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發展中的血管外科

1760s血管縫合1880s 吻合1990s移植實驗術自體靜脈

1950sVinyonTeflon1960sDacron小牛血管內膜剝脫1970sPTFE人臍血管

經皮刺穿Seldimger1953球囊導管Fogarty1963PTADotter1964擴張導管Grüntzig1974支架成形Dotter1983帶膜支架Parod1990.發展中的血管外科1760s血2近代血管外科血管影像學診斷技術經皮血管腔內技術開放手術腔內／微創治療有創性無創性檢查

快速發展

并存——轉換.近代血管外科血管影像學診斷技術快速發展并存3..4髂動脈支架.髂動脈支架.5

腘動脈PTA.腘動脈PTA.6

股動脈支架.股動脈支架.7

股動脈切開+支架.股動脈切開+支架.8導管溶栓.導管溶栓.9導管溶栓.導管溶栓.10

靜脈外科

？周圍靜脈外科

..11球囊擴張術前術后四月術后四天.球囊擴張術前術后四月術后四天.12導管溶栓.導管溶栓.13

導管溶栓.導管溶栓.14

導管溶栓.導管溶栓.15周圍靜脈外科

DVTCVI

70s抗凝取栓-硬管經典手術彈性繃帶80s取栓-Fogarty溶栓-uk-sk抗凝相對性深靜脈瓣膜關閉不全自然演變-ⅠⅡⅢPDVI瓣膜重建術IliaccompressionsyndremeCockette與CVI90s溶栓-系統-導管抗凝取栓腔內治療激光射頻SEPS腔內治療PTA支架瓣膜重建術-腔外VADs2000——CEAPCIVIQ導管溶栓PTA支架瓣膜重建術？PTSPE與腔靜脈濾網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PE預防濾器應用PTE與CVICVI分類CEAP治療傳統手術腔內技術治療原則.周圍靜脈外科DVT治療變化趨勢.17恢復通暢性保護瓣膜改善癥狀縮短病程預防肺栓塞降低PTS血栓再發預防治療藥物活動取栓抗凝溶栓降低發生率尸檢35~52%新發病25萬/年

PulmonaryembolismPEPost-thrombosisPTSRethrombosis

.恢復通暢性保護瓣膜預防治療藥物活動取栓抗凝溶栓降18

DVT自然病程-Delis2004Delis髂-股DVT5年隨訪結果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側全下肢DVT10h～53a(8.9a)不同病程靜脈形態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不規則狹窄不連貫造影劑密度低于側支

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

＞3年.III型32.91%26/79.24DVT治療手術

1930s臥床抬高患肢

Lawen取栓術（髂—股）

Homans股淺結扎

Lerich取栓術操作技術1960sFogarty球囊導管

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

1930sTilletGarnerSK50sTillet報告SK治療DVT療效1940sMefarjenePillingUK1940sAstrupPomiht-PA60s動物內臟提取80sr-tPA90s系統溶栓導管直接溶栓.DVT治療溶栓.26DVT治療抗凝1916Mclen發現肝素1930sMarray證實抗凝功能Crafoord用于臨床1940sBawn報告療效Stathman合成雙香豆素1950DeTakats小劑量預防DVT

.DVT治療抗凝.27

1906TrendlenbugIVC結扎1934Homans股淺靜脈結扎1958DeWeese“豎琴狀柵欄”縫線1959Morets腔外濾網夾1969MoBin-Uddn腔內傘形濾器1973Greenfield腔內濾器DVT治療PE.DVT治療PE.28DVT治療-取栓術療效1990年Sweden臨床前瞻性隨機研究(-)取栓術與非手術兩組不同隨訪期臨床效果(%)6m5a10a*取栓術423750非手術71823*C0-2百分比

