部分性脾动脉栓塞术前后脾动静脉及门静脉血液动力学变化定量研究

目的:定量研究脾脏动脉、静脉及门静脉在部分性脾动脉栓塞(PSE)术前后的血液动力学变化情况。方法:术前、术后即刻、术后1周分别测定脾脏动脉、静脉及门静脉血液动力学各项指标。结果:20例患者的脾动脉PSV、EDV、MV,脾静脉MV在PSE术后均显著降低(P<0.01);脾动、静脉血管截面积S术后显著减小(P<0.01);脾动静脉及门静脉血流量Q术后均显著降低(P<0.01)。术后1周PSV、EDV和MV、脾静脉S、血流量Q较术后即刻又有明显恢复(P<0.01);S/D、PI、RI术后显著增加;术后脾静脉血流量减少程度与脾脏栓塞程度成正相关,r=0.545(P<0.05);结论:PSE术能有效减少门静脉血流量,缓解门脉高压,从而降低上消化道大出血的风险。但门静脉的血流量减少程度与脾脏栓塞程度无相关性。     

术前CT血管成像对肝移植脾动脉盗血综合征的预估

目的 评价术前CT血管成像对肝移植术后脾动脉盗血综合征的预估价值.方法 脾动脉盗血组(A组)及正常对照组(B组)各8例行CT血管成像.应用GE ADW4.2工作站,测量脾动脉盗血组和正常组病人肝移植术前肝动脉直径,脾动脉直径,肝脏体积,脾体积及其比值.使用SPSS 13统计软件,对2组数据进行统计分析.结果 脾动脉盗血组和正常组脾动脉直径在统计学上有显著的差别(P=0.008,P<0.05);脾动脉与肝动脉的比值在统计学上亦有显著性差别(P=0.015,P<0.05);而肝动脉直径、脾体积、肝脏体积、脾体积/肝脏体积统计学上无显著性差别(P值分别为0.364,0.78,0.624,0.172,P>0.05).结论 脾动脉直径、脾动脉直径/肝动脉直径对术后是否发生盗血具有重要提示意义,并且脾动脉直径＞7.5 mm、脾动脉直径/肝动脉直径＞1.2提示发生盗血的概率较大.     

肝动脉阻力指数与肝移植术后胆道并发症的相关性分析

目的:通过彩色多普勒超声检测肝动脉阻力指数变化,评价其对肝移植术后胆道并发症的预测价值.方法:用彩色多普勒超声观察107例肝移植患者术后肝脏血流变化,将肝动脉阻力指数进行分类分析.结果:肝移植术后,发生胆道并发症者33例.出现低阻力指数者共44例,包括首次检查RI≤0.50、随访2次以上发现RI≤0.50及RI较首次检查降低>0.30者,其中30例术后发生胆道并发症.低阻力指数者胆道并发症发生率明显增高(P<0.01),阻力指数正常者胆道并发症发生率明显减低(P<0.01),高阻力指数者胆道并发症发生率与整体发生率差异无统计学意义(P>0.05).结论:肝动脉低阻力指数与胆道并发症有明显的相关性,超声可预测肝移植术后肝动脉供血不足导致的胆道并发症.     

TACE联合内皮抑素对兔VX2肝移植瘤的血流动力学影响的超声评价

目的 利用多普勒超声研究TACE联合内皮抑素栓塞治疗后兔VX2肝移植瘤及肝脏的血流动力学变化.方法 20只荷瘤兔,随机分为对照组和抗血管生成组,每组10只,抗血管生成组经兔肝动脉给予内皮抑素+超液化碘油+阿霉素栓塞治疗,对照组以生理盐水代替.1周后多普勒超声观察肿瘤血供及肝动脉、门静脉血流动力学变化,检测结果与治疗前相应血管的多普勒血流参数进行比较.结果 对照组治疗后肝动脉最大血流速度增大(P<0.05),肝动脉阻力指数和门静脉血流速度无明显变化(P>0.05);抗血管生成组栓塞后肝动脉血流速度明显降低(P<0.05),阻力指数增大(P<0.05),门静脉血流速度无明显变化(P<0.05).治疗前所有病灶内及其周边多普勒超声均可检测出较丰富血流信号.治疗后显示抗血管生成组瘤内及瘤周血流信号均明显减弱,部分消失.结论 TACE联合内皮抑素可有效地阻断兔VX2肝移植瘤供血,多普勒超声可显示该血流的变化.便于对其疗效进行及时评价.     

