经皮治疗门静脉血栓的临床研究

目的：研究和评价经皮治疗门静脉血栓技术的可行性和临床效果。材料与方法：16例有门静脉闭塞症状的患者,门静脉血栓均为非海绵状血管变性所致。通过建立经颈列脉肝内门腔静脉分流通道（TIPS）,带膜支架旁路术和经皮抽吸取栓法清除门静脉血栓提高门静脉的血流输出量。结果：13例采用经皮技术治疗获得成功。门静脉血栓所致的门脉高压均得到纠正,静脉曲张破裂出血立即停止;顽固性腹水和黄疸症状得到缓解。结论：经颈静脉门腔静脉分流术,门静脉内带膜支架旁路术和经皮门静脉抽吸取栓法对于治疗非海绵状血管变性和晨瘤栓所致的门静脉闭塞是安全有效的。     

门静脉血栓形成的TIPS治疗和临床结果

目的 研究和评价经皮治疗门静脉及其属支血栓的技术可行性和临床效果。方法 16例有门静脉及其属支闭塞症状的患，门静脉及其属支血栓均为非海绵状血管变性所致。通过建立经颈静脉肝内门腔静脉分流通道(TIPS)、带膜支架旁路术和经皮抽吸取栓法清除门静脉及其属支血栓提高门静脉的血流输出量。结果 13例采用经皮技术治疗获得成功。门静脉及其属支血栓所致的门脉高压均得到纠正，静脉曲张破裂出血立即停止；顽固性腹水和黄疸症状得到缓解。结论 经颈静脉门腔静脉分流术、门静脉内带膜支架旁路术和经皮门静脉及其属支抽吸取栓法对于治疗非海绵状血管变性和非瘤栓所致的门静脉闭塞是安全有效的。     

Transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension using memotherm stents: a prospective multicenter study

Purpose: In a prospective multicenter study, efficacy and safety of transjugular intrahepatic portosystemic shunts (TIPS) were evaluated in the treatment of the complications of portal hypertension using a new self-expanding mesh-wire stent (Memotherm). Methods: One hundred and eighty-one patients suffering from variceal bleeding (either acute or recurrent) or refractory ascites were enrolled. Postinterventional follow-up lasted for 8.4 months on average. Differences were analyzed by the log-rank test (chi-square) or Wilcoxon test. Results: Shunt insertion was completed successfully in all patients (n = 181 patients, 100%). During follow-up, shunt occlusion was evident in 23 patients, and shunt stenosis was found in 33 patients (12.7% and 18.2%, respectively). Variceal rebleeding occurred in 20 of 139 patients (14.4%), with at least one episode of bleeding before TIPS treatment. The overall mortality rate of the patients treated by TIPS was 39.8%. In 51.4% of these cases (37 of 72 patients), however, the patients died within 30 days after TIPS placement. Analysis of subgroups showed that patients who underwent emergency TIPS for acute variceal bleeding had a significantly higher early mortality compared with other patient groups (p = 0.0014). Conclusion: In the present prospective multicenter study, we were able to show that insertion of Memotherm stents is an effective tool for TIPS. The occlusion rates seem to be comparable to those reported for the Palmaz stent. It could be shown that in particular, those patients who were treated for acute bleeding were at high risk of early mortality. Consequently, in such a critical condition, the indication for TIPS has to be set carefully.     

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.     

Transjugular intrahepatic portosystemic shunts using the Wallstent prosthesis: A follow-up study

Purpose: The aim of the present study was to assess the efficacy of transjugular intrahepatic portosystemic shunts (TIPS) in 45 patients with cirrhosis during a mean follow-up of 7 months. Methods: Forty-five consecutive patients treated by TIPS and who had been followed for at least 6 months after TIPS or until death, were included. Mean follow-up was 7.2±5.0 months. Shunt patency was assessed at 1 week and 1 month, then every 3 months after the procedure by Doppler US and angiography whenever needed. Results: Thirty-six patients had been stented for refractory bleeding from ruptured esophagogastric varices. Of these, 8 patients (22%) rebled, 7 of whom were treated by a second shunt. Nine patients were treated for refractory ascites. Three patients had recurrent ascites due to shunt obstruction. All were treated by a second shunt which occluded in 2 patients. As a whole, 14 (31.1%) patients developed shunt obstruction within a mean of 120±136 days, 4 of whom remained asymptomatic. Other complications were septicemia by Staphylococcus aureus in 1 patient, transient encephalopathy in 9 patients, and disseminated intravascular coagulation in 1 patient. Conclusion: TIPS appears to be a relatively safe and effective technique in treating complications of portal hypertension in patients with cirrhosis. Shunt obstruction in 31% of our patients probably represents the most important limitation of this technique.     

