1、 髂静脉狭窄支架治疗髂静脉狭窄支架治疗的循证医学研究的循证医学研究中山大学附属第一医院血管外科中山大学附属第一医院血管外科王劲松王劲松 王深明王深明May-Thurner 综合征 髂静脉受压综合征：髂静脉受压综合征：1908年年McMurrich首先描述首先描述 1957年年May Thurner 1965-1967 Cockett 尸检和腔内超声发现：尸检和腔内超声发现：病理：病理：1.受压受压 2.血管壁纤维化血管壁纤维化 3.腔内网状和膜样变腔内网状和膜样变 Ehrich WE,Krumbhaar EB.A frequent obstructive anomaly of themouth
2、 of the left common ilia vein.Am Heart J 1943;26:737-50髂静脉闭塞的主要原因髂静脉闭塞的主要原因Iliofemoral stenting for venous occlusive diseaseJessica M.Titus,MD,Mireille A.Moise,MD,James Bena,MS,Sean P.Lyden,MD,andDaniel G.Clair,MD,Cleveland,Ohio诊断诊断静脉造影：不敏感静脉造影：不敏感腔内超声腔内超声(IVUS)：提高准确率提高准确率Raju S.Best management opti
3、ons for chronic iliac vein stenosis and occlusion.J Vasc Surg.2013 Apr;57(4):1163-9.IVUS可以提高髂静脉阻塞综合征的诊断率：可以提高髂静脉阻塞综合征的诊断率：性别 年龄 双侧髂静脉狭窄的治疗髂静脉狭窄的治疗手术治疗手术治疗：创伤创伤支架治疗支架治疗:1985年，首例自膨式支架在狗身上应用，随后，数年，首例自膨式支架在狗身上应用，随后，数篇文章报道在静脉内腔内治疗方面，取得较好的临篇文章报道在静脉内腔内治疗方面，取得较好的临床效果床效果手术介入治疗手术介入治疗治疗方法治疗方法Raju S.Best manage
4、ment options for chronic iliac vein stenosis and occlusion.J Vasc Surg.2013 Apr;57(4):1163-9.髂静脉狭窄支架治疗指征髂静脉狭窄支架治疗指征 有症状，无血栓形成的髂静脉狭窄有症状，无血栓形成的髂静脉狭窄 合并血栓形成的髂静脉狭窄合并血栓形成的髂静脉狭窄 急性：溶栓后支架置入急性：溶栓后支架置入 慢性：慢性：DVT发生后发生后4个月个月 严重的血栓后遗症严重的血栓后遗症技术要点技术要点 流入道和流出道建立流入道和流出道建立 慢性完全闭塞（慢性完全闭塞（chronic total occlusion,CTO)
5、:技术成功率技术成功率:83-95%：IVUS 支架：支架：自膨式大口径自膨式大口径Wallstents(Boston Scientific)较多较多 术后抗凝术后抗凝 抗凝时间报道不一抗凝时间报道不一 NIVL：抗凝不必要，抗血小板凝聚效果良：抗凝不必要，抗血小板凝聚效果良好好并发症并发症 支架内再狭窄：支架内再狭窄：50%：10%in PTS 1%in NIVL(无血栓的髂静脉狭窄无血栓的髂静脉狭窄)和血栓史，长支架，高凝状态相关 支架断裂支架断裂临床效果临床效果 疼痛缓解：疼痛缓解：86%-94%肿胀：肿胀：66%-89%溃疡愈合：溃疡愈合：58%-89%Raju S.Best mana
6、gement options for chronic iliac vein stenosis and occlusion.J Vasc Surg.2013 Apr;57(4):1163-9.支架通畅率支架通畅率近期和中期通畅率高：由于下肢运动，髂静脉支近期和中期通畅率高：由于下肢运动，髂静脉支架通畅率高于锁骨下静脉架通畅率高于锁骨下静脉 无血栓的髂静脉狭窄（无血栓的髂静脉狭窄（NIVL)：4-7年支架通年支架通畅率：畅率：90-100%合并血栓的髂静脉狭窄：合并血栓的髂静脉狭窄：I期支架通畅率：期支架通畅率：3-5年：年：25%闭塞闭塞 II期支架通畅率：期支架通畅率：4-7年：年：74-89
7、%CTO:4-7年：年：66-89%Raju S.Best management options for chronic iliac vein stenosis and occlusion.J Vasc Surg.2013 Apr;57(4):1163-9.J Vasc Interv Radiol.2012 Apr;23(4):497-502.Long-term outcomes of stent placement for symptomatic nonthrombotic iliac vein compression lesions in chronic venous disease.Ye
8、 K1,Lu X,Li W,Huang Y,Huang X,Lu M,Jiang M.A total of 227 stents were placed in 205 patients(224 limbs;median age,50.53 years).The rate of technical success was 100%.Three limbs were treated with two stents because of proximal migration of the incipient stent.Follow-up periods ranged from 1-117 mont
9、hs(mean 50 months 36).The primary and assisted-primary cumulative patency rates at a mean of 4 years were 98.7%and 100%.The cumulative edema relief rate was 89.1%(156 of 175),and the healing rate for active ulcers was 82.3%(51 of 62).The pain level(using a visual analogue scale from 0-10)declined fr
10、om a median level of 4.3 before the procedure to 0.4 after the procedure.Quality of life improved significantly after intervention.Complications were minor and improved quickly.Ann Vasc Surg.2014 Apr;28(3):695-704.Endovascular treatment for symptomatic iliac vein compression syndrome:a prospective c
11、onsecutive series of 48 patients.Liu Z1,Gao N2,Shen L3,Yang J2,Zhu Y2,Li Z4,Si Y5.The prevalence of IVCS within our cohort was 14.8%(48/324).The technical success rate of the endovascular treatment was 95.8%.There was no death,pulmonary embolism,or contrast-induced nephropathy among the patients.The
12、 1-year primary patency rate was 93.0%.IVCS is more common than previously thought among patients with unilateral left lower limb chronic venous disease.Endovascular therapy,a minimally invasive approach to treating venous lesions,is a feasible and effective treatment for left-sided IVCS and has a high technical success rate and an acceptable complication profile.结论结论髂静脉狭窄支架治疗：髂静脉狭窄支架治疗：有效，安全，微创，技术成功率高，并发有效，安全，微创，技术成功率高，并发症低，近期、中期通畅率高症低，近期、中期通畅率高需解决的问题需解决的问题 腹股沟处静脉闭塞腹股沟处静脉闭塞 支架治疗后抗凝、抗血小板治疗策略支架治疗后抗凝、抗血小板治疗策略 狭窄处理程度狭窄处理程度 IVUS应用应用 髂静脉阻塞的血流动力学髂静脉阻塞的血流动力学 评估等等评估等等杂交手术杂交手术谢 谢
