经颈静脉肝内门体分流术前肝血流动力学状态与术后肝性脑病发生的相关性研究

Relationship between pre-transjugular intrahepatic portosystemic stent shunt(TIPS) hepatic hemodynamics and incidence of post-TIPS hepatic encephalopathy

目的 探讨经颈静脉肝内门体分流 (TIPS)术前肝血流动力学的不同状态与术后发生肝性脑病的相关性。方法 采用超声评价 41例肝硬化患者TIPS术前及术后 1月的肝血流动力学状态 ,根据术前门脉主干血流方向分为门脉血流离肝组 (离肝血流或双向血流 )和门脉血流向肝组。比较两组术前一般临床资料 (年龄、性别、肝病原因、术前肝功能Child Pugh评分、术前肝性脑病发生率、门腔压差 )、两组术后肝性脑病发生率以及两组手术前后右肝动脉阻力指数 (RI)变化情况 ,同时对可能致肝性脑病的术前影响因素 (门脉血流方向、年龄、术前肝功能Child Pugh评分、术前有无肝性脑病 )进行多因素logistic回归分析。 结果 术前除肝功能积分门脉向肝血流组较离肝血流组低外 (P <0 .0 5 ) ,余各项临床资料差异无显著性意义 (P >0 .0 5 )。门脉血流向肝组术后肝性脑病发生率明显高于血流离肝组 (P <0 .0 1) ,前者术前肝动脉RI也明显高于后者 (P <0 .0 1) ,但术后前者RI明显减低 (P <0 .0 1) ,后者RI手术前后无变化。Logistic回归分析显示术前门脉血流方向与术后肝性脑病发生率密切相关。结论 术前肝血流动力学状态与肝性脑病发生密切相关。术前门脉血流离肝者术后肝血流动力学变化小 ,仍为肝动脉代偿供血 ,且肝功能受影响小 ,不?

Objective To study the relationship between pre transjugular intrahepatic portosystemic shunt(TIPS) liver hemodynamics and the incidence of post TIPS hepatic encephalopathy(HE).Methods Hepatic blood dynamics was evaluated in 41 cases of liver cirrhosis before TIPS and one month later.The patients were divided into two groups according to Doppler findings before TIPS.Group 1 composed of patients with prograde portal flow,group 2 composed of patients with hepatofugal or back forth portal flow.The clinical characteristics,incidence of post TIPS HE and pre/post TIPS hepatic arterial resistant index(RI) of the groups were compared.The independent prognostic value of pre TIPS variables for the onset of HE after TIPS was tested with a multiple regression analysis.The variables included age,pugh score,presence of HE before TIPS,the pattern of portal flow.Results The two groups did not differ significantly in their age,etiology of liver disease,indications of TIPS placement, HE incidence before TIPS and portacaval gradient before and after TIPS.But liver failure was more severe in group 2(P< 0.05 ).The incidence of post TIPS HE in group 2 was significantly lower than that in group 1 (P< 0.01 ).Before TIPS the RI of hepatic arterial in group 1 was significantly higher than that in group 2 (P< 0.01 ).But TIPS induced a significantly decrease of RI in group 1(P< 0.01 ),but not in group 2.Multiple regression analysis demonstrated that the pattern of portal flow before TIPS was an independent predictor as the onset of post TIPS HE.Conclusions Predictive factor for the onset of HE is the pattern of portal flow before TIPS.TIPS induces little change for the liver hemodynamics in patients with hepatofugal portal flow,but induced marked change for that in patients with prograde portal flow.Thus,the former is protected against post TIPS HE despite a more severe liver dysfunction at baseline.