采用聚四氟乙烯覆膜支架行经颈静脉肝内门腔分流术的临床疗效观察

目的 探讨采用聚四氟乙烯(PTFE)覆膜支架行经颈静脉肝内门腔分流术(TIPS)的临床疗效.方法 回顾性分析行PTFE覆膜支架TIPS术治疗的102例门静脉高压症患者的临床资料,其中男82例、女20例,年龄16 ～ 73岁,平均(53±13)岁.术前症状为食管胃底静脉曲张大出血(83例)或顽固性腹水(19例),肝功能Child-Pugh评分5.0 ～10.0分,平均(6.7±1.7)分.患者均采用PTFE覆膜支架行TIPS术.手术前后门静脉压力和肝功能评分的比较采用t检验.采用寿命表法绘制术后6、12、24、36、48个月的分流道开通率、术后生存率、术后肝性脑病(HE)的发生率曲线.结果 全部患者均在局部麻醉下成功建立肝内门腔覆膜支架分流道,共置入支架128枚.支架直径6.0～10.0mm,平均(8.1 ±0.9)mm.其中PTFE覆膜支架104枚,裸支架24枚.术后门静脉压力明显下降,术前平均(28.5±5.3)mm Hg(1 mm Hg=0.133 kPa),术后(18.0±4.5)mm Hg,手术前后差异有统计学意义(t =22.8,P＜0.01).3例患者出现围手术期并发症,2例腹腔出血、1例支架周围感染.术后随访0 ～58个月,平均(20±13)个月.术后3个月肝功能Child-Pugh评分(6.5±1.6)分,与术前相比[(6.7±1.7)分]差异无统计学意义(t=0.8,P＞0.05).患者术后6、12、24、36、48个月的覆膜支架分流道一期累积通畅率分别是96％、91％、82％、82％、82％,随访期间10例患者出现覆膜支架分流道再狭窄,总体一期再狭窄率为9.8％;27例出现术后HE,发生率26.5％,累积发生率分别为7％、21％、34％、46％、66％;16例出现死亡,病死率为15.7％,累积生存率分别是95％、83％、76％、76％、76％.结论 与裸支架相比,采用PTFE覆膜支架行TIPS术在技术上安全可行,可以明显提高TIPS术后分流道通畅率,但如何改善术后HE及生存率仍是目前亟待解决的问题.     

门静脉高压性上消化道出血TIPS的临床应用

目的 探讨采用Fluency自膨胀覆膜支架,行经颈静脉肝内门体静脉支架分流术(TIPS)治疗食管静脉曲张破裂出血的效果.资料与方法 对20例患者采用Fluency自膨胀覆膜支架行TIPS及食管胃底静脉栓塞术,18例成功建立分流道,2例因严重并发症未成功.结果 门静脉压力明显降低,术前平均门静脉压梯度(27.11±4.86)cm H2O,术后平均门静脉压梯度(17.13±3.81)cm H2O,控制出血近期有效率为100%,再出血率为16.7%.术后血像明显改善,上消化道出血停止,腹水吸收明显.结论 采用Fluency自膨胀覆膜支架行TIPS治疗门静脉高压性上消化道出血具有重要的临床实用价值.     

