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.

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.

Disabling portosystemic encephalopathy in a non-cirrhotic patient: successful endovascular treatment of a giant inferior mesenteric-caval shunt via the left internal iliac vein

Hepatic encephalopathy is suspected in non-cirrhotic cases of encephalopathy because the symptoms are accompanied by hyperammonaemia. Some cases have been misdiagnosed as psychiatric diseases and consequently patients hospitalized in psychiatric institutions or geriatric facilities. Therefore, the importance of accurate diagnosis of this disease should be strongly emphasized. A 68-year-old female patient presented to the Emergency Room with confusion, lethargy, nausea and vomiting. Examination disclosed normal vital signs. Neurological examination revealed a minimally responsive woman without apparent focal deficits and normal reflexes. She had no history of hematologic disorders or alcohol abuse. Her brain TC did not demonstrate any intracranial abnormalities and electroencephalography did not reveal any subclinical epileptiform discharges. Her ammonia level was > 400 mg/d L(reference range < 75 mg/d L) while hepatitis viral markers were negative. The patient was started on lactulose, rifaximin and low-protein diet.On the basis of the doppler ultrasound and abdomen computed tomography angiography findings, the decision was made to attempt portal venography which confirmed the presence of a giant portal-systemic venous shunt. Therefore, mechanic obliteration of shunt by interventional radiology was performed. As a consequence, mesenteric venous blood returned to hepatopetally flow into the liver, metabolic detoxification of ammonia increased and hepatic encephalopathy subsided. It is crucial that physicians immediately recognize the presence of non-cirrhotic encephalopathy, in view of the potential therapeutic resolution after accurate diagnosis and appropriate treatments.

Transjugular intrahepatic portosystemic shunt for Budd-Chiari syndrome:A comprehensive review

Budd-Chiari syndrome(BCS)is a relatively rare clinical condition with a wide range of symptomatology,caused by the obstruction of the hepatic venous outflow.If left untreated,it has got an high mortality rate.Its management is based on a step-wise approach,depending on the clinical presentation,and includes different treatment from anticoagulation therapy up to Interventional Radiology techniques,such as transjugular intrahepatic portosystemic shunt(TIPS).TIPS is today considered a safe and highly effective treatment and should be recommended for BCS patients,including those awaiting orthotopic liver transplantation.In this review the pathophysiology,diagnosis and treatment options of BCS are presented,with a special focus on published data regarding the techniques and outcomes of TIPS for the treatment of BCS.Moreover,unresolved issues and future research will be discussed.

Comparison of a new stent and Wallstent for transjugular intrahepatic portosystemic shunt in a porcine model

AIM: To evaluate a new balloon-expandable stainless steel stent (Cordis stent) in a transjugular intrahepatic portosystemic shunt (TIPS) porcine model and compared with Wallstent. METHODS: TIPS was performed in 26 normal domestic pigs weighing 20 kg-30 kg using a Cordis stent or Wallstent (13 pigs in each stent). All pigs were sacrificed at the 14th day after TIPS. The stent deployment delivery system, stent patency, and stent recoil after placement were evaluated.Proliferative response in representative histological sections from the center,hepatic and portal regions of the two stent designs were quantified. RESULTS: The shunt was widely patent in 4 pigs in the Cordis stent group (4/12, premature dead in 1 pig), and in 5 pigs in the Wallstent group (5/13). All remaining stents of both designs were occluded or stenotic. The mean quantified proliferation including thickness of the proliferation and the ratio of proliferation: total area in three assayed regions in Cordis stent and Wallstent was 2.18 mm:2.00 mm, and 59.18 mm2:51.66 mm2, respectively (P 】 0.05). The delivery system and mechanical properties of the Cordis stent functioned well. CONCLUSION: The new Cordis stent is appropriate for TIPS procedure.

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。

TIPS治疗肝硬化门静脉血栓的临床疗效

目的 探讨经颈静脉肝内门体分流术(TIPS)治疗肝硬化合并门静脉血栓(PVT)的临床疗效。方法 选取17例肝硬化合并PVT,并有食管胃底静脉曲张破裂出血患者,对其进行TIPS治疗,术后进行随访6~25个月(平均16个月)。根据手术结果,分析手术治疗成功率、术后血管再通、曲张静脉缓解和再发出血情况。结果 17例患者TIPS手术成功14例,成功率82.3%。术前门静脉主干血栓9例,至随访结束1例未缓解,再通率88.9%,门静脉主干伴有分支血管血栓3例,2例部分缓解;2例伴有肠系膜上静脉血栓,术后均得到缓解。3例手术失败患者均未缓解。14例手术成功患者术后3个月、6个月再发出血分别为1例、2例,出血率为21.4%。术后10例曲张静脉转为轻度或消失,缓解率为76.9%。14例手术成功患者3例术后发生肝性脑病,治疗后好转。所有患者无严重并发症发生。结论 TIPS对于抗凝治疗失败的PVT患者具有非常好的技术成功率及临床疗效,明显提高了门静脉再通率,减少了门静脉高压相关并发症,疗效肯定,可作为一线治疗方法。

