血管内支架在肝移植后血管并发症中的应用探讨

目的：探讨血管金属内支架在肝移植后血管并发症中的适应证和意义。方法：回顾性研究了8例使用血管金属内支架治疗肝移植后血管并发症的病例，并对术后病人情况进行了随访。结果：5例下腔静脉狭窄，支架置入后均获得了成功，术后2例（2／5）分别存活了22个月和8个月，另3例短期内死于其它原因，2例门静脉狭窄，1例（1／2）支架置入后存活了3个月，1例术后2周死亡；1例肝动脉狭窄支架置入患术后短期内死亡。结论：血管内支架放置术是一种处理肝移植后血管并发症的有效方法，它适用于肝移植后血管扭曲、旋转引起的血管狭窄，如肝移植术后早期发生的下腔静脉狭窄。血管内支架在治疗肝移植术后肝动脉狭窄并发症中应谨慎选择。其它原因所致的血管狭窄，血管内支架可在单纯PTA治疗不满意时选用。     

Ultrasonically guided inferior vena cava stent placement: experience in 83 cases

PURPOSE: Traditionally, inferior vena cava (IVC) stent placement is performed with fluoroscopic guidance. The object of this study was to evaluate use of ultrasound (US) as guidance for IVC stent placement for the management of Budd-Chiari syndrome. MATERIALS AND METHODS: Eighty-three patients with IVC membranous stenosis (n = 30), membranous occlusion (n = 19), segmental stenosis (n = 21), or segmental occlusion (n = 13) underwent IVC recanalization, balloon dilation, and stent placement under US guidance. Among the 83 patients, 67 had at least one patent hepatic vein, while 16 patients had three occluded hepatic veins. RESULTS: IVC stents were successfully placed in 79 of 83 patients, with a success rate of 95%. After the procedure, the symptoms and signs of IVC obstruction disappeared or markedly improved in all patients, and the blockage of hepatic outflow was alleviated in 67 patients. Pericardial effusion, complete atrial ventricular block, and stent migration into the right atrium occurred, respectively, in one patient. During 1-46-month follow-up, stent restenosis occurred in one patient; the other stents remained open and functioned effectively. CONCLUSION: Because of the absence of nonionizing radiation and iodinated contrast material, and its low cost, US is well suited and often preferred for guidance of IVC stent placement.     

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.     

不同类型Budd-Chiari综合征的介入治疗(附200例分析)

目的探讨不同类型Ｂｕｄｄ－Ｃｈｉａｒｉ综合征（ＢＣＳ）介入治疗方法，评价经皮穿刺球囊扩张术（ＰＴＡ）和内支架（ｓｔｅｎｔ）治疗Ｂｕｄｄ－Ｃｈｉａｒｉ综合征的价值。材料与方法８年中诊治Ｂｕｄｄ－Ｃｈｉａｒｉ综合征患者２００例。介入治疗方法包括：下腔静脉球囊扩张术，下腔静脉球囊扩张和血管内支架放置术，经颈静脉行肝静脉成形术，经皮经肝和经颈静脉行肝静脉成形术，副肝静脉成形术，下腔静脉和肝静脉双球囊扩张术，下腔静脉和肝静脉双支架放置术。结果介入治疗ＢＣＳ的成功率为９４．４％。术中死亡率０．５％。严重的并发症为误穿心包导致心包填塞和血管内支架脱入右心房。结论ＰＴＡ和ｓｔｅｎｔ放置是一种安全、可靠的方法，可以替代外科对ＢＣＳ的治疗。     

Clinical Outcome after Intrahepatic Venous Stent Placement for Malignant Inferior Vena Cava Syndrome

