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%、...     

门静脉金属内支架置入治疗门静脉海绵样变

目的：探讨经皮肝穿刺和经颈内静脉肝内门体分流术(TIPS)途径门静脉内支架置入治疗门静脉海绵样变(CTPV)的疗效及安全性。方法回顾性分析于本科治疗的8例 CTPV 患者的临床及影像学资料。所有患者均行门静脉金属内支架置入治疗,其中3例经 TIPS 途径放置,5例经经皮肝穿刺途径放置。结果所有患者支架置入均一次性成功,无腹腔内出血等严重并发症发生。术中即刻复查造影显示支架内血流通畅,术后1 d~2周患者腹痛及消化道出血症状均明显减轻或消失。术后所有患者均获得完整随访,随访1个月~3年,1例患者术后1 年复查支架闭塞,再次置入1枚支架后血流通畅,其余患者彩超提示支架内血流通畅,未再发消化道出血或腹痛。结论经皮肝穿刺或经 TIPS 途径门静脉金属内支架置入治疗 CTPV 是一种安全有效方法。     

经颈静脉门腔分流术中Fluency覆膜支架应用的临床观察

目的 评价Fluency覆膜支架在经颈静脉门腔分流术(TIPS)中的临床效果.方法 搜集21例采用Fluency覆膜支架行TIPS治疗患者的临床病例资料进行回顾性分析.本组患者随访时间2.0～24.0个月,平均(10.1±4.6)个月;均为门静脉高压上消化道大出血,其中原发性肝癌门静脉主干癌栓伴大出血1例,布加综合征1例.分析患者术后支架开通情况,门静脉压力及肝功能变化情况.对手术前后门静脉压力及肝功能变化情况的比较采用配对t检验.结果21例患者共放支架25枚,均成功放置,支架直径10 mm 2枚、8 mm为23枚;覆膜支架长度6～8 cm.所有患者术后上消化道出血停止;门静脉压力由术前平均(25.4±3.5)mm Hg(1mm Hg=0.133 kPa)降为(15.4±2.8)mm Hg,手术前后差异有统计学意义(t=12.495,P<0.01).随访期间,1例原发性肝癌伴门静脉主干癌栓患者于术后4个月死亡,1例随访期间发现原发性肝癌的患者术后24个月死亡,1例门静脉高压上消化道大出血患者于术后2个月死于多器官功能衰竭,1例于术后15个月出现肝静脉端狭窄,行第2枚支架治疗效果良好,余17例随访7～17个月支架无狭窄.患者死亡前1周复查超声示支架均通畅.3例术后出现一过性肝性脑病前驱症状,经对症处理后好转.存活6个月以上的19例患者,术前Child肝功能评分(6.3±1.4)分,术后6个月评分(6.4±1.9)分,两者差异无统计学意义(t=0.645,P>0.05).结论采用Fluency覆膜支架行TIPS术,能明显提高TIPS术后开通率,但长期效果及肝性脑病的评价尚需验'证.     

症状性门静脉阻塞的介入治疗

目的　评价介入技术治疗症状性门静脉 (PV)阻塞的安全性和疗效。方法　对 9例PV阻塞患者进行了介入治疗 ,5例以门静脉高压症、食管 胃静脉曲张破裂出血就诊 (2例继发于肝移植后 ,3例HCC合并PV癌栓 ) ,3例为PV血栓形成 ,另 1例继发于腹部外科手术。 4例采取经皮经肝途径穿刺PV分支 ,5例用TIPS途径。支架置入 4例、球囊扩张成型 6例次、局部溶栓和血栓清除 7例次。结果　治疗技术均成功 ,无重要并发症。介入治疗后复查PV造影显示PV主干血流通畅。 3例腹部症状较明显的PV血栓形成患者 ,术后腹痛、腹胀和腹泻等症状逐渐减轻。随访时间 4～ 36个月 ,1例HCC患者于术后 11个月死于多器官转移 ;1例继发于腹部外科术后患者 ,虽然PV主干恢复血流、临床症状曾一度改善 ,但于 12d后死于腹腔脓肿、多器官衰竭。其余 7例生存 ,Doppler超声复查证实PV主干血流通畅 ,患者未再发生静脉曲张破裂出血或PV血栓相关症状。结论　介入微创技术 ,包括球囊扩张、支架置入、局部溶栓和机械性血栓清除术 ,是治疗症状性PV阻塞的的安全、有效方法     

