Coaxial Stent Graft inside a Constraining Stent for Transjugular Intrahepatic Portosystemic Shunt Reduction

A technique to create a coaxial, self-expanding stent graft inside a constraining, bare-metal, balloon-expandable stent for transjugular intrahepatic portosystemic shunt (TIPS) reduction is described. The key steps are performed on a back table rather than inside the patient, and the resulting construct is deployed using standard unsheathing maneuvers. The construct was used in 4 patients to make 6 TIPS diameter reductions (mean postreduction diameter, 6 mm; range, 0–8 mm), all resulting in increases in the portosystemic pressure gradient (mean increase, 6 mm Hg; range, 1–19 mm Hg). On average, hepatic encephalopathy improved 1 point on the West Haven scale (range, 0–2).     

TIPSS术后肝性脊髓病（附5例报告）

目的：报告5例经颈静脉途径肝内分流术（TIPSS）后肝性脊髓病（HM）的临床表现。资料和方法：5例均有乙型肝炎和静脉曲张破裂出血病史。TIPSS术前影像学检查显示肝萎缩明显，术后分流道通畅。曾做脊髓MRI4例，1例做脊柱CT和脊髓造影。5例均行腰椎穿刺。结果：5例于TIPSS后4周－4个月出现进行性下肢痉挛性瘫痪，1例伴上肢无力，1例伴有尿失禁。5例术后有1次以上（1－6次）HE发作史。体验发现患者腱反射亢进，踝阵挛阳性，浅感觉正常，1例深感觉减退，除1例外，其余无明显肌莓缩表现。受累节段椎管影像学检查及腰椎穿刺脑脊液检查均无异常。5例均有术后持续高血低蛋白血症。结论：TIPSS术后出现进行性下肢痉挛性瘫痪、不伴有感觉障碍者应考虑HM。与TIPSS相关HM的高危因素有术前明显肝萎缩、术后持续高血氨及肝性脑病。     

Transjugular Intrahepatic Portosystemic Shunt: Histologic and Immunohistochemical Study of Autopsy Cases

Purpose: To assess the histologic findings associated with stenosed and occluded transjugular intrahepatic portosystemic shunt (TIPS) tracts. Methods: Four TIPS tracts within three autopsy livers were histologically studied for vascular components by routine staining and immunohistochemical staining. TIPS had been performed for bleeding from esophageal varices in patients with cirrhosis of the liver. Results: Two TIPS, examined on days 4 and 53, showed occlusion by fibrin thrombus. In the former, no endothelial cells were detected, but coagulative necrosis of hepatocytes was found in the surrounding liver. In the latter, bile pigments were seen on the luminal surface. In the two other TIPS without tract occlusion, examined on days 49 and 293, a layer of endothelial cells, proliferation of smooth muscle cells, and deposition of an extracellular matrix such as collagen were confirmed. In the tract examined on day 293, there was protrusion of hepatocytes into the lumen through the stent wires. Conclusion: Short- and midterm TIPS occlusions were caused by thrombus forming after necrosis of hepatocytes and bile leakage, respectively. Long-term TIPS stenosis was associated with a combination of pseudointimal hyperplasia and ingrowth of hepatocytes. Received: 0/00/00/Accepted: 0/00/00     

经颈静脉肝内门腔静脉内支架分流术：附22例分析

经颈静脉肝内门－腔静脉内支架分流术（ＴＩＰＳＳ）是用非外科手段治疗肝硬化、门脉高压，胃、食管静脉曲张的新技术，具有创伤小，技术成功率高，并发症少的优点。自１９９３年３月５日以来我们完成了２２例（包括２例急诊ＴＩＰＳＳ），成功率为９５．４５％（２１／２２）。分流道的直径为１０ｍｍ。术后平均门脉压力从术前的４．０４±０．６６ｋＰａ（１ｋＰａ＝１０．２０ｃｍＨ＿２Ｏ）降到２．４４±０．６２ｋＰａ，绝大多数患者腹水吸收，静脉曲张减轻或消失。我们的初步经验：ＴＩＰＳＳ能安全、有效地降低门脉压，控制静脉曲张破裂出血，消除腹水。ＴＩＰＳＳ的长期临床效果有待进一步观察。     

