2022年SVS/AVF/AVLS下肢静脉曲张管理临床实践指南—第I部分:浅静脉主干反流的双功能超声扫描和治疗
The 2022 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part I. Duplex Scanning and Treatment of Superficial Truncal Reflux
指南摘要
美国血管外科学会(Society for Vascular Surgery)、美国静脉论坛(American Venous Forum)和美国静脉与淋巴学会(American Vein and Lymphatic Society)合作更新了2011年美国血管外科学会/美国静脉论坛(American Venous Forum)临床实践指南，并就影响静脉曲张患者治疗的关键问题提供了新的循证建议。每一项建议都是基于最近对下肢静脉曲张患者的诊断检测和治疗方案进行的独立系统回顾和荟萃分析。
该指南的第I部分包括以下方面的循证建议:
【1】使用双功能超声扫描和其他诊断检查评估CEAP(临床分类、病因、解剖学、病理学)2级静脉曲张患者；
【2】开放手术治疗(结扎和剥脱)与静脉腔内消融技术；
【3】主干浅静脉热消融与非热消融治疗；
【4】CEAP 2级疾病中功能不全的交通静脉的管理；
【5】浅表静脉主干功能不全进行静脉消融时，对曲张支脉使用静脉切除术或液体/泡沫硬化疗法(医生配制的泡沫或市售的聚多卡醇微泡沫)的同期与分期治疗。
The Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society collaborated to update the 2011 Society for Vascular Surgery/American Venous Forum clinical practice guidelines and provide new evidence-based recommendations on critical issues affecting the care of patients with varicose veins. Each recommendation is based on a recent, independent systematic review and meta-analysis of the diagnostic tests and treatments options for patients with lower extremity varicose veins. Part I of the guidelines includes evidence based recommendations for the evaluation of patients with CEAP (Clinical Class, Etiology, Anatomy, Pathology) class 2 varicose vein using duplex ultrasound scanning and other diagnostic tests, open surgical treatment (ligation and stripping) vs endovenous ablation techniques, thermal vs nonthermal ablation of the superficial truncal veins, and management of incompetent perforating veins in CEAP class 2 disease. We have also made recommendations on the concomitant vs staged treatment of varicose tributaries using phlebectomy or liquid or foam sclerotherapy (with physician-compounded foam or commercially prepared polidocanol endovenous microfoam) for patients undergoing ablation of incompetent superficial truncal veins. (J Vasc Surg Venous Lymphat Disord 2022;-:1-31.)
指南1：使用双功能超声扫描和其他诊断检查评估CEAP2级静脉曲张患者
1.1.对于下肢慢性静脉疾病患者，建议选择双功能超声扫描作为评估静脉反流的诊断测试。
推荐等级:1B
For patients with chronic venous disease of the lower extremities, we recommend duplex ultrasound scanning as the diagnostic test of choice to evaluate for venous reflux.
Level of recommendation: grade 1 (strong), quality of evidence: B (moderate)
1.1.a.静脉反流的定义：指在主干浅静脉（大隐静脉、小隐静脉、前副大隐静脉、后副大隐静脉）和胫静脉、股深静脉和交通静脉中逆流的最小值>500 ms，在股总静脉、股静脉和腘静脉的逆流最小值>1s。
Reflux is defined as a minimum value >500 ms of reversed flow in the superficial truncal veins (great saphenous vein, small saphenous vein, anterior accessory great saphenous vein, posterior accessory great saphenous vein) and in the tibial, deep femoral, and perforating veins. A minimum value >1 second of reversed flow is diagnostic of reflux in the common femoral, femoral, and popliteal veins.
1.1.b.轴向反流的定义：指静脉从腹股沟到小腿的不间断逆行静脉流。逆流可发生在浅静脉或深静脉，伴或不伴交通静脉。交界处反流指的是局限于隐股或隐腘交界处的反流。节段性反流是发生于部分浅静脉或深静脉的反流。
Axial reflux is defined as uninterrupted retrograde venous flow from the groin to the calf. Retrograde flow can occur in the superficial or deep veins, with or without perforating veins. Junctional reflux will be limited to the saphenofemoral or saphenopopliteal junction. Segmental reflux occurs in a portion of a superficial or deep truncal vein.
