Bock Richard, Fontenot Danielle, Bock Spencer, Eiler Gwyn, Worley-Fry Kristie, Blebea John
Asheville Vein Center, Asheville, NC.
Asheville Vein Center, Asheville, NC.
J Vasc Surg Venous Lymphat Disord. 2025 Jan;13(1):101988. doi: 10.1016/j.jvsv.2024.101988. Epub 2024 Oct 9.
Spontaneous hemorrhage from erosion of varicose veins through the skin is a serious and occasionally fatal complication of varicose vein disease. Various treatments, both acute and delayed, have been advocated. Our two-step clinical protocol was designed to prevent further hemorrhage without delay and to provide durable freedom from recurrent bleeding.
All patients referred to our surgical vein practice with hemorrhage from varicose veins were entered into a prospective registry. On presentation, all patients underwent diagnostic duplex ultrasound for venous reflux. Immediate treatment consisted of ultrasound-guided polidocanol/CO foam sclerotherapy of the bleeding varicosity and adjacent veins. Subsequent endovenous ablation of underlying incompetent axial veins, with concurrent microphlebectomy when indicated, was scheduled and performed within 8 weeks.
Fifty-nine patients were referred with recent hemorrhage from varicose veins over a period of 4 years. Fifty-six (95%) had an ultrasound-identified tributary varicosity underlying the point of bleeding, and three had a skin-surface erosion only and no ultrasound-identified underlying tributary. Of the 59 study patients, 52 underwent prompt polidocanol/CO foam sclerotherapy, targeted to both the underlying tributary (when present) as well as the cutaneous bleeding varicosity. The remaining seven either declined sclerotherapy or were ineligible. Underlying incompetence of axial (great, small, or anterior saphenous) veins was found in 54 patients (92%). Of these patients with truncal vein incompetence, 48 underwent ablation-5 declined and 1 was too frail for any further intervention. There were no recurrent bleeds in the interval between immediate sclerotherapy and scheduled ablation. During a mean follow-up of 2.2 years, 55 of the 59 patients (93%) had no recurrence of bleeding. Four patients (7%) had late, recurrent hemorrhage: one had failed to return for their scheduled ablation, two were on chronic anticoagulation, and one had severe right heart failure. All four were retreated without further recurrence.
A two-step protocol of immediate ultrasound-guided foam sclerotherapy, followed within 8 weeks by endovenous ablation of incompetent axial veins and concurrent microphlebectomy, provided rapid and efficient treatment with durable freedom from subsequent hemorrhage.
静脉曲张经皮肤侵蚀导致的自发性出血是静脉曲张疾病的一种严重且偶尔致命的并发症。人们提倡了各种急性和延迟治疗方法。我们的两步临床方案旨在立即预防进一步出血，并持久防止复发性出血。
所有因静脉曲张出血而转诊至我们外科静脉诊疗科室的患者均被纳入前瞻性登记研究。就诊时，所有患者均接受诊断性双功超声检查以评估静脉反流情况。立即治疗包括对出血的静脉曲张及其相邻静脉进行超声引导下的聚多卡醇/二氧化碳泡沫硬化治疗。随后，计划在8周内对潜在的功能不全的轴向静脉进行腔内消融，并在必要时同时进行微静脉切除术。
在4年的时间里，有59例患者因近期静脉曲张出血前来就诊。56例（95%）在出血点下方有超声识别出的曲张静脉属支，3例仅有皮肤表面糜烂，未发现超声识别出的潜在属支。在59例研究患者中，5例接受了针对潜在属支（如有）以及皮肤出血性静脉曲张的及时聚多卡醇/二氧化碳泡沫硬化治疗。其余7例要么拒绝硬化治疗，要么不符合条件。54例患者（92%）发现轴向（大隐、小隐或前隐静脉）静脉存在潜在功能不全。在这些有主干静脉功能不全的患者中，48例接受了消融治疗，5例拒绝，1例因身体过于虚弱无法进行进一步干预。在立即硬化治疗和计划消融之间的间隔期内没有复发出血。在平均2.2年的随访期间，59例患者中有55例（93%）没有再次出血。4例患者（7%）出现晚期复发性出血：1例未按计划返回进行消融治疗，2例正在接受慢性抗凝治疗，1例患有严重右心衰竭。所有4例均再次接受治疗，未再复发。
两步方案，即立即进行超声引导下泡沫硬化治疗，8周内对功能不全的轴向静脉进行腔内消融并同时进行微静脉切除术，提供了快速有效的治疗，且能持久防止随后出血。
