改良式经颈静脉肝内门腔静脉分流术治疗肝静脉闭塞型Buddi-Chiari 综合征

目的阐述改良式经颈静脉肝内门腔静脉分流术(TIPS)的技术步骤和评价其对肝静脉闭塞型Buddi-Chiari综合征的治疗效果.方法 11例被诊断为Buddi-Chiari综合征的患者,经影像学证实为肝静脉广泛狭窄和闭塞后,接受改良式TIPS技术治疗,TIPS改良技术的关键在于假想肝静脉通道的设计与建立;术后对其门脉系统压力变化、分流道血流改变及内支架开通状况进行了24个月的随访.结果 11例患者全部成功地建立肝内门静脉-下腔静脉分流通道,临床症状得到改善;门静脉主干压力由分流前的平均(4.62±0.52) kPa (1 kPa=10.2 cm H2O)下降至分流术后的(2.16±0.21) kPa;术后24个月随访,分流道血液最大流率(Vmax)为(56.2±3.50) cm/s,内支架通畅7(7/11)例.结论改良式TIPS技术具有高技术成功率,为肝静脉闭塞型Buddi-Chiari综合征患者提供了新的治疗手段.     

经颈内静脉肝内门腔静脉分流术治疗BuddChiari综合征

目的探讨经颈静脉肝内门腔静脉分流术(TIPS)治疗Budd-Chiari综合征(BCS)的疗效。方法本组14例患者经影像学检查确诊为BCS,因进行性肝功能损害,或严重门脉高压并发症(顽固性腹水,食管胃底静脉曲张上消化道出血),或广泛肝静脉闭塞而行TIPS术治疗。其中混合型8例,肝静脉型5例,肝静脉广泛闭塞型1例。TIPS术中对于下腔静脉、肝静脉的不同情况,灵活选择肝静脉或下腔静脉穿刺点进行穿刺,7例从肝静脉开口处行门静脉穿刺,建立门-腔静脉分流道,4例从下腔静脉直接穿刺门静脉分支,3例经皮穿刺开通肝右静脉后再经肝右静脉穿刺门静脉。术后对分流道支架开通情况进行长期随访。结果14例手术均获成功,门静脉压力由术前平均(4.9±1.4)kPa,降至术后(3.2±1.5)kPa,术后随访5～64个月,2例因支架狭窄分别于术后13、24个月再发上消化道出血,行分流道球囊扩张治疗,术后恢复良好。结论TIPS适用BCS合并有进行性肝功能损害或门静脉高压引起的上消化道出血、顽固性腹水的治疗。对于已行下腔静脉或肝静脉成形术后再发或加重的门静脉高压患者亦为适应证,但手术难度增加。     

改良经颈静脉肝内门体分流术治疗广泛肝静脉闭塞型布-加综合征效果分析北大核心CSCD

目的评价改良经颈静脉肝内门体分流术(TIPS)治疗广泛肝静脉闭塞型布-加综合征(BCS)的临床效果。方法回顾性分析28例确诊为广泛肝静脉闭塞型BCS患者的临床资料。所有患者均经彩色超声和MRA或腹部增强CT明确诊断为广泛肝静脉闭塞型BCS,并接受改良TIPS治疗。记录腹水消退率、肝性脑病发生率及肝、肾功能情况。术后彩色超声或CTA随访,观察分流道通畅情况。结果28例患者改良TIPS手术均获成功,无手术相关严重并发症。术前门静脉压力为(33.69±5.95)mmHg(1 mmHg=0.133 kPa),术后为(19.08±3.59)mmHg,差异有统计学意义(P<0.01)。术后随访3~35个月,中位时间为16.6个月。术后3、6、12个月腹水完全消退率分别为25%(7/28)、75%(21/28)、92.8%(26/28)。术后3个月肝肾功能指标较术前明显好转(P<0.05)。术后3个月终末期肝病模型(MELD)评分为10.92±2.50,低于术前的15.42±6.03,差异有统计学意义(P<0.05)。术前、术后1周、术后3个月血氨值差异无统计学意义(P>0.05)。术后1周2例(7.1%)出现轻度肝性脑病。术后1年、2年分流道一期通畅率分别为100%(28/28)、89.3%(25/28),二期通畅率皆为100%。结论改良TIPS术治疗广泛肝静脉闭塞型BCS患者安全有效,可取得较好的中远期疗效。     

