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中华介入放射学电子杂志

中华介入放射学电子杂志 ›› 2014, Vol. 02 ›› Issue (03) : 1 -4. doi: 10.3877/cma.j.issn.2095-5782.2014.03.001

所属专题： 文献；

综合介入

经皮经肝肝内门体分流术的手术方法与临床应用
李名安1, 姜在波1,†(), 单鸿1, 周斌1, 张有用1, 王皓帆1, 黄明声1, 钱结胜1, 关守海1   
  1. 1. 510630　广州，中山大学介入放射学研究所，中山大学附属第三医院介入血管科
  • 收稿日期:2013-06-12 出版日期:2014-08-01
  • 通信作者: 姜在波
  • 基金资助:
    广东省科技计划项目(2011B031800082); 广东省科技计划项目(2012B031800085)

Technical protocol and clinical application of percutaneous transhepatic intrahepatic portosystemic shunt

Mingan Ll1, Zaibo Jiang1,†(), Hong Shan1, Bin Zhou1, Youyong Zhang1, Haofan Wang1, Mingsheng Huang1, Jiesheng Qian1, Shouhai Guan1   

  1. 1. Department of Interventional Vascular Radiology, the 3rd Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
  • Received:2013-06-12 Published:2014-08-01
  • Corresponding author: Zaibo Jiang
  • About author:
    Corresponding author: Jiang Zaibo,Email:
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李名安, 姜在波, 单鸿, 周斌, 张有用, 王皓帆, 黄明声, 钱结胜, 关守海. 经皮经肝肝内门体分流术的手术方法与临床应用[J]. 中华介入放射学电子杂志, 2014, 02(03): 1-4.

Mingan Ll, Zaibo Jiang, Hong Shan, Bin Zhou, Youyong Zhang, Haofan Wang, Mingsheng Huang, Jiesheng Qian, Shouhai Guan. Technical protocol and clinical application of percutaneous transhepatic intrahepatic portosystemic shunt[J]. Chinese Journal of Interventional Radiology(Electronic Edition), 2014, 02(03): 1-4.

目的

介绍经皮经肝肝内门体分流术（PTIPS）的手术方法及围术期情况。

方法

2009年11月—2013年3月，76例门静脉高压患者接受经门静脉右支PTIPS，临床表现为消化道出血69例（其中23例合并不同程度腹腔积液），单纯性顽固性腹腔积液7例。术前肝功能Child-Pugh A级23例，B级35例，C级18例。上腹部CT/MRI显示34例肝脏重度萎缩，肝裂明显增宽；25例伴门静脉血栓/癌栓形成合并门静脉海绵样变性。经皮成功穿刺门静脉右下分支后，沿同一穿刺道经门静脉"逆行"穿刺肝静脉或肝段下腔静脉，建立肝内门体分流道。

结果

76例患者PTIPS成功率100%。门静脉压差由术前（32.35±2.89）mmHg降至术后（18.42±1.32）mmHg（P<0.001）。2例患者发生腹腔出血，栓塞相应肝动脉后治愈。1例肝功能C级患者术后5天因肝衰竭死亡，余75例患者术后1个月内门脉高压症状消失。

结论

PTIPS是传统经颈静脉肝内门体分流术（TIPS）的补充，是一种安全、有效的治疗方法，手术成功率高，大大拓展了介入性门体分流术的应用范围。

关键词: 高血压，门静脉, 经皮经肝, 门体分流术, 放射学，介入性
Objective

To introduce the technical protocol and clinical application of percutaneous transhepatic intrahepatic portosystemic shunt (PTIPS).

Methods

Between November 2009 and March 2013, 76 patients with symptomatic portal hypertension underwent PTIPS due to bleeding varices (n=69), refractory ascites (n=7), and bleeding varices combining with refractory ascites (n=23). The severity of liver disease was Child-Pugh A in 23 cases, Child-Pugh B in 35, and Child-Pugh C in 18. The CT or MR image manifested serious hepatatrophy in 34 cases and cavernous transformation of portal vein (CTPV) in 25 cases. Under fluoroscopic guidance, the portal vein (PV) was punctured . Then, the hepatic vein (HV) or retrohepatic inferior vena cava (RIVC) was punctured PTIPS procedure was completed in the standard transjugular fashion.

Results

The procedure was technically successful in all patients. And effective portal decompression and free antegrade shunt flow were achieved. The mean portal pressure gradient decreased from (32.35±2.89) mmHg to (18.42±1.32) mmHg before and after PTIPS creation respectively, and the difference was significant statistically (P<0.001). Of the 76 patients, abdominal hemorrhage occurred in 2 cases, which was cured by artery embolization. One patient developed hepatic coma and died after 5 days while the other 75 patients survived and the symptoms of portal hypertension disappeared in one month.

Conclusions

PTIPS is both safe and effective in treatment of portal hypertension with exceptionally challenging anatomy. It is an available supplement for transjugular intrahepatic portosystemic shunt. It can extend the application scope of interventional portosystemic shunt.

Key words: Hypertension, portal, Percutaneous transhepatic, Portosystemic shunt, Radiology, interventional
图1～8 门静脉通畅患者PTIPS手术步骤示意图　图1为经皮经肝穿刺门静脉右下分支，置入鞘管及导管，行门静脉造影。图2为穿刺右侧颈内静脉，置入长鞘于肝静脉（或肝段下腔静脉），造影并留置定位，对于食管胃底静脉曲张慢性的患者给予栓塞。图3为以20G改良PTIPS穿刺针经门静脉穿刺肝静脉（或肝段下腔静脉），引入导丝并经颈内静脉拉出体外。图4为球囊扩张肝实质段分流道。图5为调整导丝、导管经门静脉进入肠系膜上静脉，并将长鞘引入门静脉。图6为球囊扩张门体分流道。图7为分流道内植入自膨式金属支架。图8为NBCA胶栓塞肝实质穿刺道，完成手术
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