Targeted puncture of left branch of intrahepatic portal vein in transjugular intrahepatic portosystemic shunt to reduce hepatic encephalopathy

BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS) is currently used for the treatment of complications of portal hypertension. The incidence of hepatic encephalopathy(HE) remains a problem in TIPS placement. It has been reported that the right branch mainly receives superior mesenteric venous blood while the left branch mainly receives blood from the splenic vein. We hypothesized that targeted puncture of the left portal vein would divert the non-nutritive blood from the splenic vein into the TIPS shunt; therefore, targeted puncture of the left branch of the intrahepatic portal vein during TIPS may reduce the risk of HE.AIM To evaluate the influence of targeted puncture of left branch of portal vein in TIPS on HE.METHODS A retrospective analysis of 1244 patients with portal-hypertension-related complications of refractory ascites or variceal bleeding who underwent TIPS from January 2000 to January 2013 was performed. Patients were divided into group A(targeting left branch of portal vein, n = 937) and group B(targeting right branch of portal vein, n = 307). TIPS-related HE and clinical outcomes were analyzed.RESULTS The symptoms of ascites and variceal bleeding disappeared within a short time.By the endpoint of follow-up, recurrent bleeding and ascites did not differ significantly between groups A and B(P = 0.278, P = 0.561, respectively).Incidence of HE differed significantly between groups A and B at 1 mo(14.94% vs36.80%, χ~2 = 4.839, P = 0.028), 3 mo(12.48% vs 34.20%, χ~2 = 5.054, P = 0.025), 6 mo(10.03% vs 32.24%, χ~2 = 6.560, P = 0.010), 9 mo(9.17% vs 31.27%, χ~2 = 5.357, P =0.021), and 12 mo(8.21% vs 28.01, χ~2 = 3.848, P = 0.051). There were no significant differences between groups A and B at 3 years(6.61% vs 7.16%, χ~2 = 1.204, P =0.272) and 5 years(5.01% vs 6.18%, χ~2 = 0.072, P = 0.562). The total survival rate did not differ between groups A and B(χ~2 = 0.226, P = 0.634, log-rank test).CONCLUSION Targeted puncture of the left branch of the intrahepatic portal vein during TIPS may reduce the risk of HE but has no direct influence on prognosis of portalhypertension-related complications.

Embolization of splenorenal shunt associated to portal vein thrombosis and hepatic encephalopathy

Hepatic encephalopathy(HE)is a cognitive disturbance characterized by neuropsychiatric alterations.It occurs in acute and chronic hepatic disease and also in patients with portosystemic shunts.The presence of these portosystemic shunts allows the passage of nitrogenous substances from the intestines through systemic veins without liver depuration.Therefore,the embolization of these shunts has been performed tocontrol HE manifestations,but the presence of portal vein thrombosis is considered a contraindication.In this presentation we show a cirrhotic patient with severe HE and portal vein thrombosis who was submitted to embolization of a large portosystemic shunt.Case report:a 57 years-old cirrhotic patient who had been hospitalized many times for persistent HE and hepatic coma,even without precipitant factors.She had a wide portosystemic shunt and also portal vein thrombosis.The abdominal angiography confirmed the splenorenal shunt and showed other shunts.The larger shunt was embolized through placement of microcoils,and the patient had no recurrence of overt HE.There was a little increase of esophageal and gastric varices,but no endoscopic treatment was needed.Since portosystemic shunts are frequent causes of recurrent HE in cirrhotic patients,portal vein thrombosis should be considered a relative contraindication to perform a shunt embolization.However,in particular cases with many shunts and severe HE,we found that one of these shunts can be safely embolized and this procedure can be sufficient to obtain a good HE recovery.In conclusion,we reported a case of persistent HE due to a wide portosystemic shunt associated with portal vein thrombosis.As the patient had other shunts,she was successfully treated by embolization of the larger shunt.

