布加综合征的介入治疗

Interventional Treatment of Budd-Chiari Syndrome (Experience of 106 cases)

目的:总结106例布加综合征介入疗法治疗的经验.病人:1986年至1998年我们共以介入疗法治疗布加综合征106例,其中男70例,女36例,年龄6～65岁,平均34岁.病变种类包括下腔静脉完全阻塞40例;下腔静脉局限性狭窄36例;下腔静脉膜性阻塞带孔者26例;单纯肝静脉膜性阻塞3例;下腔静脉广泛血栓形成者1例;106例中14例为下腔静脉和肝静脉联合病变.方法:下腔静脉破膜扩张或单纯扩张57例;下腔静脉破膜加支架术或下腔静脉扩张加支架术45例;经皮经肝静脉破膜扩张3例;经股静脉行下腔静脉溶栓1例;再次扩张者3例;再扩张加支架术者1例.因下腔静脉和肝静脉联合病变需行附加手术者16例,其中肠腔侧侧分流术10例,肠房人工血管转流术4例,腹膜腔颈静脉转流术2例.结果:下腔静脉破膜失败者13例,其中10例改用经右心房、经股静脉联合破膜术,另3例改用传统手术.下腔静脉压力下降范围为0.294～2.84kPa(3～29cmH_2O),平均118kPa(12cmH_2O).3例经皮经肝静脉破膜成功者肝静脉压力平均下降1.82kPa(17.7cmH_2O).并发症包括血胸2例,心包填塞1例,支架移位2例.下腔静脉支架术后肝静脉阻塞2例,肺栓塞2例.下腔静脉PTA后复发率为10.7%,下腔静脉PTA加支架术后复发率为2.2%.3例肝静脉再通者至今仍通畅.下腔静脉广泛血栓形成溶栓治疗后未能再通,但症状减?

Objective: To review the experience gained in the interventioanl treatment of 106 cases of Budd-Chiari Syndrome(BCS). Materials and Methods: Interventional treatment was carried out in 106 cases of BCS from 1986 to 1998; there were 70 male and 36 female; the ages ranged from 6 to 65 years, with an average of 34. The lesions included complete occlusion of the inferior vena cava(IVC) in 40 cases, localized stenosis of the IVC in 36 cases, membrane with a hole in the JVC in 26 cases, membranous occlusion of the hepatic vein(HV) in 3 cases and extensive thrombosis of the IVC in 1 case. The methods of treatment applied were: (1) membranotomy plus dilation or simple dilation of IVC in 57 cases. (2) membranotomy plus dilation or simple dilation of IVC with insertion of stent in 45 cases. (3) percutaneous transhepatic vein re-canalization in 3 cases. (4) percutaneous transfemoral vein IVC thrombolysis in 1 case, Re-PTA was used in 3 cases, and re-PTA with stent insertion in 1 case. Additional operation for reduction of portal hypertension was required in 16 cases due to combined occlusion of HV after successful intervention on the IVC, including meso-caval, meso-atrial and peritoneao-jugular shunts in 10, 4 and 2 cases respectively. Results: Membranotomy of the IVC failed in 13 cases, among which 10 were transferred to transfemoral vein and transcardiac combined membranotomy, 3 were transferred to the traditional operation. Pressure of the IVC was reduced from 3 to 29 cmH2O with an average of 12 cmH2O for those with successful interventions on the IVC. The average HV pressure was reduced 17.7 cmH2O in 3 cases of membranous occlusion of the HV. The complications included hemothorax in 2 cases, cardiac tamponade in 1 case, stent migration in 2 cases and post-stenting HV occlusion in 2 cases, pulmonary embolism in 2 cases. The recurrence rate after PTA of IVC was 10.7%; however, only 1 cases recurred after PTA with stent insertion(2.2%); 3 cases of the recanalized H V were still patent. The relief of symptoms through thrombolysis was acquired, though complete recanalization of the IVC was not achieved. Two cases died of pulmonary embolism, 3 cases died of hepatic coma after IVC intervention plus meso-caval shunt. No late death was found in the series. Conclusions: (1) IVC stenting was recommended to prevent recurrence due to elastic recoil of the vessel. (2) Rough manipulation is prohibited during membranotomy to avoid complications; for difficult cases, the combined membranotomy is suggested. (3) Additional surgery for relief of portal hypertension isrequired for those with combined HV occlusion.