人体原位肝脏移植术后胆道与血管并发症的放射介入治疗

目的 评估放射介入治疗在人体原位肝脏移植病人术后胆道与血管并发症中的应用价值。方法 回顾性分析自1999年1月至2001年4月我院连续实施的48例人体原位肝脏移植的临床资料，总结放射介入技术治疗术后胆道与血管并发症的实施体会。结果 术后经T管胆道造影术及核磁共振胆胰管成像（MRCP）证实，3例病人存在胆道狭窄，其中2例为肝门部胆管与肝总管狭窄，1例为吻合口处胆管狭窄，共实施经T管窦道选择性球囊扩张术6例次，胆道狭窄得以改善，肝功能好转。术后经彩色多普勒超声、核磁共振血管造影（MRA）及静脉造影证实，2例病人存在肝上下腔静脉狭窄与门静脉吻合口狭窄，分别实施肝上下腔静脉狭窄段球囊扩张术1例次，肝上下腔静脉内支架置入术2例次、门静脉内支架置入术1例次。放射介入治疗后，影像学检查显示血管狭窄基本消失，病人肝功能明显好转、腹水显著减少、尿量增加。5例中最长1例健康存活至今已超过19个月。结论 肝脏主后应常规联合应用胆道造影术和MRCP了解胆树全貌，彩色多普勒超声和MRA监测血管血流动力学，以尽早诊断胆道和血管并发症；及时果断采用正确的放射介入技术处理胆道与血管并发症可取得良好疗效。     

肝移植血流动力学参数的变化及其临床意义

目的利用彩色多普勒超声检测移植肝血流动力学的参数,探讨参数变化的临床意义。方法利用彩色多普勒超声检测65例肝移植患者不同时期的肝动脉、肝静脉及门静脉的峰值血流速度(PS)、时间平均血流速度(TAV)、阻力指数(RI)及肝动脉血流灌注指数(DPI)。结果术后15d内,移植肝正常者门静脉TAV及肝动脉RI均明显高于对照组(P<0.05);肝动脉PS及DPI均明显低于对照组(P<0.05)。肝动脉血栓形成时,肝动脉PS明显降低,门静脉TAV明显增高,呈锯齿波。发生排斥反应时,门静脉TAV降低,肝动脉PS降低、RI增高,肝静脉三相波消失,呈锯齿波。结论利用彩色多普勒超声监测移植肝的血流动力学参数变化,可为移植肝的血管并发症及排斥反应的诊断提供辅助依据,且安全、无创。     

肝脏移植中门静脉机化血栓的外科对策

目的：探讨肝脏移植中门静脉机化皿栓的术中处理方法。方法：回顾分析我院41例肝移植门静脉机化血栓患者，22例在取栓后门静脉端端吻合，10例血栓段门静脉切除，8例门静脉与曲张内脏血管吻合，1例门腔半转位。结果：1例死于多脏器功能衰竭；1例死于肝动脉出血；1例术后门静脉血流不足，二次肝脏移植时缝扎分流的侧支后顺利康复；2例患者术后出现吻合口狭窄，均采用经皮肝穿刺门静脉支架置7、治愈，其余36例患者分别随访6～20个月，门静脉血流均保持通畅。结论：存在门静脉机化血栓的患者行肝脏移植，首选血栓段门静脉切除或取栓后门静脉重建，当不能进行时采用门静脉与曲张内脏静脉吻合可好效果。     

肝移植术后并发症的介入治疗

目的评价肝移植术后多种并发症的介入治疗。方法回顾性的分析肝移植术后出现各种并发症并进行介入治疗的82例患者,胆管病变62例;肝动脉病变8例;下腔静脉病变13例;肝静脉狭窄7例;门静脉病变9例。胆管并发症采用经T管置入引流管、经皮肝穿刺胆管行胆汁引流或球囊扩张术。球囊扩张成形术或(和)金属支架植入术处理血管狭窄的患者;局部溶栓治疗用于术后血管内血栓形成的病例。结果在胆管并发症患者中,41例经T管置入引流管,34例行经皮穿刺胆汁引流(PTBD),球囊扩张胆道成形术9例。3例肝动脉狭窄的患者接受了球囊扩张成形术或支架植入术,1例肝动脉形成血栓者行插管溶栓,效果良好。9例下腔静脉狭窄患者行支架植入术,1例接受了球囊扩张成形术。5例肝静脉狭窄患者接受了球囊扩张成形术或支架治疗。门静脉狭窄患者中6例接受支架治疗,1例门脉血栓形成行局部溶栓,治疗不满意。结论介入治疗是处理肝移植术后胆管和血管并发症不可或缺的临床治疗方法。     

