Legiehn Gerald M
Division of Interventional Radiology, Department of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada.
Tech Vasc Interv Radiol. 2019 Dec;22(4):100630. doi: 10.1016/j.tvir.2019.100630. Epub 2019 Sep 21.
Venous malformations are very commonly encountered in interventional radiologic practice. Indications for therapy are clearly defined based on the lesion's impact on patient's quality of life. Screening laboratory coagulation studies in patients with historical or lesion morphologic risk factors often reveal abnormal coagulation parameters consistent with localized intravascular coagulation or more severe coagulopathic states. These may require chronic or periprocedural medical management to avoid potentially life-threatening disseminated intravascular coagulation or other thromboembolic phenomena. Once a multidisciplinary decision to treat a venous malformation is made, one must decide between percutaneous and/or surgical techniques. Sclerotherapy with adjunctive stasis of efflux (STASE) techniques have become the mainstay of therapy for most venous malformations as they are well-tolerated and effective. STASE techniques work primarily by (i) the administration of sclerosant(s) exerting an inhibitory and/or endotheliocidal effect on venous malformation endothelium leading to thrombosis, involution, and fibrosis, and secondarily via adjunctive outflow occlusion using any combination of local compression, balloons, gelatin, coils, laser, radiofrequency, or adhesives to improve sclerosant penetration and dwell-time in the lesion. Adhesives alone can fill the lesion to facilitate surgical resection in some cases. Common sclerosants in modern practice include sodium tetradecyl sulfate, bleomycin, polidocanol, ethanol, and hypertonic saline. Most agents can be given directly in unmodified or "neat" form or can be mixed with a gas to form a sclerofoam or embolic such as gelatin to form a sclerogel. Choice and method of sclerosant delivery in each patient is based on the intraluminal lesion volume, architecture, vital structure proximity, agent toxicity, viscosity, and level of experience of the interventional radiologist with that particular agent. Multi-session STASE therapy usually reduces symptoms of chronic pain or mass with low risk of known complications of skin or nerve impairment, compartment syndrome, hemoglobinuria, deep venous thrombosis, or pulmonary phenomena.
静脉畸形在介入放射学实践中极为常见。基于病变对患者生活质量的影响，治疗指征已明确界定。对有病史或病变形态学危险因素的患者进行筛查性实验室凝血研究，往往会发现与局部血管内凝血或更严重凝血病状态相符的异常凝血参数。这些情况可能需要长期或围手术期药物治疗，以避免潜在的危及生命的弥散性血管内凝血或其他血栓栓塞现象。一旦做出多学科治疗静脉畸形的决定，就必须在经皮和/或手术技术之间做出选择。联合流出道淤滞的硬化治疗（STASE）技术已成为大多数静脉畸形治疗的主要方法，因为它们耐受性良好且有效。STASE技术主要通过以下方式起作用：（i）注射硬化剂，对静脉畸形内皮产生抑制和/或内皮杀伤作用，导致血栓形成、退化和纤维化；其次，通过局部压迫、球囊、明胶、线圈、激光、射频或粘合剂等任何组合进行辅助流出道闭塞，以提高硬化剂在病变中的渗透和停留时间。在某些情况下，单独使用粘合剂可填充病变以利于手术切除。现代实践中常用的硬化剂包括十四烷基硫酸钠、博来霉素、聚多卡醇、乙醇和高渗盐水。大多数药物可以直接以未改性或“纯”形式给药，或者可以与气体混合形成硬化泡沫或栓塞剂，如与明胶混合形成硬化凝胶。每个患者硬化剂给药的选择和方法基于腔内病变体积、结构、与重要结构的接近程度、药物毒性、粘度以及介入放射科医生对该特定药物的经验水平。多疗程STASE治疗通常可减轻慢性疼痛或肿块症状，皮肤或神经损伤、骨筋膜室综合征、血红蛋白尿、深静脉血栓形成或肺部现象等已知并发症的风险较低。
