改良穿刺套件对肝硬化门静脉高压合并门静脉海绵样变上消化道大出血的疗效

Efficacy of modified puncture kit for upper gastrointestinal hemorrhage in cirrhosis portal hypertension combined with cavernous transformation of portal vein

目的探讨改良穿刺套件对肝硬化门静脉高压合并门静脉海绵样变(CTPV)急性上消化道大出血的临床疗效。方法收集2016年7月至2021年3月解放军联勤保障部队第九六〇医院收治的34例肝硬化门静脉高压合并CTPV急性上消化道大出血患者的临床资料,所有患者均行经颈静脉肝内门体分流术(TIPS),采用改良穿刺套件穿刺门静脉并植入直径均为8 mm的覆膜支架和裸支架,建立分流道后测量门静脉压力,观察患者的术中、术后情况,比较TIPS手术前后门静脉主干压力。通过随访复查彩色多普勒超声,观察患者的再出血、支架通畅性、肝性脑病及患者生存情况等。结果34例患者的手术成功率为94.1%(32/34),其中,32例患者均采用改良穿刺套件顺利完成手术。32例患者中,成功穿刺门静脉右支11例,成功穿刺门静脉左支21例,其余2例患者因门静脉完全闭塞而无法进行手术;24例CTPV患者均采用穿刺定位球囊的方法成功完成穿刺;25例患者同时行胃冠状静脉栓塞术,术中未出现手术相关并发症。TIPS术后门静脉主干压力明显低于术前,差异有统计学意义(P﹤0.01)。术后造影检查结果显示,分流道腔内血流通畅,侧支循环消失,24 h内消化道未再次出血,住院期间无患者死亡。术后3个月,32例患者均行彩色多普勒超声检查,分流道腔内血流通畅。术后6个月,1例患者失访,5例患者术后出现分流道狭窄或阻塞,支架狭窄程度为30%~50%,经球囊扩张治疗后支架内血流恢复通畅,其余26例患者术后分流道内血流通畅,临床疗效良好。结论采用改良穿刺套件治疗肝硬化门静脉高压合并CTPV所致的急性上消化道大出血的近期、中期疗效较好,安全可靠。

Objective To investigate the clinical efficacy of the modified puncture kit for the treatment of acute upper gastrointestinal hemorrhage in cirrhosis portal hypertension combined with cavernous transformation of portal vein(CTPV).Method The clinical data of 34 cases of acute upper gastrointestinal hemorrhage in patients with cirrhosis portal hypertension and CTPV admitted to the 960th Hospital of PLA Joint Logistics Support Force from July 2016 to March 2021 were collected.All patients received transjugular intrahepatic portosystemic shunt(TIPS)by using an modified puncture kit to puncture the portal vein and implant an 8 mm diameter overmolded stent and an bare stent to create the shunt,followed by measurement of portal vein pressure to observe intraoperative and postoperative conditions.The main portal vein pressure was compared before and after surgery.The color Doppler ultrasound was followed up to observe whether re-bleeding,stent patency,hepatic encephalopathy and survival occurred.Result The successful rate of surgery in 34 patients was 94.1%(32/34),in which,32 patients successfully completed the surgery using improved puncture kit.Among the 32 patients,11 patients were successfully punctured the right portal vein,21 patients were successfully punctured the left portal vein,and the remaining 2 patients were unable to undergo surgery due to complete occlusion of the portal vein;24 patients with partial occlusion of CTPV were successfully punctured by positioning balloon;gastric coronary venous embolization was performed in 25 patients,and no operative complications occurred.The portal vein trunk pressure after surgery was significantly lower than that before surgery(P<0.01).Postoperative angiography showed patency of blood flow in the shunt lumen and collateral circulation disappeared;there was no recurrence of gastrointestinal bleeding within 24 h,and no patient died during hospitalization.Three months after surgery,all 32 patients underwent color Doppler ultrasonography,and all showed patency of blood flow in the shunt lumen;6 months after surgery,1 patient was lost to follow-up,5 patients developed stenosis or obstruction of the shunt after surgery,and the degree of stent stenosis was about 30%-50%,which was treated with balloon dilation,and the blood flow in the stent was restored.In the remaining 26 cases,the blood flow in the shunt was smooth,and the clinical treatment effect was good.Conclusion Modified puncture kit for acute upper gastrointestinal hemorrhage caused by cirrhosis portal hypertension combined with CTPV has better short,mid-term outcomes and safety.