覆膜支架在经颈静脉门腔分流术中的应用

目的 评价经颈静脉肝内门腔分流术(TIPS)专用覆膜支架(Viatorr支架)在TIPS中的应用价值.方法 回顾性分析37例在美国俄勒冈州健康生命科技大学Dotter介入放射学研究所采用Viatorr支架行TIPS治疗的患者资料,随访时间为(15.2±9.3)个月(3-42个月).TIPS指征包括门静脉高压相关性的急慢性消化道出血,经药物及内镜治疗无效者17例;顽固性肝源性胸、腹水18例,Budd-Chiari综合征2例.采用配对t检验比较手术前后门腔静脉压力差(PSG)的变化,以Kaplan-Meier曲线分析支架开通率.结果 37例共置入41枚Viatorr支架,其中3枚直径为8 mm,38枚为10 mm,支架带膜长度为4～8 cm,无相关手术并发症.PSG由术前的(22.4±8.4)mm Hg(1 mm Hg=0.133 kPa)降为(8.1±3.2)mm Hg,差异有统计学意义(t=12.754,P<0.01).17例出血患者术后出血均停止,1例于术后17个月复发.18例严重顽固性腹水及肝性胸水患者中,4例术后腹水不消退,其余14例随访期间有2例腹水复发.2例(5.4%)发生分流道阻塞,Kaplan-Meier曲线分析结果显示1年的开通率为97.0%.术后1个月内无病死患者,2例分别于术后3个月及15个月死于多器官功能衰竭,晚期病死率为5.4%,死亡前1周内复查支架均通畅.肝移植患者5例(13.5%).结论 Viatorr支架能明显提高TIPS术后开通率,选择合适的支架,采用正确的释放技术能进一步提高疗效,但长期效果评价尚需验证.     

Creation of transjugular intrahepatic portosystemic shunts with stent-grafts: initial experiences with a polytetrafluoroethylene-covered nitinol endoprosthesis.

PURPOSE: To evaluate the safety and performance of a recently developed expanded polytetrafluoroethylene (ePTFE)-covered nitinol stent-graft to create transjugular intrahepatic portosystemic shunt (TIPS) in patients with portal hypertension and related complications. MATERIALS AND METHODS: The ePTFE-covered nitinol stent-graft was used to create TIPS in 16 patients with recurrent variceal bleeding (n = 13) or refractory ascites (n = 3). Follow-up was performed with duplex ultrasonography, clinical assessment, and venography at 6 months. Technical success and portosystemic pressure gradients (PPGs) before and after stent-graft implantation and at follow-up were assessed. Two patients died during follow-up. Histopathologic follow-up data were available for one patient at autopsy and for the other after liver transplantation. RESULTS: The implantation technical success rate was 100%. Mean (+/- SD) PPG was reduced from 24 mm Hg +/- 5 to 9 mm Hg +/- 2. Histopathologic analysis of the explanted endoprostheses revealed no inflammatory response or neointima formation. The venographic follow-up data available for 10 patients demonstrated 100% in-graft patency (mean follow-up, 289 days +/- 26). Revisions with implantation of a new ePTFE-covered nitinol stent-graft or another commercially available stent in 10 patients were necessary because of hepatic vein stenosis above the grafted portion and/or relative diameter mismatch causing TIPS dysfunction. CONCLUSION: The ePTFE-covered nitinol stent-graft was used successfully to create TIPS and has the potential to prolong TIPS patency upon complete coverage to the hepatocaval junction.     

Transjugular intrahepatic portosystemic shunts in the treatment of refractory ascites: results in 48 consecutive patients

