症状性门静脉阻塞的介入治疗

目的　评价介入技术治疗症状性门静脉 (PV)阻塞的安全性和疗效。方法　对 9例PV阻塞患者进行了介入治疗 ,5例以门静脉高压症、食管 胃静脉曲张破裂出血就诊 (2例继发于肝移植后 ,3例HCC合并PV癌栓 ) ,3例为PV血栓形成 ,另 1例继发于腹部外科手术。 4例采取经皮经肝途径穿刺PV分支 ,5例用TIPS途径。支架置入 4例、球囊扩张成型 6例次、局部溶栓和血栓清除 7例次。结果　治疗技术均成功 ,无重要并发症。介入治疗后复查PV造影显示PV主干血流通畅。 3例腹部症状较明显的PV血栓形成患者 ,术后腹痛、腹胀和腹泻等症状逐渐减轻。随访时间 4～ 36个月 ,1例HCC患者于术后 11个月死于多器官转移 ;1例继发于腹部外科术后患者 ,虽然PV主干恢复血流、临床症状曾一度改善 ,但于 12d后死于腹腔脓肿、多器官衰竭。其余 7例生存 ,Doppler超声复查证实PV主干血流通畅 ,患者未再发生静脉曲张破裂出血或PV血栓相关症状。结论　介入微创技术 ,包括球囊扩张、支架置入、局部溶栓和机械性血栓清除术 ,是治疗症状性PV阻塞的的安全、有效方法     

Percutaneous Angioplasty of Portal Vein Stenosis that Complicates Liver Transplantation: The Mid-Term Therapeutic Results

Objective

We wanted to valuate the mid-term therapeutic results of percutaneous transhepatic balloon angioplasty for portal vein stenosis after liver transplantation.

Materials and Methods

From May 1996 to Feb 2005, 420 patients underwent liver transplantation. Percutaneous transhepatic angioplasty of the portal vein was attempted in six patients. The patients presented with the clinical signs and symptoms of portal venous hypertension or they were identified by surveillance doppler ultrasonography. The preangioplasty and postangioplasty pressure gradients were recorded. The therapeutic results were monitored by the follow up of the clinical symptoms, the laboratory values, CT and ultrasonography.

Results

The overall technical success rate was 100%. The clinical success rate was 83% (5/6). A total of eight sessions of balloon angioplasty were performed in six patients. The mean pressure gradient decreased from 14.5 mmHg to 2.8 mmHg before and after treatment, respectively. The follow up periods ranged from three months to 64 months (mean period; 32 months). Portal venous patency was maintained in all six patients until the final follow up. Combined hepatic venous stenosis was seen in one patient who was treated with stent placement. One patient showed puncture tract bleeding, and this patient was treated with coil embolization of the right portal puncture tract via the left transhepatic portal venous approach.

Conclusion

Percutaneous transhepatic balloon angioplasty is an effective treatment for the portal vein stenosis that occurs after liver transplantation, and our results showed good mid-term patency with using this technique.     

Quantitative Doppler flowmetry of the portal vein in hepatic allografts: initial results in animal and human subjects

Early detection of hepatic allograft injury is essential to ensure graft viability and to minimize patient morbidity. The hepatic microvasculature is adversely affected in ischemic preservation injury and rejection, resulting in diminished sinusoidal blood flow. We investigated whether portal vein volume flow as determined by Doppler ultrasound could provide an index of graft function. In an animal model for ischemic preservation injury we found significantly reduced portal flow in animals with allograft injury. No significant difference in flow volume was demonstrated between normally functioning allografts and non-operated controls. We have evaluated 42 human patients with hepatic allografts. In patients with normally functioning livers (n = 17), mean portal vein flow (Q) was 1659 ± 524 ml/min. Patients with chronic rejection (n = 3) demonstrated markedly reduced flow (Q = 788 ± 109 ml/min; p < 0.001), similar to that seen in cirrhotic patients undergoing preoperative evaluation for liver transplantation (Q = 668 ± 256 ml/min). Patients with acute rejection demonstrated a wide variance in flow rates. Portal flow volumes < 1050 ml/min were associated with greater long term morbidity than those with greater flow volume. Quantitative doppler flowmetry of the portal vein is a promising new non-invasive technique which may provide a unique physiologic indicator of allograft perfusion. Correspondence to: G. S. Foster     

Left portal vein pseudothrombus: A pitfall on contrast medium-enhanced computed tomography

