下腔静脉及肝静脉短段病变型布-加氏综合征的外科治疗

目的 探讨布-加氏综合征的下腔静脉短段闭塞及肝静脉主干病变根治性切除的优缺点、术中的注意事项。方法 下腔静脉闭塞或狭窄段切除、人工血管原位移植术42例,肝静脉主干闭塞段切除、肝静脉流出道成形、人工血管原位移植术10例,肝静脉主干闭塞段切除、肝静脉-右心房吻合3例,经皮肝穿肝或副肝静脉破膜、扩张10例。结果 1例死于并发症,随访58例,平均30个月,介入复发3例,手术复发1例。结论 下腔静脉或肝静脉病变段切除、人工血管原位移植治疗布-加氏综合征,能根治病变、符合正常解剖生理、远期疗效好。     

肠系膜上静脉-下腔静脉-下腔静脉人工血管"Y"型架桥术治疗混合型布-加综合征32例分析

下腔静脉-右心房转流术(腔-房转流术)是治疗节段闭塞型布-加综合征(Budd-Chiari syndrome,B-CS)的常用方法,适用于肝后下腔静脉近右房处闭塞式狭窄、病变超过1 cm、至少有一支肝静脉(包括增粗的肝右后静脉)开口于阻塞段下方的下腔静脉并血流通畅的患者.     

不同类型Budd-chiari综合征的介入治疗

目的通过342例Budd-chiari综合征的治疗经验,探讨不同类型Budd-chiari综合征的治疗方法。方法利用介入放射的方法对342例不同类型Budd-chiari综合征病变进行相应的介入处理。结果 342例患者,除29例肝静脉完全闭塞患者无法行介入治疗外,其余的均行介入治疗,成功292例,成功率85.4%。2例发生急性心包填塞,经外科处理痊愈,2例发生右侧胸腔出血,经保守治疗吸收好转。其中下腔静脉膜性病变142例均介入治疗成功,成功率100%,阶段性病变65例,介入治疗成功55例,成功率84.6%;肝静脉膜性病变55例,介入治疗全部成功,成功率100%,阶段性闭塞29例,介入治疗成功24例,成功率82.8%,肝静脉完全闭塞29例,未能行介入治疗,成功率0%;下腔静脉膜性病变合并肝静脉膜性病变9例,全部介入治疗成功,下腔静脉阶段病变合并肝静脉阶段病变8例,介入治疗成功5例,成功率62.5%。下腔静脉阶段性闭塞合并肝静脉完全闭塞5例,介入治疗下腔静脉开通成功3例,成功率60%。结论介入治疗是Budd-chiari综合征最有效的治疗方法之一,不同类型Budd-chiari综合征病例应采取不同的方法治疗。     

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目的　探讨布 加综合征合理的临床病理分型、外科治疗方法及原则。方法　对 1983年 5月至 2 0 0 3年 6月收治的 136 0例布 加综合征病人的临床资料进行回顾分析。根据下腔静脉造影和经皮肝穿刺肝静脉造影 ,将其分为 4种类型 (6个亚型 ) :Ⅰa型 5 94例 ,Ⅰb型 12 3例 ,Ⅱ型 2 92例 ,Ⅲa型 2 37例 ,Ⅲb型 112例 ,Ⅳ型 2例。治疗方法包括 :(1)改良脾 肺固定术 2 6 5例 ,(2 )手指破膜或球囊导管扩张 4 0 7例 ,(3)根治性病变隔膜切除和血栓取出术 2 75例 ,(4 )下腔静脉旁路术 88例 (下腔静脉 下腔静脉架桥术 71例 ,下腔静脉 右心房架桥术 17例 ) ,(5 )肠系膜上静脉 下腔静脉C形架桥术192例 ,(6 )脾静脉 下腔静脉架桥术 32例 ,(7)脾静脉 右心房架桥术 2 3例 ,(8)脾静脉 颈内静脉胸骨后 5 7架桥术例 ,(9)肠系膜上静脉 右心房架桥术 8例 ,(10 )联合手术 6例 (包括 :肠系膜上静脉 下腔静脉 右心房架桥术 2例和脾静脉 下腔静脉 右心房架桥术 4例 ,(11)脾静脉 肾静脉分流术 4例 ,(12 )其他手术 3例 (包括肠系膜上静脉 颈内静脉架桥术 2例 )。手术死亡率 3 0 9% (4 2 / 136 0 ) ,并发症发生率 14 78% (2 0 1/ 136 0 )。结果　对 885例进行了随访 ,随访时间 9个月至 15年 ,平均 (6 8± 1 2 )年。总有效率为 89 4 %     