1.1.c. “病理性”交通静脉（C2级静脉曲张患者）的定义：双功能超声显示反流持续时间≥500 ms，并且直径≥3.5 mm的交通静脉。
A definition of “pathologic” perforating veins in patients with varicose veins (CEAP [Clinical Class, Etiology, Anatomy, Pathology] clinical class C2) includes those with an outward flow duration of $500 ms and a diameter of $3.5 mm on duplex ultrasound.
1.2.1.建议由有资质的超声医师进行超声反流评估，患者尽可能站立。如果患者不能站立，则可采用坐姿或反向头低脚高位（Trendelenburg position）。
推荐等级:未分级的良好实践声明
We recommend that evaluation of reflux with duplex ultrasound be performed in an Intersocietal Accreditation Commissione -or American College of Radiology-accredited vascular laboratory by a credentialed ultrasonographer, with the patient standing whenever possible. A sitting or reverse Trendelenburg position can be used if the patient cannot stand.
Level of recommendation: ungraded good practice statement
1.2.2.建议在使用双功能超声评估反流时，使用Valsalva屏气试验或远端静脉扩张方法来评估股总静脉和隐股交界处，并使用手动压迫或袖套囊放气扩张远端静脉来评估更远的节段。浅表静脉反流必须追溯到其源头，包括隐静脉连接处、主干静脉或交通静脉，或盆腔静脉曲张。应由接受过静脉双功能超声判读培训的医生进行判读。
推荐等级:未分级的良好实践声明
We recommend that for evaluation of reflux with duplex ultrasound, we use either a Valsalva maneuver or distal augmentation to assess the common femoral vein and saphenofemoral junction and distal augmentation with either manual compression or cuff deflation for evaluation of more distal segments. Superficial reflux must be traced to its source, including the saphenous junctions, truncal or perforating veins, or pelvic origin varicose veins. The study should be interpreted by a physician trained in venous duplex ultrasound interpretation.
Level of recommendation: ungraded good practice statement
1.3.1.建议对下肢静脉反流进行完整的双功能超声检查，应包括有无探头压迫两种情况下，股总静脉、股静脉的近端、中部和远端，腘静脉、隐股交界处、大隐静脉和小隐静脉的横向灰度图像。
推荐等级:未分级的良好实践声明
We recommend that a complete duplex ultrasound scanning examination for venous reflux in the lower extremities should include transverse grayscale images without and with transducer compression of the common femoral, proximal, mid, and distal femoral and popliteal veins, saphenofemoral junction, and great and small saphenous veins.
Level of recommendation: ungraded good practice statement
1.3.2.建议对下肢静脉回流进行完整的双功能超声检查，应包括使用卡尺测量频谱多普勒波形。应记录基线时的反流情况，采用Valsalva屏气试验或远端静脉扩张后的股总静脉和隐股交界处的反流情况，以及远端静脉扩张后的股静脉中部和腘静脉，大腿近端和膝关节处的大隐静脉、前副大隐静脉和隐腘交界处或小腿近端的小隐静脉的反流情况。
推荐等级:未分级的良好实践声明
We recommend that a complete duplex ultrasound scanning examination for venous reflux in the lower extremities should include measurement of the spectral Doppler waveform using calipers. Reflux at baseline and in response to a Valsalva maneuver or distal augmentation in the common femoral vein and at the saphenofemoral junction and in response to distal augmentation in the mid-femoral and popliteal vein, the great saphenous vein at the proximal thigh and knee, the anterior accessory great saphenous vein and small saphenous vein, and at saphenopopliteal junction or proximal calf should be documented.
