静脉外科——回顾_展望_张柏根.ppt

张 柏 根,静脉外科 回顾·展望,2009.11 上海,1950s Vinyon Teflon 1960s Dacron 小牛血管 内膜剥脱 1970s PTFE 人脐血管,经皮刺穿 Seldimger 1953 球囊导管 Fogarty 1963 PTA Dotter 1964 扩张导管 Grüntzig 1974 支架成形 Dotter 1983 带膜支架 Parod 1990,近代血管外科,血管影像学诊断技术 经皮血管腔内技术 开放手术 腔内微创治疗 有创性 无创性检查,快速发展,并存 转换,髂动脉支架,腘动脉PTA,股动脉支架,股动脉切开+支架,导管溶栓,导管溶栓,静脉外科 ？ 周围静脉外科,球囊扩张,术前,术后四月,术后四天,导管溶栓,导管溶栓,导管溶栓,周围静脉外科,DVT CVI 70s 抗凝 取栓 -硬管 经典手术 弹性绷带 80s 取栓-Fogarty 溶栓-uk-sk 抗凝 相对性深静脉瓣膜关闭不全 自然演变- PDVI 瓣膜重建术 Iliac compression syndreme Cockette与CVI 90s 溶栓-系统-导管 抗凝 取栓 腔内治疗 激光 射频 SEPS 腔内治疗 PTA 支架 瓣膜重建术-腔外 VADs 2000 CEAP CIVIQ 导管溶栓 PTA 支架 瓣膜重建术？ PTS PE与腔静脉滤网 PTS与CVI 静脉论坛 静脉指南,周围静脉外科,DVT 治疗 变化趋势 PE 预防 滤器应用 PTE 与CVI CVI 分类 CEAP 治疗 传统手术 腔内技术 治疗原则,恢复通畅性 保护瓣膜 改善症状 缩短病程 预防肺栓塞 降低PTS 血栓再发,尸检 3552% 新发病25万/年 Pulmonary embolism PE Post-thrombosis PTS Rethrombosis,DVT自然病程-Delis 2004,Delis 髂-股DVT 5年随访结果 19% 单纯浅静脉逆流 81% 深、浅静脉逆流 40% 静脉性间跛,Ann Surg 2004；239：118,髂股静脉DVT 自然再通 2030% PTS发生率 3年 3569% 510年 49100%,DVT自然病程-张柏根 1985,1979.11983.7 69例79侧全下肢DVT 10h53a(8.9a) 不同病程 静脉形态 临床特征,中华外科杂志 1985;5:257,I型 29.11% 23/79 闭塞或中断 经股浅静脉或股深静脉汇流 -3月,II型 37.98% 30/79 不规则狭窄 不连贯 造影剂密度低于侧支 6月1年,III型 32.91% 26/79 不规则扩张迂曲 造影剂密度高 3年,DVT治疗 手术,1930s 卧床 抬高 患肢 Lawen 取栓术（髂股） Homans 股浅结扎 Lerich 取栓术操作技术 1960s Fogarty 球囊导管 1970s Vollmar 附加AV瘘,DVT治疗 溶栓 1930s Tillet Garner SK 50s Tillet 报告SK治疗DVT疗效 1940s Mefarjene Pilling UK 1940s Astrup Pomih t-PA 60s 动物内脏提取 80s r-tPA 90s 系统溶栓 导管直接溶栓,DVT治疗 抗凝 1916 Mclen 发现肝素 1930s Marray 证实抗凝功能 Crafoord 用于临床 1940s Bawn 报告疗效 Stathman 合成双香豆素 1950 DeTakats 小剂量预防DVT,1906 Trendlenbug IVC结扎 1934 Homans 股浅静脉结扎 1958 DeWeese “竖琴状栅栏”缝线 1959 Morets 腔外滤网夹 1969 MoBin-Uddn 腔内伞形滤器 1973 Greenfield 腔内滤器,DVT治疗 PE,DVT治疗-取栓术疗效,1990年Sweden 临床前瞻性随机研究(-) 取栓术与非手术两组不同随访期临床效果(%) 6m 5a 10a* 取栓术 42 37 50 非手术 7 18 23 * C0-2百分比,Eur J Vasc Surg 1990;4:483,1990年Sweden临床前瞻性随机研究(二),取栓术和非手术两组不同随访期深静脉功能(%) 6m 5a 10a I FP I FP I FPr 取栓术 76 50 77 - 77 32 非手术 35 26 30 - 47 67 静脉顺行造影 Duplex Scanning 静脉逆行造影+Valsalva试验 I 髂静脉通畅率 FP股-腘静脉瓣膜功能完整 FPr股-腘静脉瓣膜关闭不全,抗凝与溶栓近期疗效比较（%） 完全再通 部分再通 SK 44.13 45.06 UK 30.00 46.00 r-tPA 28.09 49.44 肝素 9.90 33.90,Clinics in Chest Medicine 2003,抗凝与溶栓远期疗效比较（PTS%）,静脉造影 临床表现 SK 47.41 50.78 UK 71.88 68.64 r-tPA 78.50 76.39 肝素 67.42 76.39,Clinics in Chest Medicine 2003,DVT治疗-导管直接溶栓,1997年 Mewissen 300例 70%髂-股DVT 随访期 6m 导管途径 腘静脉 对侧股静脉 颈内静脉 足部静脉(10%) 观察 每12h静脉造影 总剂量 UK 700万U 支架植入 1/3 40% 髂-股DVT 半数 左侧,Venous Registry Investigators Meeting San Diego 1997,1997年 Mewissen 300例 70%髂-股DVT 随访期 6m 导管途径 腘静脉 对侧股静脉 颈内静脉 足部静脉(10%) 观察 每12h静脉造影 总剂量 UK 700万U 支架植入 1/3 40% 髂-股DVT 半数 左侧,Venous Registry Investigators Meeting San Diego 1997,溶栓效果 II-III 80% III 近1/3 通畅率 6m 90% 6m 70% 逆流(6m) III 30% II 45% I 60%,Thrombus resolution in patients with acute DVT treated with anticoagulati or thrombolytic therapy:pooled data from 14 reports Rx N Thrombus resolution None/Worse Partial Significant/Complete Anticoagulation 301 253 38 10 (84%) (13%) (3%) Thrombolysis 387 147 74 166 (38%) (19%) (43%),Long-term symptomatic outcome of patients