门静脉支架置入联合动脉化疗栓塞和序贯门静脉放疗治疗肝癌合并门静脉主干癌栓

目的 回顾性分析肝细胞肝癌伴门静脉主干癌栓(MPWIT)患者经门静脉支架置入及经导管化疗栓塞治疗后序贯门静脉适形放疗的效果.方法 45例肝癌合并MPVTY的患者行经皮门静脉支架置入,支架置入后即刻行经导管动脉内化疗栓塞.其中16例于2～3周后行门静脉适形放疗(A组),29例未行放射治疗(B组).采用Kaplan-Meier生存分析、log-rank检验评价两组间支架通畅率、累积生存率的差异;Fisher精确概率法对比分析两组间肿瘤及癌栓缓解率的差别.结果 本组支架放置过程中及置入后24 h内无患者死亡,无大出血及急性肝功能衰竭等严重并发症.支架置入后2周内所有支架通畅,术后60、180、360 d支架累积通畅率:A组分别为100.0%.62.2%、34.6%,B组分别为58.6%、21.7%、10.8%;累积生存率:A组分别为93.8%、81.3%、32.5%,B组分别为86.2%、13.8%、6.9%,两组相比差异均有统计学意义(X2值分别为9.672、14.596,P值均<0.01).支架平均通畅时间A组为(475±137)d,B组为(200±61)d,两组相比差异有统计学意义(X2=9.672,P<0.01).结论 经导管化疗栓塞联合门静脉支架置人后序贯门静脉适形放疗可提高肝细胞肝癌伴MPVTT患者支架通畅率和生存期.     

经皮支架置入术与胆道引流术治疗肝门部恶性胆道梗阻的比较研究北大核心CSCD

目的 比较经皮肝穿刺胆道支架置入术、经皮肝穿刺胆道引流(PTBD)的外引流术及内外引流术3种不同引流方式治疗Bismuth-CorletteⅠ~Ⅱ型恶性胆道梗阻的疗效及预后。方法 回顾性分析2016年1月至2020年12月恶性胆道梗阻患者133例,其中胆道支架置入为A组(52例),PTBD外引流为B组(55例),PTBD内外引流为C组(26例),比较3组患者的生存期、技术引流成功与临床引流成功率、再介入率及术后不良事件发生情况。结果 B组的中位生存时间高于A组和C组,3组比较差异有统计学意义(P<0.05)。Cox回归分析示,不同引流方式和Bismuth-Corlette分型是影响生存期的独立危险因素。3组技术引流成功率均为100%,A、B组的临床引流成功率高于C组(P<0.05),A、B组差异无统计学意义(P>0.05)。A组有8例因胆道梗阻需再次介入,C组有3例因胆道感染调整为外引流。3组的1~2级不良事件发生率差异无统计学意义(P>0.05),B组的3~4级不良事件发生率明显低于A组和C组(P<0.05),而A、C组间差异无统计学意义(P>0.05)。结论 与支架置入及PTBD内外引流相比,PTBD外引流对Bismuth-CorletteⅠ~Ⅱ型恶性胆道梗阻患者的疗效及预后更好。     

放射性~(125)Ⅰ粒子支架治疗中、晚期食管癌的疗效观察

目的探讨携带放射性~(125)Ⅰ子食管支架治疗高龄中、晚期食管癌的初步疗效。方法总结2009年9月-2010年12月新乡医学院第一附属医院食管支架治疗的43例中、晚期食管癌老年患者,根据是否自愿接受~(125)Ⅰ粒子支架分为A、B两组。A组为~(125)Ⅰ粒子支架治疗组,18例;B组为普通支架治疗对照组,25例。两组患者的年龄、病变长度、狭窄程度以及分期差异无统计学意义(患者均未做放疗及化疗)。术中、术后观察、统计并随访支架置入成功率、吞咽困难缓解率、并发症发生率及生存期。结果 A、B两组支架置入成功率均为100%,短期吞咽困难缓解率100%。A组的平均生存期为9.8个月,B组的平均生存期为4.8个月,两组间差异有统计学意义(P<0.01)。支架置入后疼痛、食管再狭窄等并发症发生率分别为27.8%及28.0%,两组间差异无统计学意义(P>0.05)。结论根据短期临床观察,125I粒子食管支架治疗中晚期食管癌能明显延长患者生存期。临床初步应用是安全、可行、有效的。治疗中、晚期食管癌放射性~(125)Ⅰ粒子支架优于传统支架。     