经皮肝穿刺联合上下腔静脉途径介入治疗肝静脉闭塞型布加综合征

目的:评价肝静脉闭塞型布加综合征(BCS)介入治疗效果。方法:回顾性分析2010年1月—2016年1月于海南省人民医院血管外科接受介入治疗的14例肝静脉闭塞型BCS患者的临床资料。结果:14例患者手术方式均采用经皮肝穿刺造影结合上下腔静脉会师造影与球囊扩张术,14例患者均成功开通。患者均行逐步扩大直径的多次球囊扩张,其中9例患者半年内行2次手术,5例患者行3次手术。与术前比较术后患者平均肝静脉内压力明显降低(54 cm H2O vs.25 cm H2O);14例患者均未植入支架,所有患者症状均得到明显改善。随访时间为12~48个月,无死亡患者,无1例复发及严重并发症。结论:经皮肝穿刺造影结合上下腔静脉会师造影与球囊扩张术治疗肝静脉闭塞型BCS安全而有效,并发症发生率低,疗效满意。     

重症布-加综合征的治疗(附95例报告)

目的　 探讨重症布 -加综合征 (BCS)的治疗方法。 方法　 对 1994年 11月～ 1999年 6月收治的 95例重症BCS病人的临床资料进行回顾性分析。 结果　 手术治疗 75例 ,其中行肠腔静脉人工血管C型架桥吻合 5 1例 ,脾静脉与右颈内静脉人工血管架桥吻合 2 3例 ,肠系膜上静脉右颈内静脉人工血管架桥吻合 1例 ;介入治疗 10例 ,均行经皮肝肝静脉球囊导管扩张成形或 (和 )内支架放置 ;介入加常规手术 10例 ,经皮腔下腔静脉球囊导管扩张成形及内支架放置后行肠腔人工血管C型架桥术。除手术死亡 5例外 ,90例随访 6个月～ 5年 ,效果优者 6 5例 ( 72 .2 % ) ,良者 2 5例 ( 2 7.8% )。 结论　 对重症布加综合征病人应依据病变类型行相应的治疗方法 ,多数病人可取得良好效果     

肝上下腔静脉与心房吻合的肝移植治疗Budd-Chiari综合征一例

对于存在广泛的肝内静脉狭窄或闭塞的Budd-Chiari综合征(BCS)的治疗,目前尚无有效的治疗方法,我院对1例有广泛肝内静脉狭窄或闭塞的BCS患者施行供肝下腔静脉与受者心房吻合的原位肝移植治疗,现报告如下。临床资料患者为女性,19岁,肝功能Child分级为C级,上下腔静脉双向联合数字减影血管造影见从右心房下0.5cm至肝静脉平面完全闭塞,肝静脉的3个属支及肝内静脉系统未显影,奇静脉、半奇静脉增粗,后腹膜大量侧支静脉开放。增强CT及磁共振检查可见肝内静脉系统广泛节段性闭塞或扩张。肝穿刺活检提示肝细胞变性坏死、肝硬化。病肝切除时,见门静脉直径约1.7cm,肝周尤其肝下粘连紧密,肝静脉入口至右心房段的腔静脉完全闭塞,并与周围粘连,形成较硬的纤维条索,使病肝与周围分离极其困难,出血较多。在未行转流情况下游离病肝,分离、切断胆总管,结扎胃十二指肠动脉,游离足够长度的肝动脉及门静脉,切断。于第五肋间隙入胸,打开心包,见下腔静脉与右心房相连处约0.3cm长的圆锥状充盈,远端完全闭塞,故分离切断右心房下端,向远端分离,并通过膈肌移去病肝。供肝获取采用快速灌洗法,切断包含部分右心房的肝上下腔静脉,其它各管道系统保留足够长度...     