We evaluated the clinical outcome of malignant inferior vena cava (IVC) syndrome after intrahepatic IVC stent placement by retrospective analysis of 50 consecutive patients (25 men, 25 women, age 32–83 years) with malignant IVC syndrome who were treated with intrahepatic stent placement. Gianturco-Rosch-Z (GRZ) stents (n = 45), and Wallstents (n = 5) were inserted. Clinical outcome was assessed from patients records using a score based on leg swelling, scrotal/vulvar edema, ascites and anasarca before and after stent placement, as well as at last follow-up visit before death. Clinical follow-up was supplemented by duplex sonography in 36 patients. Inferior venocavography was performed in 5 patients prior to re- intervention. Follow-up time ranged from 1 to 932 days (mean 62 days). Mean pressure gradient in the IVC was reduced from 14 ± 4.1 mmHg before to 2.9 ± 3.2 mmHg after stent placement (p < 0.001). Four patients had stent occlusion, 2 of whom were successfully re-stented. Primary and secondary patency was 59% and 100%, respectively at 540 days. Immediate clinical data were available in 44 patients: 38 improved; 6 did not respond. Last follow-up visit data were available in 36 patients: 24 showed persistent symptom relief till death. All symptom scores were significantly improved after stent placement (p < 0.001) and with the exception of ascites, remained significantly improved (p < 0.05) until the last follow-up. Increased serum bilirubin was a common characteristic of clinical failures and recurrences. Intrahepatic IVC stent placement resulted in significant symptomatic relief in patients with malignant IVC syndrome. Palliation was effective even in patients with a very short life expectancy.     

肝移植术后血管胆道并发症的介入治疗

目的:评价介入治疗对肝移植后胆道、血管并发症的价值。材料和方法:18例肝移植患者接受了介入治疗。其中肝动脉狭窄8例,行肝动脉造影及溶栓治疗;下腔静脉及肝静脉狭窄2例,行内支架置入术;胆瘘及胆道狭窄8例,行PTCD治疗。结果:胆道并发症8例,PTCD治疗后症状消失;肝动脉狭窄8例,溶栓后肝动脉完全开放6例,1例血流部分开放,1例肝动脉血流未恢复再次肝移植治疗;下腔静脉及肝静脉狭窄2例内支架置入术后下腔静脉梗阻及肝肿大症状消失。结论:介入治疗是治疗肝移植后胆道血管并发症的有效方法。     

大动脉炎颈动脉狭窄球囊扩张和内支架的治疗

目的：探讨应用球囊扩张和血管内支架治疗大支脉炎、颈动脉狭窄、材料和方法：３例大动脉炎性颈动脉狭窄的患者，狭窄段均超过８ｃｍ，１例单纯球囊扩张；２例球囊扩张后植入Ｗａｌｌｓｔｅｎｔ支架。结果：术后狭窄率均为０，达到了良好的治疗效果，单纯球囊扩张的动脉一年后动脉完全闭塞、西入血管内支架的２例，分别是在４．５个月和４个月检查，一例血管内支架的近端出现了再狭窄，另一例未出现再狭窄。结论：对于大动脉炎性长段     

Prototype percutaneous thrombolytic device: preclinical testing in subacute inferior vena caval thrombosis in a pig model.

PURPOSE: To develop an animal model of subacute inferior vena caval (IVC) thrombosis and apply this model in evaluating the safety and efficacy of a prototype percutaneous thrombolytic device for restoring patency. MATERIALS AND METHODS: In 11 pigs, a stent with a ligature in the middle was placed in the IVC. Thrombin was injected to induce thrombosis. Hemostasis was achieved by using an occlusion balloon. The stent was ligated to prevent thrombus migration. Five to 8 days after thrombus induction, the ligature was broken and the stent fully deployed. In 10 animals, thrombectomy was performed by using the percutaneous thrombolytic device. A vena caval filter was inserted at the beginning of each declotting procedure. Thrombus removal percentage was estimated and pulmonary angiograms obtained to detect embolism before and after thrombectomy. The IVC was analyzed histologically. To determine thrombus composition, one animal was sacrificed without thrombectomy. Concerning procedural safety, failure of the stent delivery system, stent migration, and venous perforation due to balloon inflation and the stent placement or thrombectomy procedure were evaluated. RESULTS: Thrombus creation was successful in all animals. Fragmentation led to 75%--100% thrombus removal with flow restoration in all cases. There were no episodes of stent delivery failure, stent migration, or venous perforation. No significant pulmonary embolism was observed. In one case, a vessel dissection was identified at histologic examination. CONCLUSION: In this animal model of IVC thrombosis, the percutaneous thrombolytic device is effective and safe for clot removal.     

