超声引导下微创治疗交通支静脉功能不全研究进展

下肢静脉疾病是常见慢性疾病之一,交通支静脉功能不全(IPVs)在下肢静脉疾病的发生、发展和复发中具有关键性作用。超声引导下泡沫硬化剂、腔内热消融及氰基丙烯酸酯栓塞术等逐渐用于IPVs治疗,且效果均较好。本文就超声引导下微创治疗IPVs的研究进展进行综述。     

Endoscopic subfascial surgery for incompetent perforator veins in patients with active venous ulceration

Background: Previously, subfascial ligation of perforator veins to treat venous ulceration in the lower extremities required long skin incisions through diseased skin and subcutaneous tissue. This was known as "the Linton operation." In 1985, Hauer described an endoscopic technique for ligating incompetent perforator veins; this seminal contribution marked the advent of subfascial endoscopic perforator surgery (SEPS). Methods: From 1996 to 1998, we prospectively collected data on 41 patients with chronic venous insufficiency (CVI) who underwent a SEPS procedure at our institution. Preoperative assessment consisted of color-flow duplex ultrasound scanning, as well as ascending and descending phlebography. Results: Some 45 SEPS procedures were performed on the 41 patients. Ages ranged from 42 to 84 years (mean, 60). Active venous ulcers were present in 37 legs; healing occurred within 9 weeks in 33 of them. No new ulcers developed in the follow-up period, a mean of 44 weeks. Conclusion: The results suggest that the SEPS procedure incorporated into the overall treatment plan for patients with CVI produces active healing with a minimum of postoperative complications. The study demonstrates the safety and efficiency of this procedure; it also underscores the important role incompetent perforator veins have in the formation of venous ulcers.     

The phlebotome in the management of incompetent perforating veins and venous ulceration

A shearing operation using a phlebotome has been used on 26 limbs of 24 patients with venous ulceration to deal with incompetent perforating veins. Only one ulcer has failed to heal or remain healed at mean operative follow-up of 24 months. Numbness, usually transient, and haematoma formation have been the only recorded complications. This procedure is recommended in the management of incompetent perforating veins associated with venous ulceration.     

Prevalence and distribution of incompetent perforating veins in chronic venous insufficiency

Purpose: The purpose of this study was the investigation of the prevalence and distribution of incompetent perforating veins (IPVs) in patients with different classes of chronic venous insufficiency (CVI) as defined by the updated clinical, etiologic, anatomic, and pathologic classification (CEAP) in relation to the pattern and the extent of venous reflux. Material and methods: The study included 468 limbs of 330 subjects who ranged in age from 18 to 101 years (median, 49 years). The investigation entailed a medical history, a clinical examination, and color flow duplex imaging of the lower limb veins, which were performed by the same vascular surgeon operator. The patients were classified into 7 clinical classes according to CEAP. The superficial and deep venous systems were scanned, with an emphasis on the detection of IPVs. Venous reflux was considered abnormal when its duration exceeded 0.5 seconds. IPVs were classified as medial, posterior, and anterolateral in the upper, middle, or lower third of the thigh or calf (9 thigh and 9 calf fields). Results: The IPVs were found mainly in the medial aspect, more frequently in the middle third of calf, followed by the lower calf and the middle thigh. IPVs were rare in the lateral aspect of the thigh, the medial upper and posterior lower thigh and the posterior upper and lower calf. The prevalence of the IPVs and of deep vein incompetence increased significantly with the clinical severity of CVI (r = .95, P < .01, and r = .9, P < .01, respectively). In the limbs with a documented perforating vein (PV) incompetence, the ratios of calf-to-thigh IPVs and of superficial-and-deep (S + D) over superficial-alone (S; [S + D]/S] venous incompetence increase significantly (r = .87, P < .01 and r = .9, P < .01, respectively) with CEAP grade. The prevalence of reflux involving all systems (S + D + PV) increases significantly (r = .9, P < .01) with clinical severity. In legs with CVI of CEAP 2 to 6, reflux was invariably proximal (thigh) and distal (below knee). Conclusion: In CVI, IPVs are located predominately in the medial aspect of the lower extremity, more often in the middle third of the calf, followed by the lower calf and middle thigh. The prevalence of IPVs and their calf-to-thigh ratio increase linearly with the clinical severity of CVI. Both the prevalence of deep vein incompetence and the ratio of superficial and deep to superficial ([S + D]/S) increase linearly with CEAP classification. These findings support the significant relationship between deep venous reflux and PV incompetence, although the latter may exist in the absence of the former. In CEAP classes 2 to 6, reflux is invariably proximal and distal. Incompetence involving all systems (S + D + PV) increases in prevalence with the severity of CVI. (J Vasc Surg 1998;28:815-25.)     