Portal vein (PV) thrombosis may be detected on contrast medium-enhanced computed tomographic (CECT) scans of patients with acute abdominal pathology. We describe a pitfall of dynamic CECT related to the normal arched configuration of the left PV umbilical segment. On axial images, just caudal to the left PV arch, there is an apparent discontinuity in the left PV lumen filled with low-attenuation fat in the intersegmental fisure. If opacified hepatic artery branches traverse the fissure at this level, an appearance mimicking segmental PV thrombosis with mural enhancement can result. A retrospective review of 180 CECT scans in patients without PV thrombosis revealed this phenomenon in seven cases (4%). Awareness of this pitfall obviates the need for superfluous investigations that might otherwise be necessary to confirm PV patency.     

Imaging and radiological interventions of portal vein thrombosis

Portal vein thrombosis (PVT) is diagnosed by imaging methods. Once diagnosed by means of ultrasound, Doppler ultrasound can be performed to distinguish between a benign and malignant thrombus. If further information is required, magnetic resonance angiography or contrast-enhanced computed tomography is the next step, and if these tests are unsatisfactory, digital subtraction angiography should be performed. Many papers have been published dealing with alternative methods of treating PVT, but the material is fairly heterogeneous. In symptomatic non-cavernomatous PVT, recanalization using local methods is recommended by many authors. Implantation of transjugular intrahepatic portosystemic shunt is helpful in cirrhotic patients with non-cavernomatous PVT in reducing portal pressure and in diminishing the risk of re-thrombosis. In non-cirrhotic patients with recent PVT, some authors recommend anticoagulation alone. In chronic thrombotic occlusion of the portal vein, local measures may be implemented if refractory symptoms of portal hypertension are evident.     

门静脉和肝脏静脉系统3D DCE MRA增强方法的比较研究

比较门静脉和肝静脉系统３Ｄ ＤＣＥ ＭＲＡ成像时，用快速法和慢速法注射造影剂所获图像质量和显示血管的差异。材料与方法：实验分两部分。第一部分做了１０例肝脏横断面动态增强ＭＲＩ，分为两组，分别用快速和慢速法注射造影剂，测定ＰＶ和ＩＶＣ达信号峰值的不同时间，以决定第二部分实验的延迟时间。     

LAVA结合ASSET技术在肝门静脉成像的应用价值

目的 探讨应用LAVA结合ASSET技术进行门静脉成像的可行性.资料与方法 对60例肝病患者应用LAVA结合ASSET进行门静脉成像,并与20例门静脉CE-MRA进行对照,分析两者对肝内门静脉及其分支的显示.结果 应用LAVA结合ASSET扫描获得的门静脉成像显示全部60例的门脉主干及肝内1、2级分支、32例3级分支、4级18例和10例4级以下分支.门静脉CEMRA20例显示全部门脉主干及肝内1、2级分支、10例3级分支,7例4级分支和3例4级以下显示.两种方法显示门静脉的差异无统计学意义(P>0.05).结论 LAVA结合ASSET技术可完全替代常规的CE-MRA获得门静脉图像.     

Gallbladder varices: A potential collateral pathway in portal hypertension and portal vein occlusion

Varices of the gallbladder were demonstrated angiographically in four patients. One patient who had had a mesocaval shunt developed gallbladder varices as a result of hepatoportal shunting. Three patients had gallbladder varices owing to collateral circulation from portal vein occlusion.     

动态增强磁共振门静脉造影在门脉高压症诊断中的价值

目的:探讨动态增强磁共振门静脉造影(DCE MRP)在门脉高压症诊断中的价值。方法:对门脉高压症组23例和正常对照组15例行DCE MRP检查。观察23例门静脉高压症在DCE MRP上的表现。结果:对照组15例均清楚显示门静脉。门脉高压症表现为门静脉增粗(21例)、脾静脉迂曲扩张(23例);门静脉分支级数减少(18例);门静脉延迟显影(7例);显示侧枝循环静脉(6例);门静脉血栓形成(3例)。结论:DCE MRP是评价门静脉的一项快速无创的技术,可准确显示门静脉高压症门静脉系统的病理改变。     

Percutaneous CT-guided superior mesenteric vein access for portal vein recanalization-transjugular intrahepatic portosystemic shunt

