1、临床超声医学杂志2023年10月第25卷第10期J Clin Ultrasound in Med,October 2023,Vol.25,No.10 临床研究 超声引导下射频消融联合泡沫硬化剂治疗不同管径大隐静脉曲张的临床价值曾欣周洋叶鸣王弼偲陈芮汤雪瑶周鸿摘要目的探讨超声引导下射频消融联合泡沫硬化剂治疗不同管径大隐静脉曲张及超声在术后短期疗效评估中的临床价值。方法选取我院收治的大隐静脉曲张患者145例(145条患肢),根据术前超声测量大隐静脉大腿段最大管径分为A组(管径10 mm)98例和B组(管径10 mm)47例,两组均采用超声引导下腔内射频消融闭合大隐静脉主干和注射泡沫硬化剂治疗小腿曲
2、张浅静脉。比较两组消融次数和术后即刻、1个月、6个月大隐静脉闭塞率、残留管径、汇入口残留长度,以及术后并发症发生情况。结果B组每节段平均消融次数大于A组,差异有统计学意义(P0.05)。A组、B组术后即刻大隐静脉闭塞率均为100%,术后1个月分别为97.96%、100%,术后6个月分别为95.92%、95.74%,两组各时间点大隐静脉闭塞率比较差异均无统计学意义。术后1个月、6个月B组大隐静脉残留管径均大于A组,差异均有统计学意义(均P0.05)。两组患者术后均未出现深静脉血栓、肺栓塞等严重并发症,出现皮下瘀斑和皮肤灼伤占比比较差异均无统计学意义;B组出现皮下条索僵硬静脉占比大于A组,差异有统
3、计学意义(P0.05)。结论超声引导下射频消融联合泡沫硬化剂治疗不同管径大隐静脉曲张后短期内大隐静脉闭塞率较高,但较大管径的大隐静脉可能需要更多的消融周期;超声在术中引导及监测、术后随访和疗效评估中均有重要的临床价值。关键词超声引导;射频消融;大隐静脉曲张;管径中图法分类号R445.1;R543.6文献标识码 AClinical value of ultrasound-guided radiofrequency ablation combined withfoam sclerosing agent in the treatment of varicose great saphenous vei
4、n withdifferent diametersZENG Xin,ZHOU Yang,YE Ming,WANG Bisi,CHEN Rui,TANG Xueyao,ZHOU HongDepartment of Ultrasound,the Third People s Hospital of Chengdu,Chengdu 610000,ChinaABSTRACTObjectiveTo explore the clinical value of ultrasound-guided radiofrequency ablation combined withfoam sclerosing age
5、nt in the treatment of varicose great saphenous vein with different diameters and ultrasound in the short-termefficacy evaluation after operation.MethodsA total of 145 patients(145 affected limbs)with varicose great saphenous vein inour hospital were selected and divided into group A(diameter10 mm,n
6、=98)and group B(diameter10 mm,n=47)according tothe preoperative ultrasound measurement of the maximum diameter of the thigh segment of the great saphenous vein.Both groupswere treated by ultrasound-guided intracavitary radiofrequency ablation to close the trunk of the great saphenous vein andinjecti