with acute DVT treated with thrombolytic therapy or anticoagulation (Results of two randomized studies) P T S Rx N. Severe Moderate None Anticoagulation 39 8 (21%) 23 (59%) 8 (21%) Thrombolysis 39 2 (5%) 12 (12%) 25 (64%),SugeryDeep vein obstruction Endophlebectomy Patency rates following femoro-ilio-caval stenting Aouthor Number Etiology and Duration Patency rate % of limbs adjuvant treatment of follow-up primary assisted secodary Nazarian et al., 1996 56 Mixed 4 years, 50 75 (cumulative) Binkert et al., 1998 8 With and without thrombectomy 10-121 months 100 OSullivan et al., 2000 34 With and without trombolysis 1 year 92-94 Patel et al., 2000 10 After thombolysis 1.5 years 60 100 Hurst et al., 2001 18 With and without trombolysis 1.5 years 79 Juhan et al., 2001 15 With and without thrombectomy 5-52 months 87 93 Lamont et al., 2002 15 With and without thrombectomy 41 months 87 (cumulative) Blattler and Blattler 1999 12 Chronic non-malignant obstruction 1-43 months 92 Neglen and Raju, 2004 324 Chronic non-malignant obstruction 4 years 57 92 93 (cumulative) Delis et al., 2004 41 With and without thrombolysis 6 months 58 71 76 /thrombectomy,CVI,早期认识 加压治疗 解剖学认识 硬化剂治疗 提出PTS 经典术式确立 近代发展,早期认识 加压治疗 1500BC Eber 静脉曲张文字记载 4thBC Amynos 静脉曲张肢体图 1世纪 Celsus 烧灼治疗 2世纪 Galen 钩刀处理曲张静脉 14世纪 Henri 绷带压迫 沿溃疡切口不易愈合 切除溃疡压迫疗法,CVI,解剖学认识 硬化剂治疗 15世纪 Leonardo de Vinci 静脉解剖图 1543 Andreas Vesalius 全身静脉解剖图 1547 Canano 奇静脉腔内瓣膜 1585 Browse 静脉瓣膜外观及剖面结构 1603 Aduapendente 下肢及盆腔瓣膜分布 1628 Harvey 指压法测试 1868 Gay 小腿内侧交通静脉定位 弹性绷带 Brodie 1846 弹性长袜 Unna 1854 硬化剂 Pravaz 1846,CVI,提出PTS 经典术式确立 1891 Trendelenberg 大隐V近端结扎(DVT) 1905 Keller 静脉腔内剥离器 1906 Mayo 静脉腔外剥离器 1907 Babcock 可屈的静脉腔内剥离器 1938 Linton 筋膜下结扎交通静脉 1953 Cockett 筋膜外结扎交通静脉 静脉造影 1923,Berbrien提出 1938,Santos用于临床 1942,Welth推荐,CVI,近30年进展 CVI的认识 PVI CEAP 无创检查 Duplex scanning 治疗技术 加压治疗 药物治疗静脉活性药 硬化剂治疗 腔内治疗 手术治疗,CVI,流行病学 Varicose vein Femaie 25-33% Male 10-20% Incidence (per year) 2.6% 1.9% Prevalence Edema , Skin changes 3.0-11% Venous ulcers 0.3% Active and healed Ulcers 1.0%,病因与病理生理,浅/ 深静脉 Primary 静脉扩张 瓣膜损害 无DVT史 Secondary DVT后遗征 浅静脉血栓性静脉炎 再通后阻塞/逆流 Less frequently 腔外压迫 腔内病变 Rarely 先天异常 发育不良,病因和病理生理,交通静脉机能不全 双向血流 肌泵功能 深静脉高压,病因与病理生理,DVT CVI 再通 流出道阻塞 瓣膜损毁 瓣膜关闭 不全 回流障碍 静脉逆流 主干静脉高压 毛细血管后静脉高压 皮肤损害,病因与病理生理,PTS发生率 3年 3569% 510年 49100% IPV 与浅静脉和/或深静脉逆流共存 罕见单独出现,CEAP CClinical clasification C0: no visible or palpable signs of venous disease C1、2： Telangiectasia 1mm Reticular veins 13mm Varicos veins3mm Corona phlebectatica C3: Edema C4a: Pigmentation Eczema C4b: Lipodermatosclerosis(LDS) Atrophic blanche or whit atrophy C5、6：Venoua ulcer,Clinical classification S: symptoms ache pain tightness heviness skin irritation muscle cramps A: asymptomatic.,EEtiologic classification Ec congenital Ep primary Es secondary post-thrombotic En no venous etiology identified,AANATOMIC CLASSIF As superficial veins Ap perforator veins Ad deep veins . An no venous location identified,PPathophysiologic classification Basic CEAP Pr: reflux