Application Status of Tumescent Anesthesia in the Treatment of Lower Extremity Varicose Veins with Thermal Ablation
Lower extremity varicose veins (LEVV) typically refer to the tortuosity and dilation of superficial veins caused by multiple etiological factors, often accompanied by functional abnormalities such as lower limb soreness, fatigue, and heaviness. Advanced stages may manifest pathological changes including lipodermatosclerosis and chronic ulcers, making it the most prevalent condition in vascular surgery. Surgical intervention remains the mainstay treatment, with thermal ablation emerging as the representative endovenous minimally invasive technique. Recognized for its minimal invasiveness, high controllability, and satisfactory therapeutic outcomes, this modality has been recommended as the primary treatment option by numerous clinical guidelines. However, despite its widespread application, challenges persist in reducing intraoperative pain, enhancing surgical efficiency, and minimizing postoperative complications. Tumescent anesthesia has demonstrated significant efficacy in thermal ablation procedures for LEVV, yet substantial exploration is still required regarding its optimal composition, administration methods, and timing during intervention. This review comprehensively examines current applications of tumescent anesthesia in radiofrequency ablation for lower extremity varicose veins and discusses potential avenues for clinical optimization.
Tumescent Local Anesthesia
下肢静脉曲张通常发生于大隐静脉及其分支。这种状况是由于下肢浅静脉瓣膜功能不全或静脉壁弱点导致血液逆流,远端静脉血流淤积,进而使静脉壁扩张、变性,出现不规则膨出和扭曲。早期症状包括肢体酸胀不适和浅静脉迂曲成团,病情进展可能引起皮肤瘙痒、色素沉着、脱屑和脂质硬化,严重者可发生溃疡、出血及血栓性浅静脉炎
局部肿胀麻醉(Tumescent Local Anesthesia, TLA)是一种常用的局部麻醉技术,最初由Jeffrey Klein博士在吸脂手术中提出并应用,该技术特征在于使用大量的稀释利多卡因溶液,其中加入了肾上腺素以减少出血
TLA是腔内热消融技术的重要麻醉方式,肿胀麻醉的应用显著提高了治疗的安全性和效果
下肢静脉曲手术的常用麻醉方式包括全身麻醉、脊髓麻醉和局部麻醉。然而,全身麻醉和脊髓麻醉在安全性和并发症方面存在一定的局限性,如过敏反应、心血管或中枢神经系统的不良反应。对于高龄患者以及伴有心肺功能异常、腰椎畸形的患者,全身或脊髓麻醉的风险更大,不适合作为首选麻醉方式
美国2011年下肢静脉曲诊治指南中使用的肿胀麻醉液配比为500 ml的溶液中445毫升的0.9%生理盐水、50毫升1%的利多卡因(含1:100,000肾上腺素)和5毫升8.4%的碳酸氢钠
目前,肿胀麻醉液的注射方式主要包括注射器手动注射和电泵注射。临床实践中,超声引导下的大隐静脉周围经皮多次注射,常导致患者术中感受到明显的疼痛与不适,穿刺次数的增加容易引发紧张、焦虑等情绪,并且由于注射压力不均匀,患者体验感较差
肿胀液温度控制方面,有研究探讨了麻醉液温度对术中及术后疼痛和手术效果方面的影响,低温肿胀液(4℃)可通过双重机制提升疗效:物理保护(低温形成热屏障,减少热消融对周围组织的热损伤)和血管收缩(增强肾上腺素作用,进一步减少术中出血)
总而言之,肿胀麻醉在下肢静脉曲张热消融术中的应用具有显著的临床价值,合理使用肿胀麻醉也变得十分重要。通过减少术中疼痛、降低出血风险和保护周围组织,肿胀麻醉不仅提升了手术的安全性,还改善了患者的舒适度和术后恢复情况,这是全麻及椎管内麻醉不能替代的。罗哌卡因与利多卡因的联合运用,提供了更稳定、更舒适的麻醉效果,碳酸氢钠的缓冲作用有效减轻了术中疼痛;蠕动泵的使用有助于提高肿胀麻醉的注射精度,缩短手术时间,并减少患者的术后不适;温度控制以及术中适时补充麻醉肿胀液同样有助于改善术中疼痛,提高整体手术舒适度。不足方面,如注射穿刺即刻带来的痛苦,仍是临床上难以回避的问题。一些医师采用机械快速进针、减缓肿胀速度或穿刺前使用局部镇痛药如利丙双卡因乳膏等方法,但目前仍缺乏足够的证据证明其有效性。当前关于肿胀麻醉相关的临床试验较简单,样本数量也较少,希望在未来的研究中能有相关多中心、大样本的研究。
*通讯作者。