静脉外科——回顾展望张柏根课件

1、静脉外科回顾展望张柏根张张 柏柏 根根静脉外科静脉外科 回顾回顾展望展望 2009.11 上海静脉外科回顾展望张柏根 1760s 血管缝合血管缝合 1880s 吻合吻合 1990s 移植实验术移植实验术 自体静脉自体静脉 1950s Vinyon Teflon 1960s Dacron 小牛血管小牛血管 内膜剥脱内膜剥脱 1970s PTFE 人脐血管人脐血管 经皮刺穿经皮刺穿 Seldimger 1953球囊导管球囊导管 Fogarty 1963PTA Dotter 1964扩张导管扩张导管 Grntzig 1974支架成形支架成形 Dotter 1983带膜支架带膜支架 Parod 199

2、0静脉外科回顾展望张柏根近代血管外科近代血管外科血管影像学诊断技术血管影像学诊断技术经皮血管腔内技术经皮血管腔内技术开放手术开放手术 腔内腔内微创治疗微创治疗有创性有创性 无创性检查无创性检查 快速发展快速发展 并存并存 转换转换静脉外科回顾展望张柏根静脉外科回顾展望张柏根髂动脉支架静脉外科回顾展望张柏根 腘动脉腘动脉PTA静脉外科回顾展望张柏根 股动脉支架股动脉支架静脉外科回顾展望张柏根 股动脉切开+支架静脉外科回顾展望张柏根 导管溶栓静脉外科回顾展望张柏根导管溶栓导管溶栓静脉外科回顾展望张柏根 静脉外科静脉外科 ？ 周围静脉外科周围静脉外科 静脉外科回顾展望张柏根球囊扩张术前术前术后四月术

3、后四月术后四天术后四天静脉外科回顾展望张柏根导管溶栓静脉外科回顾展望张柏根 导管溶栓导管溶栓静脉外科回顾展望张柏根 导管溶栓导管溶栓静脉外科回顾展望张柏根周围静脉外科周围静脉外科 DVT CVI 70s 抗凝抗凝 取栓取栓 -硬管硬管 经典手术经典手术 弹性绷带弹性绷带 80s 取栓取栓-Fogarty 溶栓溶栓-uk-sk 抗凝抗凝 相对性深静脉瓣膜关闭不全相对性深静脉瓣膜关闭不全 自然演变自然演变- PDVI 瓣膜重建术瓣膜重建术 Iliac compression syndreme Cockette与与CVI 90s 溶栓溶栓-系统系统-导管导管 抗凝抗凝 取栓取栓 腔内治疗腔内治疗 激

4、光激光 射频射频 SEPS 腔内治疗腔内治疗 PTA 支架支架 瓣膜重建术瓣膜重建术-腔外腔外 VADs 2000 CEAP CIVIQ 导管溶栓导管溶栓 PTA 支架支架 瓣膜重建术？瓣膜重建术？ PTS PE与腔静脉滤网与腔静脉滤网 PTS与与CVI 静脉论坛静脉论坛 静脉指南静脉指南静脉外科回顾展望张柏根周围静脉外科周围静脉外科DVT 治疗治疗 变化趋势变化趋势 PE 预防预防 滤器应用滤器应用 PTE 与与CVICVI 分类分类 CEAP 治疗治疗 传统手术传统手术 腔内技术腔内技术 治疗原则治疗原则静脉外科回顾展望张柏根恢复通畅性恢复通畅性 保护瓣膜保护瓣膜改善症状改善症状 缩短病程

5、缩短病程 预防肺栓塞预防肺栓塞 降低降低PTS PTS 血栓再发血栓再发预防预防治疗治疗 药物药物活动活动取栓取栓 抗凝抗凝溶栓溶栓 降低发生率降低发生率尸检尸检 3552%新发病新发病25万万/年年 Pulmonary embolism PEPost-thrombosis PTSRethrombosis 静脉外科回顾展望张柏根 DVTDVT自然病程自然病程-Delis 2004-Delis 2004 Delis Delis 髂髂- -股股DVTDVT 5 5年随访结果年随访结果 19% 19% 单纯浅静脉逆流单纯浅静脉逆流 81% 81% 深、浅静脉逆流深、浅静脉逆流 40% 40% 静脉性

