门静脉金属内支架置入治疗门静脉海绵样变

目的：探讨经皮肝穿刺和经颈内静脉肝内门体分流术(TIPS)途径门静脉内支架置入治疗门静脉海绵样变(CTPV)的疗效及安全性。方法回顾性分析于本科治疗的8例 CTPV 患者的临床及影像学资料。所有患者均行门静脉金属内支架置入治疗,其中3例经 TIPS 途径放置,5例经经皮肝穿刺途径放置。结果所有患者支架置入均一次性成功,无腹腔内出血等严重并发症发生。术中即刻复查造影显示支架内血流通畅,术后1 d~2周患者腹痛及消化道出血症状均明显减轻或消失。术后所有患者均获得完整随访,随访1个月~3年,1例患者术后1 年复查支架闭塞,再次置入1枚支架后血流通畅,其余患者彩超提示支架内血流通畅,未再发消化道出血或腹痛。结论经皮肝穿刺或经 TIPS 途径门静脉金属内支架置入治疗 CTPV 是一种安全有效方法。     

经TIPS途径治疗急性、亚急性门静脉血栓临床疗效

目的 探讨经TIPs途径治疗急性、亚急性门静脉血栓的临床疗效.方法 回顾性分析2005年1月-2008年6月我科经TIPS途径治疗的12例急性、亚急性门静脉血栓患者.观察术后门静脉复通情况,随访8～42个月,观察支架通畅情况及症状恢复.结果 1例患者溶栓第2天发生腹腔大出血死亡.11例患者溶检术后门静脉主干血流得到复通,其中1例3个月随访时门静脉血栓复发,支架堵塞,其余10例患者门静脉主干及分流道支架均保持通畅.结论 经TIPS途径溶栓技术是治疗急性、亚急性门静脉血栓的有效方法.     

门静脉血栓经颈静脉肝内门体分流术

目的:评估经颈静脉肝内门体分流术(transjugular intrahe-patic portosystemic shunt,TIPS)治疗门静脉血栓(portal veinthrombosis,PVT)的可行性,其可以合并门静脉阻塞或海绵样变性,也可以同时合并肝硬化。方法:13例门静脉血栓患者行TIPS治疗,其中合并顽固性腹水7例,合并静脉曲     

经颈静脉肝内门体分流术治疗门静脉血栓的现状

门静脉血栓形成的患病率在整体人群中仅为1.1%,在肝硬化患者中为10%～25%.在急性门静脉血栓形成患者中,如果血栓蔓延至肠系膜上静脉,可导致肠缺血,继而引起肠坏死等严重并发症.另外,慢性门静脉血栓形成可并发食管胃底静脉曲张出血、腹水等门静脉高压征,也可损害肝脏功能.最近的临床实践指南指出,开通门静脉血栓的治疗方法主要包括抗凝、溶栓、经颈静脉肝内门体分流术(TIPS)及外科切栓等.TIPS的优势不仅在于更直接地、有效地开通阻塞的门静脉,而且在建立肝内分流道后可以加速门静脉血流,预防进一步血栓再发.其主要的缺点在于技术难度大以及潜在的技术并发症等危险.然而,经皮经肝、经脾及经肠系膜上静脉穿刺到达门静脉的途径大大地降低了TIPS的手术难度;同时,术前充分的评估门静脉的解剖情况也使TIPS治疗门静脉海绵样变性变得更加安全、有效.但目前缺少相关的前瞻性研究仍限制TIPS的广泛应用.     