覆膜支架在经颈静脉门腔分流术中的应用

目的 评价经颈静脉肝内门腔分流术(TIPS)专用覆膜支架(Viatorr支架)在TIPS中的应用价值.方法 回顾性分析37例在美国俄勒冈州健康生命科技大学Dotter介入放射学研究所采用Viatorr支架行TIPS治疗的患者资料,随访时间为(15.2±9.3)个月(3-42个月).TIPS指征包括门静脉高压相关性的急慢性消化道出血,经药物及内镜治疗无效者17例;顽固性肝源性胸、腹水18例,Budd-Chiari综合征2例.采用配对t检验比较手术前后门腔静脉压力差(PSG)的变化,以Kaplan-Meier曲线分析支架开通率.结果 37例共置入41枚Viatorr支架,其中3枚直径为8 mm,38枚为10 mm,支架带膜长度为4～8 cm,无相关手术并发症.PSG由术前的(22.4±8.4)mm Hg(1 mm Hg=0.133 kPa)降为(8.1±3.2)mm Hg,差异有统计学意义(t=12.754,P<0.01).17例出血患者术后出血均停止,1例于术后17个月复发.18例严重顽固性腹水及肝性胸水患者中,4例术后腹水不消退,其余14例随访期间有2例腹水复发.2例(5.4%)发生分流道阻塞,Kaplan-Meier曲线分析结果显示1年的开通率为97.0%.术后1个月内无病死患者,2例分别于术后3个月及15个月死于多器官功能衰竭,晚期病死率为5.4%,死亡前1周内复查支架均通畅.肝移植患者5例(13.5%).结论 Viatorr支架能明显提高TIPS术后开通率,选择合适的支架,采用正确的释放技术能进一步提高疗效,但长期效果评价尚需验证.     

经颈静脉肝内门体分流术中覆膜支架与非覆膜支架效果的比较

目的 对比覆膜与非覆膜支架在TIPS中应用的临床疗效.方法 回顾性研究30例临床诊断为肝硬化接受TIPS治疗(按照术后是否有覆膜支架分为覆膜支架组20例、非覆膜支架组10例)的患者的临床资料.本组患者手术前后测量门静脉压力,术后彩色超声观察分流道通畅情况.采用四格表资料的Fisher确切概率法进行两组间病死率、再出血率及肝性脑病发生率等临床指标对比.结果 30例患者手术均成功,门静脉压力在覆膜组由术前(3.78±0.50)kPa降至术后(2.21±0.44)kPa,非覆膜组由术前(3.67±0.48)kPa降至术后(2.13±0.35)kPa.术后随访资料完整的26例(覆膜支架组17例,非覆膜支架组9例),随访时间为7 d～62个月(中位随访时间23个月).随访期内死亡13例,覆膜支架组8例、非覆膜支架组5例,两组差异无统计学意义(P>0.05),均死于上消化道出血及肝功能衰竭.覆膜组再出血5例、非覆膜组3例,两组差异无统计学意义(P>0.05).发生肝性脑病在覆膜支架组4例、非覆膜支架组2例,两组差异无统计学意义(P>0.05).术后6个月和1年分流道通畅率在覆膜支架组均为100.0%,非覆膜支架组分别为77.8%(7/9)和55.6%(5/9),两组差异有统计学意义(P<0.05).结论 覆膜支架组1年分流道通畅率优于非覆膜支架,但两组病死率、再出血率及肝性脑病发生率差异无统计学意义.     

改良经颈静脉肝内门体分流术双支架植入治疗肝硬化门静脉高压临床效果

目的 探讨采用改良经颈静脉肝内门体分流术(TIPS)和双支架植入治疗肝硬化门静脉高压的安全性和有效性。方法 回顾性分析2016年3月至2021年5月在解放军第九六〇医院接受治疗的92例肝硬化门静脉高压患者临床资料。对常规TIPS穿刺技术进行改良,采用覆膜支架和裸支架建立分流道,测量TIPS术前后门静脉主干压力。术后3、6、12、24、36个月进行规律随访,复查超声或CT,了解支架通畅情况。结果 92例患者完成TIPS术(常规TIPS 22例,改良TIPS 70例),技术成功率100%。术后血管造影显示支架内血流通畅,无手术相关严重并发症发生。门静脉主干压力由术前(44.1±6.8)cmH₂O降低为术后(23.0±3.4)cmH₂O,差异有统计学意义(P<0.01)。所有患者随访(21.4±7.9)个月(3～43个月),85例支架内血流通畅,4例分别于术后10、13、24、33个月出现分流道闭塞,再次植入1枚支架后血流恢复通畅,3例分别于术后4、18、30个月死于多脏器衰竭或消化道出血。术后1年、2年、3年累计支架通畅率分别为98.9%、...     