7、on of foam sclerosing agent to treat superficial varicose veins of the lower leg.The ablation times,the occlusion rate of greatsaphenous vein immediately,1 month,and 6 months after surgery,the residual lumen diameter and length,the postoperativecomplications were compared between the two groups.Resu
8、ltsThe average ablation time of each segment in group B was higherthan that in group A,and the difference was statistically significant(P0.05).The immediate occlusion rates of the greatsaphenous vein in group A and group B were 100%,and the occlusion rates of the great saphenous vein 1 month after s
9、urgerywere 97.96%and 100%,6 months after surgery were 95.92%and 95.74%,respectively.There were significant difference in the作者单位:610000成都市第三人民医院超声科(曾欣、周洋、叶鸣、陈芮、汤雪瑶、周鸿),介入血管中心(王弼偲)通讯作者:周鸿,Email: 839临床超声医学杂志2023年10月第25卷第10期J Clin Ultrasound in Med,October 2023,Vol.25,No.10大隐静脉曲张临床较常见,成人静脉曲张的发病率为20%64%
10、1。超声引导下射频消融已在部分地区替代外科高位结扎和剥离手术,成为治疗大隐静脉曲张的首选方法2。超声能清晰显示大隐静脉的宽度、走行、结构及瓣膜,并实时评估血流动力学情况,在术前诊断大隐静脉曲张、术中引导射频消融及术后疗效评估中均有重要的作用3。既往研究4-5主要探讨射频消融治疗大隐静脉曲张的优势,较少涉及消融不同管径大隐静脉曲张术后疗效的比较。本研究旨在探讨超声引导下射频消融联合泡沫硬化剂治疗不同管径大隐静脉曲张及超声在术后短期疗效评估中的应用价值。资料与方法一、研究对象选取2021年1月至2022年12月我院血管外科收治的大隐静脉曲张患者 145 例(共 145 条患肢),男84例,女61例
11、,年龄3485岁,平均(59.712.5)岁。根据术前超声测得大隐静脉大腿段最大管径分为A组(管径18岁;临床诊断为大隐静脉曲张;超声提示患肢大隐静脉大腿段管径3 mm,股隐静脉瓣功能不全,反流时间0.5 s;髂静脉、下肢深静脉通畅。排除标准:患肢急性深静脉血栓或浅静脉血栓形成、深静脉系统发育不全、血管畸形;患肢股隐静脉交界处瘤样扩张(内径20 mm);妊娠或哺乳;有严重凝血功能障碍;全身严重疾病不能耐受手术者;对硬化剂过敏者。本研究经我院医学伦理委员会批准(伦审号:2023-S-8),所有患者及家属均知情同意。二、仪器与方法1.仪器:超声检查及超声引导使用迈瑞M 6便携式彩色多普勒超声诊断仪
12、,7L4S 线阵探头,频率 811 MHz;射频主机为 Closure RFG3 静脉腔内射频闭合 发 生 器(美 国 Covidien 公 司),射 频 导 管 使 用ClosureFast射频导管(美国Medtronic公司)。2.术前超声检查:术前对所有患者行下肢静脉超声检查。患者取仰卧位,保持大腿外旋,常规扫查股静脉、股浅静脉、腘静脉、大隐静脉、小隐静脉,观察其走行及管壁有无血栓形成;于大隐静脉大腿段最宽处测量并记录管径,并在股隐静脉瓣进行Valsava试验,应用彩色多普勒及频谱多普勒观察静脉管腔内血流反流情况;然后扫查并标记与大隐静脉相通的交通支静脉及小腿曲张的浅静脉。3.超声引导下
13、射频消融和泡沫硬化剂治疗:患者取仰卧位,常规碘伏术区消毒,铺无菌巾,对穿刺点进行局部麻醉,于超声引导下在膝关节以下5 cm处采用穿刺针刺入大隐静脉主干,肝素化盐水冲洗导管和导管鞘,置入导丝,撤出穿刺针,置入7F导管鞘,经导管鞘置入ClosureFast射频导管,待超声检查确认导管进入大隐静脉主干且头端置于距大隐静脉汇入口2 cm处,固定导管。于超声引导下沿大隐静脉主干周围分段向隐筋膜间隙内注入适量麻醉肿胀液(由肾上腺素0.5 mg、2%利多卡因25 ml、碳酸氢钠10 ml及0.9%生理盐水465 ml配置而成),当纵切面观察到大隐静脉被压闭,横切面观察到大隐静脉被包绕,以确保麻醉肿胀液能完全