肝动脉化疗栓塞结合门静脉癌栓内注药治疗原发性肝癌伴门静脉癌栓临床疗效的初步观察

目的 探讨肝动脉化疗栓塞结合经皮穿刺门静脉癌栓内注药治疗原发性肝癌伴门静脉痛栓的临床价值.方法 30例不能手术切除病灶的原发性肝癌伴门静脉癌栓患者,采用完全随机方法分成A、B组,A组14例,B组16例.治疗前A、B组患者的肝功能Child-Push分级A级均为9例,B级分别为5例和7例(χ~2=0.201,P>0.05);Ⅱ型癌栓A组8例,B组9例,Ⅲ型A组6例,B组7例(χ~2=0.002,P>0.05);A、B两组患者术前丙氨酸氨基转移酶(ALT)中位数分别为58.7和70.5 U/L(W=191.5,P>0.05);总胆红素(TBIL)中位数分别为21.4和21.7 μmol/L(W=203,P>0.05);白蛋白(ALB)中位数分别为35.3和37.5 g/L(W=214,P>0.05);甲胎蛋白(AFP)中位数分别为680和873μg/L(W=179.00,P>0.05),两组相比差异均无统计学意义.A组以肝动脉化疗栓塞治疗肝内原发肿瘤灶,经皮穿刺门静脉癌栓内注药治疗门静脉癌柃;B组单纯肝动脉化疗栓塞治疗.采用Kaplan-Meier计算两组患者的中位生存期,log-rank法检验组间差异.结果 患者治疗后的中位生存期,A组14.0个月、B组4.0个月,两组差异具有统计学意义(χ~2=11.728,P<0.01).患者3、6和12个月的生存数,A组分别为11、10和7例,B组分别为10、3、0例.2组均未见与治疗相关的严重不良反应.结论 与单纯肝动脉化疗栓塞相比,肝动脉化疗栓塞结合经皮穿刺门静脉癌栓内注药治疗,可以显著延长伴有Ⅱ、Ⅲ型门静脉癌栓的原发性肝痛患者的中位生存期.     

经皮经肝胆管引流术治疗恶性梗阻性黄疸的疗效观察

目的探讨介入治疗恶性梗阻性黄疸的效果及价值。资料与方法回顾性分析恶性梗阻性黄疸患者资料146例,其中男84例,女62例,平均年龄(63±13)岁,所有患者均经辅助检查诊断为恶性胆管梗阻。先行经皮经肝胆管穿刺,随后置入引流管行胆管引流或置入胆管内支架;术后1周,37例行肝动脉化疗栓塞(TACE)。结果146例均成功穿刺并置入引流管(105例)和(或)置入支架(41例),成功率100%,术后129例患者黄疸症状好转,总有效率88.4%;胆管引流及支架引流前后总胆红素(TB)、血清丙氨酸转氨酶(ALT)、直接胆红素(DB)、血清碱性磷酸酶(ALP)、γ-谷氨酰转肽酶(γ-GT)及血清白蛋白水平进行独立样本t检验,不同引流方法在减轻黄疸,改善肝功能,延长生存期方面差异有统计学意义(P<0.05);胆管支架减轻黄疸的幅度优于胆管引流,但黄疸缓解的比例组间无差异;单纯外引流组、内外引流组及胆管支架组的中位生存期分别为3.2个月、4.5个月及6.1个月,胆管支架组在生存期方面亦优于胆管引流。结论胆管引流/胆管支架对于缓解恶性梗阻性黄疸的症状和提高患者的生活质量具有重要价值,行TACE治疗可明显加快胆红素水平下降的幅度。     