Treatment of inferior vena cava anastomotic stenoses with the Wallstent endoprosthesis after orthotopic liver transplantation

PURPOSE: To evaluate the efficacy of the Wallstent endoprosthesis for treatment of stenotic or occlusive inferior vena cava (IVC) lesions refractory to balloon angioplasty in patients after orthotopic liver transplantation. MATERIALS AND METHODS: Wallstent endoprostheses were implanted in six patients with IVC anastomotic stenoses or occlusions that were refractory to balloon angioplasty. Follow-up included both duplex ultrasound (US) and clinical evaluations. RESULTS: Ten stents were successfully implanted in six patients. Five of six patients (83%) demonstrated primary patency on duplex US for a mean period of 11 months (range, 4-17 months). One patient's symptoms recurred within 3 weeks after intervention. This patient underwent repeated stent placement. Follow-up duplex US in this patient demonstrated primary assisted patency at 7 months. Mean clinical follow-up was 12 months (range, 7-18 months). Other than the previously described case, no patient developed recurrent symptoms of IVC stenosis or occlusion. Two patients who experienced hemorrhagic complications secondary to anticoagulation were treated successfully. CONCLUSIONS: The Wallstent endoprosthesis is a useful adjunct for treatment of IVC stenosis or occlusions in patients who have undergone orthotopic liver transplantation when these lesions are refractory to simple balloon angioplasty.     

血管内支架放置治疗下腔静脉闭塞伴血栓形成

为了使下腔静脉闭塞伴血栓形成，在作成形手术时既能有效地保持下腔静脉再通，又能避免肺栓塞发生，我们对３例下腔静脉闭塞伴血栓形成的患者实施ＰＴＡ和ｓｔｅｎｔ置入术，均取得满意效果。支架置入后，下腔静脉通畅，无肺栓塞发生。支架具有支撑血管和压迫固定血栓的双重作用。     

Inferior vena cava thrombosis after transjugular intrahepatic portosystemic shunt revision with a covered stent

A 42-year-old woman who had undergone multiple revisions of a bare-stent transjugular intrahepatic portosystemic shunt was treated for in-stent stenosis by insertion of a polytetrafluoroethylene (PTFE)-covered stent. Immediately after revision with the covered stent, she developed inferior vena cava (IVC) thrombosis. The potential causes and implications of this complication are discussed.     

Filter-related,thrombotic occlusion of the inferior vena cava treated with a Gianturco stent

The authors report a case of complete thrombotic occlusion of the inferior vena cava (IVC), which occurred 4 weeks after placement of an IVC filter (TrapEase; Cordis, Miami FL). Initial treatment with suction thrombectomy and thrombolysis was ineffective. Percutaneous removal of the filter was unsuccessful because of the long period of implantation. TrapEase filters (Cordis) are easily collapsible because of their symmetric design and composition (nitinol). An expandable metallic Gianturco Z stent (Cook, Bloomington, IN) was used to exclude the filter from the vessel lumen. In cases of persistent filter-related, thrombotic occlusion of the IVC, in which initial treatment has failed, the use of a Gianturco stent (Cook) to exclude the filter from the vessel lumen is a viable treatment option if the filter has a collapsible design.     

DSA导向气道内支架置入治疗气道狭窄的手术配合与护理

目的 研究DSA导向气道内支架置入治疗气道狭窄的护理要点.方法 对采用气道内支架置入治疗的118例气管狭窄患者,在治疗中实施相应护理.结果 118例气道狭窄患者置入支架后,呼吸困难明显改善.结论 通过术前加强心理护理和手术体位训练,术后密切观察生命体征变化,预防并发症,做好康复护理及出院指导,有助于患者的康复.     