肠-腔-房转流术治疗混合型布加综合征的疗效分析

目的 探讨应用人工血管行肠-腔-房转流术(MCAS)治疗混合型布加综合征的临床效果.方法 回顾性分析2000年2月至2004年5月山东大学齐鲁医院收治的17例混合型布加综合征患者的临床资料.17例患者均为全部或两支肝静脉主干阻塞且肝后下腔静脉长段血栓形成或长段闭塞(或)狭窄,应用人工血管行MACS.观察并比较患者手术前后的临床症状、门静脉及下腔静脉压力;患者术后并发症发生率;人工血管通畅率.采用Kaplan-Meier法分析患者生存率,χ2检验和t检验分析相关数据.结果 全组患者无围手术期死亡.17例患者中15例临床症状消失或缓解,与术前比较,差异有统计学意义(χ2=9.78,P<0.05);3例出现并发症;门静脉及下腔静脉压力术后较术前平均下降1.2 cm H2O(1 cm H2O=0.098 kPa)和18.5 cm H2O,其差异有统计学意义(t=2.38,3.06,P<0.05);1、3、5年生存率分别为16/17、15/17、14/17;5年人工血管通畅率为14/17.结论 MCAS可同时缓解混合型布加综合征的门静脉高压和下腔静脉高压,术后降压效果明显,并发症少,5年生存率和人工血管通畅率高,是一种可供选择的手术方式.     

放射介入加肠腔架桥联合门奇断流术治疗布-加综合征

目的　评价下腔静脉放射介入加肠腔C型架桥联合门奇断流术对布 -加综合征的治疗效果。方法　对 1995年 7月至 1998年 12月收治的 10例下腔静脉及主肝静脉完全闭塞、又无扩张代偿的副肝静脉的10例病人 ,行经皮腔下腔静脉球囊导管扩张内支架术后 ,再行肠系膜上静脉下腔静脉人工血管C型架桥联合门奇断流术 (联合手术 )。结果　下腔静脉压力由 1 5 7～ 2 7kPa(16～ 2 8cmH2 O )降至 0 78～ 1 47kPa(8～15cmH2 O) ,门静脉压力由 2 94～ 4 41kPa(30～ 45cmH2 O)降至 2 45～ 2 94kPa(2 5～ 30cmH2 O) ,1例病人死于手术后急性肝功能衰竭 ,余随访 6个月至 2年 ,肝脾缩小 ,腹水减少或消失 ,下肢水肿消失。结论　本联合术式对某些类型的布 -加综合征病人为合理、适用的术式     

放射介入加肠腔架桥联合门奇断流术治疗布—加综合征

目的 评价下腔静脉放射介入加肠腔Ｃ型架桥联合门奇断流术对布－加综合征的治疗效果。方法 对１９９５年７月至１９９８年１２月收治的１０例下腔静脉及主肝静脉完倒闭和塞、又无扩张代偿的副肝静脉的１０例病人，行经皮腔下腔静脉球囊导管扩张内支架术后，再行肠系膜上静脉下腔静脉人工血管Ｃ型架桥联合门奇断流术（联合手术）。结果 下腔静脉压力由１．５７～２．７ｋＰａ（１６～２８ｃｍＨ２Ｏ）降至０．７８～１．４７ｋＰａ     

经腹运用肝脏游离技术治疗肾癌合并肝后下腔静脉瘤栓

目的 探讨经腹运用肝脏游离技术治疗肾癌合并肝后下腔静脉瘤栓的安全性和有效性.方法 2002年至2012年我院收治16例肾癌合并肝后下腔静脉瘤栓患者,15例经腹运用肝脏游离技术显露下腔静脉,完整切除瘤栓和根治性肾切除.结果 手术中无一例发生死亡,平均手术时间130～320 min,术中失血约200～1 000 ml,所有瘤栓均被完全切除,术中无栓塞发生.结论 经腹运用肝脏游离技术可以充分显露肝后的下腔静脉,对于肝后下腔静脉瘤栓以及部分膈上下腔静脉瘤栓可以运用肝脏游离技术经腹完全切除,避免经胸手术和心肺分流.     

布-加综合征下腔静脉阻塞合并血栓形成的治疗

目的 探讨下腔静脉阻塞并血栓形成的布-加综合征的治疗方法.方法 回顾分析近6年间收治的75例下腔静脉阻塞并血栓形成的布一加综合征患者的临床资料.其中行根治性隔膜切除、血栓取出22例,腔-腔(房)人工血管架桥41例,放射介入+内支架放置12例.结果 73例手术成功,手术死亡2例,手术后下腔静脉压力明显下降.临床症状及体征消失或缓解.随访6个月至6年,复发4例;其中人造血管堵塞2例,再发下腔静脉狭窄2例.结论 对下腔静脉阻塞合并血栓形成的布一加综合征患者,根据阻塞节段及血栓长度选择相应手术方式,大多可以取得满意效果.     

