Complete resection of the hepatic veins: The role of right inferior vein

To the editor:In the recent years liver surgery has been dramatically improved because of technical and technological innovations,perioperative and intraoperative intensive care,better knowledge of liver physiology and early recognition and treatment of postoperative complications.Last but not least,liver anatomy,though not

Percutaneous closure of ventricular septal defect associated with anomalous inferior vein cava drainage via transjugular approach

Transcatheter occlusion of ventricular septal defect (VSD) was first reported in 1987.1 Because of short recovery time and little distress, the method has been widely accepted. The most common approach of the procedure is via femoral vein. However, when the inferior vein cava is interrupted or obstructed, it is unfeasible to carry out the procedure via femoral vein. So an alternative approach such as internal jugular vein or subclavian vein needs to be considered.

PERCUTANEOUS CLOSURE OF HUGE PATENT DUCTUS ARTERIOUS ASSOCIATED WITH ANOMALOUS INFERIOR VEIN CAVA DRAINAGE AND DEXTROCARDIA WITH MUSCULAR VENTRICULAR SEPTAL DEFECT OCCLUDER

Transcatheter occlusion of patent ductus arterious （PDA） using various occluders and coils has been a well-established method since Porstmann and colleagues reported the first case in 1967. However, when patients associated with anomalous inferior vein cava drainage or/and huge high pulmonary artery pressure ductus （HPAP-PDA）, the method is not suitable. First, it is unfeasible to carry out the procedure via femoral vein. Second,

Clinical studies on inferior right hepatic veins

BACKGROUND: Many small veins are called accessory, short hepatic veins in addition to the right, middle and left hepatic veins. The size of these veins varied from a pinhole to 1 cm; the size of inferior right hepatic veins (IRHVs) is thicker than that of short hepatic veins or more than 1 cm. occasionally. Adults have a higher incidence rate of the IRHV. DATA SOURCES: A literature search of the PubMed database was conducted and research articles were reviewed. RESULTS: The size of IRHVs is related to the size of the right hepatic vein, i.e. the larger the diameter of the right hepatic vein, the smaller the diameter of the IRHVs, and vice versa. The IRHVs are divided into superior, medial and inferior groups, separately named the superior, medial and inferior right hepatic veins according to the position of the IRHV entering the inferior vena cava. The superior right hepatic vein mainly drains the superior part of segment VII, and the medial right hepatic vein drains the middle part of segment VII. A thicker IRHV mainly drains segment VI and the inferior part of segment VII and a thinner IRHV drains the inferior part of segment V. CONCLUSIONS: The clinical significance of these studies on IRHVs is varied: (1) Hepatic caudate lobe resection could be introduced after study on the veins of that lobe. (2) It is very important to identify the draining region of the IRHV for guiding hepatic segmentectomy. The postero-inferior area of the right lobe can be preserved along with the hypertrophic IRHV even if the entire main right hepatic vein is resected during segmentectomy of VII and VIII with right hepatic vein resection for patients with primary liver cancer. (3) The ligation of the major hepatic vein for the treatment of juxtahepatic vein injury is recommended because of severe hemorrhagic shock and difficulty in exposure. (4) It is very helpful to decide therapeutic modalities for Budd-Chiari syndrome.

下腔静脉滤器脱落移位至右髂外静脉1例

患者男,87岁,左下肢肿胀、疼痛1月余,加重并红肿4天;患慢性阻塞性肺疾病多年,具体不详。查体:左大腿内侧至小腿上段肿胀,皮肤潮红、皮温升高,波动感(+)。下肢静脉超声见左侧腘静脉至胫后静脉局部血栓形成。于左小腿抽出暗红色脓液,细菌涂片显示革兰氏阳性球菌(++)。

