Pokrovskiĭ A V, Ignat'ev I M, Gradusov E G
Institute of Surgery named after A.V. Vishnevsky under the RF Ministry of Public Health, Moscow, Russia; Russian Medical Academy of Continuous Professional Education under the RF Ministry of Public Health, Moscow, Russia.
Interregional Clinical Diagnostic Centre, Kazan, Russia; Kazan State Medical University of the RF Ministry of Public Health, Kazan, Russia.
Angiol Sosud Khir. 2018;24(2):57-68.
The purpose of the study was to assess the immediate and remote results of endovascular treatment of obstructive lesions of the veins of the iliofemoral segment.
We performed balloon angioplasty and stenting for iliofemoral venous thrombosis in a total of 75 patients. Of these, 60 patients were subjected to stenting of post-thrombotic obstructions and 15 patients underwent stenting of non-thrombotic obstructive lesions of the iliac veins (for May-Thurner syndrome - in 11, for extravasal tumour-induced compression and cicatricial stenosis - in 4). Stenting was performed using self-expanding stents Wallstent (Boston Scientific, n=84) or S.M.A.R.T. (Cordis, Johnson & Johnson, n=16). The stent diameter varied from 12 to 18 mm depending on the venous segment to be stented. The average number of the implanted stents amounted to 1.3 per patient. Efficacy of endovascular intervention was evaluated by measuring the pressure gradient and malleolar circumference. The clinical result was determined by the Venous Clinical Severity Score (VCSS).
Technical success of endovascular intervention amounted to 92%. Stent thrombosis in the immediate postoperative period occurred in 7 (9.3%) patients. Of these, three patients were subjected to catheter-directed thrombolysis with restoration of patency of the stented venous segment of the limb. Stent occlusion within 48 postoperative months was diagnosed in 4 cases. Two patients underwent successful repeat angioplasty and stenting. Stent restenosis of not less than 50% at 36 months of follow up was observed in 5 (16%) patients. Repeat stenting was performed in 1 case. Dynamic control of stent patency was carried out by means of ultrasonographic duplex scanning. Also performed were control multispiral computed tomography-phlebography and roentgen contrast-enhanced phlebography. Cumulative primary and secondary patency at 60 months in post-thrombotic lesions amounted to 72 and 81%, respectively, in non-thrombotic lesions to 85% (primary patency). The VCSS values demonstrated a significant decrease in manifestations of chronic venous insufficiency. The mean value of the composite parameter decreased from 14.2±4.2 to 7.5±2.6 (p<0.001), the malleolar circumference decreased from 272.3±6.7 to 250.6±6.1 mm (p<0.01). Permanent healing of trophic ulcers was noted in 5 (71%) patients.
The method of endovascular angioplasty and stenting for obstructive lesions of the veins of the iliofemoral segment is a minimally invasive, safe, and highly effective therapeutic modality, which is confirmed by significant improvement of the limb's condition and good remote results of patency of the venous segments restored. Endovascular methods should be wider implemented into the clinical practice.
本研究旨在评估血管内治疗髂股段静脉阻塞性病变的近期和远期效果。
我们共对75例髂股静脉血栓形成患者进行了球囊血管成形术和支架置入术。其中，60例患者接受了血栓形成后阻塞的支架置入术，15例患者接受了髂静脉非血栓性阻塞病变的支架置入术（11例为May-Thurner综合征，4例为血管外肿瘤压迫和瘢痕性狭窄）。使用自膨式Wallstent支架（波士顿科学公司，n = 84）或S.M.A.R.T.支架（科迪斯公司，强生公司，n = 16）进行支架置入。根据要置入支架的静脉段不同，支架直径从12毫米到18毫米不等。每位患者平均置入支架数量为1.3个。通过测量压力梯度和踝周径评估血管内干预的疗效。临床结果由静脉临床严重程度评分（VCSS）确定。
血管内干预的技术成功率为92%。术后即刻有7例（9.3%）患者发生支架血栓形成。其中，3例患者接受了导管直接溶栓治疗，肢体支架置入静脉段恢复通畅。术后48个月内诊断出4例支架闭塞。2例患者成功进行了重复血管成形术和支架置入术。随访36个月时，5例（16%）患者出现支架再狭窄，狭窄程度不少于50%。1例患者进行了重复支架置入术。通过超声双功扫描对支架通畅情况进行动态监测。还进行了多层螺旋计算机断层扫描静脉造影和X线造影增强静脉造影检查。血栓形成后病变在60个月时的累积原发性和继发性通畅率分别为72%和81%，非血栓性病变的原发性通畅率为85%。VCSS值显示慢性静脉功能不全的表现显著减轻。复合参数的平均值从14.2±4.2降至7.5±2.6（p<0.001），踝周径从272.3±6.7毫米降至250.6±6.1毫米（p<0.01）。5例（71%）患者的营养性溃疡实现了永久性愈合。
血管内血管成形术和支架置入术治疗髂股段静脉阻塞性病变的方法是一种微创、安全且高效的治疗方式，肢体状况的显著改善以及恢复的静脉段远期良好通畅效果证实了这一点。血管内治疗方法应更广泛地应用于临床实践。