第二肝门重建术治疗肝静脉阻塞型Budd-Chiari综合征

目的 分析和评价第二肝门重建术治疗肝静脉阻塞型布-加综合征(Buddi-Chiari syndrom,BCS)的可行性和中远期疗效.资料与方法 自1999年1月至2008年12月收治的肝静脉阻塞型或肝静脉阻塞伴下腔静脉阻塞的BCS患者,单独应用副肝静脉成形术或分别联合肝静脉成形术、下腔静脉成形术的方法治疗的27例患者,在副肝静脉成形术和肝静脉成形术前后经导管测定副肝静脉、肝静脉压力,观察围手术期并发症,并观察术后6、12、24、36个月受干预血管的通畅率.结果 27例中26例成功,副肝静脉成形术成功率达96%,术中3例出现心慌、胸闷症状,急性肺栓塞1例,均经保守治疗痊愈.26例随访,术后6、12、24及36个月受干预血管的初始再通率分别为96.2%、88.5%、76.9%及73.1%.结论 第二肝门重建术是治疗肝静脉阻塞型BCS行之有效的方法,在肝静脉阻塞型BCS介入治疗中应灵活运用.     

Budd-Chiari综合征介入治疗的临床疗效评价

目的 评价不同类型Budd-Chiari综合征(BCS)介入治疗的临床疗效.方法 回顾性分析159例经超声和选择性静脉造影确诊的BCS患者的临床资料,对其中147例资料完整者进行临床疗效评价.根据新的影像学分型,147例患者中,13.6/(20例)为单纯肝静脉阻塞型,66.0/(97例)为下腔静脉膜性阻寨型,6.1/(9例)为下腔静脉膜性闭塞伴远端腔内巨大血栓形成型,14.3/(21例)为下腔静脉节段性阻塞型.根据病变类型分别对147例BCS患者进行了介入治疗,包括经导管局部溶栓术、经皮腔内血管成形术(PTA)、血管内支架置入术和改良式经皮经肝门体静脉分流术(MTIPS)等.术中根据静脉造影图像判断肝静脉回流改善情况.对147例患者平均随访了(67.3±9.0)个月(16 h至104个月),随访内容包括忠者的症状、体征、肝功能检查结果和超声检查结果,评价介入治疗的首次开通率与再次治疗开通率,同时对所有患者的肝功能水平进行Child-Push评分与分级.术前与末次随访评分差异用配对样本均数t检验进行统计学评估.结果 PTA的首次治疗开通率为65.6/(86/131),再次治疗开通率为96.9/(124/128).血管内支架置入术的首次开通率为78.9/(15/19),再次开通率为92.3/(24/26).Ⅰ例Ⅲa型BCS患者在下腔静脉开通后72 h死于不明原因的咯血、1例Ⅰ b型BCS患者MTIPS术后16 h死于弥漫性血管内凝血、Ⅰ例Ⅳ b型BCS患者在接受MTIPS术后13个月死于肝功能衰竭.另有12例患者分别在术后7～79个月死于与介入治疗无关的其他原因.末次随访,存活患者肝功能明显改善,平均Child-Push评分由术前的8分降低至5分(t=2.017,P＜0.05).结论 应用多种血管介入技术治疗BCS可获得满意的临床疗效.     