超声观察肝移植术后肝动脉与门静脉及胆管的价值

目的:探讨超声观察原位肝移植术(OLT)后肝动脉、门静脉与胆管在诊断与处理术后并发症中的临床价值.材料和方法:采用二维与彩色多普勒超声(CDFI)对6例OLT术后患者行超声随访(3～22个月),观察患者的肝、胆管、脾脏声像表现,检测肝动脉、门静脉的CDFI血流参数.检查次数6～20次.结果:4例OLT术后门静脉血流速度增大,其中2例肝动脉血流速度下降,阻力指数(RI)亦下降;1例肝动脉血流消失;1例肝动脉血流速由低速逐渐升高,RI亦明显增高,之后肝动脉血流消失.3例肝内出现低回声区.2例胆总管吻合口狭窄与闭塞.1例胆总管壁明显增厚.1例肝癌复发.结论:超声跟踪随访肝动脉、门静脉与胆管的变化对尽早发现OLT术后并发症,提高患者的生存率具有重要的临床意义.     

多层面螺旋CT对肝移植术后肝动脉狭窄肝灌注的研究

目的　利用动态单层CT扫描对原位肝移植术后肝动脉狭窄肝灌注与未行肝移植、无肝脏病变者进行比较。资料与方法　对 30例肝移植术后肝动脉狭窄患者选取肝门 (包括肝、门静脉、主动脉和脾 )层面行动态单层CT扫描。高压注射器经肘静脉注射非离子型对比剂欧乃派克 4 0ml,流率 3ml/s,注射对比剂时即进行扫描 ,每间隔1s扫 1层 ,共扫描 35层。通过每一层面选定的ROI作CT值测量 ,绘制出时间 密度曲线 ,从而计算出相应灌注值并与未行肝移植、无肝脏病变者进行对照。结果　肝移植术后肝动脉狭窄 <5 0 %组 ,肝动脉灌注 (t=0 .5 ,P >0 .0 5 )、门静脉灌注 (t=1 ,P >0 .0 5 )与对照组间无显著差异 ;肝动脉狭窄≥ 5 0 % ,肝动脉灌注与对照组存在差异 (t =2 .1 4 ,P <0 .0 5 ) ,低于对照组 ,门静脉灌注与对照组有差异 (t=2 .6 3,P <0 .0 5 ) ,高于对照组。结论　肝移植术后肝动脉狭窄≥ 5 0 % ,肝动脉灌注降低而门静脉灌注升高。动态单层CT扫描对于评价肝移植术后肝脏灌注是有帮助的     

多普勒超声在肝移植中的应用

目的: 探讨多普勒超声在肝移植中的应用价值.材料和方法: 对105例原位肝移植的患者分别于术前、术中和术后多次行彩色及频谱多普勒超声检查.结果: 20例出现排斥反应,多普勒表现为肝静脉频谱变钝,正向波消失,门静脉流速减低,肝动脉阻力指数增高.7例出现肝动脉并发症,其中2例狭窄,5例血栓形成,CDFI主要表现为肝动脉血流信号消失,肝静脉和门静脉充盈良好,经血管造影证实;CDFI发现下腔静脉狭窄1例,门静脉狭窄1例,经球囊扩张后,血流灌注恢复正常.结论: 多普勒超声对移植肝血流动力学的监测、手术中及术后并发症的早期诊断具有重要作用.     

布-加综合征介入治疗近期效果评价中脾脏剪切波速与门静脉压力相关性研究

目的 探讨脾脏剪切波速(SWV)与门静脉压力相关性在布-加综合征(BCS)介入治疗近期效果评价中的应用价值.方法 收集2016年5月至10月收治的30例BCS患者临床资料,检测受治血管开通前后2次肝静脉压力梯度(HVPG),检测介入术前、术后2d及术后1个月脾脏SWV、门静脉流速及内径并计算其比值,并对上述指标进行统计学分析.结果 30例患者均治疗成功.HVPG均值由术前(13.70±4.55) mmHg显著下降至术后(3.20±1.94) mmHg(P＜0.05);术前、术后HVPG差值与术前、术后2d脾脏SWV差值及门静脉流速-内径差值均呈正相关(r=0.856,P＜0.000 1;r=0.741,P＜0.000 1).结论 脾脏SWV与HVPG有良好相关性,可用于评价BCS患者术后近期疗效.     

