■ ガイドライン解説

日本血管外科学会雑誌 2023; 32: 211–256

日本静脈学会/日本血管外科学会合同日本語訳「ヨーロッパ血管外科学会・下肢慢性静脈疾患診療ガイドライン（2022 年版）要約」
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翻訳者：広川 雅之 *，重松 邦広 ，孟真 ，東信良 ，久米 博子 ，
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小畑 貴司 ，島袋 伸洋 ，清水剛 ，高山 利夫 ，武内 謙輔 ，
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手島 英一 ，西部 俊哉 ，根本 寛子 ，保坂 晃弘 ，前田 剛志

査読者：白杉

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望 ，細井

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温 ，深山

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紀幸 ，渡部芳子

18（日血外会誌 2023; 32: 211–256）
索引用語：ガイドライン，慢性静脈疾患，下肢静脈瘤，深部静脈血栓症，静脈血栓後症候群

CVD ガイドラインは，本文 84 頁（94 の推奨を含む）とはじめに膨大な量であるため，推奨，図表および最低限の本文を要約して翻訳を行った．あくまでも要約であるため，本

今回，日本語訳を行ったのは，2015 年に発表された

503）

ヨ ー ロ ッ パ 血 管 外 科 学 会（European Society for Vascular

日本語訳の内容を引用する際は必ず英文の原著論文

Surgery: ESVS） の 慢 性 静 脈 疾 患（chronic venous disease:を引用して頂きたい．なお，本日本語訳中の参考文献はCVD）ガイドラインの 2022 年改訂版（CVD ガイドライ

原著論文の参考文献リストをそのまま用いているため，

503）

ン）

参考文献番号は連番ではないことに留意されたい．

の要約である．本ガイドラインは，ESVS のガイ

ドライン執筆委員会によって作成された下肢の CVD 患

CVD ガイドラインの内容は，腹部・骨盤部〜下肢の者の診療に関するガイドラインであり，European Journal

CVD に関する診断，検査，治療方針の決定，保存的治of Vascular and Endovascular Surgery（EJVES）編集委員会

療，侵襲的治療等，広範囲にわたっている．われわれ

および ESVS ガイドライン委員会によって査読，承認さは，本日本語訳がわが国における CVD 診療の質の向上れている．

に繋がることを期待する．最後に，初めての試みである

本日本語訳は，日本静脈学会および日本血管外科学会

両学会合同の CVD ガイドライン翻訳事業に協力してくの合同事業として，両学会会員より選出された翻訳者がれた両学会の翻訳者，査読者各位と日本語翻訳版の転載

合同で翻訳を行った．作成した日本語訳は，静脈学およを許諾して頂いた ESVS に深謝する．

び日本血管外科学会雑誌の編集委員による合同査読委員

2022 年版と 2015 年版 CVD ガイドラインの違い

会が査読を行った後，ESVS に提出，掲載の許諾後に両雑誌に同じ日本語訳が掲載されている．なお，翻訳内容

2022 年版では新たに推奨を追加し，2015 年版の推奨の担保のための逆翻訳は行わなかった．

の推奨度を一部変更している（図 1, 2）．

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お茶の水血管外科クリニック〒101–0062 東京都千代田区神田駿河台 4–1–1ウエルトンビル 6 階
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国際医療福祉大学三田病院血管外科
3横浜南共済病院心臓血管外科
4旭川医科大学外科学講座血管・呼吸・腫瘍病態外科学分野
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慶友会つくば血管センター
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金沢医科大学氷見市民病院胸部心臓血管外科
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友愛医療センター心臓血管外科
8長野松代総合病院心臓血管外科
9東京大学血管外科

たけうち静脈瘤クリニック
福岡和白病院心臓血管外科
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北海道情報大学医療情報学部医療情報学科
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東京都立多摩総合医療センター血管外科
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国際医療福祉大学成田病院血管外科
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第二川崎幸クリニック下肢静脈瘤センター
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杏林大学心臓血管外科
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関西医科大学総合医療センター血管外科
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川崎医科大学総合臨床医学* E-mail: gea01265@nifty.com
受付：2023 年 3 月 31 日 受理：2023 年 3 月 31 日
doi: 10.11401/jsvs.23-00031
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序

文としてオンラインで 公開している（https://doi.org/10.1016/

本 ガ イドラインは，2015 年に出 版 され た ESVS の CVD

j.ejvs.2021.12.024）．

診療ガイドラインをアップデートしたものである．対象は，下肢の表在静脈，穿通枝，深部静脈，および腹部・一般的事項（推奨 1, 2）

骨盤 部の静 脈 疾 患であり，下 肢 CVD に関連しない静 脈

1.