TIPS联合TACE治疗肝癌伴门静脉高压食管胃静脉曲张出血的临床疗效

目的 评价肝癌伴门静脉高压食管胃静脉曲张破裂出血(EGVB)患者行经颈静脉肝内门体分流术(TIPS)联合经动脉化疗栓塞术(TACE)的安全性及疗效。方法 16例肝癌伴门静脉高压EGVB的患者施行TIPS联合TACE治疗,男11例,女5例,年龄49～74岁,平均(59.5±8.4)岁。术后1、3、6、12个月及以后每3个月采用彩色多普勒超声和上腹部增强CT进行随访。TACE术后1个月采用改良实体肿瘤疗效评价标准(mRECIST)评价肝癌疗效。采用Kaplan-Meier曲线评估存活率。结果 16例患者TIPS技术成功率100%,门静脉压力梯度(PPG)由术前平均(36.5±4.9)mmHg降至术后平均(8.2±2.5)mmHg(t=18.595,P<0.01)。16例患者共施行36次TACE,术后出现肝脓肿1例,经穿刺引流脓腔消失。16例患者随访3～122个月,平均(34.9±34.3)个月。TIPS联合TACE治疗术后1个月完全缓解(CR)、部分缓解(PR)、疾病稳定(SD)、疾病进展(PD)分别为6、5、2、3例。TIPS术后24个月支架内再狭窄1例,经再次球囊扩张后通畅。随访...     

TIPS中8 mm直径覆膜支架应用的临床研究

目的 评价在TIPS中应用8 mm直径覆膜支架的临床效果.方法 对19例伴有食管胃底静脉曲张破裂出血和(或)难治性腹水的门脉高压症患者行TIPS术,术中应用8mm直径的覆膜支架,术后观察临床症状改善程度,并进行定期影像学和实验室检查,以评价疗效.结果 所有患者均成功完成TIPS术,技术成功率100%,术中未出现并发症.术后平均随访13.5个月(2.7～28个月),1例(1/19,5.3%)原有肝性脑病加重;2例(10.5%)再次出血;腹水改善及治愈率为66.7%(12/18);16例患者进行了6个月的随访,初次开通率100%,8例患者随访12个月,初次开通率87.5%.结论 在TIPS术中应用8mm直径覆膜支架在保证有效分流量,提高术后分流道开通率的同时,可以降低肝性脑病的发生率.     

经TIPS途径治疗急性、亚急性门静脉血栓临床疗效

目的 探讨经TIPs途径治疗急性、亚急性门静脉血栓的临床疗效.方法 回顾性分析2005年1月-2008年6月我科经TIPS途径治疗的12例急性、亚急性门静脉血栓患者.观察术后门静脉复通情况,随访8～42个月,观察支架通畅情况及症状恢复.结果 1例患者溶栓第2天发生腹腔大出血死亡.11例患者溶检术后门静脉主干血流得到复通,其中1例3个月随访时门静脉血栓复发,支架堵塞,其余10例患者门静脉主干及分流道支架均保持通畅.结论 经TIPS途径溶栓技术是治疗急性、亚急性门静脉血栓的有效方法.     