递增式扩张分流道在肝硬化门静脉高压经颈静脉肝内门体分流术中的疗效评价

目的 探讨递增式扩张分流道在肝硬化门静脉高压经颈静脉肝内门体分流术(TIPS)中的疗效。方法 选取肝硬化门静脉高压症施行TIPS治疗的68例患者资料,术中先采用直径6 mm球囊扩张,根据PPG下降情况决定是否采用直径8 mm球囊扩张者为递增扩张组(n=37),直接采用直径8 mm球囊扩张者为对照组(n=31),全部患者球囊扩张后均置入直径8 mm覆膜支架。术后1、3、6、12个月及以后每6个月进行随访,对比分析两组患者术后肝性脑病、分流道通畅率及生存率。结果 两组患者术前基线水平比较,差异无统计学意义(P>0.05)。68例患者技术成功率100%。两组患者术后中位随访时间26.6(3.3~38.8)个月,递增扩张组术后1、2、3年肝性脑病累积发生率分别为8.3%、12.6%和17.2%,对照组为22.7%、45.4%和59%,差异有统计学意义(P<0.05)。递增扩张组术后1、2、3年分流道首次累积通畅率分别为94.5%、89.8%和89.8%,对照组为96.8%、93.2%和93.2%(P=0.75)。递增扩张组术后1、2、3年累积生存率分别为91.8%、88.1%和83%,对照组为90.3%、90.3%和57.5%(P=0.34)。结论 递增式扩张与非递增式扩张分流道施行TIPS的疗效相似,但可以减少TIPS术后肝性脑病的发生率。

肝实质段覆膜支架精确覆盖技术在经颈静脉肝内门体分流术中的应用

目的：以裸支架加覆膜支架形式建立肝实质内门腔分流道,评价肝实质段覆膜支架精确覆盖技术的可行性及疗效.方法：17例肝硬化、门脉高压症所致上消化道出血患者,行经颈静脉肝内门体分流术（transjugular intrahepatic portosystemic shunt,TIPS）.改良支架放置技术,以裸金属支架连接门静脉与下腔静脉,定位分流道肝实质段,以覆膜支架精确覆盖,建立门腔分流体系.测量比较分流前后门体静脉压力梯度值（portosystemic gradient,PSG）的变化,评价技术可行性、安全性及临床治疗效果.结果：17例手术全部获得成功.分流前后PSG差异有统计学意义[（28.2±7.6） mmHg vs.（12.1±3.5） mmHg,1 mmHg=0.133 kPa,P〈0.001].术后近期死亡1例,其他所有病例均获随访,中位随访时间181 d （32～563 d）.随访过程中3例死亡,原因分别为肝性脑病、肝功能衰竭及败血症,其余13例存活.2例发生肝性脑病经药物治疗缓解.支架通畅率100%,无复发出血.术前及随访结束时Child-Pugh评分分别为（7.8±2.0）分和（7.5±1.7）分,差异无统计学意义（P=0.584）.结论：使用组合支架（裸支架＋覆膜支架形式）实现肝实质分流道准确定位,覆膜支架精确放置在操作上相对简单,PSG降低幅度在一定程度上可调控.经临床初步应用及短期随访,支架通畅率高,肝性脑病发生率及再出血率较低,综合疗效满意.

门静脉海绵样变(CTPV)的介入治疗

目的总结良性病变所致门静脉海绵样变(cavernous transformation of portal vein,CTPV)介入治疗的经验及临床疗效。方法回顾性分析2000年至2012年24例在我科行介入治疗的CTPV患者的临床资料。所有患者发病时均有不同程度的呕血、黑便或腹痛等临床症状。经颈内静脉肝内门腔分流术(transjugularintrahepatic portosystemic shunt,TIPSS)联合置管局部溶栓14例,单纯TIPSS治疗或联合冠状静脉栓塞术2例,经皮穿刺脾静脉途径门静球主干囊扩张联合TIPSS治疗1例,经皮肝穿门静脉球囊扩张2例,经皮肝穿门静脉支架植入或联合胃冠状静脉栓塞术2例,脾动脉部分栓塞术(partial splenic embolization,PSE)2例。介入手术中途停止治疗1例。随访2个月～6年,观察门静脉及分流道通畅情况并随访上消化道出血及腹痛情况。结果随访时间内2例患者分别于术后2年及3年因TIPSS分流道狭窄或闭塞发生再次上消化道出血,行分流道修正术。1例行PSE于术后2年因上消化道出血转外科行脾切除加门奇静脉断流术;1例因无法开通闭塞的门静脉转外科行门奇静脉断流术联合分流;余所有患者未再出血或腹痛发生,门静脉或分流道通畅。结论介入手术是一种对CTPV安全、有效、微创的治疗方法,选择合适的介入手术方法是治疗成功的关键。

