TIPSS技术在门脉癌栓性门脉高压中的应用

目的 探讨TIPSS技术在治疗门静脉癌栓合并门脉高压中的技术特点及禁忌证。方法 16例门静脉癌栓合并门脉高压症患者,9例门静脉主干完全堵塞,7例门静脉主干及分支有不同程度栓塞;6例合并门脉海绵样变;1例单纯上消化道大出血;4例单纯顽固性腹水;11例上消化道大出血合并顽固性腹水。结果 16例中11例患者成功行TIPSS治疗,技术成功率约68.8%,门脉压力从术前4.9kPa降至2.4kPa,平均降低2.5kPa,腹水减少或消失,症状缓解。平均生存136d。5例失败。结论 TIPSS是治疗门脉癌栓引起的上消化道大出血和顽固性腹水的有效方法,门脉海绵样变是该术的禁忌证。     

介入治疗脾动静脉瘘术后门静脉系统急性血栓形成1例

临床资料 患者女,37岁,因“持续呕血、黑便3d”入院.经内科药物及内镜止血治疗无效.患者24 d前曾行“剖宫产术”,否认肝炎及肝硬化病史.体格检查:贫血面容,四肢湿冷,血压80/50 mmHg,心率135次/min;腹稍膨隆,轻压痛,无反跳痛,未触及包块,移动性浊音(+),无其他阳性体征.血常规:红细胞2.7× 1012/L、血红蛋白82.0 g/L、红细胞压积0.24、白细胞20.4× 109/L、血小板117× 109/L.     

Traesjugular intrahepatic portosystemic shunt in portai vein thrombosis: Role of the right gastric vein with anomalous insertion

Transjugular intrahepatic portosystemic shunt (TIPS) was performed in two patients with portal vein thrombosis. In both patients, hepatopetal flow had been maintained by an anomalous insertion of the right gastric vein (RGV) into the portal vein bifurcation and into the left portal branch respectively. In one patient, the main portal trunk could not be recanalized and the RGV was used as an accessory portal vein to place one stent for TIPS. In the other case, access through the partial portal-vein occlusion was gained and three stents were placed from the hepatic vein to the main portal vein distal to the thrombus. In portal vein thrombosis, the aberrant insertion of the RGV into the left or right portal branches may maintain patency of the intrahepatic portal system and, in case of unsuccessful recanalization of the porta, may represent the sole pathway for placing a TIPS     

经颈静脉肝内门体分流术在肝癌伴门脉癌栓中的临床应用

目的:回顾分析并探讨经颈静脉肝内门体分流术(TIPS)在原发性肝癌伴门静脉癌栓(PVTT)治疗中的应用价值.方法:回顾分析原发性肝癌伴门静脉癌栓,并接受TIPS手术治疗的患者的病例资料,了解术后主要症状改善情况,并发症及生存期等随访资料.结果:接受TIPS手术的肝癌伴PVTT患者共13例,其中成功进行手术患者10例.3例上消化道出血患者成功止血,7例腹水患者中的5例腹水减少,手术成功患者的平均生存期为(112.1±41.7)天,而未获成功的平均生存期仅(34.3±25.5)天,差异具有统计学意义(P＜0.05).结论:TIPS应用于肝癌伴门脉癌栓的治疗可行,可改善生存质量、延长生存期,具有一定的临床应用价值.     

门静脉和肠系膜上静脉血栓形成的MRI诊断

目的 分析门静脉（PV）和肠系膜上静脉（SMV）血栓形成的MRI特征及其诊断价值。方法 搜集经手术与病理证实的PV和SMV血栓形成患者12例，全部行MR T1WI、T2WI、抑脂T2、血管成像及钆喷替酸葡甲胺（Gd-DTPA）3期动态增强扫描。结果 直接征象为血管内血栓信号（12例），表现为T1WI和T2WI显示PV和SMV流空信号消失。3例急性期血栓T。WI为低或等信号，T2WI为高信号；8例亚急性期血栓T1WI及T2WI均为高信号；1例慢性期血栓T1WI为混杂信号，T2WI为低信号；增强扫描静脉期PV、SMV管腔内无对比剂充盈，PV周围呈轨道样增强，其内无强化的低信号血栓。间接征象包括肠腔扩张积液（10例）、肠管积血（6例）、肠壁增厚（12例）、肠黏膜水肿（11例）、薄纸样肠壁（1例）、缆绳征（11例）、肠系膜积液（2例）、肠壁积气（3例）、腹腔积液（12例）、PV海绵样变（3例）、肝脏异常灌注（6例）。结论 MRI是诊断PV和SMV血栓形成并肠道缺血敏感有效的方法，MR多序列、多轴面成像及增强扫描对病变的显示、定位、范围及血栓的分期等有重要作用。     