Transjugular intrahepatic portosystemic shunt is effective in patients with chronic portal vein thrombosis and variceal bleeding

Background:Studies about treatment of patients with chronic portal vein thrombosis(CPVT)are still limited,especially in different types of CPVT.This study aimed to evaluate the effect of transjugular intrahepatic portosystemic shunt(TIPS)in all types of CPVT with variceal bleeding.Methods:Patients with CPVT who received TIPS treatment between January 2011 and June 2019 were divided into four types according to the extent of thrombosis.All patients had a history of variceal bleeding.The characteristics and clinical parameters were collected and recorded.Data on procedure success rate,variation in portal vein pressure,rebleeding,hepatic encephalopathy(HE),stent stenosis,and overall mortality were analyzed.Results:A total of 189 patients were included in this study(39 in type 1,84 in type 2,48 in type 3,18 in type 4).The TIPS procedure success rate was 86.2%.The success rate was significantly different among the four types(89.7%vs.88.1%vs.83.3%vs.77.8%,P=0.001).In the TIPS success group,portal vein pressure was significantly reduced from 27.15±6.59 to 19.74±6.73 mm Hg after the procedure(P<0.001)and the rebleeding rate was significantly lower than that of the fail group(14.7%vs.30.8%,P=0.017).In addition,there were no significant differences in HE rate(30.7%vs.26.9%,P=0.912)or overall mortality(12.9%vs.19.2%,P=0.403)between the TIPS success group and the fail group.In the TIPS success group,we found that the occurrence of HE was significantly different(P=0.020)among the four types,while there were no significant differences in rebleeding rate(P=0.669),stent stenosis rate(P=0.056),or overall mortality(P=0.690).Conclusions:TIPS was safe and effective in decreasing portal vein pressure and rebleeding rate in patients with CPVT.

Computed tomography perfusion in differentiating portal hypertension: A correlation study with hepatic venous pressure gradient

BACKGROUND Hepatic venous pressure gradient(HVPG)is the gold standard for diagnosis of portal hypertension(PH),invasiveness and potential risks in the process of measurement limited its widespread use.AIM To investigate the correlation of computed tomography(CT)perfusion parameters with HVPG in PH,and quantitatively assess the blood supply changes in liver and spleen parenchyma before and after transjugular intrahepatic portosystemic shunt(TIPS).METHODS Twenty-four PH related gastrointestinal bleeding patients were recruited in this study,and all patients were performed perfusion CT before and after TIPS surgery within 2 wk.Quantitative parameters of CT perfusion,including liver blood volume(LBV),liver blood flow(LBF),hepatic arterial fraction(HAF),spleen blood volume(SBV)and spleen blood flow(SBF),were measured and compared before and after TIPS,and the quantitative parameters between clinically significant PH(CSPH)and non-CSPH(NCSPH)group were also compared.Then the correlation of CT perfusion parameters with HVPG were analyzed,with statistical significance as P<0.05.RESULTS For all 24 PH patients after TIPS,CT perfusion parameters demonstrated decreased LBV, increased HAF, SBV and SBF, with no statistical difference in LBF. Compared withNCSPH, CSPH showed higher HAF, with no difference in other CT perfusion parameters. HAFbefore TIPS showed positive correlation with HVPG (r = 0.530, P = 0.008), while no correlation wasfound in other CT perfusion parameters with HVPG and Child-Pugh scores.CONCLUSIONHAF, an index of CT perfusion, was positive correlation with HVPG, and higher in CSPH thanNCSPH before TIPS. While increased HAF, SBF and SBV, and decreased LBV, were found afterTIPS, which accommodates a potential non-invasive imaging tool for evaluation of PH.

结扎脐旁静脉缓解TIPS后肝性脑病1例

患者男,57岁,黑便3天;腹胀1年余,经多次利尿、腹腔积液抽取等内科保守治疗效果不佳;罹患乙型肝炎肝硬化20余年。查体:贫血貌,结膜苍白,腹膨隆,腹壁静脉曲张。实验室检查:血红蛋白72 g/L,胆红素31.6μmol/L,凝血酶原时间15.5 s,血氨32μmol/L。腹部增强CT提示肝硬化、门静脉高压、脾大、腹盆腔大量积液、腹壁静脉曲张。胃镜示食管胃底静脉重度曲张伴红色征;行胃镜下曲张静脉套扎及硬化治疗。

