欧洲慢性静脉疾病诊疗指南 | ESVS第八章--特别注意事项(二)2.3

☆第八章 特别注意事项☆

怀孕是CVD的一个促发因素，会增加毛细血管扩张、网状静脉、静脉曲张和VVs手术后SFJ反流的频率^[491]。腿部水肿可能影响高达80%的孕妇，主要发生在妊娠第三季。一些女性会发展出阴部静脉曲张，在每次后续怀孕时通常会加重(见第7.2节)。

对于孕妇，处理腿部水肿、静脉曲张和阴部静脉曲张大多采用保守治疗，如使用压缩弹力袜。压缩弹力袜不仅对大隐静脉(GSV)和小隐静脉(SSV)的直径和反流有益，还改善了CVD的症状和体征^[492-494]。根据NICE静脉曲张管理指南，在怀孕期间不应提供干预性治疗^[495]。在大多数女性中，毛细血管、网状静脉和静脉曲张至少部分在产后的首个月内消退。因此，任何进一步的治疗应推迟至分娩后三至六个月后再考虑。

长期接受抗凝治疗的患者如果暂时中断药物可能会增加血栓栓塞事件的风险。可以考虑桥接治疗，但这会增加成本并增加静脉干预计划的复杂性。另一方面，继续抗凝治疗可能会增加出血的风险或降低消融治疗的疗效。

关于浅静脉功能不全的治疗，这一领域最大的研究包括65名长期抗凝患者进行了100次EVTA，以及89名对照组进行了127 EVTA^[496]。在18个月后，92%的抗凝患者和95%的对照组成功消融了隐静脉(p=0.96)。同侧腿部DVT的发生率较低(抗凝患者为1%，对照组为1.6%)。其他较小的研究也得出了类似的结果，并且Delphi共识也建议不要为腔内静脉消融桥接维生素K拮抗剂^[127]。抗凝治疗不是硬化疗法的禁忌^[143]。 然而，患者应被告知，治疗成功率可能会降低，可能需要额外的治疗会话。

关于深静脉病理的治疗，不同研究中使用的抗血栓方案是异质的^[355]。对于抗凝治疗的类型和持续时间没有研究。总的建议是，在术前接受抗凝患者不应中断，而应转为低分子量肝素治疗，并在干预后短期內继续治疗(见第5.3.4节)。

☆8. SPECIAL CONSIDERATIONS ☆

Pregnancy is a contributory factor to CVD, increasing the frequency of telangiectasias, reticular veins, VVs, and recurrent SFJ reflux after VV surgery.⁴⁹¹ Leg oedema can affect up to 80% of pregnant women, mainly during the third trimester. Some women develop vulvar VVs, which tend to be exacerbated with each subsequent pregnancy (see subsection 7.2).

In pregnant women treatment of leg oedema, VVs, and vulvar VVs is mostly conservative with compression hosiery. ECS not only have a beneficial effect on GSV and SSV diameter and reflux, but also improve symptoms and signs of CVD.^492--494 According to the NICE guidelines on management of VVs, interventional treatment should not be offered during pregnancy.⁴⁹⁵

In the majority of women, telangiectasias, reticular veins, and VVs subside at least partially within the first postpartum months. Any further treatment should therefore be postponed until three to six months after delivery.

Patients receiving long term anticoagulants may be at increased risk of thromboembolic events if their medication is temporarily interrupted. Bridging may be considered, but this increases costs and adds complexity to the planning of venous interventions. On the other hand, continuing anticoagulants might increase the risk of bleeding or decrease the efficacy of the ablation.

Concerning treatment of superficial venous incompetence, the largest study on this topic included 100 EVTA procedures in 65 chronically anticoagulated patients and 127 procedures in 89 controls.⁴⁹⁶ After 18 months, successful saphenous ablation was found in 92% of anticoagulated patients and in 95% of controls (p ¼ .96). The frequency of DVT in the ipsilateral leg was low (1% in anticoagulated patients versus 1.6% in controls). Other smaller studies found similar results and a Delphi consensus also advised against bridging of vitamin K antagonists for endovenous ablation.¹²⁷ Anticoagulation treatment is not a contraindication to sclerotherapy.¹⁴³ However, patients should be advised that treatment success may be reduced and/or additional treatment sessions may be required.

Concerning treatment of deep vein pathology, antithrombotic regimens used in different studies are heterogeneous.³⁵⁵ Neither type of anticoagulation nor duration have been studied. In general, the advice is that patients on anticoagulants should not pause but switch to LMWH preoperatively and continue this treatment shortly after the intervention (see subsection 5.3.4).

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