肝后段下腔静脉 肝内门静脉的CT及应用解剖学研究

Study on The Applied Anatomy and CT of the Retroheatic Segment of Inferior Vena Cava and Portal Veins

目的:分析肝后段下腔静脉(RHSIVC)与肝内门静脉的解剖关系,为经肝后段下腔静脉途径建立肝内门腔分流提供形态学依据.方法:分析25例正常和25例肝硬化患者上腹部增强图像,并利用MPR重建并分别测量肝后段下腔静脉的长度,计算周围肝实质包绕RHSIVC的范围,以及与距门脉分叉1 cm左右的肝内门脉左支(LPV)、右支(RPV)及门脉分叉部(BPV)同层面的RHSIVC中心至上述部位的距离,并测量经肝后段下腔静脉顺行性(股静脉途径)、逆行性(颈静脉途径)至LPV、RPV、BPV的穿刺深度和角度(穿刺途径与矢状面、下腔静脉纵轴之间的夹角)以及测量拟定最佳穿刺途径的深度和角度.数据采用配对t检验.观测20例正常成人离体RHSIVC与肝内门静脉的空间定位关系.结果:①SCTA组和标本组70例肝后段下腔静脉平均高度为(62.89±13.27)mm(40.2～100.7mm),50%～100%RHSIVC管腔被周围肝实质所包绕,其中37.14%(26/70)在RHSIVC的上1/4与下3/4交接处完全被肝实质包绕.②肝硬化组:从肝后段下腔静脉至LPV、RPV、BPV顺行性穿刺的深度为(46.02±12.26)mm、(30.06±8.35)mm、(25.18±7.30)mm,与矢状面的夹角为正20.28°±12.39°、正56.52°±14.31°、正28.84°±15.44°,与纵轴之间的夹角为53.92°±9.21°、57.80°±10.97°、69.32°±15.61°;而逆行性穿刺深度为(49.31±7.72)mm、(49.38±8.08)mm、(56.80±8.31)mm,与矢状面的夹角为正20.08°±12.16°、正56.64°±14.28°、正28.36°±15.16°,与纵轴之间的夹角为45.64°±10.67°、29.88°±6.41°、24.4°±5.51°.顺行性穿刺RPV、LPV、BPV的深度及角度有显著性差异(P＜0.05),而逆行性穿刺RPV、LPV的深度无显著性差异(P＞0.05).正常组:从肝后段下腔静脉至LPV、RPV、BPV顺行性穿刺的深度为(41.98±10.20)mm、(29.30±7.66)mm、(25.05±6.74)mm,与矢状面的夹角为正20.32°±13.33°、正48.16°±14.42°、正26.08°±18.91°,与纵轴之间的夹角为(53.88±9.88)mm、(58.12±11.19)mm、(69.8±12.94)mm;而逆行性穿刺深度为(48.23±7.69)mm、(50.41±9.01)mm、(56.55±10.83)mm,与矢状面的夹角为正20.32°±13.31、正48.00°±14.47°、正26.20°±18.63°,与纵轴之间的夹角为44.76°±14.67°、30.36°±8.37°、25.00°±8.17°.正常组和肝硬化组的顺行性及逆行性穿刺RPV、BPV的深度及角度无显著性差异(P＞0.05).③正常组的拟定最佳穿刺途径的深度为(32.99±5.14)mm,与矢状面的夹角为正50.16°±13.57°,与纵轴之间的夹角为45.04°±9.18°.肝硬化组的拟定最佳穿刺途径的深度为(33.75±5.98)mm,与矢状面的夹角为正56.04°±15.14°,与纵轴的夹角为44.32°±7.08°.正常组和肝硬化组的模拟最佳穿刺途径的深度及角度无显著性差异(P＞0.05).结论:①肝后段下腔静脉长度约63 mm,且在RHSIVC上1/4与下3/4的交接处50%～100%的下腔静脉被肝实质所包绕,经RHSIVC建立肝内门腔分流安全是可行的.②最佳穿刺途径应选择逆行性(经颈静脉途径)穿刺肝内门脉右支,肝后段下腔静脉的穿刺点应在RHSIVC的上1/4和下3/4的交接处,穿刺深度一般为(33.75±5.98)mm、与矢状轴的角度一般为正56°±15°,与纵轴之间的夹角一般为44°±7°.

