经TIPSS途径门静脉及肠系膜上静脉血栓溶栓治疗

Thrombolysis treatment of mesenteric and portal venous thrombosis by TIPSS pathway

目的 评价经TIPSS途径门静脉及肠系膜上静脉血栓溶栓治疗的安全性和效果。方法 对6例诊断为PV和SMV广泛血栓形成患者进行了经颈静脉途径经肝穿刺门静脉(简称TIPSS途径)介入溶栓治疗。患者主要症状有腹痛、腹胀、厌食等。腹部体检有压痛,均无明确腹肌紧张和反跳痛。B超、增强CT检查和直接PV-SMV造影确诊为本病。溶栓方法:穿刺PV分支成功后插入导管做PV-SMV造影,确定诊断及了解栓塞范围,抽吸及捣碎血栓,间断将尿激酶经多侧孔导管注入PV和SMV清除大部分血栓后,保留多侧孔导管至SMV内持续溶栓3天-13天。术后药物抗凝治疗6个月左右,此间,密切监测出凝血时间及影象学血变化。结果 介入治疗后,大部分血栓被清除,PV和SMV有血流通过,腹痛、腹胀和腹泻症状逐步缓解。经留置于SMV的导管造影显示PV和SMV主干及主要分支血流通畅,3例门静脉肝内少数分支有残留血栓,但无明显症状。随访4个月至3年,除1例死于外科手术并发症外,其余5例健在、无血栓复发证据及上消化道出血发生。结论 经TIPSS途径介入技术溶栓治疗,是治疗急性PV和SMV血栓形成的安全、具有良好的近期及中远期疗效的方法。

Objective To assess the efficacy and safety of thrombolysis treatment of mesenteric and portal venous thrombosis by TIPSS pathway. Methods Six patients with thrombosis of the PV and SMV were treated by transjugular intra-hepatic portosystemic shunt (TIPSS) pathway. All 6 patients presented with abdominal pain, distention, and anorexia etc . No clinical signs of peritonitis were seen. The diagnosis was established by doppler ultrasound scan and contrast enhanced CT. Control PV-SMV venography was performed after access to the PV branch. Then aspirate and fragment the thrombus in the PV and SMV . Contemporaneous local thrombolysis with urokinase (UK) was delivered through a catheter in the SMV. After the majority of the clot was cleared with flow restoration in the main trunk, a 4-French multiple side-hoes catheter was put in the SMV and UK was continuously infused for 3 to 13 days. Results The majority of the thrombus in PV and SMV was cleared with flow restoration in all patients after the procedures. Clinical improvement was seen in 5 patients, characterized by progressive reduction of abdominal pain, distention, and diarrhea. Before removal of the infusion catheter at the SMV, venography revealed complete resolution of the thrombosis in 3 patients, and residual thrombus in the PV branches in 3 cases without clinical significance. Follow-up Doppler ultrasound scan performed during 4-36 months after the procedure confirmed patency of the PV and SMV. The symptoms did not recurr. Conclusion With the TIPSS pathway catheter-directed thrombolysis are safe and effective in the treatment of PV and SMV thrombosis