经颈内静脉肝内门腔静脉分流术治疗BuddChiari综合征

目的探讨经颈静脉肝内门腔静脉分流术(TIPS)治疗Budd-Chiari综合征(BCS)的疗效。方法本组14例患者经影像学检查确诊为BCS,因进行性肝功能损害,或严重门脉高压并发症(顽固性腹水,食管胃底静脉曲张上消化道出血),或广泛肝静脉闭塞而行TIPS术治疗。其中混合型8例,肝静脉型5例,肝静脉广泛闭塞型1例。TIPS术中对于下腔静脉、肝静脉的不同情况,灵活选择肝静脉或下腔静脉穿刺点进行穿刺,7例从肝静脉开口处行门静脉穿刺,建立门-腔静脉分流道,4例从下腔静脉直接穿刺门静脉分支,3例经皮穿刺开通肝右静脉后再经肝右静脉穿刺门静脉。术后对分流道支架开通情况进行长期随访。结果14例手术均获成功,门静脉压力由术前平均(4.9±1.4)kPa,降至术后(3.2±1.5)kPa,术后随访5～64个月,2例因支架狭窄分别于术后13、24个月再发上消化道出血,行分流道球囊扩张治疗,术后恢复良好。结论TIPS适用BCS合并有进行性肝功能损害或门静脉高压引起的上消化道出血、顽固性腹水的治疗。对于已行下腔静脉或肝静脉成形术后再发或加重的门静脉高压患者亦为适应证,但手术难度增加。     

经颈静脉肝内门体分流术联合胃冠状静脉栓塞术治疗门脉高压上消化道出血的临床疗效

目的评价经颈静脉肝内门体分流术(TIPS)联合胃冠状静脉栓塞术(GCVE)治疗肝硬化门脉高压上消化道出血的应用价值。方法对54例肝硬化门静脉高压上消化道出血患者行TIPS联合GCVE术治疗,术前Child-Pugh评分A级16例,B级28例,C级10例,术后对其临床疗效、并发症、肝肾功能变化等进行随访观察,连续随访9~42个月。结果 54例均手术成功并有效止血,门脉压力明显降低,术后3 d、1周及1个月患者的丙氨酸转氨酶(ALT),天冬氨酸转氨酶(AST),总胆红素(TBIL)、直接胆红素(DBIL)均有一定程度上升,在半年后降至术前水平。血尿素氮(BUN)、肌酐(Cr)在术后1周即有显著下降(P<0.05),至半年随访亦有下降趋势。术后1、6个月,1、2和3年再出血率分别为0,3.7%,9.3%,14.8%,20.4%,支架累计狭窄率为27.8%,肝性脑病发生率为24.1%。随访期间共死亡7例,2例死于原发性肝癌,4例死于消化道大出血,1例死于多器官功能衰竭。结论 TIPS联合GCVE治疗门静脉高压上消化道出血,疗效肯定,再出血率低、可重复操作,是一种安全、有效的治疗方法。     

Viatorr支架行TIPS术治疗门静脉高压性静脉曲张消化道出血效果评估

目的评价应用Viatorr支架行经颈静脉肝内门体分流术(TIPS)术治疗门静脉高压性静脉曲张消化道出血的可行性、安全性和临床效果。方法回顾性分析2015年10月至2018年11月收治的42例肝硬化门静脉高压性静脉曲张消化道出血患者临床资料,所有患者符合TIPS治疗指征,均接受Viatorr支架行TIPS术治疗。术中检测门静脉压力梯度(PPG)。术后1、3、6、12个月,之后每年随访超声或增强CT检查,评价分流道通畅情况,并通过电子病历、临床或电话随访患者肝功能、凝血4项、再出血、肝性脑病发生和生存时间。配对t检验分析术前、术后PPG、总胆红素、血清白蛋白和凝血酶原时间变化,Kaplan-Meier法分析分流道通畅率和生存率。结果 42例均成功施行TIPS术,技术成功率为100%。共植入直径8 mm Viatorr支架42枚。PPG均值由术前(26.85±6.00) mmHg(1 mmHg=0.133 kPa)降低为(11.62±4.54) mmHg(t=11.359,P<0.05),平均降低(55.63±16.77)%。与术前相比,术后3 d总胆红素浓度升高(P<0.05),血清白蛋白降低(P<0.05),凝血酶原时间延长(P<0.05)。术后1个月总胆红素、血清白蛋白和凝血酶原时间与术前水平差异均无统计学意义(P>0.05)。术后中位随访14.5(2~39)个月,再出血发生率为9.5%(4/42),其中1例接受分流道再通;肝性脑病发生率为19.1%(8/42)。术后1、2、3年分流道通畅率分别为91.9%、83.9%、77.4%,生存率分别为94.7%、89.4%、82.0%。肝硬化相关死亡率为9.5%(4/42),均于术后2~30个月死于终末期肝病伴多脏器功能衰竭。结论 Viatorr支架行TIPS术治疗肝硬化门静脉高压性静脉曲张消化道出血具有较高的技术成功率,术后分流道通畅率高,肝性脑病发生率低。     

