合并胃肾分流道的胃静脉曲张临床诊疗经验

目的 总结合并胃肾分流道的胃静脉曲张临床诊疗经验。方法 回顾性分析解放军总医院第一医学中心消化内科医学部2016年1月至2021年12月期间收治的合并胃肾分流道的胃静脉曲张患者的临床资料。结果 共纳入患者30例,男13例、女17例,平均年龄(56.7±8.62)岁,孤立性胃静脉曲张9例、伴食管静脉曲张者21例,病因均为肝硬化所致门静脉高压,Child-Pugh A级8例、Child-Pugh B级21例、Child-Pugh C级1例,门静脉主干直径(11.8±2.33)mm,胃肾分流道最宽处直径(13.7±4.74)mm。所有患者均成功进行了数字减影血管造影(DSA)下胃肾分流道球囊临时封堵术联合内镜下胃静脉曲张组织胶注射治疗,9例合并食管静脉曲张的患者同时行食管静脉曲张套扎治疗。术后3例患者出现发热,5例患者出现腹痛不适,所有患者均未出现组织胶异位栓塞的情况(0.0%)。术后1年内再发出血率6.7%、生存率为100%。结论 对于合并胃肾分流道的胃静脉曲张患者,联合DSA下胃肾分流道球囊临时封堵术,可有效降低内镜下组织胶注射治疗时异位栓塞的风险。     

内镜下套扎联合经皮经肝TH胶栓塞治疗肝硬化食管胃底静脉曲张的临床应用

目的评价内镜下套扎(EVL)联合经皮经肝曲张静脉TH胶栓塞术(PTVE)治疗肝硬化食管胃底静脉曲张出血的远期疗效。方法 44例肝硬化食管胃底静脉曲张出血患者,先行食管曲张静脉的内镜下套扎治疗,1周后再行TH胶PTVE,栓塞食管胃底曲张静脉区域及其来源血管。联合治疗术后定期复查胃镜,观察曲张静脉消失情况,随访治疗后曲张静脉复发率及再出血率。结果 44例食管胃底静脉曲张患者,32例食管曲张静脉基本消失,消失率72.7%;8例胃底静脉曲张基本消失,消失率100%;12例食管静脉曲张程度明显减轻,总有效率100%。随访6~39个月,平均25.6个月,5例食管静脉曲张复发,复发率11.4%;3例再出血,再出血率6.8%。结论内镜下套扎治疗能机械性地消除食管曲张静脉,经皮经肝TH胶栓塞能栓塞食管胃底曲张静脉区域及其供血血管,二者联合能达到协同作用,具有更好的远期疗效。     

生物蛋白胶栓塞治疗门脉高压性上消化道出血30例

目的:评价生物蛋白胶在经皮经肝食管胃底曲张静脉栓塞术治疗胃底食管静脉曲张破裂出血中的可行性和临床价值.方法:60例肝硬化、食管静脉曲张破裂出血的患者,分为经皮经肝胃底曲张静脉栓塞组(percutaneous transhepatic obliteration,PTO)30例和食管曲张静脉套扎组(esophageal varices ligation,EVL)30例,PTO组是在X线透视下经皮经肝穿刺进入上消化道出血责任血管,用弹簧钢圈和生物蛋白胶栓塞曲张的食管和胃底静脉,比较两组治疗方法的急诊止血率和术后累计无出血率.结果:PTO组中28例门脉穿刺及曲张静脉栓塞手术均获成功,1例造影示为门静脉海绵样变,进入责任血管困难,无法进行栓塞治疗,1例行门静脉造影未见明显胃底曲张静脉,栓塞成功率为96.6%(28/29),其余病例术后48h止血率达100%.EVL组急诊止血率为93.3%(28/30).在12-50mo随访期内的患者中,PTO组再出血10例,EVL组再出血17例,PTO组和EVL组的6mo累计无出血率分别为89.3%vs80%,1年累计无出血率为85.7%vs56.7%,PTO组术后累计无出血率明显高于EVL组(?2=5.314,P<0.05).结论:经皮经肝食管胃底静脉栓塞中应用生物蛋白胶治疗上消化道出血安全有效,创伤小、止血效果肯定,在急诊止血方面更具优势,值得推广应用.     

