3367例经颈静脉肝内门体分流术的技术难点分析
Analysis of technical difficulties of transjugular intrahepatic portosystemic shunt in 3367 patients
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摘要:
目的:分析经颈静脉肝内门体分流术(TIPS)的技术难点。
方法:采用回顾性描述性研究方法。收集1994年8月至2015年2月首都医科大学附属北京世纪坛医院收治的3 367例行TIPS患者的临床资料。观察指标：(1)TIPS技术无难度情况。(2)TIPS技术有难度情况(技术难点原因及解决方案)。(3)再次介入术中情况。(4)手术前后门静脉压力变化。正态分布的计量资料以
±s表示，比较采用t检验。
结果:(1)TIPS技术无难度情况：3 367例行TIPS患者中，1 963例技术无难度，其中1 031例与间接门静脉造影联合应用，19例同时与间接门静脉造影和经皮肝穿刺联合应用，913例直接行TIPS。(2)TIPS技术有难度情况：3 367例行TIPS患者中，1 404例技术有难度，其中肝内门静脉主要分支直径≤5 mm 404例、肝静脉全程完全闭塞77例、门静脉海绵样变性193例、门静脉闭塞合并粗大侧支19例、门静脉主干及分支完全闭塞性血栓或癌栓142例、肝静脉或下腔静脉与肝内门静脉主要分支空间关系不合理176例、 肝内门静脉主要分支在肝外(肝裂增宽、肝部分切除后等)251例、肝内胆管扩张78例、其他情况64例 (肝脏明显小、肝囊肿、多囊肝、肝硬化严重、肝巨大肿瘤、肝静脉段下腔静脉完全闭塞等)。其中896例患者与间接门静脉造影检查联合应用，480例同时与间接门静脉造影检查和与经皮肝穿刺联合应用，7例与间接门静脉造影检查和经皮脾穿刺联合应用，9例与间接门静脉造影检查和经股静脉穿刺联合应用，12例与间接门静脉造影检查和经皮肝穿刺、经皮脾穿刺联合应用。(3)再次介入术中情况：3 367例患者中， 1 035例行再次介入治疗，其中126例技术有难度。126例患者中支架上端“盖帽”32例，应用RUPS100穿刺针穿刺支架上端；支架开口部位与下腔静脉形成的角度较大56例，其中27例应用导引导管辅助，18例应用RUPS100的金属导向管辅助，11例应用RUPS100穿刺针穿刺支架上端；支架上端开口部位完全闭塞并与右心房距离较近17例，2例应用RUPS100的金属导向管辅助，15例应用RUPS100穿刺针穿刺支架上端；支架远端部分嵌入门静脉壁内2例，应用RUPS100的金属导向管辅助；支架内全程闭塞19例，应用RUPS100穿刺针穿刺支架内增生组织。(4)TIPS手术前后门静脉压力变化：技术无难度患者术前门静脉压力由(3.9±0.7)kPa降至术后的(2.5±0.4)kPa，手术前后比较，差异有统计学意义(t=1.54，P<0.05)；技术有难度患者术前门静脉压力由(4.0±0.9)kPa降至术后的(2.5±0.4)kPa，手术前后比较，差异有统计学意义(t=1.59，P<0.05)。
结论:TIPS可有效降低门静脉压力。肝内门静脉较细、门静脉海绵样变性、门静脉闭塞合并粗大侧支、门静脉主干及分支完全闭塞性血栓(或癌栓)、肝静脉或下腔静脉与肝内门静脉主要分支空间关系不合理、肝内门静脉主要分支在肝外、肝静脉全程完全闭塞、肝内胆管扩张等是行TIPS的技术难点，需要联合应用多种技术提高成功率。再次开通闭塞的TIPS分流道可在特殊导管、穿刺等辅助下完成。-
关键词:
- 肝硬化 /
- 门静脉高压症 /
- 经颈静脉肝内门体分流术
Abstract:Objective:To analyze the technical difficulties of transjugular intrahepatic portosystemic shunt (TIPS).