股静脉途径夹角预测锥形下腔静脉滤器倾斜研究

目的了解髂总静脉与下腔静脉夹角、髂总静脉与髂外静脉夹角与锥形下腔静脉滤器(IVCF)置入时倾斜之间的关系,为临床IVCF置入手术入路选择、IVCF类型选择提供参考。方法回顾性分析2019年1月—2021年9月本院介入科收治的86例行锥形IVCF置入术患者的临床资料,根据术中DSA影像资料,采用ROC分析髂总静脉与下腔静脉之间夹角、髂总静脉与髂外静脉之间夹角以及两者结合对IVCF置入后倾斜的预测价值。结果右股静脉入路,髂总静脉与下腔静脉夹角预测IVCF置入后不倾斜(滤器倾斜角度小于5°)的AUC(0.630)大于髂总静脉与髂外静脉夹角(0.554)、两者结合(0.609)。髂总静脉与下腔静脉角度最佳截断值156.5°;左股静脉入路,髂总静脉与下腔静脉夹角预测IVCF置入后不倾斜AUC(0.908)大于髂总静脉与髂外静脉夹角(0.689)、两者结合(0.852)。髂总静脉与下腔静脉夹角最佳截断值135°。结论IVCF置入时,经左股静脉入路,造影后髂总静脉与下腔静脉角度小于135°或经右股静脉入路,造影后髂总静脉与下腔静脉角度小于156.5°,锥形滤器发生倾斜可能性大,建议选择其他入路或者选择其他类型IVCF。

大鼠原位肝移植解剖重建研究进展

大鼠肝移植模型的构建,为解决临床肝移植术后并发症及围手术期治疗等问题提供了理想的动物模型。随着对大鼠肝移植模型建立的深入研究,逐渐形成了经典的“二袖套”法。然而,在移植手术过程中,手术视野差、血管扭转、胆道损伤和无肝期较长等问题仍是传统方法无法避免的。目前国内外大鼠肝移植模型改进方式主要围绕肝上下腔静脉、门静脉、肝下下腔静脉和胆管这4个重要解剖结构的重建展开。为此,本文就肝上下腔静脉、门静脉、肝下下腔静脉和胆管重建领域的最新进展进行整理总结,以便为大鼠肝移植模型的构建提供参考,促进肝移植技术的进一步发展。

调强放疗联合化疗在肝癌合并静脉/下腔静脉癌栓中的应用

目的探讨在肝癌合并静脉/下腔静脉癌栓患者治疗中使用调强放疗联合化疗的临床治疗效果。方法选取100例肝癌合并静脉/下腔静脉癌栓患者作为研究样本,以随机数字表的方式分为实验组及对照组,各50例。实验组采用调强放疗联合化疗进行治疗,对照组给予调强放疗进行治疗。比较两组患者的临床治疗效果,不良反应发生情况,治疗前后的生活质量评分及心理状态[焦虑自评量表(SAS)、抑郁自评量表(SDS)]评分。结果实验组有效率60.00%高于对照组的30.00%(P<0.05)。两组患者不良反应发生率比较,无统计学差异(P>0.05)。治疗后,实验组社会功能、情绪功能、角色功能、躯体功能评分分别为(90.08±4.21)、(91.27±3.16)、(91.68±5.23)、(92.89±6.19)分,均显著高于对照组的(79.61±3.42)、(78.12±6.15)、(77.26±6.12)、(78.46±5.13)分(P<0.05)。治疗后,对照组SDS及SAS评分分别为(51.72±5.51)、(53.01±4.36)分,实验组分别为(40.21±3.53)、(40.01±5.32)分,实验组均低于对照组(P<0.05)。结论肝癌合并静脉/下腔静脉癌栓患者应用调强放疗联合化疗效果明显,不仅能够改善患者的生存质量,缓解不良心理,同时不会增加不良反应,建议临床大力推广。