经皮经肝TH胶栓塞治疗胃静脉曲张的疗效分析

目的观察经皮经肝组织胶粘合剂（TH胶）栓塞治疗胃静脉曲张的临床疗效。方法经皮经肝TH胶栓塞治疗胃静脉曲张30例,术后定期复查胃镜及CT门静脉成像,观察TH胶在血管内的分布范围、血管栓塞程度及静脉曲张消失情况。结果30例患者静脉曲张治疗有效率100％。21例患者随访11—33个月,平均27．9个月,静脉曲张复发率14．29％（3／21）;术后门脉高压性胃病17例80．95％（17／21）;再出血率9．52％（2／21）,均为门脉高压性胃病出血。术后CT平扫及门静脉血管成像检查显示,TH胶在胃底周围静脉、胃壁的穿支静脉及其他供血静脉内栓塞良好,TH胶持久沉积,未出现栓塞血管再通及明显新的侧枝形成。结论经皮经肝TH胶栓塞术可使胃曲张静脉及其供血静脉长期闭塞,是治疗胃曲张静脉的有效方法。     

经皮经肝组织黏合剂栓塞联合部分脾栓塞治疗食管静脉曲张

目的评价经皮经肝穿刺组织黏合剂（TH胶,α-氰基丙烯酸正丁酯）栓塞联合部分脾动脉栓塞（PSE）治疗食管静脉曲张的临床疗效。方法以食管下段曲张静脉和贲门胃底周围血管为靶血管,将TH胶灌注至食管下段及胃底曲张静脉内,使曲张静脉永久性闭塞,并联合PSE治疗食管静脉曲张出血患者84例,18例患者行急诊栓塞治疗。结果（1）81例栓塞成功,成功率96.4%,3例术后1个月因肝功能衰竭、腹腔感染和脑出血死亡。（2）TH胶栓塞到食管下段曲张静脉及胃底周围血管者38例;栓塞冠状静脉及胃底贲门周围曲张静脉但未达食管下段者31例;仅栓塞到胃冠状静脉主干者9例。术后其食管静脉曲张消失率分别为71.1%（27/38）、35.5%（11/31）、0（0/9）,χ^2=18.3105,P〈0.01。（3）随访6～47（31.0±16.5）月,13例患者再出血,总出血率为16.7%。其中食管胃底型栓塞再出血率为7.9%（3/38）;胃底型再出血率为12.9%（4/31）;主干型再出血率为66.7%（6/9）,χ^2值分别为12.6603和8.0765;P值均〈0.01。结论经皮经肝TH栓塞联合部分脾动脉栓塞不仅可控制急症出血,还可预防再出血,是治疗和预防门静脉高压食管静脉曲张出血的有效方法,术中应尽量将TH胶注射到食管下段曲张静脉和贲门胃底周围静脉内,以确保介入栓塞治疗的远期疗效。     

EUS引导弹簧圈联合组织粘合剂栓塞治疗合并自发分流道形成的胃底曲张静脉

食管胃底静脉曲张破裂出血是常见的消化系统急危重症之一。内镜治疗是食管胃底静脉曲张的有效治疗方案。自发性门体分流形成的患者组织粘合剂栓塞治疗发生异位栓塞的风险大。方法 经腹部CT门静脉血管重建确认自发性分流道形成,胃镜检查发现合并重度胃底静脉曲张的患者行EUS引导弹簧圈栓塞治疗。结果 共8例经腹部CT门静脉血管重建证实的自发性分流道形成的患者接受了EUS引导弹簧圈栓塞联合组织粘合剂栓塞治疗。4例活动性出血患者治疗后活动性出血均停止。观察至术后14天,全部8例患者（100%）均未有再出血及异位栓塞征象。 结论 EUS引导弹簧圈联合组织粘合剂栓塞治疗合并自发分流道形成的胃底曲张静脉患者安全有效。     

