采用聚四氟乙烯覆膜支架行经颈静脉肝内门腔分流术的临床疗效观察

目的 探讨采用聚四氟乙烯(PTFE)覆膜支架行经颈静脉肝内门腔分流术(TIPS)的临床疗效.方法 回顾性分析行PTFE覆膜支架TIPS术治疗的102例门静脉高压症患者的临床资料,其中男82例、女20例,年龄16 ～ 73岁,平均(53±13)岁.术前症状为食管胃底静脉曲张大出血(83例)或顽固性腹水(19例),肝功能Child-Pugh评分5.0 ～10.0分,平均(6.7±1.7)分.患者均采用PTFE覆膜支架行TIPS术.手术前后门静脉压力和肝功能评分的比较采用t检验.采用寿命表法绘制术后6、12、24、36、48个月的分流道开通率、术后生存率、术后肝性脑病(HE)的发生率曲线.结果 全部患者均在局部麻醉下成功建立肝内门腔覆膜支架分流道,共置入支架128枚.支架直径6.0～10.0mm,平均(8.1 ±0.9)mm.其中PTFE覆膜支架104枚,裸支架24枚.术后门静脉压力明显下降,术前平均(28.5±5.3)mm Hg(1 mm Hg=0.133 kPa),术后(18.0±4.5)mm Hg,手术前后差异有统计学意义(t =22.8,P＜0.01).3例患者出现围手术期并发症,2例腹腔出血、1例支架周围感染.术后随访0 ～58个月,平均(20±13)个月.术后3个月肝功能Child-Pugh评分(6.5±1.6)分,与术前相比[(6.7±1.7)分]差异无统计学意义(t=0.8,P＞0.05).患者术后6、12、24、36、48个月的覆膜支架分流道一期累积通畅率分别是96％、91％、82％、82％、82％,随访期间10例患者出现覆膜支架分流道再狭窄,总体一期再狭窄率为9.8％;27例出现术后HE,发生率26.5％,累积发生率分别为7％、21％、34％、46％、66％;16例出现死亡,病死率为15.7％,累积生存率分别是95％、83％、76％、76％、76％.结论 与裸支架相比,采用PTFE覆膜支架行TIPS术在技术上安全可行,可以明显提高TIPS术后分流道通畅率,但如何改善术后HE及生存率仍是目前亟待解决的问题.     

Transjugular intrahepatic portosystemic stent shunt (TIPSS)]

Our first clinical experience of TIPSS made for a 52-year-old patient with recurrent life threatening variceal bleeding is described. Although shunt-making between the right hepatic vein and the right portal vein and placement of Gianturco-R?sch Z stents were successfully made without significant complication related to the procedure, sufficient decompression of the portal vein pressure was not obtained because of compression on these stents at the tortuous portion of the shunting tract. Some technical problems of the procedure are also discussed, especially about choice of metallic stents and puncture technique.     

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.     

经颈内静脉肝内门腔静脉分流术治疗BuddChiari综合征

目的探讨经颈静脉肝内门腔静脉分流术(TIPS)治疗Budd-Chiari综合征(BCS)的疗效。方法本组14例患者经影像学检查确诊为BCS,因进行性肝功能损害,或严重门脉高压并发症(顽固性腹水,食管胃底静脉曲张上消化道出血),或广泛肝静脉闭塞而行TIPS术治疗。其中混合型8例,肝静脉型5例,肝静脉广泛闭塞型1例。TIPS术中对于下腔静脉、肝静脉的不同情况,灵活选择肝静脉或下腔静脉穿刺点进行穿刺,7例从肝静脉开口处行门静脉穿刺,建立门-腔静脉分流道,4例从下腔静脉直接穿刺门静脉分支,3例经皮穿刺开通肝右静脉后再经肝右静脉穿刺门静脉。术后对分流道支架开通情况进行长期随访。结果14例手术均获成功,门静脉压力由术前平均(4.9±1.4)kPa,降至术后(3.2±1.5)kPa,术后随访5～64个月,2例因支架狭窄分别于术后13、24个月再发上消化道出血,行分流道球囊扩张治疗,术后恢复良好。结论TIPS适用BCS合并有进行性肝功能损害或门静脉高压引起的上消化道出血、顽固性腹水的治疗。对于已行下腔静脉或肝静脉成形术后再发或加重的门静脉高压患者亦为适应证,但手术难度增加。     