Portal vein recanalization-transjugular intrahepatic portosystemic shunt (PVR-TIPS) is a valuable technique in the treatment cirrhosis and portal vein (PV) thrombosis. Only a few studies have reported cases of utilizing the transmesenteric approach in the procedure''s initial portal access. Here, we report the successful utilization of a CT-guided percutaneous puncture of the superior mesenteric vein (SMV) for PVR-TIPS in a patient with splenic vein thrombosis. A 54-year-old male with a history of morbid obesity (BMI: 44.67), hepatitis C, NASH cirrhosis, esophageal varices, and complete PV thrombosis presented for PVR-TIPS. An initial percutaneous transplenic approach was attempted, but was aborted due to the discovery of a splenic vein thrombosis. Subsequently, the patient was brought back into the hybrid-angio CT suite, and the SMV was accessed percutaneously with a 21-gauge needle under 4D CT-guidance. A 5-Fr micropuncture sheath was then placed. Additional portal venogram confirmed PV thrombosis. Right internal jugular vein (IJV) access was then obtained, and the right hepatic vein was catheterized. A loop snare was advanced from the SMV access into the right PV. A Colapinto needle was later positioned in the right hepatic vein, and the right PV was accessed using the loop snare as a target. A wire was then advanced and captured by the snare, and brought down through the PV. The tract was dilated with a 10 mm balloon, and a Viatorr stent was deployed. Balloon embolectomy of the SMV, splenomesenteric vein, and TIPS were then performed with a CODA balloon with improvement in flow through the TIPS on final portal venogram. Portosystemic gradient was 11 mmHg initially and 10 mmHg post-TIPS. Follow-up TIPS venogram in 3 weeks showed a widely patent TIPS. CT-guided percutaneous SMV access may serve as valuable technique in PVR-TIPS when traditional modes of initial portal access for recanalization are unobtainable.     

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.     

CT测量中老年人门静脉、腹主动脉管径及其比值

目的:应用16排CT增强扫描,探讨健康中老年入门静脉与腹主动脉管径及其比值的特点.方法:取符合条件的上腹部CT增强检查的中老年人160例,按年龄分为2组(中年组40～59岁,老年组60～79岁),每组80例(其中男女各40例).测量门静脉期门静脉(PV)、腹主动脉(AA)管径,计算两者比值(R值)并进行统计学分析.结果:PV及AA直径在不同性别之间的差异具有统计学意义(P＜0.05),R值在不同性别之间的差异无统计学意义(P＞0.05).PV直径在中老年组之间差异无统计学意义(P＞0.05),AA直径及R值在中老年组之间差异具有统计学意义(P＜0.05).结论:PV、AA管径及R值的测量可以为引起门静脉或腹主动脉管径改变的相关疾病的诊断提供具有一定价值的影像学依据,R值的适用范围更广.     

螺旋CT双期增强扫描对门静脉癌栓的诊断价值

目的探讨螺旋CT双期增强扫描对门静脉癌栓的诊断价值。方法对21例门静脉癌栓患者行螺旋CT双期增强扫描,观察门静脉癌栓在CT上的表现,并与常规CT表现进行比较。结果所有21例门静脉显示满意,均显示了癌栓所在部位门脉阻塞征象,13例显示了肝门部侧支血管。结论螺旋CT双期增强扫描是诊断门静脉癌栓的有效方法,尤其在显示侧支循环方面有很大优越性。     

Diagnosis of an accessory portal vein and its clinical implications for portosystemic shunts

Purpose To present a peculiar anatomic portal veins variant and evaluate its clinical implications. Methods Among 118 consecutive patients undergoing transjugular intrahepatic portosystemic shunting (TIPS), six male patients were found to have an accessory portal vein, which was seen during direct portography. Results In all six patients, portograms showed an accessory small-caliber vein parallel to the trunk of the main portal vein ending in the right lobe of the liver. Two of the six accessory portal veins drained blood from coronary veins, precluding access to coronary vein embolization during TIPS. Conclusion An accessory portal vein is a rare anatomical variation with clinical significance for both surgical shunt placement and TIPS, as well as for transportal embolization of coronary veins.     

Experimental TIPS with spiral Z-stents in swine with and without induced portal hypertension

Purpose To assess the suitability of spiral Z-stents for transjugular intrahepatic portosystemic shunt (TIPS) and the influence of portal hypertension on shunt patency in young swine. Methods TIPS were established using spiral Z-stents in 14 domestic swine. In 7 animals, the portal venous pressure was normal; in the other 7, acute portal hypertension was induced by embolization of portal vein branches. Follow-up portal venography and histologic evaluations were done from 1 hr to 12 weeks after TIPS. Results Follow-up transhepatic portal venograms showed progressive narrowing of the shunt, most priminent in the midportion of the tract. Ingrowth of liver parenchyma between the stent wires found after 3 weeks led to progressive shunt narrowing and shunt occlusion by 12 weeks. A pseudointima grew rapidly inside the stent, peaked in thickness around 4 weeks, and decreased later. Acutely created portal hypertension rapidly returned to normal and there was no difference in TIPS patency between the two groups of animals. Conclusion Although the spiral Z-stent can be used as a device for creation of TIPS in patients with cirrhotic livers, it is associated with extensive liver ingrowth in swine that leads to rapid shunt occlusion. Portal hypertension was only transient in this model.     