The use of coronary stent in hepatic artery stenosis after orthotopic liver transplantation

PURPOSE: This retrospective study was undertaken to evaluate the effectiveness of coronary stent placement in hepatic artery stenosis after orthotopic liver transplantation (OLT). MATERIALS AND METHODS: Of 430 consecutive adult orthotopic liver transplant recipients between November 2003 and September 2005, 17 had hepatic artery stenosis (HAS). Fourteen of them underwent coronary stent placement in the HAS. The technical results, complications, hepatic artery patency and clinical outcome were reviewed. RESULTS: Technical and immediate success was 100%. After a mean follow-up of 159.4 days (range, 9-375 days), all patients obtained patent hepatic arteries except 2 patients occurred hepatic artery restenoses at 26 and 45 days after stent placement, respectively. Kaplan-Meier curve of patency showed cumulated stent patency at 3, 6, and 12 months of 78%, 58% and 45%, respectively. During the follow-up, 8 patients survived, 5 died of septic multiple-organ failure, 1 received retransplantation because of refractory biliary infection. Hepatic artery dissection induced by a guiding catheter occurred in one patient and was successfully treated with a coronary stent. CONCLUSION: Hepatic artery stenosis after OLT can be successfully treated with coronary stent placement with low complication rate and an acceptable 1-year hepatic artery patency rate.     

Chronically occluded inferior venae cavae: endovascular treatment

PURPOSE: To report the results of endoluminal recanalization and stent placement in patients with chronic occlusions of the inferior vena cava (IVC). MATERIALS AND METHODS: Seventeen consecutive patients (12 male, five female patients; mean age, 40.6 years; age range, 15-77 years) with chronic IVC occlusions were treated during a 6-year period. The mean duration of symptoms was 32 months. Underlying active malignancy was the cause of occlusion in four patients. Five patients with superimposed acute thrombus underwent catheter-directed thrombolysis prior to IVC recanalization. Clinical patency was defined as absence or improvement of symptoms. Clinical follow-up was supplemented with ultrasonography, vena cavography, or both in 10 patients. RESULTS: Technical success was achieved in 15 (88%) patients. Additional thrombolytic therapy and stent placement was needed in two patients to maintain patency at 4 and 6 months after the procedure. Twelve patients had IVCs that remained patent after a mean follow-up of 19 months for a primary patency rate of 80%. The primary assisted patency rate was 87% (13 of 15). There were four deaths owing to underlying disease 6-21 months after the procedures. There were no procedure-related complications. CONCLUSION: Endoluminal recanalization and stent placement in chronically occluded IVCs has a good intermediate-term outcome and should be considered in patients who have symptoms and who often do not have adequate alternative therapy.     

Diffusion-weighted imaging abnormalities after percutaneous transluminal angioplasty and stenting for intracranial atherosclerotic disease

BACKGROUND AND PURPOSE: The literature contains relatively few reports of distal embolism associated with intervention for intracranial atherosclerotic disease. Our purpose was to evaluate the frequency of thromboembolic events after percutaneous transluminal angioplasty (PTA) or stent placement in this setting by using diffusion-weighted (DW) imaging. METHODS: Between October 1999 and January 2004, 16 consecutive patients with symptomatic intracranial arterial stenosis greater than 60% were treated with PTA or stent placement without a protection system. Whole-brain DW imaging was performed before and after intervention. DW imaging findings were retrospectively analyzed and divided into three groups according to new hyperintensities: type A was none; type B, a single lesion; and type C, multiple lesions. RESULTS: Nine type A, five type B, and three type C lesions were detected after the interventions. All hyperintense lesions were less than 5 mm in diameter. All type C lesions occurred in the context of internal carotid artery stenosis treated with stent placement. DW imaging abnormalities occurred most frequently when PTA followed by stent placement was performed for long internal carotid artery stenoses. No new neurologic deficits occurred in any patient. CONCLUSION: In this series, PTA or stent placement or both for intracranial atherosclerotic lesions was safe. New DW imaging abnormalities were less frequent in patients who underwent PTA alone or primary stent placement than in those receiving PTA followed by stent placement.     