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。     

Viatorr支架在门静脉高压合并上消化道出血的临床应用

目的：观察Viatorr支架在经颈静脉肝内门腔静脉分流术（TIPS）中治疗门静脉高压合并上消化道出血的临床效果。 方法：收集2016年11月至2017年10月我院收治的因门静脉高压合并食管胃底静脉曲张破裂出血患者17例,使用Viatorr支架行TIPS治疗。测量Viatorr支架分流前后门腔静脉压力梯度（PSG）值变化,手术前后肝功能、血氨、凝血酶原时间变化,以及术后支架通畅率与再出血情况,并对临床疗效及并发症情况进行分析。 结果：17例患者均获得100%技术性成功。TIPS术后的PSG为（14.47±3.39）mmHg,比术前的（25.47±5.77）mmHg明显降低,差异有统计学意义（t=12.015,P<0.05）。TIPS术后1 d,血氨较术前有所升高[（55.38 ±9.27）μmol/L vs.（40.60±8.14）μmol/L,P<0.05],而术后1周的血氨较术前没有明显变化[（34.77±5.01）μmol/L vs.（40.60±8.14）μmol/L,P>0.05],手术前后的总胆红素、白蛋白、谷丙转氨酶、谷草转氨酶、凝血酶原时间差异无统计学意义。17例患者中16例存活,1例于术后52 d并发肺部感染致呼吸衰竭死亡;4例患者出现I期或II期肝性脑病,纠正后症状逆转;所有患者至随访结束均未再出现呕血、黑便等症状,所有病例术后1周及3个月后均行腹部彩超或增强CT检查,至随访结束（或死亡前）TIPS分流通道血流通畅,通畅率100%,2例合并腹水患者复查腹水消失。术后1~3个月内4例患者复查胃镜,均提示食管胃底曲张静脉缓解或消失。 结论：TIPS术中使用Viatorr支架能明显降低门静脉压力,维持分流道的长期通畅,降低上消化道再出血率,术后肝性脑病并发率在可控制范围内,是门静脉高压患者的一种安全有效的治疗手段。     

改良式经颈静脉肝内门腔静脉分流术治疗肝静脉闭塞型Buddi-Chiari 综合征

目的阐述改良式经颈静脉肝内门腔静脉分流术(TIPS)的技术步骤和评价其对肝静脉闭塞型Buddi-Chiari综合征的治疗效果.方法 11例被诊断为Buddi-Chiari综合征的患者,经影像学证实为肝静脉广泛狭窄和闭塞后,接受改良式TIPS技术治疗,TIPS改良技术的关键在于假想肝静脉通道的设计与建立;术后对其门脉系统压力变化、分流道血流改变及内支架开通状况进行了24个月的随访.结果 11例患者全部成功地建立肝内门静脉-下腔静脉分流通道,临床症状得到改善;门静脉主干压力由分流前的平均(4.62±0.52) kPa (1 kPa=10.2 cm H2O)下降至分流术后的(2.16±0.21) kPa;术后24个月随访,分流道血液最大流率(Vmax)为(56.2±3.50) cm/s,内支架通畅7(7/11)例.结论改良式TIPS技术具有高技术成功率,为肝静脉闭塞型Buddi-Chiari综合征患者提供了新的治疗手段.     

门静脉海绵样变性的螺旋CT表现

目的：探讨门静脉海绵样变性的螺旋CT表现,提高对本病的认识和诊断。方法：搜集螺旋CT双期扫描门静脉海绵样变性20例,其中门静脉主干全塞15例,门静脉左右分支14例,肝内门静脉分支3例,肠系膜上静脉2例,脾静脉1例。结果：门静脉海绵样变性的螺旋CT主要表现为门静脉狭窄和阻塞,门静脉周围建立侧支静脉网及肝脏血流灌注的异常改变。结论：螺旋CT双期扫描对门静脉海绵样变性有一定诊断价值,可为临床治疗提供重要信息。     

门静脉支架联合125I粒子条植入治疗门脉癌栓12例

目的 介绍用门静脉支架联合125I粒子条对合并门脉癌栓的肝癌患者的综合治疗方法.方法 汇集自2014年以来中国医科大学附属盛京医院放射科收治的肝癌合并门脉癌栓的患者12例,分析其临床、影像、实验室检查资料,完成经皮经肝门静脉穿刺及支架联合125I粒子条植入术,统计手术的可行性、安全性及并发症,讨论支架的通畅情况及患者的生存情况.结果 手术成功12例(100％),2例支架未开通,其中1例并发穿刺点出血,1例并发呕血.10例患者接受随访,平均随访时间8.0个月(2～15个月),平均生存时间8.0个月(2～15个月).术后3、6和9个月及1年生存率分别为7/9、7/9、5/8和3/6.门脉支架平均通畅时间7.5个月(0～15个月).术后3、6和9个月、1年门静脉通畅率分别为7/9、6/9、5/8和3/6.随访期内共8例患者行后续TACE治疗,共行TACE 18例次,术后肝功能稳定.结论 门静脉支架联合125I粒子条植入可以降低癌栓分级、维持支架通畅、保证门脉供血、扩大TACE适应证,对合并门脉癌栓的肝细胞癌患者具有较大的综合治疗价值.     