钛夹辅助下内镜组织胶注射治疗胃静脉曲张

目的初步探讨钛夹辅助内镜下组织胶注射治疗胃静脉曲张的安全性、有效性及操作注意事项。 方法回顾性分析2018年1月至2019年7月山东省立医院东院消化科行钛夹辅助下内镜组织胶注射治疗胃静脉曲张患者10例，经胃镜证实为GOV2型或IGV1型胃静脉曲张，术前强化CT及CTA显示均存在明显胃肾分流道。先在胃镜下观察胃曲张静脉团的供血或回流血管分支、并行钛夹夹闭，以减缓或阻断胃曲张静脉内血液流速，后再胃镜下行组织胶注射，以预防组织胶的异位栓塞。分析10例患者的操作成功率、静脉曲张消失、术后再出血率、并发症等情况。 结果纳入的10例患者均成功进行钛夹辅助下内镜组织胶注射治疗，随访时间39～157 d ，平均随访85.7 d。术后强化CT复查显示10例患者胃静脉曲张均基本消失或明显减轻。术后有1例患者发生排胶溃疡再出血，未出现异位栓塞相关的症状和体征，未出现其他明显并发症。 结论钛夹辅助下内镜组织胶注射操作简便、安全，是合并胃肾分流的胃静脉曲张治疗的有效方式，值得进一步临床研究。     

内镜超声引导弹簧圈栓塞联合内镜组织胶注射治疗胃底静脉曲张的回顾性研究

目的　评价内镜超声（endoscopic ultrasound,EUS）引导弹簧圈栓塞联合内镜组织胶注射治疗合并较大自发性分流道的胃底静脉曲张的疗效和安全性。方法　回顾性分析武汉大学人民医院2016年12月—2020年12月因胃底静脉曲张伴较大自发性分流道（分流道最窄处直径5~15 mm）接受EUS引导弹簧圈栓塞联合内镜组织胶注射的24例患者资料,统计并分析短期疗效（技术成功率、术后5 d再出血率、6周死亡率）、远期疗效（1年再出血率和死亡率、3年死亡率）及安全性（异位栓塞发生率）。结果　EUS引导弹簧圈栓塞联合内镜组织胶注射技术成功率91.7%（22/24）,5 d再出血率0（0/22）。1例（4.5%）术后2 d复查门静脉系统血管CT成像显示脾静脉主干部分栓塞。22例患者中2例失访,随访时间14.9（1.0~48.6）个月,术后6周死亡率0（0/20）,术后1年再出血率35.0%（7/20）。12例行胃镜随访的患者中,5例出现不同程度食管静脉曲张加重,5例出现不同程度门静脉高压性胃病加重。术后1年死亡率5.0%（1/20）,术后3年死亡率20.0%（4/20）,均与出血及异位栓塞事件无关。结论　对于合并较大自发性分流道的胃底静脉曲张患者,EUS引导弹簧圈栓塞联合内镜组织胶注射治疗短期安全有效,并能降低异位栓塞发生风险,远期疗效及安全性仍有待进一步证实。     

经皮经肝α-氰基丙烯酸正丁酯胶和生物蛋白胶联合栓塞治疗食管胃底静脉曲张20例

目的介绍经皮经肝α-氰基丙烯酸正丁酯(NBCA胶,n-butyl-2-cyanoacrylate)和生物蛋白胶联合栓塞食管胃底静脉曲张的应用。方法采用经皮经肝NBCA胶和生物蛋白胶联合栓塞胃冠状静脉和胃短静脉为主的方法治疗门静脉高压食管胃底静脉曲张患者20例,生物蛋白胶以栓塞胃部曲张静脉的流出端为主,NBCA胶栓塞胃部曲张静脉的主体和输入段,部分加用弹簧圈栓塞减慢血流。15例患者同时行部分性脾动脉栓塞。结果栓塞成功16例(80%),术后即刻食管胃底曲张静脉血流消失而且出血控制。随访1~11个月(平均4.3个月),成功栓塞的16例患者无1例发生再出血,其中胃镜复查11例,5例曲张静脉基本消失,4例明显减轻,2例稍有减轻。4例患者曲张静脉内NBCA充填不充分,致使栓塞不彻底,其中2例发生再出血。无1患者发生异位栓塞和胃黏膜的过度栓塞。结论经皮经肝NBCA胶和生物蛋白胶联合栓塞食管胃底静脉曲张可有效防止异位栓塞及过度栓塞,安全而且疗效确切,可作为治疗食管胃底静脉曲张破裂急性出血的重要治疗手段之一。能否彻底栓塞是决定疗效的主要因素。     

