组合支架在经颈静脉肝内门体分流术中应用的随访结果

摘要

目的 探讨组合支架在经颈静脉肝内门体分流术(transjugular intrahepatic portosystemic shunt,TIPS)中应用的临床效果. 方法 2011年4月~2017年5月对61例门脉高压症所致上消化道出血或难治性腹水行TIPS.采用组合支架建立门腔分流体系,即裸金属支架连接门静脉与下腔静脉,精确定位分流道肝实质段后,再以一定长度覆膜支架覆盖肝实质段,观察分流前后门体静脉压力梯度值的变化、止血成功率、并发症发生率(再出血率、肝性脑病发生率)以及生存率. 结果61例手术全部成功.随访截止2017年5月.61例术后随访5~73个月,中位随访时间26个月,34例随访>24个月,18例随访>36个月,7例随访>60个月:9例死亡,死亡原因分别为多器官功能障碍3例、晚期恶性肿瘤2例、肝性脑病1例、肺部感染1例、消化道出血2例.术后再出血率、支架累积通畅率、肝性脑病累积发生率、累积生存率分别为6.56%、83.58%、19.60%、82.88%.52例长期生存者术前Child-Pugh评分(7.47 ±1.60)分,随访结束时(7.04 ±1.12)分,差异无统计学意义(t=1.961,P=0.055). 结论 组合支架(裸支架+覆膜支架)建立门腔分流通道在技术上安全可行,治疗上消化道出血及难治性腹水效果满意.%Objective To investigate the clinical results of combined stents(naked self-expanding stent and covered stent) placement for the construction of transjugular intrahepatic portosystemic shunt(TIPS)for the treatment of portal hypertention complications. Methods A total of 61 patients who suffered from upper digestive tract hemorrhage or intractable ascites due to portal hypertension post liver cirrhosis underwent TIPS from April 2011 to May 2017.The shunt was constructed with stepwise placement of a naked self-expending stent and a covered stent for the purpose of precisely covering the parenchymal segment of the shunt. Portosystemic gradient(PSG)before and after TIPS was measured.The rates of hemostasis, major complications(re-bleeding or hepatic encephalopathy)and patient's survival were observed. Results The 61 patients were followed up for 5 -73 months (median,26 months),including 34 cases for more than 24 months,18 cases for more than 36 months,and 7 cases for more than 60 months.There were 9 fatal cases,including 3 cases of multiple organs dysfunction,2 cases of late-staged cancer,1 case of hepatic encephalopathy,1 case of pulmonary infection,and 2 cases of re-bleeding.The remaining 52 patients were followed up for(26.8 ± 20.2)months.The re-bleeding rate, cumulative patency rate of the shunts, cumulative incidence of encephalopathy, and patients' survival were 6.56%, 83.58%,19.60%, and 82.88%, respectively.Among this 52 long-term survivors, the mean Child-Pugh scores before TIPS and at the end of the follow-up were(7.47 ±1.60)points and(7.04 ±1.12)points,without significant difference (t=1.961,P=0.055). Conclusions Combined naked self-expending stent and covered stent is relatively safe and feasible.It has satisfying results for the treatment of portal hypertention complications.