经颈内静脉肝内门体分流术治疗肝硬化门脉高压140例分析

目的探讨经颈内静脉肝内门体分流术（TIPS）治疗肝硬化门脉高压的疗效及安全性。方法回顾性分析140例经TIPS治疗肝硬化门脉高压患者的临床资料,记录术前术后门静脉压力、门静脉和脾静脉直径、食道胃底静脉、腹水的变化,观察术后肝性脑病、复发出血、支架再狭窄等并发症。结果手术成功率及即刻止血率100%,门静脉压力术前（44.7±3.5）cmH2O,术后（23.6±3.8）cmH2O（P<0.01）,门静脉主干直径术前（1.64±0.035）cm,术后（1.27±0.047）cm（P<0.01）,脾静脉直径术前（1.26±0.027）cm,术后（0.95±0.023）cm（P<0.01）。肝性脑病发生率13.6%（19/140）,腹水好转率89%（65/73）,术后12个月复发再出血8.6%（12/140）,支架再狭窄15.7%（22/140）。结论 TIPS是治疗肝硬化门脉高压的有效方法,能有效降低门静脉压力,控制上消化道出血。     

Transjugular intrahepatic portosystemic shunt in a patient with cavernomatous portal vein occlusion

A 23-year-old woman with liver cirrhosis secondary to primary sclerosing cholangitis was referred to us for the treatment of recurrent bleeding from esophageal varices that had been refractory to endoscopic sclerotherapy. Her portal vein was occluded, associated with cavernous transformation. A transjugular intrahepatic portosystemic shunt (TIPS) was performed after a preprocedural three-dimensional computed tomographic angiography evaluation to determine feasibility. The portal vein system was recanalized and portal blood flow increased markedly after TIPS. Esophageal varices disappeared 3 weeks after TIPS. Re-bleeding and hepatic encephalopathy were absent for 3 years after the procedure. We conclude that with adequate preprocedural evaluation, TIPS can be performed safely even in patients with portal vein occlusion associated with cavernous transformation.     

Transjugular intrahepatic portosystemic shunt after previous recanalization of a chronically thrombosed portal vein via a transmesenteric approach

We report a cirrhotic patient with complete occlusion of the portal vein with marked cavernous transformation due to chronic thrombosis in whom a transjugular intrahepatic portosystemic shunt (TIPS) was successfully created after direct minilaparotomy mesenteric vein catheterization, lysis and aspiration of the thrombus, and stenting in the portal vein. The methods used, we believe, provide a new technique for performing TIPS in chronically thrombosed portal veins in which previously no effective surgical therapeutic options were available. Received: 0/00/00/Accepted: 0/00/00     

Percutaneous transsplenic access in the management of bleeding varices from chronic portal vein thrombosis

Three patients with life-threatening variceal hemorrhage secondary to portal vein (PV) thrombosis underwent endovascular treatment via the transsplenic route. The indications, techniques, and early outcomes are described. Each patient had successful portal/splenic vein recanalization with or without transjugular intrahepatic portosystemic shunt (TIPS) creation and variceal embolization with conventional catheter and wire techniques. The transsplenic approach is a useful addition to the interventional armamentarium that can be used in cases refractory to endoscopic management and unsuitable for surgical shunt procedures or conventional TIPS procedures. Longer-term follow-up will be needed to establish the durability of these procedures.     

Application of percutaneous transluminal sharp recanalization in transjugular intrahepatic portosystemic shunt for patients with chronic portal vein occlusion

PURPOSEWe aimed to evaluate the feasibility and safety of a modified technique for portal vein recanalization, percutaneous transluminal sharp recanalization (PTSR), when performing transjugular intrahepatic portosystemic shunt (TIPS) for the treatment of chronic portal vein occlusion (CPVO) and portal hypertension.METHODSNine consecutive patients with CPVO and portal hypertension had undergone TIPS and PTSR procedure after failing in conventional percutaneous catheterization from March 2017 to July 2019. Technical success rates, effectiveness, and complications were evaluated. Follow-up of patients’ clinical outcomes and shunt patency were performed periodically. Primary and secondary shunt patency were analyzed by Kaplan-Meier method.RESULTSThe occluded portal veins were successfully recanalized after failing in conventional percutaneous catheterization, and TIPS procedures were completed in all 9 patients. Two patients suffered from procedure-related complications. A portosystemic pressure gradient <12 mmHg, or a percent reduction of 25% to 50% of baseline, was achieved in all 9 patients after TIPS. During the median follow-up period of 28 months (range, 9–36 months), 1 patient experienced recurrent ascites and the other 8 patients remained asymptomatic. The cumulative rates of primary and secondary shunt patency were 66.67% and 100%, respectively, at 2 years.CONCLUSIONAs a supplementary method, PTSR is a feasible and safe method for portal vein recanalization when performing TIPS for patients with CPVO and portal hypertension.