经颈静脉肝内门体分流术治疗门静脉高压伴门静脉血栓的疗效与安全性

目的探讨经颈静脉肝内门体静脉分流术(transjugular intrahepatic portosystemic shunt,TIPS)治疗门静脉高压伴门静脉血栓(portal vein thrombosis,PVT)的疗效及安全性。方法纳入2017年12月至2022年10月中国人民解放军总医院收治的符合TIPS治疗指征的31例门静脉高压伴PVT患者。收集患者临床资料,包括术前实验室检查、术式选择、术中门静脉压力(portal vein pressure,PVP)、术后随访超声或增强CT检查及有无肝性脑病(hepatic encephalopathy,HE)等。采用配对t检验比较支架植入前后PVP差异,Kaplan-Meier曲线分析患者术后分流道通畅率、再出血率、HE发生率及生存率。Log-rank检验分析伴或不伴有门静脉海绵样变性(cavernous transformation of portal vein,CTPV)患者的随访结果差异。结果TIPS成功率为93.55%(29/31)。手术成功的29例患者支架植入前后PVP由(30.15±4.61)mmHg降至(20.84±5.57)mmHg,差异有统计学意义(t=8.975,P<0.05)。术后随访时间为22.90(4.50,61.80)个月。随访期间,24.14%(7/29)的患者出现分流道功能障碍,17.24%(5/29)的患者出现再出血,17.24%(5/29)的患者出现HE,17.24%(5/29)的患者死亡。10例PVT患者伴有CTPV,伴有CTPV患者的分流道功能障碍5例、再出血3例、HE 1例、死亡3例,不伴有CTPV患者的分流道功能障碍2例、再出血2例、HE 4例、死亡2例。伴有CTPV的PVT患者的分流道功能障碍及再出血发生率高于不伴CTPV的患者(均P<0.05),而两组间HE发生率及术后病死率差异无统计学意义(均P>0.05)。结论TIPS可有效降低伴有PVT患者的PVP,PVT伴CTPV的患者TIPS后分流道功能障碍及再出血发生率高于不伴CTPV的患者。

Spontaneous porto-systemic shunts in liver cirrhosis:Clinical and therapeutical aspects

Spontaneous porto-systemic shunts(SPSS)are frequent in liver cirrhosis and their prevalence increases as liver function deteriorates,probably as a consequence of worsening portal hypertension,but without achieving an effective protection against cirrhosis'complications.Several types of SPSS have been described in the literature,each one associated with different clinical manifestations.In particular,recurrent or persistent hepatic encephalopathy is more frequent in patients with splenorenal shunt,while the presence of gastric varices and consequently the incidence of variceal bleeding is more common in gastrorenal shunt.In the advanced stage,the presence of large SPSS can lead to the so called“portosystemic shunt syndrome”,characterized by a progressive deterioration of hepatic function,hepatic encephalopathy and,sometimes,portal vein thrombosis.The detection of SPSS in patients with liver cirrhosis is recommended in order to prevent or treat recurrent hepatic encephalopathy or variceal bleeding.

肝静脉交通支对肝硬化门静脉高压患者肝静脉压力梯度的影响

目的观察肝静脉交通支对肝硬化门静脉高压(PHT)患者肝静脉压力梯度(HVPG)的影响。方法回顾性分析接受TIPS治疗的513例肝硬化PHT患者,TIPS术中均测量肝静脉压力并行球囊阻断加压肝静脉造影;根据肝静脉交通支显影情况将患者分为早期交通支显影组(早显组)、中晚期交通支显影组(中晚显组)、门静脉显影组及无交通支组,对比组间HVPG、门静脉压力梯度(PPG)、肝静脉楔压(WHVP)和门静脉压(PVP),分别以Pearson相关分析、组内相关系数(ICC)及Bland-Altman分析评估各组内WHVP与PVP、HVPG与PPG的相关性及其一致性。结果球囊阻断加压肝静脉造影中,163例肝静脉交通支早期显影,140例中晚期显影,166例门静脉显影,44例无交通支显影;4组间HVPG、PPG、WHVP及PVP总体差异均有统计学意义(P均<0.01),HVPG、WHVP呈逐渐增加,PPG、PVP呈逐渐降低趋势。各组内HVPG与PPG、WHVP与PVP差异均有统计学意义(P均<0.05);HVPG与PPG、WHVP与PVP均呈正相关(P均<0.001),且相关性及一致性在门静脉显影组均优于其他3组、而在早显组均不及其他3组。结论肝静脉交通支对肝硬化PHT患者HVPG存在一定影响。

