靜脈外科回顧展望課件

張柏根靜脈外科

——回顧·展望2009.11上海.張柏根靜脈外科

——回顧·展望21發(fā)展中的血管外科

1760s血管縫合1880s 吻合1990s移植實(shí)驗(yàn)術(shù)自體靜脈

1950sVinyonTeflon1960sDacron小牛血管內(nèi)膜剝脫1970sPTFE人臍血管

經(jīng)皮刺穿Seldimger1953球囊導(dǎo)管Fogarty1963PTADotter1964擴(kuò)張導(dǎo)管Grüntzig1974支架成形Dotter1983帶膜支架Parod1990.發(fā)展中的血管外科1760s血2近代血管外科血管影像學(xué)診斷技術(shù)經(jīng)皮血管腔內(nèi)技術(shù)開放手術(shù)腔內(nèi)／微創(chuàng)治療有創(chuàng)性無(wú)創(chuàng)性檢查

快速發(fā)展

并存——轉(zhuǎn)換.近代血管外科血管影像學(xué)診斷技術(shù)快速發(fā)展并存3..4髂動(dòng)脈支架.髂動(dòng)脈支架.5

腘動(dòng)脈PTA.腘動(dòng)脈PTA.6

股動(dòng)脈支架.股動(dòng)脈支架.7

股動(dòng)脈切開+支架.股動(dòng)脈切開+支架.8導(dǎo)管溶栓.導(dǎo)管溶栓.9導(dǎo)管溶栓.導(dǎo)管溶栓.10

靜脈外科

？周圍靜脈外科

..11球囊擴(kuò)張術(shù)前術(shù)后四月術(shù)后四天.球囊擴(kuò)張術(shù)前術(shù)后四月術(shù)后四天.12導(dǎo)管溶栓.導(dǎo)管溶栓.13

導(dǎo)管溶栓.導(dǎo)管溶栓.14

導(dǎo)管溶栓.導(dǎo)管溶栓.15周圍靜脈外科

DVTCVI

70s抗凝取栓-硬管經(jīng)典手術(shù)彈性繃帶80s取栓-Fogarty溶栓-uk-sk抗凝相對(duì)性深靜脈瓣膜關(guān)閉不全自然演變-ⅠⅡⅢPDVI瓣膜重建術(shù)IliaccompressionsyndremeCockette與CVI90s溶栓-系統(tǒng)-導(dǎo)管抗凝取栓腔內(nèi)治療激光射頻SEPS腔內(nèi)治療PTA支架瓣膜重建術(shù)-腔外VADs2000——CEAPCIVIQ導(dǎo)管溶栓PTA支架瓣膜重建術(shù)？PTSPE與腔靜脈濾網(wǎng)PTS與CVI

靜脈論壇靜脈指南.周圍靜脈外科DVT16周圍靜脈外科DVT治療變化趨勢(shì)PE預(yù)防濾器應(yīng)用PTE與CVICVI分類CEAP治療傳統(tǒng)手術(shù)腔內(nèi)技術(shù)治療原則.周圍靜脈外科DVT治療變化趨勢(shì).17恢復(fù)通暢性保護(hù)瓣膜改善癥狀縮短病程預(yù)防肺栓塞降低PTS血栓再發(fā)預(yù)防治療藥物活動(dòng)取栓抗凝溶栓降低發(fā)生率尸檢35~52%新發(fā)病25萬(wàn)/年

PulmonaryembolismPEPost-thrombosisPTSRethrombosis

.恢復(fù)通暢性保護(hù)瓣膜預(yù)防治療藥物活動(dòng)取栓抗凝溶栓降18

DVT自然病程-Delis2004Delis髂-股DVT5年隨訪結(jié)果19%單純淺靜脈逆流81%深、淺靜脈逆流>40%靜脈性間跛AnnSurg2004；239：118.DVT自然病程-Delis2004Delis19

髂股靜脈DVT

自然再通20～30%PTS發(fā)生率3年35～69%5～10年49～100%..20DVT自然病程-張柏根1985

1979.1～1983.769例79側(cè)全下肢DVT10h～53a(8.9a)不同病程靜脈形態(tài)臨床特征中華外科雜志1985;5:257.DVT自然病程-張柏根19851979.1～1921I型29.11%23/79閉塞或中斷經(jīng)股淺靜脈或股深靜脈匯流--3月.I型29.11%23/79.22II型37.98%30/79不規(guī)則狹窄不連貫造影劑密度低于側(cè)支