Level of recommendation: ungraded good practice statement
1.3.3.建议下肢静脉回流进行完整的多普勒超声检查，应包括测量腿部处于下垂位的直径：前壁至后壁、隐股交界处、大腿近端和膝关节处的大隐静脉、前副大隐静脉以及隐腘交界处或小腿近端的小隐静脉。正常和异常表现的图像都应记录在患者的病历中。
推荐等级:未分级的良好实践声明
We recommend that a complete duplex ultrasound scanning examination for venous reflux in the lower extremities should include diameter measurements in patients with the leg in the dependent position, from the anterior to the posterior wall, at the saphenofemoral junction, in the great saphenous vein at the proximal thigh and at the knee, in the anterior accessory great saphenous vein, and in the small saphenous vein at the saphenopopliteal junction or proximal calf. Images of both normal and abnormal findings should be documented in the records of the patient.
Level of recommendation: ungraded good practice statement
1.4.建议使用2020年升级版CEAP慢性静脉疾病分类系统。临床或基础CEAP分级可用于临床实践，临床研究应使用完整的CEAP分级。
推荐等级:未分级的良好实践声明
We recommend the use of the 2020 upgraded CEAP classification system for chronic venous disorders. The clinical or basic CEAP classification can be used for clinical practice, and the full CEAP classification system should be used for clinical research.
Level of recommendation: ungraded good practice statement
指南2：开放手术治疗(结扎和剥脱)与静脉腔内消融技术的建议
2.1.1.对于有症状的静脉曲张并伴有大隐静脉或小隐静脉轴向反流的患者，建议浅静脉手术治疗优于长期穿戴弹力袜。
推荐等级:1B
For patients with symptomatic varicose veins and axial reflux in the great or small saphenousvein, who are candidates for intervention, we recommend superficial venous intervention over long-term compression stockings.
Level of recommendation: grade 1 (strong), quality of evidence: B (moderate)
2.1.2. 对于有症状的静脉曲张伴有前副大隐静脉或后副大隐静脉轴向反流的患者，建议浅静脉手术治疗优于穿戴弹力袜。
推荐等级:2C
For patients with symptomatic varicose veins and axial reflux in the anterior accessory or posterior accessory great saphenous vein, who are candidates for intervention, we suggest superficial venous intervention over compression stockings.
Level of recommendation: grade 2 (weak), quality of evidence: C (low to very low)
2.1.3.对于有症状的静脉曲张伴有浅静脉主干轴向反流的患者，无论是试验性还是确定性治疗，如果患者的活动状态和基础疾病条件需要保守治疗，或者患者倾向于保守治疗，建议将压力治疗作为优先的治疗方法。
推荐等级:2C
For patients with symptomatic varicose veins and axial reflux in the superficial truncal veins, we suggest compression therapy for primary treatment if the patient’s ambulatory status and underlying medical conditions warrant a conservative approach or, if the patient prefers conservative treatment, for either a trial period or definitive management.
Level of recommendation: grade 2 (weak), quality of evidence: C (low to very low)
2.2.1.对于有症状的静脉曲张伴有大隐静脉轴向反流的患者，建议采用静脉腔内消融治疗，而不是大隐静脉高位结扎和剥脱手术，因为术后疼痛和发病率更少，可以更早地恢复正常活动。
推荐等级:1B
For patients with symptomatic varicose veins and axial reflux in the great saphenous vein, who are candidates for intervention, we recommend treatment with endovenous ablation over high ligation and stripping of the great saphenous vein because of less postprocedure pain and morbidity and an earlier return to regular activity.
Level of recommendation: grade 1 (strong), quality of evidence: B (moderate)
2.2.2.对于有症状的静脉曲张伴有小隐静脉轴向反流的患者，建议采用静脉腔内消融治疗，而不是小隐静脉结扎和剥脱手术，因为术后疼痛和发病率更少，可以更早地恢复正常活动。
推荐等级:1C
For patients with symptomatic varicose veins and axial reflux in the small saphenous vein, who are candidates for intervention, we recommend treatment with endovenous ablation over ligation and stripping of the small saphenous vein because of less postprocedure pain and morbidity and an earlier return to regular activity.