经皮经肝组织粘合剂栓塞联合内镜下套扎治疗食管静脉曲张的临床应用

目的 探讨经皮经肝组织粘合剂(TH胶)栓塞(PTVE)联合内镜下套扎(EVL)治疗食管静脉曲张的合理性和临床疗效.方法 23例食管静脉曲张患者先行PTVE使TH胶栓塞胃冠状静脉主干及胃底贲门周围静脉,1个月后对食管黏膜下曲张静脉行内镜下套扎治疗.结果 该组患者TH胶未栓塞食管下段曲张静脉,PTVE后静脉曲张缓解,但未完全消失;联合EVL后17例患者静脉曲张基本消失,消失率73.9%.21例行1次套扎治疗,2例行2次套扎治疗,平均套扎次数1.1次/例.随访3～31个月(平均19.2个月),静脉曲张复发或加重3例(13.1%),2例(8.7%)患者门脉高压性胃病出现少量出血.结论 经皮经肝TH胶栓塞能阻断冠状静脉主干、食管胃底周围血管等曲张静脉的供血血管,而内镜下套扎治疗则消除食管下段黏膜下曲张静脉,二者联合可优势互补,从而取得更好的远期疗效.     

Percutaneous transhepatic variceal embolization with cyanoacrylate vs. transjugular intrahepatic portal systematic shunt for esophageal variceal bleeding

Purpose

To compare the long-term results of modified percutaneous transhepatic variceal embolization with cyanoacrylate (PTVE) and the transjugular intrahepatic portal systemic shunt (TIPS) for treating esophageal variceal bleeding.

Methods

Patients with cirrhosis and variceal bleeding who underwent TIPS and PTVE with cyanoacrylate between January 2006 and December 2010 were selected. We performed chart reviews to determine the rebleeding rate, survival and the rate of encephalopathy.

Results

This retrospective study included 96 PTVE patients and 43 TIPS patients, with a median follow-up of 30.4 and 31.6 months in the two groups, respectively. Rebleeding occurred in 13 patients (30.2 %) in the TIPS group and in 20 patients (20.8 %) in the PTVE group (p = 0.229). For patients with model for end-stage liver disease (MELD) scores >18 at 1, 3 and 5 years, the survival rates were 84.2, 39.9 and 16.0 %, respectively, in the TIPS group, and they were 96.7, 72.0 and 36.0 %, respectively, in the PTVE group (p = 0.037). Sixteen (16.7 %) PTVE patients and 25 (58.1 %) TIPS patients developed encephalopathy (p = 0.000). Mean MELD and Child–Pugh scores improved significantly in modified PTVE patients. However, no such changes were observed in TIPS patients.

Conclusions

PTVE and TIPS were comparable in terms of variceal rebleeding prevention. However, in >18-MELD-score patients, PTVE offered better survival than TIPS. In addition, PTVE offered lower incidence of encephalopathy than TIPS.     

MDCT angiography to evaluate the therapeutic effect of PTVE for esophageal varices

