Endovenöse Therapie chronisch venöser Obstruktionen

Zusammenfassung

Bei der chronisch venösen Obstruktion (CVO) liegt ein Abstromhindernis vor, welches eine venöse Hypertension im betroffenen Bein verursacht. Die CVO tritt vornehmlich auf dem Boden eines postthrombotischen Syndroms (PTS) oder eines May-Thurner-Syndroms (MTS) auf. Die CVO kann zu einer deutlichen Einschränkung des täglichen Lebens führen und hat erhebliche sozioökonomische Konsequenzen. Bei der endovenösen Rekanalisation zur Behandlung einer symptomatischen CVO handelt es sich um eine relativ neue therapeutische Option, die mittlerweile generell als Behandlung der ersten Wahl akzeptiert ist. Seit Verwendung spezieller venöser Stents können auch ausgedehntere Befunde, die eine anspruchsvollere Rekonstruktion erforderlich machen, erfolgreich therapiert werden.

Damit nach einer venösen Rekanalisation keine Stase des Blutstroms und ein Primärverschluss auftreten, müssen ein suffizienter Ein- und Ausstrom gewährleistet sein. Zur Verbesserung des Einstroms werden Hybrideingriffe mit Endophlebektomie der Vena femoralis communis und AV-Fistel-Anlage, zur Ausstromverbesserung werden spezielle Rekonstruktionen der Vena-cava-inferior-Konfluenz, z. B. die Skipped-Technik, empfohlen.

Abstract

Chronic venous obstruction (CVO) is an outflow obstruction that causes venous hypertension in the affected leg. CVO occurs primarily on the basis of a post-thrombotic syndrome (PTS) or a May-Thurner syndrome (MTS). CVO can lead to a considerable limitation in daily life and has significant socioeconomic consequences. Endovenous recanalization for the treatment of symptomatic CVO is a relatively new therapeutic option that is now generally accepted as the first choice of treatment. Since the use of special venous stents, more extensive pathologies, which require more demanding reconstruction, can also be treated successfully.

Adequate inflow and outflow must be ensured to prevent stasis of the blood flow and early occlusion after venous recanalization. To improve the inflow, hybrid interventions with endophlebectomy of the common femoral vein and creation of an AV fistula could be helpful; special reconstruction of the inferior vena cava confluence, e. g., the skipped technique, is recommended to improve outflow.

Schlüsselwörter

chronisch venöse Obstruktion - postthrombotisches Syndrom - May-Thurner-Syndrom - venöse Rekanalisation - venöse Stents

Key words

chronic venous obstruction - post-thrombotic syndrome - May-Thurner syndrome - venous recanalization - venous stents

