经颈静脉肝内门体分流双支架技术研究进展

经颈静脉肝内门体分流术(TIPS)目前已成为治疗肝硬化门静脉高压及其并发症的主要方法.TIPS专用Viatorr支架2015年底在中国上市,但至今未能在国内广泛应用,国内多个中心目前仍采用裸支架与覆膜支架各1枚叠加释放的双支架技术模拟Viatorr支架行TIPS.双支架技术具有独特优势,但在远期疗效上不及单支架植入.该文就TIPS双支架技术分类与优势、术后分流道功能障碍原因、术后随访、分流道功能障碍处理处理等研究进展作一综述,以期更好地发挥该技术在肝硬化门静脉高压治疗中的作用.     

TIPS中8mm直径覆膜支架直用的临床研究

目的评价在TIPS中应用8mm直径覆膜支架的临床效果。方法对19例伴有食管胃底静脉曲张破裂出血和(或)难治性腹水的门脉高压症患者行TIPS术,术中应用8mm直径的覆膜支架,术后观察临床症状改善程度,并进行定期影像学和实验室检查,以评价疗效。结果所有患者均成功完成TIPS术,技术成功率100%,术中未出现并发症。术后平均随访13.5个月(2.7～28个月),1例(1/19,5.3%)原有肝性脑病加重;2例(10.5%)再次出血;腹水改善及治愈率为66.7%(12/18);16例患者进行了6个月的随访,初次开通率100%,8例患者随访12个月,初次开通率87.5%。结论在TIPS术中应用8mm直径覆膜支架在保证有效分流量,提高术后分流道开通率的同时,可以降低肝性脑病的发生率。     

TIPS术后分流道失效影响因素的多因素回归分析

目的 分析肝硬化患者行经颈静脉肝内门体分流术(TIPS)术后分流道失效的影响因素.方法 搜集2008年3月至2014年12月在本院行TIPS术(采用Fluency覆膜支架)的肝硬化患者,术后3年内发生分流道失效的30例为病例组,术后3年未发生分流道失效的30例为对照组(通过门静脉彩色多普勒超声检查及门静脉造影确定分流道是否失效),对两组病例资料进行回顾性对照研究.先对肝功能Child-Pugh评分、支架形态、术后抗凝药物使用情况等20项术前、术中及术后相关因素进行单因素分析,再将单因素分析中具有统计学差异的相关因素进行Logistic多因素回归分析.结果 对20项相关因素进行单因素分析后发现两组患者在否合并门静脉血栓(癌栓)、支架形态及术中是否行曲张静脉栓塞等3项之间的差异有统计学意义(P＜0.05),再将上述3项相关因素进行Logistic多因素回归分析,显示支架放置后的支架形态及术中是否进行曲张静脉栓塞与TIPS术后分流道失效有关(P＜0.05).结论 支架形态不良(包括扭曲折角、支架两端盖帽)为TIPS术后分流道失效的独立危险因素(OR值为4.244),而术中曲张静脉栓塞是TIPS术后分流道失效的保护因素(OR值为0.131).     

TIPS中8 mm直径覆膜支架应用的临床研究

目的 评价在TIPS中应用8 mm直径覆膜支架的临床效果.方法 对19例伴有食管胃底静脉曲张破裂出血和(或)难治性腹水的门脉高压症患者行TIPS术,术中应用8mm直径的覆膜支架,术后观察临床症状改善程度,并进行定期影像学和实验室检查,以评价疗效.结果 所有患者均成功完成TIPS术,技术成功率100%,术中未出现并发症.术后平均随访13.5个月(2.7～28个月),1例(1/19,5.3%)原有肝性脑病加重;2例(10.5%)再次出血;腹水改善及治愈率为66.7%(12/18);16例患者进行了6个月的随访,初次开通率100%,8例患者随访12个月,初次开通率87.5%.结论 在TIPS术中应用8mm直径覆膜支架在保证有效分流量,提高术后分流道开通率的同时,可以降低肝性脑病的发生率.     