超声检测下腔静脉和锁骨下静脉内径变异在预测全身麻醉诱导后低血压中的价值

目的:分析超声检测下腔静脉(IVC)和锁骨下静脉(SCV)内径变异在预测全麻诱导后低血压(PIH)中的价值。方法:回顾性选取2021年5月—2023年5月在咸宁市第一人民医院行全麻手术的204例患者作为研究对象,根据是否发生PIH将其分为研究组(发生PIH,86例)和对照组(未发生PIH,118例)。对两组患者的基础资料、麻醉诱导前血压、麻醉诱导药物用量进行对比。比较IVC内径的最大值(IVCmax)和最小值(IVCmin)、SCV内径的最大值(SCVmax)和最小值(SCVmin),并计算IVC塌陷指数(IVCCI)和SCV塌陷指数(SCVCI)。采用受试者工作特征(ROC)曲线分析IVC、SCV内径及变异对全麻PIH的预测价值。结果:两组基础资料、麻醉诱导前血压指标和麻醉诱导药物用量比较,差异均无统计学意义(P>0.05)。研究组IVCmax、IVCmin、SCVmax、SCVmin水平均低于对照组,IVCCI、SCVCI水平均高于对照组,差异均有统计学意义(P<0.05)。受试者操作特征(ROC)曲线分析结果显示,麻醉诱导前IVCmax、IVCmin、SCVmax、SCVmin、IVCCI、SCVCI水平预测PIH的ROC曲线下面积(area under curve,AUC)分别为0.674、0.675、0.618、0.707、0.895、0.905,其中,SCVCI的AUC和cut-off值下的敏感度均为最高,分别为0.905、65.12%。结论:全麻PIH患者可表现为IVC和SCV内径缩小及IVCCI、SCVCI等内径变异指标的增高,采用血管超声技术检测上述变异指标可辅助预测PIH风险。

不同入路放置下腔静脉滤器的效果分析

目的 探讨经颈静脉和经股静脉不同入路置入下腔静脉滤器(Inferior vena cava filter,IVCF)的效果差异。方法 选取我院收治的股静脉穿刺置管后发生急性髂股静脉血栓形成且单纯行IVCF置入术后资料完整患者66例,按IVCF置入的不同入路将以上患者分为经颈静脉入路组和经股静脉入路组,比较两组在出血、IVCF倾斜、排尿困难、腰背疼痛、舒适度、满意度、睡眠质量等方面的效果差异。结果 经颈静脉入路组排尿困难发生率低于经股静脉入路组,差异有统计学意义(P<0.05)。经颈静脉入路组腰背疼痛评分和睡眠质量平均评分均低于经股静脉入路组,差异有统计学意义(P<0.05),舒适度、满意度评分均高于经股静脉入路组,差异有统计学意义(P<0.05)。结论 经颈静脉穿刺IVCF置入可以降低患者术后排尿困难以及腰背疼痛的情况发生,患者具有较高的舒适度、满意度以及睡眠质量。

侵犯肾静脉的Castleman病误诊临床分析

目的探讨Castleman病(CD)的临床特点及鉴别诊断要点,以减少误诊误治。方法回顾性分析2023年收治的1例CD的临床资料,并复习相关文献。结果1例女性因发现腹腔占位10余天入院。入院完善相关检查,肿瘤标志物等未见异常。全腹部强化CT检查考虑畸胎瘤可能性大,腹膜后多发增大淋巴结。经多学科专家会诊后,行腹膜后病灶切除术、部分肾静脉切除术、肾静脉-下腔静脉自体大隐静脉搭桥术治疗,术后病理示CD,治愈出院。结论部分CD患者无明显临床表现,易误诊。临床鉴别CD与其他腹腔肿瘤时,应行多学科会诊并重视病理及免疫组织化学结果,仔细询问病史及查体,认真鉴别诊断,以减少或避免误诊误治。