Percutaneous Treatment of Hepatocellular Carcinoma in Patients with Transjugular Intrahepatic Portosystemic Shunts

Purpose To assess the role of transcatheter arterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) in patients with hepatocellular carcinoma (HCC) and transjugular intrahepatic portosystemic shunts (TIPS). Methods Between January 1999 and September 2004, 6 patients with HCC and TIPS were treated with either TACE (n = 3) or TACE in combination with PEI (n = 3). One patient had a known advanced, untreated HCC prior to TIPS. In the remaining 5 patients HCC was diagnosed 14, 17, 51, 69, and 76 months respectively after elective TIPS. TACE was performed using a mixture of 30–60 mg of epirubicin and 10 ml of lipiodol following superselective catheterization of tumor-feeding vessels. PEI was performed under CT guidance. Methods The mean follow-up time after treatment of HCC was 26.2 months (range 7–46 months). During follow-up, all patients were free of rebleeding. Two patients died 7 and 38 months after one session of TACE and PEI (77 months after TIPS) and three sessions of TACE (91 months after TIPS), respectively. The cause of death was liver failure (Child-Pugh class C) and peritonitis, respectively. A third patient underwent liver transplantation 24 months after TIPS and several sessions of TACE. In the remaining 3 patients, the HCC is well controlled 13, 30, and 46 months after repetitive percutaneous treatment without signs of hepatic deterioration or metastasis. Conclusion Transcatheter arterial superselective chemoembolization and percutaneous ethanol injection seems to be beneficial even in HCC patients treated with TIPS, provided that the liver function is adequate.     

Treatment of Portosystemic Shunt Myelopathy with a Stent Graft Deployed through a Transjugular Intrahepatic Route

A case of surgically created splenorenal shunt complicated with shunt myelopathy was successfully managed by placement of a stent graft within the splenic vein to close the portosystemic shunt and alleviate myelopathy. To our knowledge, this is the first report of a case of shunt myelopathy in a patient with noncirrhotic portal fibrosis without cirrhosis treated by a novel technique wherein a transjugular intrahepatic route was adopted to deploy the stent graft.     

急诊经颈静脉途径肝内门体分流术（附12例报告）

报告１２例急诊经颈静脉途径肝内门体分流术，旨在评价临床疗效及探讨急诊情况下的有关治疗技术问题。１２例中男性患者１０例，女性２例，年龄４２～７２岁，均为其他保守治疗方法所不能控制的食管胃静脉曲张破裂大出血患者，１０例在三腔双囊管压迫下行ＴＩＰＳＳ。结果：１１例穿刺门脉成功并建立起有效分流，１例因门脉海绵状变性而终止分流术；除１例未能控制大出血（与选择栓塞剂不当有关）、于术后１．５小时死亡外，其余技术成功的病例均获得优良的止血效果。初步结论：ＴＩＰＳＳ对于其他方法所不能控制的静脉曲张破裂大出血患者是一有效的救治措施。为及时控制出血，作者推荐常规用钢丝圈栓塞曲张的静脉。     

经颈静脉肝内门体分流术治疗门脉高压症

目的 经颈静脉肝内门体分流术(Transjugular Intrahepatic Portosytemic stent shunt,Tipss)治疗门脉高压症和消化道出血的临床疗效观察。方法 对7例肝硬化并发门脉高压症患者行Tipss,检测门脉压和门静脉及脾静脉内径的变化。结果 Tipss的成功率为85.7％(6/7),门脉压(cmH_2O)24.83±2.137(P<0.01,vs术前的43.33±2.733),提示Tipss能有效地降低门脉压;门静脉主干及脾静脉内径(cm)分别为0.98±0.098,0.80±0.064(P<0.01,vs术前的1.48±0.073,1.23±0.028),进一步说明了门脉压的降低。近期有效率及急症出血控制率为100％,肝性脑病的发生率为16.7％,其发生与分流的血管有关,左肝静脉与门脉左支分流者较右肝静脉与门脉右支及门脉主干分流者低。12月内支架狭窄、闭塞2例(2/4),18月内闭塞1例(1/2),发生再出血2例(2/6),随访6-24月无死亡。结论 Tipss是一种有效降低门脉压、控制食管、胃底静脉曲张破裂出血的新技术,对于急症出血的疗效优佳,但是,中远期分流道易发生狭窄和阻塞,其疗效有待进一步提高。     