＞6月～1年.II型37.98%30/79.23III型32.91%26/79不規(guī)則擴(kuò)張迂曲造影劑密度高

＞3年.III型32.91%26/79.24DVT治療手術(shù)

1930s臥床抬高患肢

Lawen取栓術(shù)（髂—股）

Homans股淺結(jié)扎

Lerich取栓術(shù)操作技術(shù)1960sFogarty球囊導(dǎo)管

1970sVollmar附加A—V瘺.DVT治療手術(shù)1930s25DVT治療溶栓

1930sTilletGarnerSK50sTillet報(bào)告SK治療DVT療效1940sMefarjenePillingUK1940sAstrupPomiht-PA60s動(dòng)物內(nèi)臟提取80sr-tPA90s系統(tǒng)溶栓導(dǎo)管直接溶栓.DVT治療溶栓.26DVT治療抗凝1916Mclen發(fā)現(xiàn)肝素1930sMarray證實(shí)抗凝功能Crafoord用于臨床1940sBawn報(bào)告療效Stathman合成雙香豆素1950DeTakats小劑量預(yù)防DVT

.DVT治療抗凝.27

1906TrendlenbugIVC結(jié)扎1934Homans股淺靜脈結(jié)扎1958DeWeese“豎琴狀柵欄”縫線1959Morets腔外濾網(wǎng)夾1969MoBin-Uddn腔內(nèi)傘形濾器1973Greenfield腔內(nèi)濾器DVT治療PE.DVT治療PE.28DVT治療-取栓術(shù)療效1990年Sweden臨床前瞻性隨機(jī)研究(-)取栓術(shù)與非手術(shù)兩組不同隨訪期臨床效果(%)6m5a10a*取栓術(shù)423750非手術(shù)71823*C0-2百分比

EurJVascSurg1990;4:483.DVT治療-取栓術(shù)療效29

1990年Sweden臨床前瞻性隨機(jī)研究(二)取栓術(shù)和非手術(shù)兩組不同隨訪期深靜脈功能(%)6m※5a※※10a※※※

IFPIFPIFPr取栓術(shù)765077-7732非手術(shù)352630-4767※靜脈順行造影※※DuplexScanning※※※靜脈逆行造影+Valsalva試驗(yàn)I髂靜脈通暢率FP股-腘靜脈瓣膜功能完整FPr股-腘靜脈瓣膜關(guān)閉不全.1990年Sweden臨床前瞻性隨機(jī)研究(二)取栓術(shù)30抗凝與溶栓近期療效比較（%）完全再通部分再通SK44.1345.06UK30.0046.00r-tPA28.0949.44肝素9.9033.90ClinicsinChestMedicine2003.抗凝與溶栓近期療效比較（%）ClinicsinChest31抗凝與溶栓遠(yuǎn)期療效比較（PTS%）

靜脈造影臨床表現(xiàn)SK47.4150.78UK71.8868.64r-tPA78.5076.39肝素67.4276.39ClinicsinChestMedicine2003.抗凝與溶栓遠(yuǎn)期療效比較（PTS%）靜脈造影32

DVT治療-導(dǎo)管直接溶栓1997年Mewissen

300例70%髂-股DVT隨訪期>6m導(dǎo)管途徑腘靜脈對(duì)側(cè)股靜脈頸內(nèi)靜脈足部靜脈(<10%)觀察每12h靜脈造影總劑量UK700萬(wàn)U支架植入1/340%髂-股DVT半數(shù)左側(cè)VenousRegistryInvestigatorsMeetingSanDiego1997

1997年Mewissen

300例70%髂-股DVT隨訪期>6m導(dǎo)管途徑腘靜脈對(duì)側(cè)股靜脈頸內(nèi)靜脈足部靜脈(<10%)觀察每12h靜脈造影總劑量UK700萬(wàn)U支架植入1/340%髂-股DVT半數(shù)左側(cè)VenousRegistryInvestigatorsMeetingSanDiego1997.DVT治療-導(dǎo)管直接溶栓1997年Mewi33溶栓效果II-III>80%III近1/3通暢率6m90%>6m70%逆流(6m)III<30%II45%I60%