经皮肾穿刺造瘘管误入下腔静脉2例报道并文献复习

目的探讨经皮肾穿刺造瘘管误入下腔静脉的发生原因以及处理体会。方法对2例超声引导下经皮肾穿刺造瘘管误入下腔静脉病例的治疗过程进行回顾性分析,探讨其发生原因、微创处理方式上的改变以及预防方案。结果2例患者均采用数字减影血管造影(DSA)下将肾造瘘管一步法一期回纳复位至肾盂集合系统。操作过程中患者未出现肾静脉的破裂出血,生命体征稳定。术后顺利拔除肾造瘘管。术后随访肾造瘘处伤口愈合良好,无肾周血肿等继发出血表现,预后良好。结论肾穿刺造瘘过程中肾造瘘管误入下腔静脉虽然少见,但后果严重,采用一步法一期回纳肾造瘘管能够有效安全地处理此类并发症。

Absent middle hepatic vein in a right liver graft donor

BACKGROUND: The middle hepatic vein (MHV) is normally in form of a large trunk lying within the midplane of the liver. An anomaly in form of two separate trunks, each draining segment V/VIII and segment IV, has been described by Couinaud but not been well documented in the literature. METHOD: We report a right liver donor in whom the MHV was absent and not encountered during liver transection along the midplane of the liver. RESULTS: On computed tomography (CT) scan and intraoperative ultrasonography, there was a large segment VIII hepatic vein mistaken as the MHV on preoperative assessment and a large segment IV hepatic vein close to the ligamenturn venosum. CT volumetry based on either segment VIII or IV hepatic vein led to major error in liver volume calculation. Transection of the liver guided by segment VIII or IV hepatic vein would lead to sacrifice of liver parenchyma unnecessarily or presence of necrotic liver in the graft. CONCLUSION: Absent MHV is a rare anomaly. It is revealed by careful study of the CT scan.

PI、IVC和SCV对预测全身麻醉诱导期低血压的研究

目的探讨脉搏灌注指数(PI)、下腔静脉(IVC)和锁骨下静脉(SCV)对预测全身麻醉诱导期低血压的研究。方法回顾性选择2018年1月至2021年12月来新疆医科大学第一附属医院行全身麻醉手术的患者110例,根据全身麻醉诱导期是否出现低血压将110例患者分为2组,其中正常血压组60例,低血压组50例。所有患者在麻醉诱导前均用超声诊断仪检测最小横截面积(SIVCmin)、最大横截面积(SIVCmax)、最小直径(DIVCmin)、最大直径(DIVCmax)、最小横截面积(SSCVmin)、最大横截面积(SSCVmax)、最小直径(DSCVmin)、最大直径(DSCVmax)、下腔静脉的横截面积的塌陷指数(CIsivc)、下腔静脉直径塌陷指数(CIdivc)、锁骨下静脉横截面积塌陷指数(CIssvc)、锁骨下静脉直径塌陷指数(CIdsvc),麻醉诱导至手术开始前的每分钟,记录一次平均动脉压、收缩压、舒张压、心率,取最小值,记录两组诱导前后血流动力学指标、PI及PI增加率。比较两组患者麻醉诱导前后的血流动力学参数水平,比较两组患者麻醉诱导前后的PI、PI增加率、SIVCmax、DIVCmax、SSCVmax、DSCVmax、CIdivc、CIsivc、CIssvc、CIdsvc,以及低血压组麻醉诱导前后以上指标与血流动力学参数的相关性、对全身麻醉诱导期低血压预测价值的ROC曲线及诊断价值。结果麻醉诱导前,两组的舒张压、收缩压、平均动脉压、心率比较,差异均无统计学意义(P>0.05);诱导后,两组的舒张压、收缩压、平均动脉压、心率均明显较基础值降低,而低血压组明显较正常血压组低,差异均有统计学意义(P<0.05)。正常血压组麻醉诱导前后PI、PI增加率、SIVCmax、DIVCmax较低血压组高,CIsivc、CIdivc、CIssvc、CIdsvc明显较低血压组低,差异均有统计学意义(P<0.05);两组的SSCVmax、DSCVmax比较,差异无统计学意义(P>0.05)。低血压组的舒张压降低率、收缩压降低率、平均动脉压降低率与基础PI、诱导后PI、PI增加率、SIVCmax、DIVCmax呈正相关,舒张压降低率、收缩压降低率、平均动脉压降低率与CIsivc、CIdivc、CIssvc、CIdsvc呈负相关(P<0.05)。基础PI≥3.58%,诱导后PI≥4.71%,PI增加率≥46.32%,SIVCmax=2.180 cm^(2),DIVCmax为1.847 cm,CIsivc为40.50%,CIdivc为33.50%%,ROC曲线下面积均超过0.8(P<0.05)。结论SIVCmax、DIVCmax、CIsivc、CIdivc、PI可用于预测全身麻醉诱导期低血压,SCV的预测价值无临床意义。