Abstract AIM:To evaluate the role of multi-detector row computed tomography(MDCT) angiography for assessing the therapeutic effects of percutaneous transhepatic variceal embolization(PTVE) for esophageal varices(EVs).METHODS:The subjects of this prospective study were 156 patients who underwent PTVE with cyanoacrylate for EVs.Patients were divided into three groups according to the filling range of cyanoacrylate in EVs and their feeding vessels:(1) group A,complete obliteration,with at least 3 cm of the lower EVs and peri-/EVs,as well as the adventitial plexus of the gastric cardia and fundus filled with cyanoacrylate;(2) group B,partial obliteration of varices surrounding the gastric cardia and fundus,with their feeding vessels being obliterated with cyanoacrylate,but without reaching lower EVs;and(3) group C,trunk obliteration,with the main branch of the left gastric vein being filled with cyanoacrylate,but without reaching varices surrounding the gastric cardia or fundus.We performed chart reviews and a prospective follow-up using MDCT images,angiography,and gastrointestinal endoscopy.RESULTS:The median follow-up period was 34 mo.The rate of eradication of varices for all patients was 56.4%(88/156) and the rate of relapse was 31.3%(41/131).The rates of variceal eradication at 1,3,and 5 years after PTVE were 90.2%,84.1% and 81.7%,respectively,for the complete group;61.2%,49% and 42.9%,respectively,for the partial group;with no varices disappearing in the trunk group.The relapsefree rates at 1,3 and 5 years after PTVE were 91.5%,86.6% and 81.7%,respectively,for the complete group;71.1%,55.6% and 51.1%,respectively,for the partial group;and all EVs recurred in the trunk group.Kaplan-Meier analysis showed P values of 0.000 and 0.000,and odds ratios of 3.824 and 3.603 for the rates of variceal eradication and relapse free rates,respectively.Cyanoacrylate in EVs disappeared with time,but those in the EVs and other feeding vessels remained permanently in the vessels without a decrease with time,which is important fo     

Comparison of modified percutaneous transhepatic variceal embolization and endoscopic cyanoacrylate injection for gastric variceal rebleeding

AIM:To compare the efficacy of modified percutaneous transhepatic variceal embolization(PTVE)with 2-octyl-cyanoacrylate(2-OCA)and endoscopic variceal obturation(EVO)with an injection of 2-OCA for prophylaxis of gastric variceal rebleeding. METHODS:In this retrospective study,the medical records of liver cirrhosis patients with gastric variceal bleeding who underwent either endoscopic 2-OCA(EVO) or modified PTVE using 2-OCA at Shandong Provincial Hospital from January 2006 to December 2008 were reviewed.Patient demographics,rebleeding rate,survival rate,and complications were compared between the two groups(PTVE and EVO).All results were expressed as mean±SD,or as a percentage.Quantitative variables were compared by two sample Student t tests, and qualitative variables were compared by the Fisher exact test or theχ 2 test(with Yates correction)where appropriate.A P value less than 0.05 was considered significant.Statistical computation was performed using SPSS 13.0 software. RESULTS:A total of 77 patients were included;45 patients who underwent EVO and 32 patients who received PTVE.During the follow-up(19.78±7.70 mo in the EVO group,vs 21.53±8.56 mo in the PTVE group) rebleeding occurred in 17 patients in the EVO group and in 4 patients in the PTVE group(37.78%vs 12.5%, P=0.028).The cumulative rebleeding-free rate was 75%,59%,and 49%in 1,2,and 3 years respectively for EVO,and 93%,84%,and 84%for PTVE(P=0.011). Cox analysis was used to identify independent factors that predicted rebleeding after treatment.Variables including age,gender,cause,Child-Pugh classification, size of gastric varices(GV),location of GV,and treatment methods were analyzed.It was revealed that Child-Pugh classification[risk ratio(RR)2.10,95%CI:1.03-4.28,P=0.040],choice of treatment(RR 0.25, 95%CI:0.08-0.80,P=0.019),and size of GV(RR 2.14, 95%CI:1.07-4.28,P=0.032)were the independent factors for predicting rebleeding.Follow-up computed tomography revealed that cyanoacrylate was retained in the varices and in the feeding veins of PTVE patie     

Direct stent implantation without predilatation through 5 French guiding catheter following transfemoral coronary angiogram: a feasibility study.

