn k t x i t aa p th n p ra d n rsk ii3 4 lbh b s rbl a u etma a iio n x e i ea i a db n ig a d n a p n ei DVT y n s k n e. ia dn k n e g n e d rt a ag eu dr P o a i ts u tk me d rt k n e p d p n ei r b bl a nu i n ei a k r a a e d rt a a DVT iip t 10 lbh b s rdb n ig a d n a do ai x e i e a ia dn k n e g n k p n ei DVT y n fko rsk n a dk th i 14 e d rt a a g a tr iio y iea u.11, Di p r a jg b h 1020 d r s mu k jda l o k n u a a wa a % ai e a ea in DVT y n iip t p d p n ei y n dk tk n a g do ai a a e d rt a g iaa a k a t a me d rt k n e p d a hr y a a me d rt i k n ei a k r a a k in a k n n ei d a a 14 k n e d lm wa t 3 th n a k r aa ku a u . M eia a g aa g a d n lp rn y n l t n k -n k h a a oa ag me d p ta h b n a y n c k p k a a tr n a ak n u u g n a g u u u t naa mu c ly k n e d n a ma ie ts to o i n un a a k r e g n nfsa i r mb ss d n to it un a to o i p d p n ei y n a e r i ly r mb ss a a e d rt a g mb a t a jls dk th i fko rsk n a t u s au i k ea iea u a tr iio y , i l u t d mb wa a au tk mea u a s k iig u tk me d tk i c n nu lk k n e rnn nu n ee s a a y s au k n e y n tre u y p d mee a d n a u t a k r a g es mb n i a a rk y n mn d p ta tr mb ss5, Ad n a k mau n a g e a ak n h o o i. 20 a y e ja tk oo ida n si d n p n mu n to ito itr au e n lg ig o t a e e a e r-e r eb r k lbh me d k n a a y p n a a u tk mea u a ei n u u g d n a e d p t nu lk k n s k iig tr a a k b rd a s au k n e p d e rnn eh d p e ea a n u t a k r a a p n ei d n a unp ok tromb isNa nb ki e d rt e g n rov ed h a os . mu u t b kiy n ln s n me d k n p ru y s k iig u t a g a g u g n u u g eln a e rnn ii shb lm tre i c k pb n a . Ge n e et n ma i eu es da u u a y k e z , al. s raNo o tn mea o k n b h s rnn r t s j et r se , lp r a a wa k iig ui aa n d p t n ee s a a y k n e y n tre u y.5 a a me d tk i d n a a k r a g es mb n i S u imua hr y n me gk t 8 p n ei td tk i a g n iui 64 e d rt a DVT iip t y n dp rk a d n a p meis a do ai a g ieis e g n e rk a n k s k iig r t ds ra d n a p meis a X-a , e rnn ui ieti e g n e rk a n ry n US d n b b rp bo r e s p riCA 125,P A, G, a e ea a imak r e et S CA,me d p ta a a y k n e p d 34 p se d r n a ak n d n a a k r a a a in ai 167o a gy n dc rg i 20 . Daa 1 th nf rn a g iu ia ( %) lm a u ollowup dtmu a lg s ktr27 p se d n a k n e. ,i e kn ai ei a a in e g n a k r 130

Di p r a d r su iiib h l o k n ai td n a wa d n a p nlin a egn ei a a a ly n b i ds ra d n a a a e i ln k p wa a g ak ieti e g n n mn ss e g a , p meis a fsk d n lb rtru d s ra a d p t e rk a n ii a a o ao im a a k n a a me d tk i r p ri a gc k pb s rd rk n e p d n ee s p o o s y n u u e a ai a k r a a p n ei d n a unp ok DVT21 Na nd miin e d rt e g n rov ed a . mu e ka su i n t a me y b ta a a a t d k ns k iig td ii i k n e uk n p k h i a a e rnn d n a a me eb ii aa me ig ak n s iv kn mp r ak tu n n k ta urv al p n