Retrohepatic cavoatrial bypass for coarctation of inferior vena cava with a polytetrafluoroethylene graft

Eight patients with chronic Budd-Chiari syndrome resulting from coarctation of the inferior vena cava underwent operation. Transatrial dilatation was of no avail in the first case. The obstructed segment was directly visualized in the subsequent seven cases by a transthoracic, transdiaphragmatic, retroperitoneal approach. In these latter seven cases, severe hourglass constriction of the inferior vena cava was observed just above the right hepatic vein. There was no evidence of inflammation, extrinsic compression, or thrombosis. Retrohepatic cavoatrial bypass with an antibiotic-sterilized aortic homograft was unsuccessful in three patients. Five patients including one with homograft failure underwent successful retrohepatic cavoatrial bypass with a polytetrafluoroethylene graft (20 mm plain in four cases and 16 mm ringed graft in one case). These patients have been followed up for 21 months to 6 years with no recurrence of symptoms. The term coarctation of the inferior vena cava appears more appropriate than membranous obstruction of the inferior vena cava because of the operative findings in the present series.     

Renal cell carcinoma with inferior vena caval involvement

Renal cell carcinoma extends into the lumen of the inferior vena cava in approximately 4% of patients at the time of diagnosis. Surgical removal of the intracaval tumor thrombus with radical nephrectomy is the preferred treatment for this malignancy. From January 1977 to June 1990, 31 such patients were examined for combined problems of renal carcinoma and intracaval tumor extension. Twenty-six of these patients underwent radical nephrectomy and vena caval thrombectomy. Ten patients had tumor thrombus confined to the infrahepatic vena cava, 11 had retrohepatic caval involvement, and 5 had extension to the level of the diaphragm or into the right atrium. Surgical approach was dictated by the level of caval involvement. Control of the suprahepatic vena cava plus temporary occlusion of hepatic arterial and portal venous inflow were necessary in some cases; cardiopulmonary bypass was required for transatrial removal of more extensive tumors. Five of the 26 patients had evidence before operation of distant metastatic disease; none of these survived beyond 12 months. The 5-year actuarial survival rate of the 21 patients without known preoperative metastatic disease was 57%. Complete surgical excision of all gross tumor appears to be critical for long-term survival in these patients.     

Suprarenal vena caval occlusion. Principles of operative management.

Retrohepatic occlusion of the inferior vena cava caused by tumor complicates complete resection and not infrequently is associated with life-threatening symptoms that accelerate the lethality of the underlying malignant process. This report summarizes our experience with caval thrombectomy and reconstruction that allowed complete removal of all gross tumor in seven patients with malignant occlusion of the retrohepatic inferior vena cava. Included in this group are five patients with renal cell carcinoma and extension of tumor into the retrohepatic vena cava. Three of these patients had extension of tumor thrombus into the right atrium. A sixth patient had recurrent right adrenal cortical carcinoma with tumor invasion of the vena cava and occlusion to the right atrium. Associated hepatic vein occlusion and secondary Budd-Chiari syndrome also was successfully managed in this patient. The final patient with occlusion of the entire suprarenal vena cava required caval reconstruction after resection of a primary leiomyosarcoma of the retrohepatic portion of the vena cava. Careful planning of the operative procedure, adequate exposure, complete mobilization of the retrohepatic vena cava, and control of the hepatic venous effluent will allow patients with retrohepatic vena caval occlusions to be managed with safety and success.     

Budd-Chiari syndrome with thrombosis of the inferior vena cava: long-term patency of meso-caval and cavoatrial prosthetic bypass

Portacaval or mesocaval shunts may relieve ascites that is caused by chronic forms of primary Budd-Chiari syndrome. When inferior vena cava stenosis is severe or is the site of thrombosis, another procedure has to be used. Portoatrial or cavoatrial shunting has been suggested, and a few reports have been made after only a short follow-up period. The case of a young woman with long-standing ascites caused by primary occlusion of the hepatic veins illustrates the incomplete relief of ascites after mesocaval shunt, which was caused by severe stenosis of the inferior vena cava. At 2 1/2-year follow-up, thrombosis of the retrohepatic inferior vena cava was documented and the mesocaval shunt remained patent. Cavoatrial bypass performed with the use of a long Dacron graft was successful as noted at a 4 1/2-year postoperative follow-up, and there was angiographic proof of patency. Budd-Chiari syndrome with stenosis or thrombosis of the inferior vena cava may be cured by prosthetic bypasses to the right atrium. Combined mesocaval and cavoatrial shunt should be encouraged in this specific situation.     