疾患，および血管奇形は対象としない．エビデンス収集

CVD の病態の記述には，Clinical, Etiological, Anatomical,

は，MEDLINE（PubMed 経 由 ），Embase, Cardiosource Clini-

Pathophysiological（CEAP） 分 類 が 広 く 用 い ら れ て い る

cal Trials Database および The Cochrane Library の 4 つのデー

（表 3）．本ガイドラインにおける解剖学用語およびそのタベースを 2013 年 1月1日〜2020 年 6 月30日の範囲で検索

略語は，2020 年改訂版の CEAP 分類に準拠する（表 4）．

し，必要に応じて 2021 年 6 月までの範囲で 2 次および 3 次

代表的な下肢の深部静脈および表在静脈は図 3, 4 に示す．

の文献検索を行った．エビデンスレベルおよび推奨度の評

CVD の病態の経時的変化を評価する臨床スコアリング

価は，ヨーロッパ心臓病学会（European Society of Cardiol-

システムとして，改訂版静脈疾患臨床重症度スコア（re-ogy: ESC）の評価法によって決定した（表 1, 2）．推奨度を

vised Venous Clinical Severity Score: r-VCSS）（表 5）が，静決定するために採用した論文は，各々の推奨ごとにエビ脈 血 栓 後 症 候 群（post-thrombotic syndrome: PTS） の 病 態

デンス表（Tables of Evidence: ToEs）にまとめ，補 足資 料

評価には Villalta スケール（表 6）が広く用いられている．
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検査方法（推奨 3–7）

本章では，CVD 患者に対する検査方法について解説する．主な診断と治療のアルゴリズムは図 5 に示す．

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保存的治療（推奨 8–14）

本章では，活動性静脈性潰瘍を有しない CVD 患者の保存的治療について解説する．活動性静脈性潰瘍を有する場合の保存的治療については第 6 章を参照．圧迫療法の禁忌を表 7，主な静脈作動薬（venoactive drugs: VADs）の効果を表 8，保存的治療の治療方針を図 6 に示す．

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表在静脈弁不全に対する侵襲的治療（推奨15–57）
本章では，表在静脈不全による CVD の治療について解説する．表在静脈不全には伏在型，側枝型，網目状およびクモの巣状静脈瘤を含む．不全穿通枝に対する治療についても本章で解説する．
血管内焼灼術後の血栓性合併症である endothermal heat
induced thrombosis（EHIT）分類を表 9，伏在型静脈本幹弁不全に対する治療法のまとめを表 10 に示す．側枝弁不全を伴う伏在静脈弁本幹不全患者に対する侵襲的治療の選択肢を図 7（大伏在静脈弁不全），図 8（小伏在静脈弁不全），図 9（前副伏在静脈弁不全）に示す．再発性静脈瘤の主な原因を表 11 に示す．

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5.

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深 部 静 脈 疾 患 に 対 す る 侵 襲 的 治 療（ 推 奨

58–66）
本 章 で は，PTS お よ び 非 血 栓 性 腸 骨 静 脈 病 変（nonthrombotic iliac vein lesion: NIVL）に対する侵襲的治療について解説する．深部静脈病変を有する CVD 患者の治療戦略を図 10，重度の深部静脈流出路通過障害に対す
る侵襲的治療の治療戦略を図 11 に示す．

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6.