ei - e d rt y n a hr y dk th id n a e d rt p n ei a g k in a iea u e g n a a k n e tre u. S au su i rn o s s tr o to a k r es b t u t td a d mia i ek nr l me c b me a dn k n a a a t d k n s rnn n o a mb n ig a p k h i a a k iig n a a d p tme u u k n mo tl a p n ei k n e kn aa n rn a rai s e d rt a k r t a d n a DVT iip t . T r y t t d k n s k iig egn do ai en aa i a a e rnn k n d n a p meis a d nt d k ny n c k pitn i e g n e rk a n a i a a a g u u ne sf n t a ma u me eia k u tn a p d p se i k mp d mb rk n e nu g n a a a in 22 p se tre u. a in es b t P d p se ii t a dlk k n p meis a a a a in n i k i u a e rk a n d a k u u u tk me d tk i a a y k n e y n h s s nu n ee s d n a a k r a g tre u y waa p n DVT y n dd rt p se ii es mb n i lu u a g iei a in n a a aa jnsiip t k rn t a dtmu a a a y d lh e i do ai ae a i k i k d e kn dn a fko rsk y n u m s p rida ee ,k lseo a tr iio a g mu e et ib ts oe tr l y n t g i hp re s, r k k F t trkp n ei a g i g, ietn i meo o . oo o a e d rt n a ii p d s a a l y t a dd p t a a a y n a a a t wan a i k ia ak n d n a d k c rg a a a y ma s p d p r . Ha y s th n e u ia n d n a sa a a au n a ea u k mu in p n ei me g lh b tk ds ra s s k e da e d rt a n eu au ieti e a n fsd np d g mb rnf t trkdtmu a a a y aa a a a a aa oo o a i e kn dn a tmo p r d n a eu i lu ak n n u r au e g n f s pe r a a . Dai aali dk tk nb h p n ei k n e r d t an iaa a a wa e d rt a k r a d n a VTE me u y ip o n ss y a lbh jlk egn mp n a r g o i n g e i ee bl db n ig a d n a p n ei k n e y n t a i ia dn k n e g n e d rt a k r a g i k a a d ds ra d n a VTE. An k s r ia 1 th n p d ieti e g n g a u vv l a u a a k n e d n a VTE h n a12% db n ig a d n a akr egn ay ia d n k n e g n 36% p d p n ei k n e tn a VTE.23 S u ili a a e d rt a k r a p a td an mea o k n a a y fko li s li DVT s b g i lp r a d n a a tr an ean eaa p e itr r b bl a k mu g ia mu c ly s b a rdko p o a i ts e n kn n n un a e u h i k n e,at t g iy k d r dme p d p meis a a k r i i gn a a a D i r a a e rk a n y u n a l P d su i n dlp r a a g aD dme > 4 0 wa. a a td ii i o k n n k a i r 00 n / p d s a a la a me ig ak n p o a i ts gml a a a t wa k n nn k ta r b bl a i u tk mu c ly k n e,k u u n a p d p n ei nu n un a a k r h s s y a a e d rt a y n b r mu < 60 th n d n a RR 3, p d p = a g eu r au egn 4 aa 13 00 P d k s siijg dd p ta k d rD dme ,2. a a a u n u a ia ak n a a i r
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y n t g i> 4 0 n / s b lm k b rd a k n e ag i g n 0 0 gml e eu e ea a n a k r p r n a bs dd tk i s th n k mu in d n a au y ia iee s ea u e da e g n p o n ss a glbhjlky i p n ei ii nn g l r g o i y n e i ee at e d rt n me ig a u a waa p ns d hs mp t n a a k moea i e a y k lu u u a e a me d p t e trp s b n a 6 sku tn ap r ak nkii y n n aa. ils a p eb ia l k a g y t n Katn a tr k n e d n to o i s d h i a naa a k r