Leiomyosarcoma of the retrohepatic vena cava treated by excision and reconstruction with an aortic homograft: a case report and review of literature

Leiomyosarcoma of the retrohepatic inferior vena cava is a rare entity and presents a number of diagnostic and therapeutic challenges. Here such a case is presented in which the retrohepatic inferior vena cava was excised after full mobilization of the liver under venovenous bypass. The continuity of the vena cava was restored with cryopreserved aortic homograft. The technical details with regard to total vena caval clamping, venovenous bypass, hepatic inflow occlusion, techniques of reconstruction, including the use of cryopreserved aortic homograft, and a brief review of the literature on the surgical management of retrohepatic inferior vena caval tumors are discussed.     

Segmental resection of tumoral invasion of the inferior vena cava without reconstruction

STUDY AIM: Oncological complete surgery of retroperitoneal tumours may require segmental resection of part of the invaded inferior vena cava. The aim of this retrospective study was to assess whether reconstruction of the inferior vena cava is necessary and presents any advantage. PATIENTS AND METHODS: This study included four patients who underwent partial resection of the inferior vena cava invaded by a retroperitoneal tumour, without reconstruction. Tumours were one renal cancer, one malignant phaeochromocytoma, one malignant retroperitoneal histiofibroma and one undifferentiated retroperitoneal carcinoma. The resection was located at the level of the renal confluence, associated with right nephrectomy, in 3 patients, and above this confluence, at the level of the retrohepatic inferior vena cava in 1 patient. RESULTS: Only one case of transient acute renal failure was observed during the postoperative course. One patient developed right deep vein thrombosis after three months and another one after 30 months. One patient died from cancer recurrence after 19 months. The other 3 patients were alive with anticoagulant therapy and without sequelae after 3, 6 and 15 years.     

Analysis of the complications of the piggy-back technique in 1,112 liver transplants.

BACKGROUND: The "piggy-back" technique has gained acceptance in adult orthotopic liver transplantation during the last few years, especially in European countries. At the moment, however, there is controversy over advantages or specific complications (suprahepatic thrombosis or narrowing, etc.) related to this surgical technique. The aim of this study is to know of the immediate per-and postoperative morbidity and mortality rates in 1112 orthotopic liver transplantations performed with a vena cava preservation technique. METHODS: All liver transplant units in Spain were sent a questionnaire on retrohepatic vena cava preservation during orthotopic liver transplantation. The number of orthotopic liver transplantations that had been performed in the seven centers that answered the questionnaire, because the beginning of the program, was 1674, with the vena cava preservation technique used in 1112. RESULTS: Twenty-eight patients (2.5%) had intraoperative complications related to the vena cava preservation technique, which were treated during the operation. Eleven patients (1%) had early postoperative complications (first week), the most frequent (nine cases) being an acute Budd-Chiari syndrome in the first 48 hr. Three patients developed symptoms of massive ascites between 2 and 3 months (late postoperative complications), with patency of the retrohepatic cava verified by cavography. A hemodynamic study revealed a hyperpressure at the suprahepatic veins. This chronic Budd-Chiari syndrome was controlled in all patients with diuretics. Only six patients (0.5%) died as a result of complications related to the "piggy-back" technique. These complications were more frequent when venous reconstruction was done using two suprahepatic veins than when the three veins were used (P<0.001). CONCLUSIONS: The vena cava preservation technique can be used routinely in orthotopic liver transplantation because it is safe and efficient and involves few surgical complications especially if for venous reconstruction we use the patch obtained by joining the three suprahepatic veins.     

Pathology of the inferior vena cava and liver transplantation

Pathology of the inferior vena cava is not frequently encountered in the context of liver transplantation. Such a pathology was observed in 7.9% of our recipients, in the pre- intra- and post-operative period. Pre-existing anomalies of the IVC consisted the absence of the retrohepatic vena cava in 7 children with biliary atresia; technical adjustments were quite simple. During the operative period, dissection of the supra-hepatic vena cava was made very difficult in 2 patients with hepatic alveolar echinococcosis complicated by secondary biliary cirrhosis it was necessary to make a trans-diaphragmatic approach to the inferior vena cava. Post-operative inferior vena cava thrombosis occurred in four recipients, in three cases, it was caused by the inadequate size of the graft and major anastomotic discrepancy between the inferior vena cava of donor and recipient and in one case IVC thrombosis occurred in a context of allergy to heparin. Six of the 13 recipients with pathology of inferior vena cava died directly of indirectly because of these problems. Analysis of the causes of this pathology and their possible correction will perhaps allow better results in these patients who undergo liver transplantation.