髂股静脉术后支架内再狭窄因素的分析及处理

摘要/Abstract

摘要：

髂股静脉支架植入术（IVS）是目前治疗各类急慢性深静脉阻塞疾病的一线治疗措施，有效改善临床症状。然而，IVS后发生支架内再狭窄（ISR）是影响支架通畅及造成再干预的主要原因。ISR是复杂的病理生理过程，与术前狭窄程度、病变特征、支架位置、支架受压程度、支架流入道面积以及其他生物学力学因素等多种危险因素有关。对于ISR的处理目前仍以球囊扩张为主要治疗手段，还应注重术后随访及监测，合理使用抗凝或抗血小板药物，把握合适的手术指征，根据病人情况选择合理的治疗方法。激光消融、动脉内膜切除装置以及放射治疗可能成为未来治疗ISR的新方法。

关键词:髂股静脉支架植入术,再狭窄,危险因素

Abstract:

Iliofemoral venous stent placement (IVS) is currently the first-line treatment for various acute and chronic deep vein obstruction diseases, effectively improving clinical symptoms in patients. However, in-stent restenosis (ISR) after IVS is a major cause of stent-occlusion issues and re-intervention. ISR is a complex pathophysiological process related to multiple risk factors, including preoperative stenosis severity, lesion characteristics, stent position, stent compression, inflow area of the stent, and other biomechanical factors. Currently, the management of ISR primarily involves balloon dilation, it is also essential to emphasize postoperative follow-up and monitoring, rational use of anticoagulant or antiplatelet medications, appropriate surgical indications, and choosing the right treatment method based on patient conditions. Laser ablation, intravascular endarterectomy devices, and radiation therapy may become new options for ISR treatment in the future.

Key words:Iliofemoral venous stent placement(IVS),In-stent restenosis(ISR),Risk factor

中图分类号:

R543.6

续慧民, 高红霞. 髂股静脉术后支架内再狭窄因素的分析及处理[J]. 外科理论与实践, 2024, 29(06): 481-486.

XU Huimin, GAO Hongxia. Management of in-stent restenosis after iliofemoral venous stenting[J]. Journal of Surgery Concepts & Practice, 2024, 29(06): 481-486.

图/表2

ISR病变	软病变	硬病变
病因	血栓覆盖支架引起	由胶原蛋白组成的纤维性病变，可能发生钙化
病变位置	可延伸至支架的流入道	通常不会延伸至支架的流入道
发生时间	在支架植入后早期发生	在支架植入后晚期发生
血管内超声表现	较低回声	较强回声
复发倾向	较小	较大
病变特征	临床症状复发较少，对球囊扩张的抵抗较小	临床症状复发较多，对球囊扩张的抵抗较大
发生机制	流入/流出道问题，需纠正	与流入/流出道问题无关
治疗方法	血管成形术有助于改善狭窄情况	激光消融或内膜切除术对难治性病例有帮助

表1

表2

IVS术后推荐的抗凝方案

疾病类型	治疗阶段	推荐方案	疗程	推荐等级	一致性等级
NIVLs	初始阶段	抗凝药物±抗血小板药物	1个月	A	Ⅰ
	初始阶段	推荐低分子肝素或新型口服抗凝药作为初始抗凝药物	1个月	A	Ⅲ
	维持阶段	单独抗凝治疗或单独抗血小板治疗	未明确	C	Ⅲ
	维持阶段	推荐使用直接口服抗凝药作为优选抗凝药物	未明确	A	Ⅲ
急性髂股深静脉血栓	初始阶段	治疗剂量抗凝±抗血小板药物	1个月	A	Ⅲ
	初始阶段	如果选择抗凝加抗血小板药物	≥6个月	A	Ⅲ
	维持阶段	治疗剂量DOAC	至少6个月	A	Ⅳ
PTS	初始阶段	治疗剂量DOAC±抗血小板药物	1个月	A	Ⅲ
	维持阶段	建议使用治疗剂量抗凝药物		A	Ⅲ
	维持阶段	建议使用直接口服抗凝药	≥12个月	A	Ⅳ

表2

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