6、间跛静脉性间跛Ann Surg 2004Ann Surg 2004；239239：118118静脉外科回顾展望张柏根 髂股静脉髂股静脉DVT 自然再通自然再通 2030% PTS发生率发生率 3年年 3569% 510年年 49100%静脉外科回顾展望张柏根DVTDVT自然病程自然病程- -张柏根张柏根 19851985 1979.11979.11983.71983.7 69 69例例7979侧全下肢侧全下肢DVTDVT 10h 10h53a(8.9a)53a(8.9a) 不同病程不同病程 静脉形态静脉形态 临床特征临床特征中华外科杂志中华外科杂志 1985;5:2571985;5:257静脉

7、外科回顾展望张柏根I I型型 29.11% 23/7929.11% 23/79闭塞或中断闭塞或中断经股浅静脉或股深静脉汇流经股浅静脉或股深静脉汇流 -3-3月月静脉外科回顾展望张柏根IIII型型 37.98% 30/7937.98% 30/79不规则狭窄不规则狭窄 不连贯不连贯造影剂密度低于侧支造影剂密度低于侧支 6 6月月1 1年年静脉外科回顾展望张柏根IIIIII型型 32.91% 26/7932.91% 26/79不规则扩张迂曲不规则扩张迂曲造影剂密度高造影剂密度高 3 3年年静脉外科回顾展望张柏根DVT治疗治疗 手术手术 1930s 卧床卧床 抬高抬高 患肢患肢 Lawen 取栓术（髂

8、取栓术（髂股）股） Homans 股浅结扎股浅结扎 Lerich 取栓术操作技术取栓术操作技术 1960s Fogarty 球囊导管球囊导管 1970s Vollmar 附加附加AV瘘瘘 静脉外科回顾展望张柏根DVT治疗治疗 溶栓溶栓 1930s Tillet Garner SK 50s Tillet 报告报告SK治疗治疗DVT疗效疗效 1940s Mefarjene Pilling UK 1940s Astrup Pomih t-PA 60s 动物内脏提取动物内脏提取 80s r-tPA 90s 系统溶栓系统溶栓 导管直接溶栓导管直接溶栓静脉外科回顾展望张柏根 DVT治疗治疗 抗凝抗凝 19

9、16 Mclen 发现肝素发现肝素 1930s Marray 证实抗凝功能证实抗凝功能 Crafoord 用于临床用于临床 1940s Bawn 报告疗效报告疗效 Stathman 合成双香豆素合成双香豆素 1950 DeTakats 小剂量预防小剂量预防DVT 静脉外科回顾展望张柏根 1906 Trendlenbug IVC结扎结扎 1934 Homans 股浅静脉结扎股浅静脉结扎 1958 DeWeese “竖琴状栅栏竖琴状栅栏”缝线缝线 1959 Morets 腔外滤网夹腔外滤网夹 1969 MoBin-Uddn 腔内伞形滤器腔内伞形滤器 1973 Greenfield 腔内滤器腔内滤器

10、 DVT治疗治疗 PE 静脉外科回顾展望张柏根DVTDVT治疗治疗- -取栓术取栓术疗效疗效 19901990年年Sweden Sweden 临床前瞻性随机研究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取栓术与非手术两组不同随访期临床效果(%)(%) 6m 5a 10a 6m 5a 10a* * 取栓术取栓术 42 37 5042 37 50 非手术非手术 7 18 23 7 18 23 * * C0-2 C0-2百分比百分比 Eur J Vasc Surg 1990;4:483Eur J Vasc Surg 1990;4:483静脉外科回顾展望张柏根 19901990

