经颈静脉肝内门腔分流术中覆膜支架两端长度与长期疗效的关系

Effect of covered stent length in portal and hepatic veins on long-term clinical efficacy of transjugular intrahepatic portosystemic shunt

目的探讨使用全覆膜支架行经颈静脉肝内门腔分流术(TIPS术)中支架分流道的两端长度与长期分流道通畅率、肝性脑病(HE)、生存率之间的关系。方法回顾性分析2008年1月~2011年12月在我科行TIPS术患者53例,均采用直径8mm全覆膜支架(Fluency支架,Bard)建立分流道,再视造影情况加以同等直径裸支架延长肝静脉端、门脉端。测量覆膜支架进入肝静脉长度、门静脉长度(X1、X2),肝静脉、门静脉支架总长度(X3、X4),行COX回归分析其对TIPS术后道通畅率、生存率及肝性脑病发生率的影响。结果全部患者均成功建立分流道,术前门脉压力(29.80±4.83)mm Hg,术后门脉压力(19.00±3.92)mm Hg,下降(10.80±5.15)mm Hg(t=13.44,P<0.01)。随访时间3~89月,中位随访期64月,平均39个月。期间肝性脑病发生率为23%(12/53)。16例出现分流道再狭窄,5年累积一期通畅率分别为83%、75%、63%、62%、54%。5年累积生存率分别为79%、72%、72%、69%、69%。通畅率COX回归分析显示X1有统计学意义(OR=0.42,P<0.01);生存率COX回归分析显示X4有统计学意义(OR=1.50,P=0.021);肝性脑病影响因素分析均无统计学意义。结论使用Fluency覆膜支架行TIPS术,适当增加肝静脉端覆膜支架长度、减少支架进入门静脉长度可提高分流道通畅率及生存率。

Objective To evaluate the effect of the length of covered stents in the portal and hepatic veins on long-term clinical efficacy of transjugular intrahepatic portosystemic shunt(TIPS). Methods We retrospectively reviewed 53 cases receiving TIPSs between January, 2008 and December, 2011. All the shunts were created with Fluency stents(8 mm in diameter). Bare metal grafts of the same diameter were implanted to extend the length in the portal and hepatic veins as deemed necessary according to angiographic images. The primary patency, hepatic encephalopathy and patient survival were evaluated during the follow up. The length of the covered stents within the hepatic vein(X1) and in the portal vein(X2), and the total length of stents placed in the hepatic vein(X3) and the portal vein(X4) were measured and their effects on primary patency and the patients' outcomes were evaluated. Results The procedures were completed successfully in all the patients and the mean portosystemic pressure decreased from 29.80 ± 4.83 mm Hg to 19.00 ± 3.92 mm Hg(t=13.44, P<0.01) after the procedure. The patients were followed up for a median of 64 months(3 to 89 months, 39 months on average). Hepatic encephalopathy occurred in 23%(12/53) of the patients after TIPS. Shunt dysfunction occurred in 16 cases, and the cumulative primary patency rates at 1 to 5 years were 83%, 75%, 63%, 62%, and 54%, respectively. The cumulative survival rates of the patients at 1 to 5years were 79%, 72%, 72%, 69%, and 69%, respectively. Cox proportional regression analysis showed a significant association between the length of covered-stent in the hepatic vein and the primary patency(OR=0.42, P<0.01), and there was a significant association between the length of stent in the portal vein and the patient survival. No significant correlation was found between these parameters and hepatic encephalopathy. Conclusion Increasing the length of the covered stent in the hepatic vein and decreasing the stent length in the portal vein can improve the primary patency and the patient survival receiving TIPS.