Transhepatic puncture of portal and hepatic veins for TIPS using a single-needle pass under sonographic guidance

OBJECTIVE: Creating transjugular intrahepatic portosystemic shunts (TIPS) requires accessing a portal vein branch from a metal cannula wedged in a hepatic vein. This initial step in shunt creation often requires multiple blind intrahepatic punctures and occasionally fails. We describe a method using sonographic guidance to serially puncture the portal vein and hepatic vein with a single transhepatic needle pass, after which the TIPS procedure is completed in the standard transjugular fashion. CONCLUSION: Sonographically guided transhepatic dual puncture of the portal and hepatic veins facilitates portosystemic shunt creation in a single needle pass and allows more controlled selection of the portal vein entry and hepatic vein landing sites in selected patients.     

改良式经颈静脉肝内门腔静脉分流术治疗肝静脉闭塞型Buddi-Chiari 综合征

目的阐述改良式经颈静脉肝内门腔静脉分流术(TIPS)的技术步骤和评价其对肝静脉闭塞型Buddi-Chiari综合征的治疗效果.方法 11例被诊断为Buddi-Chiari综合征的患者,经影像学证实为肝静脉广泛狭窄和闭塞后,接受改良式TIPS技术治疗,TIPS改良技术的关键在于假想肝静脉通道的设计与建立;术后对其门脉系统压力变化、分流道血流改变及内支架开通状况进行了24个月的随访.结果 11例患者全部成功地建立肝内门静脉-下腔静脉分流通道,临床症状得到改善;门静脉主干压力由分流前的平均(4.62±0.52) kPa (1 kPa=10.2 cm H2O)下降至分流术后的(2.16±0.21) kPa;术后24个月随访,分流道血液最大流率(Vmax)为(56.2±3.50) cm/s,内支架通畅7(7/11)例.结论改良式TIPS技术具有高技术成功率,为肝静脉闭塞型Buddi-Chiari综合征患者提供了新的治疗手段.     

经皮经肝肝静脉成形术治疗肝静脉阻塞型Budd-Chiari综合征

目的探讨和评价经皮肝穿刺入路肝静脉腔内成形(percutaneous transhepatic recanalization and angioplasty of hepatic vein,PTRAHV)治疗肝静脉型Budd-Chiari综合征(BCS)的可行性和中远期疗效。方法自1996年9月至2006年10月收治单纯肝静脉阻塞型及肝静脉阻塞伴有下腔静脉阻塞型BCS患者101例,在PTRAHV前后经导管测定患者肝静脉压力,观察围手术期并发症,并分别于术前、术后6个月彩超测量门静脉内径、平均流速和血流方向等,计算对比血流量,随访观察受干预血管的通畅率。结果技术成功率91.1%(92/101)。术中急性肝静脉血栓形成3例,术后发生肝穿刺道出血2例,肝包膜下血肿1例,肺栓塞1例,均经保守治疗痊愈,未发生致死性并发症。随访74例,术后6个月门静脉平均流速和血流量参数均高于术前(P<0.05);术后6个月、1年和2年的受干预血管的初始再通率分别为83.8%(62/74)、78.4%(58/74)和76.5%(39/51),其辅助再通率分别为94.6%(70/74)、91.9%(68/74)和84.3%(43/51)。结论采用PTRAHV技术治疗膜性或节段性肝静脉型BCS操作简单、安全、有效,其中远期效果令人满意。     

Ultrasonically guided percutaneous transhepatic hepatic vein stent placement for Budd-Chiari syndrome.