采用聚四氟乙烯覆膜支架行经颈静脉肝内门腔分流术的临床疗效观察

目的 探讨采用聚四氟乙烯(PTFE)覆膜支架行经颈静脉肝内门腔分流术(TIPS)的临床疗效.方法 回顾性分析行PTFE覆膜支架TIPS术治疗的102例门静脉高压症患者的临床资料,其中男82例、女20例,年龄16 ～ 73岁,平均(53±13)岁.术前症状为食管胃底静脉曲张大出血(83例)或顽固性腹水(19例),肝功能Child-Pugh评分5.0 ～10.0分,平均(6.7±1.7)分.患者均采用PTFE覆膜支架行TIPS术.手术前后门静脉压力和肝功能评分的比较采用t检验.采用寿命表法绘制术后6、12、24、36、48个月的分流道开通率、术后生存率、术后肝性脑病(HE)的发生率曲线.结果 全部患者均在局部麻醉下成功建立肝内门腔覆膜支架分流道,共置入支架128枚.支架直径6.0～10.0mm,平均(8.1 ±0.9)mm.其中PTFE覆膜支架104枚,裸支架24枚.术后门静脉压力明显下降,术前平均(28.5±5.3)mm Hg(1 mm Hg=0.133 kPa),术后(18.0±4.5)mm Hg,手术前后差异有统计学意义(t =22.8,P＜0.01).3例患者出现围手术期并发症,2例腹腔出血、1例支架周围感染.术后随访0 ～58个月,平均(20±13)个月.术后3个月肝功能Child-Pugh评分(6.5±1.6)分,与术前相比[(6.7±1.7)分]差异无统计学意义(t=0.8,P＞0.05).患者术后6、12、24、36、48个月的覆膜支架分流道一期累积通畅率分别是96％、91％、82％、82％、82％,随访期间10例患者出现覆膜支架分流道再狭窄,总体一期再狭窄率为9.8％;27例出现术后HE,发生率26.5％,累积发生率分别为7％、21％、34％、46％、66％;16例出现死亡,病死率为15.7％,累积生存率分别是95％、83％、76％、76％、76％.结论 与裸支架相比,采用PTFE覆膜支架行TIPS术在技术上安全可行,可以明显提高TIPS术后分流道通畅率,但如何改善术后HE及生存率仍是目前亟待解决的问题.     

经颈静脉肝内门体分流术中覆膜支架与非覆膜支架效果的比较

目的 对比覆膜与非覆膜支架在TIPS中应用的临床疗效.方法 回顾性研究30例临床诊断为肝硬化接受TIPS治疗(按照术后是否有覆膜支架分为覆膜支架组20例、非覆膜支架组10例)的患者的临床资料.本组患者手术前后测量门静脉压力,术后彩色超声观察分流道通畅情况.采用四格表资料的Fisher确切概率法进行两组间病死率、再出血率及肝性脑病发生率等临床指标对比.结果 30例患者手术均成功,门静脉压力在覆膜组由术前(3.78±0.50)kPa降至术后(2.21±0.44)kPa,非覆膜组由术前(3.67±0.48)kPa降至术后(2.13±0.35)kPa.术后随访资料完整的26例(覆膜支架组17例,非覆膜支架组9例),随访时间为7 d～62个月(中位随访时间23个月).随访期内死亡13例,覆膜支架组8例、非覆膜支架组5例,两组差异无统计学意义(P>0.05),均死于上消化道出血及肝功能衰竭.覆膜组再出血5例、非覆膜组3例,两组差异无统计学意义(P>0.05).发生肝性脑病在覆膜支架组4例、非覆膜支架组2例,两组差异无统计学意义(P>0.05).术后6个月和1年分流道通畅率在覆膜支架组均为100.0%,非覆膜支架组分别为77.8%(7/9)和55.6%(5/9),两组差异有统计学意义(P<0.05).结论 覆膜支架组1年分流道通畅率优于非覆膜支架,但两组病死率、再出血率及肝性脑病发生率差异无统计学意义.     

门静脉高压性上消化道出血TIPS的临床应用

目的 探讨采用Fluency自膨胀覆膜支架,行经颈静脉肝内门体静脉支架分流术(TIPS)治疗食管静脉曲张破裂出血的效果.资料与方法 对20例患者采用Fluency自膨胀覆膜支架行TIPS及食管胃底静脉栓塞术,18例成功建立分流道,2例因严重并发症未成功.结果 门静脉压力明显降低,术前平均门静脉压梯度(27.11±4.86)cm H2O,术后平均门静脉压梯度(17.13±3.81)cm H2O,控制出血近期有效率为100%,再出血率为16.7%.术后血像明显改善,上消化道出血停止,腹水吸收明显.结论 采用Fluency自膨胀覆膜支架行TIPS治疗门静脉高压性上消化道出血具有重要的临床实用价值.     