The importance of venous hypertension in the formation of dural arteriovenous fistulas: a case report of multiple fistulas remote from sinus thrombosis

Various hypotheses have been reported concerning the pathogenesis of dural arteriovenous fistulas (DAVFs). However, it is still controversial whether sinus thrombosis or venous hypertension has a greater influence on the formation of DAVFs. We present a rare case of multiple DAVFs that developed after sinus thrombosis. Chronic venous hypertension secondary to sinus thrombosis in the left transverse-sigmoid sinus induced the multiple DAVFs, including one in the right cavernous sinus, which was remote from the occluded sinus. This case indicates the importance of venous hypertension in the formation of DAVFs. Received: 27 November 2000/Accepted: 13 March 2001     

Percutaneous transhepatic treatment of a posttransplant portal vein thrombosis and a preexisting spontaneous splenorenal shunt

Percutaneous transhepatic treatment of portal vein thrombosis after liver transplantation in a patient with a preexisting high volume spontaneous splenorenal shunt is presented. Local thrombolysis with urokinase and balloon angioplasty of the main portal vein stenosis were performed followed by shunt embolization to restore hepatopetal portal blood flow.     

经颈静脉肝内门脉左支-体静脉分流术的临床意义

目的 评价选择性门静脉左支作为TIPS分流道的临床意义,分析门静脉左、右支的血液动力学变化及重要液道物质浓度差异对术后预防肝性脑病及远期疗效的影响。方法 341例有目的的选择肝内门静脉左支作为穿刺靶点,行经颈静脉矸内静脉左支门腔分流术建立门腔分流道,避开富含营养、毒素的门静脉右支血液。肝实质通道用8mm直径球囊扩张,限制分流口径。结果 所有患者术后3个月内无一例发生肝性脑病。随访期间TIPS术后341例患者仅5例（1.47%）出现肝性脑病和19例（5.57%)一年随访造影出现支架内狭窄。结论 选择性门静脉左支作为门腔静脉分流道,可心显著降低肝性脑病发生率,对保护肝功能,提高分流道远期开通率具有重要的临床意义。     

经颈内静脉门腔分流术治疗肝外门静脉分叉部门静脉瘤1例

门静脉瘤(portal vein aneurysm,PVA)是门静脉系统的梭形或瘤样扩张,临床罕见,治疗以外科手术为主.本中心采用TIPS术治疗门静脉分叉部门静脉瘤1例,术后门静脉瘤逐渐缩小消失,现报道如下. 临床资料 患者男,48岁.以“感染乙肝15年,反复消化道出血6个月”为主诉入院.5年前,因上消化道出血曾行脾切除断流术.     

经皮脾静脉途径联合TIPS治疗伴海绵样变性的门静脉血栓

目的 探讨经皮脾静脉途径联合TIPS治疗伴海绵样变性的门静脉血栓的可行性、安全性和疗效.方法 对3例门静脉血栓伴门脉海绵样变性患者行经皮脾穿脾静脉途径开通门静脉,联合TIPS重建门静脉分流道.随访22～40个月,观察治疗效果、支架通畅情况、肝功能变化和并发症.结果 3例均成功.其中1例支架经由显著扩张的海绵样变性的侧支放置,术后7个月内出现2次肝性脑病前期症状,药物治疗后症状消失.1例患者于术后6个月内出现持续性的胆红素增高,最高总胆红素为88.2μmoL/L,直接胆红素68.7 μmoL/L.予以保肝、降黄治疗后总胆红素维持在(44.4±11.6)μmol/L,直接胆红素(29.7±12.8)μmol/L.较术前无显著变化.第3例术后恢复良好.3例无术中并发症,术后随访22～40个月,支架血流通畅,未再发静脉曲张出血.结论 在有限的治疗伴有海绵样变性的门静脉血栓的方法选择中,经皮脾穿刺脾静脉途径开通门静脉,联合TIPS是安全可行和有效的,虽然技术要求上更困难和更具挑战性.     