Congenital Intrahepatic Portosystemic Venous Shunt and Liver Mass in a Child Patient: Successful Endovascular Treatment with an Amplatzer Vascular Plug (AVP)

A congenital intrahepatic portosystemic shunt is a rare anomaly; but, the number of diagnosed cases has increased with advanced imaging tools. Symptomatic portosystemic shunts, especially those that include hyperammonemia, should be treated; and various endovascular treatment methods other than surgery have been reported. Hepatic masses with either an intra- or extrahepatic shunt also have been reported, and the mass is another reason for treatment. Authors report a case of a congenital intrahepatic portosystemic shunt with a hepatic mass that was successfully treated using a percutaneous endovascular approach with vascular plugs. By the time the first short-term follow-up was conducted, the hepatic mass had disappeared.     

急诊肝动脉栓塞治疗肝癌破裂出血

目的:探讨急诊肝动脉栓塞治疗原发性肝癌破裂出血的方法、临床效果、意义。方法:回顾性分析14例原发性肝癌破裂出血患者的病例资料,其中巨块型肝癌10例、结节型3例、小肝癌1例。所有患者均行急诊肝动脉超选择插管,采用弹簧圈、明胶海绵及碘化油等栓塞出血动脉。结果:14例原发性肝癌出血得到完全控制,患者术后生存期均在5个月以上,其中1例半年后死亡,5例随访24个月均存活。结论:急诊肝动脉栓塞治疗原发性肝癌破裂出血疗效肯定,创伤小,是安全、可靠的抢救手段。     

Emergent Transjugular Intrahepatic Portosystemic Shunt Creation for Acute Gastric Variceal Bleeding in Patients with Hepatocellular Carcinoma

A total of 42 cirrhotic patients (mean age, 51.7 years ± 10.8; 38 men) with hepatocellular carcinoma who underwent emergent transjugular intrahepatic portosystemic shunt (TIPS) creation for controlling acute gastric variceal bleeding (GVB) were included in this multicenter retrospective study. Of these, 37 (88.1%) patients underwent emergent TIPS creation as the first-line treatment to control acute GVB. Five (11.9%) patients underwent emergent TIPS creation as a rescue/salvage treatment to control acute GVB after emergent endoscopic therapy and pharmacotherapy. Emergent TIPS creation was technically successful in 40 (95.2%) patients. Two (4.8%) patients had severe and moderate procedural adverse events. The median follow-up duration was 16.9 months (range, 0.1–100.8 months). Failure to control acute bleeding and failure to prevent rebleeding occurred in 8 (19.0%) patients during follow-up. Eighteen (42.9%) patients died during follow-up. Three (7.1%) patients had shunt dysfunction during follow-up. Overt hepatic encephalopathy occurred in 6 (14.3%) patients during follow-up.     

灰阶超声影像组学鉴别肝细胞肝癌与肿块型肝内胆管细胞癌的价值

目的探讨基于常规灰阶超声的影像组学方法对肝细胞肝癌(HCC)和肿块型胆管细胞癌(IMCC)的鉴别诊断价值。资料与方法收集经手术或穿刺病理证实的原发性肝癌124例,其中IMCC 62例,HCC 62例,训练数据与测试数据按7∶3分割,使用MaZda软件手动勾画病灶提取影像组学特征,应用LASSO算法与10折交叉验证方法进行降维与选择特征参数,然后建立多变量Logistic回归模型,并绘制受试者工作特征(ROC)曲线评估其诊断效能。结果特征筛选后,建立基于直方图偏度(β=-5.39,OR=4.55)、直方图99%百分位数(β=-0.02,OR=0.90)、灰度共生矩阵对比度(β=-6.79,OR=1.16)、灰度共生矩阵共生和均值(β=-7.06,OR=1.01)的多因素Logistic回归预测模型,该模型在测试数据中的敏感度为100.0%,特异度为77.8%,ROC曲线下面积为0.94。结论灰阶超声图像同样蕴含肿瘤异型性信息,应用基于灰阶超声图像的影像组学方法对HCC和IMCC有较高的鉴别诊断效能。     

