经颈内静脉肝内门体分流术的疗效观察及对门静脉血流动力学的影响

作者研究了经颈内静脉肝内门体分流术（ＴＩＰＳＳ）治疗门静脉高压症的临床疗效及对门静脉血流动力学的影响。对１４０例门静脉高压症患者实施ＴＩＰＳＳ治疗，采用超声多普勒、门静脉造影和测压观察了１００例患者门静脉血流动力学的改变。ＴＩＰＳＳ技术成功率９４．６２％，操作并发症发生率４．６２％，轻度肝性脑病９．０３％，术后死亡率３．０８％；术后１～２４个月随访，分流道狭窄或阻塞率１２％，症状复发率９．０％，死亡率６．０％。肝内分流道建立后门静脉压力和肝外门体分流量显著下降，门静脉流速增加，分流道通畅者分流道和门静脉流速分别下降１１．９３％和２０．１４％，分流道狭窄者流速进一步下降。ＴＩＰＳＳ治疗门静脉高压症疗效显著，动态观察血流变化有助于早期诊断和治疗分流道狭窄或阻塞。     

覆膜支架对肝内分流道通畅的影响

经颈内静脉肝内门体分流术(TIPS)已广泛用于治疗门静脉高压症伴食管静脉曲张破裂大出血和顽固性腹水,临床近期疗效十分显著.近十年来,国外采用Viatorr覆膜支架取代裸支架,用于肝内分流道的建立,成功解决了分流道狭窄和阻塞,显著提高了TIPS治疗门静脉高压症的远期疗效[1].我们采用覆膜支架建立肝内门体分流道,并对100例门静脉高压症患者实施治疗,通过超声、CT血管成像(CTA)和直接门静脉造影研究了覆膜支架对肝内分流道通畅的影响.     

经颈静脉肝内门体静脉分流术治疗门脉高压症的临床应用

我院采用经颈静脉肝内门体静脉分流术（ＴＩＰＳＳ）对１０３例肝硬变门脉高压症患者进行了治疗，其成功率为９５．２％。肝内门体分流建立后出血立即停止，门静脉压力下降，平均下降１．３６±０．０２ｋＰａ，胃冠状静脉和食管静脉曲张消失，脾脏缩小，腹水消退。术后１月内因急性肝功能衰竭死亡３例，再出血１例，轻度肝性脑病１０例。经１～２２个月随访，出现分流道狭窄１０例，出血和腹水复发６例。本组资料表明：ＴＩＰＳＳ是治疗门脉高压症的有效方法。     

经颈内静脉肝内门体分流术治疗门静脉高压症

经颈内静脉肝内门体分流术（ｔｒａｎｓｊｕｇｕｌａｒｉｎｔｒａｈｅｐａｔｉｃｐｏｒｔｏｓｙｓｔｅｍｉｃｓｔｅｎｔｓｈｕｎｔ，ＴＩＰＳＳ）是门静脉高压症治疗方法的重大进展一。作用采用该方法对５０例Ｃｈｉｉｄ－ｐｕｇｈ平均评分１０．３３±２．３４的肝硬变门静脉高压症患者进行治疗。５例门静脉血栓除外，ＴＩＰＳＳ成功率是９５．６％，肝内门体分流建立后出血立即停止，门静脉压力下降１．３６±０．４８ｋＰａ，食管曲张静脉和其它侧支血管消失；术后１周脾脏缩小，腹水消退，体重减轻，支撑内血流速度足８５．６１±３５．８３ｃｍ／ｓ；随访１～９个月，无出血、腹水复发。支撑内血流速度是８３．８３±３４．７４ｃｍ／ｓ，术后１个月内死亡３例，死因为肝功能衰竭和复发出血性。轻度肝性脑病６例，本组资料表明：ＴＩＰＳＳ对门静脉高压症食管静脉曲张出血、腹水的近期疗效显著；而且创伤小，并发症少，有进一步推广应用的价值。     