肝移植术行脾动脉环阻预防脾动脉盗血综合征的效果及其安全性

 目的 探讨脾动脉环阻术(splenic artery banding, SAB)预防肝移植术后脾动脉盗血综合征(splenic artery ateal syndrome, SASS)的效果及其安全性。方法 2004-01至2013-12,对127例肝硬化、脾脏增大、术前脾动脉直径/肝动脉直径(SA/CHA)≥1.5、术中HA血流＜30 cm/s的肝移植患者(SASS高危者)采用预防性SAB(干预组),观察其预防SASS效果及安全性。分析术中HA血流≥30 cm/s未接受环阻术的191例患者(对照组)手术前后情况,同时对两组部分资料进行比较。结果 干预组患者处理后肝动脉(CHA)血流量立即改善,环阻前(19.34±5.45) cm/s,环阻后(45.89±9.13)cm/s, P<0.001;阻力指数(RI)全部恢复到正常水平(0.5~0.8) ,移植术后无SASS发生,亦未观察到移植术后受者动脉相关并发症。而对照组术后发现SASS 17例(8.90%),其中11例继发肝动脉血栓形成。结论 高风险患者预防性SAB具有可靠的疗效和安全性。     

MSCTA在肝移植中的应用价值

目的:探讨多层螺旋CT血管造影(MSCTA)在肝移植中的临床应用价值.方法:病例组选择32例肝癌和肝硬化在移植前后行多层螺旋CT(MSCT)多期扫描,包括肝癌10例(肝癌组)、22例肝硬化CTP分级C级(肝硬化组).分别于肝动脉期和门脉期进行血管3D成像,重建方法包括MPR、MIP、VR.于MIP图像上分别测量腹腔动脉 (CA)、胃左动脉(LGA)、肝总动脉(CHA)、肝固有动脉(PHA)、肠系膜上动脉(SMA)及门静脉(PV)、脾静脉(SV)、肠系膜上静脉(SMV) 的管径.数据用SPSS10.0处理,资料用均数±标准差(±S)表示,两组均数比较采用t检验;多组间的比较用单因素方差分析(ANOVA),两两比较用q检验.P＜0.05有统计学意义.结果:肝动脉期血管成像可清晰显示扫描范围内的腹主动脉、腹腔干,胃十二指肠动脉,肝固有动脉,肝左、右动脉及其分支;门静脉期血管成像能清晰显示门静脉系统情况.病例组32例中有21例肝动脉及其分支解剖正常,MIP及VR所显示的正常解剖肝动脉无明显差异.病例组中11例、正常对照组6例显示肝动脉分支异常.于MIP像上能准确测量腹腔大动脉血管管径及门静脉、肠系膜上静脉及脾静脉的管径,对照组与肝硬化组及肝癌组动脉管径无统计学差异,而门脉高压患者门静脉主干、肠系膜上静脉及脾静脉的管径与对照组相比,差异有统计学意义(P<0.05).结论:肝脏MSCTA能准确显示血管解剖、变异及病变情况,对静脉、变异的肝动脉进行管径测量,掌握个体化肝脏血管变异及其血管大小信息,为手术方式、制订术中血管吻合方案提供客观依据,并监测术后血管并发症.     

The value of serial Doppler ultrasound as a predictor of clinical outcome and the need for transplantation in fulminant and severe acute liver failure.

The aim of this study was to document the changes in Doppler ultrasound variables of the hepatic artery and portal vein in fulminant and severe acute liver failure, and to assess their prognostic significance. 18 adult patients with fulminant and severe acute liver failure underwent serial Doppler sonography, in the early stages after presentation. 12 hourly measurements of hepatic artery resistance index (HARI), spleen length, portal vein cross-sectional area, time average velocity (TAV) and flow volume were performed. Mean HARI (p = 0.03) and mean maximum HARI (p = 0.03) were significantly higher in those who fulfilled criteria for liver transplantation. Increased portal vein flow was demonstrated, although the difference between the groups was not significant. A significant increase in portal vein cross-sectional area (p < 0.02) and spleen length (p < 0.02) was demonstrated. In summary, an increase in portal blood flow to the damaged liver has been demonstrated. The mean HARI is significantly higher in patients who fulfil transplant criteria and may possibly be used as an indicator of poorer prognosis and the need for liver transplantation in acute severe and fulminant liver failure.     