肝静脉型Budd-Chiari综合征的介入治疗

目的　探讨肝静脉型Budd Chiari综合征介入治疗方法选择和疗效的评估。方法　 36例肝静脉型Budd Chiari综合征患者 ,肝功能Child分级 :A级 9例 ,B级 2 1例 ,C级 6例。术前常规行腹部彩超检查及胃镜检查 ,31例患者行CT扫描及肝脏血管重建。介入治疗方法 :经颈静脉 (股静脉 ) 下腔静脉途径行肝静脉 (或副肝静脉 )开通 ;经皮经肝穿刺肝静脉途径行肝静脉开通 ;经颈静脉行肝内门 腔静脉支架分流术 (改良式TIPS)。术中常规行肝静脉、门静脉造影和测压和下腔静脉造影 ,术后给予护肝、抗感染及长期口服阿司匹林和双嘧达莫抗凝治疗。结果　 19例患者行肝静脉球囊扩张术 ,其中 14例患者扩张后置入网状内支架共 18枚。 5例患者经股静脉穿刺行副肝静脉球囊扩张术 ,其中 4例患者扩张后共置入网状内支架 4枚。 2 4例患者术后肝静脉 (或副肝静脉 )压力均明显降低 ,术前肝静脉 (或副肝静脉 )压力为 (37.4± 5 .2 )cmH2 O(2 6 .3～ 5 2 .5cmH2 O) ,PTA或内支架置入术后即刻降为 (2 1.4± 4 .6 )cmH2 O(12 .4～ 31.2cmH2 O) (T =12 .34,P <0 .0 1)。 12例患者行改良式TIPS术 ,分流前门静脉主干压力为 (4 5 .2± 3.5 )cmH2 O ,分流后降至 (2 0 .4± 4 .1)cmH2 O。结论　肝静脉型Budd Chiari综合征可根据肝静脉闭塞和肝内侧     

改良经颈静脉肝内门体分流术治疗布- 加综合征所致顽固性腹水效果分析

【摘要】 目的 探讨改良经颈静脉肝内门体分流术（TIPS）治疗布-加综合征（BCS）所致顽固性腹水患者的效果。方法 回顾性分析2015年6月至2019年7月徐州医科大学附属医院采用改良TIPS 治疗的31例BCS所致顽固性腹水患者临床资料。其中早期接受改良TIPS治疗17例（肝静脉广泛阻塞8例,残存肝静脉代偿不全9例）,肝静脉开通失败或反复再狭窄转改良TIPS治疗14例。记录手术成功率、腹水缓解率、肝性脑病发生率。采用彩色多普勒超声或CT随访观察分流道通畅情况。 结果 31例患者改良TIPS手术均成功。患者门静脉压力由术前（34.5±6.7） mmHg（1 mmHg=0.133 kPa）显著降至术后（18.9±2.6） mmHg（P＜0.01）,无手术相关严重并发症发生。术后随访2～34个月,中位随访15.6个月。术后1、3、6、12个月时腹水完全缓解率分别为74.2%（23/31）、93.1%（27/29）、95.8%（23/24）、95.8%（23/24）;术后发生肝性脑病1例,发生率为3.3%（1/30）;术后1年、2年分流道原发通畅率分别为95.8%（23/24）、91.7%（11/12）,继发通畅率皆为100%（24/24,12/12）。 结论 改良TIPS术治疗BCS所致顽固性腹水安全有效,可获得较好的中远期疗效。     

穿刺套针在布-加综合征介入治疗中的应用

目的　探讨穿刺套针在布 加综合征 (BCS)介入治疗中的应用价值。方法　对 16例血管造影诊断BCS的患者进行介入治疗。 5例肝静脉膜性阻塞为主及 9例下腔静脉完全性阻塞患者使用穿刺套针经颈静脉或股静脉穿刺破膜并行球囊扩张术或 (和 )内支架置入术。结果　 14例穿刺套针均成功越过阻塞部位 ,16例PTA或内支架置入后造影证实阻塞段已开通 ,肝静脉压力平均下降 1.85kPa ,下腔静脉压力平均下降 1.2 1kPa。结论　穿刺套针的应用显著提高了BCS介入治疗的成功率。     

布-加综合征介入治疗及并发症分析

目的 探讨不同类型布-加综合征(BCS)介入治疗并发症发生的原因及防治方法.方法 204例BCS患者根据不同类型采用不同的介入治疗方法,分别为下腔静脉经皮球囊扩张成形术(PTA)和支架植入术;经皮肝穿刺肝静脉开通术和扩张术;经颈静脉或下腔静脉的肝静脉扩张术和支架植入术及经颈静脉肝内门腔静脉分流术(TIPS).结果 BCS Ia型22例进行了介入治疗,成功率95.5%(21/22):I b型成功率81.8%(9/11);Ⅱ a型成功率97.3%(109/112);Ⅱb型成功率92.9%(13/14);Ⅲ a型成功率88.9%(8/9);Ⅲ b型成功率100%(2/2);Ⅳa型成功率92%(23/25);Ⅳb型成功率88.9%(8/9).术中、术后出现的并发症有:急性心功能不全2例;肺动脉栓塞4例;弥漫性血管内凝血1例;对比剂外溢3例;心律失常2例;心脏压塞1例.讨论介入治疗BCS是一种简单、安全、有效的治疗方法,要严格掌握适应证,采取各种有效措施避免和减少并发症的发生.     

