多层螺旋CT血管造影对原发性肝癌动静脉瘘和肝外供血动脉评估价值

Multislice spiral CT angiography in evaluation of arteriovenous fistula for hepatocellular carcinoma

目的原发性肝癌(primary liver cancer,PLC)是我国常见的恶性肿瘤之一,治疗尤其是介入治疗前,需详细了解肝脏及肝脏肿瘤的血管准确解剖。多层螺旋CT血管造影(multislice spiral CT angiography,MSCTA)具有扫描速度快,覆盖范围广,后处理技术成熟等优势,本研究旨在探讨MSCTA在PLC患者肝动脉-门静脉瘘(hepatic artery-portal vein fistula,HAPVF)及肝外供血动脉术前评估中的临床应用价值。方法回顾性分析2014-10-01-2015-10-01山东大学附属山东省肿瘤医院介入科收治的90例PLC患者MSCTA和数字减影血管造影(digital subtraction angiography,DSA)临床资料,评价HAPVF和肝动脉-肝静脉瘘(hepatic artery-hepatic vein fistula,HAHVF)发生率及其与肿瘤大小、部位和肝硬变程度的关系;肝外供血动脉与毗邻肿瘤的关系。以DSA结果为金标准,分析MSCTA评估PLC血管异常的准确性。结果 90例PLC患者中,共发现HAPVF 48例,发生率为53.3%,其中A组0例,B组5例(10.4%),C组17例(35.4%),D组26例(54.2%);中心型28例(58.3%),周围型20例(41.7%);Child-Pugh A级34例(70.8%),Child-Pugh B级12例(25%),Child-Pugh C级2例(4.2%)。HAHVF 4例,发生率为4.4%。二元Logistics回归分析显示,肿瘤大小及肝硬变程度是HAPVF的独立危险因素,P<0.05。MSCTA共检出HAPVF 45例,中央型28例,准确率为100.0%(28/28);周围型17例,准确率85.0%(17/20);总体准确率为93.8%(45/48),与DSA结果进行比较,差异无统计学意义,χ~2=3.097,P>0.05。19例患者存在24条肝外供血动脉,均发生于C组和D组,周围型和中心型分别为87.5%和12.5%,MSCTA发现22条,两者比较差异无统计学意义,χ~2=2.087,P>0.05。结论 MSCTA技术可准确显示HAPVF及肝外供血动脉,肿瘤大小及肝硬化分级是肝动-静脉瘘的独立危险因素。肝外供血动脉多发生于块状型、巨块型且位于多肝脏边缘区域的肝癌。

OBJECTIVE Primary liver cancer（PLC）is one of the common malignant tumors in our country.It is necessary to understand the precise anatomy of the blood vessels of the liver and the tumor before treatment,especially in the interventional therapy.Multi-slice spiral CT angiography（MSCTA）has the advantages of fast scanning speed,wide coverage,and after processing technology maturity,this paper aims to evaluate the clinical value of MSCTA in primary hepatic carcinoma arteriovenous fistula.METHODS We retrospectively analyzed 90 patients with hepatocellular carcinoma by MSCTA and digital subtraction angiography（DSA）from October 1,2014 to October 1,2015,in Shandong University affiliated Shandong Provincial Cancer Hospital Department of interventional radiology.The incidence of hepatic artery-portal vein fistula（HAPVF）and HAHVF as well as its relationship with tumor size,location,levels of cirrhosis and portal hypertension were evaluated.Using DSA results as gold standard,the accuracy of MSCTA was analyzed for vascular abnormalities in patients with hepatic carcinoma.RESULTS A total of 48 HAPVF were detected by DSA in90cases（53.3%）,0cases in group A,group B：5cases（10.4%）,group C：17cases（35.4%）,group D：26cases（54.2%）;28cases of them were central type（58.3%）and 20 cases of them were peripheral type（41.7%）;Child-Pugh grade：34cases（70.8%）,Child-Pugh B：12cases（25.0%）,Child-Pugh C（4.2%）：2cases.4 HAHVF（4.4%）were detected by DSA.Multivariable analysis with gender,age,tumor size,location and other factors demonstrated tumor size and degree of liver cirrhosis were the independent factors for HAPVF（P〈0.05）.A total of 45 HAPVF were detected by MSCTA,central type：28cases,the accuracy was 100.0%（28/28）;peripheral type：17cases,the accuracy was 85.0%（17/20）;The total accuracy was 93.8%（45/48）,compared with the results of DSA,there was no statistical difference（χ^2=3.097,P〈0.05）.24 extrahepatic arterials occurred in group C and group D were detected by DSA in 19patients;the peripheral type and the central type were 87.5% and 12.5%,respectively.22 extrahepatic arterials were detected by MSCTA in total of 24.There is no statistical difference between MSCTA and DSA（χ^2=2.087,P〈0.05）.CONCLUSIONS In our opinion,MSCTA is an accurately diagnostic technique to detect arteriovenous fistula and extrahepatic arterials in patients with primary hepatic carcinoma.Tumor size and degree of liver cirrhosis were the independent factors for HAPVF.Extrahepatic arterial blood supply occurs in massive and located in peripheral areas of hepatic carcinoma.