11、年年SwedenSweden临床前瞻性随机研究临床前瞻性随机研究( (二二) )取栓术和非手术两组不同随访期深静脉功能取栓术和非手术两组不同随访期深静脉功能(%)(%) 6m 6m 5a 5a 10a 10a I FP I FP I FPr I FP I FP I FPr取栓术取栓术 76 50 77 - 77 3276 50 77 - 77 32非手术非手术 35 26 30 - 47 6735 26 30 - 47 67 静脉顺行造影静脉顺行造影 Duplex Scanning Duplex Scanning 静脉逆行造影静脉逆行造影+Valsalva+Valsalva试验试验I I 髂静

12、脉通畅率髂静脉通畅率FPFP股股- -腘静脉瓣膜功能完整腘静脉瓣膜功能完整FPrFPr股股- -腘静脉瓣膜关闭不全腘静脉瓣膜关闭不全静脉外科回顾展望张柏根抗凝与溶栓近期疗效比较（抗凝与溶栓近期疗效比较（% %） 完全再通完全再通 部分再通部分再通 SK 44.13 45.06SK 44.13 45.06 UK 30.00 46.00 UK 30.00 46.00 r-tPA 28.09 49.44 r-tPA 28.09 49.44 肝素肝素 9.90 33.909.90 33.90Clinics in Chest Medicine 2003静脉外科回顾展望张柏根抗凝与溶栓远期疗效比较（PTS

13、%） 静脉造影静脉造影 临床表现临床表现 SK 47.41 50.78SK 47.41 50.78 UK 71.88 68.64 UK 71.88 68.64 r-tPA 78.50 76.39 r-tPA 78.50 76.39 肝素肝素 67.42 76.3967.42 76.39Clinics in Chest Medicine 2003静脉外科回顾展望张柏根 DVTDVT治疗治疗- -导管直接溶栓导管直接溶栓 1997年年 Mewissen 300例例 70%髂髂-股股DVT 随访期随访期 6m 导管途径导管途径 腘静脉腘静脉 对侧股静脉对侧股静脉 颈内静脉颈内静脉 足部静脉足部静脉(

14、6m 导管途径导管途径 腘静脉腘静脉 对侧股静脉对侧股静脉 颈内静脉颈内静脉 足部静脉足部静脉(80% III 近近1/3 通畅率通畅率 6m 90% 6m 70% 逆流逆流(6m) III 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% 静脉外科回顾展望张柏根病因与病理生理 浅浅/ 深静脉深静脉 Primary 静脉扩张静脉扩张 瓣膜损害瓣膜损害 无无DVT史史 Secondar

15、y DVT后遗征后遗征 浅静脉血栓性静脉炎浅静脉血栓性静脉炎 再通后阻塞再通后阻塞/逆流逆流 Less frequently 腔外压迫腔外压迫 腔内病变腔内病变 Rarely 先天异常先天异常 发育不良发育不良静脉外科回顾展望张柏根病因和病理生理病因和病理生理 交通静脉机能不全交通静脉机能不全 双向血流双向血流 肌泵功能肌泵功能 深静脉高压深静脉高压静脉外科回顾展望张柏根病因与病理生理病因与病理生理 DVT CVI 再通再通 流出道阻塞流出道阻塞 瓣膜损毁瓣膜损毁 瓣膜关闭瓣膜关闭 不全不全 回流障碍回流障碍 静脉逆流静脉逆流 主干静脉高压主干静脉高压 毛细血管后静脉高压毛细血管后静脉高压 皮

16、肤损害皮肤损害静脉外科回顾展望张柏根病因与病理生理病因与病理生理 PTS发生率发生率 3年年 3569% 510年年 49100% IPV 与浅静脉和与浅静脉和/或深静脉逆流共存或深静脉逆流共存 罕见单独出现罕见单独出现静脉外科回顾展望张柏根 CEAPCClinical clasification C0: no visible or palpable signs of venous diseaseC1、2： Telangiectasia 1mm Reticular veins 13mm Varicos veins3mm Corona phlebectaticaC3: EdemaC4a: Pig