Direct stenting (DS) is accepted as reducing procedural cost and duration and 5 Fr guiding catheters as lowering peripheral vascular complications. We aimed to evaluate the feasibility and safety of both strategies. We retrospectively studied 150 consecutive patients treated with DS strategy using a 5 Fr femoral approach. A need for 6 Fr devices or balloon predilatation defined 5 Fr DS failure. Procedural success was defined as good angiographic result (residual stenosis < 30% and TIMI flow 3) without ischemic complications. A total of 161 out of 174 lesions were elected as suitable for DS. The success rate of 5 Fr DS was 87.6% (141/161 lesions). The procedural success rate was 92% (138/150 patients). The angiographic success rate was 96.3% (155/161 lesions). Other complications were six non-Q-wave MI and one repeat angioplasty for acute in-stent thrombosis. Only one major peripheral vascular complication occurred. Direct stenting through 5 Fr guiding catheters in selected lesions is safe and effective with a low incidence of peripheral arterial complications.     

Bleeding gastric varices： Results of endoscopic injection with cyanoacrylate at King Chulalongkorn Memorial Hospital

AIM: To evaluate the efficacy and safety of gastric varices injection with cyanoacrylate in patients with gastric variceal bleeding. METHODS: Twenty-four patients (15 males, 9 females) with gastric variceal bleeding underwent endoscopic treatment with cyanoacrylate injection. Successful hemostasis, rebleeding rate, and complications were retrospectively reviewed. Followed up endoscopy was performed and repeat cyanoacrylate injection was given until gastric varices were obliterated. RESULTS: Seventeen patients achieved definite hemostasis. Of these, 14 patients had primary success after initial endoscopic therapy. Ten patients developed recurrent bleeding. Repeated cyanoacrylate injection stopped rebleeding in three patients. Transjugular intrahepatic portosystemic shunt (TIPS) was performed to control rebleeding in one patient which occured after repeat endoscopic therapy. Six patients died (three from uncontrolled bleeding, two from sepsis, and one from mesenteric vein thrombosis). Minor complications occurred in 11 patients (six epigastric discomfort and five post injection ulcers). Cyanoacrylate embolism developed in two patients. One of these patients died from mesenteric vein thrombosis. The other had pulmonary embolism which resolved spontaneously. Advanced cirrhosis and hepatocellular carcinoma (HCC) were major risk factors for uncontrolled bleeding. CONCLUSION: Endoscopic treatment for bleeding gastric varices with cyanoacrylate injection is effective for immediate hemostasis. Repeat cyanoacrylate injection has a lower success rate than the initial injection. Cyanoacrylate embolism is not a common serious complication.     

A Modified Percutaneous Transhepatic Variceal Embolization with 2-Octyl Cyanoacrylate Versus Endoscopic Ligation in Esophageal Variceal Bleeding Management: Randomized Controlled Trial

BACKGROUND: Conventional percutaneous transhepatic varices embolization (PTVE) has rarely been used in recent years due to high rates of variceal recurrence and rebleeding. Herein we report a modified PTVE with 2-octyl cyanoacrylate (2-OCA) in which the whole lower esophageal and peri or para-esophageal varices, the submucosal varices, and the advertitial plexus of the cardia and fundus were sufficiently obliterated. We compared this PTVE with endoscopic band ligation (EVL) in the treatment of esophageal variceal bleeding. METHODS: In this prospective randomized controlled trial, cirrhotic patients with acute or recent esophageal variceal bleeding were assigned randomly to PTVE (52 patients) or EVL (50 patients) groups. Upper gastrointestinal (UGI) rebleeding, esophageal variceal rebleeding, and survival were followed-up. Computerized tomography (CT) scanning and portal venography were used to observe 2-OCA distribution. RESULTS: During the follow-up period (median 24 and 25 months in the PTVE and EVL groups, respectively) UGI rebleeding developed in eight patients in the PTVE group and 21 patients in EVL group (P = 0.004). Recurrent bleeding from esophageal varices occurred in three patients in the PTVE group and twelve in the EVL group (P = 0.012, relative risk 0.24, 95% confidence interval 0.05-0.74). Multivariate Cox analysis indicated that the treatment was the only factor predictive of rebleeding. A Kaplan-Meier curve showed there was no significant difference between survival in the two groups (P = 0.054). CONCLUSIONS: With the whole lower esophageal and peri or para-esophageal varices, the submucosal varices, and the adventitial plexus of the cardia and fundus sufficiently obliterated by 2-OCA, this modified PTVE was more effective than EVL in the management of esophageal varices recurrence and rebleeding. Survival in these two groups was not significantly different, however.     