Objective:To study the anatomy and variation of the retroheatic segment of inferior vena cava(RHSIVC) and relationship of both,to provide morphological information for the estab Lishment of intrahepatic portacaval shunt via retroheatic segment of inferior vena cava.Methods: Upper abdominal Enhanced CT images of 25 normal case and 25 patients with cirrhosis were studied,reestablished images with MPR and measured the length of retroheatic segment of inferior vena cava,calculated the extent enclosed by the hepatic parenchyma of retroheatic segment of inferior vena cava.The distances from the center of retroheatic segment of inferior vena cava to the left portal vein(LPV),the right portal vein(RPV)and the bifureation of portal vein(BPV) were measured at the same CT slice respectively.Both antegrade(via femoral arteay) and retrograde(via jugular vein) puncturing angle from RHSIVC to LPV,RPV and BPV were calculated.The data was analysed by paired samples t test.Results:①②③The mean length of RHSIVC of SCTA group and sample group was 62.89 mm±13.27 mm (40.2～100.7 mm),50%～100% RHSIVC of the canal of RHSIVC was enclosed by hepatic parenchyma,37.14%(26/70) RHSIVC was enclosed by hepatic parenchyma among junction of upper 1/4 and lower 3/4 of RHSIVC.②Cirrhosis group: The depths from RHSIVC to LPV,RPV and BPV.For antegrade puncturing were(46.02±12.26) mm,(30.06±8.35) mm,(25.18±7.30) mm,the angles in sagittal plane were positive 20.28°±12.39°,positive56.52°±14.31°,positive28.84°±15.44°,the angles in vertical axis were 53.92°±9.21°,57.80°±10.97°,69.32°±15.61° respectively;while for retrograde puncture were(49.31±7.72) mm,(49.38±8.08) mm,(56.80±8.31) mm,the angles in sagittal plane were positive20.08°±12.16°,positive 56.64°±14.28°,positive 28.36°±15.16°,the angles in vertical axis were 45.64°±10.67°,29.88°±6.41°,24.4°±5.51° respectively.The depths and angle of antegrade puncturing of RPV,LPV,BPV had significant difference(P<0.05),while there was not significant difference in retrograde puncturing(P>0.05).Normal group: The depths from RHSIVC to LPV,RPV and BPV.for antegrade puncturing were(41.98±10.20)mm,(29.30±7.66)mm,(25.05±6.74)mm,the angles in sagittal plane were positive 20.32°±13.33°,positive 48.16±14.42°,positive 26.08°±18.91°,the angles in vertical axis were 53.88°±9.88°,58.12°±11.19°,69.80°±12.94° respectively;while for retrograd puncture were(48.21±7.69) mm,(50.41±9.01) mm,(56.55±10.83) mm,the angles in sagittal plane were positive 20.32°±13.31°,positive 48.00°±14.47°,positive 26.20°±18.63°, the angles in vertical axis were 44.76°±14.67°,30.36°±8.37°,25.00±8.17° respectively.There is not significance difference between normal and cirrhosis groups.③The best puncturing way was(32.99±5.14) mm in depth,angle was 50.16°±13.57° in sagittal plane,angle was 56.04°±15.14° in vertical axis in the normal group.There was not significant difference in the best simulative puncturing of normal and cirrhosis groups(P>0.05). Conclusion:① The length of RHSIVC was about 63 mm,retroheatic segment of inferior vena cava was enclosed by hepatic parenchyma among junction of upper 1/3 and lower 1/4 of retroheatic segment of inferior vena cava.To built intrahepatic portacaval shunt via retroheatic segment of inferior vena cava is feasible and safe.②The best puncturing way is RPV(via jugular vein) retrograde,the puncturing point between upper 1/3 and lower 1/4 of retroheatic segment of inferior vena cava.The depth is(33.75±5.98) mm,the angle is 56°±15° in sagittal plane,the angle in vertical axis is 44°±7°.