超声在TIPS术后随访中的应用

目的探讨彩色多普勒超声在经颈静脉肝内门-体静脉分流术(TIPS)术后随访中的应用价值。方法 40例TIPS患者分别于术后1周内、1、3、6个月分别行超声检查,比较患者术后1周内与术前门静脉高压指标变化,并通过超声检查肝、脾变化以及支架内血流情况,包括正常、狭窄和闭塞。结果术后1周内,患者门静脉压力指标较术前明显降低(P<0.05),术后肝脏分流叶缩小,左叶代偿增大,脾脏缩小,随访期间超声共检查出6例(次)支架内狭窄,均复通成功,2例支架闭塞,复通失败后重新置入支架。结论彩色多普勒超声不仅能检查TIPS术后患者肝、脾变化情况,还能较好地观察支架内血流情况,尽早发现支架内狭窄或闭塞,为临床治疗提供参考。     

经颈静脉肝内门体分流术治疗门静脉血栓形成伴急性消化道大出血效果评价北大核心CSCD

目的 评价经颈静脉肝内门体分流术(TIPS)治疗门静脉血栓形成(PVT)伴消化道大出血的可行性及临床效果。方法 回顾性分析2015年3月至2017年3月采用TIPS术治疗的18例PVT伴消化道大出血患者临床资料,观察围手术期并发症发生率、再出血率、血栓开通情况、肝性脑病发生率、支架中远期通畅率。结果 所有患者均在消化道大出血72 h内成功完成TIPS术,手术成功率100%。围手术期死亡率5.5%(1/18),术后发生Ⅰ~Ⅱ级肝性脑病5例(27.8%,5/18)。术后随访6~24个月,平均12.4个月,PVT完全消失6例,明显减少7例,无明显进展4例;所有患者支架均通畅,2例出现支架内狭窄,其中1例无出血,未予处理,1例术后8个月再出血,予球囊扩张修复术后出血停止。结论 TIPS术治疗PVT伴急性消化道大出血安全、有效,值得推广。     

经皮脾静脉途径联合TIPS治疗伴海绵样变性的门静脉血栓

目的 探讨经皮脾静脉途径联合TIPS治疗伴海绵样变性的门静脉血栓的可行性、安全性和疗效.方法 对3例门静脉血栓伴门脉海绵样变性患者行经皮脾穿脾静脉途径开通门静脉,联合TIPS重建门静脉分流道.随访22～40个月,观察治疗效果、支架通畅情况、肝功能变化和并发症.结果 3例均成功.其中1例支架经由显著扩张的海绵样变性的侧支放置,术后7个月内出现2次肝性脑病前期症状,药物治疗后症状消失.1例患者于术后6个月内出现持续性的胆红素增高,最高总胆红素为88.2μmoL/L,直接胆红素68.7 μmoL/L.予以保肝、降黄治疗后总胆红素维持在(44.4±11.6)μmol/L,直接胆红素(29.7±12.8)μmol/L.较术前无显著变化.第3例术后恢复良好.3例无术中并发症,术后随访22～40个月,支架血流通畅,未再发静脉曲张出血.结论 在有限的治疗伴有海绵样变性的门静脉血栓的方法选择中,经皮脾穿刺脾静脉途径开通门静脉,联合TIPS是安全可行和有效的,虽然技术要求上更困难和更具挑战性.     