经颈静脉肝内门体分流术治疗脾切除术后静脉曲张再出血

目的评价经颈静脉肝内门体分流术（TIPS）治疗脾切除术后静脉曲张再出血的疗效及随访结果。 方法回顾性分析中山大学附属第三医院2010年12月至2016年12月间，因脾切除术后静脉曲张再出血而接受了TIPS治疗的患者33例，观察手术成功率、并发症及临床随访结果。 结果33例患者TIPS手术成功31例（93.9%），失败2例。成功的患者其门体压力梯度（PPG）从分流前平均23.5±5.9 mmHg下降至分流后平均12.1±3.3 mmHg（P<0.05）。除1例患者因感染性休克于围手术期死亡外，对手术成功的30例进行了随访（中位随访时间62.5个月）。10例发生分流道失功，其中4例再发消化道出血伴1例死亡、1例再发大量腹水、1例并发急性肠系膜静脉血栓、肠梗阻。10例出现显性肝性脑病，其中4例轻度发作经药物治疗后好转、1例反复发生3期肝性脑病行分流道限流术、5例术后死于肝功能衰竭。随访期间除上述6例死亡以外，另有2例因肺部疾病及1例因肝细胞癌死亡。余患者随访期间分流道通畅且未再发生静脉曲张破裂出血。术后第6个月随访结果显示，30例患者的平均血清白蛋白、血清总胆红素较术前改善（P<0.05）。 结论TIPS是治疗脾切除术后静脉曲张再出血安全且有效的方式。     

经颈内静脉肝内门体分流术治疗肝硬化门脉高压140例分析

目的探讨经颈内静脉肝内门体分流术（TIPS）治疗肝硬化门脉高压的疗效及安全性。方法回顾性分析140例经TIPS治疗肝硬化门脉高压患者的临床资料,记录术前术后门静脉压力、门静脉和脾静脉直径、食道胃底静脉、腹水的变化,观察术后肝性脑病、复发出血、支架再狭窄等并发症。结果手术成功率及即刻止血率100%,门静脉压力术前（44.7±3.5）cmH2O,术后（23.6±3.8）cmH2O（P<0.01）,门静脉主干直径术前（1.64±0.035）cm,术后（1.27±0.047）cm（P<0.01）,脾静脉直径术前（1.26±0.027）cm,术后（0.95±0.023）cm（P<0.01）。肝性脑病发生率13.6%（19/140）,腹水好转率89%（65/73）,术后12个月复发再出血8.6%（12/140）,支架再狭窄15.7%（22/140）。结论 TIPS是治疗肝硬化门脉高压的有效方法,能有效降低门静脉压力,控制上消化道出血。     

Transjugular intrahepatic portosystemic shunt creation with the Viatorr expanded polytetrafluoroethylene-covered stent-graft

