经皮穿肝辅助肝内门腔静脉分流治疗门静脉血栓

lntrahepalic portosystemic shunt assisted by percutaneous transhepalic approach for treatment of portal vein thrombosis

目的回顾性分析通过经皮穿肝辅助建立的肝内门静脉分流道，采用机械性血栓清除联合药物性溶栓的方法治疗非急性、症状性门静脉血栓的安全性及疗效。方法从2006年4月至2012年5月，共对18例门静脉血栓形成患者采用经皮穿肝辅助的方法建立肝内门静脉分流道，然后实施球囊扩张碎栓、经长鞘抽吸血栓、连续灌注尿激酶溶栓治疗。结果18例患者建立肝内门腔静脉分流的成功率为100％，平均溶栓刚恫为（65．3土29．5）h，尿激酶平均用量为（2324000±945000）U，平均门腔静脉梯度压由术前的（33．8士4．9）mmHg降至溶栓结束后的（15．4±2．1）111121Hg，治疗前后比较，f=18．263，P〈0．001，差异有统计学意义，治疗后患者临床症状缓解率达94．40／0。1例患者于术后第2天死亡，另2例患者分别于术后第5天及术后当天出现轻度肝性脑病及右侧血性胸腔积液，经对症治疗后缓解。在平均（18．6±17．5）个月的随访期内，1例患者死亡，5例患者分流道闭塞，其余患者分流道通畅，无门静脉血栓相关症状复发。结论通过经皮穿肝辅助建立的肝内门静脉分流道，采用机械性血栓清除联合药物性溶栓的方法，治疗非急性、症状性门静脉血栓形成安全有效。

Objective To retrospectively analyze the safety and efficacy of mechanical thrombectomy combined with pharmacologic thrombolysis to treat non-acute and symptomatic portal vein thrombosis （PVT） using an intrahepatic portosystemic shunt （IPS） assisted by percutaneous transhepatic approach. Methods From April 2006 to May 2012, 18 patients with non-acute and symptomatic PVT were treated with balloon dilation, sheath-directed thrombus aspiration and continuous infusion of urokinase using the IPS assisted by pereutaneous transhepatic approach. The significance of differences in the portosystemie gradient measured before and after therapy was assessed by paired samples t-test, and survival analysis was made by the Kaplan-Meier method. Results IPS was successfully created in all patients. The mean duration of the thrombolytic therapy was 65.3± 29.5 h, and the mean concentration of urokinase used for the thrombolysis was 2 324 000 ± 945 000 U. Comparison of the mean portosystemic gradients showed a significant improvement in response to the therapy （before： 33.8 ±4.9 mm Hg vs. after： 15.4± 2.1 mm Hg; P 〈 0.001）. The overall rate of clinical improvement was 94.4%. One patient died on day 2 post-therapy and another two patients experienced mild hepatic eneephalopathy or fight hemothorax, respectively, on day 5 post-therapy, with conservative medical management achieving complete recovery for both. The mean follow-up time was 18.6 ± 17.5 months, during which only one patient died and five others experienced shunt dysfunction; all remaining patients showed maintenance of shunt patency without symptoms of recurrence. Conclusion Mechanical thrombectomy combined with pharmacologic thrombolysis via the IPS assisted by percutaneous transhepatic approach is a safe and effectivetherapeutic option for patients with non-acute and symptomatic PVT.