观察改良TIPS在胃食管出血应用中的技术可行性及临床效果。

收集接受改良TIPS治疗的肝硬化门静脉消化道出血的患者56例。操作技术改良是在线阵血管探头引导下穿刺右颈内静脉，引入导丝并将Rups-100穿刺系统送至肝右静脉，自肝静脉向门静脉穿刺成功后，引入加强硬度导丝至肠系膜上静脉，撤出Rups-100穿刺系统，直接将8 mm×40 mm球囊经12F鞘沿加硬导丝快速通过肝静脉-肝实质-门静脉，扩张球囊并保留球囊上肝静脉和门静脉切迹图像。支架技术改良是先释放1枚8 mm×60 mm的裸支架，根据球囊切迹，再释放1枚8 mm×40 mm的覆膜支架，覆膜部分覆盖实质全程而不阻挡同侧门静脉入肝血流，其余部分伸入肝静脉内，常规用弹簧栓子和明胶海绵栓塞胃冠状静脉。测量分流前后门静脉压力变化。

56例均获得技术性成功，成功率为100%。分流道建立前后门静脉压力分别为（31.20±3.98）mmHg和（17.36±3.48）mmHg,平均下降幅度为（13.839±2.585）mmHg（t=40.062,P<0.001）。随访1～3年。1、2、3年分流道通畅率分别为89.3%、75.0%、67.8%；再出血率分别为7.1%、12.5%、16.1%；肝性脑病发生率为12.5%。有1例术后第2天出现腹腔感染，抗感染治疗7天后好转；有7例于术后1～3年内因分流道完全闭塞而复发再出血，分别给予了介入开通和覆膜支架植入。所有病例均未出现其他严重并发症。5例在随访期间分别死于肝衰竭、肝癌和多器官衰竭。

通过对支架的改良，采用模拟Viatorr支架方法能够提高TIPS分流道的中远期通畅率，降低再出血率；简化TIPS操作步骤可减少与技术操作相关的并发症。

To observe feasibility and efficacy of the modified TIPS in treatment of gastro-esophageal bleeding.

A total of 56 patients with gastro-esophageal bleeding underwent modified TIPS. Puncture the right internal jugular vein under the guidance of ultrasound, push the Rups-100 to the right hepatic vein along the guide wire, after successful puncture through hepatic vein to portal vein, a stiff wire was exchanged and a balloon (8 mm×40 mm) was sent and inflated across the liver parenchymal. A bare stent (8 mm×60 mm) was released through the track, and a stent-graft (8 mm×40 mm) was released within the bare stent according to the markers on the balloon. The stent-graft must cover the liver parenchymal track. Gastric coronary veins were emblazed with coils routinely. The portal pressure were measured before and after the shunt established.

Of all 56 cases were technically successful (100%). The portal pressure fell to (17.36±3.48)mmHg from (31.20±3.98)mmHg. All patients were followed up from 1 to 3 years. The decrease of portal vein pressure pre- and post-TIPS was statistically significant (t=40.062, P<0.001). During the period of 1—3 years follow-up, the shunts patency rate was 89.3%, 75.0%, 67.8% and the rate of rebleeding was 7.1%, 12.5%, 16.1% respectively; the rate of encephalopathy was 12.5%. One case accepted antibiotics treatment because of sepsis; 7 cases underwent re-TIPS due to the shunt occlusion. No other procedure related complications occured. Five cases died of hepatic failure, hepatocellular carcinoma and multiple organ failure.

The modified TIPS with bare stent combined with stent-graft can effectively improve the patency rate of shunt, decrease the rate of rebleeding, and reduce complications related to technique through simplifying the procedure.