University of Mississippi Medical Center, Jackson, MS, USA.
J Vasc Surg. 2010 Feb;51(2):401-8; discussion 408. doi: 10.1016/j.jvs.2009.08.032. Epub 2009 Dec 14.
Treatment of chronic venous insufficiency (CVI) has largely focused on reflux. Minimally-invasive techniques to address superficial and perforator reflux have evolved, but correction of deep reflux continues to be challenging. The advent of intravascular ultrasound (IVUS) scan and minimally invasive venous stent technology have renewed interest in the obstructive component in CVI pathophysiology. The aim of this study is to assess stent-related and clinical outcomes following treatment by iliac venous stenting alone in limbs with a combination of iliac vein obstruction and deep venous reflux.
A total of 528 limbs in 504 patients, ranging in age from 15 to 87, underwent IVUS-guided iliac vein stent placement to correct obstruction over an 11-year period. The etiology of obstruction was nonthrombotic in 196 (37%), post-thrombotic in 285 (54%) limbs, and combined in 47 (9%). Clinical severity class of CEAP was C3 in 44%, C(4,5) in 27%, and C6 in 25% of stented limbs. Deep venous reflux was present in all limbs, associated with superficial and/or perforator reflux in 69%. Reflux was severe in 309/528 (59%) limbs (reflux multisegment score > or = 3) and 224/528 (42%) limbs had axial reflux. Venography and other functional tests had poor diagnostic sensitivity to detect obstruction, which was ultimately diagnosed by IVUS. The IVUS-guided iliac vein stenting was the only procedure performed and the associated reflux was left uncorrected.
There was no mortality; morbidity was minor. Cumulative secondary stent patency was 88% at 5 years; no stent occlusions occurred in nonthrombotic limbs. Cumulative rates of limbs with healed active ulcers, freedom of ulcer recurrence in legs with healed ulcers (C5), and freedom from leg dermatitis at 5 years were 54%, 88%, and 81%, respectively. Cumulative rate of substantial improvement of pain and swelling at 5 years was 78% and 55%, respectively. Quality of life improved significantly. Reflux parameters did not deteriorate after stenting.
Iliac venous stenting alone is sufficient to control symptoms in the majority of patients with combined outflow obstruction and deep reflux. Partial correction of the pathophysiology in limbs with multisystem or multilevel disease can provide substantial symptom relief. Percutaneous stent technology in concert with other minimally-invasive techniques to address superficial and/or perforator reflux offers such partial correction in limbs with advanced CVI and complex venous pathology. Open correction of obstruction or reflux is now required only infrequently as a "last resort".
慢性静脉功能不全（CVI）的治疗主要集中在反流上。已经出现了微创技术来解决浅静脉和穿孔反流，但深层反流的矫正仍然具有挑战性。血管内超声（IVUS）扫描和微创静脉支架技术的出现，重新激发了对 CVI 病理生理学中阻塞性成分的兴趣。本研究旨在评估单纯髂静脉支架置入治疗髂静脉阻塞合并深静脉反流肢体的支架相关和临床结局。
504 例患者的 528 条肢体，年龄 15 至 87 岁，接受了 IVUS 引导的髂静脉支架置入术，以纠正 11 年来的阻塞。阻塞的病因在 196 条（37%）肢体中为非血栓性，在 285 条（54%）肢体中为血栓后，在 47 条（9%）肢体中为两者兼有。接受支架治疗的肢体中，CEAP 临床严重程度 C3 为 44%，C（4,5）为 27%，C6 为 25%。所有肢体均存在深静脉反流，与浅静脉和/或穿孔反流相关的肢体占 69%。309/528 条（59%）肢体存在严重反流（反流多节段评分≥3），224/528 条肢体存在轴向反流。静脉造影和其他功能检查对检测阻塞的敏感性较差，最终通过 IVUS 诊断。IVUS 引导的髂静脉支架置入术是唯一进行的手术，相关反流未予纠正。
无死亡病例，并发症轻微。5 年时继发性支架通畅率为 88%；非血栓性肢体无支架闭塞。5 年时，活动性溃疡愈合的肢体比例、愈合溃疡腿的溃疡复发率（C5）和腿部皮炎消退率分别为 54%、88%和 81%。5 年时，疼痛和肿胀显著改善的比例分别为 78%和 55%。生活质量显著提高。支架置入后反流参数无恶化。
单纯髂静脉支架置入足以控制大多数伴有流出道阻塞和深静脉反流的患者的症状。对多系统或多水平疾病肢体进行部分病理生理学矫正，可以提供显著的症状缓解。经皮支架技术与其他微创技术联合治疗浅静脉和/或穿孔反流，为晚期 CVI 和复杂静脉病变的肢体提供了这种部分矫正。作为“最后的手段”，现在仅需要偶尔进行开放纠正阻塞或反流。