金属支架、内涵管治疗恶性胆管梗阻的临床疗效比较

目的比较金属支架与塑料支架(内涵管)置入术治疗恶性胆管梗阻的临床疗效.资料与方法 95例实施经皮穿肝胆总管支架置入术的恶性胆管梗阻患者,其中61例置入自膨式金属支架(支架组),34例置入10F塑料内涵管(内涵管组).所有患者均随访至死亡或至少术后1年.用Kaplan-Meier方法分析比较两组患者的生存率及支架开通率.结果支架组患者的30天死亡率(6/61,9.8%)低于内涵管组(9/34,26.5%,P＜0.05).支架组30天再阻塞率(15.0%)和并发症发生率(16.4%)均明显低于内涵管组(分别为32.4%和29.4%,P＜0.01).支架组中位开通期(230天)和中位生存期(224天)明显长于内涵管组(分别为90天和94天,P＜0.01).结论金属支架置入术治疗恶性胆管梗阻临床疗效优于内涵管置入术.     

冠状动脉内注射比伐卢定对急性ST段抬高型心肌梗死接受直接冠状动脉介入治疗患者影响研究

目的探讨冠状动脉内注射比伐卢定对急性ST段抬高型心肌梗死接受直接冠状动脉介入治疗患者冠状动脉无复流预防作用的影响。方法选取北部战区总医院2017年3—8月收治的86例急性ST段抬高型心肌梗死接受直接冠状动脉介入治疗的患者为研究对象。根据随机编码信封进行分组,将患者分入A组(冠状动脉内注射生理盐水10.00 ml组,n=40)和B组(冠状动脉内注射比伐卢定0.75 mg/kg组,n=46)。记录并比较主要终点[靶血管矫正心肌梗死溶栓治疗(TIMI)帧数、术后90 min心电图ST段完全回落率]和次要终点[术后30 d内净临床不良事件(包括全因死亡、再次心肌梗死、靶血管血运重建、脑卒中、支架内血栓及出血学术研究联合会定义的出血事件)发生率]。结果纳入时,A、B组的靶血管矫正TIMI帧数分别为(78.43±36.62)、(85.10±31.16),差异无统计学意义(P>0.05);靶血管矫正TIMI帧数≥40的比例分别为72.5%(29/40)、82.6%(38/46),差异无统计学意义(P>0.05)。分组时,A、B组的靶血管矫正TIMI帧数分别为(31.43±16.62)、(27.10±15.16),差异无统计学意义(P>0.05);靶血管矫正TIMI帧数≥40的比例分别为30.0%(12/40)、34.8%(16/46),差异无统计学意义(P>0.05)。在冠状动脉支架置入后(包括支架后扩张全部完成)即刻复查冠状动脉造影,结果显示,A、B组的靶血管矫正TIMI帧数分别为(34.16±19.22)、(20.90±12.04),差异有统计学意义(P<0.05);靶血管矫正TIMI帧数≥40的比例分别为27.5%(11/40)、4.3%(2/46),差异有统计学意义(P<0.05)。术后,A、B组的靶血管矫正TIMI帧数分别为(24.16±22.62)、(17.95±7.17),差异无统计学意义(P>0.05);靶血管矫正TIMI帧数≥40的比例分别为7.5%(3/40)、2.2%(1/46),差异无统计学意义(P>0.05)。A、B组的术后90 min心电图ST段完全回落率分别为85.0%(34/40)、87.0%(40/46),差异无统计学意义(P>0.05)。A、B组的术后30 d内净临床不良事件发生率分别为12.5%(5/40)、6.5%(3/46),差异无统计学意义(P>0.05)。结论冠状动脉内注射比伐卢定对急性ST段抬高型心肌梗死接受直接冠状动脉介入治疗患者的冠状动脉无复流具有较好的预防作用,且安全性高。     

腔内近距离放疗联合及支架植入治疗恶性胆道梗阻

目的：评价经皮植入125I粒子条及支架治疗恶性胆道梗阻的安全性及疗效。方法对2009年6月至2013年6月,在上海中山医院接受介入治疗的68例恶性胆道梗阻患者的资料进行回顾性分析,其中41例在胆道梗阻段同时植入支架和125I粒子条(联合治疗组),27例仅植入支架(传统治疗组),对两组患者的生存期、至黄疸进展时间及手术相关不良事件发生率进行比较。结果所有125I粒子条和支架植入均获成功。传统支架组和联合支架组术后7、14 d血清胆红素水平组间差异有统计学意义(P<0．05);联合支架组术后未发生明显骨髓抑制;单纯支架组和联合支架组中位生存期分别为123和215 d,差异有统计学意义(P<0．05)。结论腔内近程放疗联合支架植入治疗恶性胆道梗阻安全,疗效较单纯植入支架明显。     