联合内镜注射组织黏合剂与经皮肝门静脉栓塞治疗食管胃底静脉曲张出血的临床研究

目的:评价内镜下注射组织黏合剂(histoacryl)与内镜下注射组织黏合剂联合经皮肝穿胃冠状静脉栓塞(PTVE)治疗胃底食管静脉曲张二种治疗方法的疗效。方法:对57例食管胃底静脉曲张患者分别进行内镜下注射组织黏合剂(单纯组38例)与内镜下注射组织黏合剂联合经皮肝穿胃冠状静脉栓塞(联合组19例),并比较两种方法止血率、再出血发生率、曲张静脉消失率、并发症发生率等指标。结果:二组随访2～24个月;近期再出血分别为5.3%、18.4%;>6个月再发出血发生率分别10.5%、31.6%;术后3～6个月行食道钡餐检查,食道静脉曲张消失或基本消失分别为68.4%、42.1%。结论:联合治疗组比单纯内镜下治疗有效率高、重复性少、安全性好、近期复发再出血发生率低,是一种较安全、有效的方法。     

PTIPS治疗脾切除术后并发门静脉血栓形成的门静脉高压症患者安全性和效果分析*

目的 探讨经皮经肝肝内门体分流术（PTIPS）治疗脾切除术后并发门静脉血栓形成的门静脉高压症患者的安全性和效果。方法 回顾性分析2011年1月~2015年12月在我院接受PTIPS治疗的30例脾切除术后并发门静脉血栓形成的门静脉高压症患者的病历资料,采用经皮经肝穿刺门静脉分支,采用球囊扩张术扩张闭塞的门静脉和肝内门体分流道,在分流道内植入8 mm的金属支架处理,使用320排CT机检查,随访（22.1±3.8）个月。结果 在30例接受PTIPS术患者中,27例（90.0%）手术成功,3例（10.0%）患者因术中未能开通门静脉闭塞而终止手术;27例手术成功患者术前门体静脉压力梯度为（21.5±3.4） mmHg,术后下降至（13.0±2.8） mmHg,差异具有统计学意义（t=10.0,P<0.05）;术后CT检查,发现4例（13.3%）患者发生分流道支架闭塞,均及时给予球囊扩张并再次置入支架处理,血管再通,2例（6.7%）患者发生肝性脑病,给予降血氨药物和营养支持等治疗后好转;5例（16.7%）患者死亡,其中3例死于肝功能衰竭,2例死于脑出血。结论 采用PTIPS处理脾切除术后并发门静脉血栓形成的门静脉高压症患者疗效较好,创伤小、较安全,未来仍需进一步深入研究其应用适应证和并发症处理等问题。     

Carotid stenting: acute results and complications]

The treatment of carotid stenoses with balloon angioplasty and stenting is a new and not generally established method.During a one year period 65 patients (22 female, 43 male, mean age: 73 years, 47 with neurologic symptoms, 8 with contralateral carotid occlusion) with significant (>70%) carotid stenosis were treated with balloon angioplasty and balloon expandable stents. The primary technical success rate was 98% (65/66 patients) respectively 99% (69/70 stenoses). A combined procedure was performed in 11 /17%) patients with stenting in both carotid arteries in 4 patients with additional coronary interventions in 6 patients and stenting of the origin of the common carotid artery in one patient.Severe neurologic complications occurred in 4 (6.2%) patients (1 death, 1 major stroke, 2 minor strokes) and short lasting neurologic deficits in additional 4 (6.2%) patients. Cardiovascular complications were not observed. Local (inguinal) problems occurred in 3 (4.5%) patients (2 aneurysma spuria, 1 transfusion for hematoma). Frequently, balloon insufflation was associated with bradycardia (40%) and additional hypotension (11%).In summary, carotid stenting can be performed with technically high success rates (99%), but it is adversely influenced by not infrequent thromboembolic cerebral events (12.4%). The possibility to perform combined procedures with interventions in other vessels (both carotid arteries, coronary arteries, aortic arch arteries) is advantageous.