Prospective randomized efficacy of ultrasound-guided foam sclerotherapy compared with ultrasound-guided liquid sclerotherapy in the treatment of symptomatic venous malformations

OBJECTIVE: To compare the clinical outcome between ultrasound-guided foam sclerotherapy (UGFS) and ultrasound-guided liquid form sclerotherapy (UGLS) in patients with venous malformations (VM). METHODS: Eighty-nine patients with symptomatic VM were treated with ultrasound-guided sclerotherapy. There were 22 males and 67 females with mean age of 14.5 years. The sclerosing agents used were 1% polidocanol (POL) or 10% ethanolamine oleate (EO). POL was injected predominantly into smaller, superficial lesions, whereas EO was used for large, deeper lesions. Foam sclerosing solution was provided using Tessari's method. Patients were randomized to receive either UGFS or UGLS. Post-sclerotherapy surveillance was done at 6 months after last session using duplex ultrasound. Findings obtained by duplex scanning were divided into four groups: (1) disappeared group: the venous space was occluded and was totally shrunk; (2) partially recanalized group: the venous space was partially recanalized and was partially shrunk; (3) totally recanalized group: the venous space was totally recanalized and returned at the same size; and (4) worsened group: the venous space was totally recanalized and became worse. RESULTS: Forty-nine patients were treated with UGFS and the remaining 40 were treated with UGLS. There were no significant differences in age and men:women ratio. There was no significant difference in the anatomic distribution of VMs between the two groups. The amount of POL was significantly smaller in patients who were treated with UGFS (P = .022). Similarly, there was a significant reduction in the use of EO in patients treated with UGFS (P = .005). The proportion of VM with total disappearance and partial recanalization was significantly higher in patients treated with UGFS (P = .002). No major complications related to sclerotherapy were encountered in both groups. CONCLUSIONS: These findings suggest that UGFS could have greater promise compared with UGLS in the treatment of VMs.     

彩超引导下聚桂醇泡沫硬化治疗静脉畸形临床疗效观察

目的:分析彩超引导下聚桂醇泡沫硬化剂治疗静脉畸形的临床疗效。方法:选择笔者医院2012年11月~2013年6月收治的静脉畸形患者96例,其中婴幼儿35例,成人及儿童61例,分别行彩超引导下畸形管腔内注射聚桂醇泡沫硬化剂,观察治疗后畸形管腔闭合情况及吸收情况。96例患者均在彩超引导下分次、多部位成功注射聚桂醇泡沫硬化剂,每日1次,每次2~6ml,总疗程4~8次,疗程结束3个月后复查。结果:97.9%的患者经此方法治疗后,畸形血管腔全部或者部分闭塞吸收,肿块萎缩,颜色消退。治疗后2例患者出现轻微静脉炎症,经抗炎治疗后好转。2例患者因畸形静脉表浅,出现局部表皮小面积坏死,经对症处理后愈合。结论:聚桂醇泡沫硬化剂治疗静脉畸形临床疗效满意,合理应用该药物可显著提高静脉畸形的治疗效果。     

Division of incompetent perforator veins and subfascial interposition of a polypropylene foil in post-thrombotic syndrome. Preliminary results

AIM: The safety, feasibility and early efficacy of subfascial endoscopic perforator surgery was gradually accepted for patients who had severe chronic venous insufficiency but, in the literature, the recurrence rate of ulceration is about 10-40%, especially in patients with previous deep vein thrombosis (DVT). METHODS: From October 1998 to February 2002, 205 patients with 280 inferior leg ulcers were followed; 115 had venous ulcers but only 20 patients had chronic ulcers with previous DVT; 4 patients were excluded and only 16 patients (9 female, 7 male, mean age 61 years) with 18 chronic ulcers were included. These patients underwent sub-aponeurotic interruption of perforating veins with blind technique in association with subfascial interposition of a hand-made polypropylene foil. Eight of these patients had persistent non-healing ulcers at the time of surgery and 10 had chronic recurrent ulceration healed at the time of the surgical procedure. All patients were assessed clinically and with duplex scanning. RESULTS: The follow-up was done clinically and with eco-Doppler from 6 to 38 months with a mean follow up period of 23.2 months. The healing rate was 100%. The 2-year life table incidence of ulcer recurrence was 0%. Hospital stay ranged from 1-2 days, early operative complications included extensive ecchymosis in 1 patient, oedema in 3 patients. CONCLUSION: The division of perforating veins, with the subfascial support of a polypropylene foil give promising results in the treatment of venous ulcers in post-thrombotic syndrome with low morbidity and short hospital stay.     

