Whiteley Mark Steven
The Whiteley Clinic, Guildford, GU2 7RF, UK.
Clin Cosmet Investig Dermatol. 2022 Apr 6;15:567-583. doi: 10.2147/CCID.S294990. eCollection 2022.
This article outlines the current best practice in the management of varicose veins. "Varicose veins" traditionally means bulging veins, usually seen on the legs, when standing. It is now a general term used to describe these bulging veins, and also underlying incompetent veins that reflux and cause the surface varicose veins. Importantly, "varicose veins" is often used for superficial venous reflux even in the absence of visible bulging veins. These can be simply called "hidden varicose veins". Varicose veins usually deteriorate, progressing to discomfort, swollen ankles, skin damage, leg ulcers, superficial venous thrombosis and venous bleeds. Patients with varicose veins and symptoms or signs have a significant advantage in having treatment over conservative treatment with compression stockings or venotropic drugs. Small varicose veins or telangiectasia without symptoms or signs can be treated for cosmetic reasons. However, most have underlying venous reflux from saphenous, perforator or local "feeding veins" and so investigation with venous duplex should be mandatory before treatment. Best practice for investigating leg varicose veins is venous duplex ultrasound in the erect position, performed by a specialist trained in ultrasonography optimally not the doctor who performs the treatment. Pelvic vein reflux is best investigated with transvaginal duplex ultrasound (TVS), performed using the Holdstock-Harrison protocol. In men or women unable to have TVS, venography or cross-sectional imaging is needed. Best practice for treating truncal vein incompetence is endovenous thermal ablation. Increasing evidence suggests that significant incompetent perforating veins should be found and treated by thermal ablation using the transluminal occlusion of perforator (TRLOP) approach, and that incompetent pelvic veins refluxing into symptomatic varicose veins in the genital region or leg should be treated by coil embolisation. Bulging varicosities should be treated by phlebectomy at the time of truncal vein ablation. Monitoring and reporting outcomes is essential for doctors and patients; hence, participation in a venous registry should probably be mandatory.
本文概述了目前静脉曲张管理的最佳实践。传统意义上，“静脉曲张”指的是通常在站立时出现在腿部的凸起静脉。现在它是一个通用术语，用于描述这些凸起静脉以及导致表面静脉曲张的潜在功能不全静脉。重要的是，即使没有可见的凸起静脉，“静脉曲张”也常被用于描述浅表静脉反流。这些可简单称为“隐匿性静脉曲张”。静脉曲张通常会恶化，进而发展为不适、脚踝肿胀、皮肤损伤、腿部溃疡、浅表静脉血栓形成和静脉出血。有症状或体征的静脉曲张患者接受治疗比使用弹力袜或静脉活性药物进行保守治疗具有显著优势。无症状或体征的小静脉曲张或毛细血管扩张可出于美容原因进行治疗。然而，大多数此类情况存在来自大隐静脉、穿通静脉或局部“供血静脉”的潜在静脉反流，因此在治疗前必须进行静脉双功超声检查。检查腿部静脉曲张的最佳实践是由接受过超声检查培训的专家在直立位进行静脉双功超声检查，最好不是进行治疗的医生。盆腔静脉反流最好通过经阴道双功超声（TVS）检查，采用Holdstock-Harrison方案。对于无法进行TVS检查的男性或女性，需要进行静脉造影或横断面成像。治疗主干静脉功能不全的最佳实践是腔内热消融。越来越多的证据表明，应通过经皮腔内穿通静脉闭塞术（TRLOP）对明显功能不全的穿通静脉进行热消融治疗，对于反流至生殖器区域或腿部有症状的静脉曲张的功能不全盆腔静脉，应通过弹簧圈栓塞治疗。在主干静脉消融时，应通过静脉切除术治疗凸起的静脉曲张。对结果进行监测和报告对医生和患者都至关重要；因此，参与静脉登记可能是必要的。