Dural arteriovenous fistula associated with neoplastic dural sinus thrombosis: two cases

Intracranial dural arteriovenous fistulae are direct arteriovenous shunts within the dura matter. We report two cases of arteriovenous fistulae upstream to a neoplastic dural sinus thrombosis. These cases add further support to the acquired etiology of dural arteriovenous fistulae and to the fact that venous hypertension is one of the most important precipitating factors. Received: 9 January 2001/Accepted: 10 January 2001     

Anomalous venous connections involving the portal system

Five cases representing four different venous anomalies involving the portal system are described. The clinical importance of these anomalies, especially in patients with portal hypertension, is stressed.     

经颈静脉肝穿刺门静脉途径门静脉及肠系膜上静脉血栓溶栓治疗6例报告

目的 评价经颈静脉经肝穿刺门静脉(TIPSS)途径门静脉及肠系膜上静脉血栓溶栓治疗的安全性和治疗效果。方法 对6例诊断为门静脉(PV)和肠系膜静脉(SMV)广泛血栓形成的患者进行了经TIPSS途径介入溶栓治疗。患者主要症状有腹痛、腹胀、厌食等。腹部体检有压痛,均无明确腹肌紧张和反跳痛。经B超、增强CT检查和直接PV-SIV造影确诊为本病。溶栓方法：穿刺PV分支成功后插入导管做PV-SMV造影,确定诊断及了解栓塞范围,抽吸及捣碎血栓,间断将尿激酶经多侧孔导管注入PV和SMV清除大部分血栓后,保留多侧孔导管于SMV内持续溶栓3～13天。术后药物抗凝治疗6个月左右。此间,密切监测出凝血时间及影像学变化。结果 介入治疗后,大部分血栓被清除,PV和SMV有血流通过,腹痛、腹胀和腹泻症状逐步缓解。经留置于SMV的导管造影显示,PV和SMV主干及主要分支血流通畅,3例门静脉的肝内少数分支有残留血栓,但无明显症状。随访4个月至3年,除1例死于外科手术并发症外,其余5例患者健在,无血栓复发证据及上消化道出血发生。结论 经TIPSS途径介入溶栓治疗急性PV和SMV血栓形成是安全有效的,近期及中远期疗效均好。     

A suggestive case report of acute mesenteric venous thrombosis diagnosed at Computed Tomography Angiography

Acute mesenteric venous thrombosis (MVT) is a rare but potentially fatal condition with superior mesenteric vein being the most common site of thrombosis development. It is more common in patients with underlying disorders which cause disruptions to Virchow''s Triad of hypercoagulability, stasis and endothelial injury. The disease is often associated with intestinal ischemia in its acute form, further complicating its management. We present a case of acute superior mesenteric venous thrombosis, in a 65 years old man with initial features of intestinal infarction, diagnosed at Computed Tomography Angiography (CTA) scan. However, the patient was stable, with a nonperitonitic abdomen, and was subsequently managed with conservative measures.     

Imaging and radiological interventions of portal vein thrombosis

Portal vein thrombosis (PVT) is diagnosed by imaging methods. Once diagnosed by means of ultrasound, Doppler ultrasound can be performed to distinguish between a benign and malignant thrombus. If further information is required, magnetic resonance angiography or contrast-enhanced computed tomography is the next step, and if these tests are unsatisfactory, digital subtraction angiography should be performed. Many papers have been published dealing with alternative methods of treating PVT, but the material is fairly heterogeneous. In symptomatic non-cavernomatous PVT, recanalization using local methods is recommended by many authors. Implantation of transjugular intrahepatic portosystemic shunt is helpful in cirrhotic patients with non-cavernomatous PVT in reducing portal pressure and in diminishing the risk of re-thrombosis. In non-cirrhotic patients with recent PVT, some authors recommend anticoagulation alone. In chronic thrombotic occlusion of the portal vein, local measures may be implemented if refractory symptoms of portal hypertension are evident.     

Diagnosis of portal vein thrombosis discontinued with liver tumors in patients with liver cirrhosis and tumors by contrast-enhanced US: A pilot study

Aims

We assessed the role of contrast-enhanced ultrasound (CEUS) in the differential diagnosis between benign and malignant portal vein thrombosis (PVT) in patients who had liver tumors.