经颈静脉肝穿刺门静脉途径门静脉及肠系膜上静脉血栓溶栓治疗6例报告

目的 评价经颈静脉经肝穿刺门静脉(TIPSS)途径门静脉及肠系膜上静脉血栓溶栓治疗的安全性和治疗效果。方法 对6例诊断为门静脉(PV)和肠系膜静脉(SMV)广泛血栓形成的患者进行了经TIPSS途径介入溶栓治疗。患者主要症状有腹痛、腹胀、厌食等。腹部体检有压痛,均无明确腹肌紧张和反跳痛。经B超、增强CT检查和直接PV-SIV造影确诊为本病。溶栓方法：穿刺PV分支成功后插入导管做PV-SMV造影,确定诊断及了解栓塞范围,抽吸及捣碎血栓,间断将尿激酶经多侧孔导管注入PV和SMV清除大部分血栓后,保留多侧孔导管于SMV内持续溶栓3～13天。术后药物抗凝治疗6个月左右。此间,密切监测出凝血时间及影像学变化。结果 介入治疗后,大部分血栓被清除,PV和SMV有血流通过,腹痛、腹胀和腹泻症状逐步缓解。经留置于SMV的导管造影显示,PV和SMV主干及主要分支血流通畅,3例门静脉的肝内少数分支有残留血栓,但无明显症状。随访4个月至3年,除1例死于外科手术并发症外,其余5例患者健在,无血栓复发证据及上消化道出血发生。结论 经TIPSS途径介入溶栓治疗急性PV和SMV血栓形成是安全有效的,近期及中远期疗效均好。     

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.     

Viatorr支架在门静脉高压合并上消化道出血的临床应用

目的：观察Viatorr支架在经颈静脉肝内门腔静脉分流术（TIPS）中治疗门静脉高压合并上消化道出血的临床效果。 方法：收集2016年11月至2017年10月我院收治的因门静脉高压合并食管胃底静脉曲张破裂出血患者17例,使用Viatorr支架行TIPS治疗。测量Viatorr支架分流前后门腔静脉压力梯度（PSG）值变化,手术前后肝功能、血氨、凝血酶原时间变化,以及术后支架通畅率与再出血情况,并对临床疗效及并发症情况进行分析。 结果：17例患者均获得100%技术性成功。TIPS术后的PSG为（14.47±3.39）mmHg,比术前的（25.47±5.77）mmHg明显降低,差异有统计学意义（t=12.015,P<0.05）。TIPS术后1 d,血氨较术前有所升高[（55.38 ±9.27）μmol/L vs.（40.60±8.14）μmol/L,P<0.05],而术后1周的血氨较术前没有明显变化[（34.77±5.01）μmol/L vs.（40.60±8.14）μmol/L,P>0.05],手术前后的总胆红素、白蛋白、谷丙转氨酶、谷草转氨酶、凝血酶原时间差异无统计学意义。17例患者中16例存活,1例于术后52 d并发肺部感染致呼吸衰竭死亡;4例患者出现I期或II期肝性脑病,纠正后症状逆转;所有患者至随访结束均未再出现呕血、黑便等症状,所有病例术后1周及3个月后均行腹部彩超或增强CT检查,至随访结束（或死亡前）TIPS分流通道血流通畅,通畅率100%,2例合并腹水患者复查腹水消失。术后1~3个月内4例患者复查胃镜,均提示食管胃底曲张静脉缓解或消失。 结论：TIPS术中使用Viatorr支架能明显降低门静脉压力,维持分流道的长期通畅,降低上消化道再出血率,术后肝性脑病并发率在可控制范围内,是门静脉高压患者的一种安全有效的治疗手段。     

Applications of percutaneous mechanical thrombectomy in transjugular intrahepatic portosystemic shunt and portal vein thrombosis