Portal vein thrombosis is one of the important causes of extrahepatic portal vein obstruction and prehepatic portal hypertension (1). When the acute portal vein thrombosis becomes chronic, the occluded portal vein gradually atrophies, fibrosis develops and chronic portal vein occlusion (CPVO) ensues, eventually leading to the cavernous transformation of portal vein (2), which is a compensatory response to the portal vein occlusion whereby a collateral vein forms to help reduce portal pressure and maintain liver blood perfusion (3, 4). However, they are usually not completely effective in decompressing the portal system, and many patients have persistent portal hypertension and develop serious portal hypertensive complications, such as variceal bleeding and ascites (5).Accumulating evidence has shown that transjugular intrahepatic portosystemic shunt (TIPS) (5–8) or modified TIPS combined with transhepatic or transsplenic approaches (9, 10) is technically feasible and effective to relieve portal hypertension in cirrhotic or non-cirrhotic patients with portal vein thrombosis or CPVO, with a technical success rate of 70% to 100%. Recanalization of the occluded portal vein is the key to the TIPS procedure for patients with portal hypertension and CPVO, while failed portal vein recanalization is the leading cause of TIPS failure (11). Conventional percutaneous catheterization techniques for portal vein recanalization mainly include percutaneous transhepatic and percutaneous transsplenic approaches. Recanalization can be achieved in most cases through either technique alone or in combination; however, they are not feasible in patients with portal vein atrophy and severe fibrosis.Therefore, for the cases of failed portal vein recanalization by conventional percutaneous catheterization, we have developed a procedure of percutaneous transluminal sharp recanalization (PTSR) of the portal vein to complete TIPS. The purpose of this study is to introduce this technique when performing a TIPS procedure for patients with CPVO and portal hypertension, as well as to evaluate its feasibility and safety.     

门静脉癌栓合并门脉高压症的TIPS姑息治疗

目的 评价门静脉癌栓（portal vein tumor thrombosis,PVTT) 合并门脉高压症患者行经颈静脉肝内门体静脉分流术（transjugular intrahepatic portosystemic shunt,TIPS)姑息治疗的疗效，并讨论其技术特点。方法 本组报告14例终末期肝癌合并门静脉癌栓及门静脉高压症患者，平均年龄53．6％。8例门静脉主干完全堵塞，6例门静脉主干及分支有不同程度栓塞，5例合并门静脉海绵样变。1例单纯上消化道大出血，3例单纯顽固性腹水，10例上消化道大出血合并顽固性腹水。结果 14例中10例患者成功行TIPS治疗，门静脉压力平均从术前37.2mmHg(1mmHg=0.133kPa)降至术后18.2mmHg，平均降低19.0mmHg；腹水减少或消失，消化道出血，腹胀，腹泻等症状缓解，平均生存32.3d。4例失败。结论 TIPS是姑息治疗肝癌合并门静脉癌栓引起的上消化道大出血和顽固性腹水的有效方法。     

TIPSS技术在门脉癌栓性门脉高压中的应用

目的 探讨TIPSS技术在治疗门静脉癌栓合并门脉高压中的技术特点及禁忌证。方法 16例门静脉癌栓合并门脉高压症患者，9例门静脉主干完全堵塞，7例门静脉主干及分支有不同程度栓塞；6例合并门脉海绵样变；1例单纯上消化道大出血；4例单纯顽固性腹水；11例上消化道大出血合并顽固性腹水。结果 16例中11例患者成功行TIPSS治疗，技术成功率约68.8%，门脉压力从术前4.9kPa降至2.4kPa，平均降低2.5kPa，腹水减少或消失，症状缓解。平均生存136d。5例失败。结论 TIPSS是治疗门脉癌栓引起的上消化道大出血和顽固性腹水的有效方法，门脉海绵样变是该术的禁忌证。     