PURPOSE: To evaluate the utility of ultrasonically guided hepatic vein stent placement in the treatment of Budd-Chiari syndrome (BCS) in patients with short hepatic vein obstruction. MATERIALS AND METHODS: Twenty-five patients with BCS, each with three obstructed hepatic veins diagnosed with ultrasound (US), color Doppler, probing with guide wire, and echo contrast, underwent hepatic vein stent placement under US guidance. Nine patients had hepatic vein obstruction alone, and 16 had hepatic vein obstruction along with primary inferior vena cava (IVC) obstruction. In each patient, only one of the hepatic veins was selected for recanalization and stent placement. In patients with primary IVC lesions, a stent was placed in the IVC first. Clinical and US examinations were performed at 3-6-month intervals on every patient during follow-up. RESULTS: Hepatic vein stents were successfully placed in 23 of the 25 patients, a success rate of 92%. The mean +/- SD hepatic vein pressure decreased from 25.57 mm Hg +/- 9.46 to 9.67 mm Hg +/- 2.31 (P < .01), and the flow direction in the hepatic vein became centripetal and its spectral analysis showed a normal phasic flow. Twenty-two patients experienced a significant improvement in hepatic outflow, as evidenced by disappearance of ascites, remission of hepatosplenomegaly, improvement in liver function, and alleviation of esophageal varices. Severe intraperitoneal hemorrhage occurred in one patient. No other serious procedure-related complications were observed. During follow-up of 1-43 months (mean, 23 months), stent reocclusion occurred in one patient. The other stents remained patent, and clinical features of BCS did not recur. CONCLUSION: Percutaneous transhepatic hepatic vein stent placement is a reasonable treatment for BCS in patients with hepatic vein obstruction, and the procedures can be performed safely and accurately with US.     

Ultrasound-guided fine-needle puncture of the thyroid

If properly performed, modern high-resolution real-time ultrasonography will disclose subtle differences in the texture of thyroid tissue and thereby enable the examiner to suggest a diagnosis. Nevertheless, there is often a need for a more specific diagnosis of solid or semisolid thyroid lesions - especially when the lesion might be malignant. Ultrasonically guided fine-needle aspiration biopsy (UG-FNB) allows a final cytological and/or histological diagnosis to be made in patients with benign or malignant space-occupying growths even if they are small. In its simplest form, thyroid nodules (diameter greater than 1.5 cm) with a uniform sonographic texture are punctured blind after determination of the site and size of the lesion on the basis of ultrasonic imaging. When the lesion is small and deeply situated (diameter less than or equal to 1.5 cm), this method will not be sufficiently accurate and more precise needle guidance is mandatory. In ultrasonically guided fine-needle puncture, the idea is to place the tip of an appropriate needle safely and accurately in the suspect lesion, so that representative specimens of solid tissue or fluid can be obtained and technical failures reduced. The main indication for biopsy of the thyroid gland is to differentiate between benign and malignant tumors. To compare the accuracy of conventional puncture techniques and ultrasonically guided puncture methods, 835 patients with benign or malignant space-occupying growth (even the small ones) were examined simultaneously with conventional and ultrasonically guided fine-needle aspiration biopsy over a period of 3 years (prospectively). Our results showed a significant difference in the sensitivity between conventional puncture without sonographic guidance and ultrasonically guided puncture techniques performed on patients with small and very small lesions (phi less than 2 cm). The size, macroscopic structure, and topographic-anatomical localization of the lesions were found to influence the diagnostic accuracy of the puncture techniques. UG-FNB is an excellent, effective, safe and painless method of treating uncomplicated thyroid cysts; it should be considered an alternative to surgery, if there are no clinical and cytological findings indicating malignancy and no severe space-occupying complications. Since the tip of the needle can be visualized on the scan, the needle may be advanced or withdrawn during aspiration so it is possible to empty the cyst completely. The use of ultrasound in the follow-up of patients with thyroid cyst puncture is mandatory to evaluate the results. Surgical therapy should be reserved for large cysts causing space-occupying complications.     

Ultrasound evaluation of TIPS placement

Sonography is a valuable tool for evaluating shunts used to treat variceal bleeding due to portal hypertension. This article defines the protocol for ultrasound imaging of the transjugular intrahepatic portosystemic shunt (TIPS) and abnormal findings associated with TIPS placement. It also discusses common pitfalls in TIPS imaging, including artifacts, echoes and incomplete visualization.     

改良式TIPS治疗肝静脉广泛阻塞型布-加综合征的近期疗效

目的 观察改良式TIPS治疗肝静脉广泛阻塞型布-加综合征(BCS)的近期疗效.方法 7例肝静脉广泛阻塞型BCS患者,使用改良术式TIPS治疗,其中2例为急性,5例为亚急性或慢性.术后给予正规抗凝治疗,并用彩色多普勒超声随访疗效.结果 7例肝静脉广泛阻塞型BCS均成功完成改良式TIPS,7例患者共置入12枚支架(覆膜支架...     