Outcome of ultrasound-guided sclerotherapy for varicose veins: medium-term results assessed by ultrasound surveillance.

OBJECTIVE: To estimate medium-term success after a technique for ultrasound-guided sclerotherapy for superficial chronic venous disease. DESIGN: A prospective study in a single unit with ultrasound surveillance after treatment. MATERIALS: Results after 1189 treatment sessions for 807 venous saphenous veins and related tributaries or non-saphenous tributaries in 489 patients. METHODS: Univariate life table analysis determined primary and secondary success rates. Multivariate Cox regression analysis detected covariates that affected outcome. RESULTS: Primary and secondary success rates at 36 months for all veins were 52.4% (95%CI 46-58%) and 76.8% (95%CI 71-82%). Cox regression analysis for primary success for all veins showed significantly worse results for saphenous veins compared to tributaries (HR 3.72 - 95%CI 1.9 to 7.3). Cox regression for all saphenous veins showed independently worse results for patients less than 40 years age (HR 2.16 - 95%CI 1.27-3.66), small compared to great saphenous veins (HR 1.58 - 95%CI 1.11-2.24), veins greater than 6mm diameter compared to smaller veins (HR 2.22 - 95%CI 1.40-3.50), liquid compared to foam sclerotherapy (HR 2.20 - 95%CI 1.28-3.78), lower volumes of sclerosant compared to volumes greater than 12 ml (HR 0.51 - 95%CI 0.33-0.81) and highly diluted compared to concentrated sclerosant (HR 2.05 - 95%CI 1.21-3.46) with worse results using highly diluted or undiluted 3% sclerosant compared to a 1.5% concentration. There were no significant differences for primary success for saphenous veins for date of procedure, sex, side, primary or recurrent varicose veins, or commercial type of sclerosant. CONCLUSIONS: Ultrasound-guided sclerotherapy gives satisfactory results if it is accepted that treatment may need to be repeated to achieve secondary success. Results provide a basis for further research to explore factors that might affect outcome. Younger patients with larger diameter saphenous veins may warrant alternative forms of treatment, particularly for small saphenous reflux.     

Development of reflux in the perforator veins in limbs with primary venous disease

OBJECTIVE: To determine the patterns by which perforator vein (PV) reflux develops in patients with primary chronic venous disease (CVD). METHODS: Patients with CVD who had at least two examinations with duplex ultrasonography before any treatment were included in this study. These were patients who were offered an operation at their first visit, but for various reasons treatment was postponed. All affected limbs were classified by the CEAP classification system. A detailed map of normal and refluxing sites was drawn on an anatomic chart by using several landmarks of the skin, muscle, and bone. Reflux was induced by distal limb compression followed by sudden release by using rapid-inflation pneumatic cuffs and dorsiplantar flexion. All new reflux sites were documented. The PV reflux was divided into ascending type, descending type (re-entry flow), and those that developed in new locations, which did not have reflux in any system at that level. RESULTS: The total number of patients studied was 127 (158 limbs). There were 29 limbs (18%) in 26 patients with reflux development in the PV. In total, 38 new incompetent PVs were identified. The median time for the examination was 25 months (range, 9-52 months). Reflux in a previously normal PV at a re-entry site was detected in 15, in an ascending manner from an extension of superficial vein reflux in 18, and in a new, previously intact location in 5. At the new sites, reflux in the superficial veins connected to the incompetent PVs was always present. PVs connected to the great saphenous vein system were most common (n = 27), followed by those connected to short saphenous (n = 8) and nonsaphenous (n = 3) veins. Worsening in the clinical class was observed in 11 limbs: 5 from class 2 to 3, 2 from class 2 to 4, 2 from class 3 to 4, and 2 from class 4 to 6. The worsening could not be attributed to the PV reflux alone, because other veins became incompetent as well. CONCLUSIONS: Reflux in PVs develops in ascending fashion through the superficial veins, at re-entry points, and at new sites. Worsening of CVD is observed with new PV reflux, but many other factors play a major role, and therefore a causative association is difficult to prove.     

