欧洲慢性静脉疾病诊疗指南 | ESVS第九章--(四) (五) (六)

☆第九章证据的空白和未来展望 ☆

需要进一步指导，以了解不同临床表现和解剖反流模式的最佳战略方法。几乎没有证据支持哪种方式最适合不同的静脉主干、不同的临床分级(根据CEAP)或不同的解剖因素，如隐静脉干的直径或深度。

孤立性干静脉消融后支流分解的真实速率尚不清楚。

关于对功能不全SSV和AASV进行静脉腔内消融的长期结果的RCT仍然缺失。

需要进一步揭示何时以及如何治疗功能不全的PVs。

应澄清每种静脉腔内消融模式后压缩的需求和持续时间，因为目前的证据存在很大矛盾。

关于围手术期血栓预防的患者选择以及不同产品(LMWH、DOACs)、剂量和预防时间的使用，可靠证据极少。

总体而言，需要明确且基于证据的标准来选择深静脉干预患者。目前的评分系统未包括静脉跛行。

需要更好的特异性疾病生活质量评分，以评估深静脉干预前后患者的情况。

深静脉阻塞的诊断大多基于形态学发现，有关阻塞血流动力学评估的数据有限。特别是这可能导致对非血栓性髂静脉病变的过度治疗。

髂静脉支架植入术后的抗凝和抗血小板治疗仍存在争议。

髂静脉成像在静脉腿溃疡中的作用尚不明确。

对于静脉腿溃疡，如何彻底消除浅静脉反流及是否需要溃疡下静脉丛消融的证据不足。

对于慢性溃疡超过六个月的患者，在溃疡愈合中，浅静脉消融手术的作用尚不明确。

在慢性静脉溃疡管理策略中，诊断和治疗静脉外流阻塞的时机和作用作为浅静脉消融和压缩的辅助尚不清楚。

对于静脉腿溃疡患者，需要更多的随机对照试验来评估不同策略对溃疡愈合、复发率以及长期随访中需要重新手术次数的影响。

☆ 9. GAPS IN EVIDENCE AND FUTURE PERSPECTIVES☆

Further guidance is needed to understand the optimal strategic approaches to different clinical presentations and anatomical reflux patterns. There is little evidence to support which modalities are best for different truncal veins, varying clinical class (according to CEAP) or differing anatomical factors, such as saphenous trunk diameter or depth.

The true rate of tributary regression following isolated truncal vein ablation remains unclear. 

RCTs looking at the long term outcome of endovenous ablation of an incompetent SSV and AASV are still missing.

When and how to treat incompetent PVs in which patients needs to be further unravelled.

The requirement for and duration of compression following each modality of endovenous truncal ablation should be clarified, as the available evidence is very contradictory.

There is minimal reliable evidence on patient selection for peri-procedural thromboprophylaxis and the use of different products (LMWH, DOACs), dose and duration of prophylaxis.

In general, clear and evidence based criteria are needed to select patients for deep venous interventions. Venous claudication is not included in the available scoring systems. 

Better disease specific QoL scores are needed, to evaluate patients before and after deep venous intervention.

Diagnosis of deep venous obstruction is mostly based on morphological findings and limited data on haemodynamic evaluation of obstruction are available. In particular this may lead to overtreatment of NIVLs.

Post-procedural anticoagulation and antiplatelet treatment after iliac vein stenting remains a matter of debate.

The role of iliac venous imaging in VLU is unknown.

There is a lack of evidence about how radical elimination of superficial venous reflux should be for a VLU and whether subulcer venous plexus ablation is necessary.

The role of superficial venous ablation procedures in ulcer healing for patients with chronic ulcers of greater than six months duration is unknown.

In the chronic VLU management strategy, the timing and role of diagnosing and treating venous outflow obstruction as an adjunct to superficial venous ablation and compression is unclear.

In patients with VLU, more RCTs are needed to evaluate the different strategies on ulcer healing, recurrence rate, and the effect on the number of re-operations needed at long term follow up.

未完待续...

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