TIPS术后分流道闭塞的平行分流

Parallel shunt for management of transjugular intrahepatic portosystemic shunt occlusion

目的探讨建立平行通道治疗经颈静脉肝内门腔静脉分流术(transjugular intrahepatic portosystemic shunt,TIPS)后分流道闭塞的疗效及安全性.方法回顾性分析2012-03/2015-10贵州医科大学附属医院18例TIPS术后分流道完全闭塞的肝硬化患者的临床资料,18例患者均选择建立平行分流道,术后定期随访6-42 mo(平均16.7 mo±10.8 mo).记录所有患者平行分流手术技术成功率,手术持续时间(初次分流及平行分流),平行分流前、后门体静脉压力梯度(portal pressure gradient,PPG),分流道通畅情况等.结果18例患者均成功重建平行分流道;建立平行分流通道手术时间为57.1 min±12.9 min(建立初次分流道手术的平均持续时间为89.2 min±29.4 min,t=4.24,P<0.01);平行分流前PPG平均为25.5 mm Hg±7.4 mm Hg(范围,16-37 mm Hg),术后为10.9 mm Hg±2.4 m m H g(范围,7-16 mm Hg),平行分流后PPG明显降低,差异有统计学意义(t=10.1,P<0.01);随访阶段4例患者再次出现不同程度的分流道功能障碍,再次分流道造影见3例患者门静脉端狭窄,1例患者肝静脉端狭窄,均经支架及球囊成形后平行分流道恢复通畅.单用覆膜支架、联合运用裸支架及覆膜支架行平行TIPS后1年分流道通畅率分别为70.1%及87.6%.结论建立平行分流通道治疗TIPS后分流道完全闭塞是一种安全、有效的方法.

AIM To evaluate the security and efficacy of parallel shunt in the treatment of transjugular intrahepatic portosystemic shunt（TIPS）occlusion.METHODS From March 2012 to October 2015,18 drrhotic patients who underwent TIPS revision with the creation of parallel shunt were investigated retrospectively in our institution.Parallel shunt was established due to the original shunt occlusion.The mean follow-up period was16.7 mo ± 10.8 mo（range,6-42 mo）.Technical success and the duration of the first and second operation were recorded.Branch of hepatic vein receiving TIPS,portal pressure gradient and shunt patency were also assessed.RESULTS Technical success rate of parallel shunt creation was 100%.The mean duration of the second operation was 57.1 min ± 12.9 min,which was significantly shorter than that of the first operation（89.2 min ± 29.4 min,t = 4.24,P 0.01）.The mean portosystemic pressure gradient significantly decreased from 25.5mmHg ± 7.4 mmHg（range,16-37 mmHg） to10.9 mmHg ± 2.4 mmHg（range,7-16 mmHg）after the parallel shunt was created（t = 10.1,P 0.01）.Four patients developed recurrent TIPS dysfunction during the follow-up period,of whom three presented with stenosis in the portal vein and one with stenosis in the liver vein.One patient received angioplasty.Insertion of an additional stent-graft was performed in the other three patients.The shunt patency rates at 12 mo after the creation of parallel shunt was 70.1%with Fluency endoprostheses and 87.6%with Fluency endoprostheses and bare stent.CONCLUSION The creation of parallel shunt is a safe and effective approach for managing TIPS occlusion.