原发性肝癌患者肝静脉压力梯度与门静脉压力梯度相关性研究

目的 探讨原发性肝癌患者肝静脉压力梯度(hepatic vein pressure gradient, HVPG)与门静脉压力梯度(portal pressure gradient, PPG)相关性。方法 161例原发性肝癌患者在TIPS术中测量下腔静脉压力(inferior vena cava pressure,ICVP)、肝静脉自由压(free hepatic vein pressure, FHVP)、肝静脉楔压(wedged hepatic vein pressure, WHVP)和门静脉压力(portal vein pressure, PVP),计算HVPG(HVPG=WHVP-FHVP)和PPG(PPG=PVP-IVCP)。结果 161例患者HVPG为(20.18±9.22)mmHg,PPG为(26.44±6.82)mmHg,2者无相关性(r=0.112);PPG明显高于HVPG (P <0.05)。HVPG与PPG相差在5 mmHg以上者90例,占55.9%,HVPG与PPG相差在5 mmHg以内者71例,占44.1%。球囊阻断肝静脉造影有肝内静脉-静脉侧支分流(intrahepatic venous-venous collateral shunt, HVVC)者42例(26.09%),HVPG为(10.91±6.11)mmHg,PPG为(28.43±6.11)mmHg,2者呈弱相关(r=0.384);PPG显著高于HVPG(P <0.05)。球囊阻断肝静脉造影无HVVC者119例,HVPG为(23.45±7.81)mmHg,PPG为(25.74±6.94) mmHg,2者呈弱相关(r=0.249);PPG明显高于HVPG(P <0.05)。结论 原发性肝癌合并门静脉高压(portal hypertension, PHT)HVPG与PPG总体相关性差,大部分患者的HVPG不能准确代表PPG,并且前者低于后者;有HVVC形成是严重低估HVPG值的重要原因。

肝硬化门静脉高压TIPS术后HVPG下降相关因素

目的探究肝硬化门静脉高压病人经颈静脉-肝内门腔静脉分流术(TIPS)后肝静脉压力梯度(HVPG)下降的相关因素。方法测定2019年6月—2022年6月于河北中石油中心医院行TIPS术的75例肝硬化门静脉高压病人手术前后HVPG,并将其分为HVPG下降组(观察组)和未下降组(对照组)。回顾性分析病人的一般资料、肝脏储备功能量化评估分级、终末期肝病模型评分、静脉曲张及腹水等因素对HVPG影响。结果与对照组比较,观察组40~49岁构成比升高、≥60岁构成比降低,乙型肝炎、丙型肝炎和门静脉血栓病人的构成比也降低,无腹水比例升高,差异均有显著性(χ^(2)=5.775~13.195,P<0.05)。多因素Logistic回归分析显示,年龄、肝硬化病因、门静脉血栓和腹水等为HVPG下降的影响因素,差异均有显著性(OR=1.865~3.219,95%CI=1.385~10.524,P<0.05)。结论年龄、肝硬化病因、门静脉血栓和腹水等为HVPG下降的独立影响因素。

肝静脉阻塞性Budd-Chiari综合征的介入治疗

目的 评价肝静脉阻塞性Budd Chiari综合征 (HVBCS)的介入治疗方法及效果。方法 83例HVBCS患者经历了下腔和肝静脉造影 ,71例实施介入治疗。结果 83例HVBCS分为中央性肝静脉阻塞 (COHV ,n =65 )和广泛性肝静脉阻塞 (EOHV ,n =18)两型。 65例COHV型皆成功地实施了PTA(n =46)和支架 (n =19)治疗 ,64例术后症状消失或明显改善。 6例EOHV型接受TIPS治疗 ,术后症状明显改善 4例 ,2例发生了分流道再狭窄。结论 COHV型适应于PTA和支架治疗 ,疗效满意 ;EOHV型可采用TIPS治疗 ,长期疗效尚不够满意。