Splenic Artery Syndrome After Orthotopic Liver Transplantation: Treatment With the Amplatzer Vascular Plug

Purpose  

To evaluate the safety and efficacy of the Amplatzer vascular plug (AVP) for embolization of the splenic artery in patients with hepatic hypoperfusion after orthotopic liver transplantation (OLT).     

肝脏移植术中肝动脉并发症的预防

目的　探讨肝移植术后肝动脉栓塞或狭窄的预防。方法　将供肝肝动脉至腹腔动脉起始部一并切取 ,在修整肝动脉时 ,尽量保留其全部 ;同时避免动脉的损伤 ,尤其动脉主干及分支内膜。肝移植术中 ,供、受体门静脉吻合开放后 ,选择内膜完整、与供肝动脉口径相匹配的血管 ,直接行端端吻合。若术中发现血管内径较细 ,无论是供、受者动脉均应寻找动脉主干与血管分叉处 ,剪开分叉处 ,使动脉吻合口呈喇叭口状 ,并保护动脉内膜不受损伤。在肝动脉重建过程中 ,保证内膜的完整性。结果　 36例肝移植术后患者经B超证实无 1例发生肝动脉并发症。结论　供体器官完整的动脉采集、术中合理的动脉选择、精确的血管吻合技术及术后的适当抗凝是预防肝移植肝动脉并发症的重要因素。     

原位肝移植后血管并发症的血管腔内介入治疗

目的 分析总结血管腔内介入治疗在原位肝移植后血管并发症中的作用和意义. 资料与方法 回顾性分析31例原位肝移植术后血管并发症患者的血管腔内介入治疗资料与随访结果. 结果 31例患者中单纯肝动脉并发症11例,门静脉并发症11例,腔静脉并发症6例,合并肝动脉与门静脉并发症1例,合并腔静脉、肝静脉、门静脉复杂并发症1例,脾动脉窃血综合征1例.均成功进行了血管腔内介入治疗.共置入肝动脉支架13枚,静脉支架21枚,进行肝动脉栓塞1例,部分性脾动脉栓塞2例,单纯腔静脉球囊扩张1例,1例患者肝动脉局部灌注溶栓后置入肝动脉支架,1例患者先后置入腔静脉、肝静脉与门静脉支架各1枚,1例患者同时置入门静脉和肠系膜上静脉支架.所有血管腔内介入操作成功有效,技术成功率100%,手术相关并发症发生率12.9%,并且并发症经处理无后继影响.随访中除1例肝动脉于支架置入后19天发生再狭窄外,其余血管至随访结束未出现明确再狭窄. 结论 肝移植术后血管并发症的血管腔内介入治疗安全有效,技术成功率高而并发症发生率低,是一种理想的微创治疗选择.     

The use of coronary stent in hepatic artery stenosis after orthotopic liver transplantation

PURPOSE: This retrospective study was undertaken to evaluate the effectiveness of coronary stent placement in hepatic artery stenosis after orthotopic liver transplantation (OLT). MATERIALS AND METHODS: Of 430 consecutive adult orthotopic liver transplant recipients between November 2003 and September 2005, 17 had hepatic artery stenosis (HAS). Fourteen of them underwent coronary stent placement in the HAS. The technical results, complications, hepatic artery patency and clinical outcome were reviewed. RESULTS: Technical and immediate success was 100%. After a mean follow-up of 159.4 days (range, 9-375 days), all patients obtained patent hepatic arteries except 2 patients occurred hepatic artery restenoses at 26 and 45 days after stent placement, respectively. Kaplan-Meier curve of patency showed cumulated stent patency at 3, 6, and 12 months of 78%, 58% and 45%, respectively. During the follow-up, 8 patients survived, 5 died of septic multiple-organ failure, 1 received retransplantation because of refractory biliary infection. Hepatic artery dissection induced by a guiding catheter occurred in one patient and was successfully treated with a coronary stent. CONCLUSION: Hepatic artery stenosis after OLT can be successfully treated with coronary stent placement with low complication rate and an acceptable 1-year hepatic artery patency rate.     