.溶栓效果II-III>80%.34ThrombusresolutioninpatientswithacuteDVTtreatedwithanticoagulati

orthrombolytictherapy:pooleddatafrom14reportsRxNThrombusresolutionNone/WorsePartialSignificant/CompleteAnticoagulation3012533810(84%)(13%)(3%)Thrombolysis38714774166(38%)(19%)(43%).Thrombusresolutioninpatient35Long-termsymptomaticoutcomeofpatientswithacuteDVTtreatedwiththrombolytictherapyoranticoagulation(Resultsoftworandomizedstudies)

PTSRxN.SevereModerateNoneAnticoagulation398(21%)23(59%)8(21%)Thrombolysis392(5%)12(12%)25(64%).Long-termsymptomati36

Sugery…DeepveinobstructionEndophlebectomy

Patencyratesfollowingfemoro-ilio-cavalstenting

AouthorNumberEtiologyandDurationPatencyrate%oflimbsadjuvanttreatmentoffollow-upprimaryassistedsecodaryNazarianetal.,199656Mixed4years,50—75(cumulative)Binkertetal.,19988Withandwithoutthrombectomy10-121months100——O’Sullivanetal.,200034Withandwithouttrombolysis1year—92-94Pateletal.,200010Afterthombolysis1.5years60—100Hurstetal.,200118Withandwithouttrombolysis1.5years—79Juhanetal.,200115Withandwithoutthrombectomy5-52months87—93Lamontetal.,200215Withandwithoutthrombectomy41months—87(cumulative)BlattlerandBlattler199912Chronicnon-malignantobstruction1-43months92——NeglenandRaju,2004324Chronicnon-malignantobstruction4years579293(cumulative)Delisetal.,200441Withandwithoutthrombolysis6months587176/thrombectomy.

37..38

CVI早期認(rèn)識(shí)加壓治療

解剖學(xué)認(rèn)識(shí)硬化劑治療

提出PTS經(jīng)典術(shù)式確立

近代發(fā)展

.

CVI早期認(rèn)識(shí)加壓治療

39

早期認(rèn)識(shí)加壓治療1500BCEber靜脈曲張文字記載4thBCAmynos靜脈曲張肢體圖1世紀(jì)Celsus燒灼治療2世紀(jì)Galen鉤刀處理曲張靜脈14世紀(jì)Henri繃帶壓迫

沿潰瘍切口不易愈合切除潰瘍壓迫療法CVI.早期認(rèn)識(shí)加壓治療CVI.40

解剖學(xué)認(rèn)識(shí)硬化劑治療15世紀(jì)LeonardodeVinci靜脈解剖圖1543AndreasVesalius全身靜脈解剖圖1547Canano奇靜脈腔內(nèi)瓣膜1585Browse靜脈瓣膜外觀及剖面結(jié)構(gòu)1603Aduapendente下肢及盆腔瓣膜分布1628Harvey指壓法測(cè)試1868Gay小腿內(nèi)側(cè)交通靜脈定位彈性繃帶Brodie1846彈性長(zhǎng)襪Unna1854硬化劑Pravaz1846CVI.

解剖學(xué)認(rèn)識(shí)硬化劑治療41

提出PTS經(jīng)典術(shù)式確立1891Trendelenberg大隱V近端結(jié)扎(DVT)1905Keller靜脈腔內(nèi)剝離器1906Mayo靜脈腔外剝離器1907Babcock可屈的靜脈腔內(nèi)剝離器1938Linton筋膜下結(jié)扎交通靜脈1953Cockett筋膜外結(jié)扎交通靜脈靜脈造影1923,Berbrien提出1938,Santos用于臨床1942,Welth推薦CVI.提出PTS經(jīng)典術(shù)式確立42

近30年進(jìn)展

CVI的認(rèn)識(shí)PVICEAP無(wú)創(chuàng)檢查Duplexscanning治療技術(shù)加壓治療藥物治療…靜脈活性藥硬化劑治療腔內(nèi)治療手術(shù)治療

CVI.近30年進(jìn)展CVI.43

流行病學(xué)

VaricoseveinFemaie25-33%>Male10-20%Incidence(peryear)2.6%1.9%PrevalenceEdema,Skinchanges3.0-11%Venousulcers0.3%ActiveandhealedUlcers1.0%

..44病因與病理生理

淺/深靜脈

Primary靜脈擴(kuò)張瓣膜損害無(wú)DVT史SecondaryDVT后遺征淺靜脈血栓性靜脈炎再通后阻塞/逆流Lessfrequently腔外壓迫腔內(nèi)病變Rarely先天異常發(fā)育不良.病因與病理生理淺/深靜脈.45病因和病理生理

