再谈经颈静脉肝内门腔分流术

经颈静脉肝内门腔分流术 (下称TIPSS)广泛试用于临床以来 ,引起放射科和肝胆科医生们的高度重视和极大的兴趣。近年来 ,美国和欧洲的医学界就此项技术应用于治疗门静脉高压症及预防肝硬化病人近期出血有过多次专题讨论和经验交流[1～ 8] 。我国也先后有很多医院开展了这项工作     

Elective Transjugular Intrahepatic Portosystemic Shunt Using Viatorr Stent-Grafts: A Single-Center Experience from China

Background and Aims:Transjugular intrahepatic portosystemic shunt (TIPS) is a well-established approach for the management of variceal bleeding, refractory ascites, hepatic hydrothorax, and preoperative treatment of portal hypertension prior to major abdominal surgery in patients with compensated cirrhosis, and so on. This study aimed to investigate the safety and long-term efficacy of TIPS implantation using Viatorr TIPS stent-grafts.Material and Methods:A cohort of 59 patients undergoing TIPS placement using Viatorr TIPS stent-grafts were included, and the periprocedural events, and long-term mortality, shunt dysfunction, variceal rebleeding and incidence of hepatic encephalopathy (HE) were analyzed.Results:The technical success rate was 100%. The median portosystemic pressure gradient was reduced from 21 mmHg (interquatile range: 19–25) to 13 mmHg (interquatile range: 10–16) before and after TIPS, leading to a hemodynamic success rate of 72.9%. The cumulative rate of overall mortality was 34.2% at five years, and direct bilirubin (hazard ratio [HR] = 1.336, 95% confidence interval [CI]: 1.050–1.700, P = 0.018) and post-TIPS right atrial pressure (HR = 1.238, 95% CI: 1.015–1.510, P = 0.035) were independent predictors for mortality. The cumulative rates of shunt dysfunction and variceal rebleeding were 11.0% and 28.3% at five years, respectively, and portal venous pressure gradient (HR = 2.572, 95% CI: 1.094–6.047, P = 0.030) was the only independent predictor for shunt dysfunction. The cumulative four-year HE-free rate was 48.6%. No severe adverse event was noted during TIPS procedures.Conclusion:Elective TIPS implantation using Viatorr TIPS stent-grafts is generally safe, and the long-term efficacy is favorable for the treatment of cirrhotic patients with recurrent variceal bleeding or refractory ascites.     

Late Intrahepatic Hematoma Complicating Transjugular Intrahepatic Portosystemic Shunt for Budd-Chiari Syndrome

Late intrahepatic hematoma is a rare complication of the transjugular intrahepatic portosystemic shunt (TIPS) procedure. We describe a patient with Budd-Chiari syndrome (BCS) who presented with a large intrahepatic hematoma 13 days after TIPS. Review of the literature revealed only 2 previous cases, both occurring in patients with BCS and presenting after a similar time interval. This potentially serious complication appears to be specific for TIPS in BCS.     

Late Intrahepatic Hematoma Complicating Transjugular Intrahepatic Portosystemic Shunt for Budd-Chiari Syndrome

Late intrahepatic hematoma is a rare complication of the transjugular intrahepatic portosystemic shunt (TIPS) procedure. We describe a patient with Budd-Chiari syndrome (BCS), who presented with a large inrahepatic hematoma 13 days after TIPS. Review of the literature reveals only two previous cases, both occurring in patients with BCS and presenting after a similar time interval. This potentially serious complication appears to be specific for TIPS in BCS.     

Radiation Exposure in Transjugular Intrahepatic Portosystemic Shunt Creation

Purpose

Transjugular intrahepatic portosystemic shunt (TIPS) creation is considered as being one of the most complex procedures in abdominal interventional radiology. Our aim was twofold: quantification of TIPS-related patient radiation exposure in our center and identification of factors leading to reduced radiation exposure.

Materials and methods

Three hundred and forty seven consecutive patients underwent TIPS in our center between 2007 and 2014. Three main procedure categories were identified: Group I (n = 88)—fluoroscopic-guided portal vein targeting, procedure done in an image intensifier-based angiographic system (IIDS); Group II (n = 48)—ultrasound-guided portal vein puncture, procedure done in an IIDS; and Group III (n = 211)—ultrasound-guided portal vein puncture, procedure done in a flat panel detector-based system (FPDS). Radiation exposure (dose-area product [DAP], in Gy cm² and fluoroscopy time [FT] in minutes) was retrospectively analyzed.

Results

DAP was significantly higher in Group I (mean ± SD 360 ± 298; median 287; 75th percentile 389 Gy cm²) as compared to Group II (217 ± 130; 178; 276 Gy cm²; p = 0.002) and Group III (129 ± 117; 70; 150 Gy cm² p < 0.001). The difference in DAP between Groups II and III was also significant (p < 0.001). Group I had significantly longer FT (25.78 ± 13.52 min) as compared to Group II (20.45 ± 10.87 min; p = 0.02) and Group III (19.76 ± 13.34; p < 0.001). FT was not significantly different between Groups II and III (p = 0.73).