a r mb ss u a s jk 150 th n y n ll dk th i n mu a p k ea a u a g au iea u, a n s e bo lk lr y b r mua lb h jls dk th i imoe uen a au li e u ea iea u. S mp is a iis b tn iy n p nig p d k n e a a a t n u sa s a g e t n aa akr y n ea k i n d n a to o i a aa p oen a g rt at a e g n r mb ss d lh r ti fko jrn a y n ds b t s b g i c er c a tr aig n a g ie u e a a anc ell p oag roc ulant ,, P oen iia a b rtrk id n a .7924 r ti n k n ei a s e g n e p oenk a ua i a p oenfb ii t s ra o o e r ti o g lsd n r ti irnl i et k mp n n ik s llrd r sse h mo tss y i paee,e d tl eue ai itm e sa i at ltlt n oe u d n ma r fg s hn g a a tr e tk to o i. a k o a e ig a k n eb nu r mb ss Dia ig i a a y stkn p oen fs a u d n s mpn t d n a i i, r ti a e k t a u o moe u a e i jg b r ea a t s b g i b ga lk l d s u a ep rn ki e a a a in f d r rs o a t tb h tr a a s lk n e tre u. ai e p n ki u u eh d p e a k r es b t f Ke e a p o e iia a b r ea p l p d p o e s mu r s s n k n ep rn ua a a r s s p ru u a k n e k u u n a p d me a ime etmb h n a k r h s s y a a k ns tra iy mea ts . Ha i a hrd r itrk is mu ejdn a tsa e sl k i ai nea s e a s n a td jg dtnu a oe b b rp h l e et e y wa a i u a i tk n lh e ea a a s p ri e jnsk n e, e p ntb h d rjt ai e y kty .5, e i a k r rs o u u , eaa d r p n a i a 8 n S b g i mia, a e o asn ma y n me r d k i eaa s l d n k rio ag mp o u s mu i ua n a k n e p n ra , a aim, p r cn tma y a k r a k e s v ru au me u y i h b n a y n tr u t d n a DVT mp n a u u g n a g ek a e g n db n ig a d n a k n e lin a d n k n e ia dn k n e g n a k r an y , a a k r d n a sa im mea ts me u y iisd n VTE e g n tdu tsa e mp n a n ie y n lbh t g ibl db n ig a d n a k n e a g e i i g i ia dn k n e g n a k r n a p d sa im a l , a a tdu wa.813 S n r ma p rn o lt meu a a h l y n id o aa e pai k rp k n a a g p nig dk th ioe k rn sn r ma iimu g i et n iea u lh ae a id o n n kn s b g i tn a a l d r s au k n e, s hn g e a a a d wa ai u t a k r e ig a me n kn a u tk me d tk ik n e p d fs mu g ik n nu n ee s a k r a a a e a l a me a g nn ad n a lbhb i.17, S mp i wa d n n n a iy e g n e i ak 25 a a s a ii a ama as b a k n e d p t mp n au i a tn b g i n e u h a k r a a me e g r h jrn a y n ju d rn a b lm dk th id n a aig n a g a h aiy eu iea u e g n p si P n mu n a t b d a t e rl p d k s s a t e e a ni o i ni u a a a a u . n sn r map rn o lsi, mb r k s nb h h ln id o aa e pa t me ei e a a wa a ii k t u oe a a y rs o i ny n b r ea , lu i l lh d n a e p n mu a g ep rn waa mb t a s t p sn r ma iia a diuioe tmu n i k ei id o d a n k n i t lh e a k
DeepVein T romb iss b g i a ie ts S n r maP rn o lsi d r Ka k rP r h os e a a M nfsa i id o aa e pa t ai n e au k Ket S a ut ueg

