复发性静脉性溃疡的原因分析及再处理方法

Potential causes and optimal treatment strategy of recurrent venous ulceration in lower limb

目的 分析复发性静脉溃疡的原因及再次手术策略.方法 回顾性分析2000年1月至2010年6月收治的复发性静脉性溃疡患者的临床资料.共73例患者81条肢体入组,男性55例（60条肢体）,女性18例（21条肢体）,平均年龄52.6岁（31～73岁）.所有患者入院前均因下肢静脉溃疡接受过一次或数次手术.溃疡复发距上次手术8～37个月,平均10.6个月;溃疡直径1.3～6.5 cm,平均3.7 cm.再次手术前多普勒超声发现小腿交通静脉反流57条肢体（70.4%）,原发性深静脉瓣膜功能不全38条肢体（46.9%）,DVT后遗症16条肢体（19.8%）,大隐静脉属支残留11条肢体（13.6%）,大隐静脉主干再通或残留8例（9.9%）.针对存在的病因采取大隐静脉高位结扎抽剥及属支结扎、内镜深筋膜下交通静脉结扎、溃疡周边环形缝扎、曲张静脉环形缝扎加切除、深静脉瓣膜修复术以及穿着弹力袜等治疗措施.结果 随访3～60个月,平均37.3个月.3个月时溃疡平均直径明显缩小,6个月时溃疡完全愈合,血流动力学指标明显改善.1年后3条肢体（3.7%）溃疡再次复发.结论 小腿交通静脉功能不全、深静脉瓣膜功能不全以及大隐静脉再通或属支残留是静脉性溃疡术后复发的主要原因,针对性的冉次手术仍然可以达到满意疗效.

Objective To explore the potential causes and the optimal treatments of recurrent venous ulceration of lower limbs after initial operation. Methods Data of patients admitted between January 2000 and June 2010 for recurrent ulceration in lower limbs after previous operation were retrospectively analyzed. Altogether 81 limbs in 73 patients were recruited. There were 55 male patients （60 limbs） and 18 female patients （21 limbs）. The average age was 52. 6 years（ranging from 31 to 73 years）. All the patients had received at least one surgery procedures before recurrence. The average time between ulceration recurrence and the last operation was 10.6 months （ ranging from 5 to 37 months）. Average diameter of ulcers was 3. 7 cm （ ranging from 1. 3 to 6. 5 cm） . Color duplex sonography before re-treatment revealed incompetent calf perforators in 57 limbs （70. 4% ） , primary deep vein insufficiency in 38 limbs （46. 9% ） ,post-DVT syndrome in 16 limbs （19. 8% ） , reflux of accessory saphenous veins in 11 limbs （13. 6% ） and residual/re-opened great saphenous vein in 8 limbs （ 9. 9% ） . Managements including stripping of great saphenous vein, ligation around the ulcer, percutanous ligation of varicose veins, valvoplasty, and adjuvant compressive therapy were adopted according to different venous abnormality. Results All the patients were followed. All the ulcers healed and hemodynamic indexes were greatly improved 6 months after re-operation.Only 3 limbs （3.7% ） suffered again from recurrence 1 year after re-operation. Conclusions Incompetent perforators in calf, primary or secondary deep vein insufficiency and incorrectly treated saphenous veins are main causes for recurrent venous ulceration in our series. Management of residual vein abnormalities can still achieve satisfying clinical outcome.