经颈静脉肝内门-体分流术后再次介入治疗肝硬化门静脉高压长期疗效及再次手术原因分析

Clinical analysis of long-term outcomes of re-intervention of transjugular intrahepatic porto-systemic shunt

目的探讨经颈静脉肝内门-体分流术（TIPS）再次介入治疗肝硬化门静脉高压的安全性、有效性及临床影响因素。方法回顾分析771例应用TIPS治疗肝硬化门静脉高压患者的临床资料，其中再次介入463例，共计625例获得随访，根据介入治疗次数将患者分为治疗1次组（组1）219例，治疗2次组（组2）246例和治疗3次及以上组（组3）160例。对比分析3组患者的临床症状、生存率、再狭窄率，重点探讨影响再次介入治疗的效果和因素。结果所有患者初次手术成功率98．2％（757／771），病死率0．7％（5／757）、严重合并症发生率2．5％（19／757）；再次手术成功率98．7％（457／463），无严重合并症及死亡发生。3组结果显示：术后1年再狭窄率组3患者明显低于组1（x2=7．908，P〈0．05），组2分别与组1（x2=3．777，P〉0．05）和组3（X2=1．100，P〉0．05）比较，差异无统计学意义；2—5年再狭窄率组2及组3均明显低于组1（x2值分别为27．046、25．724、37．002、19．046，P值均〈0．05）。1年生存率组3和组2均明显高于组1（x2值分别为9．114、4．929，P值均〈0．05），但组2与组3相比差异无统计学意义（x2=2．678，P〉0．05）；2～5年生存率组2及组3也明显高于组1（x2值分别为41．314、26．920、13．692、6．713，P值均〈0．05）。再次介入治疗的患者19．4％（79／406）有症状复发与分流道狭窄或闭塞同时存在；单纯症状复发伴有预示门静脉压力增高临床症状，及单纯分流道狭窄或闭塞伴有预示门静脉压力增高症状的患者分别为11．6％（47／406）与62．8％（255／406）。结论分流道狭窄或闭塞、症状复发及预示门静脉压力增高等是再次介入治疗的主要原因。TIPS再次介入治疗安全有效，可以提高患者的长期生存率及支架通畅率。

Objective To evaluate the safety, effectiveness and clinical factors of re-intervention of transjugular intrahepatic porto-systemic shunt （TIPS）. Methods A retrospective study of safety and longterm outcomes of TIPS was made in 771 patients from August 1994 to August 2010. The 625 patients had follow-up data. The patients who received TIPS once, twice, and more than twice were divided into group 1, group 2 and group 3, respectively. Clinical symptoms, survival rate and restenosis rate of each group were analyzed. Clinical influencing factors of re-intervention effect were discussed. Results The success rate of first intervention was 98.2% （757/771） , the death rate was 0. 7% （5/757） and severe complication rate was 2. 5% （19/757）. The success rate of re-intervention was 98.7% （457/463）, no death and severe complications occurred. The restenosis rate in group 3 decreased significantly than group 1 （ x2 = 7. 908, P 〈 0. 05 ） in the first year of TIPS. The restenosis rates in group 2 and group 3 were lower than group 1 from 2 to 5 years of TIPS （ x2 values were 27. 046,25. 724,37. 002 and 19. 046, respectively, P 〈 0. 05 ）. The survival rate in group 3 was higher than group 1 （X2 = 9. 114, P 〈 0. 05 ）and group 2 was higher than group 1 （ X2 = 4. 929, P 〈 0. 05） in the first year of TIPS, while there was no statistical difference between group 2 and group 3 （ X2 = 2. 678, P 〉 0. 05 ）. The patients in group 2 and group 3 also had higher survival rates than group 1 from 2 to 5 years of TIPS （X2 value were 41. 314, 26. 920, 13. 692 and 6. 713, respectively, P 〈 0. 05 ）. 19. 4% （79/406） of patients who received re-intervention had symptom recurrence and shunt stenosis or occlusion. 11.6% （47/406） of patients had symptom recurrence with portal hypertension signs, 62. 8% （255/406） had shunt stenosis or occlusion with portal hypertension signs. Conclusions Restenosis or occlusion of TIPS, symptom recurrence and portal hypertension signs were important factors for re-intervention. Re-intervention of TIPS was safe and effective, and could improve the survival rate of patients with TIPS.