Methods:The retrospective descriptive study was adopted. The clinical data of 3 367 patients who underwent TIPS at Beijing Shijitan Hospital of Capital Medical University from August 1994 to February 2015 were collected. Observed indices included: (1) situations of TIPS without techincal difficulties, (2) situations of TIPS with technical difficulties, (3) intraoperative situations of reintervention, (4) pre and postoperative portal venous pressure changes. Measurement data with normal distribution were presented as
±s. Comparison was done using t test.
Results:(1) Situations of TIPS without techincal difficulties: of 3 367 patients undergoing TIPS, 1 963 had no technical difficulties, including 1 031 combined with indirect portography, 19 combined with indirect portography and percutaneous transhepatic puncture simultaneously, and 913 receiving TIPS directly. (2) Situations of TIPS with technical difficulties: of 3 367 patients undergoing TIPS, 1 404 had technical difficulties, including 404 of main branch diameter of intrahepatic portal vein≤5 mm, 77 of complete occlusion of hepatic veins, 193 of portal vein cavernous transformation, 19 of portal vein occlusion combined with thick collateral vessels, 142 of completely occlusive thrombosis or tumor thrombus of portal vein and its branches, 176 of unreasonable spatial relationship between hepatic vein or inferior vena cava and main branchs of intrahepatic portal vein, 251 of main branches of intrahepatic portal vein located extrahepaticly (crack widened liver, after partial hepatectomy, etc.), 78 of intrahepatic bile duct dilatation, and 64 of other circumstances (microhepatia, hepatic cyst, polycystic liver, severe liver cirrhosis, huge liver neoplasms, complete occlusion of hepatic vein segmental of inferior vena cava). Of the 1 404 patients, 896 underwent TIPS combined with indirect portography, 480 combined with indirect portography and percutaneous transhepatic puncture, 7 combined with indirect portography and percutaneous transsplenic puncture, 9 combined with indirect portography and femoral vein puncture, 12 combined with indirect portography, percutaneous transhepatic puncture and percutaneous transsplenic puncture. (3) Intraoperative situations of reintervention: of 3 367 patients, 1 035 underwent repeated intervention therapy. Among 126 patients with technical difficulties, 32 with head of stent covered were punctured head of stent using RUPS100 puncture needle. Fiftysix patients had large angel between stent and inferior vena cava, 27 of which were assisted by guiding catheter, 18 were assisted by RUPS100 metallic guide tube and 11 were punctured head of stent by RUPS100 puncture needle. Seventeen patients had complete occlusion at opening position of stent head and close distance from right atrium, 2 of which were assisted by RUPS100 metallic guide tube and 15 were punctured head of stent by RUPS100 puncture needle. Two patients with distal end of stent embeded into the wall of portal vein were assisted by RUPS100 metallic guide tube. Nineteen patients with intrastent occlusion were punctured proliferating tissue using RUPS100 puncture needle. (4) Pre and postoperative portal venous pressure changes: the portal venous pressure of patients without technical difficulties was changed from (3.9±0.7)kPa before TIPS to (2.5±0.4)kPa after TIPS, with a statistically significant difference (t=1.54, P<0.05). The portal venous pressure of patients with technical difficulties was changed from (4.0±0.9)kPa before TIP to (2.5±0.4)kPa after TIPS, with a significant difference (t=1.59, P<0.05).
Conclusions:TIPS could effectively reduce portal vein pressure. Thinner intrahepatic portal vein, portal vein cavernous transformation, portal vein occlusion combined with thick collateral vessels, complete occlusive thrombosis or tumor thrombus of portal vein and its branches, spatial relationships disorder between hepatic vein or inferior vena cava and portal vein main branchs, extrahepatic location of main branches of intrahepatic portal vein, complete occlusion of hepatic veins, intrahepatic bile duct dilatation are technical difficulties of TIPS. Combined use of various interventional techniques could increase technical success rate. In addition, reoperation of occluded TIPS shunt may be solved by applying the guiding catheter and/or puncture. -
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