Safety and Efficacy of Segmental Yttrium-90 Radioembolization for Hepatocellular Carcinoma after Transjugular Intrahepatic Portosystemic Shunt Creation

PurposeTo evaluate safety and efficacy of segmental yttrium-90 (Y90) radioembolization for hepatocellular carcinoma (HCC) after transjugular intrahepatic portosystemic shunt (TIPS) placement. The hypothesis was liver sparing segmental Y90 for HCC after TIPS would provide high antitumor response with a tolerable safety profile.Materials and MethodsThis single-arm retrospective study included 39 patients (16 women, 23 men) with ages 49–81 years old who were treated with Y90. Child-Pugh A/B liver dysfunction was present in 72% (28/39) with a median Model for End-stage Liver Disease score of 18 (95% confidence interval, 16.4–19.4). Primary outcomes were clinical and biochemical toxicities and antitumor imaging response by World Health Organization (WHO) and European Association for the Study of the Liver (EASL) criteria. Secondary outcomes were orthotopic liver transplantation (OLT), time to progression (TTP), and overall survival (OS) estimates by the Kaplan-Meier method.ResultsThe 30-day mortality was 0%. Grade 3+ clinical adverse events and grade 3+ hyperbilirubinemia occurred in 5% (2/39) and 0% (0/39), respectively. Imaging response was achieved in 58% (22/38, WHO criteria) and 74% (28/38, EASL criteria), respectively. Median TTP was 16.1 months for any cause and 27.5 months for primary index lesions. OLT was completed in 88% (21/24) of listed patients at a median time of 6.1 months (range, 0.9–11.7 months). Median OS was 31.6 months and 62.9 months censored and uncensored to OLT, respectively.ConclusionsSegmental Y90 for HCC appears safe and efficacious in patients after TIPS. Preserved transplant eligibility suggests that Y90 is a useful tool for bridging these patients to liver transplantation.     

ACI大鼠肝细胞癌模型的免疫化疗栓塞术研究

目的:评价生物反应调节剂(BRM)经肝动脉化疗栓塞术(TACE)治疗ACI大鼠肝细胞癌的疗效。方法:在30只雄性ACI大鼠肝包膜下植入Morris Hepatom 3924A肝癌瘤块(2 mm3),移植术后13天行MRI检查,测量肿瘤体积V1;第14天时,经腹部切开术及胃十二指肠动脉逆行插管而采取以下3种介入治疗方案:①A组,0.1 mg丝裂霉素、0.1 ml碘油、7.5μg TNFα和5×103IU IL-2(n=10);②B组,0.1 mg丝裂霉素、0.1 ml碘油、0.05 mg链球菌提取物(OK-432)和5×103IU IL-2(n=10);③C组(对照组),0.1 mg丝裂霉素、0.1 ml碘油(n=10);13天后再次行MRI检查以确定肿瘤体积V2变化。比较肝肿瘤体积生长率V2/V1。结果:肿瘤治疗前和治疗后体积分别为A组0.0377 cm3和0.2752 cm3;B组0.0344 cm3和0.2233 cm3;C组0.0380 cm3和0.3398 cm3。介入治疗后肿瘤体积与治疗前肿瘤体积之比(V2/V1)分别为A组7.31、B组6.53、C组9.14。与对照组相比,采取A组的治疗方案能抑制肝肿瘤体积的生长(P=0.042),采取B组的治疗方案能明显抑制肿瘤的生长(P=0.004)。结论:采取免疫化疗栓塞术能有效抑制ACI大鼠肝细胞癌的生长。     

Reversal of Transjugular Intrahepatic Portosystemic Shunt (TIPS)-Induced Hepatic Encephalopathy Using a Strictured Self-Expanding Covered Stent

Hepatic encephalopathy is a known complication following percutaneous transjugular intrahepatic portosystemic shunt (TIPS) placement. We describe herein a simple and effective strategy of TIPS revision by creating an intraluminal stricture within a self-expanding covered stent, which is deployed in the portosystemic shunt to reduce the TIPS blood flow. This technique was successful in reversing a TIPS-induced hepatic encephalopathy in our patient. An erratum to this article can be found at .     