肝移植术后肝动脉狭窄的治疗

目的探讨肝移植术后肝动脉狭窄的治疗。方法连续503例肝移植中出现15例肝动脉狭窄,根据临床表现、动态肝功能和彩色多普勒检查、CT动脉成像、选择性肝动脉造影诊断。结果术后早期出现肝动脉狭窄10例,2例合并肝动脉血栓形成,再移植3例,介入治疗7例,其中动脉支架植入5例,球囊扩张溶术后6天肝功能衰竭死亡1例,支架植入术后9天肝功能衰竭死亡1例。1月后发现肝动脉狭窄5例,介入治疗均行肝动脉支架植入,1例支架植入术后186天因胆道感染死亡。结论根据肝动脉狭窄程度、发生时间、移植肝功能状态和病人情况选择治疗措施。再移植是治疗肝移植术后肝动脉狭窄的有效方法。肝动脉支架植入可挽救移植肝,改善移植肝功能,延长移植肝发挥功能以等再次肝移植。     

肝移植术后肝动脉狭窄的内支架治疗

目的 对内支架植入术治疗肝移植术后肝动脉狭窄的价值进行初步的探讨。方法 对34例肝移植发生肝动脉狭窄、闭塞患者行球囊扩张治疗，其中5例患者接受内支架植入治疗，3例为球囊扩张治疗无效患者，1例为球囊扩张后出现肝动脉内膜撕裂，另1例为肝动脉狭窄伴吻合口破裂出血。结果 5例患者均成功进行了内支架植入治疗，其中1例肝动脉狭窄伴吻合口破裂出血的患者植入支架后24h内发生支架内急性血栓形成，经手术行肝动脉重建治疗，其余4例术后治疗效果良好。结论 介入方法治疗肝移植术后肝动脉狭窄具有微创、安全、有效的优势，对于球囊扩张治疗无效或合并吻合口破裂出血的病例，可采用内支架植入治疗。     

彩色多普勒血流显像对肝移植术后监测的应用价值

目的探讨彩色多普勒血流显像技术在移植肝术后检测中的应用价值。方法对38例肝移植术后患者行床旁彩色多普勒血流显像超声检查，观察移植肝实质及周围回声变化及肝动、静脉系统的血流动力学参数改变。结果38例移植肝中3例（7．8％）肝实质回声增强或肝包膜下见部分大小不一的低回声灶。血流动力学变化：2例（5．2％）肝动脉血流流速减慢，呈低速高阻型，；5例（13．1％）门静脉流速增快；1例（2．6％）肝静脉呈单向波。5例（13．1％）胆总管腔显示不清；11例（28．9％）先后发生排斥反应；1例（2．6％）肝动脉血栓形成（HAT）；6例（15．8％）门静脉吻合口狭窄；3例（7．8％）门静脉血栓形成；30例（78．9％）于肝周及胸腹腔有少量积液。结论：彩色多普勒血流显像技术应用于移植肝术后检测其物理形态及血流动力学变化对早期发现肝移植排异反应及并发症具有重要的临床应用价值。     

经皮球囊导管成形支架植入术治疗布-加综合征的临床观察

目的 探讨经皮下腔静脉球囊成形加支架植入术治疗布加综合征(BCS)的临床疗效。方法 120例患者均经彩色多普勒超声、下腔静脉及肝静脉造影等检查明确诊断，并进行经皮下腔静脉球囊成形(PTA)加支架植入术(EMS)治疗。所有病例随访6-108个月。结果 扩张前静脉狭窄段内径0-6mm(平均3mm)，肝静脉内径2mm。扩张并置放血管内支架后，腔静脉、肝静脉内径分别为18—20mm和8mm。扩张前下腔静脉至右房压力差为18-35cmH20(1．76-3．43Da)，平均20．3cmH20(1．989kPa)，扩张后压差消失，119例手术顺利，1例左肝静脉轻度损伤。术后96例主要症状及体征消失或基本消失，19例明显改善。120例(100％)获1-108(平均67．35)个月随访，其中门5例在随访期间血管内支架形态良好，支架内血流通畅；3例在术后8，11，16个月发生腔静脉再阻塞，经二次PTA EMS治愈；2例于术后2—3个月发生3支肝静脉再阻塞，转为外科手术。结论 经皮下腔静脉球囊成形、支架植入术是非长段阻塞型布—加综合征良好的治疗方法。     