门静脉和下腔静脉阻断与开放后门静脉高压犬肺动脉和肺组织超微结构改变

目的观察门静脉和下腔静脉阻断与开放后门静脉高压模型犬肺组织与肺动脉的超微结构改变。方法正常家犬18只,随机均分为阴性对照组（仅用于取肺组织和肺动脉标本）、对照组和门静脉高压模型组（采用部分结扎门静脉的方法建立患门静脉高压症犬模型并饲养12周）,进行门静脉、肝上和肝下下腔静脉阻断与开放实验。在术毕后取右下肺动脉和肺组织,应用透射电镜观察其超微结构。结果门静脉和下腔静脉阻断与开放后门静脉高压犬肺组织内皮细胞、Ⅰ型肺泡上皮细胞和Ⅱ型肺泡上皮均出现明显的病理性改变;肺泡隔纤维化明显,胶原纤维增生;肺毛细血管内血栓形成,基膜明显增厚;肺动脉血管内皮细胞损伤明显,部分脱落;肺动脉内皮细胞与中膜间隙明显增宽,内皮下水肿,内皮下胶原纤维增多。结论伴门静脉高压的肝移植犬肺组织和肺动脉的超微结构有明显改变,这可能是肝移植受者围术期出现急性肺高压和急性肺损伤的超微病理学基础之一。     

经颈静脉肝内门体分流术治疗门静脉海绵样变并发门静脉高压

目的探讨经颈静脉肝内门腔静脉分流术治疗合并门静脉海绵样变的门静脉高压症的疗效。方法 8例反复上消化道出血患者(均有肝硬化、门静脉高压)术前均经B超及CT等影像学证实伴有门静脉海绵样变,门静脉主干及左右支有完全或部分闭塞,对其行TIPS治疗,并评价疗效。结果对7例患者均成功施行TIPS术,1例失败,6例为先经皮穿刺右肝门静脉分支,建立经门静脉右支至主干通道,并行球囊扩张成形治疗。其中4例经常规TIPS途径由肝右静脉穿刺门静脉右支建立门腔静脉分流道,2例由门静脉右支穿刺右肝静脉建立门腔静脉分流道。1例穿刺门静脉右支失败,改由常规TIPS途径穿刺门静脉左支建立门腔静脉分流道。门静脉压力由术前的(33.72±8.35)mmHg降低至术后的(21.43±7.64)mmHg;1例在术后6个月发现分流道狭窄,再次植入支架后恢复通畅。1例术后5个月再发黑便,复查提示分流道堵塞,并门静脉广泛血栓形成,放弃进一步治疗。另5例在12个月随访中分流道通畅,未再发消化道出血。结论 TIPS是治疗伴门静脉海绵样变的门静脉高压症的安全、有效的方法。     

TIPSS在门静脉高压症治疗中的临床价值

研究经颈内静脉肝内门体分流术(TIPSS)在门静脉高压症治疗中的价值。方法:1993年8月～1998年8月,我院对200例门静脉高压症患者实施TIPSS治疗,其中20例行TIPSS与Sugiura改良术联合治疗。结果:TIPSS的技术成功率为94.59％,术后近期死亡率3.87％,出血复发率2.58％,轻度肝性脑病18.71％。经1至5年随访,出血和腹水复发率分别为27.08％和41.18％,分流道狭窄阻塞率30.77％,死亡率28.46％;TIPSS加改良Sugiura术后经1～24月随访,无出血复发,肝内分流道保持通畅。结论:TIPSS与改良Sugiura术的联合应用,可提高门静脉高压症的临床疗效。     

采用Viatorr覆膜支架行经颈静脉肝内门体分流术

目的评价采用Viatorr覆膜支架行经颈静脉肝内门体分流术(TIPS)治疗门静脉高压并发症的疗效与安全性。方法回顾性分析8例接受Viatorr覆膜支架TIPS治疗的肝硬化门静脉高压症患者的资料。术后进行随访,复查上腹部CT,以评价TIPS疗效。结果对8例患者均成功手术,均采用直径8mm、覆膜段长度50~80mm的Viatorr覆膜支架建立肝内分流道。对其中1例合并门静脉海绵样变的患者于门静脉端置入8mm×40mm的E-Luminexx裸支架1枚;1例患者因肝静脉端狭窄于肝静脉端置入8mm×40mm的Fluency覆膜支架1枚。术后患者门静脉压力由术前的[33.08(29.32,40.22)]mmHg降为[23.31(21.43,26.51)]mmHg,差异有统计学意义(Z=-2.52,P=0.012)。术后随访1.1~7.7个月,所有患者均存活,均未再发生门静脉高压相关并发症。术后2例患者发生肝性脑病。术后1~7.7个月复查示所有患者TIPS分流道通畅。结论对国内肝硬化门静脉高压症患者应用Viatorr支架行TIPS治疗安全、有效。     

静脉内支撑治疗布加综合征临床研究

为了研究静脉内支撑治疗布上的临床疗效,作者采用该方法对１０例布加综合征患者实施的治疗,根据血管病变的部位和范围选择下腔静脉扩张内支撑、肝脉扩张内支撑和肝内门体分流术。结果显示：术后患者临床症状明显改善、门静脉压力、下腔差显著下降,支撑血管血液流动正常,无操作并发症。经１－２１个月随访,出血复发１例,静造影示肝内分流道狭窄１例,下腔静再狭窄１例,均行丙次介入治疗。作者认为,静脉内支撑治疗布加综合片人     