静脈性潰瘍の管理（推奨 67–82）

本章では，CVD の最重症型である静脈性下腿潰瘍（venous leg ulcer: VLU）の管理について解説する．活動性静脈性下腿潰瘍（C6）の治療戦略を図 12，治癒した潰瘍（C5）および活動性潰瘍（C6）における表在静脈逆流に対する治療と圧迫療法の治療方針を図 13 に示す．

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7.

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本 章 で は， 下 肢 静 脈 瘤 を 伴 う 性 腺 静 脈（ 卵 巣 静 脈，精巣静脈）および内腸骨静脈逆流の治療について解説
す る． こ れ ら は 骨 盤 静 脈 疾 患（pelvic venous disorders:PeVD）に含まれ，メイ・ターナー症候群（May-Thurner
syndrome）， 骨 盤 内 う っ 滞 症 候 群， ナ ッ ト ク ラ ッ カ ー症候群（nutcracker syndrome） と呼ばれてきた． 最近では， 米 国 静 脈 リ ン パ 学 会（American Vein and Lymphatic
Society） が 新 し い PeVD の 分 類 と し て Symptoms-VaricesPathophysiology classiﬁcation（SVP 分 類 ） を 提 唱 し て い
る．SVP 分類における PeVD が発生する解剖学的部位を
図 14 に示す．臨床的に PeVD による下肢静脈瘤が疑われる患者の治療方針を図 15 に示す．

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特別な留意点（推奨 89–94）

本章では，急性合併症（表在静脈血栓症，出血）および患者の特別な状態（肥満，妊娠，抗凝固療法中，小児）について解説する．

9.

エビデンスが不足している分野（推奨なし）

本章では，現時点ではエビデンスが不足しており，今後，研究を行うべき課題について解説する．

10.

患者向けの情報（推奨なし）

本 章 で は， 患 者 向 け に 本 ガ イ ド ラ イ ン を 解 説 す る．
CVD の臨床所見を図 16 に示す．

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statement. Eur J Vasc Endovasc Surg 1996; 12: 487–492.
5) Eklöf B, Rutherford RB, Bergan JJ, et al. Revision of the
CEAP classiﬁcation for chronic venous disorders: consensus
statement. J Vasc Surg 2004; 40: 1248–1252.
6) Lurie F, Passman M, Meisner M, et al. The 2020 update of
the CEAP classification system and reporting standards. J
Vasc Surg Venous Lymphat Disord 2020; 8: 342–352.
7) Salim S, Machin M, Patterson BO, et al. Global epidemiology ofchronic venous disease: a systematic review with pooled prevalence analysis. Ann Surg 2021; 274: 971–976.
8) Rabe E, Guex JJ, Puskas A, et al. Epidemiology of chronic venous disorders in geographically diverse populations: resultsfrom the Vein Consult Program. Int Angiol 2012; 31: 105–115.
9) Evans CJ, Fowkes FG, Ruckley CV, et al. Prevalence of varicose
veins and chronic venous insuﬃciency in men and women in thegeneral population: Edinburgh Vein Study. J Epidemiol Community Health 1999; 53: 149–153.
10) Robertson LA, Evans CJ, Lee AJ, et al. Incidence and risk factors for venous reﬂux in the general population: Edinburgh Vein
Study. Eur J Vasc Endovasc Surg 2014; 48: 208–214.
11) Lee AJ, Robertson LA, Boghossian SM, et al. Progression ofvaricose veins and chronic venous insufficiency in the general
population in the Edinburgh Vein Study. J Vasc Surg Venous
Lymphat Disord 2015; 3: 18–26.
12) Schultz-Ehrenburg U, Reich-Schupke S, Robak-Pawelczyk B, etal. Prospective epidemiological study on the beginning of vari-利益相反
広川雅之は株式会社インテグラルの顧問である．

