髂静脉狭窄支架治疗的循证医学研究.ppt

髂静脉狭窄支架治疗的循证医学研究,中山大学附属第一医院血管外科 王劲松 王深明,May-Thurner 综合征,髂静脉受压综合征： 1908年McMurrich首先描述 1957年May Thurner 1965-1967 Cockett 尸检和腔内超声发现： 病理： 1. 受压 2. 血管壁纤维化 3. 腔内网状和膜样变,Ehrich WE, Krumbhaar EB. A frequent obstructive anomaly of the mouth of the left common ilia vein. Am Heart J 1943;26:737-50,髂静脉闭塞的主要原因,Iliofemoral stenting for venous occlusive disease Jessica M. Titus, MD, Mireille A. Moise, MD, James Bena, MS, Sean P. Lyden, MD, and Daniel G. Clair, MD, Cleveland, Ohio,诊断,静脉造影：不敏感 腔内超声(IVUS)： 提高准确率,Raju S. Best management options for chronic iliac vein stenosis and occlusion. J Vasc Surg. 2013 Apr;57(4):1163-9.,IVUS,可以提高髂静脉阻塞综合征的诊断率： 性别 年龄 双侧,髂静脉狭窄的治疗,手术治疗：创伤 支架治疗: 1985年，首例自膨式支架在狗身上应用，随后，数篇文章报道在静脉内腔内治疗方面，取得较好的临床效果 手术介入治疗,治疗方法,Raju S. Best management options for chronic iliac vein stenosis and occlusion. J Vasc Surg. 2013 Apr;57(4):1163-9.,髂静脉狭窄支架治疗指征,有症状，无血栓形成的髂静脉狭窄 合并血栓形成的髂静脉狭窄 急性：溶栓后支架置入 慢性：DVT发生后4个月 严重的血栓后遗症,技术要点,流入道和流出道建立 慢性完全闭塞（chronic total occlusion, CTO): 技术成功率: 83-95%： IVUS 支架： 自膨式大口径Wallstents (Boston Scientific) 较多,术后抗凝,抗凝时间报道不一 NIVL：抗凝不必要，抗血小板凝聚效果良好,并发症,支架内再狭窄： 50%：10% in PTS 1% in NIVL(无血栓的髂静脉狭窄) 和血栓史，长支架，高凝状态相关 支架断裂,临床效果,疼痛缓解：86%-94% 肿胀：66%-89% 溃疡愈合：58%-89%,Raju S. Best management options for chronic iliac vein stenosis and occlusion. J Vasc Surg. 2013 Apr;57(4):1163-9.,支架通畅率,近期和中期通畅率高：由于下肢运动，髂静脉支架通畅率高于锁骨下静脉 无血栓的髂静脉狭窄（NIVL)： 4-7年支架通畅率：90-100% 合并血栓的髂静脉狭窄： I期支架通畅率：3-5年：25%闭塞 II期支架通畅率：4-7年：74-89% CTO: 4-7年： 66-89%,Raju S. Best management options for chronic iliac vein stenosis and occlusion. J Vasc Surg. 2013 Apr;57(4):1163-9.,J Vasc Interv Radiol. 2012 Apr;23(4):497-502. Long-term outcomes of stent placement for symptomatic nonthrombotic iliac vein compression lesions in chronic venous disease. Ye K1, Lu X, Li W, Huang Y, Huang X, Lu M, Jiang M.,A total of 227 stents were placed in 205 patients (224 limbs; median age, 50.53 years). The rate of technical success was 100%. Three limbs were treated with two stents because of proximal migration of the incipient stent. Follow-up periods ranged from 1-117 months (mean 50 months 36). The primary and assisted-primary cumulative patency rates at a mean of 4 years were 98.7% and 100%. The cumulative edema relief rate was 89.1% (156 of 175), and the healing rate for active ulcers was 82.3% (51 of 62). The pain level (using a visual analogue scale from 0-10) declined from a median level of 4.3 before the procedure to 0.4 after the procedure. Quality of life improved significantly after intervention. Complications were minor and improved quickly.,Ann Vasc Surg. 2014 Apr;28(3):695-704. Endovascular treatment for symptomatic iliac vein compression syndrome: a prospective consecutive series of 48 patients. Liu Z1, Gao N2, Shen L3, Yang J2, Zhu Y2, Li Z4, Si Y5. The prevalence of IVCS within our cohort was 14.8% (48/324). The technical success rate of the endovascular treatment was 95.8%. There was no death, pulmonary embolism, or contrast-induced nephropathy among the patients. The 1-year primary patency rate was 93.0%. IVCS is more common than previously thought among patients with unilateral left lower limb chronic venous disease. Endovascular therapy, a minimally invasive approach to treating venous lesions, is a feasible and effective treatment for left-sided IVCS and has a high technica