彩色多普勒超声及超声造影在肝移植术后血管并发症中的应用

目的探讨彩色多普勒超声（CDU）和超声造影（CEUS）在检测肝移植术后血管并发症中的应用价值并对两者进行比较。方法对肝移植术后患者常规行CDU检查，对CDU疑肝血管血流异常患者行超声造影检查，观察肝动脉、门静脉、下腔静脉及肝实质的血流灌注，对其中29例经数字减影血管造影术（DSA）或CT血管造影（CTA）／MR血管造影（MRA）证实病例的CDU及造影检查资料进行分析。结果术后血管并发症患者29例，其中肝动脉狭窄22例，肝动脉血栓闭塞3例（肝动脉血栓闭塞合并肝梗死2例），门静脉狭窄2例，下腔静脉狭窄1例，另1例为肝门部血肿并肝动脉、门静脉受压狭窄。CDU显示25例狭窄均有血流参数异常，但不能判断狭窄部位及程度，3例血栓闭塞者，动脉血流均未显示，但不能肯定诊断；超声造影可明确诊断肝动脉血栓闭塞，显示肝动脉、门静脉及下腔静脉狭窄，与DSA或CTA／MRA结果符合率分别为100％（3，3）、90．9％（20／22）、100％（2／2）及100％（1／1）。结论CDU与超声造影互为补充，有利于提高肝移植术后血管并发症的诊断准确性。     

大鼠异位节段小肠移植模型建立技术的改进

目的：建立大鼠异位节段小肠移植模型。方法：对40例（80只）Wistar大鼠施行异位小肠移植,供受体术前抗生素灌胃,改变供受体术式,减少受体手术时间、手术损伤及供肠缺血时间;采用腹主动脉-肠系膜上动脉吻合以及左肾静脉-门静脉单套管吻合,血管吻合方法采用单纯间断吻合,重建供肠血管;移植小肠双造口,静脉补液通路采用股静脉。结果：肠缺血时间≤35min,吻合口无狭窄,40例大鼠接受小肠移植,建模成功35例。结论：改进小肠移植技术中的多个细节后,降低了大鼠小肠移植术的难度。     

彩色多普勒超声对肝移植术后11例血管并发症的诊断

目的评价彩色多普勒超声对肝移植术后血管并发症的诊断意义。方法回顾性分析和总结11例肝移植术后血管并发症的彩色多普勒超声检查资料,检测指标包括肝动脉及左右分支的峰值速度、阻力指数、加速度及加速时间,门静脉平均流速。结果5例经手术或造影证实为动脉并发症(血栓形成2例,肝动脉狭窄2例,肝动脉痉挛1例),彩色多普勒超声表现有肝动脉狭窄处的高速高阻血流并伴有湍流,而狭窄远端肝内动脉峰值速度<40cm/s,阻力指数<0.5,加速时间>0.08s,加速度<300cm/s2,2例肝动脉血栓形成肝门部无动脉血流信号;6例为门静脉并发症(3例门静脉狭窄,3例门静脉血栓形成)。结论彩色多普勒超声对肝移植术后血管并发症的诊断具有重要的指导意义。     

原位肝移植术后下腔静脉狭窄的原因及防治

目的 探讨肝移植术后下腔静脉狭窄的原因和防治方法。方法 本组共施行原位肝移植术8例,通过彩超及下腔静脉造影检查证实术后发生下腔静脉狭窄2例。结果 在2例下腔静脉狭窄中,1例经球囊扩张及支架置入术而治愈;另1例病人拒绝手术自动出院。结论 肝移植术后下腔静脉狭窄的重要因素是吻合技术不当,肝脏体积过大,血肿形成,腹水生成,癌肿复发。球囊扩张、支架置入是有效的治疗手段。     

Application of interventional radiology for stenosis of vascular anastomosis in living-donor liver transplantation

Stenosis of vascular anastomosis is a significant complication leading to graft loss after liver transplantation. For the diagnosis of portal vein stenosis, clinical signs of portal hypertension such as ascites and thrombocytopenia, stenosis and/or poststenotic dilatation on ultrasonography (US), and jet flow, rambling, or scarcity flow of the intrahepatic portal vein on Doppler US are useful. Three-dimensional computed tomography is used to confirm the indications for interventional radiography (IVR) to treat portal stenosis. For the diagnosis of hepatic vein stenosis, clinical signs such as ascites and slight jaundice, dilatation and stenosis on US, and reduced flow with a flat wave form of the intrahepatic portal vein on Doppler US are useful. The percutaneous transcaval approach is safer than the percutaneous transhepatic approach for patients with ascites. The requirement for multiple procedures could be a good indication for stent placement before patients develop liver cirrhosis. For hepatic artery stenosis, percutaneous intraluminal angioplasty and stenting are possible and good results have been reported recently. However, the long-term results must be evaluated in the future. IVR can be safely and successfully applied to the treatment of vascular complications using balloon dilatation and/or stent placement techniques before graft dysfunction becomes irreversible.     