经颈静脉肝内门体分流术支架选择和释放位置研究进展

【摘要】 门静脉高压症是终末期肝病的血管并发症。经颈静脉肝内门体分流术（TIPS）通过支架植入建立分流道降低门静脉压力，其安全性和有效性已经证实。目前TIPS术有多种支架可供选择，释放位置也不相同。该文就支架直径，裸支架、覆膜支架类型，是否充分扩张，初始支架位置及穿刺位置等研究进展作一综述，以期对临床实践有一定指导意义。     

限流支架植入治疗TIPS引起的难治性肝性脑病

目的　评价限流支架装置在缩小 TIPS分流道直径对治疗由门腔分流引起的肝性脑病的有效性。　方法　 9例TIPS术后并发严重肝性脑病患者经颈静脉沿原肝内支架同轴植入可限制血流量的支架装置。　结果　限流支架植入未出现术中并发症 ,平均门静脉压力由术前 12± 4 .2 cm H2 O升至 2 0± 2 .6 cm H2 O,彩色多普勒超声显示分流道内血流减少 4 7.3%±15 .1% ,肝性脑病得到实质性改善和控制。血氨浓度及胆红素明显降低。　结论　用限流支架治疗门腔分流因起的肝性脑病是安全有效的     

内皮祖细胞种植支架在经颈静脉肝内门体分流术中应用的实验研究

目的 评价内皮祖细胞(EPC)种植支架在经颈静脉肝内门腔分流(TIPS)家猪动物模型中减少分流道再狭窄的疗效.方法 体外分离、培养、鉴定家猪外周血内皮祖细胞,并构建内皮祖细胞种植支架.15头家猪行TIPS介入手术,采用随机区组设计分为EPC种植支架组9头(实验组),裸支架组6头(对照组).术后14 d行直接门静脉造影,然后处死动物,作病理分析及免疫组织化学检查,记录分流道狭窄及阻塞率,并用图像处理软件计算TIPS分流道假性内膜厚度及面积.计数资料用Fisher精确概率法,计量资料行t检验,作统计学分析.结果 15头猪TIPS手术均成功.实验组分流道通畅5头,狭窄2头(狭窄率50%、70%),阻塞2头(共9头).对照组狭窄1头(狭窄率80%),阻塞5头(共6头).2组通畅率差异有统计学意义(P=0.03).实验组假性内膜增生的厚度(肝静脉、肝实质、门静脉段)显著小于对照组[分别为(1.0 ±0.6)、(0.9±0.5)、(1.0±0.4)mm和(1.2±0.4)、(1.3±0.5)、(1.5±0.4)mm,P值均＜0.05].免疫组织化学显示实验组中通畅的分流道有完整的内皮形成;再狭窄分流道的假性内膜主要由胶原纤维组成,而通畅分流道的假性内膜主要由细胞成分组成.结论 体外构建EPC种植支架是可行的,置入后促进了家猪模型TIPS分流道内皮化形成,可以提高分流道的通畅性.     

Flouroscopically–guided transhepatic puncture for difficult TIPS re-do procedures utilizing the En Snare retrieval device: A new approach to occluded TIPS in patients with recurrent ascites

Portal hypertension and variceal bleeding are complications due to cirrhosis. Transjugular Intraphepatic Portosystemic shunt (TIPS) procedure is a well-established treatment for recurrent ascites and variceal bleeding related to portal hypertension. After a TIPS has been placed, the potential of TIPS occlusion or stenosis is high. A TIPS re-do procedure has been used in treatment of progressive clinical symptoms. The standard approach is via the jugular route to recannulate the TIPS shunt. Rarely, it cannot be performed from the jugular approach. Therefore, a fluoroscopically -guided transhepatic approach has been devised for these difficult situations. This case describes the use of the transhepatic route through an indwelling Viatorr covered stent utilizing an En-Snare device to help complete the TIPS re-do procedure. With this newer approach to TIPS re-do procedures, endovascular specialists can achieve TIPS patency despite difficult venous anatomical challenges and the various types of available TIPS stents presently on the market.     

