经颈内静脉肝内门体分流术治疗肝肾综合征临床研究

[目的]观察经颈内静脉肝内门体分流术(TIPS)治疗肝肾综合征(HRS)的临床疗效,探讨其可能的作用机制。[方法]10例确诊为HRS患者行TIPS,分别于术前及术后测门静脉压力、门静脉内径及血流速度、尿钠排泄、尿量、血肌酐(Cr)、尿素氮(BUN)及血Cr清除率;术前及术后7 d测定肾素(PRA)、血管紧张素Ⅱ(AT-Ⅱ)、醛固酮(ALD)水平。[结果]TIPS术后门静脉压力、门静脉内径及血流速度分别为(2.3±0.3)kPa、(1.26±0.04)cm、(44.2±14.5)cm/s,与术前比较均P<0.01。BUN、血Cr、尿钠排泄、血Cr清除率及尿量手术前后差异有统计学意义(均P<0.01)。术后PRA、AT-Ⅱ、ALD分别为(67.12±25.28)、(138.02±58.54)、(597.37±284.25)ng/L,与术前比较,P<0.01,<0.05,<0.05。[结论]TIPS治疗HRS近期疗效明显,其作用可能与血容量的增加和肾素-血管紧张素-醛固酮系统改变有关。     

Current diagnosis and management of post‐transjugular intrahepatic portosystemic shunt refractory hepatic encephalopathy

Transjugular intrahepatic portosystemic shunt has evolved into an important option for management of complications of portal hypertension. The use of polytetrafluoroethylene covered stents enhances shunt patency. Hepatic encephalopathy (HE) remains a significant problem after TIPS placement. The approach to management of patients with refractory hepatic encephalopathy typically requires collaboration between different specialties. Patient selection for TIPS requires careful evaluation of risk factors for HE. TIPS procedure‐related technical factors like stent size, attention to portosystemic pressure gradient reduction and use of adjunctive variceal embolization maybe important. Conservative medical therapy in combination with endovascular therapies often results in resolution or substantial reduction of symptoms. Liver transplantation is, however, the ultimate treatment.     

Budd–Chiari syndrome: illustrated review of current management

Budd–Chiari syndrome (BCS) is characterized by hepatic venous outflow obstruction at any level from the small hepatic veins to the atriocaval junction. BCS is a complex disease with a wide spectrum of aetiologies and presentations. This article reviews the current literature with respect to presentation, management and prognosis of the disease. Medical, interventional and surgical management of BCS is discussed. Particular attention is paid to interventional and surgical aspects of management. The review is augmented by images, which provide a clinical corollary to the text.     

Budd-Chiari syndrome: long-term effect on outcome with transjugular intrahepatic portosystemic shunt

BACKGROUND: The long-term outcome of Budd-Chiari syndrome (BCS) with transjugular intrahepatic portosystemic shunts (TIPS) is not well studied. To address this, the records of 47 consecutive patients with BCS evaluated in one center from January 1989 to April 2004, were analyzed. RESULTS: Seven patients with liver tumors were excluded from analyses. Eleven patients had Bechet's disease, 14 had thrombophiliac disorders, four had myeloproliferative diseases and 11 patients had other or unknown causes. The site of block was hepatic vein in 16 patients, in the suprhepatic inferior vena cava in 19 and not known in five. The majority of patients (21/40; 52.5%) presented with subacute disease with massive ascites and abdominal pain as the dominant manifestations. Eight patients with membranes or segemental block were treated with transluminal angiopalsty, and six were treated with clinical and biochemical recovery. The TIPS was placed through a transcaval puncture in eight patients with progressive liver disease who were on medical therapy and had thrombosis limited to hepatic veins. One patient bled from portal vein puncture, which was managed by placing stent across the punctured site. The TIPS was very effective in decreasing portal pressure gradient, improving synthetic functions, reducing transaminase levels and controlling ascites. Five patients had TIPS dysfunction needing revision. In two patients it was difficult to maintain TIPS patency due to repeated TIPS dysfunction. However, both these patients were asymptomatic with normal liver function tests. Long-term follow up revealed that patients with TIPS had significantly better survival than those treated with medical therapy alone (log-rank test, P = 0.04). In a multivariate Cox-model analysis four variables, namely, more florid presentation, male sex, no treatment with TIPS and increasing Child-Pugh-Turcotte score, adversely affected the survival. CONCLUSIONS: Budd-Chiari syndrome needs an individualized multidisciplinary approach and TIPS is indicated in a subgroup of patients with progressive liver disease. It is safe, feasible and improves survival.     