Conclusions

Real-time ultrasound-guided targeting of the portal venous system during TIPS creation results in a significantly lower radiation exposure and reduced FT. Further reduction in radiation exposure can be achieved through the use of modern angiographic units with FPDS.

     

Pancreaticoportal Fistula and Disseminated Fat Necrosis After Revision of a Transjugular Intrahepatic Portosystemic Shunt

A 59-year old man with alcohol related cirrhosis and portal hypertension was referred for transjugular intrahepatic portosystemic shunt (TIPS) to treat his refractory ascites. Ten years later, two sequential TIPS revisions were performed for shunt stenosis and recurrent ascites. After these revisions, he returned with increased serum pancreatic enzyme levels and disseminated superficial fat necrosis; an iatrogenic pancreaticoportal vein fistula caused by disruption of the pancreatic duct was suspected. The bare area of the TIPS was subsequently lined with a covered stent-graft, and serum enzyme levels returned to baseline. In the interval follow-up period, the patient has clinically improved.     

Transcaval Transjugular Intrahepatic Portosystemic Shunt: Preliminary Clinical Results

Objective

To determine the feasibility of transcaval transjugular intrahepatic portosystemic shunt (TIPS) creation in patients with unusual anatomy between the hepatic veins and portal bifurcation, and inaccessible or inadequate hepatic veins.

Materials and Methods

Transcaval TIPS, performed in six patients, was indicated by active variceal bleeding (n=2), recurrent variceal bleeding (n=2), intractable ascites (n=1), and as a bridge to liver transplantation (n=1). The main reasons for transcaval rather than classic TIPS were the presence of an unusually acute angle between the hepatic veins and the level of the portal bifurcation (n=3), hepatic venous occlusion (n=2), and inadequate small hepatic veins (n=1).

Results

Technical and functional success was achieved in all patients. The entry site into liver parenchyma from the inferior vena cava was within 2 cm of the atriocaval junction. Procedure-related complications included the death of one patient due to hemoperitoneum despite the absence of contrast media spillage at tractography, and another suffered reversible hepatic encephalopathy.

Conclusion

In patients with unusual anatomy between the hepatic veins and portal bifurcation, and inaccessible or inadequate hepatic veins, transcaval TIPS creation is feasible.     

Analyzing Radiation Use during Transjugular Intrahepatic Portosystemic Shunt Creation

Portal vein access during transjugular intrahepatic portosystemic shunt creation was examined in 11 patients. Radiation metrics (kerma area product, reference point air kerma, and fluoroscopy times) during portal vein access were significantly greater for conventional versus intravascular US–guided transjugular intrahepatic portosystemic shunt (54.8 mGy ∙ cm² ± 27.6 vs 8.4 mGy ∙ cm² ± 5.0, P = .009; 210.4 mGy ± 109.1 vs 29.5 mGy ± 18.4, P = .009; 19.1 min ± 8.6 vs 8.9 min ± 4.6, P = .04). Wedged hepatic venography is a major contributor to radiation exposure. Intravascular US guidance is associated with significantly reduced radiation use.     

Transjugular Intrahepatic Portosystemic Shunt Creation Using Intravascular Ultrasound Guidance

PurposeTo describe the use of intravascular ultrasound (US) guidance for creation of transjugular intrahepatic portosystemic shunts (TIPSs) in humans.Materials and MethodsThe initial 25 cases of intravascular US–guided TIPS were retrospectively compared versus the last 75 conventional TIPS cases during the same time period at the same institution in terms of the number of needle passes required to establish portal vein (PV) access, fluoroscopy time, and needle pass–related complications.ResultsIntravascular US–guided TIPS creation was successful in all cases, and there was no statistically significant difference in number of needle passes, fluoroscopy time, or needle pass–related complications between TIPS techniques. Intravascular US–guided TIPS creation was successful in cases in which conventional TIPS creation had failed as a result of PV thrombosis or distorted anatomy. Intravascular US guidance for TIPS creation was additionally useful in a patient with Budd–Chiari syndrome and in a patient with intrahepatic tumors.ConclusionsIntravascular US is a safe and reproducible means of real-time image guidance for TIPS creation, equivalent in efficacy to conventional fluoroscopic guidance. Real-time sonographic guidance with intravascular US may prove advantageous for cases in which there is PV thrombus, distorted anatomy, Budd–Chiari syndrome, or hepatic tumors.     

