微创时代下腔静脉开放手术的治疗机遇

因下腔静脉在解剖学及组织学方面的特性,治疗上具有特殊性。本文通过回顾既往文献报道,对下腔静脉综合征、平滑肌肉瘤及布加综合征等下腔静脉疾病外科治疗方式的进展进行论述。下腔静脉综合征为下腔静脉部分或完全阻塞所致的临床症候群,较常见且病因多样,占位性病变中下腔静脉平滑肌肉瘤发病罕见,根治性切除是目前唯一有效的治疗手段,其中下腔静脉及肾静脉的处理为手术难点。布加综合征表现为肝后性门脉高压,外科治疗包括手术治疗及介入治疗。     

布-加综合征的影像诊断及综合介入治疗

目的回顾性分析31例门诊疑诊为布加综合征患者的诊疗过程,探讨布加综合征的影像学诊断方法及影响介入疗效的因素。方法31例门诊疑诊为布加综合征的患者行DSA,17例证实为布加综合征,其中16例行介入治疗。结果16例行介入治疗的病人技术上均获成功。治疗采用单纯球囊扩张7例,放置下腔静脉支架4例(5枚),放置肝静脉支架1例,下腔静脉支架结合下腔静脉滤器1例,单纯溶栓1例,行TIPSS术2例。术后30天症状明显改善13例,无变化1例,死亡2例。结论超声可作为布加综合征的筛查手段,最终确诊要依靠DSA。介入术后开通的静脉血管再闭塞是影响布加综合征疗效的主要因素。     

Experts consensus on Chinese nomenclature of Budd-Chiari syndrome

In China, Budd-Chiari syndrome has been transliterated into six names according to the pronunciation of the letters. To standardize and unify the Chinese names of the disease, multi-disciplinary experts suggest translating Budd-Chiari syndrome into hepatic vein inferior venal cava obstruction syndrome as its Chinese name after reaching a consensus through discussion.     

多层螺旋CT对评价肝静脉流出道梗阻的价值

目的:探讨多层螺旋CT(MSCT)增强扫描及血管成像技术在诊断肝静脉流出道梗阻中的价值。方法:回顾性分析经MSCT扫描诊断为肝静脉流出道梗阻患者12例,其中肝移植术后流出道梗阻患者9例,布加综合征患者3例。其中5例患者行数字减影血管造影(DSA),5例患者接受剖腹探查手术或二次肝移植手术,均得到证实。结果:9例肝移植术后肝静脉流出道梗阻患者中,共发现6支肝右静脉闭塞,3支肝左静脉闭塞,3支肝中静脉闭塞,1支肝右后上静脉闭塞,4支肝后下腔静脉狭窄,2支肝后下腔静脉血栓形成。3例布加综合征患者均为混合型,肝静脉和下腔静脉同时受累。结论:MSCT血管成像作为一种无创性检查方法,在诊断肝脏流出道梗阻中具有重要意义。     

Hepatic heterogeneity on CT in Budd-Chiari syndrome: Correlation with regional disturbances in portal flow

A comparative study of the imaging findings of computed tomography (CT), selective arteriography, CT arteriography, and/or CT portography is presented in 4 patients with Budd-Chiari syndrome. Hepatic differences in attenuation and morphologic changes were generally found to be closely related with regional disturbances in portal flow. Areas with complete hepatic vein obstruction were hypodense on pre- and postcontrast scans, probably due to portal flow inversion. In 2 of 4 cases, these were subsequently atrophied, while areas receiving the remaining venous outflow appeared hypertrophied. They were markedly enhanced on postcontrast scans. Enhancement may be patchy due to portal and sinusoidal stasis.     