Doppler echography in the intraoperative assessment of the liver circulation: an experimental study in swine

In this experimental study the authors report an experience in the evaluation of hepatic blood flow with intraoperative echo-Doppler during orthotopic liver transplantation and side-to-side or end-to-side portacaval shunt. Doppler ultrasonography studied the flow of portal vein, hepatic artery and inferior vena cava before the recipient hepatectomy, and after reperfusion during liver grafting. Furthermore echo-Doppler of the portal system was performed to confirm portacaval shunt efficacy. Usually intraoperative Doppler ultrasonography may give informations about the patency of the shunt and regarding the development of early hepatic artery thrombosis during liver transplantation, but often unclear is the exact evaluation of the velocity of the blood flow through the liver. Further experimental studies and clinical evaluations need to find safe parameters and markers of vascular alteration using this superior diagnostic procedure.     

Replacement of the vena cava with aortic graft for living donor liver transplantation in budd-Chiari syndrome associated with hydatid cyst surgery: a case report

A 12-year-old girl, operated because of a hydatid cyst of the liver, with Budd-Chiari syndrome was evaluated for postoperative development of ascites and paraumbilical varicose veins. A vena caval stent was placed for the relief of inferior vena caval obstruction. The patient was admitted because of progressive deterioration in ascites and liver functions. Imaging techniques showed degeneration adjacent to the right hepatic vein in liver segments 7 to 8, a partially calcified 5-cm hydatid cyst, and a thrombosis in the inferior vena cava was that addressed with a 10-cm metal stent. A living donor segments 2 to 3 liver transplantation was obtained from the patient's mother. After completion of the donor operation without complications, the vena caval stent was removed following the recipient hepatectomy. Suprarenal flow continued after resection of the fibrotic vena cava and placement of a cadaveric cryopreserved aortic graft for the vena cava, anastomosed between the suprarenal and subdiaphragmatic segments of the vena cava. An end-to-side anastomosis was performed between the left hepatic vein of the donor liver and the aortic graft. There was no complication and the patient was discharged on postoperative day 19. Follow-up Doppler ultrasonography showed the aortic vena caval graft to be open, along with the hepatic/portal vein and hepatic artery. This case demonstrated that operations for liver hydatid cyst surgeries can iatrogenically induce Budd-Chiari syndrome; a cryopreserved aortic graft can be an alternative to ensure the continuity of the vena cava in living donor liver transplantation.     

肝移植术中血管超声检查在血管并发症预防和诊断中的价值

目的 探讨肝移植术中血管超声检杳在预防和诊断血管并发症中的价值.方法 肝移植术中对116例患者进行血管超声检查,检测血管吻合后肝动脉峰值流速和门静脉流量.以肝动脉峰值流速2>30 cm/s为正常肝动脉标准,以门静脉流量2>800ml/min为正常门静脉标准.结果 在116例患者中,有14例肝动脉峰值流速<30 cm/s,其中9例通过应用利多卡因腹腔于根部浸润、罂粟碱及盐酸消旋山莨菪碱肝动脉内注射,解除血管痉挛后,肝动脉峰值流速达到正常标准,但术后仍有3例患者发生肝动脉并发症;另5例经过上述处理,肝动脉峰值流速仍<30 cm/s,故采用供者髂内动脉对受者腹主动脉与供者肝动脉进行搭桥吻合,吻合后测肝动脉峰值流速2>30 cm/s,术后未发生肝动脉并发症.116例患者中,有5例门静脉流量<800 ml/min,其中4例经证实存在门腔分流,行门腔分流静脉结扎后,门静脉流量达到正常标准,但术后仍有1例发生门静脉血栓;另1例存在门静脉Ⅲ级血栓,血栓切除后进行门静脉端端吻合,门静脉流量仍达不到标准,故利用供者髂静脉通过胰腺前胃十二指肠后与受者肠系膜上静脉远端进行搭桥吻合,术中测量门静脉流量达到正常标准,术后未发生门静脉并发症.结论 肝移植术中血管超声检查对血管并发症具有较高的预防和诊断价值.对术中超声检查提示异常的患者,术后应该严密监测,以尽早发现可能出现的血管并发症并进行相应治疗.     