EurJVascSurg1990;4:483.DVT治療-取栓術療效29

1990年Sweden臨床前瞻性隨機研究(二)取栓術和非手術兩組不同隨訪期深靜脈功能(%)6m※5a※※10a※※※

IFPIFPIFPr取栓術765077-7732非手術352630-4767※靜脈順行造影※※DuplexScanning※※※靜脈逆行造影+Valsalva試驗I髂靜脈通暢率FP股-腘靜脈瓣膜功能完整FPr股-腘靜脈瓣膜關閉不全.1990年Sweden臨床前瞻性隨機研究(二)取栓術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抗凝與溶栓遠期療效比較（PTS%）

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

DVT治療-導管直接溶栓1997年Mewissen

300例70%髂-股DVT隨訪期>6m導管途徑腘靜脈對側股靜脈頸內靜脈足部靜脈(<10%)觀察每12h靜脈造影總劑量UK700萬U支架植入1/340%髂-股DVT半數左側VenousRegistryInvestigatorsMeetingSanDiego1997

1997年Mewissen

300例70%髂-股DVT隨訪期>6m導管途徑腘靜脈對側股靜脈頸內靜脈足部靜脈(<10%)觀察每12h靜脈造影總劑量UK700萬U支架植入1/340%髂-股DVT半數左側VenousRegistryInvestigatorsMeetingSanDiego1997.DVT治療-導管直接溶栓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早期認識加壓治療

解剖學認識硬化劑治療

提出PTS經典術式確立

近代發展

.

CVI早期認識加壓治療

39

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

沿潰瘍切口不易愈合切除潰瘍壓迫療法CVI.早期認識加壓治療CVI.40

解剖學認識硬化劑治療15世紀LeonardodeVinci靜脈解剖圖1543AndreasVesalius全身靜脈解剖圖1547Canano奇靜脈腔內瓣膜1585Browse靜脈瓣膜外觀及剖面結構1603Aduapendente下肢及盆腔瓣膜分布1628Harvey指壓法測試1868Gay小腿內側交通靜脈定位彈性繃帶Brodie1846彈性長襪Unna1854硬化劑Pravaz1846CVI.

解剖學認識硬化劑治療41

提出PTS經典術式確立1891Trendelenberg大隱V近端結扎(DVT)1905Keller靜脈腔內剝離器1906Mayo靜脈腔外剝離器1907Babcock可屈的靜脈腔內剝離器1938Linton筋膜下結扎交通靜脈1953Cockett筋膜外結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經典術式確立42

近30年進展

CVI的認識PVICEAP無創檢查Duplexscanning治療技術加壓治療藥物治療…靜脈活性藥硬化劑治療腔內治療手術治療

CVI.近30年進展CVI.43

流行病學

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靜脈擴張瓣膜損害無DVT史SecondaryDVT后遺征淺靜脈血栓性靜脈炎再通后阻塞/逆流Lessfrequently腔外壓迫腔內病變Rarely先天異常發育不良.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閉不全回流障礙靜脈逆流主干靜脈高壓

毛細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出現.病因與病理生理PTS發生率.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

靜脈壓測定靜脈血流量測定彩超

順行造影逆行造影CTMRCVI檢查層次.CVI檢查層次.59

臨床表現012

疼痛無輕度，不需鎮痛劑重度，需鎮痛劑浮腫無輕/中度重度靜脈性跛行無輕/中度重度色素沉著無局限廣泛脂質硬皮癥無局限廣泛潰瘍大小無<2cm>2cm病期<3月>3月復發一次一次以上數量單個多個

臨床表現評分.

臨床表現評分.60

類型造影征象0無逆流1輕度逆流，股靜脈上段1~2個瓣膜2明顯逆流，股靜脈遠側或腘靜脈瓣膜關閉不全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.類型造影征61

類型造影征象正常關閉完全，Valsalva時無逆流輕度Valsalva時束狀逆流中度Valsalva時明顯逆流重度非Valsalva時出現瀑布狀逆流深靜脈瓣膜逆流程度分級.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