B-TFE与3D DCE-MRA联合应用在布加综合征诊断中的价值

目的探讨B-TFE与3D DCE-MRA联合应用在布加综合征（BCS）诊断中的价值。材料与方法搜集经DSA证实的布加综合征患者32例,其中8例为单纯下腔静脉阻塞,2例为单纯肝静脉阻塞,22例为下腔静脉阻塞伴肝静脉阻塞。32例患者均行B-TFE和3D DCE-MRA检查,分析两种方法及联合应用时对BCS及其侧支循环的显示情况。结果 B-TFE正确诊断8例下腔静脉阻塞、18例下腔静脉阻塞伴肝静脉阻塞和2例肝静脉阻塞,总检出率为87.5%（28/32）;3D DCE-MRA正确诊断8例下腔静脉阻塞、19例下腔静脉阻塞伴肝静脉阻塞和1例肝静脉阻塞,总检出率为93.8%（30/32）。B-TFE共显示个193侧支循环,3DDCE-MRA则显示248个侧支循环。两者结合准确诊断全部BCS及其肝内外侧支循环。结论联合应用B-TFE和3DDCE-MRA是诊断BCS的理想方法。I     

Numerical simulation of hemodynamics in membranous obstruction of the suprahepatic inferior vena cava based on a subject-specific Budd-Chiari syndrome model

BackgroundThis study was performed to determine the hemodynamic changes of Budd-Chiari syndrome when the inferior vena vein membrane is developing.MethodsA patient-specific Budd-Chiari syndrome vascular model was reconstructed based on magnetic resonance images using Mimics software and different degrees (16%, 37%, and 54%) of idealized membrane were built based on the Budd-Chiari syndrome vascular model using Geomagic software. Three membrane obstruction Budd-Chiari syndrome vascular models were established successfully and fluent software was used to simulate hemodynamic parameters, including blood velocity and wall shear stress.FindingsThe simulation results showed that there is low velocity and a low wall shear stress region at the junction of the inferior vena cava and the branches of the hepatic veins, and swirl may occur in this area. As the membrane develops, the size of the low velocity and low wall shear stress regions enlarged and the wall shear stress was increased at the membrane region. There was a significant difference in the mean values of wall shear stress between the different obstruction membrane models (P < 0.05).InterpretationHemodynamic parameters play an important role in vascular disease and there may be a correlation between inferior vena cava wall shear force changes and the slow development process of the inferior vena cava membrane.     

布加综合征的螺旋CT诊断(附6例分析)

目的:通过总结,加深认识布加综合征的CT表现及临床特点,提高本病的影像诊断率,减少临床漏诊及误诊;材料与方法:回顾2000年——2010年收集的6例布加综合征,经DSA诊疗证实,行腹部CT平扫加增强,分析其各种临床症状及CT征象;结果:CT表现肝硬化4例,脾大4例,腹水2例,肝段下腔静脉充盈缺损5例,胸腹部侧枝静脉形成或静脉曲张5例。结论:加强对布加综合征的认识,认真分析病史及临床症状,仔细阅读CT影像,应该能对布加综合征做出准确的影像学诊断。     

多层螺旋CT诊断肝移植术后肝静脉流出道梗阻

目的 探讨多层螺旋CT(MSCT)在诊断肝移植术后肝静脉流出道梗阻(HVO)中的价值. 方法 回顾性分析5例在肝移植术后4～102天接受肝脏MSCT动态增强扫描并经血管造影证实为HVO患者的MSCT增强特征. 结果 5例患者中,肝左静脉吻合口狭窄1例,肝中静脉吻合口狭窄(闭塞)2例,肝右静脉吻合口狭窄1例,合并肝中静脉及下腔静脉吻合口狭窄1例.5例患者CT动态增强扫描显示为典型的肝脏淤血征象.CT平扫见梗阻的肝静脉引流区肝实质密度降低(1例因有出血而呈高、低混杂密度);增强扫描动脉期病变区均未见明显强化,静脉期病变区可见轻中度强化,并可见病变区内门静脉分支显影,延迟期病变区强化程度进一步增强.静脉期或延迟期可见梗阻的肝静脉显影,显示肝静脉吻合口狭窄.5例患者均接受介入治疗,术后临床症状改善,其中2例CT复查显示肝淤血缓解、肝静脉血流通畅. 结论 MSCT动态增强扫描可明确诊断肝移植术后HVO的部位及肝脏淤血范围.     