覆膜支架置入和/或放疗治疗中晚期食管癌

目的　评价支架置入或放疗以及二者联合应用在中晚期食管癌治疗中的作用。方法　将 2 30例患者分为三组 :先放疗后支架置入组 ,单纯支架置入组和支架置入后放疗组。随访观察比较各组疗效、不良反应、并发症及生存率。结果　放疗改善梗阻症状较慢但副反应轻 ,出现并发症再置入支架的难度大于单纯支架置入组 ,疼痛增加且较重 ,但生存期长于另外两组。单纯支架置入组患者在 1～ 3d内症状缓解 ,生存期短于另外两组。支架置入后再放疗的患者并发症较多且重 ,放疗计划完成困难 ,生存期介于另外两组之间。结论　中晚期食管癌宜先行放疗 ,酌情行支架置入既可延长生存期又可缓解症状。支架置入后再行放疗虽然可以延长患者生存期 ,但放疗反应重。单纯支架置入仅能缓解症状 ,6个月后复发率增加     

覆膜支架联合介入化疗治疗恶性食管气管瘘的对照研究

目的探讨覆膜支架置入联合介入化疗治疗恶性食管气管瘘的安全性和疗效,并与单纯支架置入治疗比较。方法选择食管癌合并食管气管瘘60例患者行内支架置入联合介入化疗或单纯内支架置入治疗。60例患者随机分为支架组(A组)28例、支架联合介入化疗组(B组)32例,定期随访观察两组的近、远期疗效,并对有效率、中位生存时间、并发症进行统计分析。结果 60例患者中,58例支架置入堵瘘成功,成功率96.7%。A组中位生存时间为3.6个月,B组为8.7个月,两组差异有统计学意义(P<0.05)。B组1、3、6个月时的有效率分别为78.1%、68.8%、62.5%。并发症中食管支架再狭窄率,B组低于A组。结论内支架置入联合介入化疗能提高恶性食管气管瘘患者的中位生存期,并减少了支架带来的并发症,是一种安全、有效的治疗方法。     

胆道支架位置对治疗低位恶性梗阻性黄疸的影响

目的 比较胆道支架跨与不跨十二指肠壶腹部放置治疗低位恶性梗阻性黄疸患者的临床预后差异.方法 分析本院符合条件的56例恶性梗阻性黄疸患者的临床资料,其中支架跨十二指肠壶腹部放置31例,支架不跨十二指肠壶腹部放置25例,比较2组患者间支架置入术后4~7 d总胆红素下降率、胆道感染率及支架再阻塞率等方面的差异.结果 跨壶腹部组与不跨壶腹部组的生存期分别为(180.3±142.5) d、(178.6±137.7) d(P=0.840).2组患者术后4~7 d总胆红素下降率为42.0%±43.6%、41.4%±28.7%(P=0.950);治疗成功率分别为93.5%、92.0%(P=1.0).跨壶腹部组术后胆道感染7例(22.6%),不跨壶腹部组术后胆道感染5例(20.0%)(P=0.815).2组患者支架再阻塞率分别为22.6%、28.0%(P=0.642).结论 2种支架置入方式均是治疗低位胆道梗阻安全、有效的方法;与支架非跨壶腹部放置相比,支架跨壶腹部放置未增加胆道感染及支架再狭窄发生率.     