14、包裹压闭的大隐静脉。待麻醉肿胀液注射完毕,再次复查超声确定射频导管位置后开始射频消融,由近心段向远心段逐段闭合大隐静脉主干,射频导管能量最高温度为 120,治疗有效长度为7 cm,每20 s为1个治疗周期。射频消融过程中应用超声实时监测,消融大隐静脉汇入口2 cm处时可适量加压探头,使导管与血管壁充分接触,并观察射频导occlusion rate of great saphenous vein between the two groups(both P0.05).The residual diameter of great saphenous vein ingroup B was larger
15、 than that in group A at 1 month and 6 months after surgery,and the differences were statistically significant(both P0.05).There were no severe complications such as deep vein thrombosis and pulmonary embolism occurred in the twogroups after surgery,and there were no significant difference in the pr
16、oportion of subcutaneous ecchymosis and skin burnsbetween the two groups.The proportion of subcutaneous cord stiffness veins in group B was higher than that in group A,and thedifference was statistically significant(P5 cm静脉节段探及血流信号为完全再通,存在长度5 cm静脉节段探及血流信号为部分再通6。5.一般资料收集及术后随访:术前根据下肢静脉曲张临床表现、病因学因素、解剖定
17、位和病理生理改变(CEAP)分级7评估静脉曲张临床严重程度。收集患者年龄、性别、手术患肢部位、手术时间、住院时间、CEAP分级、消融大隐静脉长度、每节段平均消融次数等。术后随访并发症发生情况,包括皮肤灼伤、皮下瘀斑、硬结、感染、邻近神经损伤、静脉炎、深静脉血栓及肺动脉栓塞等。三、统计学处理应用SPSS 23.0统计软件,符合正态分布的计量资料以xs表示,采用t检验;不符合正态分布的计量资料以 M(Q1,Q3)表示,采用 Mann-Whitney U 检验。计数资料以例或率表示,采用2检验或Fisher确切概率法。P0.05为差异有统计学意义。结果术前超声检查、术中超声引导及监测、术后超声随访见
18、图16。图1术前超声检查见曲张的大隐静脉图2超声引导下将麻醉肿胀液注入隐筋膜间隙使其压闭包绕大隐静脉图3射频消融过程中超声实时监测导管上产生气体样强回声伴彗星尾征图4射频消融后即刻超声示大隐静脉管壁增厚,管腔变窄,腔内透声差图5射频消融后即刻超声复查大隐静脉主干全段,CDFI示未探及血流信号图6射频消融后即刻超声测量大隐静脉汇入口残留长度一、两组一般资料、超声参数、术中情况比较两组年龄、性别、手术患肢部位、手术时间、住院时间、CEAP分级、消融大隐静脉长度等比较,差异均无统计学意义。两组大隐静脉管径及每节段平均消融次数比较,差异均有统计学意义(均 P0.05)。见表1。二、两组术后超声随访情况
19、两组消融术后即刻超声扫查提示所有消融的大 841临床超声医学杂志2023年10月第25卷第10期J Clin Ultrasound in Med,October 2023,Vol.25,No.10隐静脉均全段闭合,闭塞率均为100%。术后1、6个月复查超声,两组大隐静脉管壁均增厚,其内可见低弱回声充填,均未发现完全再通的大隐静脉。A组术后1个月随访见2例部分再通,管腔内可见稀疏点状血流信号,术后 6 个月随访见 4 例部分再通;B 组术后1 个月随访未发现部分再通,术后 6 个月见 2 例部分再通。两组术后 1 个月、6 个月大隐静脉闭塞率比较(97.96%vs.100%、95.92%vs.9