a a y a t a t o iBu ttrk ime g tk nb h d n a uo ni d. kiea hr n aa a a wa b sn r maiimeu a a a ia d r rs o i n kt id o n r p k n kb t ai e p n mu i a tr a a s lk n e. Olh k rn n a a a i rs o eh d p e a k r e ae a y p bl e p n a i n ii s d miin h b ty ,ma a h l in a a mu n e e ka e an a k a n kn d p t mp ra a p ru u a s l a k r es b t a a me elmb t etmb h n e k n e tre u. Ha ii nea k nk n p p d sn r maii a a g l n me jls a e a a a a id o n kdn k n e p i r y t a aa b lm dk th i a as a a k r rmen a i k tu eu iea u p d a t d p e e ts a ld r sn r maii Ak n ttp k n e rs na i wa ai id o n. a ea i a k r y n tre u y iia a i p d a hr y mu c l a g es mb n i n p bl a a k in a n u a ba a y me u y i p o n ss y n lbh jlk is n a mp n a r g o i a g e i ee oe k rn ba a y djmp is d h p d sa im lh ae a is n a i u a u a a a tdu lnu a ia d r g jl a ltmo iidttp oe a jt kb t ai eaa wa u r n i u i lh u 16, 17 k b rd a sn r map rn o lsi ii Be ea a e ea a n id o aa e pa t n. k b rp tmo s l y n s rn dtmu a d n a sn r ma u r oi a g eig i d e k n e g n id o p rn o lsi a aa tmo p n ra ,p r ,o aim aa e pa t d lh u r a k e s au v ru k d ns lrnc r a Daa s lhs t lp rn10da tr a au a en . lm aa au a o a inaa 11 p n ei k n e d n a sn r maii d lhtmo e d rt a k r e g n id o n a aa u r a p r d na t Hua t o i r p k ns lhs t mak au a ni ni d meu a a aa au r a b p nigu tkk b rd a tmo p r .25 et n nu e ea a n u r au P d k s siik b rd a DVT s b g i a in a a a u n, e ea a n e a a b ga d rsn r map rn o lsi dd g k rn meu a a ai id o aa e pa t iu a ae a r p k n k tn a a l d r s au k n e p r y n dk th i a d wa ai u t a k r au a g iea u s ktrs th n k mu in s tlh p n ei me g lh e i ea u e da eea e d rt a a n eu b tk b tk lma ds ra d n a s s k n fs P d au - au a ieti e g n e a aa . a a s a a l DVT dk lh a k b rd a tmo p r a t wa ieu k n e ea a n u r au b lm bs db kia waa p n p d s a tre u eu ia iu t n lu u a a a t es b t k s d h dlk k n b b rp p meis a tr s k f t u a i u a e ea a e rk a n ema u oo a trk . De ka p l h ln ak b rd a DVT p d o a s miin ua a y e ea a n aa k n e ii k nme eia p o n ssy n lbhjlk a k rn a a mb rk n r g o i a g e i ee d niieb ki e g nme ig an ap se ii aa a n tr u td n a nn g ly a in n d lm wa t c k psn k t lu u tlhs mp t ieia ku u u ig a waa p n ea e a db rk n trp k mbn s k r o lt d ng mstbn ea i o ia i ab pai a e i i. n a Kae a tn a d n g jl d r s au sn r ma rn a d a eaa ai u t id o p rn o lsi s n a b r ais d n t a s e ii aa e pa t a g t ev ra i a i k p sfk k d ma a dp ru a s au p ma a n y n k mp e sf k ielk n u t e h ma a g o rn i u tk me g n ld n me e a a a a a y n kt nu n ea a mb d k n p k h a g i a h d p s ausn r map rn o lsi aa k hk n ii a a i u t id o aa e pa t tu a o ds k kii a ia p n a i lin a Ha iime jd s n a l k kb t e y kt an y . l n n na i a g t p nig oe k rn sn r ma iid p tmeu a a et n lh ae a id o n aa rp k n s t-au y g jl a l u t k n e, a p n e aa au s tn a eaa wa s au a k rd n e g n ln iitnu y a a me u tnkt u tkme c r tmo n e tn a k n n n u i nu a n ai u r 131

