聚四氟乙烯覆膜支架经颈静脉肝内门腔分流术后分流道再狭窄及影响因素分析

Restenosis of the transjugular intrahepatic portosystemic shunt using stent covered with polytetrafluoroethylene and the analysis of its affecting factors

目的探讨采用聚四氟四烯(PTFE)覆膜支架行经颈静脉肝内门腔分流术(TIPS)后分流道再狭窄及相关影响因素。方法 2005年10月至2011年7月收治102例门脉高压症患者,均采用PTFE覆膜支架行TIPS手术,其中男82例,女20例,年龄16～73岁,平均(52.6±12.6)岁。术前症状为食管胃底静脉曲张大出血(83例)或顽固性腹水(19例),术前肝功能Child-Pugh评分为5～10分,平均(6.65±1.66)分。术后随访0～58个月,平均(19.9±13.3)个月,采用寿命表法得出术后6、12、24、36、48个月的累积分流道开通率,对影响因素采用Cox回归进行单因素和多因素分析。结果全部102例均在局麻下成功建立肝内门腔覆膜支架分流道,技术成功率100%。门静脉-右房压力梯度由术前(27.57±4.19)mmHg下降为(15.82±2.18)mmHg,差异有统计学意义(t=22.8,P<0.01)。术前Child-Pugh评分为(6.65±1.66)分,术后3个月为(6.46±1.55)分,差异无统计学意义(t=0.829,P=0.408)。随访期间确诊出现覆膜支架分流道再狭窄10例,总体一期再狭窄率为9.8%。术后6、12、24、36、48个月的累积分流道通畅率分别为96%、91%、82%、82%、82%。Cox单因素分析示覆膜支架门脉端长度和支架肝静脉端位置评价有统计学意义;多因素分析示后者为独立影响因素(P=0.004,OR=27.758,95%CI:2.85-270.72)。结论PTFE覆膜支架可以明显提高TIPS术后分流道通畅率,支架肝静脉端位置良好的患者术后分流道再狭窄发生率低,同时不建议覆膜支架门脉端伸入过长。

Objective To evaluate the postoperative shunt restenosis of transjugular intrahepatic portosystemic shunt（TIPS） using polytetrafluoroethyoethylene（PTFE） covered stent in patients with portal hypertension,and to discuss its affecting factors.Methods During the period from Oct.2005 to July 2011,a total of 102 patients,including 82 males and 20 females with a mean age of（52.6 ± 12.6） years（ranged 16-73 years）,with portal hypertension due to cirrhosis were admitted to authors’ hospital.TIPS with PTFE covered stent was carried out in all patients.Before operation,the patients had massive bleeding due to ruptured esophageal and gastro-fundal varices（n = 83） or refractory ascites（n = 19）,and the Child-Pugh score was 5-10 with a mean of（6.65 ± 1.66）.The patients were followed up for 0-58 months with a mean of（19.9 ± 13.3） months.The cumulative patency rates of shunt at 6,12,24,36 and 48 months after TIPS were calculated using life-table method.Single and multiple factor analysis using Cox regression method was performed to evaluate the affecting factors.Results Under local anaesthesia TIPS was successful performed in all 102 patients.The mean portosystemic pressure gradient decreased from preoperative（27.57 ± 4.19） mmHg to postoperative（15.82 ± 2.18）mmHg,thedifference was statistically significant（t = 22.8,P 0.01）.Preoperative Child-Pugh score was（6.65 ± 1.66）,and three months after treatment the Child-Pugh score was（6.46 ± 1.55）,the difference between the two was not significant（t = 0.829,P = 0.408）.During the follow-up period,shunt restenosis occurred in 10 patients（9.8%）.The cumulative primary patency rates were 96%,91%,82%,82% and 82% at 6,12,24,36 and 48 months after the procedure,respectively.Cox single analysis showed that the covered stent length within portal vein and its location in hepatic vein had statistical significance,and multiple factor analysis indicated that the covered stent location in hepatic vein was an independent factor affecting shunt restenosis（P = 0.004,OR = 27.758,95% CI：2.85-270.72）.Conclusion TIPS with PTFE covered stent can markedly increase the shunt patency rate.A proper location of the covered stent within hepatic vein carries lower restenosis incidence.Hyperextension of the stent into portal vein is not recommended.