双J管静脉内异位1例报告及文献复习

目的 探讨双J管静脉内异位的原因及诊治策略,提高临床医师对该病的认知。方法 回顾分析我院1例双J管静脉内异位患者的临床资料,并进行文献复习。结果 患者女性,51岁,因子宫切除术后尿瘘入院,诊断为右侧双J管静脉内异位并输尿管阴道瘘,行达芬奇机器人辅助腹腔镜下右侧双J管拔除加输尿管膀胱再植术。结论 静脉内异位是双J管置入术的罕见且可进一步迁移危及生命的并发症。根据双J管位置及患者一般情况选择手术方式,多数患者可行微创手术治疗。

Treatment of deep vein thrombosis (DVT) around renal vein

Objective To study and evaluate the treatment of the deep vein thrombosis(DVT) around the renal vein(DVT involving the renal vein and it's surrounding,shortly as DVTAR in our study)by two-positioned filter for catheter thrombectomy assisted with a Fogarty balloon.Methods We retrospectivly analysed seven cases of DVTAR and by comparison to elicit the respective effect different methods in DVT treatment.The methods used were:1.direct thrombectomy 2.thrombectomy facillitated by blocking of blood flow with a balloon 3.direct thrombolysis via Peripheral vein and 4.thrombectomy with simultaneous placement of a two-positioned filter with a Fogarty balloon and followed by intubation thrombolysis.Result Segmental pulmonary embolism(PE)or thrombosis in vena cava were still observed by CT angiography(CTA)or venography in those cases treated with the first three methods.As for the 3 cases where two-positioned filter for catheter thrombectomy with Fogarty balloon was used,neither pulmonary embolism during and after the operation nor thrombosis in the inferior vena cava was observed.Conclusion For DVTAR,thrombectomy with simultaneous placement of a two-positioned filter with a Fogarty balloon and followed by intubation thrombolysis can be regarded as safe and effective.

下肢深静脉血栓患者下腔静脉滤器置入术后发生静脉不畅的影响因素

目的:探讨下肢深静脉血栓(DVT)患者下腔静脉滤器(IVCF)置入术后发生静脉不畅的影响因素。方法:回顾性分析2020年3月至2022年4月该院收治的70例下肢DVT患者的临床资料,患者均行IVCF置入术治疗,术后3个月复查,根据静脉通畅程度将其分为静脉通畅组32例和静脉不畅组38例。收集患者的临床资料,采用单因素和多因素Logistic回归分析下肢DVT患者IVCF置入术后发生静脉不畅的影响因素。结果:两组性别、年龄、体质量指数、DVT分期、D-二聚体水平比较,差异均无统计学意义(P>0.05);静脉不畅组合并糖尿病、高血压占比和白细胞计数(WBC)、血小板计数(PLT)、纤维蛋白原(FIB)水平均高于静脉通畅组,差异有统计学意义(P<0.05);Logistic回归分析结果显示,合并糖尿病、高血压和WBC、PLT、FIB水平升高均为下肢DVT患者IVCF置入术后发生静脉不畅的危险因素(P<0.05)。结论:合并糖尿病、高血压和WBC、PLT、FIB水平升高均为下肢DVT患者IVCF置入术后发生静脉不畅的危险因素,临床可针对上述危险因素实施针对性干预措施,以改善预后。