原发性肝癌致下腔静脉梗阻的介入性开通治疗

目的：评价原发性肝癌引起的下腔静脉恶性梗阻Z形自膨式腔内支架介入治疗的疗效。方法：对46例原发性肝癌所致下腔静脉恶性梗阻患者采用Z形自膨式金属内支架治疗。术前对患者行CT或MRI查了解下腔静脉梗阻情况及临床梗阻症状。放置支架前后分别行下腔静脉造影,测量梗阻段两端压力差。术后每1～2个月行下腔静脉造影或CT检查随访支架通常情况。结果：46例患者梗阻下腔静脉均开通成功,手术成功率100％（46／46）。2例患者因梗阻段超过10cm而置入2个支架,其余均置入1个支架。开通前后下腔静脉压由术前2．4±0．5kPa降至0．6±0．12kPa。经t检验,开通前后下腔静脉狭窄端压力变化具有非常显著差异（t=3．135,P〈0．05）。术后1～5天患者症状明显改善,未见严重并发症发生。随访2～10个月,4例患者出现下腔静脉再狭窄,支架通畅率为91．3％（42／46）。结论：置入Z形自膨式金属支架,是对原发性肝癌引起的下腔静脉梗阻一种安全有效的姑息性治疗方法。     

Symptomatic vertebral artery stent fracture: a case report

Percutaneous transluminal angioplasty (PTA) with stent placement is the preferred treatment modality at present for atherosclerotic stenotic lesions of vertebral artery origin. A complication of stent placement in the vertebral artery origin that has received little attention is the risk of stent fracture. A case with four-vessel pathology treated with PTA and stent placement in the left vertebral artery origin is presented. Symptoms recurred 4 months after stent placement, and arteriogram revealed a fractured stent, which was treated surgically with stent removal and vertebral artery-common carotid artery reimplantation.     

Primary stent placement for infrarenal aortic stenosis: immediate and midterm results

PURPOSE: To evaluate the safety and the long-term clinical and hemodynamic results of primary stent placement of atherosclerotic calcified stenosis of the infrarenal aorta. MATERIAL AND METHODS: Between July 1996 and July 1999, 15 patients (nine male, si- female; mean age, 53.9 years) with symptomatic, calcified aortic stenosis were treated with primary stent placement. Patients underwent abdominal aortography and bilateral lower extremity arteriography. Follow-up was performed in all 15 patients. Technical success was defined as residual stenosis of less than 30% or a resting trans-systolic pressure gradient of less than 10 mm Hg after stent placement. Clinical patency was defined as the absence or improvement of symptoms after stent placement. Hemodynamic patency was defined as a normal triphasic Doppler waveform in the common femoral artery, an ankle-brachial index greater than 0.90, or the absence of a thigh-brachial pressure gradient at rest in either limb. RESULTS: Technical success was achieved in 13 of 15 patients. The two patients considered to be technical failures had resting trans-systolic pressure gradients of 12 and 13 mm Hg, respectively, after stent placement. After the mean follow-up of 36 months, primary clinical and hemodynamic patency rates were 85% and the secondary hemodynamic patency rate was 100%. Two of five symptomatic recurrences during the 36-month follow-up period (range, 12-46 months) were a result of aortic restenosis and were treated with repeated percutaneous transluminal angioplasty. None of the patients required aortic surgery. Complications of the primary procedure included one puncture site infection, one pseudoaneurysm, and one distal embolization, which delayed discharge of three patients. There was no morbidity during the secondary interventions. CONCLUSION: Primary stent placement as treatment of calcified infrarenal aortic stenosis proved to be safe and also provided durable long-term clinical improvement.     

Primary endovascular stent placement for focal infrarenal aortic stenosis: initial and midterm results

The objectives of this retrospective study were to determine the technical success, safety, and midterm results of primary stent placement of infrarenal aortic stenosis. Eight stenoses and one occlusion were treated with stent placement after balloon pre-dilation. Primary technical success was achieved in all patients. Five patients showed reperfusion or restored normal direction of flow of the inferior mesenteric artery. No complications occurred. There was a mean follow-up of 12 months (range, 3-20 months). Primary clinical and hemodynamic patency rates were 100% on follow-up examinations. Stent placement after balloon pre-dilation in properly selected patients with isolated infrarenal aortic stenosis is a promising durable treatment.