欧洲慢性静脉疾病诊疗指南 | ESVS第八章--特别注意事项(二)1

☆第八章 特别注意事项☆

多项研究已充分确认了CVD与肥胖之间的关系。现代肥胖流行病学的发展反映在社区和人群研究中肥胖者比例的增加，这些研究均与CVD有关^[484]。肥胖患者往往在静脉门诊中占比过高，而极度肥胖患者通常伴有下肢皮肤变化和与CVD一致的溃疡^[485,486]。

肥胖对静脉血流动力学的影响已广泛描述，包括增加反流和更高的静脉压力，这些都加重了CVD的严重程度^[487]。这主要是由于腹内压升高所致^[488]。肌肉泵功能不全也被认为与肥胖相关。尽管肥胖患者的肌肉泵增加了静脉排血量，但其使用频率较低，每日步数也较少^[487]。

因此，肥胖日益重要，因为它加重了CVD的严重程度，影响治疗策略和结果。在包括65,329名接受EVTA、静脉点剥手术和超声引导下静脉硬化剂治疗或联合治疗的患者的回顾性分析中，相比于较低BMI的患者，BMI为35＞kg/m²的患者显示较差的结果(r-VCSS，CIVIQ-20)。然而，所有BMI类别的患者在治疗后六个月内的r-VCSS和CIVIQ-20得到了改善^[489]。如果需要静脉干预治疗，则EVTA或非热消融干预优先于开放手术^[127]，因为静脉消融后的创面感染等并发症很少见。然而，与非肥胖患者相比，由于静脉较深，插管和消融可能在技术上更具挑战性。

减重是治疗的有效辅助手段。对于极度肥胖者，减重手术可以将皮肤问题从75%至80%降低到36.4%^[486]。另一项研究比较了对72名极度肥胖且CVI表现严重的患者进行减重手术与51名类似患者未接受手术的效果。减重手术组显示BMI显著下降，这些患者的VLU愈合率增加，静脉跛行减少，并改善了静脉生活质量^[490]。对于轻度肥胖患者，通过生活方式改变推荐减重以达到类似的益处(见第3.1节)。

☆8. SPECIAL CONSIDERATIONS ☆

The relationship between CVD and obesity is well recognised in numerous studies. The modern epidemic of obesity is reflected in the increasing proportion of those who are obese in community and population studies on CVD.⁴⁸⁴ Obese patients are often over-represented in venous clinics. Morbidly obese patients often have lower limb skin changes and ulcers consistent with CVD.^485,486

The impact of obesity on venous haemodynamics, with increased reflux and greater venous pressures contributing to the greater CVD severity are all well described.⁴⁸⁷ The primary mechanism for this is the raised intraabdominal pressure.⁴⁸⁸ Muscle pump deficiency has also been implicated in the obese. Despite the muscle pump of an obese patient having increased venous ejection volumes, it is used less frequently with fewer daily steps.⁴⁸⁷

Therefore, obesity is increasingly important, as it contributes to the severity of CVD and influences treatment strategies and outcomes. In a retrospective analysis including 65 329 patients undergoing EVTA, phlebectomies, and UGFS or combined treatment, inferior outcomes (r-VCSS, CIVIQ-20) were observed in patients with a BMI of  35 kg/m2 compared with those having a lower BMI. However, improvements in r-VCSS and CIVIQ-20 were found in all BMI categories six months after treatment.⁴⁸⁹ If venous intervention is indicated, EVTA or nonthermal ablation of incompetent saphenous trunks is preferred over open surgery,¹²⁷ as complications such as wound infection after endovenous ablation are rare. However, cannulation and ablation may be technically demanding as veins are deeper under the skin compared with non-obese patients.

Weight loss is an effective adjunct to treatment. For those with morbid obesity, bariatric surgery improves skin problems from 75% to 80% down to 36.4% after weight loss.⁴⁸⁶ Another study compared the effect of bariatric surgery in 72 patients with morbid obesity and severe manifestations of CVI with 51 similar patients who did not have surgery. In addition to a significant drop in BMI in the surgery group, these patients showed an increased rate of VLU healing, a decrease in venous claudication, and an improvement in venous QoL.⁴⁹⁰ Weight loss, by lifestyle changes in those with less severe obesity, is recommended to achieve similar benefits (see subsection 3.1).

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