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 for the treatment of medically refractory ascites

PURPOSE

This study was performed to assess the safety, efficacy, and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation for treatment of medically refractory as-cites and to identify prognostic factors for clinical response, morbidity, and mortality.

MATERIALS AND METHODS

In this retrospective study, 80 patients (male:female, 52:28; mean age, 56 years; mean Model for End-Stage Liver Disease [MELD] score, 15.1) who underwent elective TIPS creation for refractory ascites between 1999–2012 were studied. A medical record review was performed to identify data on demographics, liver disease, procedures, and outcome. The influence of these parameters on 30-day, 90-day, and one-year mortality was assessed using binary logistic regression. Overall survival was analyzed with Kaplan-Meier statistics.

RESULTS

TIPS was successfully created using covered (n=70) or bare metal (n=10) stents. Hemodynamic success was achieved in all cases. The mean final portosystemic pressure gradient (PSG) was 6.8 mmHg. Thirty-day complications included mild encephalopathy in 35% of patients. Clinical improvement in ascites occurred in 78% of patients, with complete resolution or a ≥50% decrease in 66% of patients. No predictors of response or optimal PSG threshold were identified. The 30-day, 90-day, and one-year mortality rates were 14%, 23%, and 33%, respectively. Patient age (P = 0.026) was associated with 30-day mortality, while final PSG was associated with 90-day (P = 0.020) and one year (P = 0.032) mortality. No predictors of overall survival were identified.

CONCLUSION

TIPS creation effectively treats medically refractory ascites with nearly 80% efficacy. The incidence of mild encephalopathy is nontrivial. Older age and final PSG are associated with mortality, and these factors should be considered in patient selection and procedure performance.The development of medically refractory ascites is associated with a grave prognosis in patients with liver cirrhosis. One-year survival in this population is less than 50%, and there is an increased risk of complications such as spontaneous bacterial peritonitis, hepatorenal syndrome, and dilutional hyponatremia (1). Moreover, these patients typically have low Model for End-Stage Liver Disease (MELD) scores despite their high mortality rate, and thus hold low positions on national transplant listings (2, 3). Transjugular intrahepatic portosystemic shunt (TIPS) creation, an established treatment for complications of portal hypertension, has demonstrated utility in patients with refractory ascites (4). By diverting blood from the portal venous system to the systemic circulation, TIPS acts to lower hepatic sinusoidal pressure and increase effective circulatory flow, thereby reducing excess sodium retention and achieving ascites recurrence rates as low as 30% (5). Two recent studies revealed reduced mortality in patients undergoing TIPS placement, compared with those receiving serial large-volume paracentesis procedures, with one-year survival rates ranging from 63% to 80% (6, 7). Despite these objective benefits, adverse sequelae of TIPS, such as hepatic encephalopathy, may temper its utility, and predictive factors for clinical outcomes, such as ascites control, remain unclear (8). Mortality after TIPS creation has been associated with a variety of factors, including persistent refractory ascites, patient age, procedural urgency, various laboratory parameters, various liver disease scoring systems, and the occurrence of hepatic encephalopathy (7, 9–11). However, an ideal prognostic tool remains to be found.While the benefits of TIPS creation for refractory ascites are well documented, the lingering inability to accurately predict adverse events and responses to treatment warrants further evaluation. Thus, this investigation was undertaken to review the safety, efficacy, and clinical outcomes of elective TIPS creation in a large single-center cohort of patients with refractory ascites and conduct, thereby, a detailed analysis of prognostic factors associated with clinical response, morbidity, and mortality.     

