不同支架构型对经颈静脉肝内门体分流术后分流道失效和肝性脑病的影响

Effects of different stent configurations on shunt failure and hepatic encephalopathy after transjugular intrahepatic portosystemic shunt

目的对比不同支架构型对经颈静脉肝内门体分流术（TIPS）后分流道失效率、肝性脑病和肝性脊髓病发生率的影响。方法回顾性分析2014年3月至2015年6月收治的符合纳入及排除标准的73例肝硬化门静脉高压所致上消化道出血行TIPS治疗患者的临床资料，按其术中放置支架构型分为单用覆膜支架组（肝静脉门静脉肝实质覆膜支架，23例）、模拟Viatorr支架组（肝静脉肝实质覆膜支架＋门静脉裸支架，27例）和联合支架组（肝静脉门静脉裸支架＋肝静脉门静脉肝实质覆膜支架，23例）。随访1年，比较3组术后1年内分流道失效率、肝性脑病发生率、肝性脊髓病发生率。组间比较采用卡方检验或Fisher确切概率法，以及方差分析，采用Cox回归分析3组间不均衡的变量及结局事件发生率的差异。结果单用覆膜支架组、模拟Viatorr支架组、联合支架组的门静脉压力梯度依次由术前的（22.15±4.52）、（23.01±5.48）、（21.13±4.49） mmHg（1 mmHg＝0.133 kPa）下降为（9.15±2.94）、（11.20±3.27）、（8.75±4.06） mmHg，3组分流前后门静脉压力梯度差异均有统计学意义（t＝10.488、7.188、7.850，P均〈0.05）。单用覆膜支架组、模拟Viatorr支架组、联合支架组分流道失效率分别为13.0%（3/23）、18.5%（5/27）、30.4%（7/23），Cox回归分析发现，不同支架构型的TIPS术后分流道失效率比较差异无统计学意义（P＝0.339）。单用覆膜支架组、模拟Viatorr支架组、联合支架组术后肝性脑病发病率分别为69.6%（16/23）、33.3%（9/27）、30.4%（7/23），3组比较差异无统计学意义（P〉0.05），Cox回归分析发现，单用覆膜支架组术后肝性脑病发病率分别与模拟Viatorr支架组、联合支架组比较的相对危险度（RR）值（95%CI）依次为2.901（1.279-6.584）、2.735（1.123-6.658），差异均有统计学意义（P均〈0.05）。单用覆膜支架组、模拟Viatorr支架组、联合支架组肝性脊髓病发病率分别为8.7%（2/23）、3.7%（1/27）、4.3%（1/23），3组术后肝性脊髓病的发生率比较差异无统计学意义（P〉0.05）。在1年的随访过程中，73例患者中2例死亡，其中单用覆膜支架组1例，联合支架组1例，TIPS术后1年生存率为97.3%。结论联合支架组、模拟Viatorr支架组和单用覆膜支架组的术后1年分流道失效率近似。联合支架组与模拟Viatorr支架组术后1年肝性脑病发生率近似，均低于单用覆膜支架组。肝性脊髓病因发生率较低，与TIPS相关性仍有待研究。

Objective To compare the effects of different stem configurations on shunt failure, hepatic eneephalopathy, and hepatic myelopathy after transjugular intrahepatic portosystemic shunt （TIPS）. Methods From March 2014 to June 2015, the clinical data of 73 hospitalized patients who met the inclusion and exclusion criteria, and underwent TIPS for upper gastrointestinal hemorrhage caused by cirrhotic portal hypertension were retrospectively analyzed. According to the stent configuration during operation, patients were divided into simple coated stent group （hepatic vein, portal vein and hepatic parenchyma coated stent, 23 cases）, simulated Viatorr stent group （hepatic vein and hepatic parenchyma coated stent plus portal vein bare stent, 27 cases） and combined stent group （hepatic vein and portal vein bare stent plus hepatic parenchyma coated stent, 23 cases）. Patients were followed up for one year, the incidences of shunt failure, hepatic encephalopathy and hepatic myelopathy within one year after TIPS of three groups were compared. Chi-square test, Fisher exact probability method and variance analysis were performed for comparison among groups. Cox regression analysis was used for difference analysis in imbalance of variables and incidence of outcome events among the three groups. Results The portal vein pressure gradient of simple coated stent group, simulated Viatorr stent group and combined stent group decreased from （22.15±4.52）, （23.01±5.48） and （21.13±4.49） mmHg （1 mmHg=0. 133 kPa） to （9.15±2.94）, （11.20±3.27） and （8.75±4.06） mmHg after operation, respectively. Before and after operation, the differences in portal venous pressure gradient were statistically significant of three groups （t=10. 488, 7. 188 and 7. 850, all P〈0.05）. The shunt failure rates of simple coated stent group, simulated Viatorr stent group and combined stent group were 13.0% （3/23）, 18.50/00 （5/27） and 30.4% （7/23）, respectively. The results of Cox regression analysis indicated that there was no statistically significant difference in shunt failure rates among different stent configurations after TIPS （P= 0. 339）. The incidences of hepatic encephalopathy of simple coated stent group, simulated Viatorr stent group and combined stent group postoperative were 69. 60/40 （16/23）, 33. 3% （9/27） and 30. 40./00 （7/23）, respectively, the difference was not statistically significant among the three groups （P〉0. 05）. The results of Cox regression analysis showed that the relative ratio values 〈95% confidence interval） of incidence of postoperative hepatic encephalopathy of simple coated stent group compared with simulated Viatorr stent group and combined stent group were 2. 901 （1. 279 to 6. 584） and 2. 735 （1. 123 to 6. 658）, and the differences were statistically significant （both P〈0.05）. The incidences of hepatic myelopathy of simple coated stent group, simulated Viatorr stent group and combined stent group were 8.7%（2/23）, 3.7% （1/27） and 4.3% （1/23）, respectively, and there was no statistically significant difference in the incidence of hepatic myelopathy among three groups after operation （P〉0.05）. During one-year follow- up, among 73 patients, two patients died, one in simple coated stent group and the other in combined stent group. The one-year survival rate after TIPS was 97.3%. Conclusions One year after operation, the incidences of shunt failure are similar between simple coated stent group, simulated Viatorr stent group and combined stent group. One year after operation, the incidence of hepatic encephalopathy is similar between simulated Viatorr stent group and combined stent group which are both lower than that of simple coated stent. The incidence of hepatic myelopathy is low, and its association with TIPS remains to be further investigated.