双支架技术在TIPS治疗中的临床应用研究

摘要

目的：观察采用双支架技术模拟Viatorr支架在TIPS中的应用效果。方法整群抽取2004年6月至2012年6月本院收治肝硬化门静脉高压出血和顽固性腹水患者242例，将2004年6月至2009年6月采用裸支架技术治疗的入组患者186例设为裸支架组（对照组），将2009年6月至2012年6月采用双支架技术模拟Viatorr支架方法治疗的入组患者56例设为模拟Viatorr组（观察组）。两组患者进行前后对照临床试验研究。两组患者在治疗前性别、年龄、肝功能Child分级及门静脉高压并发症等方面均无显著差异。模拟Viatorr组在分流道开通后先释放1枚8 mm ×60 mm的裸支架，根据球囊上肝静脉-门静脉切迹，释放1枚8 mm ×40 mm的覆膜支架，覆膜部分覆盖肝实质全程而不阻挡门静脉入肝血流，其余部分伸入肝静脉内。裸支架组（对照组）分流道开通后只放置1枚8 mm ×60 mm的裸支架。两组患者常规用弹簧栓子栓塞胃冠状静脉。结果模拟Viatorr组56例均获得成功，裸支架组186例中有2例不成功，改为其他治疗。技术成功率分别为100%和98.9%。两组分流道建立后门静脉压力分别下降了（18±5.7）cm H2O和（18±3.4）cm H2O。随访12～36个月，用彩色多普勒超声观察分流道通畅情况。模拟Viatorr组和裸支架组分流道累计通畅率分别为67.8%和41.9%，差异有显著统计学意义（P=0.0007）；模拟Viatorr组和裸支架组复发再出血率分别为21.4%和40%，差异显著有统计学意义（P=0.0056）；模拟Viatorr组和裸支架组肝性脑病发生率分别为19.6%和10.2%，差异无统计学意义（P=0.0605）。模拟Viatorr组和裸支架组在治疗顽固性腹水的有效率分别为80%和72.7%，差异无统计学意义（P=0.425）。模拟Viatorr组有1例患者术后出现腹腔感染，抗感染治疗后好转；1例患者于术后2个月出现支架肝静脉端“盖帽”，再次介入干预时未能成功。裸支架组有3例患者腹腔穿刺证实为腹腔内出血，经保守治疗后好转，无其他严重并发症发生。随访期间，模拟Viatorr组有7例（12.5%）、裸支架组有47例（25.2%）患者因分流道严重狭窄闭塞进行了1～3次再通术和支架植入术；模拟Viatorr组有5例、裸支架组有39例分别死于肝功能衰竭、肝癌和多器官衰竭。结论双支架模拟Viatorr支架方法能够提高TIPS中远期分流道通畅率，降低再出血率。%Objective To explore the efficacy of the double stents technique simulating Viatorr stent-graft in correlation with the bare stent in TIPS. Methods From June 2004 to June 2012, 242 patients with gastro-esophageal bleeding and refractory ascites were treated with TIPS. Total of 56 cases (from 2009 to 2012) underwent TIPS with the simulative Viatorr technique; 186 cases (from 2004 to 2009) underwent TIPS with bare stent only. The sex, age, Child-Pugh scores and complications of portal hypertention were comparative between the two groups. In the ifrst group, a PTFE-covered stent (8 mm × 40 mm;Fluency Plus Vascular Stent Graft, BARD Co.) was implanted according to the markers on the balloon after the shunt was established with a bare stent (8 mm × 60 mm;Astron, Biotronik GmbH Co. ). In the bare stent group, the shunt was maintained with a bare stent alone. Embolization of the gastric coronary veins with coils were done as routine in both groups. The shunt patency, the rate of rebleeding and nephalopathy were compared withχ2 test. Results All TIPS were technically successful in the Viatorr simulant group (100%), while the technical success rate was 98.9%in the bare stent group;the portal pressure fell to (18 ± 5.7) cm H2O and (18 ± 3.4) cm H2O, respectively. All patients were followed up for 12 to 36 (mean 21 ± 8.4) months. The difference of shunt patency rate, rebleeding rate were reviewed statistical signiifcance between the two groups (P<0.05). There was a little higher of encephalopathy in the double stent group than that in the bare stent group, however, there was no obviously statistical difference (P>0.05). In the simulative Viatorr group, one case accepted antibiotics because of sepsis after TIPS, one case underwent a second TIPS due to the shunt occlusion within 50 days. In the bare stent group, three cases were demonstrated hemoperitoneum within the ifrst 2 to 4 hours after TIPS, no other procedure related complications occurred. During the period of follow-up, 7 cases (“Viatorr”group) and 47 cases (bare stent group) needed re-TIPS;5 cases (“Viatorr”group) and 39 cases (bare stent group) died of hepatic failure, HCC and MOF, respectively. Conclusions Simulative double-stent Viatorr technique can effectively improve the patency rate of shunt, and decrease the rebleeding rate compare with the bare stent.