TIPSS技术在门脉癌栓性门脉高压中的应用

目的 探讨TIPSS技术在治疗门静脉癌栓合并门脉高压中的技术特点及禁忌证。方法16例门静脉癌栓合并门脉高压症患者 ,9例门静脉主干完全堵塞 ,7例门静脉主干及分支有不同程度栓塞 ;6例合并门脉海绵样变 ;1例单纯上消化道大出血 ;4例单纯顽固性腹水 ;11例上消化道大出血合并顽固性腹水。结果 16例中 11例患者成功行TIPSS治疗 ,技术成功率约 6 8.8% ,门脉压力从术前 4.9kPa降至 2 .4kPa ,平均降低 2 .5kPa ,腹水减少或消失 ,症状缓解 ,平均生存 136d。 5例失败。结论 TIPSS是治疗门脉癌栓引起的上消化道大出血和顽固性腹水的有效方法 ,门脉海绵样变是该术的禁忌证。

经颈静脉肝内门体静脉分流(TIPS)术后并发肝性脑病的临床分析

目的研究经颈静脉肝内门体静脉分流(TIPS)术后患者肝性脑病的发生机制及与手术方式/支架规格的关系,改进TIPS手术。方法对我科1999～2006年间225例患者的术前及术后肝功、血氨,及手术中使用支架规格,穿刺门静脉情况,曲张静脉栓塞情况等资料进行统计、分析。结果行TIPS术后临床症状和体征均得到不同程度改善,急诊出血停止,腹水逐渐消退。穿刺门脉左支患者肝性脑病发生率明显低于穿刺门脉右支。使用8mm支架肝性脑病发生率亦明显低于使用10mm支架。结论选择门静脉左支作为门腔静脉分流道,植入8mm内径血管支架,可以显著降低肝性脑病发生率,并保护肝功能,而对分流道远期开通率无明显差异。

TIPSS术后肝性脑病的发生与门静脉血流方向的关系——附212例分析

目的研究经颈静脉途径肝内门体静脉内支架分流术TIPSS术后肝性脑病的发生与门静脉血流方向的关系。方法:采用彩色多普勒超声测量212例TIPSS术后患者的肝内门静脉血流。结果:212例TIPSS术后病人发生肝性脑病33例,占16%;门静脉血流方向呈离肝型的病人的肝性脑病发生率较呈向肝型的病人高(60%比3%,<0.02)。结论:TIPSS术后门静脉血流方向呈离肝型者容易发生肝性脑病;彩色多普勒超声可作为监测TIPSS术后肝性脑病的方法之一。

经颈静脉肝内门脉左支-体静脉分流术的临床意义

目的 评价选择性门静脉左支作为 TIPS分流道的临床意义 ,分析门静脉左、右支的血液动力学变化及重要液递物质浓度差异对术后预防肝性脑病及远期疗效的影响。 方法 34 1例有目的地选择肝内门静脉左支作为穿刺靶点 ,行经颈静脉肝内门静脉左支门腔分流术建立门腔分流道 ,避开富含营养、毒素的门静脉右支血液。肝实质通道用 8mm直径球囊扩张 ,限制分流口径。 结果 所有患者术后 3个月内无一例发生肝性脑病。随访期间 TIPS术后 34 1例患者仅 5例 (1.47%)出现肝性脑病和 19例 (5 .5 7%)一年随访造影出现支架内狭窄。 结论 选择性门静脉左支作为门腔静脉分流道 ,可以显著降低肝性脑病发生率 ,对保护肝功能、提高分流道远期开通率具有重要的临床意义。

DSA在经颈静脉途径肝内门体分流术（TIPSS）中的应用

本文报告９例应用ＤＳＡ进行经颈静脉途径肝内门体分流术。使用ｐｈｉｌｉｐｓ公司生产的ＡＲＣ－Ａ型ＤＳＡ机器。患者年龄２４岁－６２岁，肝硬化病史３－１０年，内镜和上消化道钡餐证实为食管及胃底中重度静脉曲张。结果：７例成功，２例失败。建立分流术后门脉压从术前３．６５～４．１０ｋＰａ，降至２．３０～２．７０ｋＰａ，Ｄｏｐｐｅｒ超声波显示门脉主干血流从术前１１～２２ｃｍ／ｓｅｃ，增加至３４～６８ｃｍ／ｓｅｃ，静脉曲张消失或减轻，３例术前少量腹水，术后消失。初步结论，利用ＤＳＡ进行ＴＩＰＳ具有造影剂用量小，浓度低，节省胶片之优点；可变换部位多次投照，便于了解肝静脉主要分支的空间关系。ＴＩＰＳＳ创伤小，降低门脉压可靠，是治疗门脉高压症的优良方法。