肝硬化非肿瘤性肝动脉门静脉分流DSA诊断价值

目的评价DSA对肝硬化非肿瘤性肝动脉门静脉分流(APS)的诊断价值。方法170例非肿瘤肝硬化患者在接受经肝动脉自体骨髓干细胞移植前行DSA检查。对造影图像进行动态播放观察,记录APS出现时相、持续时间和相应区域肝实质染色特点,对非肿瘤性APS和肝癌造影特征作鉴别。对术中发现的小肝癌行节段性TACE治疗。结果170例肝硬化患者DSA检查中31．7%显示了APS相关征象(54/170)。术前CT检查未见APS的142例中21．8%在DSA中显示了APS(31/142)。23例增强CT不均匀强化病例均有DSA阳性发现,其中16例诊断非肿瘤性APS,7例因CT动脉期局部密度增高区在门静脉期无明显低密度表现而不能确诊肿瘤者,经DSA诊断为小肝癌,其中1例伴有肿瘤性APS。结论DSA对肝硬化患者APS的发现率高,有助于肝内非肿瘤性改变与肝癌的鉴别诊断并指导介入治疗。

部分门静脉动脉化对大鼠肝脏血管铸型变化的影响

目的探讨用部分门静脉动脉化重建肝血流后对肝脏微血管和组织学的影响。方法建立大鼠部分门静脉动脉化重建肝脏血流的实验模型,观察该模型大鼠肝脏微血管和组织学的变化。结果行门静脉动脉化手术后1个月动物肝脏组织未见明显异常。血管铸型标本显示肝窦略变粗,较正常充盈,肝窦无明显变形,仍呈放射状分布于中央静脉的周围。墨汁灌注标本显示肝窦内墨汁灌注规整,略显增宽,颜色均匀并加深。结论部分门静脉动脉化后在近期内不影响肝脏的微血管及组织学结构。

改良式TIPS治疗肝静脉广泛阻塞型布-加综合征的近期疗效

目的观察改良式TIPS治疗肝静脉广泛阻塞型布-加综合征(BCS)的近期疗效。方法 7例肝静脉广泛阻塞型BCS患者,使用改良术式TIPS治疗,其中2例为急性,5例为亚急性或慢性。术后给予正规抗凝治疗,并用彩色多普勒超声随访疗效。结果 7例肝静脉广泛阻塞型BCS均成功完成改良式TIPS,7例患者共置入12枚支架(覆膜支架3枚,自膨式支架9枚),随访彩色多普勒超声2～12个月,1例术后5个月又出现狭窄,并行第2次介入治疗,置入1枚支架。术后门脉压力由术前的(40.7±12.6)cmH2O下降到(17.2±3.4)cmH2O,术后1个月肝功能指标及脾功能亢进血象明显好转。结论改良式TIPS治疗肝静脉广泛阻塞型BCS近期疗效满意。

双源CT肝静脉和门静脉成像在经颈静脉肝内门体分流术术前的应用

目的探讨双源CT肝静脉和门静脉成像在经颈静脉肝内门体分流术(TIPS)前的临床应用价值。方法门静脉高压合并上消化道出血或大量腹水的28例肝硬化患者接受双源CT门静脉成像,采用最大密度投影(MIP)、多平面重建(MPR)、容积再现(VR)和表面遮盖显示(SSD)等后处理技术判断肝静脉及门静脉的显示情况、分支走行及二者的关系。结果 28例患者均成功完成双源CT肝静脉和门静脉成像,能够清晰显示肝静脉1～3级以上分支及门静脉的解剖变异,MIP、MPR及VR重建图像可以直观地评价门静脉和肝静脉的位置、管径,并了解门静脉高压侧支循环的分布范围和程度。双源CT门静脉成像有助于TIPS术前定位。结论双源CT门静脉成像是无创性检查门静脉和肝静脉的可靠方法 ,为TIPS术前制定个体化手术方案提供了依据,具有较高的临床应用价值。