Level of recommendation: grade 1 (strong), quality of evidence: C (low to very low)
2.2.3.对于有症状的静脉曲张伴有前副大隐静脉或后副大隐静脉轴向反流的患者，建议进行静脉腔内消融治疗，必要时进行额外的静脉切除术，而不是结扎和剥脱手术，因为术后疼痛和发病率较低，可以更早地恢复正常活动。
推荐等级:2C
For patients with symptomatic varicose veins and axial reflux in the anterior accessory or posterior accessory great saphenous vein, who are candidates for intervention, we suggest treatment with endovenous ablation, with additional phlebectomy, if needed, over ligation and stripping of the accessory great saphenous vein because of less postprocedure pain and morbidity and an earlier return to regular activity.
Level of recommendation: grade 2 (weak), quality of evidence: C (low to very low)
2.3.1.对于有症状的静脉曲张伴有大隐静脉或小隐静脉轴向反流的患者，如果不具备静脉腔内消融技术或专业知识，或者静脉解剖结构不允许进行静脉内治疗，建议采用结扎和剥脱隐静脉的治疗方式。
推荐等级:1B
For patients with symptomatic varicose veins and axial reflux in the great or small saphenous vein, we recommend treatment with ligation and stripping of the saphenous vein if technology or expertise in endovenous ablation is not available or if the venous anatomy precludes endovenous treatment.
Level of recommendation: grade 1 (strong), quality of evidence: B (moderate)
2.3.2.对于有症状的静脉曲张伴有前/后副大隐静脉轴向反流的患者，如果不具备静脉腔内消融技术或专业知识，或者静脉解剖结构不允许进行静脉内治疗，建议采用结扎和剥脱副大隐静脉，并进行额外的静脉切除术。
推荐等级:2C
For patients with symptomatic varicose veins and axial reflux in the anterior accessory or the posterior accessory great saphenous vein, we suggest treatment with ligation and stripping of the accessory great saphenous vein, with additional phlebectomy, if needed, if technology or expertise in endovenous ablations is not available or if the venous anatomy precludes endovenous treatment.
Level of recommendation: grade 2 (weak), quality of evidence: C (low to very low)
2.4.1.对于有症状的静脉曲张伴有大隐静脉轴向反流的患者，且高度重视治疗的长期效果（生活质量和复发），建议采用静脉腔内激光消融、射频消融或高位结扎和剥脱手术治疗，而不是医生复合超声引导泡沫硬化剂治疗。
推荐等级:2B
For patients with symptomatic varicose veins and axial reflux in the great saphenous vein who place a high priority on the long-term outcomes of treatment (quality of life and recurrence), we suggest treatment with endovenous laser ablation, radiofrequency ablation, or high ligation and stripping over physician-compounded ultrasound-guided foam sclerotherapy.
Level of recommendation: grade 2 (weak) quality of evidence: B (moderate)
2.4.2.对于有症状的静脉曲张伴有小隐静脉轴向反流的患者，且高度重视治疗的长期效果（生活质量和复发），建议采用静脉腔内激光消融、射频消融或从膝关节到小腿上部或小腿中部结扎剥离，而不是医生复合超声引导泡沫硬化剂治疗。
推荐等级:2C
For patients with symptomatic varicose veins and axial reflux in the small saphenous vein who place a high priority on the long-term outcomes of treatment (quality of life and recurrence), we suggest treatment with laser ablation, radiofrequency ablation, or ligation and stripping from the knee to the upper or mid-calf over physician-compounded ultrasound- guided foam sclerotherapy.
