彩色多普勒超声联合血管增强技术诊断髂静脉压迫综合征的临床价值

The clinical value of color Doppler ultrasound combined with vascular enhancement technology in the diagnosis of iliac vein compression syndrome

目的探讨彩色多普勒超声(color Doppler ultrasound,CDUS)联合血管增强技术(vascular enhancement technology,VET)诊断髂静脉压迫综合征(iliac vein compression syndrome,IVCS)的临床价值。方法选取2016年1月至2018年10月在河北医科大学第二医院就诊的252例下肢慢性静脉疾病(chronic venous diseases,CVD)患者,于X线顺行静脉造影(X-Ray venography,XRV)前分别应用CDUS、VET检查患肢同侧髂静脉,以髂静脉横断面直径狭窄比率(diameter stenosis ratio,DSR)>50%作为超声诊断IVCS的标准。记录髂静脉狭窄部位,有无侧支循环形成、髂内静脉反向血流等间接征象。选取CDUS、VET及两者联合与XRV结果一致的病例,分为IVCS组和非IVCS组。以XRV为诊断IVCS的金标准,对三种方法的诊断效能进行评价。选取超声诊断效能最高的方法与XRV结果一致的病例,根据下肢有无并发深静脉血栓(deep vein thrombosis,DVT),分为并发深静脉血栓组(DVT组)与无并发深静脉血栓组(non-DVT组),分析IVCS与下肢DVT发生的关系;non-DVT组患肢按照下肢CVD的CEAP临床分级分为C2~C6级5组,分析IVCS与不同CEAP临床分级的关系。评估髂静脉狭窄好发部位及侧支循环形成和髂内静脉反向血流对诊断IVCS的价值。结果①以XRV为金标准,与CDUS、VET单独诊断比较,CDUS联合VET对IVCS的诊断效能最高(均P<0.05)。②CDUS联合VET诊断的IVCS组和非IVCS组中,DVT和non-DVT的分布差异有统计学意义(χ2=145.0,P<0.001)。③non-DVT组中,CEAP临床分级C3级、C5级病例分布在IVCS组和非IVCS组间差异有统计学意义(均P<0.05),C2级、C4级、C6级差异则无统计学意义(均P>0.05)。④IVCS组髂静脉狭窄部位的构成比,左髂总静脉起始段与其中远段、右髂总静脉起始段、中远段差异有统计学意义(均P<0.05),双侧髂总静脉中远段、髂外静脉与股总静脉交界区差异无统计学意义(均P>0.05)。⑤IVCS组中侧支循环形成、髂内静脉反向血流的阳性率差异有统计学意义(χ^2=6.717,P=0.010),前者比例高于后者。结论CDUS联合VET对IVCS的诊断效能最大,优于CDUS、VET单独诊断。IVCS与下肢DVT关系密切,与CEAP临床分级无相关性。IVCS发生最常见部位是左髂总静脉起始段狭窄。侧支循环形成可作为诊断IVCS的间接指标。

Objective To evaluate the clinical value of color Doppler ultrasound(CDUS)combined with vascular enhancement technology(VET)in diagnosis of iliac vein compression syndrome(IVCS).Methods From Jan 2016 to Oct 2018,252 patients with the lower extremities chronic venous diseases(CVD)were selected in the Second Hospital of Hebei Medical University.The ipsilateral iliac veins of the affected limbs were examined by CDUS,VET and the combined diagnosis of IVCS before X-Ray venography(XRV).Iliac vein diameter stenosis ratio(DSR)>50%in transverse section was the criterion of ultrasound diagnosis of IVCS.The stenosis site of iliac vein and indirect signs of IVCS,such as presence of collateral circulation and the retrograde flow of internal iliac vein were recorded.The cases,which had the same results in CDUS,VET and both and XRV,were divided into IVCS group and non-IVCS group.The results of XRV were taken as the gold standard,the diagnostic efficiency of the above 3 methods in diagnosis of IVCS was calculated.The cases identically diagnosed by the most effective ultrasonic method and XRV were divided into DVT group and non-DVT group according to the deep vein thrombosis in lower limbs.In the non-DVT group,there were five groups of C2-C6 on the basis of the CEAP clinical grades of CVD in lower extremity.The relationship between IVCS and different CEAP clinical grades were analyzed.The locations of common iliac vein stenosis and collateral circulation formation and internal iliac vein reverse flow were evaluated for the diagnosis of the IVCS.Results①XRV diagnosis of IVCS was used as the gold standard.Compared with CDUS and VET alone,the sensitivity and specificity of CDUS combined with VET was the highest(all P<0.05).②The distribution of DVT and non-DVT was significantly different in IVCS group and non-IVCS group diagnosed by the CDUS combined with VET(χ^2=145.0,P<0.001).③In the non-DVT group,statistically significant differences of grades C3 and C5 were found between IVCS group and non-IVCS group(all P<0.05),while the differences of grades C2,C4 and C6 were non-significant(all P>0.05).④For the proportion of the iliac vein stenosis sites,the prevalence of the primary section of left common iliac vein was much higher than those of the primary section of right common iliac vein and the middle-distal sections of bilateral common iliac veins(all P<0.05).There was no statistical difference between the middle-distal section of bilateral common iliac veins,and nor was bilateral junction area between external iliac vein and common femoral vein(all P>0.05).⑤In IVCS group,which had the same results of CDUS combined with VET and XRV,there were statistical differences in the positive rate of collateral circulation and the retrograde flow of internal iliac vein(χ^2=6.717,P=0.010),and the former is higher than the latter.Conclusions CDUS combined with VET has a higher diagnostic efficiency for IVCS than VET or CDUS alone.The presence of IVCS is closely related to DVT of lower extremities,but not related to clinical class of CEAP.The most common site of IVCS is the initial segment of the left common iliac vein.The presence of collateral circulation can be used as indirect indicators for the diagnosis of IVCS.