超声引导下经颈静脉肝内门体分流术治疗门静脉高压症的研究进展

目前,中国门静脉高压症患者的数量不断增加。门静脉高压症引起的食管胃底静脉曲张破裂出血、瘀血性脾大、脾功能亢进、顽固性胸腔积液、顽固性腹腔积液是影响患者生存的高危因素。经颈静脉肝内门体分流术(TIPS)通过在肝静脉与门静脉之间的肝实质内建立分流道,以微创介入的方式降低门静脉阻力,是降低肝硬化患者门静脉压力的关键措施之一。但是,传统的TIPS手术在手术时间、并发症等方面存在较多问题。近年来,超声引导下穿刺门静脉及肝静脉作为一种新技术,能够辅助TIPS手术治疗门静脉高压症,可以缩短手术时间,减少辐射暴露,减轻患者的痛苦。     

经颈静脉肝内门体分流术后抗凝治疗现状

经颈静脉肝内门体分流术(TIPS)可治疗门静脉高压,但术后常发生分流道狭窄或闭塞。TIPS术后抗凝治疗可预防支架内血栓形成,但同时增加出血风险,且目前尚缺乏统一标准。本文就TIPS术后抗凝治疗现状进行综述。     

Transjugular intrahepatic portosystemic shunts: An update

Transjugular intrahepatic portosystemic shunts (TIPS) have been used in the treatment of complications of portal hypertension. TIPS is used for the control of acute variceal bleeding and for the prevention of vericeal rebleeding when pharmacologic therapy and endoscopic therapy have failed. Patients with refractory ascites with adequate hepatic reserve and renal function who fail to respond to large volume paracentesis may be reasonable candidates for TIPS. Promising indications for TIPS are Budd-Chiari syndrome uncontrolled by medical therapy, severe portal hypertensive gastropathy, refractory hepatic hydrothorax, and hepatorenal syndrome. TIPS cannot be recommended for preoperative portal decompression solely to facilitate liver transplantation. Special care should be taken to insure proper placement of the stent to avoid increasing the technical difficulty of the transplantation procedure. The major limiting factors for TIPS success are shunt dysfunction and hepatic encephalopathy. Because shunt stenosis is the most important cause of recurrent complications of portal hypertension, a surveillance program to monitor shunt patency is mandatory. The MELD score may be useful in predicting post-TIPS survival, and also in counseling patients and their families. (Liver Transpl 2003;9:207-217.)     

覆膜支架和裸支架行TIPS治疗门静脉高压症的对比研究

目的 比较研究覆膜支架移植物和裸支架在经颈内静脉肝内门体分流术(TIPS)治疗门静脉高压症中的临床疗效.方法 2007年4月至2009年4月,采用覆膜支架移植物行rIPs治疗门静脉高压症患者30例(A组),同期采用裸支架行TIPS治疗30例(B组),观察两组患者的肝功能、门静脉血流变化及l临床疗效.结果 住院期间两组均未出现出血和肝性脑病,各出现分流道急性阻塞1例.A组术后随访(6.2±3.9)个月,B组术后随访(8.3±4.4)个月,A组和B组的再出血率、分流道阻塞率、肝性脑病发生率和病死率分别为3.3%和20.0%、0和30.0%、16.7%和20.0%、0和13.3%,A组再出血率、分流道阻塞率和病死率低于B组(P<0.05),肝性脑病发生率无差异(P>0.05).A组门静脉压力、门体压力梯度下降程度、门静脉血流增快程度、分流道血流速率高于B组(P<0.05),两组肝功能、血氨及MELD评分无差异(P>0.05).结论 覆膜支架移植物能显著提高分流道通畅率,降低出血复发率,提高TIPS治疗门静脉高压症的疗效.     

Orthotopic liver transplantation in case of TIPS stent dislocation

Transjugular intrahepatic portosystemic shunts (TIPS) are indicated in patients with liver cirrhosis and portal hypertension for treatment of variceal bleeding or refractory ascites. Additionally implantation of stents may lead to stent dislocation or thrombosis in up to 20 % of cases. Detailed information about stent dislocation and its impact on subsequent orthotopic liver transplantation (OLT) is rare regarding the literature. We report on a patient suffering from ethyltoxic liver cirrhosis in which OLT was technically complicated by a thrombosed TIPS stent, dislocated in the portal vein. This stent was implanted prior to OLT due to refractory ascites and partial portal vein thrombosis. We conclude that TIPS stent insertion, especially in liver transplant candidates, should only be performed by radiologists in centers with expertise and experience.     