Relationship between severity of lumbar disc disease and disability scores in sciatica patients

OBJECTIVE: To study the association between the clinical examination and the radiological assessment of lumbar disc disease in patients with sciatica. METHODS: The study included 394 consecutive sciatica patients. The patients' disabilities were evaluated by a visual analog pain scale, the Prolo functional-economic rating scale, the modified Roland-Morris disability questionnaire, and the health-related quality of life short form (SF-36) questionnaire. Radiological imaging findings were independently classified according to the Modic criteria into five groups of increasing severity of disc disease. Stepwise multivariate logistic regression was used to determine which scores were significant independent predictors of a severe disc disease (extrusion or sequestration). RESULTS: Of these patients, 9.6% had no disc disease, 3.3% had a bulging, 11.4% had a protrusion, 68.5% had an extrusion, and 7.1% had a disc sequestration. Statistically significant positive linear associations with the severity of disc disease were found for the leg pain scale, the Roland-Morris and Prolo disability scales, and the SF-36 scores related to physical functioning, physical role, and bodily pain (all P < 0.005). A poor (<5) Prolo score (odds ratio, 2.91; 95% confidence interval, 1.74-4.87), a higher leg pain score (odds ratio, 1.16 per centimeter increase; 95% confidence interval, 1.07-1.27), and a lower low back pain score (odds ratio, 0.90 per centimeter decrease; 95% confidence interval, 0.82-0.98) were retained in the multivariate logistic model as independent predictors of severe disc disease. CONCLUSION: The positive correlation between disability status and imaging findings validates both assessment methods. Routine use of disability scores brings a useful contribution to the assessment of sciatica patients.     

The impact of the AIS 2005 revision on injury severity scores and clinical outcome measures

Background

The abbreviated injury scale (AIS) was updated in 2005 from the AIS 1998 version. The purpose of this study is to describe the effects of this change on injury severity scoring and outcome measures.

Materials and methods

Analyses were performed on all trauma patients consecutively admitted over a 6-month period at two geographically separate Level I trauma centers. Injuries were manually double-coded according to the AIS 05 and the AIS 98. Changes in AIS, ISS, and new ISS (NISS) were analysed using paired t-tests. Apparent differences in outcome by ISS strata (<16, 16-24, >24) were compared for AIS 05 versus AIS 98 using the Wald-type statistic. Lastly, the percent of patients with a change in ISS strata are reported.

Results

There were 2250 patients included in the study. Nearly half (46.4%) of AIS codes changed, resulting in a different AIS score for 18.9% of all codes. The mean ISS was significantly lower using the AIS 05 (11.7) versus the AIS 98 (13.3, p < 0.001). Similarly, the mean NISS was significantly lower (16.3 versus 18.7, p < 0.001). In the ISS strata 16-24 an apparent increase in mortality, length of stay, and percent of patients not discharged home was observed for the AIS 05 versus AIS 98. Changes in outcome measures for this stratum were as follows (AIS 98 versus AIS 05): mortality, 4.3% versus 7.7% (p = 0.002); hospital length of stay, 5.2 days versus 7.3 days (p < 0.001); percent of patients not discharged home, 39.2% versus 49.3% (p < 0.001). Finally, there was a 20.5% reduction in patients with an ISS ≥ 16 and a 26.2% reduction in patients with an ISS ≥ 25 using the AIS 05.

Conclusions

The AIS revision had a significant impact on overall injury severity measures, clinical outcome measures, and percent of patients in each ISS strata. Therefore, the AIS revision affects the ability to directly compare data generated using AIS 05 and AIS 98 which has implications in trauma research, reimbursement and ACS accreditation.     

Subfascial endoscopic ligation of perforator veins (SEPS) in the treatment of venous ulcers

BACKGROUND: Subfascial endoscopic ligation of perforator veins (SEPS) is presently considered the procedure of choice for the treatment of venous ulcers. This study was undertaken in order to determine the efficacy and effectiveness of SEPS in the treatment of venous ulcers as reported in the literature. DATA: 428 active ulcers, treated by SEPS are included in this study. SOURCE: Current world literature. CONCLUSIONS: 428 active ulcers were treated by SEPS. 17 patients had a history of a healed ulcer. 101 patients had moderately severe to severe lipodermatosclerosis. 79% of the active ulcers healed on average in 2.3 months, with a range of 21 days to 5.4 months. 2.8% recurrent ulcers were identified. 6.5% of the active ulcers did not heal. 5 active ulcers apparently got worse postoperatively. SEPS is both an efficacious and effective procedure in the treatment of venous ulcers.