Combined Transjugular Intrahepatic Portosystemic Shunt Plus Variceal Obliteration versus Transjugular Intrahepatic Portosystemic Shunt Alone for the Management of Gastric Varices: Comparative Single-Center Clinical Outcomes

PurposeTo compare the safety and clinical outcomes of combined transjugular intrahepatic portosystemic shunt (TIPS) plus variceal obliteration to those of TIPS alone for the treatment of gastric varices (GVs).Materials and MethodsA single-center, retrospective study of 40 patients with bleeding or high-risk GVs between 2008 and 2019 was performed. The patients were treated with combined therapy (n = 18) or TIPS alone (n = 22). There were no significant differences in age, sex, model for end-stage liver disease score, or GV type between the groups. The primary outcomes were the rates of GV eradication and rebleeding. The secondary outcomes included portal hypertensive complications and hepatic encephalopathy.ResultsThe mean follow-up period was 15.4 months for the combined therapy group and 22.9 months for the TIPS group (P = .32). After combined therapy, there was a higher rate of GV eradication (92% vs 47%, P = .01) and a trend toward a lower rate of GV rebleeding (0% vs 23%, P = .056). The estimated rebleeding rates were 0% versus 5% at 3 months, 0% versus 11% at 6 months, 0% versus 18% at 1 year, and 0% versus 38% at 2 years after combined therapy and TIPS, respectively (P = .077). There was no difference in ascites (13% vs 11%, P = .63), hepatic encephalopathy (47% vs 55%, P = .44), or esophageal variceal bleeding (0% vs 0%, P > .999) after the procedure between the groups.ConclusionsThe GV eradication rate is significantly higher after combined therapy, with no associated increase in portal hypertensive complications. This translates to a clinically meaningful trend toward a reduction in GV rebleeding. The value of a combined treatment strategy should be prospectively studied in a larger cohort to determine the optimal management of GVs.     

Feasibility of Augmented Reality–Guided Transjugular Intrahepatic Portosystemic Shunt

PurposeTo investigate an augmented reality (AR)–guided endovascular puncture to facilitate successful transjugular intrahepatic portosystemic shunt (TIPS).Materials and MethodsAn AR navigation system for TIPS was designed. Three-dimensional (3D) liver models including portal and hepatic vein anatomy were extracted from preoperative CT images. The 3D models, intraoperative subjects, and electromagnetic tracking information of the puncture needles were integrated through the system calibration. In the AR head-mounted display, the 3D models were overlaid on the subjects, which was a liver phantom in the first phase and live beagle dogs in the second phase. One life-size liver phantom and 9 beagle dogs were used in the experiments. Imaging after puncture was performed to validate whether the needle tip accessed the target hepatic vein successfully.ResultsEndovascular punctures of the portal vein of the liver phantom were repeated 30 times under the guidance of the AR system, and the puncture needle successfully accessed the target vein during each attempt. In the experiments of live canine subjects, the punctures were successful in 2 attempts in 7 beagle dogs and in 1 attempt in the remaining 2 dogs. The puncture time of needle from hepatic vein to portal vein was 5–10 s in the phantom experiments and 10–30 s in the canine experiments.ConclusionsThe feasibility of AR-based navigation facilitating accurate and successful portal vein access in preclinical models of TIPS was validated.     

多层螺旋CT在TIPSS术后随访中的应用研究

目的:探讨多层螺旋CT血管成像(MSCTA)在TIPSS术后随访中的价值.方法:17例TIPSS术后患者(共19支支架)行MSCT门静脉成像,采用最大密度投影(MIP)、曲面重组(CPR)和容积再现(VR)技术进行图像后处理.17例中6例进行了DSA检查,11例得到了病理标本.将MSCTA表现与病理或DSA结果进行对照分析.结果:MSCTA发现19支支架中完全闭塞3支,支架狭窄4支,肝静脉端狭窄3支,同时伴有支架内和肝静脉端狭窄3支,未见明显异常6支.与DSA或病理对照,CTA诊断支架狭窄的诊断符合率和特异度分别为90%和83.3%,诊断支架闭塞的诊断符合率和特异度分别为100%和94.1%.结论:MSCTA可准确显示TIPSS术后支架的通畅性,为外科提供了一种无创的随访和筛查的手段.     

Cardiac Perforation and Tamponade During Transjugular Intrahepatic Portosystemic Shunt Placement

A patient developed acute severe hemodynamic compromise during a transjugular intrahepatic portosystemic shunt (TIPS) procedure for intractable ascites. Rapid clinical and radiographic evaluation of the patient disclosed pericardial blood and cardiac tamponade as the cause, probably due to right heart perforation from guidewire and catheter manipulation. The tamponade was successfully treated percutaneously, and the patient survived. Cardiac tamponade should be considered in the differential diagnosis of patients who develop hypotension during TIPS placement.     

经颈静脉肝内门腔静脉内支架分流术的临床应用：附86例随访分析

报告８６例经颈静脉肝内门腔静脉内支架分流术（ＴＩＰＳＳ）的临床应用结果，主要探讨与建立分流道有关的技术问题和影响疗效的因素。８６例中男６８例，女１８例，年龄２２～７４岁（平均４８岁）７１例有明确的乙型肝炎病史，６９例有一次以上呕血或黑便中，５８例曾接受一次以上经内镜注射硬化剂治疗，６例因大出血不止行急诊ＴＩＰＳＳ。全部病例有中度以上食管胃底静脉曲张。结果：７８例成功，８例失败，无死记并发症，建立分