布-加综合征的彩超诊断分型及应用价值

目的探讨彩超对布一加综合征诊断分型及应用价值。方法回顾性分析15例布一加综合征患的彩超声像图特征。结果彩超可准确、无创获取布一加综合征血流动力学改变信息，准确反映下腔静脉、肝静脉、和门静脉的血流循环状态。结论彩超对布一加综合征的诊断、分型及治疗方案的选择具有重要意义，是筛选和诊断布一加综合征的首选方法之一。     

肝静脉阻塞性Budd-Chiari综合征的介入治疗

目的评价肝静脉阻塞性Budd-Chiari综合征(HVBCS)的介入治疗方法及效果.方法 83例HVBCS患者经历了下腔和肝静脉造影,71例实施介入治疗.结果 83例HVBCS分为中央性肝静脉阻塞(COHV,n=65)和广泛性肝静脉阻塞(EOHV,n=18)两型.65例COHV型皆成功地实施了PTA(n=46)和支架(n=19)治疗,64例术后症状消失或明显改善.6例EOHV型接受TIPS治疗,术后症状明显改善4例,2例发生了分流道再狭窄.结论 COHV型适应于PTA和支架治疗,疗效满意;EOHV型可采用TIPS治疗,长期疗效尚不够满意.     

超声造影成像在肝脏的应用

超声造影经过40余年的研究发展到目前已经成为一种稳定、安全的影像检查方法,其在肝脏病变中有突出的应用价值,特别是在肝脏局灶性病变、肿瘤介入性治疗术后的跟踪监测及评价、肝硬化的检测评价、肝脏移植术、布-加氏综合征等方面,超声造影大大改善了超声检查的敏感性及准确性,为各类肝脏疾病的诊断提供了重要依据及积极信息.     

布-加综合征的彩色多普勒超声征象分析

目的探讨布-加综合征的彩色多普勒超声征象及其诊断价值。方法回顾性分析55例布-加综合征的彩色多普勒超声表现和血管造影比较。将布加综合征分为3型:肝内型,肝外型和混合型。结果超声结果与血管造影分型一致为50例(肝内型5例,肝外型29例,混合型16例),诊断准确率为90.9%(50/55)。在下腔静脉狭窄或闭塞的病因中,超声提示单纯膜性狭窄17例(血管造影23例);血栓或癌栓性14例(血管造影16例)。彩色多普勒超声诊断肝脾大16例(29.1%),腹水15例(27.3%),侧枝循环45例(81.8%),尾状叶增大18例(32.7%)。结论超声检查能够为布-加综合征提供直接定位定性和间接征象的诊断依据,可作为诊断该疾病首选影像学检查方法。     

彩色多普勒超声在不同类型布-加综合征诊断与治疗中的价值

目的探讨彩色多普勒超声在不同类型布-加综合征(BCS)诊断与治疗中的价值。方法应用彩色多普勒超声对临床拟诊的不同类型BCS患者106例及30例健康对照者进行检测,观察其特异性血管形态及血流动力学变化,与DSA对比,并治疗后随访。结果(1)超声诊断BCS90例,DSA确诊89例,超声诊断的敏感性97.8%,特异性82.4%,准确性95.3%,假阳性率17.7%,假阴性率2.3%。(2)血流动力学变化:与对照组相比,下腔静脉(IVC)狭窄者可见局部高速血流,阻塞者局部无血流信号;肝静脉(HV)扩张,血流减慢,并可见肝内侧枝血管;门静脉(PV)入肝血流速度减慢.(3)介入治疗及手术后随访:①介入治疗后,IVC病变处增宽,血流恢复,并可见支架回声,HV及PV血流速度加快;②手术治疗组,根治者可见IVC及HV血流恢复正常,人工血管转流者,可见人工血管呈螺旋管状,内血流清晰。结论彩色多普勒超声对BCS的诊断与血管造影具有良好的相关性,可明确BCS特异性异常血管形态及血流动力学变化,是BCS诊断及术后随访的可靠方法。     