17、mentation EczemaC4b: Lipodermatosclerosis(LDS) Atrophic blanche or whit atrophyC5、6：Venoua ulcer静脉外科回顾展望张柏根 Clinical classification S: symptoms ache pain tightness heviness skin irritation muscle cramps A: asymptomatic.静脉外科回顾展望张柏根 EEtiologic classification Ec congenital Ep primary Es secondary post-

18、thrombotic En no venous etiology identified静脉外科回顾展望张柏根 AANATOMIC CLASSIF As superficial veins Ap perforator veins Ad deep veins. An no venous location identified静脉外科回顾展望张柏根 PPathophysiologic classification Basic CEAP Pr: reflux Po: obstruction Pr,o: reflux and obstruction Pn: no venous pathophysiolo

19、gy identifiableAdvanced CEAP Same as basic 18 named venous segments be utilized locators for venous pathology静脉外科回顾展望张柏根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 classific

20、ation Advance CEAP 18 named venous segments 静脉外科回顾展望张柏根 Deep veins 6. Inferior vena cava 7. Common iliac vein 8. Internal iliac vein 9. External iliac vein10. Pelvic: gonadal broad ligament veins11. Common femoral vein12. Deep femoral vein13. Femoral vein14. Popliteal vein15. Crural: anterior tibial

21、 posterior tibial peronea veins 16. Muscular: gastrocnemial soleal veins静脉外科回顾展望张柏根 Perforating veins 17.Thigh 18,Calf静脉外科回顾展望张柏根Basic and advanced CEAP18 named venous segments 静脉外科回顾展望张柏根 原发于浅静脉原发于浅静脉 交通静脉功能不全交通静脉功能不全 深静脉瓣膜功能不全深静脉瓣膜功能不全 DVT DVT后后( (阻塞、逆流阻塞、逆流) ) 髂静脉阻塞髂静脉阻塞静脉外科回顾展望张柏根 临床检查临床检查 超声多普勒

22、血仪超声多普勒血仪 静脉压测定静脉压测定 静脉血流量测定静脉血流量测定 彩超彩超 顺行造影顺行造影 逆行造影逆行造影 CT MR 静脉外科回顾展望张柏根 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 多个静脉外科回顾展望张柏根 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

23、静脉外科回顾展望张柏根 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时出现瀑布状逆流静脉外科回顾展望张柏根CVI治疗治疗 1.Compression therapy 2.Drug 3.Sclerotherapy4.Endovascular therapy5.Surgery静脉外科回顾展望张柏根Reduced edema VolumetryReduced venous volumeIncreased venous velocityBlood shift into central compar

24、tmentsDecreased venous reflux Improved venous pumpDecreased arterial flowEffect on microcirculationIncreased lymphatic drainageEffect on ultrastructure and cytokines pression therapyEffectePrevent ulcer recurrenceReduce the incidence and severity of the PTSAt least 2 years after DVT静脉外科回顾展望张柏根 2.Dru

25、g Venoactive drugs ( VADs) increase venous toneweakness of the vein wall noradrenaline pathway venous dilatat secondary valvular incompetencepathophysiological mechanisms静脉外科回顾展望张柏根Drug Venoactive drugs( VADs) pathophysiological mechanisms anti-inflammatory inflammation hypoxia EC EC lukocytes Primm

26、ary failure of venous valve protect venous wall,valve * MPFF:Micronized purified flavonoid fractionMPFF* Protects endothelial cells against hypoxiainhibiting the adhesion of leukocytes Accelerates endothelial cells proliferation静脉外科回顾展望张柏根 Other drugsPentoxifilline Vasoactive drug reduc leucocyte ad

27、hesion rheological action on erythrocytes mild fibrinolyticaction Combination with compression increas the rate of ulcer healing Prpstaglandins E small vessel dilatation augment blood flow in the capillaries increas fibrinolytic activity reduce platelet ,leucocyte adherence to endothelium reduction