Transjugular Intrahepatic Portosystemic Shunt Creation for the Prevention of Gastric Variceal Rebleeding in Patients with Hepatocellular Carcinoma: A Multicenter Retrospective Study

PurposeTo evaluate the effectiveness and safety of transjugular intrahepatic portosystemic shunt (TIPS) creation for the prevention of gastric variceal rebleeding in patients with hepatocellular carcinoma (HCC).Materials and MethodsThis multicenter retrospective study included 126 cirrhotic patients (mean age, 54.1 ± 10.2 years; 110 men) with HCC who underwent TIPS creation for the prevention of gastric variceal rebleeding. Of these, 110 (87.3%) patients had gastroesophageal varices and 16 (12.7%) patients had isolated gastric varices. Thirty-five (27.8%) patients had portal vein tumor thrombus.ResultsTIPS creation was technically successful in 124 (98.4%) patients. Rebleeding occurred in 26 (20.6%) patients during the follow-up period. The 6-week and 1-year actuarial probabilities of patients remaining free of rebleeding were 98.3% ± 1.2% and 81.2% ± 3.9%, respectively. Forty-nine (38.8%) patients died during the follow-up period. The 6-week and 1-year actuarial probabilities of survival were 98.4 ± 1.1% and 65.6 ± 4.4%, respectively. Two (1.6%) patients had major procedure-related complications, including acute liver failure (n = 1) and intra-abdominal bleeding (n = 1). Thirty-three (26.2%) patients had at least 1 episode of overt hepatic encephalopathy during the follow-up period. Shunt dysfunction occurred in 15 (11.9%) patients after a median follow-up time of 11.4 months (range, 1.4–41.3 months). Lung metastasis occurred in 3 (2.4%) patients, 3.9–32.9 months after TIPS creation.ConclusionsTIPS creation may be effective and safe for the prevention of gastric variceal rebleeding in patients with HCC.     

Efficacy of a Dexamethasone-Eluting Nitinol Stent on the Inhibition of Pseudointimal Hyperplasia in a Transjugular Intrahepatic Portosystemic Shunt: An Experimental Study in a Swine Model

Objective

We wanted to evaluate the feasibility and efficacy of using a dexamethasone (DM)-eluting nitinol stent to inhibit the pseudointimal hyperplasia following stent placement in the transjugular intrahepatic portosystemic shunt tract (TIPS) of a swine.

Materials and Methods

Fifteen stents were constructed using 0.15 mm-thick nitinol wire; they were 60 mm in length and 10 mm in diameter. The metallic stents were then classified into three types; type 1 and 2 was coated with the mixture of 12% and 20%, respectively, of DM solution and polyurethane (PU), while type 3 was a bare stent that was used for control study. In fifteen swine, each type of stent was implanted in the TIPS tract of 5 swine, and each animal was sacrificed 2 weeks after TIPS creation. The proliferation of the pseudointima was evaluated both on follow-up portogram and pathologic examination.

Results

One TIPS case, using the type 1 stent, and two TIPS cases, using the type 2 stent, maintained their luminal patency while the others were all occluded. On the histopathologic analysis, the mean of the maximum pseudointimal hyperplasia was expressed as the percentage of the stent radius that was patent, and these values were 51.2%, 50% and 76% for the type 1, 2, and 3 stents, respectively.

Conclusion

The DM-eluting stent showed a tendency to reduce the development of pseudointimal hyperplasia in the TIPS tract of a swine model with induced-portal hypertension.