介入开通术治疗门静脉血栓性狭窄闭塞的临床疗效观察

Clinical observation on interventional recanalization of portal vein stenosis and occlusion due to thrombosis

目的探讨采用门静脉成形开通术治疗门静脉血栓引起的门静脉狭窄或闭塞的临床疗效。方法在X线或超声引导下用22G穿刺针经皮经肝穿刺门静脉右支，将0．018in微导丝送入门静脉主干，沿导丝将头带金标的血管鞘送入门静脉，更换0．035in导丝，引导5F直头多侧孔导管越过狭窄或栓塞段，用多侧孔导管在负压状态下吸除柔软血栓，不能吸除的机化血栓用球囊扩张后植入支架进行旷置。若胃冠状静脉开口未被支架覆盖，应予栓塞。结束前常规用弹簧栓子栓塞肝实质穿刺道。结果12例肝硬化门静脉血栓引起门静脉狭窄或闭塞病人中除1例病人因经济原因仅接受了单纯溶栓治疗而未接受支架成形，其它11例病人均接受了门静脉支架成形开通术，开通后门静脉压力由（38．6±3．3）cmH2O降至（27．5±5．6）cmH2O，血氨由（48．3±6．6）μmol／L降至（33．2±5．7）μmol／L，（P〈0．05）。5例肝功能Child C级者有4例术后恢复至B级，7例ChildB级者2例术后恢复至A级；5例病人在开通术后6个月内先后接受了肠镜复查，发现肠黏膜淤血水肿消失；4例腹水病人在开通术后3周内腹水完全消失；1例肝性脑病病人于术后第2天恢复，随访期间未见复发。结论采用门静脉支架成形开通术治疗肝硬化门静血栓引起的门静脉狭窄或闭塞可以使门静脉入肝血流迅速恢复，对降低门静脉压力、控制上消化道出血、解除肠道淤血降低血氨和恢复肝脏功能都具有积极意义，而且具有很好的安全性。

Objective To explore the clinical efficacy of portal vein stenosis and occlusion due to thrombosis with the method of interventional recanaliztion. Methods The right portal branch was punctured under the guidance of X-ray or B-mode ultrasonography, the 0.018 in guide wire was inserted into the portal vein and then the sheath was pushed into portal vein along the guide wire. The 0. 018in guide wire was changed into the 0. 035in one, the catheter was induced to overcome the block area to suck the soft thrombosis with it. The remaining part that can not be sucked was dilated with balloon and then stent placement was performed. If gastric coronal vein was not covered by stent, embolization was conducted. Finally, the puncture route was occluded in the liver parenchyma with emboll. Results Eleven of the 12 cases accepted the interventional recanaliztion and stent placement and the other 1 did not receive the stent placement because of economic reason. The pressure of portal vein and the level of NH3 declined from（38. 6±3. 3）cm H2O to（27. 5±5. 6）cm H2O and from（48. 3±6.6） μmol/L to（33. 2H-5.7）μmol/L, respectively（P〈0.05）. During the period of follow-up, 4 of 5 cases with Child C improved to Child B and 2 of 7 cases with Child B improved to Child A. Five of the 12 cases re-accepted colonoscope examination, and the results showed that the colon mucosa edema relieved. The ascites in 4 cases disappeared within 3 weeks after portal vein recanalization. One case with coma stayed in good condition all the time. Conclusions The method of interventional recanalization and stent placement against portal vein stenosis and occlusion can both decline portal pressure, remove ascites and can improve liver function as well. The procedure of the technique is also safe.