付記

本論文は倫理的配慮を必要としない．

参考文献
本日本語訳に関連する参考文献は太字体として表記した．太字体以外の文献は本日本語訳には登場せず，原文にのみ掲載されている．
1) Wittens C, Davies AH, Bækgaard N, et al. Management ofchronic venous disease: clinical practice guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc
Surg 2015; 49: 678–737.
2) Kakkos SK, Gohel M, Baekgaard N, et al. European Society for
Vascular Surgery (ESVS) 2021 clinical practice guidelines on
the management of venous thrombosis. Eur J Vasc Endovasc
Surg 2021; 61: 9–82.
3) Eklof B, Perrin M, Delis KT, et al. Updated terminology ofchronic venous disorders: the VEIN-TERM transatlantic interdisciplinary consensus document. J Vasc Surg 2009;49: 498-501.
4) Beebe HG, Bergan JJ, Bergqvist D, et al. Classiﬁcation and grading of chronic venous disease in the lower limbs. A consensus
訳注 1）いわゆる低濃度大量局所浸潤麻酔（tumescent local anesthesia:
TLA）のこと
訳注 2）座位から立位や運動時の圧迫圧の変動が弾性包帯よりも大きく，浮腫や静脈性下腿潰瘍の圧迫療法に使用される．一部の多層包帯法，ギプス様の圧迫装具が含まれる
訳注 3）主に面ファスナー（ベルクロ）を使用した圧迫装具を指す
訳注 4）侵襲的治療（血管内治療，ストリッピング，超音波ガイド下フォーム硬化療法）の適応となる有症状の伏在型静脈瘤を意味する

訳注 5）静脈内膜の機械的損傷と硬化療法を組み合わせた血管内治療，NTNT 法の 1 つ
訳注 6）上行性理論に基づき，主に静脈瘤のみを切除する伏在静脈温存低侵襲手術の 1 つ
訳注 7）超音波検査で逆流静脈を綿密にマッピングして，適切な部位の静脈を結紮する伏在静脈温存低侵襲手術の 1 つ
訳注 8）患者と医療者による意思決定の共有（shared decision making:SDM）のこと239

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cose veins. Bochum Study IeIV. Phlebologie 2009; 38: 17–25.
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第 3 号（2023）

A Summary of European Society for Vascular Surgery (ESVS) 2022 Clinical Practice
Guidelines on the Management of Chronic Venous Disease of the Lower Limbs:
Japanese Translation by Japanese Society of Phlebology andJapanese Society for Vascular Surgery
Translators: Masayuki Hirokawa1, Kunihiro Shigematsu2, Makoto Mo3, Nobuyoshi Azuma4, Hiroko Kume5,
Takashi Kobata6, Nobuhiro Shimabukuro7, Tsuyoshi Shimizu8, Toshio Takayama9, Kensuke Takeuchi10,
Eiichi Teshima11, Toshiya Nishibe12, Hiroko Nemoto3, Akihiro Hosaka13, and Koji Maeda14
Reviewers: Nozomu Shirasugi15, Yutaka Hosoi16, Noriyuki Miyama17, and Yoshiko Watanabe18
1

Ochanomizu Vascular and Vein Clinic
Department of Vascular Surgery, International University of Health and Welfare Mita Hospital3
Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital
4
Department of Cardiovascular Surgery, Asahikawa Medical University
5
Tsukuba Vascular Center
6
Department of Cardiovascular Surgery, Kanazawa Medical University Himi Municipal Hospital
7
Department of Cardiovascular Surgery, Yuuai Medical Center
8
Department of Cardiovascular Surgery, Nagano Matsushiro General Hospital
9
Department of Vascular Surgery, The University of Tokyo
10
Takeuchi Vascular Clinic
11
Department of Cardiovascular Surgery, Fukuoka Wajiro Hospital
12
Department of Medical Management and Informatics, Hokkaido Information University
13
Department of Vascular Surgery, Tokyo Metropolitan Tama Medical Center
14
Department of Vascular Surgery, International University of Health and Welfare Narita Hospital
15
Varicose Vein Treatment Center, The Second Kawasaki Saiwai Clinic
16
Department of Cardiovascular Surgery, Kyorin University
17
Department of Vascular Surgery, Kansai Medical University Medical Center
18
Department of General Medicine, Kawasaki Medical School2

Key words: guidelines, chronic venous disease, varicose veins, deep vein thrombosis, post-thrombotic syndrome(Jpn J Vasc Surg 2023; 32: 211–256)256