Combined transhepatic and transvenous approach to hepatic vein stenosis after transjugular intrahepatic portosystemic shunt (TIPS)

We describe a simple technique for recatheterization of transjugular intrahepatic portosystemic shunts (TIPS) with severe hepatic vein ostial stenoses that are inaccessible to standard transvenous approaches. A small gauge needle is used to transhepatically introduce a guidewire into the shunt; the wire is passed through the hepatic vein stenosis, snared, and used to guide jugular or brachial catheters into the TIPS.     

US-guided paraumbilical vein puncture: an adjunct to transjugular intrahepatic portosystemic shunt (TIPS) placement.

Transjugular intrahepatic portosystemic stent-shunt placement has shown great promise as a means of protal decompression in patients with severe portal hypertension. Passage of a needle from the hepatic venous system into the portal venous system during this procedure may be technically difficult; while it would be advantageous to precisely target the portal vein, most methods of localization are themselves technically difficult, risky, or time-consuming. The authors describe a method of localization of the portal vein that, when feasible, appears to be both safe and technically simple. This method involves percutaneous catheterization of a paraumbilical portosystemic collateral vein under sonographic guidance.     

经皮经肝穿刺门静脉置管术在良性肝脏及胰腺疾病中的临床应用

经皮经肝穿刺门静脉置管术目前已广泛应用于临床介入治疗,尤其是肝脏、胰腺恶性肿瘤的化疗中,而在肝脏和胰腺的良性病变中应用尚不多.这一技术除了具有创伤小等特点,还能明显的提高门脉血药浓度,达到静脉给药血药浓度的100～400倍,在肝脏和胰腺的良性疾病如肝炎、肝硬化、糖尿病中都有着广泛的应用前景.随着穿刺技术,材料学及置管方法的改进和发展,经皮经肝穿刺门静脉置管术必将在肝脏和胰腺良性疾病的介入治疗中扮演越来越重要的角色.     

Combined transhepatic and transjugular approach for mechanical thrombectomy of massive TIPS thrombosis

Transjugular intrahepatic portosystemic shunt (TIPS) is a well-validated decompressive therapy option to manage ascites and variceal bleeding secondary to portal hypertension. Complications following TIPS procedures include hepatic encephalopathy, liver failure, and TIPS dysfunction. TIPS dysfunction is due to occlusion or stenosis of the TIPS shunt and can be caused by acute or chronic thrombosis. TIPS thrombosis is often treated with mechanical thrombectomy or catheter-directed thrombolytic therapy. Most cases of in-stent occlusion can be treated via a transjugular approach with recanalization or placement of additional stents. We present a case of a 72-year-old female who presented with worsening ascites 17 months after initial TIPS procedure; she was found to have a large thrombus completely occluding the TIPS stent. In our case, a combined transhepatic and transjugular approach was required for TIPS revision given the extent of well-organized clot located near the hepatic venous end of the stent, resulting from prolonged stent occlusion. This was an extremely challenging scenario with two overlapping covered stents and a bare metal stent at the hepatic venous end in the setting of chronic thrombosis and a well-organized fibrous cap. The case highlights the need for optimal initial placement of the primary TIPS shunt to avoid the need for subsequent complex interventions to maintain TIPS shunt patency.     

Management of bleeding after percutaneous transhepatic cholangiography or transhepatic biliary drain placement

Bleeding complications occur in 2 to 3% of percutaneous transhepatic biliary drains. These complications include: hemothorax, hemoperitoneum, subcapsular hepatic bleeding, hemobilia, melena, and bleeding from the percutaneous biliary drain. The bleeding sites can be classified into (1) perihepatic bleed sites (hemothorax, hemoperitoneum, subcapsular hepatic hematoma), (2) gastrointestinal bleeding (hemobilia and/or melena), and (3) bleeding from the percutaneous biliary drain itself, which is the most common clinical presentation. There are several bleeding sources. These include skin-bleeds, intercostal artery, portal vein, hepatic vein, and the hepatic artery. There are a variety of maneuvers that can be utilized in the management of bleeding percutaneous biliary drains. These include tractography, angiography, tract embolization, arterial embolization, and tract site changes. This article proposes a protocol for approaching bleeding complications after percutaneous biliary drain placement and details the diagnostic and therapeutic procedures in the management of these bleeding complications.     

Direct US-guided puncture of the innominate veins for central venous access

Maintenance of functioning venous access is recognized as the Achilles heel of long-term hemodialysis treatment. In patients who require catheter-directed hemodialysis, the internal jugular veins are recognized as the optimal veins for insertion of dialysis catheters. When these sites are no longer available, alternative venous access sites are required. The authors describe two hemodialysis patients with limited access sites in whom hemodialysis catheters were successfully inserted directly into the innominate veins with use of ultrasound-guided punctures.     