金属支架治疗恶性肿瘤引起的气管狭窄（附30例分析）

目的 评价金属支架治疗肺癌、食管癌等恶笥肿瘤引起的气管狭窄的可行性和疗效。方法 ３０例肺癌、管癌等恶性肿瘤压迫或侵犯气管，引起气管狭窄和严重的呼吸困难，分别置入自扩型金属支架。１１例患者进行了后续的化学治疗和放射治疗。结果 ３０例狭窄都位于主气管，共置入支架３０个（１２个ＧｉａｎｔｕｒｃｏＺ形支架，８个Ｗａｌｌｓｔｅｎｔ支架１０个Ｕｌｔｒａｆｌｅｘ支架）。所有患者呼吸困难得到立即缓解。１例杖后５６     

TACE Combined with Implantation of Irradiation Stent Versus TACE Combine with Bare Stent for HCC Complicated by IVCTT

Purpose

This study was designed to evaluate the safety and efficacy of transarterial chemoembolization (TACE) combined with intra-IVC implantation of an irradiation stent for the treatment of hepatocellular carcinoma (HCC) complicated by inferior vena cava tumor thrombosis (IVCTT).

Methods

Sixty-one consecutive patients with HCC complicated by IVCTT treated by TACE combined with IVC stenting were retrospectively analysed. IVC stenting was performed using a stent loaded with ¹²⁵I seeds strands (the irradiation stent) in 33 patients (Group A) and 28 patients with a bare stent (Group B). Propensity score matching eliminated the baseline differences. Overall survival, oedema related to IVC obstruction remission rate and procedure-related adverse events were compared between the two groups.

Results

The adverse effect rate was similar for both Group A and Group B patients, and complications were adequately handled by medical treatment. TACE combined with implantation of an irradiation stent showed a significant median survival benefit over TACE combined with a bare stent, with a median survival time of 203.0 ± 28.135 days versus 93.0 ± 24.341 days (p = 0.006). The propensity score-matched (24 pairs) cohort analyses (200 ± 31.231 days vs. 66 ± 23.270 days, p = 0.019). The oedema remission rate was 97.0 % in group A patients and 96.4 % in group B, respectively. TACE-irradiation stent and object tumor response were the independent prognostic factors of favorable survival.

Conclusions

TACE combined with irradiation stent implantation is a safe and effective treatment modality for patients with HCC complicated by IVCTT and may extend their survival time.

     

肝癌伴下腔静脉癌栓行TACE联合下腔静脉放射性支架或裸支架治疗的对照研究

目的 探讨TACE联合下腔静脉放射性支架植入治疗肝细胞肝癌伴下腔静脉癌栓的安全性及有效性.方法 对61例肝细胞肝癌伴下腔静脉癌栓患者的资料行回顾性分析,放射性支架采用125I粒子条捆载裸支架的方法,共对33例患者采用此方法(A组),28例患者植入裸支架(B组).采用倾向性评分匹配(propensity score matching)对原数据进行后随机化分析以减少选择性偏倚,对两组患者的生存期,症状缓解率及不良反应进行对照分析.结果 两组患者术后不良反应发生率相仿,均采用内科对症处理.A组患者较B组显示更长的生存期优势,A组中位生存时间(203.0±28.1)d,B组(93.0±24.3)d(P=0.006),倾向性评分匹配后(24对)A组(200±31)d,B组(66.0±23) d(P=0.019),A组水肿缓解率97.0％,B组为96.4％,多因素分析显示放射性支架植入与肿瘤客观有效率为患者预后好的独立性影响因素.结论 TACE联合放射性支架植入对治疗肝细胞肝癌伴下腔静脉癌栓安全有效,可能延长患者生存时间.     

A Survival Analysis of Patients with Malignant Biliary Strictures Treated by Percutaneous Metallic Stenting