PURPOSE: To assess the efficacy, morbidity, and mortality involved in the creation of transjugular intrahepatic portosystemic shunts (TIPS) in the treatment of patients with refractory ascites in Child-Pugh classes B and C. MATERIALS AND METHODS: Forty-eight consecutive patients with refractory ascites were treated with TIPS creation in a tertiary care institution. They were followed for a median of 337 days (range, 3-1376 d). RESULTS: TIPS significantly decreased the portohepatic pressure gradient (20.7 +/- 5.9 mm Hg vs. 6.8 +/- 4.1 mm Hg; P < .0001). Seventy-three percent of patients had complete or partial response. One year after TIPS creation, survival was 73% in Child class B patients and 56% in Child class C patients. Thirteen patients experienced procedural complications (portal vein thrombosis, peritoneal bleeding, acute renal failure, pneumothorax, hemoptysis, spontaneous bacterial peritonitis, and heart failure) and TIPS creation was considered the cause of death in five patients (10.4%). Primary patency was 65% at 3 months and 23% at 1 year, but shunt obstruction was accessible for a second intervention. Ten patients (21%) had de novo encephalopathy after TIPS creation. CONCLUSIONS: This series suggests that TIPS is an effective treatment for refractory ascites; however, it is a challenging procedure and serious complications--usually renal and heart failure--can be seen. A careful selection of patients is mandatory.     

A new nitinol monofilament stent: early experience with use for transjugular intrahepatic portosystemic shunts

The purpose of this study was to investigate the suitability of a new nitinol monofilament stent (Niti-S) for transjugular intrahepatic portosystemic shunt (TIPS) creation. TIPS was performed with a Niti-S stent in 22 patients for variceal bleeding (n = 20) or intractable ascites (n = 2). The efficacy, complication, and patency rates during the follow-up period (up to 27 months, mean 13.9 months) were evaluated. TIPS was successfully performed in all patients. The mean portosystemic pressure gradient decreased from 23.8 ± 7.2 mmHg to 10.2 ± 3.1 mmHg. No mortality or significant morbidity was encountered at 1 month. Variceal bleeding and/or ascites were controlled in all patients. Primary patency rates were 77.3% at 6 months and 71.8% at 1 year. Secondary patency rates were 95.4% up to 26 months. TIPS with the Niti-S stent produced short-term technical and clinical results comparable to the other commercially available stents. A prospective randomized comparison study is indicated.     

Polytetrafluoroethylene-covered nitinol stent-graft for transjugular intrahepatic portosystemic shunt creation: 3-year experience

PURPOSE: To prospectively evaluate the use of a recently developed expanded polytetrafluoroethylene (PTFE)-covered nitinol stent-graft in preventing the need for repeated intervention after transjugular intrahepatic portosystemic shunt (TIPS) creation. MATERIALS AND METHODS: Fifty-three consecutive patients underwent TIPS procedures between January 2000 and February 2002. Minimum patient follow-up was 9 months (mean, 16.3 months). Fifty-six stent-grafts were implanted in 53 patients; eight of the devices were 8 mm in diameter and 48 were 10 mm in diameter. The stent length varied from 4 to 7 cm. Indications for the procedure included recurrence of bleeding after sclerotherapy (28 patients with cirrhosis, one patient without), refractory ascites or hydrothorax (21 patients with cirrhosis, one patient without), and Budd-Chiari syndrome (two patients). RESULTS: A technical success rate of 100% was obtained, with an early clinical success rate of 96.2%. During the follow-up period, the recurrence rate was 3.4% (one of 29 patients) for bleeding and 9.0% (two of 22 patients) for ascites. Shunt malfunction occurred in nine of 53 patients (16.9%); in one of these nine patients, shunt occlusion was evident after revision, and a parallel shunt was created. The 1-year primary and secondary patency rates were 83.8% and 98.1%, respectively. In this series, the incidence of encephalopathy (included even as a single short-lived episode) was 47.1% (25 of 53 patients). The 30-day mortality rate was 3.8% (two of 53), and the late mortality rate was 17.3% (eight of 46), excluding seven patients who underwent transplantation. CONCLUSION: The new PTFE-covered nitinol stent-graft used appears to be excellent in preventing the need for repeated interventions. A primary patency rate of 83.8% and a secondary patency rate of 98.1% were achieved.     

Transjugular intrahepatic portosystemic shunt in patients who have undergone liver transplantation.

PURPOSE: Transjugular intrahepatic portosystemic shunt (TIPS) placement is an accepted treatment for refractory variceal bleeding and/or ascites in end-stage liver disease and is an effective bridge to liver transplantation. The authors present their experience with TIPS in patients with a liver transplant, who subsequently developed portal hypertension. MATERIALS AND METHODS: Thirteen TIPS were placed in 12 adult patients from 6 months to 13 years after liver transplantation for variceal bleeding that failed endoscopic treatment (n = 6) and intractable ascites (n = 6). All patients were followed to either time of retransplantation or death. RESULTS: No technical difficulties were encountered in TIPS placement in any of the patients. Four of six patients treated for bleeding stopped bleeding and did not experience re-bleeding, two had functional TIPS at 3 and 36 months and two underwent retransplantation at 3 and 7 months. Two patients had recurrent bleeding within 1 week and required reintervention. In the ascites group, one is 32 months since TIPS placement with control of his ascites, two patients underwent retransplantation at 2 and 6 weeks with interval improvement in ascites. Two patients died within a week of TIPS of fulminant hepatic failure. The last patient died 1 month after TIPS subsequent to a splenectomy. CONCLUSION: In conclusion, the placement of a TIPS in a transplanted liver, in general, requires no special technical considerations compared to placement in native livers. Although this series is small, the authors believe that TIPS should be considered a treatment option in liver transplant recipients who present with refractory variceal bleeding. TIPS may have a role in the management of intractable ascites.     