Portal vein thrombosis (PVT) is an uncommon cause for presinusoidal portal hypertension. PVT can be caused by one of three broad mechanisms: (1) spontaneous thrombosis when thrombosis develops in the absence of mechanical obstruction, usually in the presence of inherited or acquired hypercoagulable states; (2) intrinsic mechanical obstruction because of vascular injury and scarring or invasion by an intrahepatic or adjacent tumor; or (3) extrinsic constriction by adjacent tumor, lymphadenopathy or inflammatory process. Usually, several combined factors are necessary to result in PVT. The consequences of portal vein thrombosis are mostly related to the extension of the clot within the vein. Gastrointestinal bleeding from gastroesophageal varices is the most frequent presentation. Noninvasive imaging techniques are currently used for the screening of patients and the initial diagnosis of PVT. The invasive techniques are reserved for cases when noninvasive techniques are inconclusive, before percutaneous interventional treatment, or in preoperative assessment of patients who are candidates for surgery. Recanalization of the portal vein with anticoagulation alone may not be consistent or appropriate in highly symptomatic patients. Catheterization of the superior mesenteric artery (SMA) is helpful for diagnosis as well as for therapy by allowing the intra-arterial infusion of thrombolytic drugs in the same setting. Direct transhepatic portography allows precise determination of the degree of stenosis and extension within the portal vein, as well as pressure measurements. Thrombotic occlusions of the portal, mesenteric, and splenic veins can be managed by mechanical thrombectomy (MT) or pharmacologic thrombolysis. Underlying occlusions because of organized or refractory thrombus or fixed venous stenosis are best corrected by balloon angioplasty and stent placement. Access into the portal venous system can also be established through creating a transjugular intrahepatic portosystemic shunt (TIPS). Creating a TIPS is also important in the setting of PVT associated with cirrhosis to decompress portal hypertension and improve portal venous flow. PVT involving the portal, splenic, and/or mesenteric veins can also complicate a preexisting TIPS in which case the shunt can be readily used as therapy access. Several techniques may be used to recanalize the shunt and portal venous system, including thrombolytic therapy, balloon angioplasty/embolectomy, suction embolectomy, basket extraction of clots, and mechanical thrombectomy with a variety of devices. Advantages of MT include the potential to rapidly remove thrombus without the need for prolonged thrombolytic infusions, and reducing the potential life-threatening complications of thrombolytic therapy. Possible drawbacks include the risk of intimal or vascular trauma to the portal vein, which may promote recurrent thrombosis.     

Percutaneous transsplenic access in the management of bleeding varices from chronic portal vein thrombosis

Three patients with life-threatening variceal hemorrhage secondary to portal vein (PV) thrombosis underwent endovascular treatment via the transsplenic route. The indications, techniques, and early outcomes are described. Each patient had successful portal/splenic vein recanalization with or without transjugular intrahepatic portosystemic shunt (TIPS) creation and variceal embolization with conventional catheter and wire techniques. The transsplenic approach is a useful addition to the interventional armamentarium that can be used in cases refractory to endoscopic management and unsuitable for surgical shunt procedures or conventional TIPS procedures. Longer-term follow-up will be needed to establish the durability of these procedures.     

经皮治疗门静脉血栓的临床研究

目的：研究和评价经皮治疗门静脉血栓技术的可行性和临床效果。材料与方法：16例有门静脉闭塞症状的患者,门静脉血栓均为非海绵状血管变性所致。通过建立经颈列脉肝内门腔静脉分流通道（TIPS）,带膜支架旁路术和经皮抽吸取栓法清除门静脉血栓提高门静脉的血流输出量。结果：13例采用经皮技术治疗获得成功。门静脉血栓所致的门脉高压均得到纠正,静脉曲张破裂出血立即停止;顽固性腹水和黄疸症状得到缓解。结论：经颈静脉门腔静脉分流术,门静脉内带膜支架旁路术和经皮门静脉抽吸取栓法对于治疗非海绵状血管变性和晨瘤栓所致的门静脉闭塞是安全有效的。     