20、5.74%),差异均无统计学意义(P=0.326、0.961)。术后1个月、6个月两组大隐静脉汇入口残留长度比较差异均无统计学意义;B 组大隐静脉残留管径均大于 A 组(均 P0.05)。见表2。表2两组术后1个月、6个月超声参数比较mm组别A组(98)B组(47)t/Z值P值大隐静脉残留管径术后1个月2.5(2.2,3.0)3.8(3.3,4.2)-6.1450.001术后6个月2.2(1.8,2.5)3.0(2.9,3.4)-4.7860.001大隐静脉汇入口残留长度术后1个月9.62.19.82.4-0.4750.636术后6个月9.32.39.51.4-0.3790.705三、两组术后
21、并发症比较两组术后均未出现深静脉血栓、肺栓塞等严重并发症,其中A组出现皮下条索僵硬静脉2例、皮下瘀斑2例、皮肤灼伤1例,B组出现皮下条索僵硬静脉7例、皮下瘀斑1例、皮肤灼伤1例。B组出现皮下条索僵硬静脉占比大于A组,差异有统计学意义(P12 mm的大隐静脉曲张进行射频消融,术后随访显示大隐静脉闭塞率高达98%,但该研究未分析不同管径大隐静脉与射频消融次数的关系。本研究结果显示,两组年龄、性别、手术时间、住院时间、CEAP分级、消融大隐静脉长度等比较差异均无统计学意义,而B组术中每节段平均消融次数多于A组,差异有统计学意义(P0.05),表明消融管径10 mm的大隐静脉曲张较管径8 mm的大隐静
22、脉曲张,但与管径8 mm的大隐静脉曲张相比,消融管径越粗可能越需要额外的能量输送,而射频消融仪1个周期所产生的能量是固定的,若要输出额外的能量传递,可通过重复治疗实现。研究11认为消融治疗管径10 mm 的大隐静脉曲张时,静脉收缩需要更长的时间,增加射频能量可以加快收缩时间,从而提高射频消融的治疗效率,这也解释了本研究结果中B组每节段平均消融次数多于A组的原因。表1两组一般资料、超声参数、术中情况比较组别A组(98)B组(47)t/Z/2值P值年龄(岁)59.712.959.811.6-0.0240.981男性(例)57270.0070.935左侧患肢(例)52290.9620.327手术时间
23、(min)30.54.631.76.5-1.1020.274住院时间(d)6.82.37.42.4-1.4060.162CEAP分级(例)C250173.6330.455C33320C4106C543C611大隐静脉管径(mm)5.3(5.0,6.5)12.5(11.5,14.0)-9.7350.001消融大隐静脉长度(cm)37.23.338.22.9-1.7340.085每节段平均消融次数(次)2.2(2.0,2.2)3.0(3.0,3.2)-8.9930.001CEAP:临床表现、病因学因素、解剖定位和病理生理改变 842临床超声医学杂志2023年10月第25卷第10期J Clin Ul
24、trasound in Med,October 2023,Vol.25,No.10本研究中两组术后均未出现深静脉血栓、肺栓塞等严重并发症,其中 A 组出现皮下条索僵硬静脉2例、皮下瘀斑2例、皮肤灼伤1例;B组出现皮下条索僵硬静脉7例、皮下瘀斑1例、皮肤灼伤1例。表明射频消融后并发症少见且轻微。深静脉血栓形成是射频消融术后主要严重不良事件12,本研究中所有患者均未发生。B组皮下条索僵硬静脉占比大于A组,且术后1个月、6个月B组大隐静脉残留管径均大于A组(均P0.05),分析可能为术前大隐静脉管径越粗,术后残留管径也相对较粗,其内实变、纤维化、钙化,形成条索僵硬静脉概率也越大。本研究B组每节段平均
25、消融次数多于A组,但两组仅出现少量皮下瘀斑和皮肤灼伤等轻微并发症,表明适当增加消融次数并不会增加深静脉血栓、肺栓塞、皮下瘀斑等并发症的风险。术中超声引导对避免这些并发症也发挥了至关重要的作用,不仅能够有效精准引导麻醉肿胀液注入隐筋膜间隙完全包裹大隐静脉,保护周围皮肤软组织、神经不被高温灼伤,还可以术中实时监测大隐静脉主干闭合效果及有无损伤股总静脉;而术前超声能清晰显示大隐静脉解剖学形态、走行并反映瓣膜功能等,还可以评估下肢深静脉血栓,对手术适应证进行有效筛选;术后超声定期随访能安全、便捷、直观地对大隐静脉闭塞情况进行准确评估。综上所述,超声引导下射频消融联合泡沫硬化剂治疗不同管径大隐静脉曲张后
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