多层螺旋CT及其门静脉造影在TIPS联合胃冠状静脉栓塞术前应用价值

目的：探讨多层螺旋CT（MSCT）及多层螺旋CT门静脉造影（MSCTP）在经颈静脉肝内门体分流（TIPS）联合胃冠状静脉栓塞（GCVE）术前应用的价值。方法对126例肝硬化门静脉高压伴发食管胃底静脉曲张破裂出血或顽固性腹水拟行TIPS联合GCVE患者,术前行MSCT及MSCTP检查。采用最大密度投影（MIP）、多平面重组（MPR）、遮蔽表面显示（SSD）和容积再现（VR）等后处理技术全面了解肝脏情况。结果 MSCT及MSCTP能清晰显示肝硬化肝脏形态变化、肝静脉与门静脉空间位置关系、门静脉侧支循环开放程度和范围以及腹水等情况,为TIPS联合GCVE术前评估提供了重要的解剖信息。结论 MSCT 及MSCTP 是无创性检查并明确诊断肝硬化门脉高压症的可靠方法,对 TIPS 联合GCVE术中准确引导门静脉穿刺及曲张静脉栓塞治疗具有重要指导意义。     

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.     

声触诊组织量化技术评估经颈静脉肝内门体分流术联合胃冠状静脉栓塞术疗效

目的 探讨应用声触诊组织量化(VTQ)技术测量脾脏剪切波速度(SSWV)无创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)疗效的价值。方法 将19例接受TIPS联合GCVE治疗的肝硬化门静脉高压患者分为A(13例,接受1次治疗)、B(6例,首次治疗后因支架闭塞再次接受治疗)两组。应用VTQ技术分别与治疗前1天、治疗后6天测量SSWV,以脉冲波多普勒测量门静脉主干血流速度(PVV)、脾静脉主干血流速度(SVV)。于TIPS联合GCVE治疗过程中,以直接测压法测量支架植入前及植入后的门静脉压(PPG),并进行统计分析。结果 TIPS联合GCVE治疗后,A、B两组PPG均较治疗前明显减低(P均<0.05);SSWV均较治疗前明显减低,PVV、SVV均较治疗前明显升高(P均<0.05)。A、B两组治疗前及治疗后SSWV均与PPG呈正相关(P均<0.05),PVV、SVV均与PPG无相关性(P均>0.05)。结论 应用VTQ技术所测SSWV与PPG存在相关性,可作为TIPS联合GCVE治疗前后监测门静脉压力的无创定量评估指标。     

Biliary complications of arterial chemoembolization of hepatocellular carcinoma

Rationale and backgroundTransarterial chemoembolization (TACE) is the most frequently used palliative therapy for unresectable hepatocellular carcinoma (HCC). It is a safe and effective procedure with few major and minor complications. Rarely, biliary complications are also encountered following TACE. The goal of our study was to investigate the incidence and the presentation of biliary complications following TACE in patients with HCC.Material and methodsIn this retrospective study, data of patients with HCC who underwent TACE between June 2002 to December 2014 were obtained from the records. Their detailed information about the procedure of TACE, diagnosis of biliary complications and subsequent management details were reviewed.ResultOne hundred and sixty-eight patients with HCC underwent 305 procedures of TACE. Of these, biliary complications of various severities developed in 6 (3.6%) patients leading to an incidence of 1.9% (6/305). Minimal intrahepatic biliary dilatation (IHBD) occurred in three, biliary stricture in one and intrahepatic biloma in two patients. Supportive management was undertaken for IHBD patients while percutaneous aspiration and naso-biliary drainage was performed for the infected bilomas.ConclusionBiliary complications following TACE are infrequent. Diagnosis should be suspected clinically and confirmed with imaging. Treatment depends on the severity. Enforcing specific measures can minimize its frequency.     

Chronic Albumin Infusions to Achieve Diuresis in Patients with Ascites Who Are Not Candidates for Transjugular Intrahepatic Portosystemic Shunt (TIPS)

While transjugular intrahepatic portosystemic shunt (TIPS) is a common therapy for cirrhotic patients with diuretic-resistant or diuretic-refractory ascites, some patients are unsuitable for the procedure for technical or medical reasons. We report our experience with the use of chronic intravenous albumin infusions to achieve diuresis in this difficult patient population and review the historic experience of chronic albumin infusions as a treatment for ascites. Nineteen patients with cirrhosis and diuretic-resistant or diuretic-refractory ascites who were deemed unsuitable for TIPS received outpatient intravenous albumin infusions (50 g) weekly for at least 4 weeks. The following endpoints were retrospectively recorded: serum sodium, serum creatinine, blood urea nitrogen, hematocrit, bilirubin, albumin, international normalized ratio, body weight, and Model for End-stage Liver Disease (MELD) score. The contraindicatoins for TIPS included the following: portal vein thrombosis, two; advanced age, one; encephalopathy, nine; hyperbilirubinemia, five; and other, two. Compared to pretreatment, posttreatment weight decreased in 17 patients, remained unchanged in 0 patients, and increased in 2 patients. The overall mean change in body weight (before vs. after therapy) was 8 lb (P < 0.05). The only significant change in biochemistries was an increase in serum albumin from 2.5 g/dl before therapy to 3.5 g/dl after therapy (P < 0.05). We conclude that (1) recurrent intravenous weekly albumin infusions resulted in significant loss of edema and ascites as measured by loss of body weight, and (2) clinicians may want to consider chronic albumin infusions for selected patients with refractory ascites who are not candidates for TIPS.     

Nontumoral Portal Vein Thrombosis: A Challenging Consequence of Liver Cirrhosis

Nontumoral portal vein thrombosis (PVT) is an increasingly recognized complication in patients with cirrhosis. Substantial evidence shows that portal flow stasis, complex thrombophilic disorders, and exogenous factors leading to endothelial dysfunction have emerged as key factors in the pathogenesis of PVT. The contribution of PVT to hepatic decompensation and mortality in cirrhosis is debatable; however, the presence of an advanced PVT increases operative complexity and decreases survival after transplantation. The therapeutic decision for PVT is often determined by the duration and extent of thrombosis, the presence of symptoms, and liver transplant eligibility. Evidence from several cohorts has demonstrated that anticoagulation treatment with vitamin K antagonist or low molecular weight heparin can achieve recanalization of the portal vein, which is associated with a reduction in portal hypertension-related events and improved survival in cirrhotic patients with PVT. Consequently, interest in direct oral anticoagulants for PVT is increasing, but clinical data in cirrhosis are limited. Although the most feared consequence of anticoagulation is bleeding, most studies indicate that anticoagulation therapy for PVT in cirrhosis appears relatively safe. Interestingly, the data showed that transjugular intrahepatic portosystemic shunt represents an effective adjunctive therapy for PVT in cirrhotic patients with symptomatic portal hypertension if anticoagulation is ineffective. Insufficient evidence regarding the optimal timing, modality, and duration of therapy makes nontumoral PVT a challenging consequence of cirrhosis. In this review, we summarize the current literature and provide a potential algorithm for the management of PVT in patients with cirrhosis.