TheTreatmentofPost-ThromboticSyndromeTheRoleofEndovascularRecanalizationinChronicIliacVeinObstruction血栓后综合征的治疗血管内再通对于慢性髂静脉阻塞的作用张强医生集团国际静脉病中心(下肢静脉曲张CHIVA治疗中心)张强医生集团国际静脉病中心邱畅BackgroundWhatisPTS?Thepost-thromboticsyndrome(PTS)isachronicconditionthatdevelopsin20–50%ofpatientsafterdeepvenousthrombosis(DVT).Itadverselyaffectshealthandqualityoflife,andiscostlyasmeasuredbyhealthcarecosts,outofpocketexpenditures,andlostproductivityWhataretheclinicalmanifestationsofPTS?•Thereisnogoldstandardlaboratory,imaging,orfunctionaltestthatestablishesthediagnosisofPTS.•PTSisprimarilydiagnosedonclinicalgrounds,basedonthepresenceoftypicalsymptomsandsignsinapatientwithpreviousDVT.HowisPTSdiagnosed?Methods•ThisreviewisbasedonpertinentpublicationsretrievedbyaselectiveliteraturesearchinPubMedandtheCochraneLibrary,andontheguidelinesoftheGermanSocietiesofPhlebologyandVascularSurgery.Treatment•Thetreatmentoptionsareconservativetreatmentwithcompressionandpatientexercises,endovascularrecanalizationwithstentangioplasty,andopenbypasssurgeryoftheiliacobstructions.ConservativetreatmentThegoaloftreatmentforPTSissymptomaticrelief,sincetheconditionitselfisnotcurable.•Reducingthediameteroftheveinandhenceimprovingvenousvalvularfunction,•Acceleratingvenousbackflow•PreventingandreducinglegedemaOpensurgery•Theopenoperationshaveonlybeendocumentedinstudieswithsmallcasenumbers(3to85casesperstudy,patencyrates58to100%).EndovascularTechniquesTheendovasculartechniquesyieldpatencyratesof73to100%,withthromboticstentocclusionandhematomaaspotentialcomplications.Hybridprocedure•Wheninflowisobstructedbypostthrombotictrabeculaeintheregionofthecommonfemoralvein•Inadditiontostentangioplasty,surgicaldesobliteration(endovenotomy)ofthecommonfemoralveinandtheostiaofitstributaries,especiallythedeepfemoralvein,mustbecarriedout•Figure4:Hybridsurgicalprocedure•a)Schematicillustrationofthehybridprocedure(iliacstentangioplasty,endovenectomyofthecommonfemoralveinwithpatchplastyplusplacementofaloop-shapedarteriovenousfistula(polytetrafluoroethyleneprosthesis)•b)Intraoperativesiteduringendovenectomyoftheleftcommonfemoralvein(statuspostlongitudinalvenotomy,guidewireinsituforthesubsequentiliacstentangioplasty,evidenceofpostthrombotictrabeculae,markedwithblackarrows)Peri-andpostoperativeconcomitanttreatment•Afterrecanalization,thromboticocclusionofthere-canalizedsegmentisthemostfrequentpostoperativecomplication(1.5%duringtheearlypostoperativeperiod[<30days],3%duringthelaterpostoperativeperiod)•Anticoagulationtreatmentshouldbecon-tinuedforatleast6monthspostoperatively,eitherwithvitaminKantagonists(targetINR:2.5to3.5)orwiththeneworalanticoagulants(NOAC).Earlymobili-zationandcompressiontherapyshouldalsobepartofthepostoperativetreatmentregimenResult•Thecomplicationsoftheseinvasiveprocedurescanincludethromboticbypassocclusion,hematoma,andwoundinfection.•Therehavebeenrandomizedtrialsofconservativetreatment,butnotofsurgicaltreatment.•TheAmericanHeartAssociation,initsguidelines,givesthesameweakrecommendationforallsurgicalmethods(IIb).Conclusions•Allconservativeoptionsshouldbeexhaustedasthefirstlineoftreatment.•IfPTSsymptomspersistandmarkedlyimpairthepatient’squalityoflife,thepossibleindicationforsurgeryshouldbeconsidered.•AsPTShardlyeverleadstodeathorlimbloss,itstreatmentshouldbeasuninvasiveaspossible.Conclusions•Endovascularrecanalizationisanattractiveoptioninthisrespect.•AconclusiveevaluationoftheroleofendovascularproceduresinPTSmustawaitrandomizedtrialsofthisformoftreatmentandoftheoptimalstentconfigu-ration.KeymessagePostthromboticsyndromeoccursinabout20%to50%ofpatientsinwhomdeepveinthrombosishasbeendiagnosed,andhasconsiderablesocioeconomicconsequences.●Thefollowingtherapeuticoptionsexist:a)Conservativetreatmentb)Opensurgicalproceduresc)Endovascularrecanalizationandhybridprocedures.●Onlywhenconservativetreatmenthasfailedshouldaninvasiveprocedurebeconsidered.●Sinceatpresentthereisinsufficientevidencetoshowanyproceduretobesuperior,theleastinvasiveprocedurepossibleshouldbeemployed.●Thissuggeststhatendovascularrecanalizationmayberegardedasthetreatmentofchoiceforchroniciliacveinobstruction.