Level of recommendation: grade 2 (weak) quality of evidence: C (low to very low)
2.4.3.对于有症状的静脉曲张伴有前/后副大隐静脉轴向反流的患者，且高度重视治疗的长期效果（生活质量和复发），建议对反流的浅静脉主干进行静脉腔内激光消融、射频消融或高位结扎与剥脱，如有必要，增加额外的静脉切除术，而不是采用在医生复合超声引导下泡沫硬化治疗。
推荐等级:2C
For patients with symptomatic varicose veins and axial reflux in the anterior accessory or posterior accessory great saphenous vein who place a high priority on the long-term outcomes of treatment (quality of life and recurrence), we suggest treatment of the refluxing superficial trunk with endovenous laser ablation, radiofrequency ablation, or high ligation and stripping, with additional phlebectomy, if needed, over physician-compounded ultrasound-guided foam sclerotherapy.
Level of recommendation: grade 2 (weak), quality of evidence: C (low to very low)
指南3：浅静脉主干的热消融与非热消融治疗的建议
3.1.1.对于有症状的大隐静脉轴向反流的患者，建议从腹股沟到膝关节下的热消融或非热消融的治疗方式，这取决于治疗医生的专业知识和患者偏好。
推荐等级:1B
For patients with symptomatic axial reflux of the great saphenous vein, we recommend both thermal and nonthermal ablation from the groin to below the knee, depending on the available expertise of the treating physician and the preference of the patient.
Level of recommendation: grade 1 (strong), quality of evidence: B (moderate)
3.1.2.对于有症状的小隐静脉轴向反流的患者，建议从膝关节到小腿上部或小腿中部的热消融或非热消融的治疗方式，这取决于治疗医生的专业知识和患者偏好。
推荐等级:1C
For patients with symptomatic axial reflux of the small saphenous vein, we recommend both thermal and nonthermal ablation from the knee to the upper or mid-calf, depending on the available expertise of the treating physician and the preference of the patient.
Level of recommendation: grade 1 (strong), quality of evidence: C (low to very low)
3.1.3.对于有症状的前副大隐静脉或后副大隐静脉轴向反流的患者，建议进行热消融或非热消融的治疗方式，如有必要，增加额外的静脉切除术，这取决于治疗医生的专业知识和患者偏好。
推荐等级:2C
For patients with symptomatic axial reflux of the anterior accessory or posterior accessory great saphenous vein, we suggest either thermal or nonthermal ablation, with additional phlebectomy, if needed, depending on the available expertise of the treating physician and the preference of the patient.
Level of recommendation: grade 2 (weak), quality of evidence: C (low to very low)
指南4：CEAP 2级疾病中功能不全的交通静脉管理
4.1.1.对于显著的症状性大隐静脉或小隐静脉轴向反流的静脉曲张(CEAP C2级)患者，不建议在初始消融浅静脉主干的同时治疗功能不全的交通静脉。
推荐等级:1C
For patients with varicose veins (CEAP class C2) who have significant, symptomatic axial reflux of the great or small saphenous vein, we recommend against treatment of incompetent perforating veins concomitant with initial ablation of the superficial truncal veins.
Level of recommendation: grade 1 (strong), quality of evidence: C (low to very low)
4.1.2.对于显著的症状性前副大隐静脉或后副大隐静脉轴向反流的静脉曲张(CEAP C2级)患者，不建议在初始消融浅静脉主干的同时治疗功能不全的交通静脉。
推荐等级:2C
For patients with varicose veins (CEAP class C2) who have significant, symptomatic axial reflux of the anterior accessory or posterior accessory great saphenous vein, we suggest against treatment of incompetent perforating veins concomitant with initial ablation of the superficial truncal veins.
Level of recommendation: grade 2 (weak), quality of evidence: C (low to very low)
4.2.对于静脉曲张(CEAP C2类)在既往功能不全的浅静脉主干完全消融后出现持续或复发症状的患者，如果发现交通静脉的功能不全是其复发的根源，则建议对该交通静脉进行治疗。
推荐等级:2C
For patients with varicose veins (CEAP class C2) and persistent or recurrent symptoms after previous complete ablation of incompetent superficial truncal veins, we suggest treatment of perforating vein incompetence if it is the origin of the symptomatic varicose tributaries.