原发性肝癌伴门脉高压的TIPSS治疗

本文对伴有门脉高压症的５名原发性肝癌（ＰＨＣ）患者的ＴＩＰＳＳ治疗进行报道。在ＴＩＰＳＳ术中，成功地建立了肝内门腔分流道，未发生肝内病变的误穿；术后患者的门脉压力得到下降，食管胃底静脉曲张得以减轻和消失。４名曾于ＴＰＳＳ术前有上消化道出血者术后有３例未再出血。作者认为：ＰＨＣ不是ＴＩＰＳＳ治疗门脉高压症的禁忌症；ＰＨＣ患者经ＴＰＳＳ治疗后，由于避免了门脉高压合并症的出现，因此生活质量得以提高。

实时三维超声血管成像在经颈静脉肝内门体分流术前的应用价值

目的探讨实时三维超声(RT 3D-US)在经颈静脉肝内门体分流术(TIPS)前血管成像中的应用价值。方法 30例肝硬化门静脉高压合并上消化道出血或大量腹水行TIPS的患者,术前应用实时三维超声行肝内血管成像,明确肝右静脉和门静脉右支的空间走行关系,选取穿刺位点、测量穿刺角度和二者间的距离以及了解有无肝包膜包裹。结果 RT 3D-US彩色血流成像可以实现对肝内门静脉、肝右静脉走行及空间关系的直观显示,矢状面观肝右静脉距下腔静脉开口2cm处与门静脉右支的平均距离为(3.8±1.3)cm,平均角度为(39.1±8.3)°。运用RT 3D-US多平面成像技术可以确定门静脉周围是否有肝组织及肝包膜,并提示裸露的部位。根据术前RT 3D-US血管成像制定穿刺路径和角度,术中一次穿刺成功26例(86.7%),2次穿刺成功4例(13.3%),术中未出现严重并发症。结论应用无创RT 3DUS可以直观再现肝硬化患者肝内血管的空间走行及相互关系,有助于指导TIPS术前制定手术方案,减少穿刺并发症,可在临床推广应用。

贲门周围血管离断术与联合肠腔静脉侧侧分流术治疗门静脉高压症的疗效比较

目的 评价联合应用贲门周围血管离断术和肠腔静脉侧侧分流术治疗门静脉高压症的临床疗效。方法 对 75例肝功能分级相近的门静脉高压症分为两组 ,A组 37例行贲门周围血管离断加肠腔静脉侧侧分流术 ,B组 38例行单纯贲门周围血管离断术。两组资料比较采用 χ2 检验。结果 A、B两组食管静脉曲张改善或消失分别为 82 .9%和 6 0 .6 % (P <0 .0 5 ) ,腹水消失为 10 0 %和 73.5 % (P <0 .0 5 ) ,肝功能好转则为 75 .7%和 44 .7% (P <0 .0 5 ) ,其中A组无肝性脑病及再出血发生 ,而B组有 7.9%和 15 .8%的患者分别发生肝性脑病和再出血。A、B两组患者全部获得随访 5月～ 3年 ,术后 1年生存率分别为 97.2 %和 89.4% (P >0 .0 5 ) ,而术后 3年生存率分别为 90 .9%和 70 .3% (P <0 .0 5 )。结论 贲门周围血管离断加肠腔静脉侧侧分流术是治疗门静脉高压症一种合理、有效的治疗术式。

不同手术方式对门体分流率和肝功能影响的实验研究

目的 通过动物实验检测肠腔侧侧分流术 (MCS)、远端脾腔分流术 (DSCS)及门奇断流术 (PAD)对门体分流率和肝功能的影响 ,为合理选择手术方式提供理论依据。方法 采用CCl4/乙醇诱导的肝硬变门脉高压大鼠模型行肠腔侧侧分流术 (MCS)、远端脾腔分流术 (DSCS)及门奇断流术(PAD)。观察术前及术后 1、2、3周时的自由门脉压力 (FPP)、门体分流率 (PSS)和肝脏功能的变化。结果 MCS组术后FPP明显下降 ,PSS显著升高 ,肝脏功能进一步恶化 ,至术后 3周仍未恢复 ;DSCS组和PAD组术后FPP及PSS变化较小 ;DSCS组肝脏功能无明显下降 ;PAD组术后 1周肝功能明显下降 ,2周后逐渐恢复到术前状态。结论 远端脾腔分流 (同时施行彻底的脾胰断流 )术有助于维持向肝血流 。