肝移植术后肝静脉和下腔静脉梗阻的诊断及介入治疗

Obstruction of hepatic vein or inferior vena cava after liver transplantation： the diagnosis and interventional treatment

目的探讨肝移植术后肝静脉、下腔静脉梗阻的诊断及介入治疗技术。方法在831例原位肝移植（OLT）、26例活体肝移植（LDLT）患者中，共有11例在移植术后2—111d经血管造影证实为肝静脉、下腔静脉梗阻并进行了介入治疗。其中肝静脉吻合口狭窄或闭塞5例、下腔静脉吻合口狭窄5例、肝静脉狭窄伴下腔静脉吻合口狭窄1例。11例中，5例为成人OLT、4例为LDLT、2例为儿童减体积OLT，介入治疗前9例接受了肝脏CT、2例接受了MR增强扫描。术后随访患者肝肾功能指标、临床症状及肝静脉、下腔静脉血流状况。对11例患者的影像资料、介入治疗技术要点和治疗效果进行回顾性分析。介入治疗前后梗阻两端静脉压力差比较，采用配对t检验。结果11例患者，cT或MR检查均可明确显示肝脏淤血范围、肝静脉或下腔静脉梗阻部位及程度；其中4例肝静脉梗阻和5例下腔静脉梗阻者行支架植入治疗，1例肝静脉梗阻者行经皮腔内血管球囊扩张术（PTA），1例肝静脉伴下腔静脉梗阻者，行肝静脉PTA和下腔静脉支架植入，介入治疗手术均成功。术后检测梗阻两端静脉压力差为（2．9±1．7）m／nHg（1mm Hg=0．133kPa），较术前（16．5±4．1）mmHg明显下降（t=11．5，P〈0．01）。术后10例患者临床症状改善，肝肾功能恢复；1例肝功能恶化，于术后第9天死于多器官功能衰竭。患者术后随访9—672d，2例肝静脉PTA治疗者术后1个月内发生血管再狭窄，支架植入治疗者未发生再狭窄，无严重并发症发生。结论支架植入是治疗肝移植术后肝静脉和下腔静脉梗阻安全、有效的方法；术前CT或MR对明确肝淤血范围及静脉梗阻具有重要价值。

Objective To investigate the diagnosis and interventional therapeutic technology for the obstruction of hepatic vein （HV） or inferior vena cava （IVC） after liver transplantation. Methods In the 831 patients who received orthotopic liver transplantation （OLT） and 26 patients who received living donor liver transplantation （LDLT）, 11 cases were confirmed with HV or IVC obstruction by venography and received interventional treatment from 2 to 111 days after liver transplantation . Of the 11 patients, five had the obstruction of HV anastomosis, five had the obstruction of IVC anastomosis, and one had the obstruction of HV and IVC anastomosis. In the eleven patients, five patients underwent OLT, four patients underwent LDLT, and two pediatric patients underwent reduced-size OLT. Before interventional treatment, 9 patients received CT enhanced scans, 2 received MR enhanced scans. Follow-up evaluations included liver or renal function tests, clinical symptom, and monitoring of HV or IVC flow. Pressure gradients before and after interventional treatment were compared by using a paired t test. The imaging data and interventional therapeutie technology of 11 eases were retrospectively analyzed. Results In all 11 patients, CT or MRI could clearly show congested areas of the liver, and the location and degree of HV or IVC obstruction. Of the 11 patients, four with HV obstruction and five with IVC obstruction were treated with stent placement, one with HV obstruction was treated with percutaneous transluminal angioplasty （PTA）, one with HV and IVC obstruction was treated with HV PTA and IVC stent placement. Interventional technical success was achieved in all patients. The venous pressure gradient across obstruction was significantly reduced from （ 16. 5 ± 4. 1 ） mm Hg （ 1 mm Hg = 0. 133 kPa） before the procedure to （ 2.9 ± 1.7 ） mm Hg after the procedure （ t = 11.5, P 〈 0. 01 ）. Clinical improvement was noted in 10 patients except one pediatric patient who died of multiple-organs failure at the 9 th day after the treatment. During the follow-up period of 9 to 672 days, two patients with PTA treatment had recurrent HV stenosis within one month after treatment, no patient with stent placement developed venous restenosis. No major complications occurred during the procedures. Conclusions Stent placement is safe and effective for HV or IVC obstruction after liver transplantation. CT or MRI before treatment is of important value for the diagnosis of congested areas of the liver, and the observation of HV or IVC obstruction.