Ultrasound-guided puncture. Modern treatment of liver abscess

The treatment of liver abscesses has benefitted from progress in imaging, particularly ultrasonography which allows simple and reliable aspiration and drainage. A series of 32 cases is reported, consisting of 29 pyogenic abscesses and 3 amoebic abscesses. Eighty-one per cent of patients were cured by aspiration and/or drainage, while 19% of patients had to be operated. The mean hospital stay was 11 days. Failures of ultrasound-guided aspiration are essentially due to multifocal abscesses caused by multiple organisms.     

Single-wall puncture: a new technique for percutaneous transhepatic biliary drainage

OBJECTIVE: The purpose of our study is to evaluate the safety and utility of a new single-wall puncture technique for percutaneous transhepatic biliary drainage in comparison with the conventional double-wall puncture technique. CONCLUSION: Our results suggest that the single-wall puncture technique is a useful method for percutaneous transhepatic biliary drainage and may be safer than the conventional double-wall puncture technique.     

经皮肝穿胆道造影术靶胆管定位穿刺方法的应用

目的 精确测定肝内扩张胆管位置.设计穿刺途径,提高经皮肝穿胆道造影术(PTC)成功率.方法 对73例恶性阻塞性黄疸患者进行PTC,其中30例采用经皮肝穿靶胆管定位方法穿刺为实验组,43例采用传统法为对照组.实验组:在CT或MRI片上,取肝内胆管扩张最明显的层面,选择外周直径合适,与预计针道走行方向呈锐角的肝内胆管分支为靶胆管,靶胆管中点作为穿刺进入点,测量穿刺进入点至背部体表的距离为h值,h值为确定穿刺层面的参考值;分别测量靶胆管两端至腹部(矢状面)正中线距离为a值和b值,(a-b)值为靶胆管体表投影区的参考值;穿刺点定在h值层面与右侧肋膈角下2个肋间隙肋骨上缘相交点,针尖对准靶胆管体表投影区进行水平穿刺.对照组:取右侧腋中线肋膈角下2个肋间隙(常为第8～10肋间隙肝脏中部)肋骨上缘为穿刺点,针尖指向胸10～胸12椎体之间进行水平穿刺,至接近椎体右缘2～6 cm处.结果 实验组穿刺次数为1～4次,共62次,每例平均2.07次,成功率为48.4%;对照组穿刺次数为1～9次,共186次,每例平均4.33次,成功率为23.1%;两组比较具有显著性差异(χ2=14.294,P<0.01).结论 经皮肝穿胆道造影术靶胆管定位穿刺准确测定可提高穿刺成功率,减少肝脏损伤等并发症,对PTC是一种有效方法.     

超声引导下穿刺置管引流术治疗脊柱术后术区血肿研究

目的探讨超声引导下穿刺置管引流术治疗脊柱术后术区血肿的临床疗效。方法选取2012—2017年间沈阳军区总医院收治的105例脊柱术后术区血肿患者为研究对象,根据不同的治疗方法分为穿刺置管引流组(n=36)、保守治疗组(n=34)及切开引流组(n=35),经治疗后,比较3组患者有效率、症状持续时间及术后住院天数。结果术后第1天,穿刺置管引流组患者的有效率高于保守治疗组,但低于切形引流组,差异有统计学意义(P<0.05);切开引流组患者的有效率高于保守治疗组,差异有统计学意义(P<0.05)。术后第5天,穿刺置管引流组患者的有效率高于保守治疗组,差异有统计学意义(P<0.05);穿刺置管引流组与切开引流组患者的有效率比较,差异无统计学意义(P>0.05)。3组患者治疗后均未发生严重不良反应。穿刺置管引流组患者的症状持续时间及术后住院天数显著低于保守治疗组,差异有统计学意义(P<0.05);比较穿刺置管引流组与切开引流组患者的症状持续时间及术后住院天数,差异无统计学意义(P>0.05)。结论超声引导下穿刺置管引流术的疗效明显优于保守治疗,与切开引流术疗效相当,但极大地避免了患者行外科手术的痛苦,具有创伤小、安全、简便、经济、有效等优点,患者易于接受。