Acute Budd-Chiari syndrome with liver failure: the experience of a policy of initial interventional radiological treatment using transjugular intrahepatic portosystemic shunt

BACKGROUND AND AIMS: The optimal management of acute Budd-Chiari syndrome (BCS) with liver failure is controversial. Options include anticoagulation, portal systemic shunting or liver transplantation. In recent years, transjugular intrahepatic portosystemic shunts (TIPS) have been tried in place of shunt surgery. We report our experience with a policy of initial interventional radiological treatment (TIPS) in this patient group. METHODS: A consecutive, non-selected series of five patients with acute BCS with liver failure presenting to our liver unit over a 36-month period from October 2000 were treated with a policy of initial attempt at transjugular shunt. RESULTS: Stents were successfully inserted in four patients. In one patient the hepatic vein remnant could not be cannulated. One of the four stented patients had a hepatic venous web. Rapid recurrent portal and hepatic vein thrombosis occurred in one patient despite anticoagulation and trans-shunt thrombectomy. This patient and the patient with failed stenting underwent successful liver transplantation. One successfully stented patient died unexpectedly at home 2 weeks after TIPS insertion. Four of five patients are alive (80%) at a mean follow-up time of 30 months. CONCLUSION: Initial TIPS, with liver transplantation for treatment failures, may be a reasonable, cost-effective and surgery-sparing treatment for acute Budd-Chiari presenting with liver failure.     

Clinical study of transjugular intrahepatic portosystemic shunt combined with AngioJet thrombectomy for acute portal vein thrombosis in non-cirrhosis

To evaluate the outcomes of the transjugular intrahepatic portosystemic shunt (TIPS) combined with AngioJet thrombectomy in patients with noncirrhotic acute portal vein (PV) thrombosis.Retrospective analysis from January 2014 to March 2017, 23 patients underwent TIPS combined with AngioJet thrombectomy for acute PV thrombosis in noncirrhosis. The rates of technical success, the patency of the PV, liver function changes, and complications were evaluated.Twenty-three patients underwent combined treatment, with a technical success rate of 100%. Twenty-four hours after treatment, PV thrombosis grade was improved significantly (P = .001). Before and after treatment, Albumin (gm/dl), aspartate transaminase (IU/l), alanine transaminase (IU/l), and platelets (10⁹/L) were all significantly improved (P < .05). Minor complications include hematoma, hematuria, and hepatic encephalopathy. After 1 week of treatment, computed tomography scan revealed 8.7% (2/23) cases of hepatic envelope hematoma (thickness less than 2 cm). Hemoglobinuria occurred in 18/23 (78.3%) patients after treatment and returned to normal within 1 to 2 days. Two patients 2/23 (8.7%) had transient grade I encephalopathy after TIPS. The 1-year overall survival rate was 100% (23/23). No major complications during treatment in all patientsAngioJet thrombectomy via TIPS has a favorable short-term effect in clearing thrombus and alleviating symptoms in diffuse acute PVT. The long-term efficacy of this treatment needs to be further studied.     

Effects of transjugular intrahepatic portosystemic shunt treatment of patients with liver cirrhosis and portal hypertension: Case series

Rationale:Transjugular intrahepatic portosystemic shunt (TIPS) is well established as an effective treatment tool for portal hypertension. However, the effects of TIPS in patients with liver cirrhosis and portal hypertension have not been adequately verified in clinical trials.Patient Concerns:To evaluate the effects of TIPS in patients with liver cirrhosis and portal hypertension with or without portal vein thrombosis (PVT).Interventions:A total of 55 patients with liver cirrhosis and portal hypertension received TIPS treatment from December 2014 to April 2018 were enrolled. Clinical data, including portal pressure, Child-Pugh score, and relevant complications were recorded.Outcomes:TIPS was successfully performed in 54 patients. The overall technical success rate was 98.19% without serious technical complications. After TIPS treatment, portal pressure was significantly reduced from 38.13 ± 4.00 cmH₂O to 24.14 ± 3.84 cmH₂O (P < 0.05). In addition, symptoms including gastrointestinal bleeding and ascites were improved after TIPS treatment. During the 6 to 21-month follow up, hepatic encephalopathy in 15 patients (27.8%), shunt dysfunction in 5 patients (9.3%), rebleeding in 12 patients (22.2%) and deterioration of liver function in 2 patients (3.7%) were recorded. Moreover, there were no significant differences in the rates of rebleeding and hepatic encephalopathy between patients with PVT and the non-PVT group, whereas the occurrence rate of TIPS dysfunction was higher in the PVT group, but not statistically significant.Lessons:TIPS treatment could alleviate the symptoms of liver cirrhosis and portal hypertension in individuals with or without PVT. However, complications during follow-up should be appropriately noted and addressed with corresponding treatments.     