BACKGROUND: Percutaneous metal stenting is an accepted palliative treatment for malignant biliary obstruction. Nevertheless, factors predicting survival are not known. METHODS: Seventy-six patients with inoperable malignant biliary obstruction were treated with percutaneous placement of metallic stents. Twenty patients had non-hilar lesions. Fifty-six patients had hilar lesions classified as Bismuth type I (n = 15 patients), type II (n = 26), type III (n = 12), or type IV (n = 3 patients). Technical and clinical success rates, complications, and long-term outcome were recorded. Clinical success rates, patency, and survival rates were compared in patients treated with complete (n = 41) versus partial (n = 35) liver parenchyma drainage. Survival was calculated and analyzed for potential predictors such as the tumor type, the extent of the disease, the level of obstruction, and the post-intervention bilirubin levels. RESULTS: Stenting was technically successful in all patients (unilateral drainage in 70 patients, bilateral drainage in 6 patients) with an overall significant reduction of the post-intervention bilirubin levels (p < 0.001), resulting in a clinical success rate of 97.3%. Clinical success rates were similar in patients treated with whole-liver drainage versus partial liver drainage. Minor and major complications occurred in 8% and 15% of patients, respectively. Mean overall primary stent patency was 120 days, while the restenosis rate was 12%. Mean overall secondary stent patency was 242.2 days. Patency rates were similar in patients with complete versus partial liver drainage. Mean overall survival was 142.3 days. Survival was similar in the complete and partial drainage groups. The post-intervention serum bilirubin level was an independent predictor of survival (p < 0.001). A cut-off point in post-stenting bilirubin levels of 4 mg/dl dichotomized patients with good versus poor prognosis. Patient age and Bismuth IV lesions were also independent predictors of survival. CONCLUSIONS: Percutaneous metallic biliary stenting provides good palliation of malignant jaundice. Partial liver drainage achieved results as good as those after complete liver drainage. A serum bilirubin level of less than 4 mg/dl after stenting is the most important independent predictor of survival, while increasing age and Bismuth IV lesions represent dismal prognostic factors.     

Malignant esophageal-tracheobronchial strictures: parallel placement of covered retrievable expandable nitinol stents

Purpose: To assess the safety and clinical effectiveness of the parallel placement of covered retrievable expandable metallic stents in the palliative treatment of malignant esophageal and tracheobronchial strictures.

Material and Methods: Under fluoroscopic guidance, parallel stents were placed in 12 symptomatic patients with both malignant esophageal and tracheobronchial strictures. Seven of these 12 patients also had an esophagorespiratory fistula (ERF) and one patient had an esophagocutaneous fistula. Technical success, clinical improvement, complications, and survival rates were evaluated.

Results: A total of 28 esophageal and airway stents were successfully placed. The grade of dysphagia and dyspnea score significantly decreased after stent placement (P = 0.002 and 0.003, respectively). ERF and esophagocutaneous fistula were sealed off in all eight patients after esophageal stent placement; however, the esophagocutaneous fistula reopened 1 month later. Complications included stent migration or expectoration (n = 3), tracheal compression by the esophageal stent (n = 3), new fistula development due to covering membrane degradation of the esophageal stent (n = 1), and symptomatic sputum retention (n = 1). Stent removal was easily performed for two stents; one migrated stent and the other with covering membrane degradation. All 12 patients died within the mean survival period of 72.50 days (range 7-375 days).

Conclusion: Parallel placement of covered retrievable expandable metallic stents is safe and effective for the palliative treatment of malignant esophageal and tracheobronchial strictures.     

Ultrasonically guided percutaneous transhepatic hepatic vein stent placement for Budd-Chiari syndrome.

PURPOSE: To evaluate the utility of ultrasonically guided hepatic vein stent placement in the treatment of Budd-Chiari syndrome (BCS) in patients with short hepatic vein obstruction. MATERIALS AND METHODS: Twenty-five patients with BCS, each with three obstructed hepatic veins diagnosed with ultrasound (US), color Doppler, probing with guide wire, and echo contrast, underwent hepatic vein stent placement under US guidance. Nine patients had hepatic vein obstruction alone, and 16 had hepatic vein obstruction along with primary inferior vena cava (IVC) obstruction. In each patient, only one of the hepatic veins was selected for recanalization and stent placement. In patients with primary IVC lesions, a stent was placed in the IVC first. Clinical and US examinations were performed at 3-6-month intervals on every patient during follow-up. RESULTS: Hepatic vein stents were successfully placed in 23 of the 25 patients, a success rate of 92%. The mean +/- SD hepatic vein pressure decreased from 25.57 mm Hg +/- 9.46 to 9.67 mm Hg +/- 2.31 (P < .01), and the flow direction in the hepatic vein became centripetal and its spectral analysis showed a normal phasic flow. Twenty-two patients experienced a significant improvement in hepatic outflow, as evidenced by disappearance of ascites, remission of hepatosplenomegaly, improvement in liver function, and alleviation of esophageal varices. Severe intraperitoneal hemorrhage occurred in one patient. No other serious procedure-related complications were observed. During follow-up of 1-43 months (mean, 23 months), stent reocclusion occurred in one patient. The other stents remained patent, and clinical features of BCS did not recur. CONCLUSION: Percutaneous transhepatic hepatic vein stent placement is a reasonable treatment for BCS in patients with hepatic vein obstruction, and the procedures can be performed safely and accurately with US.     