Severe venoocclusive disease after liver transplantation treated with transjugular intrahepatic portosystemic shunt

Venoocclusive disease (VOD) is due to hepatic sinusoidal lining injury leading to portal hypertension; its incidence after liver transplantation is about 2%. When severe, it does not respond to medical therapy and has a high mortality; retransplantation is the only therapeutic option. However, there are no detailed data regarding the use of transjugular intrahepatic portosystemic shunt for VOD after liver transplantation. We describe two patients who developed severe VOD after liver transplantation, failed defibrotide therapy, and were treated by transjugular intrahepatic portosystemic shunt (TIPS). The portal hypertension resolved completely and one had full histological recovery. We believe that TIPS should be attempted as it may resolve progressive portal hypertension and the hepatic congestion, while allowing the clinician time for listing for further liver transplantation if the patient fails to respond.     

浅析经颈静脉肝内门体静脉分流术治疗门静脉高压并发症

目的评估经颈静脉肝内门体静脉分流术(TIPS)治疗肝硬化门静脉高压并发症的安全性和有效性。方法自2013年12月至2014年6月,收集31例接受TIPS治疗的肝硬化门静脉高压症的临床资料。术前均接受肝脏CT增强扫描和血管三维重建,了解肝静脉与门静脉的解剖结构关系,以便确定穿刺门静脉分支的靶点,术中,28例栓塞曲张的食管胃底静脉,28例置入巴德公司的一个裸支架加一个Fluency覆膜支架,2例置入单个Fluency覆膜支架。结果 31例患者中30例TIPS操作成功,其中穿刺门静脉右支26例,穿刺门静脉左支4例,成功率为96.8%(30/31);1例因门静脉海绵样变性未成功;无严重并发症发生,近期止血率为100%。结论 TIPS治疗肝硬化门静脉高压并发症是安全和有效的。     

Biliary-Venous Fistula Complicating Transjugular Intrahepatic Portosystemic Shunt Presenting With Recurrent Bacteremia, Jaundice, Anemia and Fever

A 50-year-old White man with noncirrhotic portal hypertension presented with bleeding from gastric varices. Bleeding was initially managed with band ligation and subsequent transjugular intrahepatic portosystemic shunt (TIPS). Over the next few months, the patient had recurrent episodes of anemia, jaundice, fever and polymicrobial bacteremia. Computed tomography (CT) of the abdomen and chest, upper and lower endoscopy, endoscopic retrograde cholangiopancreatography (ERCP), and echocardiography failed to explain the bacteremia and anemia. Follow-up CT scan and Doppler sonography 9 months after placement showed TIPS was occluded. Repeat ERCP showed a bile leak with free run-off of contrast from the left hepatic duct into a vascular structure. The patient's status was upgraded for liver transplantation with Regional Review Board agreement and subsequently received a liver transplant. Gross examination of the native liver demonstrated a fistula between the left bile duct and the middle hepatic vein. Pathologic evaluation confirmed focal necrosis of the left hepatic duct communicating with an occluded TIPS and nodular regenerative hyperplasia consistent with noncirrhotic portal hypertension. Infection is rarely reported in a totally occluded TIPS. Biliary fistulas in patent TIPS have been treated by endoluminal stent graft and endoscopic sphincterotomy with biliary stent placement. Liver transplantation may be the preferred treatment if TIPS becomes infected following its complete occlusion.     

Transjugular intrahepatic portosystemic stent shunt: indications and long-term outcome

The transjugular intrahepatic portosystemic stent shunt has replaced surgical shunt procedures as the standard therapy for complications of portal hypertension such as refractory ascites and recurrent variceal bleeding. However, reinterventions due to TIPS stenosis are necessary in 25-50 %. Major complications are the manifestation or worsening of hepatic encephalopathy. Recent studies using PTFE covered stents have shown lower stenosis rates and a trend towards prolonged survival.     

经颈静脉肝内门体静脉分流术治疗门静脉高压的临床研究现状与进展

目前,经颈静脉肝内门体静脉分流术(TIPS)在治疗门静脉高压方面的有关适应证、禁忌证和技术标准相继确立。本文主要从目前的手术适应证、禁忌证、并发症、技术操作及内支架材料的选择和应用等方面,探讨TIPS的临床研究现状及进展。