彩色多普勒超声在诊断肝移植术后并发症中的价值

目的探讨彩色多普勒超声在肝移植术后并发症的诊断价值。方法回顾分析彩色多普勒超声对95例肝移植患者术后并发症的诊断结果。结果95例中发现肝动脉血栓形成3例（3.15%）,肝动脉狭窄2例（2.10%）,门静脉血栓形成1例（1.05%）,门静脉狭窄1例（1.05%）,下腔静脉狭窄2例（2.10%）,胆道并发症10例（10.52%）,排异反应7例（7.36%）,浆膜腔积液93例（97.89%）,肝周血肿7例（7.36%）,肿瘤复发5例（29.41%）。结论彩色多普勒超声在肝移植术后并发症诊断中具有重要的实用价值。     

Routine Doppler ultrasound for the detection of clinically unsuspected vascular complications in the early postoperative phase after orthotopic liver transplantation

To assess the role of routine Doppler ultrasound in the detection of clinically unsuspected vascular complications in the early postoperative phase after orthotopic liver transplantation (OLT), the findings of 858 routinely performed Doppler ultrasound examinations were analyzed in 268 transplants. At various time intervals after OLT, we encountered 46 abnormal Doppler findings: hepatic artery (thrombosis), portal vein [anastomotic stenosis, (non)occlusive thrombosis or reversed flow], inferior vena cava [anastomotic stenosis with reversed flow, no flow, or (non)occlusive thrombosis], and hepatic veins (to-and-fro flow or stenosis with reversed flow) in 14, 20, 9, and 2 transplants, respectively. Most of these abnormal Doppler findings were confirmed by angiography, cavography, or surgery. The positive predictive value for hepatic artery thrombosis (HAT) was 12 out of 14, or 86 %. In the first 2 weeks after OLT, routine Doppler ultrasound revealed 20 of the 46 abnormal findings (43 %). Clinically unsuspected complications of the hepatic artery, portal vein, inferior vena cava, and hepatic veins were found in 9 of the 14 (64 %), 6 of the 20 (30 %), 3 of the 9 (33 %), and 2 of the 2 (100 %) transplants, respectively. The highest incidence – nine vascular complications – was found on the 1st day. On each of the remaining days (except for the 2nd and 9th days), one or two vascular complications were detected. HAT was found mainly in the 1st week. Vascular complications developed independently or concomitantly. We conclude that routine Doppler ultrasound is very important for the detection of clinically unsuspected vascular complications, particularly HAT, in the first 2 weeks after OLT. We recommend routine Doppler ultrasound of all hepatic vessels every 3 days in the early postoperative phase after OLT. Special attention should be paid to the 1st day. Received: 29 August 1997 Revised after revision: 10 February 1998 Accepted: 2 March 1998     

Angioplasty treatment of hepatic vein stenosis in pediatric liver transplants: long-term results

We reviewed long-term results of percutaneous venoplasty in children with hepatic vein stenosis after partial liver transplants, of which excellent early results were shown. Percutaneous transjugular hepatic venoplasty using balloon dilatation or stent implantation was performed in six cases with hepatic vein stenosis identified on routine post-transplant Doppler sonography and confirmed by transjugular hepatic venography from 1994 to 2003. Repeated procedure was carried out if necessary. Six of 105 patients with partial liver graft developed hepatic stenosis characterized by low hepatic venous velocity with monophasic waveform with significant pressure gradient (>5 mmHg). The incidence was 4.46% for all 112 pediatric liver transplants. Successful balloon venoplasty was achieved in four cases. Self-expanding stent was used in two cases with absent waisting or angulated balloon catheter during dilatation and persisted pressure gradient (>5 mmHg). Repeated procedure was required in two initially successful cases with additional stent used in one case. Three cases had transient hyperdynamic hepatic venous flow with markedly increased central venous pressure after stent implantation. Nonprocedural-related mortality rate was 16.7%. Patent hepatic vein was maintained in five patients after a mean follow-up of 3.67 years (0.75-9.5). Higher incidence of hepatic vein stenosis was noted in pediatric partial liver transplant. However, encouraging long-term results showed that hepatic venoplasty or stent implantation could be a preferable alterative to surgical revision or retransplantation, which has been the procedure of choice in our hospital.