Transjugular intrahepatic portosystemic shunts: long-term patency and clinical results in a patient cohort observed for 3-9 years

PURPOSE: To retrospectively assess the outcome of transjugular intrahepatic portosystemic shunt (TIPS) placement in a nonselected group of consecutive patients. MATERIALS AND METHODS: TIPS placement was attempted in 82 patients. Patients were followed up for at least 3 years according to a standard protocol that included repeated shunt evaluations. Fifty-four patients underwent TIPS placement for variceal bleeding, 24 for refractory ascites, and four for other indications. Recurrent bleeding, effect on ascites, long-term patency, development of encephalopathy, and survival and complication rates were evaluated with Kaplan-Meier survival analysis and Cox multivariate analysis. RESULTS: TIPS placement was successful in 75 patients (91%). Mean follow-up lasted 29.4 months. Primary patency was 22% and 12%, primary-assisted patency was 67% and 46%, and secondary patency was 91% and 91% at 1- and 5-year follow-up, respectively. Nonalcoholic liver disease (P =.007) and increasing platelet counts (P =.006) independently predicted development of shunt insufficiency. The 1- and 5-year rates of recurrent variceal bleeding were 21% and 27%, respectively. In the majority of patients with refractory ascites, a beneficial effect of TIPS placement was observed. The risk for encephalopathy was 25% at 1-month follow-up and 52% at 3-year follow-up. The risk for chronic or severe intermittent encephalopathy was 15% at 1-year follow-up and 20% at 3-year follow-up. Serum creatinine levels (P =.001) and age (P =.02) were independent risk factors. Overall survival rate was 61%, 49%, and 42% at 1-, 3-, and 5-year follow-up, respectively. Age (P =.03), serum albumin level (P =.02), and serum creatinine level (P <.001) were independently related to mortality. CONCLUSION: The risk for definitive loss of shunt function was 17% at 5-year follow-up, indicating that surveillance with shunt revision-when indicated-results in excellent long-term TIPS patency. TIPS placement effectively protects against recurrent bleeding.     

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。     

Transjugular Intrahepatic Portosystemic Shunt Placement in Patients with Cirrhosis and Concomitant Portal Vein Thrombosis

Purpose To determine the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation in patients with liver cirrhosis complicated by thrombosed portal vein. Methods This study reviewed 15 cases of TIPS creation in 15 cirrhotic patients with portal vein thrombosis at our institution over an 8-year period. There were 2 women and 13 men with a mean age of 53 years. Indications were refractory ascites, variceal hemorrhage, and refractory pleural effusion. Clinical follow-up was performed in all patients. Results The technical success rate was 75% (3/4) in patients with chronic portal vein thrombosis associated with cavernomatous transformation and 91% (10/11) in patients with acute thrombosis or partial thrombosis, giving an overall success rate of 87%. Complications included postprocedural encephalopathy and localized hematoma at the access site. In patients with successful shunt placement, the total follow-up time was 223 months. The 30-day mortality rate was 13%. Two patients underwent liver transplantation at 35 days and 7 months, respectively, after TIPS insertion. One patient had an occluded shunt at 4 months with an unsuccessful revision. The remaining patients had functioning shunts at follow-up. Conclusion TIPS creation in thrombosed portal vein is possible and might be a treatment option in certain patients.     

