大球囊扩张治疗肝静脉阻塞型布-加综合征临床研究

Dilatation of hepatic vein with large balloon for the treatment of primary Budd-Chiari syndrome associated with hepatic vein obstruction: a clinical study

目的探讨大球囊导管经皮腔内血管成形术(PTA)治疗肝静脉(HV)阻塞型布-加综合征(BCS)的安全性及临床效果。方法回顾性分析2010年1月至2015年12月收治的80例HV阻塞型BCS患者临床资料。所有患者均经彩色多普勒超声、MRA明确诊断,其中HV膜性闭塞36例,节段性闭塞44例。PTA术中78例经颈静脉途径,2例经皮穿刺途径结合右颈静脉途径行HV球囊扩张。术后随访复查彩色多普勒超声,观察HV通畅情况, Kaplan-Meier曲线评价首次及再次通畅率。结果 80例BCS患者HV均成功开通。HV-下腔静脉压差由术前平均(27.7±10.3) cmH_2O(1 cmH_2O=0.098 kPa)下降至术后平均(9.2±6.8) cmH_2O,差异有显著统计学意义(t=12.1,P<0.01)。80例患者均获得随访2～73个月,平均(34.2±18.3)个月。19例发生HV再狭窄(膜性5例,节段性14例),均经再次球囊扩张治疗成功。膜性和节段性闭塞患者术后1、3、5年首次通畅率分别为97.2%、91.1%、82.0%和83.7%、71.4%、58.0%(P=0.027),再次通畅率分别为100%、97.2%、93.3%和97.6%、90.9%、77.8%(P=0.245)。1例术后1年死于肝衰竭。结论大球囊导管PTA治疗HV阻塞型BCS患者安全可行,膜性闭塞型患者中远期疗效较好于节段性闭塞型患者,对多次复发的节段性闭塞型患者推荐植入支架。

Objective To evaluate the safety and clinical efficacy of percutaneous transluminal angioplasty （FFA） with a large balloon catheter in treating Budd- Chiari syndrome （BCS） associated with hepatic vein （HV） obstruction. Methods The clinical data of a total of 80 patients with BCS complicated by HV obstruction, who were admitted to authors＇ hospital during the period from January 2010 to December 2015 to receive treatment, were retrospectively analyzed. The disease was confirmed by color Doppler ultrasound and MRA in all patients. Among the go patients, membranous obstruction of HV was seen in 36 and segmental obstruction of HV was found in 44. PTA via right jugular vein approach was used in 78 patients, and PTA via percutaneous transhepatie approach combined with the right jugular vein approach was employed in 2 patients; and balloon dilatation of HV was carried out. Postoperative follow-up reexamination with color Doppler ultrasound was adopted to check the patency of HV. Kaplan- Meier curve was used to evaluate the primary and secondary patency ratio. Results HV was successfully re-canalized in all the 80 patients with BCS. The mean pressure gradient between HV and inferior vena cava reduced from preoperative （27.7±10.3） cmH2O （1 cmH2O=0.098 kPa） to postoperative （9.2±6.8） cmH2O, the difference was statistically significant （t=12.1, P〈0.01）. All patients were followed up for 2-73 months, with a mean of （34.2±18.3） months. Nineteen patients developed re-stenosis of HV, including membranous stenosis （n=5） and segmental stenosis （n=14）, which were cured after balloon dilatation therapy. The cumulative 1-, 3- and 5-year primary HV patency rates in the membranous obstruction group were 97.2%, 91.1% and 82.0% respectively, which in the segmental obstruction group were 83.7%, 71.4% and 58.0% respectively （P=0.027）. The cumulative 1-, 3- and 5-year secondary HV patency rates in the membranous obstruction group were 100%, 97.2% and 93.3% respectively, which in the segmental obstruction group were 97.6%, 90.9% and 77.8% respectively （P=0.245）. One patient died of hepatic failure one year after the operation. Conclusion For the treatment of BCS complicated by obstruction of HV, PTA by using a large balloon catheter is feasible and safe. The long-term curative effect in patients with BCS of membranous occlusion type is better than that in patients with BCS of segmental occlusion type. For BCS patients who have recurrent segmental occlusion of HV, stent implantation therapy is recommended.