覆膜支架与裸支架对经颈静脉肝内门体分流术远期疗效影响的Meta分析

目的通过比较经颈静脉肝内门体分流术(TIPS)中应用聚四氟乙烯(PTFE)覆膜支架与裸支架的术后远期疗效,为TIPS的支架选择提供循证医学依据。方法检索中国生物医学文献数据库、万方数据库、中国知网、维普数据库、Medline、Pub Med中1989-2015年发表的有关TIPS治疗肝硬化门静脉高压的对照试验,选取符合纳入标准的研究并对文献进行质量评价。采用RevMan5.3软件对TIPS治疗后支架功能障碍发生率、肝性脑病发病率及1年生存率进行分析,发表偏倚采用漏斗图进行评估。结果共纳入11项研究,包括PTFE覆膜支架组698例及裸支架组1283例患者。Meta分析结果显示,PTFE覆膜支架组的支架功能障碍发生率(14.8%)低于裸支架组(47.0%),差异有统计学意义[比值比(OR)=0.18,95%可信区间(95%CI):0.13~0.24,P0.001];2组肝性脑病发病率差异无统计学意义(23.5%vs 25.7%,OR=0.88,95%CI:0.66~1.17,P=0.37);PTFE覆膜支架组患者术后1年生存率(76.9%)高于裸支架组(62.7%),差异有统计学意义(OR=2.10,95%CI:1.54~2.85,P0.001)。基于支架功能障碍发生率、肝性脑病发病率、术后1年生存率绘制的漏斗图分布欠对称,提示可能存在一定的发表偏倚。结论应用PTFE覆膜支架较裸支架可改善TIPS治疗后支架功能障碍,提高患者术后1年生存率,但不会影响肝性脑病发病率,故PTFE覆膜支架在TIPS手术中的应用较裸支架具有一定优势。     

Refractory hepatic hydrothorax treated with transjugular intrahepatic portosystemic shunt

A 66-year-old cirrhotic woman was referred to our hospital for evaluation of refractory pleural effusion and dyspnea. Massive right sided-pleural effusion but no ascites was detected. She had been treated with diuretics and albumin, repeated thoracenteses, and pleural drainage with an intercostal catheter, all of which had failed to relieve her symptoms. The diagnosis of hepatic hydrothorax without ascites was made by injection of technetium-99m-sulfur colloid into the peritoneal cavity. A transjugular intrahepatic portosystemic shunt was placed and successfully reduced the pleural effusion, resulting in complete relief of her symptoms. The patient has been free of symptoms for 18 months after the procedure. (Received Jan. 19, 1998; accepted June 24, 1998)     

Differences in long-term survival after transjugular intrahepatic portosystemic shunt for refractory ascites and variceal bleed

OBJECTIVE: To compare the survival after transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites and variceal bleed, and to identify the factors predictive of survival. METHODS: Single tertiary center, retrospective-prospective study. Chart review was performed on all patients who underwent TIPS between 1993 and 2000 and prospective follow-up to determine survival. Pre- and post-TIPS clinical parameters were compared and Kaplan-Meier analysis was applied to compare the survival of both groups. Cox regression was used to identify predictors of survival after TIPS. RESULTS: A total of 163 patients were included, 62 with refractory ascites and 101 with variceal bleed. Both groups had similar age (48.2 vs 48.9 year; P = 0.65) and consisted of predominantly Caucasians (51%) and Mexican-Americans (39%). More than 75% had chronic hepatitis C, alcoholic liver disease or both. Overall, the median survival was significantly better for variceal bleed (2 years) compared with refractory ascites (6 months) (P < 0.001). This survival advantage persisted in patients with Mayo risk score greater than 1.17. Transjugular intrahepatic portosystemic shunt improved severe ascites in 45% of patients (P = 0.03). Mayo risk score was highly predictive of survival after TIPS with a hazard ratio of 2.3, followed by Child-Pugh score, creatinine, albumin and ethnicity, with better survival among Mexican-Americans. Shunt dysfunction (31%) and hepatic encephalopathy (27%) were the most common complications of TIPS. CONCLUSIONS: Patients who received TIPS for variceal bleed had significantly longer survival compared with those for refractory ascites. Mexican-Americans had an improved long-term survival compared with Caucasians. The reason for this ethnic difference in survival is unclear and warrants further prospective evaluation.     