肝移植术后肝静脉和下腔静脉梗阻的诊断及介入治疗

目的 探讨肝移植术后肝静脉、下腔静脉梗阻的诊断及介入治疗技术.方法 在831例原位肝移植(OLT)、26例活体肝移植(LDLT)患者中,共有11例在移植术后2～111 d经血管造影证实为肝静脉、下腔静脉梗阻并进行了介入治疗.其中肝静脉吻合口狭窄或闭塞5例、下腔静脉吻合口狭窄5例、肝静脉狭窄伴下腔静脉吻合口狭窄1例.11例中,5例为成人OLT、4例为LDLT、2例为儿童减体积OLT,介入治疗前9例接受了肝脏CT、2例接受了MR增强扫描.术后随访患者肝肾功能指标、临床症状及肝静脉、下腔静脉血流状况.对11例患者的影像资料、介入治疗技术要点和治疗效果进行回顾性分析.介入治疗前后梗阻两端静脉压力差比较,采用配对t检验.结果 11例患者,CT或MR检查均可明确显示肝脏淤血范围、肝静脉或下腔静脉梗阻部位及程度;其中4例肝静脉梗阻和5例下腔静脉梗阻者行支架植入治疗,1例肝静脉梗阻者行经皮腔内血管球囊扩张术(PTA),1例肝静脉伴下腔静脉梗阻者,行肝静脉PTA和下腔静脉支架植入,介入治疗手术均成功.术后检测梗阻两端静脉压力差为(2.9±1.7)mm Hg(1 mm Hg=0.133 kPa),较术前(16.5±4.1)mm Hg明显下降(t=11.5,P＜0.01).术后10例患者临床症状改善,肝肾功能恢复;1例肝功能恶化,于术后第9天死于多器官功能衰竭.患者术后随访9～672 d,2例肝静脉PTA治疗者术后1个月内发生血管再狭窄,支架植入治疗者未发生再狭窄,无严重并发症发生.结论 支架植入是治疗肝移植术后肝静脉和下腔静脉梗阻安全、有效的方法;术前CT或MR对明确肝淤血范围及静脉梗阻具有重要价值.     

Clinical outcomes with airway stents for proximal versus distal malignant tracheobronchial obstructions

PURPOSE: This study evaluates the outcome of tracheobronchial stent placement in symptomatic patients with malignant disease. MATERIALS AND METHODS: From 1993 to 2002, 30 patients had stents placed for malignant strictures. Five of 30 patients underwent stent placement distal to the mainstem bronchi, 13 received stents in both the proximal and distal airways, and 12 received stents in only the proximal airways. Clinical response and survival were determined from the patients' medical records. A positive clinical response was judged to have occurred if the patient improved in two of these three categories: subjective symptoms (patient-reported), objective signs (clinician-reported), and postprocedural imaging. RESULTS: The condition of 29 of 30 patients improved within 4 weeks of stent placement. The mean survival duration after stent placement was 261 days (SD, 395.1 days). The location of stent placement was not associated with significant differences in clinical improvement or survival (P =.51). Eight patients had additional airway segments that were too diffusely involved in which to place a stent or could not be recanalized. Mean survival in this group with incomplete stent placement was significantly reduced at 24.9 days (SD, 23.1 days), compared with 345.5 days (SD, 436 days) for the remaining patients who underwent complete stent placement (P <.05). Four patients lived less than 10 days after the procedure and three patients (75%) had mediastinal invasion. CONCLUSION: Tracheobronchial stent placement effectively palliates malignant airway obstruction, and clinical improvement is independent of the location in which the stent is implanted. When patients had diffuse or highly obstructive airway involvement and underwent incomplete stent placement, clinical response was also satisfactory, even though survival was worse. Patients with mediastinal invasion were poor candidates for stent placement as a result of their short survival.