限流支架植入治疗TIPS引起的难治性肝性脑病

目的 评价限流支架装置在缩小 TIPS分流道直径对治疗由门腔分流引起的肝性脑病的有效性。 方法 9例TIPS术后并发严重肝性脑病患者经颈静脉沿原肝内支架同轴植入可限制血流量的支架装置。 结果 限流支架植入未出现术中并发症 ,平均门静脉压力由术前 12± 4 .2 cm H2 O升至 2 0± 2 .6 cm H2 O,彩色多普勒超声显示分流道内血流减少 4 7.3%±15 .1% ,肝性脑病得到实质性改善和控制。血氨浓度及胆红素明显降低。

Renal-function change after transjugular intra-hepatic portosystemic shunt placement and its relationship with survival:a single-center experience

Background:The effect of transjugular intra-hepatic portosystemic shunt(TIPS)placement on renal function and the correlation of post-TIPS Cr with mortality remain unclear.This study aimed to assess the effect of TIPS placement on renal function and to examine the relationship between post-TIPS Cr and mortality risk.Methods:A total of 593 patients who underwent de novo TIPS placement between 2004 and 2017 at a single institution were included in the study.The pre-TIPS Cr level(T0;within 7 days before TIPS placement)and post-TIPS Cr levels,at 1–2 days(T1),5–12 days(T2),and 15–40 days(T3),were collected.Predictors of Cr change after TIPS placement and the 1-year mortality rate were analysed using multivariable linear-regression and Cox proportional-hazards models,respectively.Results:Overall,21.4%of patients(n=127)had elevated baseline Cr(≤1.5 mg/dL;mean,2.5161.49 mg/dL)and 78.6%(n=466)had normal baseline Cr(<1.5 mg/dL;mean,0.9260.26 mg/dL).Patients with elevated pre-TIPS Cr demonstrated a decrease in post-TIPS Cr(difference,-0.60 mg/dL),whereas patients with normal baseline Cr exhibited no change(difference,<0.01 mg/dL).The 30-day,90-day,and 1-year mortality rates were 13%,20%,and 32%,respectively.Variceal bleeding as a TIPS-placement indication(hazard ratio=1.731;P=0.036),higher T0 Cr(hazard ratio=1.834;P=0.012),and higher T3 Cr(hazard ratio=3.524;P<0.001)were associated with higher 1-year mortality risk.Conclusion:TIPS placement improved renal function in patients with baseline renal dysfunction and the post-TIPS Cr level was a strong predictor of 1-year mortality risk.

Utility of Doppler ultrasonography for predicting improvement of platelet count after transjugular intrahepatic portosystemic shunt

Objective.Portal pressure gradient(PPG)after transjugular intrahepatic portosystemic shunt(TIPS)<12mmHg has been reported as the only factor predictive of increase in platelet count.As flow velocities measured on Doppler ultrasound are related to pressure gradient based on the Bernoulli equation,we used this parameter to predict increased platelet count after TIPS placement.Methods.A total of 161 consecutive patients who underwent TIPS placement entered this retrospective study.The platelet count was measured before,one week after and one month after TIPS placement.Clinically significant thrombocytopenia was defined as platelet count≤100000.Pre-and post-TIPS PPGs were measured.The velocity of blood flow in the proximal,mid and distal TIPS stent was measured using Doppler ultrasound,and the difference in the highest and lowest measured velocity was entitled flow velocity gradient(FVG),which was considered normal when≤100 cm/s.Results.In 121 patients with pre-TIPS thrombocytopenia,the mean platelet count one week and one month after TIPS placement increased 25.7×10^(3) and 35.0 × 10^(3) in 90 patients with PPG≤12mmHg(P=0.028 and P=0.015),while there was no significant change in platelet count in patients with a PPG>12mmHg(P=0.098 and P=0.075).Platelets increased significantly when FVG≤100 cm/s(n=95)vs FVG>100 cm/s(n=26)one week(37.0×10^(3) vs 11.0×10^(3);P=0.005 vs 0.07)and one month after TIPS placement(17.0×10^(3) vs 5.2×10^(3);P=0.01 vs 0.21).Conclusion.FVG>100 cm/s is not associated with increase in post-TIPS platelet count.On the other hand,findings suggestive of proper TIPS function(FVG≤100 cm/s and PPG≤12mmHg)predict a significant increase in post-TIPS platelet count.