较大量之隐静脉逆流的新治疗


  2003 年4月1 日-根据二篇在3月29 日于犹他州盐湖城所举办的介入性放射线学协会所发表的演说指出,雷射和无线电波疗法可以成功地治疗更大量的隐静脉(GSV) 逆流,这二种治疗均使并发症和复发率降低了。
  
  纽约康奈尔大学Weill 医学院的R. J. Min和N. Khilnani表示,2 年的后续结果可利用在88位四肢接受静脉内雷射治疗的患者之追踪结果,证实了复发率低于7%,这些结果可以和GSV逆流的其它治疗选择相比拟更胜一筹。静脉内雷射似乎可以提供这些优点,以及较低的并发症并且不需进行全身麻醉。
  
  Min博士描述344 名静脉曲张患者的389GSV雷射治疗。这项技术包含经皮的GSV和肿胀麻醉,以100到200 毫升的0.25% lidocaine,使用超音波导引,再以810 毫微米的二极管雷射能量进行传输,通过600 微米雷射纤维至GSV。
  
  在1-36个月的追踪中,以彩色都谱勒仪检测,显示出无血液的流动,这代表在389个GSV中,成功地封住了383个(98%)GSVs,以及在至少二年的追踪中,88只四肢中有82 (93%)只成功。
  
  作者表示,所有复发均发生于在九个月之前,大多数的人在静脉内雷射后三个月以内被发现。并未发生皮肤烧伤、皮肤感觉异常,或深部静脉血栓症(DVT)。在一项分开的研究中,纽约Sloan-Kettering纪念癌症中心的M. Rosenblatt 和同事,测定124 名以双重超音波确认,出现症状性静脉血流不足的GSV病人经导管静脉内无线电波治疗(ERFT)之结果。
  
  共计145次技术上成功的手术,由一位手术操作者在影像的引导下,于139个四肢中进行,其中135个四肢有症状上的改进(97.1%)。并发症包括16个 (11.0%)轻微的瞬间皮肤感觉异常,这些症状均于四个月内获得缓解,以及2起皮肤烧灼(1.4%),但是并没有形成深部静脉血栓。
  
  超音波证实了133 个四肢的GSV封锁(95.7%) ,以及在6个四肢持续的开放性及血管通透(4.3%),包括四个部份封锁。在仔细评估治疗失败的原因后,再以ERFT治疗,所有病例均成功地造成持续的封锁。在三个部份GSV 封锁的患者中,逆流的来源是一个大的穿孔,导致GSV的开放性部份。
  
  作者注意到,图象引导的ERFT 对于GSV不足是安全和有效的。在这个系列中,其并发症和错误治疗的比率较低于之前的报告。治疗失败通常与大的GSV穿孔有关,它们会成为散热器,而阻止静脉壁进行充足的热烧灼。以同样形式的ERFT重新治疗,经证实是有效和持久的。
  
  SIR第28届年会:摘要:98, 99。

New Treatments for Greater Sap

By Laurie Barclay, MD
Medscape Medical News

April 1, 2003 — Both laser and radiofrequency therapy successfully treat greater saphenous vein (GSV) reflux, according to two presentations on March 29 at the Society for Interventional Radiology annual meeting in Salt Lake City, Utah. Rates of complication and recurrence were low for both procedures.

"Two-year follow-up results available on 88 limbs treated with endovenous laser demonstrate a recurrence rate of less than 7%," write R. J. Min and N. Khilnani, from Weill Medical College of Cornell University in New York City. "These results are comparable or superior to those reported for the other options available for treatment of GSV reflux. Endovenous laser appears to offer these benefits with lower rates of complication and avoidance of general anesthesia."

Dr. Min described laser treatment of 389 GSVs in 344 patients with varicose veins. The technique involved percutaneous access of GSVs and tumescent anesthesia with 100 to 200 mL of 0.25% lidocaine using ultrasound guidance, followed by delivery of 810 nm diode laser energy into the GSV via a 600-micron laser fiber.

Color doppler revealed absence of flow indicating successful GSV occlusion in 383 (98%) of 389 GSVs at 1- to 36-month follow-up, and in 82 (93%) of 88 limbs followed for at least two years.

"Of note, all recurrences have occurred prior to nine months, with the majority noted less than three months following endovenous laser," the authors write. "There have been no skin burns, paresthesias, or DVTs."

In a separate study, M. Rosenblatt and colleagues from the Memorial Sloan-Kettering Cancer Center in New York City, determined outcomes of transcatheter endovenous radiofrequency treatment (ERFT) of the GSV in 124 patients with symptomatic venous insufficiency documented by duplex ultrasound.

All 145 procedures performed in 139 limbs by a single operator using image guidance were technically successful, with symptomatic improvement in 135 treated limbs (97.1%). Complications included mild transient paresthesias in 16 (11.0%), which completely resolved by four months, and skin burns in two (1.4%), but no deep vein thrombosis.

Ultrasound demonstrated GSV occlusion in 133 limbs (95.7%) and persistent patency or recanalization in six limbs (4.3%), including four with partial occlusion. After careful assessment of the potential cause of treatment failure, retreatment with ERFT was successful in all cases, resulting in persistent occlusion. In three of the patients with partial GSV occlusion, the source of reflux was a large incompetent perforator leading into the patent portion of the GSV.

The authors note that image-guided ERFT is safe and effective for GSV insufficiency, with lower complication and treatment failure rate in this series than reported previously. "Treatment failures were commonly associated with a large incompetent GSV perforator that may have acted as a heat-sink preventing adequate thermal ablation of the vein wall," they write. "Retreatment of ERFT failures with the same modality was found to be effective and durable."

SIR 28th Annual Meeting: Abstracts: 98, 99. Presented March 29, 2003.

Reviewed by Gary D. Vogi, MD

    
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