血流动力学导向选择性属支切除联合腔内射频消融治疗原发性下肢静脉曲张的疗效与安全性分析

Efficacy and safety of hemodynamically guided selective tributary phlebectomy combined with endovenous radiofrequency ablation for primary lower extremity varicose veins

摘要:

背景与目的 近年来，慢性静脉疾病（CVD）的治疗理念逐渐由单纯解剖学切除向血流动力学导向的精准治疗转变。对于接受腔内射频消融（RFA）的原发性下肢静脉曲张（PLEVV）患者，曲张属支是否均需同期切除尚存在争议。本研究旨在评价RFA联合血流动力学导向选择性属支切除治疗PLEVV的临床疗效与安全性。方法 回顾性分析2024年12月—2025年11月首都医科大学附属北京同仁医院血管外科接受RFA治疗的PLEVV患者166例。根据属支处理方式不同分为常规组56例和改良组110例。常规组行RFA联合全面点状曲张静脉切除，改良组行RFA联合基于术前彩色多普勒超声血流动力学评估的选择性属支切除。比较两组患者基线资料、围手术期指标、术后并发症、超声随访结果及静脉临床严重程度评分（VCSS）和慢性静脉疾病生活质量问卷（CIVIQ-20）变化情况。结果 两组患者年龄、性别、病程、术前VCSS及CIVIQ-20评分差异均无统计学意义（均P>0.05），但改良组CEAP C3级患者比例高于常规组，而常规组CEAP C2级患者比例较高（均P<0.05）。与常规组比较，改良组局部麻醉应用比例更高，手术时间更短，术区切口数量及术中出血量更少，术后1 h疼痛评分更低（均P<0.05）；两组RFA时间及离院前疼痛评分差异均无统计学意义（均P>0.05）。术后1个月和3个月，两组残余曲张静脉、皮下硬结发生率以及超声随访指标比较差异均无统计学意义（均P>0.05）。两组VCSS和CIVIQ-20评分均较术前明显改善（均P<0.05）；改良组VCSS改善幅度低于常规组（P<0.05），但两组CIVIQ-20评分改善幅度相当（P>0.05）。结论 血流动力学导向选择性属支切除联合RFA治疗PLEVV安全、有效，在获得与传统全面点状切除相近的短期疗效的同时，可减少手术创伤、缩短手术时间、降低术中出血量并促进围手术期恢复，体现了CVD精准化和微创化治疗的发展方向。

Abstract:

Background and Aims The management of chronic venous disease has gradually shifted from extensive anatomical removal toward hemodynamic-oriented precision treatment. Whether all varicose tributaries should be routinely removed during endovenous radiofrequency ablation (RFA) remains controversial. This study aimed to evaluate the efficacy and safety of hemodynamically guided selective tributary phlebectomy combined with RFA for primary lower extremity varicose veins.Methods A retrospective analysis was conducted on 166 patients with primary lower extremity varicose veins who underwent RFA at Beijing Tongren Hospital, Capital Medical University, between December 2024 and November 2025. According to the tributary treatment strategy, 56 patients underwent RFA with conventional extensive stab phlebectomy (conventional group), whereas 110 patients underwent RFA with hemodynamically guided selective tributary phlebectomy (modified group). Baseline characteristics, perioperative outcomes, postoperative complications, duplex ultrasound findings, the Venous Clinical Severity Score (VCSS), and the Chronic Venous Insufficiency Questionnaire-20 (CIVIQ-20) scores were compared.Results No significant differences were observed between the two groups regarding age, sex, disease duration, preoperative VCSS, or CIVIQ-20 scores (all P>0.05). However, the modified group had a higher proportion of CEAP class C3 patients, whereas CEAP class C2 patients predominated in the conventional group (both P<0.05). Compared with the conventional group, the modified group showed a significantly higher use of local anesthesia, shorter operative time, fewer skin incisions, less intraoperative blood loss, and lower pain scores at 1 h after surgery (all P<0.05). No significant differences were found in ablation time or pain scores before discharge (both P>0.05). At 1 and 3 months after surgery, the incidences of residual varicose veins and subcutaneous induration, as well as duplex ultrasound findings, were comparable between the two groups (all P>0.05). Both groups achieved significant improvements in VCSS and CIVIQ-20 scores compared with baseline (all P<0.05). Although VCSS improvement was less pronounced in the modified group (P<0.05), the improvement in CIVIQ-20 scores was similar between groups (P>0.05).Conclusion Hemodynamically guided selective tributary phlebectomy combined with RFA is a safe and effective treatment for primary lower extremity varicose veins. It achieves comparable short-term clinical outcomes to conventional extensive phlebectomy while reducing surgical trauma, operative time, and blood loss, thereby facilitating perioperative recovery.