Arteriography and portal venography on routine follow-up after orthotopic liver transplantation

RATIONALE AND OBJECTIVES: To describe the findings of routinely performed angiographic examinations in patients at discharge 2 months after orthotopic liver transplantation (OLT) and at follow-up 1 year later. METHODS: The findings of 315 angiographic examinations performed in 190 patients 2 months and 1 year after OLT were reviewed, and the changes at the anastomotic site of the hepatic artery and portal vein were analyzed. RESULTS: Routine angiography 2 months and 1 year after OLT demonstrated a normal anastomosis or low-grade stenosis in 82% and 84% of the patients (hepatic artery) and in 88% and 84% (portal vein), respectively. High-grade stenosis occurred in 9% and 5% of the patients (hepatic artery) and in 3% and 5% (portal vein). Hepatic artery occlusion and portal vein occlusion were observed in two and seven patients and in one and three patients, respectively. In 76% of patients, the anastomotic site of the hepatic artery did not change significantly. In eight patients, a normal anastomosis or a low- or medium-grade stenosis developed into high-grade stenosis or occlusion. Conversely, in nine patients, medium- or high-grade stenosis developed into a normal anastomosis or a low-grade stenosis. In all eight patients who initially had a high-grade stenosis, the hepatic artery proved to be patent at 1 year. In 98% of patients, the anastomotic site of the portal vein did not change significantly. In one patient who initially had a normal anastomosis, occlusion was found at I year. CONCLUSIONS: In most patients, routine angiography 2 months and 1 year after OLT demonstrated normal findings or a low-grade stenotic anastomosis of the hepatic artery and portal vein. Significant changes occurred mainly at the anastomotic site of the hepatic artery and could not be predicted by previous angiograms.     

Diagnostic role of colour Doppler US at 1-year follow-up after orthotopic liver transplantation

Purpose

This paper discusses the role of colour Doppler ultrasound (CDUS) in the midterm follow-up of patients after orthotopic liver transplantation (OLT).

Materials and methods

We retrospectively studied 134 patients — 102 men and 32 women, age range 21–68 years — who underwent liver transplantation between May 2006 and April 2007. In the first week after OLT, CDUS examination was performed daily in patients with anastomoses at a high risk of thrombosis, and on the basis of clinical and laboratory findings in other patients. After discharge, follow-up was performed 1, 3, 6 and 12 months after transplantation. Any new parenchymal focal lesion was studied by computed tomography (CT) and, where needed, biopsy.

Results

CDUS identified the following complications: 22 biliary (B), nine vascular (V) and seven focal lesions (FL). Sensitivity, specificity, positive and negative predictive values and diagnostic accuracy were, respectively: 79.2%, 97.3%, 86.3%, 95.5%, 94% (B), 100%, 99.2%, 88.9%, 100%, 99.3% (V) and 100%, 96.9%, 42.8%, 100%, 97% (FL). CDUS also showed 16 blood collections and eight suspected biliary collections (four of which were confirmed by percutaneous puncture).

Conclusions

CDUS is an essential diagnostic tool in the follow-up of OLT. An early diagnosis of complications can improve graft integrity and patient survival.     

CT angiography for the evaluation of adult orthotopic liver transplantation arterial complications]

PURPOSE: In this study we compared duplex Doppler sonography, conventional angiography and CT angiography for the evaluation of hepatic arterial complications following orthotopic liver transplantation (OLT). MATERIAL AND METHODS: CT angiography, with Maximum Intensity Projection (MIP) and Volume Rendering reconstructions, was performed in 11 patients with well-grounded suspect of hepatic artery stenosis or thrombosis after routine duplex Doppler examination. Eight patients underwent conventional angiography. RESULTS: CT detected three out of four duplex doppler false positives and confirmed the diagnostic suspect in four cases. In two cases it showed a shift of the blood flow towards the splenic artery with hepatic hypoperfusion. In one case a wrong delay rendered the study unuseful. In seven out of eight patients conventional angiography confirmed CT angiography findings. DISCUSSION. The follow up of OLT arterial complications is now performed with duplex doppler sonography; this technique has a satisfactory sensitivity and specificity, but far from 100%. Therefore in some patients the diagnosis of arterial obstruction might be delayed, with the risk of serious complications; in other cases with ultrasonographic false positive findings, useless angiographic examinations are performed. In our experience CT angiography proved to be a precious tool, which might be included in the diagnostic algorithm of arterial complications after OLT. Particularly CT angiography seems to be suitable for the cases of discordance between clinical and duplex doppler findings, to improve the overall diagnostic accuracy. CONCLUSION: In our experience CT-angiography proved to be accurate and satisfactory as a second step examination after duplex-doppler in the diagnostic algorythm of adult OLT arterial complications.