Recurrent TIPS failure associated with biliary fistulae: Treatment with PTFE-covered stents

Purpose: To evaluate the efficacy of covered stents for the treatment of transjugular intrahepatic portosystemic shunt (TIPS) obstruction in human subjects with identified or suspected biliary fistulae. Methods: Five patients were treated for early failure of TIPS revisions. All had mid-shunt thrombus, and four of these had demonstrable biliary fistulae. Three patients also propagated thrombus into the native portal venous system and required thrombolysis. TIPS were revised in four patients using a custom-made polytetrafluoroethylene (PTFE)-covered Wallstent, and in one patient using a custom-made PTFE-covered Gianturco Z-stent. Results: All identified biliary fistulae were successfully sealed. All five patients maintained patency and function of the TIPS during follow-up ranging from 2 days to 21 months (mean 8.4 months). No patient has required additional revision. Thrombosis of the native portal venous system was treated with partial success by mechanical thrombolysis. Conclusion: Early and recurrent failure of TIPS with mid-shunt thrombosis, which may be associated with biliary fistulae, can be successfully treated using covered stents. Stent-graft revision appears to be safe, effective, and potentially durable.     

Transjugular intrahepatic portosystemic shunts formed with polyethylene terephthalate-covered stents: experimental evaluation in pigs

PURPOSE: To evaluate the safety, efficacy, and tissue response associated with Wallstents covered with polyethylene terephthalate (PETP) compared with those associated with uncovered Wallstents for creation of transjugular intrahepatic portosystemic shunts (TIPS) in a porcine model. MATERIALS AND METHODS: Thirteen TIPS were created in 13 minipigs: eight with PETP-covered Wallstents, five with standard Wallstents. Shunt venography was performed at 5-8 weeks, and necropsy was performed at 7-8 weeks. Histopathologic, immunohistochemical, and scanning electron microscopic examinations were performed. RESULTS: Mean shunt stenoses of the control and graft groups were 45% and 53%, respectively. Graft stenoses involved the entire graft-bearing segment, whereas bare stent stenoses were localized within the liver tract. Myofibroblast and extracellular collagen matrix proliferation encompassed both control and graft-covered stents. There was one graft TIPS occlusion. One control TIPS stenosis was due to transstent proliferation of normal porcine hepatic tissue. A small focus of bile staining was seen on the abluminal surface of one TIPS, which was a patent PETP-lined shunt. CONCLUSION: PETP graft TIPS provided equal, but not superior, patency to that of bare stent TIPS. The pattern of PETP TIPS graft healing differed from that of bare stents but was similar to that reported with other polyester graft vascular implants and consisted of diffuse transmural penetration and paving of the graft surface by extracellular collagen matrix and myofibroblasts.     

Endovascular shunt reduction in the management of transjugular portosystemic shunt-induced hepatic encephalopathy: preliminary experience with reduction stents and stent-grafts

OBJECTIVE: The purpose of this study was to retrospectively evaluate the safety, feasibility, and midterm clinical outcome of the use of three types of reduction stents inserted to manage transjugular intrahepatic portosystemic shunt (TIPS)-induced hepatic encephalopathy refractory to medical treatment. CONCLUSION: The use of a covered reduction stent-graft results in a greater increase in portosystemic gradient immediately after reduction than does use of a bare reduction stent. Relief of TIPS-induced hepatic encephalopathy tends to be greater in patients with reduction stent-grafts than in those with bare reduction stents.     

Iatrogenic dissection of the portal vein during TIPS procedure

Dissection of the portal vein is a rare entity which has been rarely described during transjugular intrahepatic portosystemic shunt (TIPS) procedure. We report three cases of dissection during this procedure and their complications. One dissection was immediately treated with coaxial stents. The two others were complicated either by a thrombus or by a false aneurysm. In the first case a second parallel stent was used to treat this complication. The patient with the portal vein false aneurysm was transplanted 4 days after this diagnosis. Portal vein dissection in TIPS procedure appeared to be less rare than has been reported and must be considered as a potential cause of TIPS dysfunction. Received: 5 May 1999; Revised: 14 July 1999; Accepted: 14 July 1999     

