欧洲慢性静脉疾病诊疗指南 | ESVS第八章--特别注意事项(一)1.2

☆第八章 特别注意事项☆

大多数浅静脉血栓形成(SVT)是自发的或在轻微局部创伤后发生，通常出现在静脉曲张(VVs)患者中。SVT并非总是良性疾病，因为血栓可能向上移行并延伸至深静脉系统。患者通常表现为疼痛的红色肿块或索状，患处局部水肿和温热。超声多普勒(DUS)检查是评估血栓范围和排除并发深静脉血栓形成的必需方法。如果SVT仅涉及静脉曲张支流的短段(<5cm)，通过穿刺或小切口清除血栓可能能迅速缓解局部疼痛。关于SVT治疗的详细指南可参考ESVS静脉血栓临床实践指南。^[2]

由于未经治疗的静脉曲张(VVs)、髂静脉出口阻塞或右心衰竭引起的静脉高压可能对网状静脉或毛细血管施加过量压力。随后，皮肤可能变得更薄，形成水泡。只要表皮保持完整，可能只会造成淤青，但是，即使在轻微创伤后，如在温暖的淋浴中由于静脉扩张或在睡眠时发生，这可能导致异常出血，甚至可能致命^[34]。这类事件通常发生在独居的老年患者身上。有脉动性静脉曲张的患者特别容易发生急性出血(见第8.2.4节)。出血也可能发生在下肢溃疡(VLU)中。

出血通常通过立即抬高患处并施加外部压力来止血。使用泡沫硬化疗法可以有效治疗小直径的静脉曲张和水泡，以避免进一步出血^[483]。如有可能，调查和治疗潜在的静脉功能不全还将进一步减少复发出血的风险。

☆ 8. SPECIAL CONSIDERATIONS ☆

Most cases of SVT are spontaneous or after a minor local trauma, usually in patients with VVs. SVT is not always a benign condition, as thrombus may ascend and extend into the deep venous system. Patients usually present with a painful red lump or cord, with localised oedema and warmth over the affected area. DUS is mandatory to evaluate thrombus extent and to exclude concomitant DVT. If the SVT is involving only a short segment of a varicose tributary (<5cm), evacuation of the thrombus by puncture or through a small incision, may alleviate local pain quickly. Detailed guidelines for treatment of SVT are provided in the ESVS Clinical Practice Guidelines on Venous Thrombosis.²

Venous hypertension, resulting from untreated VVs, iliac outflow obstruction, or right cardiac failure, may apply excess pressure to reticular veins or telangiectasias. The overlying skin then may become thinner and blebs may form. Provided the overlying skin remains intact, it may cause only bruising, but, in case of injury, even after minor trauma, it may cause excessive bleeding which can exceptionally be fatal.³⁴ Such an event often occurs during a warm shower because of venous dilation, or it may occur while sleeping, often in elderly patients living alone. Patients with pulsatile VVs may be particularly at risk of acute haemorrhage (see subsection 8.2.4). Bleeding may also occur in a VLU.

Bleeding usually subsides with immediate elevation and external pressure. Treatment of small diameter VVs and blebs can be performed effectively with foam sclerotherapy, to avoid further bleeding.⁴⁸³ Investigation for and treatment of underlying venous incompetence, if possible, will further reduce the risk of recurrent haemorrhage.

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