急性髂股静脉血栓合并髂静脉压迫诊疗进展

Advances in Diagnosis and Treatment of Acute DVT with Iliac Vein Compression

摘要: 累及下肢近端深静脉的髂股静脉血栓(Iliofemoral deep vein thrombosis, IFDVT)合并盆腔静脉受压的髂静脉压迫综合征(iliac vein compression syndrome, IVCS)是引发肺栓塞(pulmonary embolism, PE)及长期影响下肢功能的血栓后综合征(post-thrombosis syndrome, PTS)的风险相对较高的临床疾病。本综述详细梳理其诊疗相关的前沿内容：影像诊断决策：用于下肢血管筛查的加压超声(compression ultrasonography, CUS)初筛操作时需重点关注血管反流、管壁增厚等间接征象；用于静脉解剖成像的计算机断层扫描/磁共振静脉成像(computed tomography venography/magnetic resonance venography, CTV/MRV)可清晰呈现病变部位的血管走行、管腔形态等解剖细节；用于血管腔内精准评估的血管内超声(intravascular ultrasound, IVUS)及具备精准血管成像能力的数字减影血管造影(digital subtraction angiography, DSA)被临床视作诊断的金标准，可精确测量量化血管狭窄程度、区分新鲜与陈旧血栓的性质。治疗方案更新及决策：在开展规范抗凝治疗的前提下，血栓脱落风险相对较高的患者置入下腔静脉滤器(inferior vena cava filter, IVCF)预防肺栓塞发作；血栓清除操作更常选用机械技术—经皮机械血栓清除(percutaneous mechanical thrombectomy, PMT)较传统的导管接触性溶栓(catheter-directed thrombolysis, CDT)明显降低出血风险，而操作相对简便的经皮血栓抽吸术(manual aspiration thrombectomy, MAT)与结合药物及器械的药械联合(pharmacomechanical catheter-directed thrombolysis, PCDT)临床效果相近且治疗成本不算太高；对髂静脉存在重度狭窄的患者开展球囊血管成形术(percutaneous transluminal angioplasty, PTA)联合髂静脉支架植入，可明显降低PTS发生风险。长期管理：开展规范的抗凝治疗及定期开展影像学随访检查可降低血栓复发概率。后续可改进髂静脉专用支架的设计、验证下腔静脉滤器的长期使用安全性，并通过实时动态血流成像技术增强个体化治疗的精准度。采用“精准诊断–机械清栓–支架成形–规范抗凝”的一站式综合介入干预方案，可明显改善IFDVT患者的临床预后。

Abstract: Acute iliofemoral deep vein thrombosis (IFDVT) complicated by iliac vein compression syndrome (IVCS) represents a high-risk condition predisposing patients to pulmonary embolism (PE) and post-thrombotic syndrome (PTS). This review comprehensively delineates advances in diagnosis and management: 1. Diagnostic Strategies: Initial screening with compression ultrasonography (CUS) necessitates scrutiny of indirect signs of obstruction. Computed tomography venography/magnetic resonance venography (CTV/MRV) delivers detailed anatomical visualization, while intravascular ultrasound (IVUS) and digital subtraction angiography (DSA), as diagnostic gold standards, enable precise quantification of stenosis severity and characterization of thrombus composition. 2. Therapeutic Advances: Beyond foundational anticoagulation, prophylactic inferior vena cava filter (IVCF) implantation is indicated for high-risk PE prevention. Mechanical thrombectomy techniques are prioritized for clot clearance—percutaneous mechanical thrombectomy (PMT) substantially reduces bleeding risk compared to catheter-directed thrombolysis (CDT). Manual aspiration thrombectomy (MAT) achieves comparable efficacy to pharmacomechanical catheter-directed thrombolysis (PCDT) at lower cost. For severe iliac vein stenosis, percutaneous transluminal angioplasty (PTA) with adjunctive stent placement significantly mitigates PTS risk. 3. Long-Term Management: Standardized anticoagulation protocols and scheduled imaging surveillance reduce recurrence rates. Future priorities include optimizing dedicated iliac vein stent designs, validating long-term IVCF safety, and refining personalized therapy through dynamic hemodynamic imaging technology. Integrating a comprehensive interventional strategy of precision diagnosis, mechanical thrombectomy, stent revascularization, and consolidated anticoagulation significantly improves IFDVT prognosis.