肝移植术后门静脉狭窄内支架治疗的价值

目的 探讨内支架治疗技术在肝移植术后门静脉狭窄治疗中的应用价值.方法 回顾性分析肝移植术后发生门静脉狭窄的7例患者资料,所有患者均采用内支架置入治疗,对患者临床资料、影像随访资料、介入治疗的并发症和预后等情况进行总结.结果 7例均成功置入门静脉内支架,所有患者术后均无与门静脉治疗相关的并发症发生.患者随访3～34个月.除1例因同时合并肝动脉闭塞、缺血性胆道损伤于术后3个月死于多脏器功能衰竭,其余6例患者影像随访显示门静脉通畅.结论 肝移植术后门静脉狭窄的介入内支架治疗是一种安全、有效的治疗方法.     

Percutaneous transhepatic angioplasty and stent implantation for prehepatic portal vein obstruction

Twenty-nine months after a Whipple procedure for pancreatic carcinoma, a 47-year-old woman developed esophageal variceal bleeding. Percutaneous transhepatic portography revealed a severe stenosis of the portal vein with prehepatic portal hypertension and collateral circulation mainly to the gastric and esophageal veins. Percutaneous transhepatic balloon angioplasty was used to dilate the stenoses, but it did not remove the stenosis sufficiently. Therefore, an 8-mm, self-expandable stent was implanted, creating a nearly normal lumen without a pressure gradient. Portal hypertension was relieved, and the patient had no recurrent variceal bleeding for the 5 months up to her death.     

经皮门静脉栓塞治疗肝癌的临床应用

目的探讨经皮选择性门静脉右支栓塞(PVE)在肝癌治疗中的应用价值。方法12例无手术切除指征的中晚期肝癌患者,在电视透视引导下经导管行经皮穿肝或穿脾行PVE。栓塞前、后用CT测量左侧肝叶的体积,并测量栓塞前后的门静脉压力、肝功能。结果12例患者均成功行经皮PVE,栓塞术后左肝叶代偿增生明显,其中3例PVE后顺利实行右肝切除术。PVE后未出现门静脉高压,肝功能损害轻,均未发现并发症。结论经皮选择性PVE能诱导非栓塞侧肝叶代偿性增生及栓塞侧肝叶萎缩,增加肿瘤手术切除机会,提高手术切除的安全性,对于无法手术切除的肝癌患者重新获得手术切除的机会,具有潜在的临床应用价值。     

肝纤维化门脉血流的磁共振相位对比法测定

目的　探讨磁共振血流测定在肝纤维化患者中的临床应用。材料与方法　采用磁共振相位对比法测定 2 0例正常对照组、15例肝纤维化患者和 10例肝硬化患者的门脉血流 ,并作统计学比较方差分析。结果　肝纤维化患者门脉主干截面积和平均血流速度无明显改变 (分别为 15 2 .2 5± 2 4.60mm2 和 11.90± 1.2 3cm/s) ,但门脉血流 ( 17.99± 2 .67ml/s)显著增加。结论　无创伤的磁共振技术可以用于门脉血流的测定 ,反映肝脏损害程度 ,动态观察肝纤维化、肝硬化的病程演进。     

门静脉结构异常的影像诊断及意义

本文报道了７例门静脉结构异常的影象诊断，包括门静脉海绵样变３例，门静脉重度狭窄２例，门静脉畸形１例，１例门静脉海绵样变血管结构同正常门静脉系统同时存在。检查方法包括ＵＳ、ＣＴ、ＭＲＩ和动脉法门静脉造影，ＵＳ和ＭＲＩ对门静脉结构异常的显示尚不能为ＴＩＰＳＳ治疗提供满意的信息，正确诊断率有待进一步提高，在行ＴＩＰＳＳ治疗的前，如疑有门静脉结构异常，应行间接门静脉造影，以判断ＴＩＰＳＳ治疗可行性。