探讨5例布-加氏综合症介入围手术期护理重点

目的：探讨布-加氏综合症介入围手术期的护理重点,以保证介入治疗护理的有效性和安全性。方法：对5例布-加氏综合症患者介入围手术期实施重点护理,如：饮食护理,对患者、家属心理支持,准确评估病情,有效控制腹水、出血等并发症及防治复发。结果：5例布-加氏综合症介入术后2-3 d腹壁静脉及双下肢静脉曲张基本消失,X片显示支架位置正常,扩张良好;进食及生命体征正常,无心累,双下肢水肿减退,无并发症发生。住院时间10-13 d,患者满意。结论：通过对布-加氏综合症介入围手术期实施重点护理,提高了护理质量,防治了并发症,保证了介入治疗效果。     

超声观测副肝静脉(肝短静脉)在Budd-Chiari综合征中的临床意义

目的 评价超声检测Budd-Chiari综合征（Bcs）患者副肝静脉的可行性及价值。方法 运用彩超对31例BCS患者的副肝静脉进行检测和分析。 结果 31例BSC患者中，28例超声检测到副肝静脉，显示率90．3％（28／31）。典型的副肝静脉表现为与下腔静脉相通的异常迂曲的管道，并通过交通支与3支肝静脉相通；肝右后叶内走行无明显迂曲或稍迂曲的副肝静脉主要分布于肝段VI及邻近的肝组织内，与三大肝静脉较少形成交通支。 结论 超声显像在大多数BCS患者中可以直观、动态地观察副肝静脉的形态、侧支循环情况及其血流动力学变化，对病情的诊断、治疗方案的制定和预后判断都有重要意义。     

超声对布-加综合征的诊断价值

目的探讨灰阶与彩色多普勒、频谱多普勒及能量多普勒超声对布-加综合征的诊断价值。方法对38例经下腔静脉造影和／或经手术证实的布-加综合征患者的超声影像资料进行分析总结。结果38例布-加综合征患者中，超声确诊36例，漏诊2例，诊断准确率95％，与行下腔静脉造影相比，二者诊断准确率无显著性差异（P〉0．05）。其中下腔静脉型23例，肝静脉型5例，混合型10例。结论灰阶超声结合彩色多普勒、频谱多普勒、能量多普勒超声对布-加综合征的诊断符合率高，对临床治疗方式的选择具有重要意义。     

Sonography and color Doppler imaging of Budd-Chiari syndrome of membranous obstruction of the inferior vena cava.

We examined 18 patients with Budd-Chiari syndrome (membranous obstruction of the hepatic IVC). IVC obstruction was detected by sonography in 17 cases (94%). The causes were a web in 10 cases and a fibrous cord in four cases. In three cases, the cause was unspecified. Obliteration of the hepatic veins or intrahepatic collateral vessels or both was delineated in 16 cases (89%). With seven cases of color Doppler imaging, there was no detectable color or Doppler signal within the IVC, and the direction of hepatic venous blood flow through intravenous communications was fairly well demonstrated in all cases. In four cases of follow-up color Doppler imaging, the patency of the IVC was well demonstrated. Sonography is useful in detecting obstruction of the hepatic IVC and in demonstrating the hepatic venous obstruction and intrahepatic collateral vessels. Color Doppler sonography is useful in demonstrating the direction of blood flow through interconnecting vessels and in evaluating the patency of the IVC after treatment.     

超声引导下经皮经肝肝静脉内支架成形术

超声监测下行经皮经肝肝静脉开通（穿刺破膜和球囊扩张）及金属内支架置入术，治疗肝静脉阻塞型Ｂｕｄｄ－ｃｈｉａｒｉ综合症８例。术后肝静脉直径平均０．９１ｃｍ，肝静脉压由３．６７ｋｐａ降至１．３２ｋｐａ（Ｐ＜０．０１），肝静脉血流恢复正常，门静脉血流也明显改善。患者腹水、腹胀等症状很快消失，肝脾肿大明显缓解。本研究表明，超声引导下经皮肝静脉开通并内支架成形术，能从根本上解除Ｂｕｄｄ－Ｃｈｉａｒｉ综合症的病因，恢复肝静脉的向心血流，操作安全简便。应作为肝静脉阻塞的首选治疗方法。