经皮经肝穿刺改良式肝内门体分流术的临床应用

自1988年Rossle等首次将经颈内静脉肝内门体分流术(TIPS)引入临床治疗以来,TIPS作为治疗肝硬化合并门静脉高压症及其他并发症的重要方法已在临床广泛应用,并且疗效确切[1-2].然而,在一些特殊情况下,如解剖变异、中心静脉或肝静脉狭窄或闭塞等,常规TIPS难以甚至无法完成,对此类患者建立肝内门体分流道需要对常规TIPS术式进行改良.笔者经皮经肝途径成功完成2例特殊患者的改良式肝内门体分流术,达到了预期的效果,介绍如下.     

Role of TIPS as a bridge to hepatic transplantation in Budd-Chiari syndrome.

PURPOSE: To investigate the role of transjugular intrahepatic portosystemic shunt (TIPS) as a bridge to transplantation for patients with Budd-Chiari syndrome (BCS). MATERIALS AND METHODS: Eight patients (five women, three men) with a mean age of 49.8 years (range, 20-61 years) were diagnosed with BCS by means of computed tomography, hepatic venography, and liver biopsy. One patient had acute liver failure, with subacute or chronic failure in seven. TIPS placement was attempted in all eight patients. Clinical follow-up and portograms were obtained in all patients until death or transplantation. RESULTS: TIPS placement was completed in seven of eight patients (87.5%). During the follow-up period, TIPS occlusion occurred in four patients. TIPS revision in this patient, although successful, was complicated by hemorrhage and multiorgan failure, and the patient died. Assisted patency rate, excluding the technical failure, was 100%. Mean follow-up in the six survivors with TIPS was 342 days (range, 19-660 days). All six survivors had complete resolution of their ascites. Albumin levels improved an average of 0.43 g/dL (range, 0.3-1.4 g/dL). Bilirubin levels improved in five of six patients (83%), decreasing by an average of 5.6 mg/dL (range, 3.0-15.2 mg/dL). Of the six survivors, three underwent elective liver transplantation, one is awaiting transplantation, and one has been removed from the transplantation list because of clinical improvement. One patient was a candidate for transplantation but declined to be put on the list. CONCLUSION: Hepatic synthetic dysfunction improves markedly after TIPS placement in patients with BCS. Significant improvement in ascites can also occur. TIPS can be an effective bridge to transplantation for patients with BCS.     

Treatment of Budd-Chiari syndrome with transjugular intrahepatic portosystemic shunt (TIPS)

PURPOSE: This study was performed to evaluate the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of patients affected by Budd-Chiari syndrome (BCS). MATERIALS AND METHODS: From January 1999 to December 2006, 15 patients (seven male and eight female subjects, age range 7-52 years) with BCS uncontrolled by medical therapy were treated with TIPS placement. In seven cases BCS was idiopathic, in four it was caused by myeloproliferative disorders and in four by other disorders. One patient also had portal vein thrombosis. In 5/15 cases TIPS was created through a transcaval approach. Eight patients (53.4%) received a bare stent, and seven (46.6%) received a stent graft. The follow-up lasted a median of 29.4 (range 3.2-68) months. RESULTS: Technical success was achieved in all patients without major complications. TIPS was very effective in decreasing the portosystemic pressure gradient from 26.2+/-5.8 to 10+/-6.2 mmHg. All patients but two were alive at the time of writing. Acute leukaemia was the cause of the single early death and was unrelated to the procedure. The patient with portal vein thrombosis underwent thrombolysis before TIPS, but the vein occluded again after 3 weeks, and the patient died 6 months later. The other patients showed significant improvements in liver function, ascites and symptoms related to portal hypertension. Primary patency was 53.3%, and primary assisted patency was 93.3%. No patient required or was scheduled for liver transplantation. CONCLUSIONS: TIPS is an effective and safe treatment for BCS and may be considered a valuable alternative to traditional surgical portosystemic shunting or liver transplantation.     