Trombosis y cavernomatosis portal: las claves para el éxito de un TIPS

Portal vein thrombosis is a common complication in patients with cirrhosis. Anticoagulation involves a high risk of bleeding secondary to portal hypertension, so placing transjugular intrahepatic portosystemic shunts (TIPS) has become an alternative treatment for portal vein thrombosis. Three strategies for TIPS placement have been reported: 1) portal recanalization and conventional implantation of the TIPS through the jugular vein; 2) portal recanalization through percutaneous transhepatic/transsplenic) access; and (3) insertion of the TIPS between the suprahepatic vein and a periportal collateral vessel without portal recanalization. We describe different materials that can be used as fluoroscopic targets for the TIPS needle and for portal recanalization.This article aims to show the success of TIPS implantation using different combinations of the techniques listed above, which is a good treatment alternative in these patients whose clinical condition makes them difficult to manage, and to show that portal vein thrombosis/cavernous transformation should not be considered a contraindication for TIPS.     

Applications of percutaneous mechanical thrombectomy in transjugular intrahepatic portosystemic shunt and portal vein thrombosis

Portal vein thrombosis (PVT) is an uncommon cause for presinusoidal portal hypertension. PVT can be caused by one of three broad mechanisms: (1) spontaneous thrombosis when thrombosis develops in the absence of mechanical obstruction, usually in the presence of inherited or acquired hypercoagulable states; (2) intrinsic mechanical obstruction because of vascular injury and scarring or invasion by an intrahepatic or adjacent tumor; or (3) extrinsic constriction by adjacent tumor, lymphadenopathy or inflammatory process. Usually, several combined factors are necessary to result in PVT. The consequences of portal vein thrombosis are mostly related to the extension of the clot within the vein. Gastrointestinal bleeding from gastroesophageal varices is the most frequent presentation. Noninvasive imaging techniques are currently used for the screening of patients and the initial diagnosis of PVT. The invasive techniques are reserved for cases when noninvasive techniques are inconclusive, before percutaneous interventional treatment, or in preoperative assessment of patients who are candidates for surgery. Recanalization of the portal vein with anticoagulation alone may not be consistent or appropriate in highly symptomatic patients. Catheterization of the superior mesenteric artery (SMA) is helpful for diagnosis as well as for therapy by allowing the intra-arterial infusion of thrombolytic drugs in the same setting. Direct transhepatic portography allows precise determination of the degree of stenosis and extension within the portal vein, as well as pressure measurements. Thrombotic occlusions of the portal, mesenteric, and splenic veins can be managed by mechanical thrombectomy (MT) or pharmacologic thrombolysis. Underlying occlusions because of organized or refractory thrombus or fixed venous stenosis are best corrected by balloon angioplasty and stent placement. Access into the portal venous system can also be established through creating a transjugular intrahepatic portosystemic shunt (TIPS). Creating a TIPS is also important in the setting of PVT associated with cirrhosis to decompress portal hypertension and improve portal venous flow. PVT involving the portal, splenic, and/or mesenteric veins can also complicate a preexisting TIPS in which case the shunt can be readily used as therapy access. Several techniques may be used to recanalize the shunt and portal venous system, including thrombolytic therapy, balloon angioplasty/embolectomy, suction embolectomy, basket extraction of clots, and mechanical thrombectomy with a variety of devices. Advantages of MT include the potential to rapidly remove thrombus without the need for prolonged thrombolytic infusions, and reducing the potential life-threatening complications of thrombolytic therapy. Possible drawbacks include the risk of intimal or vascular trauma to the portal vein, which may promote recurrent thrombosis.     

Percutaneous extrahepatic splenomeso-caval shunt creation in a patient with portal vein thrombosis after Whipple procedure

A 72-year-old male presented with refractory ascites secondary to portal vein occlusion with cavernomatous transformation following pancreaticoduodenectomy (Whipple procedure). Due to the unfavorable anatomy, transjugular intrahepatic portosystemic shunt was not an option. However, given patency of the spleno-mesenteric confluence and absence of the pancreatic head after the Whipple procedure, a splenomeso-caval shunt was successfully created using a transjugular–transsplenic rendezvous technique.