Stent graft in TIPS: technical and procedural aspects

Transjugular intrahepatic portosystemic shunt (TIPS) is a nonoperative therapeutic option for the management of portal hypertension, variceal bleeding, recurrent ascites, Budd-Chiari syndrome. In view of the many issues surrounding the use of TIPS, in 1994 the US National Digestive Diseases Advisory Board convened a scientific conference to review the current data available and to establish the indications and controindications for this procedure. However there are still unsolved problems especially short primary patency of the shunt due to intimal hyperplasia, which causes a reduction of the shunt lumen thus favoring a return of the portal hypertension with recurrent variceal bleeding. Several study were performed in the last years to evaluate the efficacy of covered stent in order to reduce shunt disfunction secondary to intimal hyperplasia. PTFE seems to be more efficient in the prevention of restenoses. In our experience more then 100 patients were treated with the Viatorr stent-graft. After a follow-up ranging from 1 to 50 months we reported a 1- year primary patency rate of 83.8%. However the use of the stentgraft is correlate with a high rate of hepatic hencefalopathy (46.6 %). In case of hepatic hencefalopathy refractory to the conventional medical therapy, TIPS reduction should be performed.     

Transjugular intrahepatic portosystemic shunt. Experiences at a liver transplantation center

Objective: Transjugular intrahepatic portosystemic shunt (TIPS) placement is an established therapy for portal hypertension that leads to variceal bleeding or refractory ascites. We present experiences of the role of TIPS at a liver transplantation center.Material and Methods: One hundred and ten patients were referred to the Radiological Department for TIPS placement. One of the 110 patients had recurrent cirrhosis after liver transplantation with refractory ascites. Function of the TIPS was controlled with Doppler US at 1 day, 1 week, 4 weeks and 4 months after TIPS placement and subsequently every 3 months. Shunt insufficiency was supposed when the blood flow velocity within the stent tract was under 50 cm/s and was an indication for TIPS revision.Results: TIPS was placed in 101 patients. After TIPS placement, 10 patients underwent liver transplantation. While waiting for the new liver, none of them developed variceal rebleeding, ascites or other complications of portal hypertension. Two of the 101 patients had episodes of rebleeding. The frequency of patients undergoing TIPS revision within the first year after TIPS placement was 67.5%, within the second year 38.0% and within the third year 24.4%. The revisions led to sufficient reduction of the portosystemic pressure gradient.Conclusion: In some liver transplant candidates, TIPS can be useful in minimizing the risk of complications of portal hypertension during the waiting time for a liver transplantation. TIPS can be monitored by Doppler US and revised if occlusion occurs.     

Results of a retrospective multicenter trial of the Viatorr expanded polytetrafluoroethylene-covered stent-graft for transjugular intrahepatic portosystemic shunt creation

PURPOSE: To report the results of a multicenter experience with the Viatorr expanded polytetrafluoroethylene-covered stent-graft for transjugular intrahepatic portosystemic shunt (TIPS) creation in which patency and clinical outcome were evaluated. MATERIALS AND METHODS: One hundred consecutive patients with portal hypertension, with a mean age of 52 years (range, 22-86 years), underwent implantation of the Viatorr TIPS stent-graft at one of three hospital centers. The indications for TIPS creation were variceal bleeding (n = 81) and refractory ascites (n = 19). Twenty patients had Child-Pugh class A disease, 46 had class B disease, and 34 had class C disease. Eighty-seven patients underwent de novo TIPS placements, with 13 treated for recurrent TIPS stenosis. Sixty-two patients were available for follow-up portal venography and portosystemic pressure gradient (PSG) measurement commencing 6 months after Viatorr stent-graft placement. RESULTS: The technical success rate was 100%. TIPS creation resulted in an immediate decrease in mean PSG (+/-SD) from 21 mm Hg +/- 6 to 7 mm Hg +/- 3. Acute repeat intervention (within 30 days) was required for portal vein thrombosis (n = 1), continued bleeding (n = 3), and encephalopathy (n = 1). The all-cause 30-day mortality rate was 12%. Two patients developed acute severe refractory encephalopathy, which led to death in one case. New or worsening encephalopathy was identified in 14% of patients. The incidence of recurrent bleeding was 8%. The cumulative survival rate at 1 year was 65%. Sixty-two patients available for venographic follow-up had a mean PSG of 9 mm Hg +/- 5 at a mean interval of 343 days (range, 56-967 days). There were four stent-graft occlusions (6%) and seven hemodynamically significant stenoses (11%), four within the stent-graft and three in the non-stent-implanted hepatic vein. The primary patency rate at 1 year by Kaplan-Meier analysis was 84%. CONCLUSIONS: This retrospective multicenter experience with the Viatorr stent-graft confirms the preliminary findings of other investigators of good technical results and improved patency compared with bare stents. Early mortality and symptomatic recurrence rates are low by historical standards. The theoretical increase in TIPS-related encephalopathy was not demonstrated. Longer-term follow-up will be required to determine whether the additional cost of the Viatorr stent-graft will be offset by reduced surveillance and repeat intervention.     