经颈静脉肝内门腔分流术治疗复杂型Budd-Chiari综合征

目的　探讨和评价经颈静脉肝内门腔静脉分流术（TIPS）治疗复杂型Budd-Chiari综合征（BCS）并门脉高压的临床应用价值。方法　患者男4例，女1例，平均年龄33岁，均有不同程度的食管胃底静脉曲张，4例有上消化道出血史，2例伴有腹水。经下腔静脉相当于右肝静脉开口部进针穿刺门脉行TIPS治疗。结果　5例均获成功。门脉压力由术前平均（4.7±1.3）kPa降至（3.5±1.5）kPa（1kPa=7.5mmHg）。术后24h1例死于心肺衰竭；术后3周1例死于肝功能衰竭。另3例平均随访64个月，肝功能均正常。2例于术后6、9个月均有分流道狭窄，并行二次介入治疗。结论　TIPS是解决复杂型BCS伴门脉高压的一种安全有效的治疗方法。     

Transjugular Intrahepatic Portosystemic Shunt Creation in Budd-Chiari Syndrome: Percutaneous Ultrasound-Guided Direct Simultaneous Puncture of the Portal Vein and Vena Cava

Budd-Chiari syndrome (BCS) is an uncommon disorder that can be life-threatening, depending on the degree of hepatic venous outflow obstruction. Transjugular intrahepatic portosystemic shunt (TIPS) provides decompression of the congested liver but the hepatic vein obstruction makes the procedure more difficult. We describe a modified method that involved a single percutaneous puncture of the portal vein and inferior vena cava simultaneously for TIPS creation in a patient with BCS.     

肝静脉阻塞型Budd－Chiari综合征的介入治疗（附10例报告）

肝静脉阻塞型Ｂｕｄｄ－Ｃｈｉａｒｉ综合征（ＢＣＳ）既是内外科临床治疗的“难治之症”，也是介入放射学领域尚未完全解决的课题。作者采用肝静脉开通术（ＰＴＡ及ＥＭＳ置入术等）和经颈静脉肝内门腔静脉内支架分流术（ＴＩＰＳＳ）对１０例肝静脉阻塞型ＢＣＳ进行了治疗，取得了满意的临床效果。作者认为：肝静脉开通术是治疗肝静脉口部狭窄或闭塞型ＢＣＳ的较为合理而且安全有效的非手术方法。尽管它较下腔静脉开通术的难度和风险更大些，但临床效果显著持久，因而，应将其作为此类ＢＣＳ的首选治疗方法。但对不适于此项治疗者，即肝静脉广泛阻塞型ＢＣＳ则可将ＴＩＰＳＳ作为主要的治疗手段。     

副肝静脉成形术在Budd-Chiari综合征治疗中的应用

目的 评价副肝静脉成形术[经皮腔内血管成形术（PTA）及支架置入术]在Budd-Chiari综合征（BCS）介入治疗中的价值。方法 本组14例BCS患者均为肝静脉，副肝静脉狭窄或闭塞，主要症状和体征为腹胀，腹痛，腹水，肝脾肿大等，均接受了副肝静脉成形术，采用经股静脉或经颈静脉和经皮经副肝静脉途径开通副肝静脉的方法。结果 14例BCS开通副肝静脉均获得成功，未发生严重并发症，术后临床治愈7例，有效5例，无效2例。随访3-48个月。3例PTA后再狭窄（支架内血栓形成1例），1例术后2个月死于消化道大出血。结论 开通副肝静脉有着与开通肝静脉同等的治疗价值。易于操作，且更加安全，适应证为：（1）肝静脉和副肝静脉同时闭塞，而且肝静脉为节段性闭塞；（2）副肝静脉明显代偿性扩张，其管径大于8mm。     

Transjugular intrahepatic portosystemic shunt in a patient with cavernomatous portal vein occlusion

