肝内静脉分流对肝静脉压力梯度测量的影响

Effect of intrahepatic veno-venous shunt on the measurement of hepatic venous pressure gradient

目的探讨肝内静脉分流(intrahepatic veno-venous shunt,IHVS)对窦性肝硬化门脉高压患者肝静脉压力梯度(hepatic venous pressure gradient,HVPG)测量的影响。方法回顾性分析复旦大学附属中山医院2015年1月至2020年11月接受经颈静脉肝内门体分流术(transjugular intrahepatic portosystemic shunt,TIPS)治疗的259例肝硬化门静脉高压患者的临床资料。采用血管造影参数成像(angiographic parameter imaging,API)软件对前后位数字减影血管造影(digital subtraction angiography,DSA)图像进行时间-强度的彩色像素编码,从而定量分析IHVS,并与直接门静脉压(portal venous pressure,PVP)进行比较,评估其对HVPG的影响。结果36.3%的患者(94/259)存在不同程度的IHVS:轻度11.6%(30/259),中度10.0%(26/259),重度14.7%(38/259)。与无IHVS的患者相比,IHVS患者平均肝静脉楔压(wedged hepatic venous pressure,WHVP)和HVPG更低(P均<0.001)。IHVS的严重程度不同对WHVP和HVPG的影响程度也不同。相较于平均PVP和门静脉压力梯度(portal venous pressure gradient,PPG),轻度IHVS患者的平均WHVP和HVPG降低约7 mmHg(WHVP:P=0.027,HVPG:P=0.039),中度IHVS患者降低约10 mmHg(WHVP:P=0.022,HVPG:P=0.013),重度IHVS患者降低约15 mmHg(WHVP:P<0.001,HVPG:P<0.001)。结论对伴有IHVS的患者,HVPG的测量结果可能严重低估了实际的PVP,应通过门静脉导管直接测定实际PVP。

Objective To investigate the effect of intrahepatic veno-venous shunt(IHVS)on the measurement of hepatic venous pressure gradient(HVPG)in patients with sinusoidal cirrhotic portal hypertension.Methods A retrospective analysis was performed for the clinical data of 259 patients with cirrhotic portal hypertension who underwent transjugular intrahepatic portosystemic shunt(TIPS)in Zhongshan Hospital,Fudan University from Jan 2015 to Nov 2020.Angiographic parameter imaging(API)software was used to color-code each pixel of an anterior-posterior digital subtraction angiography(DSA)series according to time-intensity curve to quantitatively analyze IHVS.Compared with direct portal venous pressure(PVP),the impact of IHVS on hepatic venous pressure gradient(HVPG)was evaluated.Results There were 36.3%of patients(94/259)with varying degrees of IHVS:mild IHVS accounted for11.6%(30/259),moderate IHVS accounted for 10.0%(26/259),and severe IHVS accounted for 14.7%(38/259).Compared with patients without IHVS,patients with IHVS had lower mean wedged hepatic venous pressure(WHVP)and hepatic venous pressure gradient(WHVP:P<0.001;HVPG:P<0.001).Meanwhile,the impact on WHVP and HVPG was dependent upon the severity of IHVS.The average WHVP and HVPG were 7 mm Hg lower in patients with mild IHVS(WHVP:P=0.027;HVPG:P=0.039),10 mm Hg lower in patients with moderate IHVS(WHVP:P=0.022;HVPG:P=0.013)and15 mm Hg lower in patients with severe IHVS(WHVP:P<0.001;HVPG:P<0.001)than mean PVP and portal venous pressure gradient(PPG).Conclusion For patients with IHVS,the actual portal vein pressure may be seriously underestimated by HVPG measurement,and should be measured directly by portal catheterization.