门静脉血栓形成的TIPS治疗和临床结果

目的 研究和评价经皮治疗门静脉及其属支血栓的技术可行性和临床效果。方法 16例有门静脉及其属支闭塞症状的患，门静脉及其属支血栓均为非海绵状血管变性所致。通过建立经颈静脉肝内门腔静脉分流通道(TIPS)、带膜支架旁路术和经皮抽吸取栓法清除门静脉及其属支血栓提高门静脉的血流输出量。结果 13例采用经皮技术治疗获得成功。门静脉及其属支血栓所致的门脉高压均得到纠正，静脉曲张破裂出血立即停止；顽固性腹水和黄疸症状得到缓解。结论 经颈静脉门腔静脉分流术、门静脉内带膜支架旁路术和经皮门静脉及其属支抽吸取栓法对于治疗非海绵状血管变性和非瘤栓所致的门静脉闭塞是安全有效的。     

Limitations of percutaneous techniques in the treatment of portal vein thrombosis

New therapeutic alternatives to portal vein thrombosis (PVT) include the percutaneous, transhepatic infusion of fibrinolytic agents, balloon dilatation, and stenting. These maneuvers have proven to be effective in some cases with acute, recent PVT. We have treated two patients with acute PVT via transhepatic or transjugular approaches and by using pharmacologic and mechanical thrombolysis and thrombectomy. Although both patients clinically improved, morphologic results were only fair and partial rethrombosis was observed. The limitations of percutaneous procedures in the recanalization of acute PVT in noncirrhotic patients are discussed.     

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.     

Percutaneous transhepatic thrombolysis in the treatment of acute portal venous thrombosis

Acute portal vein thrombosis (PVT) is a rare clinical condition that can cause portal hypertension and bowel infarction. Early diagnosis and treatment of PVT is crucial for the restoration of portal venous flow and reduction of morbidity and mortality. We report a successful treatment of acute PVT which was seen following splenectomy, utilizing catheter directed transhepatic thrombolysis. No complication was encountered related to the procedure. Thrombolytic therapy via transhepatic route proved to be a safe and effective method in the treatment of PVT.     

Flouroscopically–guided transhepatic puncture for difficult TIPS re-do procedures utilizing the En Snare retrieval device: A new approach to occluded TIPS in patients with recurrent ascites

Portal hypertension and variceal bleeding are complications due to cirrhosis. Transjugular Intraphepatic Portosystemic shunt (TIPS) procedure is a well-established treatment for recurrent ascites and variceal bleeding related to portal hypertension. After a TIPS has been placed, the potential of TIPS occlusion or stenosis is high. A TIPS re-do procedure has been used in treatment of progressive clinical symptoms. The standard approach is via the jugular route to recannulate the TIPS shunt. Rarely, it cannot be performed from the jugular approach. Therefore, a fluoroscopically -guided transhepatic approach has been devised for these difficult situations. This case describes the use of the transhepatic route through an indwelling Viatorr covered stent utilizing an En-Snare device to help complete the TIPS re-do procedure. With this newer approach to TIPS re-do procedures, endovascular specialists can achieve TIPS patency despite difficult venous anatomical challenges and the various types of available TIPS stents presently on the market.     

Prevention of hepatic infarction as acute-phase complication of TIPS by temporary balloon occlusion in a patient with primary myelofibrosis

Severe acute liver dysfunction occurred following transjugular intrahepatic portosystemic shunt (TIPS) creation in a patient with massive ascites due to portal hypertension associated with primary myelofibrosis. On US and TIPS venography, we considered that the acute liver ischemia was induced by TIPS. To avoid diffuse hepatic infarction and irreversible liver damage, a balloon catheter was inserted transjugularly into the TIPS tract and occluded it to increase portal venous flow toward the peripheral liver parenchyma. The laboratory data indicating hepatic dysfunction were improved after the procedure. We should pay attention to the possible occurrence of acute hepatic ischemia and infarction after TIPS creation even in a case of noncirrhotic portal hypertension. In such cases, temporary balloon occlusion of TIPS is an effective therapeutic method, probably as a result of inducing the development of arterial compensation through the peribiliary plexus.