TIPSS的临床应用和中远期疗效评价

目的:评价经颈静脉肝内门腔静脉内支架分流术(TIPSS)的临床应用和探讨影响中远期疗效的原因。材料和方法:对9例患者的临床资料、操作过程和术后随访观察进行分析。结果:9例均成功地降低了门脉压力,随访仅1例发生了再狭窄,经扩张后再通。结论:TIPSS适合广泛用于治疗肝硬化门脉高压症。中远期疗效尚满意。术后狭窄是影响疗效的主要原因,应定期随访,及时发现及时处理,尽管狭窄和闭塞可成功地进行再通,但根本解决内膜增生的原因,尚待研究。

经颈静脉肝内门体分流术治疗门静脉血栓形成伴急性消化道大出血效果评价

目的 评价经颈静脉肝内门体分流术(TIPS)治疗门静脉血栓形成(PVT)伴消化道大出血的可行性及临床效果。方法 回顾性分析2015年3月至2017年3月采用TIPS术治疗的18例PVT伴消化道大出血患者临床资料,观察围手术期并发症发生率、再出血率、血栓开通情况、肝性脑病发生率、支架中远期通畅率。结果 所有患者均在消化道大出血72 h内成功完成TIPS术,手术成功率100%。围手术期死亡率5.5%(1/18),术后发生Ⅰ~Ⅱ级肝性脑病5例(27.8%,5/18)。术后随访6~24个月,平均12.4个月,PVT完全消失6例,明显减少7例,无明显进展4例;所有患者支架均通畅,2例出现支架内狭窄,其中1例无出血,未予处理,1例术后8个月再出血,予球囊扩张修复术后出血停止。结论 TIPS术治疗PVT伴急性消化道大出血安全、有效,值得推广。

经颈静脉肝内门静脉分流术治疗门脉高压症(附8例报告)

报告38例肝硬变门脉高压症行TIPSS治疗的结果,其中成功6例,术中门脉压明显下降(平均35.2cmH_2O降至20.8cmH_2O),术后病人腹水明显减少,脾脏回缩,食道胃底静脉曲张明显改善。短期内未发生再次出血。失败1例,认为:当术中不能除外穿中门脉主干或分叉下壁时,切忌盲目导人较粗的导管及扩张器,尤其不能进行球囊导管扩张。在行肝内门脉穿刺时,应充分了解各系统血管的位置及走行方向,把握合适的穿刺途径,必要时借助B超及楔入性肝静脉造影,以减少损伤。TIPSS是目前治疗门脉高压症的一种有效的非手术疗法,但仍存在通道闭塞及如何确定合适分流量问题。

不同介入方法治疗门静脉高压的临床研究:倾向性分析

目的:探讨不同介入方法治疗门静脉高压的治疗效果。方法:选取进行介入治疗的门脉高压症患者28例,门静脉通畅患者采用单纯经颈静脉门腔分流术(TIPS)16例,合并有门静脉系统栓塞患者采用经脾静脉门静脉重建及门腔分流术(TPR-TIPS)12例,3个月后通过随访,对两组患者肝功能MELD评分,肝性脑病发生率、再出血率和门静脉通畅率方面进行比较,并通过倾向性分析匹配出6对患者进行分析。结果:两组患者均成功进行介入治疗,均未出现介入相关性严重并发症,两组患者在肝功能MELD评分及肝性脑病发生率上差异存在统计学意义,门静脉通畅率及再出血率方面的差异无统计学意义(P>0.05),倾向性分析表明,两组患者在肝功能MELD评分及肝性脑病发生率差异存在统计学意义,在门静脉通畅率及再出血率差异无统计学意义。结论:经介入途径治疗门静脉高压可以改善门静脉高压症状及消化道出血风险,但患者的预后仍受到肝脏基础情况影响。

介入治疗急性大出血25例临床总结

目的探讨介入治疗急性大出血的临床应用价值。方法 25例患者,根据出血部位的不同:动脉性出血造影明确诊断后对靶血管用PVA颗粒、明胶海绵或弹簧圈进行栓塞治疗;门脉高压性出血根据患者情况分别行TIPS分流术,经皮肝穿胃冠状静脉栓塞术和(或)部分脾栓塞术。结果介入治疗急性大出血的有效率为84%(21/25),术后随访3个月至1年,有2例复发(2/25)。结论介入治疗是一种安全、高效、简便、损伤小的治疗方法,对急性大出血有很好的临床应用价值。