Budd–Chiari syndrome: Focus on surgical treatment

Budd–Chiari syndrome (BCS) is caused by an obstruction in the hepatic venous outflow tract at various levels from small hepatic veins to the inferior vena cava (IVC) due to thrombosis or fibrous sequelae. This rare disease mainly affects young adults. Risk factors have been identified and patients often have multiple risk factors. Myeloproliferative diseases of atypical presentation account for nearly 50% of patients in Europe and North America countries. Multistep management is required for such patients. Interventional revascularization and transjugular intrahepatic portosystemic shunt procedure are indicated after initial anticoagulation therapy, whereas IVC plasty using a patch graft is indicated for obstruction of the IVC. Liver transplantation (LT) is usually indicated as a treatment for liver failure despite various treatments. The outcomes of LT are good, with a 5‐year survival after LT of nearly 70%.     

Long term outcome after transjugular intrahepatic portosystemic stent-shunt in non-transplant cirrhotics with hepatorenal syndrome: a phase II study

BACKGROUND: Recent small studies on hepatorenal syndrome (HRS) indicate some clinical benefit after transjugular intrahepatic portosystemic stent-shunt (TIPS) but sufficient long term data are lacking. AIM: We studied prospectively feasibility, safety, and long term survival after TIPS in 41 non-transplantable cirrhotics with HRS (phase II study). PATIENTS AND METHODS: HRS was diagnosed using current criteria (severe (type I) HRS, n=21; moderate (type II) HRS, n=20). Thirty one patients (14 type I, 17 type II) received TIPS (8-10 mm) while advanced liver failure excluded shunting in 10. During follow up (median 24 months) we analysed renal function and survival (Kaplan-Meier). RESULTS: TIPS markedly reduced the portal pressure gradient (21 (5) to 13 (4) mm Hg (mean (SD)); p<0.001) with one procedure related death (3.2%). Renal function deteriorated without TIPS but improved (p<0.001) within two weeks after TIPS (creatinine clearance 18 (15) to 48 (42) ml/min; sodium excretion 9 (16) to 77 (78) mmol/24 hours) and stabilised thereafter. Following TIPS, three, six, 12, and 18 month survival rates were 81%, 71%, 48%, and 35%, respectively. As only 10% of non-shunted patients survived three months, total survival rates were 63%, 56%, 39%, and 29%, respectively. Multivariate Cox regression analysis revealed bilirubin (p<0.001) and HRS type (p<0.05) as independent survival predictors after TIPS. CONCLUSIONS: TIPS provides long term renal function and probably survival benefits in the majority of non-transplantable cirrhotics with HRS. These data warrant controlled trials evaluating TIPS in the management of HRS.     

The effects of transjugular intrahepatic portosystemic shunt on portal hypertensive gastropathy

In addition to variceal bleeding, haematemesis may occur due to haemorrhagic gastritis in patients with portal hypertension. This has been known as portal hypertensive gastropathy (PHG). We have evaluated the effects of the transjugular intrahepatic portosystemic shunt (TIPS) on portal venous pressure (PVP) and endoscopic gastric mucosal changes observed in patients with portal hypertension. We performed TIPS in 12 patients with complications due to portal hypertension as follows: variceal bleeding in nine patients (bleeding from oesophageal varices in seven and gastric varices in two), refractory ascites in three and haemorrhage from severe PHG in one. Endoscopic examinations were performed before and after TIPS for all patients. Changes of PVP and gastric mucosal findings on endoscopy were analysed. Before TIPS, PHG was seen in 10 patients. Portal venous pressure decreased from an average of 25.1 ± 8.8 to 17.1 ± 6.2 mmHg after TIPS ( P < 0.005). On endoscopy, PHG improved in nine of 10 patients. Oesophagogastric varices improved in eight of 11 patients. In one patient with massive haematemesis, haemorrhage from severe PHG completely stopped after TIPS. Because TIPS effectively reduced PVP, this procedure appeared to be effective for the treatment of uncontrollable PHG.     

经颈静脉肝内门体分流术应用的回顾与展望

近年来,经颈静脉肝内门体分流术(TIPS)在国内逐步推广并得到广泛认可,此项技术的技术标准、适应证和禁忌证也逐步建立。覆膜支架的诞生成功解决了裸支架分流道闭塞率高的问题,使TIPS迎来了另一个春天。遗憾的是,大多数临床研究发表于覆膜支架前,因此TIPS的临床疗效并不代表本领域的目前状态。随着此项技术的发展,TIPS正不断扩大其适应证,中国作为TIPS大国也急需更多高质量的多中心临床随机对照试验。TIPS在治疗门静脉高压症和肝血管疾病的各种并发症中,取得了越来越多的认可,并必将迎来一个美好的未来。