欧洲慢性静脉疾病诊疗指南 | ESVS第九章--(一) (二) (三)

☆第九章证据的空白和未来展望 ☆

全人群和特定亚组的CVD自然史仍然知之甚少。目前没有强有力的证据来指导哪些C2级病例/肢体会进展为C4级疾病，或者哪些C4级疾病的肢体最有可能进展为溃疡。

需要更好地定义“静脉水肿”(CEAP的C3级)这一术语，以及静脉曲张与水肿之间的关系。

在进行DUS时，评估额外的血流动力学参数的作用(如反流量、再循环指数、体位直径变化、静脉动脉流指数)，而不仅仅是“反流”，仍然不明确，需要进一步研究。

哪些患者在疑似或明显的CVD初步诊断中需要进行额外的腹部DUS也应进一步调查。

空气充盈法在患有慢性外流阻塞的患者中的临床潜力，特别是使用静脉引流指数，需要探索。

在DUS、MRV和CTV上缺乏量化后血栓性梗阻的验证标准。

动态MRV在深静脉阻塞和失禁中的角色需要进一步研究。

对于考虑植入支架的静脉外流阻塞患者，血流入口的评估仍然是一个主要挑战。

生活方式改变和体重减轻在CVD患者中的效果尚未得到适当研究。

运动疗法和特定运动方案的作用理解不足。未来的研究应考虑运动类型(强度、频率和时间)、样本大小、盲法以及根据CVD严重程度的同质性。

目前，重点是在急性DVT后预防PTS的压缩作用，而不是治疗已确诊PTS的患者。需要更多证据来验证ECS的作用及IPC的潜在附加益处，特别是对于中度或重度PTS患者。

☆9. GAPS IN EVIDENCE AND FUTURE PERSPECTIVES☆

The natural history of CVD for the whole population and for specific subgroups remains poorly understood. There is no strong evidence to guide which patients/limbs with C2 disease will progress to C4 disease, or which limbs with C4 disease are at the highest risk of progressing to ulceration.

The term “venous oedema” (C3 of CEAP), as well as the relationship between varicose veins and oedema need to be better defined.

When performing DUS, the role of evaluating additional haemodynamic parameters (such as reflux volume, recirculation index, postural diameter change, venousarterial flow index), instead of “reflux” only, remains unclear and needs more research.

Which patients require additional abdominal DUS during the initial work up for suspected or obvious CVD should be further investigated.

The clinical potential of air plethysmography, in particular the use of the venous drainage index, in patients with chronic outflow obstruction needs to be explored.

Validated criteria for quantification of post-thrombotic obstruction on DUS, MRV, and CTV are lacking.

The role of dynamic MRV in deep venous obstruction and incompetence needs further investigation.

Assessment of inflow remains a major challenge for patients with venous outflow obstruction being considered for stenting.

The effect of lifestyle changes and weight loss has not been studied properly in patients with CVD.

The role of exercise therapy and specific exercise programmes is poorly understood. Future research into the effect of physical exercise should consider types of exercise protocols (intensity, frequency, and time), sample size, blinding, and homogeneity according to the severity of CVD.

So far, the focus has been on the role of compression to prevent PTS after acute DVT, not on treatment of patients with established PTS. More evidence is needed to validate the role of ECS and also the potential additional benefit of IPC, in particular for patients with moderate or severe PTS.

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