经皮经肝门腔静脉分流术血流动力学与支架构型关系的临床研究

目的介绍一种全新肝内分流预应力支架的结构和在经皮经肝肝内门腔静脉分流术（PTPS）中应用的临床结果。分析应用该支架建立的门腔静脉分流道与经典TIPS所用支架血流动力学之间的区别,探讨其潜在的临床意义。方法38例门静脉高压患者采用预应力支架行经皮经肝途径门腔静脉分流术（PTPS）。静脉曲张出血36例,难治性腹水1例及肝肺综合征1例;Child＇s B级27例、C级11例。经皮经肝穿刺进入门静脉右支,再经门静脉左支矢状部穿刺肝段下腔静脉,经皮经肝植入预应力支架于门静脉左支与肝段下腔静脉之间。结果38例采用预应力支架行PTPS均获成功,技术成功率100％,未出现术中与技术相关并发症,术后门腔压力梯度平均下降14cmH2O,平均随访493d,所有患者未发生再出血,难治性腹水得到有效地控制。初步开通率98．9%,明显高于经典直管形裸支架TIPS。结论采用预应力支架经皮经肝途径建立门腔静脉分流是安全可行的,其血流动力学结果提示：预应力支架形状及与相关血管壁间“吻合”严密,符合正常肝内门静脉血流动力学分布,既起到门静脉部分性降压作用,亦保障了门静脉右支血流的肝内灌注,对预防术后分流道再狭窄及降低肝性脑病发生率具有明显的临床意义。     

Fifteen years’ experience with transjugular intrahepatic portosystemic shunt (TIPS) using bare stents: retrospective review of clinical and technical aspects

Purpose

The authors present a retrospective analysis of a large series of patients who underwent transjugular intrahepatic portosystemic shunt (TIPS) placement.

Materials and methods

Between March 1992 and December 2006, 658 patients were referred to our centre for TIPS placement. Indications for the procedure were digestive tract bleeding (52.8%), refractory ascites (35.3%), preservation of portal vein patency prior to liver transplantation (3.0%) and thrombosis of the suprahepatic veins (2.3%). Other indications (6.6%) included pleural ascites, portal thrombosis and hepatorenal and hepatopulmonary syndromes. All patients were evaluated with colour Doppler ultrasonography and in a few cases with computed tomography. The portal system was punctured under sonographic guidance. Wallstent, Palmaz and Nitinol thermosensitive stents were used. Embolisation of persistent varices was performed in 6.8% of cases.

Results

Technical success was 98.9%. During a 1,500-day follow-up, the cumulative incidence of stent revision was 25.7% (Nitinol), 32.9% (Wallstent) and 1.8% (Palmaz). Mortality rates were 31.1%, 38.5% and 56.4%, respectively. The technical complications included six cases of heart failure, six of haematobilia, three of stent migration, two of intrahepatic haematoma and one of haemoperitoneum. Eight patients with severe portosystemic encephalopathy (PSE) were treated with a reduction stent.

Conclusions

TIPS placement is safe and effective and may act as a bridge to liver transplantation. Ultrasonography plays a fundamental role in the preliminary assessment, in portal vein puncture and during the follow-up. Stent patency is satisfactory.     

Pull-Through Technique for Recanalization of Occluded Portosystemic Shunts (TIPS): Technical Note and Review of the Literature

Transjugular intrahepatic portosystemic shunt (TIPS) dysfunction is an important problem after creation of shunts. Most commonly, TIPS recanalization is performed via the jugular vein approach. Occasionally it is difficult to cross the occlusion. We describe a hybrid technique for TIPS revision via a direct transhepatic access combined with a transjugular approach. In two cases, bare metal stents or polytetrafluoroethylene (PTFE)-covered stent grafts had been placed in TIPS tract previously, and they were completely obstructed. The tracts were inaccessible via the jugular vein route alone. In each case, after fluoroscopy or computed tomography-guided transhepatic puncture of the stented segment of the TIPS, a wire was threaded through the shunt and snared into the right jugular vein. The TIPS was revised by balloon angioplasty and additional in-stent placement of PTFE-covered stent grafts. The patients were discharged without any complications. Doppler sonography 6 weeks after TIPS revision confirmed patency in the TIPS tract and the disappearance of ascites. We conclude that this technique is feasible and useful, even in patients with previous PTFE-covered stent graft placement.