肝小静脉闭塞病介入治疗21例

Interventional therapy of hepatic veno-occlusive disease:an analysis of 21 cases

目的:评价肝小静脉闭塞病(hepatic veno-occlusive disease,HVOD)介入治疗的可行性及探讨两步法嫁接支架"吻合"建立门腔分流新技术的临床意义.方法:21例临床上均符合巴尔的摩(Baltimore)标准和西雅图(Seattle)标准的HVOD患者首先行下腔静脉支架术,恢复其肝后下腔静脉血流,再经其支架缝隙穿刺肝内门静脉分支,将两支架进行嫁接.静脉曲张出血4例,难治性腹水16例,肝肺综合征1例;Child's B级6例、C级15例.结果:21例肝小静脉闭塞病患者两支架嫁接分流术均获成功,技术成功率100%,未出现术中技术相关并发症,术后门腔压力梯度平均下降23cmH2O(门静脉压:26.33cmH2O±4.06cmH2O vs50.61cmH2O±7.12cmH2O;下腔静脉压力:8.67cmH2O±6.71cmH2O vs26.16cmH2O±2.74cmH2O,P<0.01),平均随访416d,所有患者未发生再出血,难治性腹水得到有效的控制.1年内初步开通率100%.结论:肝小静脉闭塞病两步法嫁接支架"吻合"分流术是安全可行的,由于肝小静脉闭塞病肝肿大,尾叶压迫肝后下腔静脉的特殊性,两步法嫁接支架"吻合"建立门腔分流新技术比单一介入方法干预具有明显的临床效果优势.

AIM：To evaluate the feasibility of interventional therapy of hepatic veno-occlusive disease and to explore the clinical significance of two-step stent grafting in the establishment of portacaval shunts. METHODS：Twenty-one patients with hepatic veno-occlusive disease underwent inferior vena cava stenting first to restore blood flow to the subhepatic inferior vena cava,followed by intrahepatic puncture of the portal vein via the bracket slot to conduct stent grafting. Of all 21 patients,4 had variceal bleeding,16 had refractory ascites,1 had hepatopulmonary syndrome; 6 had Child-Pugh grade B liver function,and 15 had Child-Pugh grade C liver function. RESULTS：Stent grafting was successful in all 21 patients,and the success rate was 100%. No operation-related complications occurred. Mean postoperative portosystemic pressure gradient decreased by 23 cmH2O （26.33 cmH2O ±4.06 cmH2O vs 50.61 cmH2O ±7.12 cmH2O; 8.67 cmH2O ±6.71 cmH2O vs 26.16 cmH2O ±2.74 cmH2O,all P 0.01）. The average follow-up period was 416 d. No rebleeding occurred,and refractory ascites was effectively controlled. The one-year primary patency rate was 100%. CONCLUSION：Two-step stent grafting is safe and feasible in the treatment of hepatic veno-occlusive disease. Due to the development of hepatomegaly and hepatic caudate lobe compression of the subhepatic inferior vena cava in patients with veno-occlusive disease,the two-step stent grafting procedure has obvious advantages over single interventions in the establishment of portacaval shunts.