Linear endoscopic ultrasound evaluation of hepatic veins

Liver resection surgery can be associated with significant perioperative mortality and morbidity. Extensive knowledge of the vascular anatomy is essential for successful, uncomplicated liver surgeries. Various imaging techniques like multidetector computed tomographic and magnetic resonance angiography are used to provide information about hepatic vasculature. Linear endoscopic ultrasound(EUS) can offer a detailed evaluation of hepatic veins, help in assessment of liver segments and can offer a possible route for EUS guided vascular endotherapy involving hepatic veins. A standard technique for visualization of hepatic veins by linear EUS has not been described. This review paper describes the normal EUS anatomy of hepatic veins and a standard technique for visualization of hepatic veins from four stations. With practice an imaging of all the hepatic veins is possible from four stations. The imaging from fundus of stomach is the easiest and most convenient method of imaging of hepatic veins. EUS of hepatic vein and the tributaries is an operator dependent technique and in expert hands may give a mapping comparable to computed tomographic and magnetic resonance imaging. EUS of hepatic veins can help in identification of individual sectors and segments of liver. EUS guided interventions involving hepatic veins may require approach from different stations.

下导静脉显影是右侧肾上腺静脉插管成功的可靠标志

目的:评估下导静脉(IEV)显影是否是右侧肾上腺静脉插管成功的可靠标志。方法:连续纳入2019年1月至2020年12月期间在中国医学科学院阜外医院住院的111例行肾上腺静脉取血的原发性醛固酮增多症(PA)患者的临床和手术资料。所有患者均经肘前静脉路径行肾上腺静脉插管造影,影像学上确定插管成功后取血。肾上腺静脉/外周静脉血浆皮质醇浓度比值≥2定义为肾上腺静脉取血成功。记录右侧肾上腺静脉取血术中IEV是否显影和肾上腺静脉取血结果,按IEV是否显影分为IEV显影组(n=51)和IEV未显影组(n=60),分析IEV显影与右侧肾上腺静脉插管成功的关系。结果:111例PA患者中有103例(92.86%)右侧肾上腺静脉取血成功,其中51例(42.86%)患者右侧肾上腺静脉造影可见IEV,取血均成功(100%),其余60例右侧肾上腺静脉造影未显示IEV,取血成功率为86.67%,两组成功率差异有统计学意义(P=0.007)。结论:右侧肾上腺静脉造影时IEV显影是插管成功的可靠标志之一,但需要更大样本研究予以验证。

临时性肾上下腔静脉滤器在静脉血栓栓塞症中的应用

目的 探讨临时性肾上下腔静脉滤器(IVCF)在静脉血栓栓塞症(VTE)中的应用情况。方法 收集2013年1月至2021年12月于福建医科大学附属协和医院行临时性肾上IVCF的28例VTE患者的临床资料,所有患者均接受抗凝和/或溶栓、吸栓治疗,待肺栓塞(PE)风险解除后均取出肾上IVCF。观察IVCF置入及取出情况、围手术期并发症发生情况、IVCF留置时间,比较治疗前后血肌酐水平的变化情况,记录IVCF断裂、移位、倾斜等情况。结果 28例患者均成功置入IVCF,成功率为100%,其中,22例置入Optease滤器,置入时间为6.00(5.00,7.00)d;2例置入Aegisy滤器,置入时间分别为7、10 d;4例置入Denali滤器,置入时间为34.50(29.00,39.25)d。28例患者均成功取出滤器,围手术期均未出现颅脑出血、腹腔出血、PE、滤器断裂或移位等。随访期间,1例患者左下肢静脉血栓复发,加强抗凝治疗后好转,其他患者均未发生PE、滤器断裂或移位等。治疗前后血肌酐水平比较,差异无统计学意义(P﹥0.05)。结论 VTE患者行临时性肾上IVCF放置及取出安全、有效,待血栓清除干净或PE风险解除后均应尽早回收,从而减少留置时间过长导致的严重并发症。