• Literatur

• 1 MacDougall DA, Feliu AL, Boccuzzi SJ. et al. Economic burden of deep-vein thrombosis, pulmonary embolism, and post-thrombotic syndrome. Am J Health Syst Pharm 2006; 63: S5-S15
• 2 Kahn SR, Galanaud JP, Vedantham S. et al. Guidance for the prevention and treatment of the post-thrombotic syndrome. J Thromb Thrombolysis 2016; 41: 144-153
• 3 Galanaud JP, Kahn SR. Postthrombotic syndrome: a 2014 update. Curr Opin Cardiol 2014; 29: 514-519
• 4 Birn J, Vedantham S. May-Thurner syndrome and other obstructive iliac vein lesions: meaning, myth, and mystery. Vasc Med 2015; 20: 74-83
• 5 Einar S. Edema in venous insufficiency. In: Hugo P. Hrsg. Phlebolymphology. Les Laboratoires Servier; 2011: 3-14
• 6 Kahn SR, Ginsberg JS. The post-thrombotic syndrome: current knowledge, controversies, and directions for future research. Blood Rev 2002; 16: 155-165
• 7 Kahn SR, Comerota AJ, Cushman M. et al. The postthrombotic syndrome: evidence-based prevention, diagnosis, and treatment strategies: a scientific statement from the American Heart Association. Circulation 2014; 130: 1636-1661
• 8 Villalta S, Bagatella P, Piccioli A. et al. Assessment of validity and reproducibility of a clinical scale for the post-thrombotic syndrome. Haemostasis 1994; 24: 158a
• 9 Arnoldussen CW, de Graaf R, Wittens CH. et al. Value of magnetic resonance venography and computed tomographic venography in lower extremity chronic venous disease. Phlebology 2013; 28 (Suppl. 01) 169-175
• 10 Neglén P. Chronic deep venous obstruction: definition, prevalence, diagnosis, management. Phlebology 2008; 23: 149-157
• 11 Wen-da W, Yu Z, Yue-Xin C. Stenting for chronic obstructive venous disease: A current comprehensive meta-analysis and systematic review. Phlebology 2016; 31: 376-389
• 12 Schleimer K, Barbati ME, Grommes J. et al. Update on diagnosis and treatment strategies in patients with post-thrombotic syndrome due to chronic venous obstruction and role of endovenous recanalization. Journal of vascular surgery Venous and lymphatic disorders 2019; 7: 592-600
• 13 Schleimer K, Barbati ME, Gombert A. et al. The Treatment of Post-Thrombotic Syndrome. Dtsch Arztebl Int 2016; 113: 863-870
• 14 Berger A, Jaffe JW, York TN. Iliac compression syndrome treated with stent placement. J Vasc Surg 1995; 21: 510-514
• 15 Neglen P, Hollis KC, Olivier J. et al. Stenting of the venous outflow in chronic venous disease: long-term stent-related outcome, clinical, and hemodynamic result. J Vasc Surg 2007; 46: 979-990
• 16 Neglén P, Tackett Jr TP, Raju S. Venous stenting across the inguinal ligament. J Vasc Surg 2008; 48: 1255-1261
• 17 de Wolf MA, Jalaie H, van Laanen JH. et al. Endophlebectomy of the common femoral vein and arteriovenous fistula creation as adjuncts to venous stenting for post-thrombotic syndrome. Br J Surg 2017; 104: 718-725
• 18 Jalaie H, Arnoldussen C, Barbati M. et al. What predicts outcome after recanalization of chronic venous obstruction: hemodynamic factors, stent geometry, patient selection, anticoagulation or other factors?. Phlebology 2014; 29: 97-103
• 19 van Vuuren T, de Wolf MAF, Arnoldussen C. et al. Editor’s Choice – Reconstruction of the femoro-ilio-caval outflow by percutaneous and hybrid interventions in symptomatic deep venous obstruction. Eur J Vasc Endovasc Surg 2017; 54: 495-503
• 20 Comerota AJ, Grewal NK, Thakur S. et al. Endovenectomy of the common femoral vein and intraoperative iliac vein recanalization for chronic iliofemoral venous occlusion. J Vasc Surg 2010; 52: 243-247
• 21 Kurstjens RL, de Graaf R, Barbati ME. et al. Arteriovenous fistula geometry in hybrid recanalisation of post-thrombotic venous obstruction. Phlebology 2015; 30: 42-49
• 22 Gombert A, Barbati ME, Grommes J. et al. Wound complications after common femoral vein endophlebectomy: Influence on outcome. Phlebology 2017;
• 23 de Graaf R, de Wolf M, Sailer AM. et al. Iliocaval Confluence Stenting for Chronic Venous Obstructions. Cardiovasc Intervent Radiol 2015; 38: 1198-1204
• 24 Barbati ME, Gombert A, Toonder IM. et al. Iliocaval Skip Stent Reconstruction Technique for Chronic Bilateral Iliocaval Venous Occlusion. J Vasc Interv Radiol 2020;
• 25 Barbati ME, Gombert A, Toonder I. et al. Detecting stent geometry changes after venous recanalization using duplex ultrasound. Phlebology 2018;