经颈内静脉肝内门体分流术联合封堵器封堵治疗肝硬化门脉高压伴自发性脾、胃-肾分流

Transjugular intrahepatic portosystemic shunt combined with Amplatzer plugging device therapy for cirrhotic portal hypertension with spontaneous spleno-gastric-renal shunt

目的探讨经颈静脉肝内门体分流术(TIPS)联合封堵器封堵术治疗肝硬化合并自发性脾、胃-肾静脉分流的安全性及可行性。方法 2011年3月至2012年6月经影像学及实验室检查确诊肝硬化失代偿期伴上消化道出血或顽固性腹水合并脾、胃-肾分流患者28例,将其中分流道直径>1.2 cm的9例患者纳入研究,行间接、经肾静脉逆行或经皮穿刺门静脉直接门静脉造影了解门静脉、曲张静脉及脾、胃-肾分流道情况。穿刺右侧颈内静脉后送入RUPS100穿刺系统至肝静脉,穿刺门静脉,建立门体分流通道。另引入1支导丝探查脾、胃-肾分流道,沿留置至脾、胃-肾分流的导丝送入封堵器输送器,确定封堵器位置后,准确释放。球囊扩张肝实质及穿刺道,引入支架,定位并释放覆膜支架,送入造影导管至脾静脉,造影观察支架位置、血流、曲张静脉、脾、胃-肾分流道情况,必要时弹簧钢圈栓塞曲张静脉,计算压力梯度。结果 9例患者成功进行TIPS联合封堵器封堵治疗,无术中并发症。4例为TIPS术中直接联合封堵术治疗,术后无支架功能障碍及肝性脑病发生。5例为先行TIPS,术后4例发生严重肝性脑病(Ⅲ级),3例发生支架功能失常,1例并发上消化道出血。TIPS球囊扩张治疗后行封堵器封堵,5例患者未再发生支架功能障碍,仅1例发生Ⅰ级肝性脑病。结论 TIPS联合封堵器封堵术是一种安全、可行的治疗肝硬化合并自发性脾、胃-肾静脉分流的方法,可预防肝硬化门静脉高压伴自发性脾、胃-肾静脉分流引起的肝性脑病或上消化道出血。

Objective To discuss the safety and feasibility of transjugular intrahepatic portosystemic shunt （TIPS） combined with Amplatzer plugging device therapy in treating symptomatic portal hypertension and large spleno- gastric- renal shunt in cirrhosis. Methods A total of 28 patients with decompensated cirrhosis complicated by upper gastrointestinal bleeding or intractable ascites together with large spleno- gastric-renal shunt, who were encountered at the hospital during the period from March 2011 to June 2012, were collected. Of the 28 patients, the diameter of the spleno-gastric-renal shunt was 〉 1.2 cm in 9, and these 9 patients were enrolled in the study. First, the conditions of portal vein, varices, spleno-gastric-renal shunt were evaluated by indirect portography via renal vein or direct portography via hepatic vein. Then, a portosystemic shunt between intrabepatic portal vein and hepatic vein was established via a right jugular vein access. Subsequently, an Amplatzer plugging device was released. Finally, a covered stent was placed into the liver parenchyma. Stent position, blood flow, varices and spleno- gastric- renal shunt were evaluated. If necessary, embolization of varices was carried out with coils.Portosystemic pressure gradient was determined. Results Successful TIPS combined with Amplatzer plugging device procedure was accomplished in all 9 patients, and no complications occurred during operation. In 4 patients TIPS was perfumed with simultaneous spleno- gastric＇,- renal shunt occlusion, and neither shunt dysfunction nor hepatic encephalopathy occurred after the treatment. In 5 patients TIPS was perfonued first. After the treatment, severe hepatic encephalopathy （grade III ） occurred in 4, shunt dysfun-ction in 3 and upper gastrointestinal bleeding in one case. TIPS balloon dilatation followed by spleno- gastric- renal shunt oeelusion was carried out in 5 patients, and after the treatment no shunt dysfunction occurred, only one patient developed mild hepatic encephalopathy （grade I ）. Conclusion For the treatment of cirrhosis associated with symptomatic portal hypertension and large spleno-renal or gastric-renal shunt, transjugular intrahepatic portosystemie shunt combined with Amplatzer plugging device therapy is safe and feasible. This therapy can effectively prevent the occurrence of hepatic encephalopathy and variceal bleeding caused by cirrhotic portal hypertension with large spleno-gastric-renal shunt.（J Intervent Radiol, 2013, 22： 801-805）