交通靜脈機(jī)能不全

雙向血流肌泵功能深靜脈高壓.病因和病理生理交通靜脈機(jī)能不全.46病因與病理生理

DVTCVI再通流出道阻塞瓣膜損毀瓣膜關(guān)閉不全回流障礙靜脈逆流主干靜脈高壓

毛細(xì)血管后靜脈高壓皮膚損害.病因與病理生理47病因與病理生理

PTS發(fā)生率3年35～69%5～10年49～100%IPV與淺靜脈和/或深靜脈逆流共存罕見單獨(dú)出現(xiàn).病因與病理生理PTS發(fā)生率.48

CEAPC…Clinicalclasification

C0:novisibleorpalpablesignsofvenousdiseaseC1、2：Telangiectasia＜1mm

Reticularveins1～﹤3mmVaricosveins≥3mmCoronaphlebectaticaC3:

EdemaC4a:PigmentationEczemaC4b:Lipodermatosclerosis(LDS)AtrophicblancheorwhitatrophyC5、6：Venouaulcer.CEAP.49ClinicalclassificationS:symptoms

achepaintightnesshevinessskinirritationmusclecramps

A:asymptomatic..Clinicalclassification.50E…EtiologicclassificationEccongenitalEpprimaryEssecondarypost-thrombotic

Ennovenousetiologyidentified.E…Etiologicclassifi51

A…ANATOMICCLASSIF

AssuperficialveinsApperforatorveins

Addeepveins.

Annovenouslocationidentified.A…ANATOMICCLASSIF.52

P…PathophysiologicclassificationBasicCEAPPr:refluxPo:obstructionPr,o:refluxandobstruction

Pn:novenouspathophysiologyidentifiableAdvancedCEAPSameasbasic18namedvenoussegmentsbeutilizedlocatorsforvenouspathology.P…Pathophysiologicclassif53Superfialveins1.Telangiectasies/reticularveins2.Greatsaphenousvein(GSV)aboveknee3.GSVbelowknee4.Smallsaphenousvein5.Non-saphenousveinsPathophiologicclassificationAdvanceCEAP…18namedvenoussegments.SuperfialveinsPathophiol54Deepveins6.Inferiorvenacava7.Commoniliacvein8.Internaliliacvein9.Externaliliacvein10.Pelvic:gonadalbroadligamentveins11.Commonfemoralvein12.Deepfemoralvein13.Femoralvein14.Poplitealvein15.Crural:anteriortibialposteriortibialperoneaveins16.Muscular:gastrocnemialsolealveins.Deepveins.55Perforatingveins17.Thigh18,Calf.Perforatingveins.56BasicandadvancedCEAP18namedvenoussegments

ENANPN

C4C4aC4b.BasicandadvancedCEAP18name57

原發(fā)于淺靜脈交通靜脈功能不全深靜脈瓣膜功能不全DVT后(阻塞、逆流)髂靜脈阻塞診斷程序.診斷程序.58

臨床檢查超聲多普勒血儀

靜脈壓測(cè)定靜脈血流量測(cè)定彩超

順行造影逆行造影CTMRCVI檢查層次.CVI檢查層次.59

臨床表現(xiàn)012

疼痛無(wú)輕度，不需鎮(zhèn)痛劑重度，需鎮(zhèn)痛劑浮腫無(wú)輕/中度重度靜脈性跛行無(wú)輕/中度重度色素沉著無(wú)局限廣泛脂質(zhì)硬皮癥無(wú)局限廣泛潰瘍大小無(wú)<2cm>2cm病期<3月>3月復(fù)發(fā)一次一次以上數(shù)量單個(gè)多個(gè)

臨床表現(xiàn)評(píng)分.

