目的:静脉淋巴水肿是西方社会下肢淋巴水肿最常见的原因之一。虽然复杂的减充血疗法(CDT)是淋巴水肿的主要治疗方法,它在慢性髂股静脉阻塞(CIVO)引起的静脉血栓水肿(PLE)中的作用值得进一步探讨。作者通过对患有CEAP临床3级(C3)疾病的肢体首先使用CDT方案和对患有更晚期CEAP临床级(C4-6)疾病的患者首先进行阻塞的支架矫正来评估这一点。这项研究代表了使用这种方案后的结果分析。
方法:对192例四肢(166例患者)进行前瞻性收集的数据分析,这些患者接受了因淋巴闪烁图确定的静脉水肿导致的VO症状损害的生活质量(QoL)治疗。评估的特征包括CEAP临床分类,静脉临床严重程度评分(VCSS),肿胀等级(GOS),VAS疼痛评分,QoL(CIVIQ-20),CIVO支架置入及与CDT和支架置入相关的结局。在接受CDT或支架植入后接受CDT的四肢中,在6周时评估结果,3-,CDT完成后6个月和12个月。配对/非配对t-测试,卡方检验和方差分析用于临床变量的比较,而Kaplan-Meier分析用于评估支架的通畅性,并使用对数秩检验来区分不同的曲线。
结果:整个队列中有192条肢体,C3组74条,C4-6组118条。中位年龄为63岁。有57名男性和109名女性。在C3组中,CDT后,在6周时,VCSS和VAS疼痛评分有所改善(p<0.0001),3(p<0.0001),6个月(p<0.0001)和12个月(p<0.0001)。在6个月(p<0.0001)和12个月(p=0.0005)观察到GOS的改善。CIVIQ-20评分从63分提高到38分(p=0.009)。C3组的9条肢体(12%)在CDT后需要支架置入。在C4-6组中,在139个肢体中,75(54%)四肢仅接受支架置入术,而64(46%)肢体由于持续的QoL损害症状而接受了支架置入术,然后接受了CDT。对于后一组,CDT后,VCSS有所改善,6周时的GOS和VAS疼痛评分(p<0.0001),3(p<0.0001),6个月(p<0.0001)和12个月(p<0.0001)。CIVIQ-20评分从61分提高到34分(p<0.0001)。Primary,初级辅助,C4-6组在36个月时的继发性通畅率为92%,100%,分别为100%。
结论:在因慢性髂股静脉阻塞而出现静脉血栓水肿的CEAPC3患者中,复杂的减充血疗法应该是一线治疗的一部分。尽管进行了复杂的减充血治疗,但仍有生活质量受损症状的患者应保留支架治疗。此外,CDT还有助于缓解患有更晚期CEAPC4-6疾病的患者的症状,并在支架置入后持续/残留水肿。需要进一步研究。
OBJECTIVE: Phlebolymphedema has been noted to be one of the most common causes of lymphedema in the lower extremity in western societies. Although complex decongestive therapy (CDT) represents the mainstay of lymphedema treatment, its role for
phlebolymphedema arising from chronic iliofemoral venous obstruction (CIVO) merits further exploration. We evaluated this through the use of a protocol of CDT first for limbs with CEAP (clinical, etiologic, anatomic, pathophysiologic) clinical C3 disease and stent correction of obstruction before CDT for those with more advanced disease (CEAP C4-C6). In the present study, we analyzed the outcomes after the use of such a protocol.
METHODS: We analyzed prospectively collected data for 192 limbs (166 patients) that underwent treatment of quality-of-life (QoL) impairing symptoms from CIVO due to lymphoscintigraphically determined
phlebolymphedema between 2017 and 2022. The characteristics evaluated included CEAP clinical class, venous clinical severity score (VCSS), grade of swelling (GOS), visual analog scale (VAS) pain score, QoL (CIVIQ-20 [20-item chronic venous disease quality of life questionnaire]), stenting for CIVO, and outcomes related to CDT and stenting. For the limbs undergoing CDT or stenting followed by CDT, the outcomes were evaluated at 6 weeks and 3, 6, and 12 months after completion of CDT. Paired and unpaired t tests, χ2 tests, and analysis of variance were used for comparisons of clinical variables. Kaplan-Meier analysis was used to evaluate stent patency, with the log-rank test used to discriminate between different curves.
RESULTS: Of the 192 limbs (166 patients) in the entire cohort, 74 were in the C3 group and 118 were in the C4-C6 group. The median patient age was 63 years; 57 were men and 109 were women. In the C3 group, after CDT, improvement had occurred in the VCSS and VAS pain score at 6 weeks (P < .0001) and at 3 (P < .0001), 6 (P < .0001), and 12 (P < .0001) months. Improvement in the GOS was noted at 6 (P < .0001) and 12 (P = .0005) months. The CIVIQ-20 score improved from 63 to 38 (P = .009). Nine limbs (12%) in the C3 group required stenting after CDT. In the C4-C6 group, of the 118 limbs, 75 (64%) underwent stenting only and 43 (36%) underwent stenting followed by CDT for persistent QoL impairing symptoms. For this latter group, after CDT, improvement occurred in the VCSS, GOS, and VAS pain score at 6 weeks (P < .0001) and 3 (P < .0001), 6 (P < .0001), and 12 (P < .0001) months. The CIVIQ-20 score improved from 61 to 34 (P < .0001). The primary, primary assisted, and secondary patency in the C4-C6 group at 36 months was 92%, 100%, and 100%, respectively.
CONCLUSIONS: For CEAP C3 patients with
phlebolymphedema due to CIVO, CDT should be a part of the first line of treatment. Stenting should be reserved for those with QoL impairing symptoms despite the use of CDT. Additionally, CDT helps provide symptom relief for patients with more advanced CEAP C4-C6 disease with persistent or residual edema after stenting. Further study is warranted.