Methods

Seventeen consecutive patients who had cirrhosis, liver tumors, and PVT were prospectively studied with CEUS. CEUS was performed at low mechanical index after intravenous administration of a second-generation contrast agent (SonoVue, Bracco, Milan, Italy). Presence or absence of thrombus enhancement on CEUS were considered diagnostic for malignant or benign PVT. Five patients also underwent percutaneous portal vein fine-needle biopsy under US guidance. All patients were followed-up. Shrinkage of the thrombus and/or recanalization of the vessels on CDUS during follow-up were considered definitive evidence of the benign nature of the thrombosis, whereas the enlargement of the thrombus, disruption of the vessel wall, and parenchymal infiltration over follow-up were considered consistent with malignancy.

Results

Follow-up showed signs of malignant thrombosis in 14 of 17 patients. CEUS showed early arterial enhancement of the PVT in 14 patients of 14 malignant PVT, 1 patient of 3 benign PVT and the absence of thrombus enhancement in 2 patients of 3 benign PVT. FNB confirmed the results for malignant PVT in four of five patients, for benign granulomatous inflammation PVT in one of five patients in which CEUS showed early arterial enhancement of the PVT. The sensitivity, specificity and accuracy is 100%, 66.7% and 93.3% at diagnosis of malignant PVT using CEUS. In one patient with intrahepatic bile duct stone, CEUS were positive for malignant PVT, whereas FNB was negative (benign granulomatous inflammation PVT); follow-up examination confirmed benign PVT.

Conclusion

CEUS seems to be the pretty sensitive and specific test for diagnosing malignant portal vein thrombosis in patients with cirrhosis and tumors.     

Malignant islet cell tumor of the pancreas associated with portal venous thrombus

In this report, CT and MR findings of a malignant islet cell tumor of the pancreas associated with tumor thrombus in the portal vein is presented. Imaging findings revealed diffuse involvement of the body and tail of the pancreas by the tumor. The most unusual finding was that this invasive tumor was an insulinoma.     

Septic thrombosis of the portal vein due to peripancreatic ligamental abscess

Septic thrombus formation of both the main portal vein and its intrahepatic branches were observed on CT in a patient with peripancreatic abscess. The septic thrombosis of portal vein (STPV) extended from the level of porta hepatis into the intrahepatic branches, but the portal vein and superior mesenteric vein at the level of pancreatic head were preserved with no evidence of thrombosis angiographically. The gas-containing abscess near the head of the pancreas extended toward the hepatic hilum and surrounded the portal vein and its branches on CT. It was concluded that these thrombi of portal vein branches at porta hepatis and intrahepatic branches were caused by extensions of peripancreatic abscess via the hepatoduodenal ligament and ligamentum teres. Computed tomography was useful in depicting the ligamentous spread of peripancreatic abscess resulting in STPV. Received: 29 September 1997; Revision received: 13 February 1998; Accepted: 16 February 1998     

Hepatic portal venous gas as a complication of diverticulitis with a colovenous fistula: a case report

We report here a case of sigmoid diverticulitis complicated by a colovenous fistula, as a rare but also a nonfatal cause of hepatic portal venous gas. The different radiological examinations and their features will be discussed. Electronic Publication     

CT结合D-二聚体对急性胰腺炎并发门静脉系血栓的探讨

目的 应用增强CT联合n二聚体检测,提高对急性胰腺炎(AP)并发门静脉系统血栓的诊断.方法 对23例已经确诊的AP并发门静脉系统血栓患者的影像学和临床资料进行回顾性分析.结果 (1)增强CT确诊21例患者并发门静脉系统血栓形成,表现静脉闭塞3支静脉、充盈缺损19支静脉、管腔变细9支静脉、管壁边缘模糊12支静脉,其血栓的部位与胰周积液分布一致.(2)23例患者D-二聚体均有不同程度升高,提示门静脉系统血栓或(和)微血栓的形成,并在一定程度上可以预测AP有无并发坏死.(3)CT Balthazar分级B级2例,D级3例,E级18例.结论 AP患者CT平扫胰周出现积液时高度提示可见血栓的形成,并建议早期行CT增强扫描.D-二聚体升高但无胰周渗出液时,则提示小静脉或(和)微循环血栓形成.