臨床表現(xiàn)評(píng)分.60

類型造影征象0無(wú)逆流1輕度逆流，股靜脈上段1~2個(gè)瓣膜2明顯逆流，股靜脈遠(yuǎn)側(cè)或腘靜脈瓣膜關(guān)閉不全3明顯逆流，超越腘靜脈瓣膜4瀑布狀逆流，直至小腿深靜脈深靜脈瓣膜逆流范圍分級(jí).類型造影征61

類型造影征象正常關(guān)閉完全，Valsalva時(shí)無(wú)逆流輕度Valsalva時(shí)束狀逆流中度Valsalva時(shí)明顯逆流重度非Valsalva時(shí)出現(xiàn)瀑布狀逆流深靜脈瓣膜逆流程度分級(jí).類型造影征象62CVI治療

1.Compressiontherapy2.Drug3.Sclerotherapy4.Endovasculartherapy5.Surgery.CVI治療1.Compressiontherap63ReducededemaVolumetryReducedvenousvolumeIncreasedvenousvelocityBloodshiftintocentralcompartmentsDecreasedvenousrefluxImprovedvenouspumpDecreasedarterialflowEffectonmicrocirculationIncreasedlymphaticdrainageEffectonultrastructureandcytokines

1.compressiontherapyEffectePreventulcerrecurrenceReducetheincidenceandseverityofthePTSAtleast2yearsafterDVT.ReducededemaVp64

2.DrugVenoactivedrugs(VADs)

increasevenoustoneweaknessoftheveinwall

VADs

noradrenalinepathwayvenousdilatatsecondaryvalvularincompetencepathophysiologicalmechanisms.2.Drugpathophysiologicalm65Drug

Venoactivedrugs(VADs)pathophysiologicalmechanisms

anti-inflammatoryinflammationhypoxiaECEClukocytes

Primmaryfailureofvenousvalve

protectvenouswall,valve

*MPFF:MicronizedpurifiedflavonoidfractionMPFF*Protectsendothelialcells

againsthypoxiainhibitingtheadhesionofleukocytes

Acceleratesendothelialcellsproliferation.Drug66

OtherdrugsPentoxifillineVasoactivedrug

reducleucocyteadhesionrheologicalactiononerythrocytesmildfibrinolyticaction

Combinationwithcompressionincreastherateofulcerhealing

PrpstaglandinsE

smallvesseldilatationaugmentbloodflowinthecapillariesincreasfibrinolyticactivityreduceplatelet,leucocyteadherencetoendotheliumreductionofwhitecellactivationvenousulcer.Otherdrug67

3.Sclerotherapy

LiquidsclerotherapyC1C2combinewithotherinterventions(10years……90%)FoamsclerotherapyC2---C6paticularC4---C6clinicaleffectivnessrates80%(5years)combinewithsapheno-_femorallightonlessexpensiveshortertreatmenttimemorerepidrecovery.3.Sclerotherapy.68

4.EndovasculartherapyRadiofrequency(RF)ablation85?Ccontractionofcollagenfiberendothelialdenudationmusclenecrosis

Endovenouslasertreatment(EVLT)thermalenergy(810,940,980,1064,1320nmdiode)toboilbloodthermochemecaldestructionofthevenouswallCombinewithphlebectomyorsclerotherapy..69ResultRFocclusionrate:90~99%(1~2years)87%(5years)EVLT88~100%(5years)Complicationthermalinsulttoperivenoustissueskinburnrecanalizationfemoralveinstenosis.Result.70

5.Surgery…superficialreflux

goalrelievesymptomseradicatemainstemrefluxremovevisiblevarices

superficialrefluxSFJorSPJligationanddivisionGSVorSSVstrippingbelowkneephlebectomyorsclerotherapy…perforatingveinligationorSEPSCEAPC2CEAPC4-6

Gastrocnemiusvein

GVSSV---commontermination—politealvcommoncauseofrecurrence

.5.Surgery…superfici71

Sugery…Deep

veinreflux

1.Deepveinsreflux(single)<10%associatewithsuperficiland/orperforatorreflexmostpatients2.PTS60~85%Primarystructuralabnormality(veinwall,valve)lesscommoncongenitalvalvularabsencerare3.PTSrefluxassociatewithobstructionIliofemoralobstructiontreatedfirst

.Sugery…Deepveinreflux.72

Sugery…deepveinrefluxTechniqure:deepvenousreconstrucion

Thefirstgroupphlebotomy

internalvalvuloplastytranspositionauto-transplantationneo-valvecreationcryopreservedallografts

Thesecondgroupnon_phlebotomy

wrappingexternalvalvuloplasty(transmuralortranscommissural)angioscopyassistedpercutaneousplaceddevices.Sugery…deepveinreflux.73

Sugery…deepveinrefluxIndicationclinicalseverityC4bC5-6perforatorrefluxalsobetreatedImagingcriteriadeepveinreflux3-4(K