28、of white cell activation venous ulcer静脉外科回顾展望张柏根 3.SclerotherapyLiquid 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

29、repid recovery静脉外科回顾展望张柏根 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

30、with phlebectomy or sclerotherapy静脉外科回顾展望张柏根Result RF occlusion rate:9099% (12years) 87% (5years) EVLT 88100% (5years)Complication thermal insult to perivenous tissue skin burn recanalization femoral vein stenosis静脉外科回顾展望张柏根 5.Surgerysuperficial reflux goal relieve symptoms eradicate main stem reflu

31、x 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 静脉外科回顾展望张柏根 SugeryDeep vein

32、reflux静脉外科回顾展望张柏根 Sugerydeep vein reflux Techniqure: deep venous reconstrucion internal valvuloplasty transposition auto-transplantation neo-valve creation cryopreserved allografts wrapping external valvuloplasty (transmural or transcommissural) angioscopy assisted percutaneous placed devices静脉外科回顾展

33、望张柏根 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 4years external50% Transposition Transplantation 50% Wrapp

34、ing variable result Neovalve ,crepreseved allograft shorter follow-up 静脉外科回顾展望张柏根 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”

35、gold standard” asending transfemoral phlebography intravascular ultrasound(IYUS) MAI spiral CT iliocaval obstruction 静脉外科回顾展望张柏根 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(15

36、years) Endophlebectomy femoro-ilio-caval stenting 静脉外科回顾展望张柏根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

37、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 100Hurst et al., 2001 18 With and without trombolysis 1.5 years 79Juhan et

38、al., 2001 15 With and without thrombectomy 5-52 months 87 93Lamont 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 (cumul

39、ative)Delis et al., 2004 41 With and without thrombolysis 6 months 58 71 76 /thrombectomy静脉外科回顾展望张柏根 1980s 股静脉壁环缝缩窄术浅静脉剥脱、交通静脉和溃疡周围静脉结扎术肌襻腘静脉瓣膜替代术游离带瓣膜肱静脉移植术游离带瓣膜肱静脉移植术原位大隐-腘静脉旁路术静脉外科回顾展望张柏根1984.21990.11 151151例例 男男 122 122 女女 2929 193 193侧下肢侧下肢 左左 65 65 右右 44 44 双双4242 静脉性溃疡静脉性溃疡 45.08%(87/193)45.0

40、8%(87/193)股静脉壁环缝缩窄术股静脉壁环缝缩窄术静脉外科回顾展望张柏根 股部切口局限性淋巴积液股部切口局限性淋巴积液 3 3例例 交通静脉结扎切口延期愈合交通静脉结扎切口延期愈合 4 4例例 溃疡面植皮部分脱落溃疡面植皮部分脱落 5 5例例静脉外科回顾展望张柏根随访数随访数 109109例例 118118侧肢体侧肢体 随访期随访期( (年年) ) 肢体数肢体数(%)(%) 5 20(16.95)56/11847.46%静脉外科回顾展望张柏根 肢体数(%) 随访率(随访数/总数) 浅静脉曲张 4(4.24) 61.14(118/193) 静脉性溃疡 3(4.55) 75.86(66/87)静脉外科回顾展望张柏根6767例例 男男 44 44 女女 2323年龄年龄 43-7543-75岁岁静脉性溃疡静脉性溃疡 27/67 27/67 静脉外科回顾展望张柏根 随访期随访期（年）（年）例数例数 曲张曲张 溃疡溃疡 造影造影 1 25 22 1 25 22 1 18 17 1 18 17 3 17 1 1 14 3 17 1 1 14 5 7 5 5 7 5 总计总计 67 1 1 5867 1 1 58（86.57)86.57)静脉外科回顾展望张柏根图3a 术前平静呼吸图3b 术前Valsalva呼吸后图3c 环形缩窄术后平静呼吸图3d 环形缩窄术后Valsalva呼吸静脉外科