经皮经肝穿刺肝内门体分流术30例临床分析

Percutaneous transhepatic intrahepatic portosystemic shunt： a study on 30 patients

目的评估经皮经肝穿刺肝内门体分流术对不同病因所致复杂门静脉高压患者的临床疗效。方法2012年10月至2014年6月，我科收治的30例复杂门静脉高压患者。按病因分类：门静脉癌栓15例，其中2例合并海绵样变性；门静脉血栓形成8例，其中3例合并海绵样变性；不明原因门静脉海绵样变性7例。所有患者均接受经皮经肝穿刺肝内门体分流术。回顾性分析手术成功率、并发症及临床随访结果。结果30例患者技术成功率100％，未出现严重的手术相关并发症。术中共植入自膨式覆膜支架64枚，其中植入2枚支架20例，3枚支架7例，1枚支架3例。分流道建立后门静脉压力由（54．2±4．5）cmH20降至（30．5±3．8）cmH20（P〈0．05）。术后1周临床症状有效缓解。随访3-18个月，中位随访时间8个月。随访期间，因肝功能衰竭死亡8例。2例患者出现分流道狭窄，给予球囊扩张后狭窄解除。5例患者出现轻度肝性脑病，经对症治疗后症状缓解。1例患者发生重度肝昏迷，经再次植入支架缩小分流道后症状缓解。结论经皮经肝穿刺肝内门体分流术安全、有效，为复杂门脉高压症患者的肝内门体分流提供了一种新的手术方式。

Objective To evaluate the feasibility and efficacy of percutaneous transhepatic intrahepatic portosystemie shunt （PTIPS） for patients with complicated portal hypertension caused by different di-seases. Methods From October 2012 to June 2014, 30 patients who suffered from complicated portal hypertension caused by tumor thrombus （ n = 15 ） , thrombus （ n = 8 ） , and cavernous transformation of portal vein （ n = 7 ） underwent PTIPS in our institution. The clinical results, complications, and long-term outcomes were reviewed. Results PTIPS was successfully performed for these 30 patients with complete relief of clinical symptoms 1 week after the procedure. There were not serious procedure related complications. Sixty four self-expanding cov- ered stents were deployed with one stent in 3 patients, two stents in 20 patients, and three stents in 7 patients. The mean portal pressure gradient decreased from （54. 2 ± 4. 5 ） cmH20 to （30. 5 ± 3.8） cmH：O after the PTIPS procedure （ P 〈 0. 05）. On follow-up （ median, 8 months ; range, 3 ～ 18 months）, 8 patients died of liver failure. Shunt stenosis occurred in 2 patients and was treated successfully by balloon dilation. Hepatic enceph- alopathy occurred in 5 patients who responded to conservative treatment. Serious hepatic coma occurred in one pa- tient who responded to diminution of the shunt by another stent deployment. Conclusion PTIPS is a safe and fea- sible treatment for patients with complicated portal hypertension.