Level of recommendation: grade 2 (weak), quality of evidence: C (low to very low)
指南5：浅表静脉主干功能不全进行静脉消融时，对曲张支脉的同期与分期治疗建议。
5.1.1.对于大隐静脉或小隐静脉有症状性反流并伴有相关静脉曲张的患者，建议对回流静脉主干进行消融，并同时对相关的曲张静脉进行静脉切除术或泡沫硬化疗法。泡沫硬化疗法可在超声引导下，使用医生配置的泡沫或市售的聚多卡醇静脉内微泡沫。
推荐等级:1C
For patients with symptomatic reflux in the great or small saphenous vein and associated varicosities, we recommend ablation of the refluxing venous trunk and concomitant phlebectomy or ultrasound-guided foam sclerotherapy of the varicosities with physician-compounded foam or commercial polidocanol endovenous microfoam.
Level of recommendation: grade 1 (strong); quality of evidence: C (low to very low)
5.1.2.对于前副大隐静脉或后副大隐静脉有症状性反流的患者，建议对回流静脉主干进行消融，并同时对相关的曲张静脉进行静脉切除术或泡沫硬化疗法。泡沫硬化疗法可在超声引导下，使用医生配置的泡沫或市售的聚多卡醇静脉内微泡沫。
推荐等级:2C
For patients with symptomatic reflux in the anterior accessory or posterior accessory great saphenous vein, we suggest ablation of the refluxing venous trunk and concomitant phlebectomy or ultrasound-guided foam sclerotherapy of the varicosities with physician-compounded foam or commercial polidocanol endovenous microfoam.
Level of recommendation: grade 2 (weak), quality of evidence: C (low to very low)
5.2.1.对于大隐静脉或小隐静脉有症状性回流的患者，建议消融反流静脉主干，仅在存在解剖学或医学原因无法同期手术时，分期行静脉切除术或超声引导下泡沫硬化方式治疗支静脉。建议与患者共同决策。
推荐等级:2C
For patients with symptomatic reflux in the great or small saphenous vein, we suggest ablation of the refluxing venous trunk and staged phlebectomy or ultrasound-guided foam sclerotherapy of the varicosities only if anatomic or medical reasons present. We suggest shared decision-making with the patient.
Level of recommendation: grade 2 (weak); quality of evidence: C (low to very low)
5.2.2.对于前副大隐静脉或后副大隐静脉有症状性反流的患者，建议消融反流静脉主干，仅在存在解剖学或医学原因无法同期手术时，分期行静脉切除术或超声引导下泡沫硬化方式治疗支静脉。建议与患者共同决策。
推荐等级:2C
For patients with symptomatic reflux in the anterior accessory great saphenous vein or posterior accessory great saphenous vein, we suggest ablation of the refluxing venous trunk and staged phlebectomy or ultrasound-guided foam sclerotherapy of the varicosities only if anatomic or medical reasons present. We suggest shared decision-making with the patient.
Level of recommendation: grade 2 (weak), quality of evidence: C (low to very low)
5.3.对于浅静脉主干有症状性反流和相关静脉曲张的患者，如果首次仅做了消融治疗，建议随访3个月，以评估是否需要再行分期的静脉切除术或超声引导硬化治疗持续或复发症状。对于有复发症状的患者和参与临床试验的患者，建议进行更长时间的随访。
推荐等级:未分级良好临床实践
For patients with symptomatic reflux in the major superficial venous trunks and associated varicosities undergoing initial ablation alone, we recommend that patients be followed up for $3 months to assess the need for staged phlebectomy or ultrasound-guided sclerotherapy for persistent or recurrent symptoms. Longer follow-up is recommended for patients with recurrent symptoms and for patients who participate in clinical trials.
Level of recommendation: ungraded good clinical practice.
【Ref】:Gloviczki et al. The 2022 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part I. Duplex Scanning and Treatment of Superficial Truncal Reflux Endorsed by the Society for Vascular Medicine and the International Union of Phlebology.[J]. Journal of Vascular Surgery: Venous and Lymphatic Disorders.2022