p i r y s hn g d tk i iin a a me ig ak n rmen a e ig a ee s dn ii k n nn k ta a g a k s mb h n y .15 S au k mp ln d r g jl n k e e u a n a u t u ua ai eaa d p t da g a s b g i sn r ma p rn o lsi a a in g p e a a id o aa e pa t k a a i g jl- eaa tre u b r u u g n d n a p bl eaag jl es b t eh b n a e g n a b h n a t y n dk lak a oe s ltmo n ad n a a ki a g ieu r k n lh e u r y a f b rd rd lm d rh y n a a i dlk k n rs k i ee a aa aa , a g p bl i u a e e s a a d r tmo n a a a diui d n a me g i n n a ai u r y k n i t e g n k n hl g y a g jl- eaakii td d nb h ntre u h r sd p t eaag jl l k a i a a a es b t au a a n db kia s c r in v o ma p nin v ro.17 iu t n e aa iv k uu it RI NGKAS AN Di p r a s b a k s s e rn p n ei wa i l o k n e u h a u s o a g e d rt nt a a a 4 th n t a meo o , n ei k n e p r sa im 6 a u ,i k r k k me d rt a k r au tdu d a lnu y n k lh n a ly s th n s b lmn a a jt a g eu a wan a ea u e eu y h n ab r p p mb n k k nk k k n n( a y eu a e e g a a a i a a DVT)tn a ap ds ra d n a k lia lin a Daa p raa a n a ieti e g n ean n an y . lm ejln n y p n ei me g lh b tk y n b ra g u g c k p e d rt a n eu au a g eln s n u u lma hln t u d nma i me ea y n ds ra a ,i gi la a mb kn mb rt a g ieti d n a s s k n fsd n p n r n n b rtb d n P d e g n e a aa a e u u a ea a a . a a a hr y p n ei dda n ss me d rt k n e k in a e d rt iig o i a n ei a akr p r sa im lnu. S mp t me jln p n o aa au tdu a jt e a naa i e g b tn d n a rgme k moea i o ia i ab pai d n e g n e i n e trp k mbn s k r o lt a n g mstbns lma sku a a ttp p n a ip n ei e i i ea 6 ils k n ea i e y kt e d rt a a ma i b ra a b rtd n me ig a a ia g g l kn etmb h ea a nn g l kb t a a n fsk rn tmo y n p o rsfDii uk nb h aa ae a u r a g r g e i. smp la a wa bn kk kk ( e g a a i DVT) p d p n ei iimeu a a a a e d rt n a rp k n sn r ma p rn o lt y i ma ie ts a l d r id o aa e pai at k u nfsa i wa ai s auk n e d lm h ln a aa k n e p r . u t a k r aa a ii d lh a k r au DAF AR RUJ T UKAN

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Ro nc J T b l T e a. Cu rn da n ss d ik E, o oi , t l re t ig o i c o v n u tr mb e oim i p i r c r:a f e o s h o o mb l s n rmay ae ciia p a t e g ieie fo te Ameia l c l rci ud l n c n rm h rc n Ac d myo F mi P y iina dteAmeia ae f a l h sca n h y rc n Colg o P y iin . An F m M e 20 7 l e f h sca s e n a d 0; 5( : 1)57 62. S av l D, l P Dig o i a dT e t n o c r ei Wel . a n ss n rame t f s s d e - entr mb ssCM AJ 0 17 9 : 8 e p v i h o o i. 20 6; 5( )10 7 10 2. 9 Le AYY. Th o o i a d c n e:te r l o e r mb ss n a c r h oe f s re ig f ro c l c n e a d rc g iig te ce nn o c ut a c r n e o nzn h u d ryn boo ia me h ns . He tlg n elig ilgc l c a ims maoo y 20 6; 1125- . 0 66: 8 Ka k rAK,Le ie M ,P n d HM ,Wof R, ka vn ie o lf Wa J Ve o s tr mb ss i c n e p t n: y . n u h o o i n a c r ai t e isg tfo te F o t n s r e . On oo it n ih r m h r n l e u v y i c l gs 20 3,: 5- . 