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。

Clinical application of Viatorr stent in upper gastrointestinal bleeding with portal hypertension

Objective:To observe the clinical effects of Viatorr stent used in transjugular intrahepatic portosystemic shunt (TIPS) for treating upper gastrointestinal bleeding with portal hypertension. Methods:Seventeen patients with portal hypertension combined with variceal hemorrhage using Viatorr stent in our hospital from November 2016 to October 2017 were included. The clinical effects and rate of complications were analyzed through comparing the portosystemic gradient (PSG) , total bilirubin, human albumin and prothrombin time before and after 1 d and 1 week of TIPS. In addition, the clinical follow-up of the patency rate of Viatorr stent and recurrence of hemorrhage were conducted. Results:Seventeen patients were operated successfully in one time and the success rate of the technique was 100%. The PSG before and after TIPS were (25.47±5.77) and (14.47±3.39) mmHg (t=12.015, P<0.05) . The blood ammonia after 1 d of TIPS was higher than that before TIPS (P<0.05) , but there was no significant difference between 1 week postoperation and pre-operation (P>0.05) . There was no significant difference of the total bilirubin, human albumin, glutamic oxalacetic transaminase, glutamic pyruvic transaminase and blood ammonia between 1 d and 1 week postoperation and pre-operation (P>0.05) . During the follow-up, 16 patients survived. One patient died after 52 d of operation because of pneumonia, and grade I or II hepatic encephalopathy occurred in 4 patients. All the patients never had haematemesis or melena. All the patients underwent color Doppler ultrasound or enhanced CT examination at 1 week and 3 months post-operation, and the results showed that all patients got smooth TIPS shunts till the end of follow-up visits (or before death) . The symptoms of ascites in two patients disappeared. Four patients underwent gastroscopy re-examination at 1-3 months after operation. The results showed that varicosed veins were relieved or disappeared. Conclusions:The usage of Viatorr stent can decrease the portal venous pressure and maintain the long-term circulation of shunts, reduce the rebreeding rate and keep the incidence of hepatic encephalopathy stay in control during the procedure of TIPS, so it is a safe and effective method for the treatment of patients with portal hypertension.