欧洲慢性静脉疾病诊疗指南 | ESVS第八章--特别注意事项(二)4.5

☆第八章 特别注意事项☆

一项对美国38,750名患者进行的大型研究的流行病学数据显示，多达30% CVD是在65岁以上的患者中^[497]。这一队列中常见的合并症包括糖尿病(25%)、高血压(64%)、慢性阻塞性肺病(5%)、癌症史(12%)和中风(3%)。冠状动脉疾病(0.12%)和外周动脉疾病(0.03%)较少见。需要注意的是，与年轻患者相比，65岁以上的患者更可能需要静脉介入治疗，因为他们报告的静脉症状和皮肤变化率更高(12% vs. 6%，p<0.001)，以及下肢溃疡(5% vs. 2%，p<0.001)^[497]。

一项多中心前瞻性研究证实，对于年龄超过75岁且合并症较多的患者群体，局部肿胀麻醉下的腔內静脉热消融术(EVTA)的疗效和安全性与年轻患者相当^[498]。然而，年龄在另一项老年患者中的研究中被发现是再通的显著风险因素,其OR为1.03 (95% CI:1.01~1.04, p<0.001)，这在多变量分析中仍然具有统计学意义^[165]。

右心衰竭或三尖瓣反流患者有时可能因高压反流导致搏动性静脉曲张。在这些患者中，标准腔內静脉治疗方法可能失效因为不足的炎症和静脉闭合。搏动性静脉曲张是进行术前心脏评估的指征，但相关信息稀缺。

在儿童中，慢性静脉疾病(CVD)罕见，可能是先天性静脉畸形(包括深静脉闭锁)、主要浅表和/或深静脉瓣膜功能不全，或广泛的深静脉血栓形成(DVT)导致的深静脉功能不全(DVI)和/或梗阻。由于在危重病儿科患者中中心静脉导管的更频繁使用，DVT和静脉血栓栓塞病(VTE)的发生率在过去几十年中有所增加^[2]。这导致了儿童PTS的增加，根据一项荟萃分析，PTS在儿童DVT中发生率为26%(0~77%)^[499]。

儿童CVD的管理主要是保守治疗，尽管在症状严重的情况下可以考虑静脉介入治疗。在一小群年龄中位数为14岁的35名儿童中，EVLA已被报道对静脉畸形、Klippel-Trenaunay综合征和浅表静脉反流伴有静脉曲张的主要治疗是可行和安全的，治疗成功率为83%^[500]。

☆ 8. SPECIAL CONSIDERATIONS ☆

Epidemiological data from a large study on 38 750 US patients suggest that up to 30% of CVD presentations are in patients aged > 65 years.⁴⁹⁷ Commonly reported comorbidities in this cohort include diabetes (25%), hypertension (64%), chronic obstructive pulmonary disease (5%), history of cancer (12%), and stroke (3%). Coronary artery disease (0.12%) and peripheral artery disease (0.03%) are infrequent. Importantly those aged > 65 years are more likely to require venous intervention than their younger counterparts, given their higher rates of reported venous symptoms, as well as skin changes (12% vs. 6%, p < .001) and VLU (5% vs. 2%, p < .001).⁴⁹⁷

A multicentre prospective study confirmed comparable rates of efficacy and safety for EVTA in local tumescent anaesthesia in cohorts of patients aged > 75 years, with more comorbidities compared with younger patients.⁴⁹⁸ However, age was found to be a statistically significant risk factor for recanalisation in another study in elderly patients with an OR of 1.03 (95% CI 1.01--1.04, p < .001), which remained statistically significant in multivariable analysis.¹⁶⁵

Patients with right heart failure or tricuspid valve regurgitation may sometimes present with pulsatile VVs from high pressure reflux. In these patients, standard endovenous treatment modalities might fail as a result of insufficient inflammation and collapse of the treated vein. Pulsatile VVs are an indication for pre-operative cardiac evaluation, but information on this is scarce.

In children CVD is rare and may be a result of congenital venous malformation (including atresia of deep veins), primary superficial and/or deep vein valve incompetence, or extensive DVT with secondary DVI and/or obstruction. Incidence of DVT and VTE has been increasing during the last decades because of more frequent use of central venous catheters in critically ill paediatric patients.² This has resulted in a rising incidence of paediatric PTS as, according to a meta-analysis, PTS occurs in 26% (0 -- 77%) of paediatric DVTs.⁴⁹⁹

Management of children with CVD is mainly conservative, although venous interventions may be considered in highly symptomatic cases. EVLA has been reported feasible and safe in a small group of 35 children, with a median age of 14 years, undergoing EVLA mainly for venous malformations, Klippel-Trenaunay syndrome, and superficial venous reflux with VVs. The treatment was deemed successful in 83% of cases.⁵⁰⁰

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