0 838 8 S u o T Kh rn AA. Ne isg t it c n eo s u , oa a w n ih s n o a c r a s cae tr mb ssAreis lr r mbVa c so itd h o o i. tro ce Th o s Bil 0 ; : 20 o 20 929316- . Hi e HF Th o o i i c n e p t ns An l n . r mb ss n a c r ai t. l e n On o 20 011( 3)27 6. c l 0 ; S : 3Bo c c i C,Co gi P . A f n t n lr l c a co mo l M o u ci a oe o f r h mo tss i e ry c n e d v lp n. o e sa i n al a c r e eo me t Ca c rRe 20 5; 19 :57 - 2. n e s 0 65( )8 9 8 Kr g r K,Weln D, Os C, Ne ma n N, oe i d a e u n Wes S His hC, t lRikfco sf rv n u is , rc e a. s a tr o e o s tr mb e oi e e t i c n e p t ns An h o o mb l v ns n a c r ai t. c e n On o 20 6; : 7 30 c l 0 1729 - 3. P n o n P P c il A, Gioa A. Ca c r a d n i , icoi r lmi ne a d v n u tr mb e oim: a o eve n e o s h o o mb l s n v r iw. Ha maoo ia19 98 :37 4 e tlgc 9 ;44 - 5. P a d n P Ho Ira v n u tr mb e oim rn o i . w te t e o sh o o mb l s i p t ns wi c n e. Blo 20 5; 6: n ai t e t a cr h od 0 10 4 27 33. 0 S h te s R,Be k r M ,Ha s F Bis D. c ug n c es a , e ma Th p e it e v le o D- i rme s rme t e rdci au f dme v aue n f r a c r np t nswi d e v i tr mb ss o c n e i ai t t e p en h o o i. e h Ha maoo ia20 5;0214 9 e t lgc 0 9 : - . Ro et . Th p tnil e ei o lw- lc lr b rF e oe t b n ft fo moe uaa s weg th p rn i c n e p t ns J u n lo ih e ais n a c r ai t. o r a f e He tlg a dOn oo y20 ; 3maoo y n c lg 103: 6.
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Dan l RB, P s e J r el o n r B. P rn o lsi aa e pa t c s n r me iv ligten r u s se N En J y d o s n ovn h ev s y tm. g M e 20 3; 9154 54 d 0 34 : 3- . Blo F P rn o lsi s n r me . Th o m E. aa e pa t y d o s c e c mpee d n g ie t b an h at. Av i be o lt a a ud o ri e l h al l a t fo www.d n p e s o Ac se o : 10h r m: a a rs.c m. esd n M ac 20 7 rh 0 . Wo g AK,AletM ,Ca ti o DH,S e Q, n fr srl n l hn Hoa h J Ya c p uu GD. Ex e sv tmo ls , n o o ls c s ie u r ea o ae VEGF a d i n url ain d fn lb rtd n t e tai t s z o eie a lta p rn o lsi s n r me P eh l aa e pa t c y do . NAS 20 1;87 8 6. 0 9 :4 1His J Le A. Ho weda n s a dte t e p rh , e w ig o e n ra d e v i tr mb ss Blo 20 2;9 9 : 2- . en h o o i. o d 0 9 ( )310 10 M u c io J ,W y e L,S o ko DL. Ex e s rhs n T k tc tn cs rs o c n e i p t nswi p i r v n u ik f a c r n ai t t rmay e o s e h tr mb e oim: a n t n l p p uain h o o mb l s ai a, o p lt o o b s dc h r su y BrJCa c r20 49 9 5. a e o o t td . n e 0 ;1:2Care M ,LeGa G,W i s P ,F r u s n D, rir - l l S eg so l rms y T Ro g rM A. S se t rve te a a , de y tmai e iw: h c T o se s n r mervstd s o l wes ce ru su y do e ii : h ud e e rn e tn iey f rc n e i p t nswi v n u xe sv l o a c r n ai t t e o s e h tr mb e oim? An I tr M e 20 814 : h o o mb l s n ne d 0; 9 32333.

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