PURPOSE: To evaluate the midterm clinical results and patency of transjugular portosystemic shunts (TIPS) created with a commercially available expanded polytetrafluoroethylene (ePTFE)-covered stent-graft based on angiographic and ultrasonographic (US) criteria in a series of 71 patients. MATERIALS AND METHODS: Seventy-one patients (61 men, 10 women; mean age, 58.6 years, range, 25-78 years) were included in this series, which was performed in two centers. Indications for TIPS creation were refractory ascites (n = 44) and recurrent esophageal bleeding (n = 27). Ten patients had Child-Pugh class A liver cirrhosis, 43 had class B disease, and 18 had class C disease. Underlying liver diseases were alcoholic cirrhosis (n = 58), cirrhosis resulting from hepatitis (n = 9), cryptogenic cirrhosis (n = 3), and Budd-Chiari syndrome (n = 1). TIPS were created with commercially available ePTFE-covered stent-grafts in all patients. The diameters of the stent-grafts were 10 mm in 58 patients and 8 mm in the remaining 13 patients. Follow-up included clinical examination and color-coded US after 5 days, 1, 3, and 6 months, and every 6 months thereafter. Shunt angiograms were obtained every 6 months. Median follow-up was 16.3 months (range, 3.8-26.6 months). RESULTS: TIPS creation was successful in all patients without complications, and effective portal decompression was observed with a reduction of the mean portal gradient from 19 mm Hg to 6 mm Hg before and after TIPS creation. Four shunt occlusions were observed after 5 days, 2 months, 3 months, and 6 months. Shunt stenosis was observed in three patients at the hepatic vein, which was not fully covered by the stent-graft, after 6 months (n = 2) and 12 months, and at the portal side after 1 month in a patient who initially had portal vein thrombosis. The repeat intervention rate was 11.3%. The primary patency rates were 87.4% (95% CI, 77.7%-97.1%) after 6 months and 80.8% (95% CI, 68.2%-93.4%) after 12 months. The rate of de novo or deteriorated hepatic encephalopathy was 31%. The recurrent bleeding rate was 3.7% (one of 27), and ascites improved or resolved in 64% of patients after 1 month. CONCLUSION: TIPS patency can be significantly increased if the ePTFE-covered stent-graft is used for shunt creation. The increased shunt patency contributes to low repeat intervention and recurrent bleeding rates. The rate of hepatic encephalopathy is within the range of previously reported rates.     

经颈静脉肝内门腔分流术治疗复杂型Budd-Chiari综合征

目的　探讨和评价经颈静脉肝内门腔静脉分流术（TIPS）治疗复杂型Budd-Chiari综合征（BCS）并门脉高压的临床应用价值。方法　患者男4例，女1例，平均年龄33岁，均有不同程度的食管胃底静脉曲张，4例有上消化道出血史，2例伴有腹水。经下腔静脉相当于右肝静脉开口部进针穿刺门脉行TIPS治疗。结果　5例均获成功。门脉压力由术前平均（4.7±1.3）kPa降至（3.5±1.5）kPa（1kPa=7.5mmHg）。术后24h1例死于心肺衰竭；术后3周1例死于肝功能衰竭。另3例平均随访64个月，肝功能均正常。2例于术后6、9个月均有分流道狭窄，并行二次介入治疗。结论　TIPS是解决复杂型BCS伴门脉高压的一种安全有效的治疗方法。     

Transjugular intrahepatic portosystemic shunt in a patient with cavernomatous portal vein occlusion

A 23-year-old woman with liver cirrhosis secondary to primary sclerosing cholangitis was referred to us for the treatment of recurrent bleeding from esophageal varices that had been refractory to endoscopic sclerotherapy. Her portal vein was occluded, associated with cavernous transformation. A transjugular intrahepatic portosystemic shunt (TIPS) was performed after a preprocedural three-dimensional computed tomographic angiography evaluation to determine feasibility. The portal vein system was recanalized and portal blood flow increased markedly after TIPS. Esophageal varices disappeared 3 weeks after TIPS. Re-bleeding and hepatic encephalopathy were absent for 3 years after the procedure. We conclude that with adequate preprocedural evaluation, TIPS can be performed safely even in patients with portal vein occlusion associated with cavernous transformation.     

