Congenital intrahepatic portosystemic shunt

The authors report a congenital intrahepatic portosystemic shunt detected by angiography in a young patient with acute onset of hyperammoniemia and hepatic encephalopathy.     

Congenital intrahepatic portosystemic shunt with variant inferior right hepatic vein

We present a case of congenital intrahepatic aneurysmal portosystemic shunt in which the right portal vein communicates with both a variant inferior right hepatic vein and the right hepatic vein. We also describe the importance and efficacy of three dimensional computed tomography reconstruction images in determining subtle, small shunt vessels.     

Congenital intrahepatic portosystemic venous shunt: sonographic and magnetic resonance imaging

We report an intraheptic portosystemic venous shunt (IPVS) detected by ultrasound in an asymptomatic newborn. The lesion, which was further documented using color Doppler ultrasound and magnetic resonance imaging (MRI), had almost totally disappeared 6 months later without any treatment. Intraheptic portosystemic venous shunts (IPVS) are uncommon and their etiology is controversial. Some cases of IPVS have been reported in the literature, most of them in adult patients with portal hypertension and cirrhosis of the liver [1–3]. However, only scattered reports describe IPVS in the absence of liver pathology [4–8]. A revision of the proposed etiologies of IPVS is made and the usefulness of gray-scale and color Doppler sonography and MRI in diagnosing IPVS is discussed.     

Transjugular intrahepatic porto-systemic shunt placement in a patient with left-lateral split-liver transplant and mesenterico-left portal vein by pass placement

This is a report of a successful placement of a transjugular intrahepatic porto-systemic shunt in a young patient with previous left-lateral, split-liver transplant and mesenterico-left portal vein by pass placement after posttransplant extrahepatic portal vein thrombosis.     

Spontaneous aneurysmal intrahepatic portosystemic venous shunt

A 55-year-old man with hepatic cirrhosis, gastroesophageal varices, ascites, slight abdominal pain, and transient encephalopathy experienced unexpected spontaneous relief of his symptoms during hospitalization. Percutaneous transhepatic portography showed an aneurysmal intrahepatic portosystemic venous shunt. Three years later, the shunt was still patent and had led to disappearance of the patient's varices and ascites. The patient remains stable 6 years later.     

Emergency transjugular intrahepatic portosystemic shunt for uncontrolled variceal bleeding.

This study was designed to retrospectively evaluate transjugular intrahepatic portosystemic shunt (TIPS) performed on an emergency basis in patients with hemorrhagic shock from recurrent uncontrolled variceal bleeding. Over a 3.5-year period we reviewed the medical records as well as the imaging studies of 16 patients who had uncontrolled variceal bleeding and presented to our department for an emergent placement of TIPS. In our study the technical success was 88% (14/16 patients), the overall mortality was 36% (5/14 patients), and the shunt immediately reduced the portal venous pressure gradient by a mean of 64%. Given the poor outcome of other alternatives, aggressive treatment and placement of TIPS is justified regardless of the severity of the bleeding episode.     

肝内门体分流术的应用解剖学研究

对３０具经福尔马林固定的成人肝脏的肝静脉和肝门静脉的主要分支进行了观察和测量。重点探讨了肝内门 分流术中建立肝静脉与门静脉之间永久性肝内分流通道时经常选用的血管段的部位、管径、穿刺点间物距离、各主要分支之间的空间位置关系以及定位方法。结果表明，肝右静脉或中脉近端１－２ｃｍ处与肝门静脉左支横部中点至角部的血管段之间是建立肝内分流通道的理想部位，为临床应用提供了详尽的解剖学资料。     

Measurement of intrahepatic shunt using Rutland method

Intrahepatic shunt ratio was calculated from the fraction of the uptake constant and the blood background, analyzing the data of 99mTc-(Sn)-N-pyridoxyl-5-methyltryptophan (99mTc-PMT) hepatobiliary imaging by Rutland method. Shunt flow and total hepatic blood flow (THBF) were also calculated from the values for the effective hepatic blood flow (EHBF) estimated from the blood clearance technique. In 15 cases of normal volunteer, the average of the shunt ratio, shunt flow, and THBF were 18.4 +/- 5.4 (S.D.)%, 137.8 +/- 49 ml/min, and 753 +/- 83.2 ml/min, respectively. In 8 cases of chronic hepatitis, the values were 35.2 +/- 2.6%, 276 +/- 55.4 ml/min, and 794.1 +/- 119.4 ml/min, respectively. In 12 cases of liver cirrhosis, the values were 51.4 +/- 12.6%, 353.9 +/- 141.3 ml/min, and 685.6 +/- 174.8 ml/min, respectively. In cases of chronic hepatitis and liver cirrhosis, in comparison with normal cases, the values for the shunt ratio and shunt flow were significantly increased (p less than 0.001) and those for EHBF were significantly decreased (p less than 0.001), but those for THBF were not significantly altered. There was a significant inverse correlation between the shunt ratio and EHBF (r = -0.842) in all 35 cases. This method is considered to be useful for differential diagnosis, estimation of the grade of the diseases, and evaluation of pathophysiology of various diffuse liver diseases.     

Transjugular intrahepatic cavoportal shunt for Budd-Chiari syndrome

Budd-Chiari syndrome (BCS) is characterized by obstruction of the hepatic venous outflow tract. Therapeutic options for BCS are limited. We report a case of a 21-year-old woman with protein S and C deficiency with gross ascites. Treatment with transjugular intrahepatic portosystemic shunt (TIPS) was attempted, which revealed occluded hepatic veins, so transcaval TIPS was performed. No serious procedure-related complication occurred. After successful shunt creation, the patient's symptoms subsided and she was discharged and followed up for 6 months.     

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.     

肝内肝动脉-门静脉分流的研究进展

近年来，随着多层螺旋CT或MR动态增强成像、高分辩力DSA和彩色Doppler超声扫描（CDUS）等新技术的发展和临床广泛应用，不仅明显提高了伴发于肝脏疾病和累及门脉血流的肝外病变中的肝内器质性或功能性肝动脉-门静脉分流（aaerial portal venous shunt，APVS）的检出率，而且可以显示血液动力学改变引起的局部肝实质密度或信号强度增高（即局部肝实质一过性灌注异常），甚至还可辨别肝内APVS对门静脉血流方向的影响。于此文中，笔者主要通过近期文献的复习，对肝内APVS的研究进展作了较全面的综述，以供同道参考讨论。     

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.     

Intentional occlusion of a transjugular intrahepatic portosystemic shunt

The transjugular intrahepatic portosystemic shunt (TIPS) procedure is a well-described means of treating portal hypertension and its complications. Occasionally, the consequences of this shunt prompt the desire for its subsequent obliteration. We report one unsuccessful and one successful method of TIPS occlusion. Key words: TIPS, complications-Occlusion-Thrombosis-Balloon occlusion catheter-Amplatz spi-der-Embolization coil     

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.