经颈内静脉肝内门腔分流术及联合经皮肝/脾穿刺途径治疗门静脉血栓和(或)海绵样变性

目的 评价经颈内静脉肝内门腔静脉分流术(TIPS)和经肝/脾穿刺先开通门静脉再联合TIPS重建门静脉分流道,治疗伴有或不伴有海绵样变性的门静脉血栓的可行性、有效性和安全性.方法 回顾性分析第四军医大学西京消化病医院2002年7月至2007年8月65例伴或不伴有海绵样变性的慢性门静脉血栓患者,采取经皮途径开通门静脉,其中直接行TIPS 40例,经皮肝穿门静脉25例,或经皮脾穿脾静脉5例,行球囊扩张门静脉后再行TIPS,分别于术后1周、1个月、3个月,之后每隔3个月进行血常规、肝功能、胃镜和超声复查,观察成功率、并发症及生存率.结果 65例中54例成功行TIPS(83.1%),其中直接行TIPS、经肝、经脾联合TIPS分别成功36例、15例和3例.51例伴有肝硬化的成功率82.4%(42/51)与14例不伴有肝硬化的成功率85.7%(12/14),差异无统计学意义(P=0.766).39例伴有门静脉海绵样变性的成功率71.8%(28/39)]与不伴有门静脉海绵样变性的成功率100%(26/26)]相比,差异有统计学意义(P=0.002).经肝的25例中,15例开通门静脉成功,之后对失败的5例行经脾开通门静脉,成功3例,再联合行TIPS,总成功率为72.0%(18/25).术后30 d死亡3.7%(2/54),随访1 d到63个月,肝性脑病的发生率为27.8%(15/54);修正率为22.2%(12/54);中位生存时间为31.4个月.结论 用常规TIPS或经肝/脾穿刺开通门静脉再联合,TIPS治疗伴或不伴海绵样变性的门静脉血栓,是临床可选择的安全、有效的方法;经皮肝穿、经皮脾穿和(或)经颈内静脉入路是处理门静脉可供选择的途径,开通门静脉并维持其血流回流通畅是门静脉血栓治疗的关键.

Transjugular intrahepatic portosystemie shunt and combination with percutaneous transhepatic or transsplenic approach for the treatment of portal vein thrombosis with or without cavernomatous transformation

Objective To evaluate retrospectively the feasibility, efficacy and safety of transjuglar intrahepatic portosystemic shunt (TIPS) or percutaneous transhepatic or transsplenic approach to the portal vein with the combination of TIPS for the treatment of patients with portal vein thrombosis with or without cavernous transformation. Methods Sixty-five patients with portal vein thrombosis from July 2002 to August 2007 at our hospital were analyzed retrospectively. Indirect pertography through superior mesenteric artery was performed to determine the approaches for TIPS procedure. If the intrahepatic portal vein branches were visualized, TIPS was implemented directly from transjugular approach; if the intrahepatic portal vein branches failed to be visualized, an ultrasound-guided pereutaneous transhepatie or transsplenic approach was performed to recanalize the thrombosed portal vein initially followed by TIPS placement to reconstruct the portal venous flow. Efficacy and complications were observed and revision and survival rates monitored during the follow-up. Results TIPS were successfully created in 54 of 65 patients with portal vein thrombosis with a success rate of 83.1%. Among them, TIPS were performed directly in 36 of 40 patients; portal vein recanalization were successfully performed via transhepatic access in 15 of 25 patients, and 3 of remaining 5 who failed the transhepatic approach were successfully done from transsplenic access. Then TIPS placement was accomplished with a success rate of 72.0% (18/25). The success rate in cirrhotic patients was 82.4% (42/51) and it was not significant different from those without cirrhosis 85.7% (12/14) (P=0.766). While the success rate in the patients with cavernous transformation 71.8% (28/39) showed a significant difference compared to that without cavernous transformation 100% (26/26) (P=0.002). The success rates in portal vein thrombosis and cavernous transformation with or without cirrhosis were 42.9% (18/42) and 83.3% (10/12) respectively, exhibiting a significant difference (P=0.021). The mortality rate of 30 days post-operation was 3.7% (2/54). From Day 1 to 63 months follow-up, The incidence rate of hepatic encephalopathy was 27.8% (15/54); revision rate 22.2% (12/54); median survival time 31.4 months. Conclusions Conventional TIPS or percutaneous transhepatic or transsplenic approach combined with TIPS for the treatment of portal vein thrombosis with or without cavernous transformation are feasible, safe and effective. It is essential to recanalize the thrnmbosed portal vein initially followed by TIPS placement to reconstruct the portal venous flow.