138例肝静脉阻塞型Budd-Chiari综合征介入治疗的研究

Study on Interventional Therapy of 138 Cases of Budd-Chiari Syndrome with Hepatic Venous Obstruction

背景:肝静脉阻塞型Budd-Chiari综合征(BCS)的病因尚未完全明了,其传统治疗方法为门体或肠腔分流术,近年介入放射学技术已成为治疗BCS的常用方法。目的:总结11年期间以介入技术治疗肝静脉阻塞型BCS的经验,评价其疗效。方法:以介入技术治疗138例肝静脉阻塞型BCS患者。介入治疗方法有经皮腔内血管成形术(PTA)、置入支架和经导管清除血栓。以血管造影表现和压力变化评价即刻疗效,以症状显著改善或消除评价临床疗效,随访期间行超声检查,部分复查CT和CT血管造影(CTA)。结果:肝静脉阻塞多为膜性阻塞(60.1%)。同时存在肝静脉和下腔静脉阻塞者占25.4%,合并下腔静脉血栓占8.0%,肝静脉血栓形成占5.1%。介入治疗成功率为97.1%。单纯行肝静脉球囊扩张成形术28例(20.9%),球囊扩张后向狭窄段置入支架106例(79.1%)。介入开通阻塞后,肝静脉压力从(36+9)cm H_2O(1cm H_2O=0.098kPa)降至(18±7)cm H_2O。术中未出现并发症。治疗成功者术后相关症状明显改善或完全消失;32例术前以门静脉高压症为主要表现者术后未发生静脉曲张破裂出血,复查内镜示静脉曲张程度减轻。术后随访118例,均生存,其中9例(7.6%)临床症状复发,经血管造影证实支架区狭窄,开通再狭窄成功6例。结论:介入放射学技术,如PTA、置入支架和经导管清除血栓是治疗肝静脉阻塞型BCS安全和有效的方法,远期疗效优良。

Background： The pathogenesis of Budd-Chiari syndrome （BCS） with hepatic venous obstruction is not completely clear. Traditionally, BCS is managed by portal or mesenteric-systemic shunting. Currently, interventional radiology techniques are more frequently used as an alternative to surgical shunting. Aims： To summarize 11-year experience in the treatment of BCS with hepatic venous obstruction by interventional techniques, and to evaluate the therapeutic efficacy. Methods： One hundred and thirty-eight patients with BCS with hepatic venous obstruction were treated with percutaneous transluminal angioplasty （PTA）, stent placement and catheter-directed thrombolysis. Immediate response was assessed by angiography and change of pressure. Clinical response was defined as absence or improvement of symptoms. Clinical follow-up was supplemented with Doppler ultrasound, CT and CT angiography （CTA） were performed in selective cases. Results： Venography demonstrated that membranous obstruction of the hepatic vein was present in 60.1% of the patients. Both hepatic vein and inferior vena cave were involved in 25.4%, associated with thrombus in inferior vena cave were 8.0%, and in hepatic vein 5.1%. Technical success was achieved in 97.1%. Twenty-eight patients （20.9%） underwent balloon angioplasty alone, 106 （79.1%） patients had balloon angioplasty plus stents. Hepatic vein pressure dropped from （36±9） cm H20 （1 cm H2O=0.098 kPa） to （18±7） cm H2O. No procedure-related complications were observed. The symptoms and signs disappeared or were relieved after the treatment in 134 patients. Relief of portal hypertension were achieved in 32 patients who presented with esophagogastric varices before the treatment. Follow-up data were available for 118 patients. Nine patients （7.6%） had symptoms recurrence and restenosis of the stents confirmed by angiography, six of them responded to reintervention. Conclusions： Interventional techniques, including PTA, stent placement and catheter-directed thrombolysis, have been proved safe and effective in the treatment of BCS with hepatic venous obstruction, and have a good long-term outcome.