TIPS治疗肝硬化门脉高压急性静脉曲张出血:救命治疗还是一线治疗?

Transjugular intrahepatic portosystemic shunt for patients with cirrhosis and acute variceal bleeding:rescue or first-line therapy?

美国肝脏病学会门静脉高压防治指南和TIPS治疗门脉高压指南均推荐TIPS应作为药物及内镜控制急性静脉曲张出血失败后的"救命"治疗。然而,虽然出血控制率较好,但病死率仍较高。最近,对肝功能不好的肝硬化急性静脉曲张出血患者的多中心随机对照研究显示,用覆膜支架早期TIPS与药物联合内镜比较,前者能显著减低出血控制失败率和延长生存率。当急性静脉出血发生在Child-Pugh B级或C级(≤13分)患者时,应将覆膜支架TIPS做为一线治疗,而非"救命"治疗。

In the current American Association for the Study of Liver Disease Practice Guidelines,the use of transjugular intrahepatic portosystemic shunt（TIPS） to control variceal bleeding has largely been recommended for patients who require rescue therapy because hemostasis has not been achieved.TIPS is extremely effective in controlling bleeding,nevertheless,mortality at 6 weeks among patients treated with rescue TIPS for uncontrolled index bleeding is very high.Recently,the results of a multi-center randomized controlled study that compared early TIPS with optimal medical therapy in patients at high risk for rebleeding who were either in Child-Pugh class B with active bleeding at endoscopy or in Child-Pugh class C showed the benefit of early TIPS.Therefore,the early use of TIPS with an e-PTFE-covered stent as first-line therapy rather than as rescue treatment if rebleeding occurs in high-risk patients with Child-Pugh B or C disease.