原发性肝癌合并动静脉瘘的数字减影血管造影表现及介入治疗

目的:探讨原发性肝癌合并动-静脉瘘(arteriovenous shunting,AVS)的数字减影血管造影(DSA)表现及介入治疗效果.方法:回顾性分析了97例原发性肝癌伴有肝动脉-门静脉瘘(HA-PVS)患者的临床资料.其中术前合并消化道出血者16例,中等至大量腹水者51例,食道-胃底静脉曲张者53例.所有患者均给予肝动脉内化疗栓塞术(TACE)和肝动脉内化疗灌注术(TAI)治疗.使用碘油封堵瘘口者40例,使用碘油 明胶海绵或丝线封堵瘘口者34例,还有6例应用弹簧圈封堵瘘口,其余17例给予单纯TAI治疗.结果:有12例患者同时合并肝动脉-肝静脉瘘(HA-HVS,12.4%),32例患者有门静脉癌栓(PVTT,33%).全部患者中,70例瘘口基本闭合(72.2%),15例瘘口部分闭合(15.5%),12例(12.3%)因瘘口过大或者血管造影时无法判明瘘口准确位置未能成功封堵.在首次封堵成功的患者中,12例患者在后续治疗中发现原有的AVS重新开通,开通后的瘘口大多比前次瘘口的流量小,经再次封堵后闭塞.另有17例出现新的AVS.患者经TACE治疗后,57例(58.7%)肿瘤缩小,24例(24.7%)肿瘤增大,16例(16.5%)肿瘤大小无明显改变.术后51例合并腹水的患者中,29例腹水消失,18例减少,4例无明显改善.曾经合并消化道出血的患者于术后再次出现消化道出血者5例.47例合并腹泻的患者中23例好转.67例甲胎蛋白(AFP)阳性的患者中53例AFP的值有所下降.随访中81例死亡患者的中位生存期为12.9个月.大部分病例未发生严重肝功能损害.结论:原发性肝癌合并AVS增加了介入治疗的难度,但是只要采取积极而恰当的治疗措施,仍能取得较好的疗效而不出现严重并发症,能有效缓解患者的临床症状,提高患者生存质量.DSA能直接、全面地显示AVS的类型、部位及程度,为制定治疗方案及改善预后提供重要参考价值.

Digital subtraction angiography manifestation and interventional therapy of arteriovenous shunting in primary hepatocellular carcinoma of advanced stage

OBJECTIVE:To explore the appearances of digital subtraction angiography (DSA) and therapeutic efficacy of interventional therapy of hepatic carcinoma accompanied with arteriovenous shunting (AVS). METHODS: To retrospectively analyze clinical material of 97 patients with hepatocellular carcinoma with hepatic artery-portal vein shunting(HA-PVS), of whom, 16 had upper gastrointestinal hemorrhage, 51 had middle to large amounts of ascites, and 53 had varices of esophagus and fundus gastricus. All the patients were treated with transcatheter arterial chemoembolization (TACE) or transcatheter arterial infusion chemotherapy (TAI). Shunts were embolized by lipidol in 40 patients, by lipidol and sponjgia gelatinosa particle in 34 patients, and by coil in 6 patients. The remaining 17 were treated only with TAI. RESULTS:Twelve (12.4%) cases had hepatic arteryjhepatic vein shunting (HA-HVS)ìwhile 32 (33%)cases had portal vein tumor thrombosis (PVTT). In 70(72.2%) patients, all shunts were completely closed successfully, in 15(15.5%) patients, the shunts were partly closed, and in 12(12.3%)patients, the shunts were not closed. In 12 patients, the shunts reopened in later therapy, their blood flow was smaller than before and they were closed after second embolization. In 17 patients, new shunts emerged. After TACE therapy ìthe tumors were smaller in 57(58.7%)ìbigger in 24 (24.7%)ìand 16(16.5%) were the same in size before and after TACE. Ascites disappeared in 29 patients, decreased in 18 patients and had no change in 4 patients. Five patients who had upper gastrointestinal hemorrhage prejoperation had new hemorrhage. Of the 47 patients who had diarrhea, 23 improved. In 67 alpha fetoprotein (AFP) positive patients, degree of AFP in 53 patients decreased. Eighty-one patients died and their middle survival period was 12.9 months. No serious damage to hepatic function due to the treatment was observed in most patients. CONCLUSION:Primary hepatic carcinoma with AVS increases difficulty of interventional therapyìbut as long as we take active and proper treating measureìwe could acquire satisfactory curative effect without serious syndrome. DSA can demonstrate the type, the site and the degree of AVS completely and directly, thus having important value in treating primary hepatic carcinoma and improving prognosis.