肝实质段覆膜支架精确覆盖技术在经颈静脉肝内门体分流术中的应用

Technological modification of transjugular intrahepatic portosystemic shunt: the precise covering of parenchymal shunt with stent-graft

目的：以裸支架加覆膜支架形式建立肝实质内门腔分流道,评价肝实质段覆膜支架精确覆盖技术的可行性及疗效.方法：17例肝硬化、门脉高压症所致上消化道出血患者,行经颈静脉肝内门体分流术（transjugular intrahepatic portosystemic shunt,TIPS）.改良支架放置技术,以裸金属支架连接门静脉与下腔静脉,定位分流道肝实质段,以覆膜支架精确覆盖,建立门腔分流体系.测量比较分流前后门体静脉压力梯度值（portosystemic gradient,PSG）的变化,评价技术可行性、安全性及临床治疗效果.结果：17例手术全部获得成功.分流前后PSG差异有统计学意义[（28.2±7.6） mmHg vs.（12.1±3.5） mmHg,1 mmHg=0.133 kPa,P〈0.001].术后近期死亡1例,其他所有病例均获随访,中位随访时间181 d （32～563 d）.随访过程中3例死亡,原因分别为肝性脑病、肝功能衰竭及败血症,其余13例存活.2例发生肝性脑病经药物治疗缓解.支架通畅率100%,无复发出血.术前及随访结束时Child-Pugh评分分别为（7.8±2.0）分和（7.5±1.7）分,差异无统计学意义（P=0.584）.结论：使用组合支架（裸支架＋覆膜支架形式）实现肝实质分流道准确定位,覆膜支架精确放置在操作上相对简单,PSG降低幅度在一定程度上可调控.经临床初步应用及短期随访,支架通畅率高,肝性脑病发生率及再出血率较低,综合疗效满意.

Objective：To introduce the technological modification of stents placement with combined naked self-expanding stent and stent-graft for the construction of portosystemic shunt during transjugular intrahepatic portosystemic shunt （TIPS）. Methods： In the study, 17 patients who suffered from upper digestive tract hemorrhage due to portal hypertension post liver cirrhosis underwent modified TIPS. The shunts were constructed with stepwise placement of naked self-expanding stent and a stent-graft other than stent-graft only for the purpose of precisely covering the parenchymal segment of the shunt and the active control of portosystemic gradient （PSG）. The feasibility, safety, and clinical application results of the new technique were analyzed. Results： Technically, the success rate of operation was 100%. The mean PSG before and after TIPS was （28.2 ±7.6） mmHg, （ 12.1 ± 3.5 ） mmHg, respectively （ 1 mmHg -- 0. 133 kPa, P 〈0. 001 ）. One patient died 6 days after operation. The median follow-up period was 181 days （ranging from 32 days to 563 days） for all the other 16 cases, during which period 3 patients died because of encephalopathy, liver failure and septicemia, respectively, and 2 cases of encephalopathy oc- curred and were relieved with medical treatment. The shunts patency rate was 100% and no chance of di- gestive re-bleeding occurred. The mean Child-Pugh score before TIPS and at the end of the follow-up was （ 7.8 ±2.0） points and （7.5 ±1.7 ） points, respectively （ P = 0. 584 ）. Conclusion： The technological modification of TIPS with combined naked self-expanding stent and stent-graft for the precise covering of the parenchymal segment of the shunts was relatively simple to apply, and was helpful for the adjustment of PSG. The preliminary clinical application indicated that it had satisfying results in the matter of shunts patency, incidence of encephalopathy, and the relapse of digestive bleeding during the short-term follow- up.