Po: obstruction Pr,o: reflux and obstruction Pn: no venous pathophysiology identifiable Advanced CEAP Same as basic 18 named venous segments be utilized locators for venous pathology,Superfial veins 1.Telangiectasies/reticular veins 2. Great saphenous vein (GSV) above knee 3. GSV below knee 4. Small saphenous vein 5. Non-saphenous veins,Pathophiologic classification Advance CEAP 18 named venous segments,Deep veins 6. Inferior vena cava 7. Common iliac vein 8. Internal iliac vein 9. External iliac vein 10. Pelvic: gonadal broad ligament veins 11. Common femoral vein 12. Deep femoral vein 13. Femoral vein 14. Popliteal vein 15. Crural: anterior tibial posterior tibial peronea veins 16. Muscular: gastrocnemial soleal veins,Perforating veins 17.Thigh 18,Calf,Basic and advanced CEAP,18 named venous segments,EN AN PN C4 C4a C4b,原发于浅静脉 交通静脉功能不全 深静脉瓣膜功能不全 DVT后(阻塞、逆流) 髂静脉阻塞,诊断程序,临床检查 超声多普勒血仪 静脉压测定 静脉血流量测定 彩超 顺行造影 逆行造影 CT MR,CVI检查层次,临床表现 0 1 2 疼痛 无 轻度，不需镇痛剂 重度，需镇痛剂 浮肿 无 轻/中度 重度 静脉性跛行 无 轻/中度 重度 色素沉着 无 局限 广泛 脂质硬皮症 无 局限 广泛 溃疡 大小 无 2cm 病期 3月 复发 一次 一次以上 数量 单个 多个,临床表现评分,类型 造影征象 0 无逆流 1 轻度逆流，股静脉上段12个瓣膜 2 明显逆流，股静脉远侧或腘静脉瓣膜关闭不全 3 明显逆流，超越腘静脉瓣膜 4 瀑布状逆流，直至小腿深静脉,深静脉瓣膜逆流范围分级,类型 造影征象 正常 关闭完全，Valsalva时无逆流 轻度 Valsalva时束状逆流 中度 Valsalva时明显逆流 重度 非Valsalva时出现瀑布状逆流,深静脉瓣膜逆流程度分级,CVI治疗,1.Compression therapy,2.Drug,3.Sclerotherapy,4.Endovascular therapy,5.Surgery,Reduced edema Volumetry Reduced venous volume Increased venous velocity Blood shift into central compartments Decreased venous reflux Improved venous pump Decreased arterial flow Effect on microcirculation Increased lymphatic drainage Effect on ultrastructure and cytokines,1.compression therapy,Effecte,Prevent ulcer recurrence Reduce the incidence and severity of the PTS At least 2 years after DVT,Drug Venoactive drugs( VADs),pathophysiological mechanisms anti-inflammatory inflammation hypoxia EC EC lukocytes Primmary failure of venous valve protect venous wall,valve,* MPFF:Micronized purified flavonoid fraction,MPFF*,Protects endothelial cells against hypoxia,inhibiting the adhesion of leukocytes,Accelerates endothelial cells proliferation,Prpstaglandins E small vessel dilatation augment blood flow in the capillaries increas fibrinolytic activity reduce platelet ,leucocyte adherence to endothelium reduction of white cell activation venous ulcer,3.Sclerotherapy Liquid sclerotherapy C1 C2 combine with other interventions (10 years90%) Foam sclerotherapy C2-C6 paticularC4-C6 clinical effectivness rates 80% (5years) combine with sapheno-_femoral lighton less expensive shorter treatment time more repid recovery,4.Endovascular therapy Radiofrequency(RF) ablation 85C contraction of collagen fiber endothelial denudation muscle necrosis Endovenous laser treatment (EVLT) thermal energy (810,940,980,1064,1320 nm diode) to boil blood thermochemecal destruction of the venous wall Combine with phlebectomy or sclerotherapy,Result RF occlusion rate:9099% (12years) 87% (5years) EVLT 88100% (5years) Complication