Transjugular Intrahepatic Portosystemic Shunt Creation for the Prevention of Gastric Variceal Rebleeding in Patients with Hepatocellular Carcinoma: A Multicenter Retrospective Study

PurposeTo evaluate the effectiveness and safety of transjugular intrahepatic portosystemic shunt (TIPS) creation for the prevention of gastric variceal rebleeding in patients with hepatocellular carcinoma (HCC).Materials and MethodsThis multicenter retrospective study included 126 cirrhotic patients (mean age, 54.1 ± 10.2 years; 110 men) with HCC who underwent TIPS creation for the prevention of gastric variceal rebleeding. Of these, 110 (87.3%) patients had gastroesophageal varices and 16 (12.7%) patients had isolated gastric varices. Thirty-five (27.8%) patients had portal vein tumor thrombus.ResultsTIPS creation was technically successful in 124 (98.4%) patients. Rebleeding occurred in 26 (20.6%) patients during the follow-up period. The 6-week and 1-year actuarial probabilities of patients remaining free of rebleeding were 98.3% ± 1.2% and 81.2% ± 3.9%, respectively. Forty-nine (38.8%) patients died during the follow-up period. The 6-week and 1-year actuarial probabilities of survival were 98.4 ± 1.1% and 65.6 ± 4.4%, respectively. Two (1.6%) patients had major procedure-related complications, including acute liver failure (n = 1) and intra-abdominal bleeding (n = 1). Thirty-three (26.2%) patients had at least 1 episode of overt hepatic encephalopathy during the follow-up period. Shunt dysfunction occurred in 15 (11.9%) patients after a median follow-up time of 11.4 months (range, 1.4–41.3 months). Lung metastasis occurred in 3 (2.4%) patients, 3.9–32.9 months after TIPS creation.ConclusionsTIPS creation may be effective and safe for the prevention of gastric variceal rebleeding in patients with HCC.     

观察改良TIPS在治疗门静脉高压消化道出血中的应用

目的观察改良TIPS在胃食管出血应用中的技术可行性及临床效果。 方法收集接受改良TIPS治疗的肝硬化门静脉消化道出血的患者56例。操作技术改良是在线阵血管探头引导下穿刺右颈内静脉,引入导丝并将Rups-100穿刺系统送至肝右静脉,自肝静脉向门静脉穿刺成功后,引入加强硬度导丝至肠系膜上静脉,撤出Rups-100穿刺系统,直接将8 mm×40 mm球囊经12F鞘沿加硬导丝快速通过肝静脉-肝实质-门静脉,扩张球囊并保留球囊上肝静脉和门静脉切迹图像。支架技术改良是先释放1枚8 mm×60 mm的裸支架,根据球囊切迹,再释放1枚8 mm×40 mm的覆膜支架,覆膜部分覆盖实质全程而不阻挡同侧门静脉入肝血流,其余部分伸入肝静脉内,常规用弹簧栓子和明胶海绵栓塞胃冠状静脉。测量分流前后门静脉压力变化。 结果56例均获得技术性成功,成功率为100%。分流道建立前后门静脉压力分别为（31.20±3.98）mmHg和（17.36±3.48）mmHg,平均下降幅度为（13.839±2.585）mmHg（t=40.062,P<0.001）。随访1～3年。1、2、3年分流道通畅率分别为89.3%、75.0%、67.8%;再出血率分别为7.1%、12.5%、16.1%;肝性脑病发生率为12.5%。有1例术后第2天出现腹腔感染,抗感染治疗7天后好转;有7例于术后1～3年内因分流道完全闭塞而复发再出血,分别给予了介入开通和覆膜支架植入。所有病例均未出现其他严重并发症。5例在随访期间分别死于肝衰竭、肝癌和多器官衰竭。 结论通过对支架的改良,采用模拟Viatorr支架方法能够提高TIPS分流道的中远期通畅率,降低再出血率;简化TIPS操作步骤可减少与技术操作相关的并发症。     

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.