摘要目的 探讨采用全覆膜支架完成经颈静脉肝内门腔静脉分流术(TIPS)后出现分流道功能不全的介入处理方法.方法 分析2009年10月至2013年1月24例采用全覆膜支架建立TIPS术后出现分流道功能不全患者的临床资料.其中男17例、女7例;年龄31~63岁,平均(51±8)岁.首次TIPS术后全部患者均表现为术前症状复发.介入处理方法首先支架原位开通,若导丝及导管由肝静脉端向门静脉端通过困难时,则采用经皮肝穿刺途径逆向导丝引导技术;无法开通时则采用平行TIPS术.术后口服阿司匹林(0.1 g,1次/d).再次介入处理前、后门腔压力梯度比较采用配对t检验;疗效判断,采用彩色B超观察分流道血流情况结合首次TIPS术前症状(上消化道出血或顽固性腹水)复发情况.随访27~66个月,中位时间41月.结果 24例患者血管造影均证实分流道再狭窄,其中支架肝静脉端狭窄21例、门静脉端狭窄3例;其中20例(83.3%)术前彩色超声提示分流道再狭窄.20例患者采用原位开通,其中3例采用经皮肝穿刺途径逆向导丝引导技术;4例采用平行TIPS术.修正后门静脉压力明显下降[术前(3.5±0.4)kPa,术后(1.4±0.4)kPa(1 mmHg=0.133 kPa);t=18.3,P=0.001].随访期间1例门静脉海绵样变患者于术后1个月再次出血后失访,余病例无症状复发,超声检查未见支架再狭窄,二期通畅率为95.8%(23/24).结论 TIPS术后狭窄以肝静脉端常见,再次介入处理效果良好.

abstractsObjective To explore the interventional revision method on shunt dysfunction after transjugular intrahepatic portosystemic shunt(TIPS)using covered stents. Method Twenty-four patients with shunt dysfunction who underwent TIPS using covered stents between October 2009 and January 2013 were enrolled. Seventeen patients were males and 7 were females, with age ranging from 31 to 63, average 51 ± 8. All the enrolled patients were characterized by recurrence of preoperative symptoms after first TIPS. All cases were treated by in-situ recanalization firstly, and when the guide wire and catheter was difficult to get through from the liver vein end to portal vein end, retrograde wire guiding technique was introduced through percutaneous transhepatic puncture. If all the attempts failed, parallel TIPS was employed. Oral administration of aspirin (0.1 g, 1/d) was conducted for antiplatelet therapy after surgery. Pair t-test was used to compare the portal venous pressure before and after the interventional revision. The therapeutic effect was evaluated by ultrasonic Doppler and the symptoms,such as upper gastrointestinal hemorrhage or intractable ascites. Follow up time was 27-66 months, and median time was 41 months. Results All the 24 cases were confirmed to be shunt stenosis by angiography, including 21 cases of stents-liver vein end stenosis and 3 cases of portal vein end stenosis. All the patients were examined by color Doppler ultrasound and 20 cases prompted shunt stenosis. The positive rate was 83.3%. Twenty patients were revised by in-situ recanalizationand 4 patients were revised by parallel TIPS. Portal venous pressure decreased from (3.5 ± 0.4)kPa to (1.4 ± 0.4) kPa after interventional revision (t=18.3,P=0.001). Except one case of portal cavernoma rebleeding one month after the revision and missing follow up, all patients had no symptom recurrence and shunt restenosis by color doppler ultrasound. The second patency was 95.8% (23/24).Conclusions Stents-liver vein end stenosis was common among the shunt stenosis after TIPS. The interventional revision can improve the shunt dysfunction significantly.