thermal insult to perivenous tissue skin burn recanalization femoral vein stenosis,5.Surgerysuperficial reflux goal relieve symptoms eradicate main stem reflux remove visible varices superficial reflux SFJ or SPJ ligation and division GSV or SSV stripping below knee phlebectomy or sclerotherapy perforating vein ligation or SEPS CEAP C2 CEAP C4-6 Gastrocnemius vein GV SSV-common terminationpoliteal v common cause of recurrence,SugeryDeep vein reflux 1.Deep veins reflux (single) 10% associate with superficil and/or perforator reflex most patients 2.PTS 6085% Primary structural abnormality(vein wall ,valve) less common congenital valvular absence rare 3.PTS reflux associate with obstruction Iliofemoral obstruction treated first,Sugerydeep vein reflux Techniqure: deep venous reconstrucion The first group phlebotomy internal valvuloplasty transposition auto-transplantation neo-valve creation cryopreserved allografts The second group non_phlebotomy wrapping external valvuloplasty (transmural or transcommissural) angioscopy assisted percutaneous placed devices,Sugerydeep vein reflux Indication clinical severity C4b C5-6 perforator reflux also be treated Imaging criteria deep vein reflux 3-4(Kistner) Hemodynamic criteria significantly abnormal venouse refill time 12 seconds difference pressure 40% (rest/standardized exercise in the standing position),Sugerydeep vein reflux Indications according to etiology primary failure after conservation treatment reluctant to wear permanent compression (young,active) suitable technique:Internal valvuloplasty-Kistner External transcommissural valvuloplasty-Raju secondery(PTS) failure after conseventation treatment recommend technique: valve transplantation valve transposition neo-vaive insertion,Sugerydeep vein reflux Deep vein valve reconstrucion Result Valvuloplasty internal70%,4years external50% Transposition Transplantation 50% Wrapping variable result Neovalve ,crepreseved allograft shorter follow-up,Sugerydeep vein obstraction PTS obstruction + reflux the highest levels of venous hypertation the most severe symptoms Iliofemoral DVT spontaneously recanalize 2030% to assess the chronic outflow obstruction lack of a”gold standard” asending transfemoral phlebography intravascular ultrasound(IYUS) MAI spiral CT iliocaval obstruction,Sugerydeep vein obstraction cross-over bypass femoro-femoral bypass 83%patency in-line bypass femoro-ilio-cava 54%patency(2years) sapheno-popliteal bypass 56-67%patency(15years) Endophlebectomy femoro-ilio-caval stenting,SugeryDeep vein obstruction Endophlebectomy Patency rates following femoro-ilio-caval stenting Aouthor Number Etiology and Duration Patency rate % of limbs adjuvant treatment of follow-up primary assisted secodary Nazarian et al., 1996 56 Mixed 4 years, 50 75 (cumulative) Binkert et al., 1998 8 With and without thrombectomy 10-121 months 100 OSullivan et al., 2000 34 With and without trombolysis 1 year 92-94 Patel et al., 2000 10 After