A 23-year-old woman with liver cirrhosis secondary to primary sclerosing cholangitis was referred to us for the treatment of recurrent bleeding from esophageal varices that had been refractory to endoscopic sclerotherapy. Her portal vein was occluded, associated with cavernous transformation. A transjugular intrahepatic portosystemic shunt (TIPS) was performed after a preprocedural three-dimensional computed tomographic angiography evaluation to determine feasibility. The portal vein system was recanalized and portal blood flow increased markedly after TIPS. Esophageal varices disappeared 3 weeks after TIPS. Re-bleeding and hepatic encephalopathy were absent for 3 years after the procedure. We conclude that with adequate preprocedural evaluation, TIPS can be performed safely even in patients with portal vein occlusion associated with cavernous transformation.     

Transjugular intrahepatic portocaval shunt placed through the strut of an inferior vena cava stent in a patient with Budd–Chiari syndrome: a technical modification

Transjugular intrahepatic portocaval shunt (TIPS) is performed in patients with symptomatic Budd–Chiari syndrome (BCS) who do not have repairable hepatic veins. We report the case of a patient who had an inferior vena cava (IVC) stent placed previously as part of the management for BCS, and who subsequently required TIPS. The TIPS tract was created through the strut of the previously placed IVC stent; the TIPS stent was placed after dilatation of the liver parenchyma as well as the strut of the IVC stent. This novel technique of “strutplasty” of a previously placed stent as part of TIPS has not been reported in the literature.The transjugular intrahepatic portocaval shunt (TIPS) procedure, as well as stent technology, is continually being improved [1–5]. Direct intrahepatic portocaval shunt (DIPS) – a modification of the TIPS procedure – is especially useful when there are occluded hepatic veins or an unfavourable angle between the inferior vena cava (IVC) and the hepatic vein resulting from hydrothorax and hypertrophy of the caudate lobe of the liver [1]. Herein, we report a technical modification of the TIPS procedure in Budd–Chiari syndrome (BCS).     

Traesjugular intrahepatic portosystemic shunt in portai vein thrombosis: Role of the right gastric vein with anomalous insertion

Transjugular intrahepatic portosystemic shunt (TIPS) was performed in two patients with portal vein thrombosis. In both patients, hepatopetal flow had been maintained by an anomalous insertion of the right gastric vein (RGV) into the portal vein bifurcation and into the left portal branch respectively. In one patient, the main portal trunk could not be recanalized and the RGV was used as an accessory portal vein to place one stent for TIPS. In the other case, access through the partial portal-vein occlusion was gained and three stents were placed from the hepatic vein to the main portal vein distal to the thrombus. In portal vein thrombosis, the aberrant insertion of the RGV into the left or right portal branches may maintain patency of the intrahepatic portal system and, in case of unsuccessful recanalization of the porta, may represent the sole pathway for placing a TIPS     

3D DCE MRA在诊断Budd-Chiari综合征中的应用价值

目的评价三维对比动态增强磁共振血管成像(3D DCE MRA)在诊断Budd-Chiari综合征(BCS)中的价值。方法8例BCS术前接受了常规MRI和3D DCE MRA检查,着重于回顾性分析其3D DCE MRA表现。结果8例3D DCE MRA检查显示下腔静脉阻塞3例,下腔静脉和肝静脉阻塞5例。下腔静脉阻塞部位在肝段5例、膈段1例及膈上段2例,阻塞表现形式包括膜性1例及节段性7例。伴有肝静脉阻塞的5例中肝静脉开口处阻塞3例,肝静脉分支阻塞2例。8例中有5例显示肝内侧枝循环,包括肝包膜下静脉侧枝循环、叶间静脉侧枝循环及肝内未定型侧枝循环。8例均显示肝外侧枝循环,包括深层静脉侧枝循环、中层静脉侧枝循环、浅层静脉侧枝循环及门静脉侧枝循环。8例BCS的其他征象包括肝实质信号异常、肝脏形态改变、下腔静脉内血栓形成、脾大、腹水及胸水。结论3D DCE MRA在诊断BCS中具有很高的价值,是诊断和治疗前后全面评价BCS的无创性血管成像技术。