Bile resistance of coated transjugular intrahepatic portosystemic shunt stents in a flow-model

PURPOSE: We sought to test the bile resistance of transjugular intrahepatic portosystemic shunt (TIPS) stents with 3 different coatings. MATERIALS AND METHODS: Three stents with different coating materials (monolayer polyethylene terephthalate [PETP], monolayer polytetrafluoroethylene [PTFE], and double layer [PTFE]) were tested in a flow model. After testing the sealing of the system with isotonic saline solution, fresh human bile was circulated. Constant pressure was 50 cm H2O. Bile resistance of the stent membranes was analyzed. RESULTS: Two of the 3 stents proved completely resistant to water. Only the PETP stent was resistant to bile. The PTFE-coated stents were not bile resistant. CONCLUSION: The bile resistance of coated TIPS stents and, thus, the dependency of TIPS shunt patency is called into question. The stent with the reported superior patency rates does not show experimental bile resistance.     

Preliminary results of a new expanded-polytetrafluoroethylene-covered stent-graft for transjugular intrahepatic portosystemic shunt procedures.

OBJECTIVE: The purpose of our study was to evaluate the feasibility and the safety of transjugular intrahepatic portosystemic shunts (TIPS) with a new expanded-polytetrafluoroethylene-covered stent and the influence of the covering on occlusion rate. SUBJECTS AND METHODS: Twenty cirrhotic patients (57 +/- 11 years old) admitted with a history of esophageal variceal bleeding (n = 11), refractory ascites (n = 5), or both (n = 4) were included. Five of the patients were treated for TIPS revision, and 15 as de novo TIPS placements. The endoprostheses used were composed of a 2-cm noncovered nitinol stent and a 4- to 8-cm expanded-polytetrafluoroethylene graft covering, and were placed from the portal vein to the ostium of the hepatic vein. Patients underwent Doppler sonography at discharge and again at 1, 3, 6, 9, 12, and 15 months and underwent venography with portosystemic pressure gradient measurement at 6 months and whenever necessary. RESULTS: At the time of this writing, complications included three TIPS restenoses and one recurrent ascites successfully treated by balloon dilation, two cases of segmentary liver ischemia, and one patient with encephalopathy that required shunt reduction. After TIPS placement, the portosystemic pressure gradient dropped from 18 +/- 5 to 5 +/- 4 mm Hg. Primary and secondary patency rates were 80% and 100%, respectively, at 387 days. CONCLUSION: These results clearly show the feasibility of TIPS placement with the Gore TIPS endoprosthesis stent-graft and its improved patency compared with results in the literature for bare stents. These preliminary results must be certified further with randomized comparative trials between covered and noncovered TIPS stents.     

Added Value of Covered Stents in Transjugular Intrahepatic Portosystemic Shunt: A Large Single-Center Experience

Purpose

Transjugular intrahepatic portosystemic shunts (TIPS) were historically placed using uncovered bare-metal stents. Current practice has now shifted toward the use of polytetrafluoroethylene (PTFE)-covered stents, given the improved primary patency seen with these stents. The aim of this study was to determine whether there is any added value, such as overall survival or stent patency, when using covered stents versus uncovered stents in TIPS placement in a large cohort.

Materials and Methods

From April 1995 to June 2012, a total of 744 consecutive adult patients underwent de novo TIPS placement (378 receiving uncovered stents, 366 receiving covered stents). Information was obtained on demographics, baseline clinical variables, and outcomes after TIPS placement. Data were collected, compared, and analyzed to assess outcomes including mortality, primary patency (determined via repeat intervention), and secondary patency (determined via ultrasound parameters).

Results

Covered stents were associated with significantly improved primary patency (P < 0.001) and secondary patency (P < 0.001) when compared with uncovered stents in TIPS procedures. Additionally, covered stents were associated with higher estimated overall survival rates and higher survival rates when TIPS was performed emergently and in patients with higher Model for End-Stage Liver Disease (MELD) scores. For example, in patients with MELD scores between 11 and 18, there was a predicted survival of 59.2% with covered stents versus 42.8% with uncovered stents at 1 year.

Conclusion

This study demonstrated that covered stents offer the additional value of higher estimated overall survival and higher estimated survival in patients undergoing TIPS emergently and in those with higher MELD scores when compared to uncovered stents.