Transjugular intrahepatic portosystemic shunt creation with the Viatorr expanded polytetrafluoroethylene-covered stent-graft

PURPOSE: To evaluate the midterm clinical results and patency of transjugular portosystemic shunts (TIPS) created with a commercially available expanded polytetrafluoroethylene (ePTFE)-covered stent-graft based on angiographic and ultrasonographic (US) criteria in a series of 71 patients. MATERIALS AND METHODS: Seventy-one patients (61 men, 10 women; mean age, 58.6 years, range, 25-78 years) were included in this series, which was performed in two centers. Indications for TIPS creation were refractory ascites (n = 44) and recurrent esophageal bleeding (n = 27). Ten patients had Child-Pugh class A liver cirrhosis, 43 had class B disease, and 18 had class C disease. Underlying liver diseases were alcoholic cirrhosis (n = 58), cirrhosis resulting from hepatitis (n = 9), cryptogenic cirrhosis (n = 3), and Budd-Chiari syndrome (n = 1). TIPS were created with commercially available ePTFE-covered stent-grafts in all patients. The diameters of the stent-grafts were 10 mm in 58 patients and 8 mm in the remaining 13 patients. Follow-up included clinical examination and color-coded US after 5 days, 1, 3, and 6 months, and every 6 months thereafter. Shunt angiograms were obtained every 6 months. Median follow-up was 16.3 months (range, 3.8-26.6 months). RESULTS: TIPS creation was successful in all patients without complications, and effective portal decompression was observed with a reduction of the mean portal gradient from 19 mm Hg to 6 mm Hg before and after TIPS creation. Four shunt occlusions were observed after 5 days, 2 months, 3 months, and 6 months. Shunt stenosis was observed in three patients at the hepatic vein, which was not fully covered by the stent-graft, after 6 months (n = 2) and 12 months, and at the portal side after 1 month in a patient who initially had portal vein thrombosis. The repeat intervention rate was 11.3%. The primary patency rates were 87.4% (95% CI, 77.7%-97.1%) after 6 months and 80.8% (95% CI, 68.2%-93.4%) after 12 months. The rate of de novo or deteriorated hepatic encephalopathy was 31%. The recurrent bleeding rate was 3.7% (one of 27), and ascites improved or resolved in 64% of patients after 1 month. CONCLUSION: TIPS patency can be significantly increased if the ePTFE-covered stent-graft is used for shunt creation. The increased shunt patency contributes to low repeat intervention and recurrent bleeding rates. The rate of hepatic encephalopathy is within the range of previously reported rates.     

腔内超声辅助下经颈静脉肝内门体分流术1例

肝硬化合并反复上消化道出血、顽固性腹水已经成为经颈静脉肝内门体分流术(TIPS)的适应证.国外近年来逐渐开展了腔内超声(IVUS)辅助下TIPS,取得了良好效果.我们尝试使用IVUS辅助进行TIPS,现报道如下.临床资料患者女,58岁.因反复黑便1年余就诊.2015年5月及2016年1月患者分别解柏油样便,量共500～600ml,无呕血、腹痛、黄疸等症状,予内科对症治疗后症状均缓解.     

Transjugular intrahepatic portosystemic shunt creation for recurrent gastrointestinal bleeding during pregnancy

Treatment of bleeding esophageal varices during pregnancy is a rare clinical dilemma. Primary therapy remains endoscopy and band ligation. Refractory variceal hemorrhage treated with a transjugular intrahepatic portosystemic shunt (TIPS) procedure potentially exposes the fetus to radiation. The present report describes a TIPS procedure performed at 22 weeks gestation with the use of radiation-sparing maneuvers in a patient with recurrent esophageal variceal hemorrhage. The TIPS procedure delivered an estimated fetal dose of 5.49 mSv (0.549 Rad), much less than the dose threshold thought to induce biologic effects and only slightly greater than annual background radiation. The interventional radiologist should not hesitate to perform a TIPS procedure for refractory variceal hemorrhage with use of strategies aimed at minimizing radiation.