肝硬化门静脉高压TIPS术中门体侧支DSA造影的表现及临床意义

发布时间：2018-02-28 00:19

  本文关键词： PSCV 门静脉高压 静脉曲张 DSA 血管成像 肝内分流　出处：《南方医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：背景:在肝硬化门静脉高压(portalhypertension,PHT)患者中,常存在着门体静脉之间侧支血管(portosystemic collateral vessels,PSCV)的开放,其血液流向通常为离肝血流。随着门静脉高压的进展,这些PSCV的数量及血流量的增加。PSCV是出血和肝性脑病发生的重要原因,明确PSCV的部位以及对其流入流出道的识别对临床诊断及治疗有重要意义。目前对PSCV的影像学研究主要是增强CT,且已有对PSCV进行了多种分类的研究。但增强CT的研究不能准确显示PSCV的血流动力学状况,尚不是金标准。查阅文献,暂无直接PSCV的DSA造影表现的系统性研究。因此,本研究通过经TIPS途径置管到门脉属支(肠系膜上静脉和脾静脉)行直接门静脉DSA造影,观察PSCV显示的情况,并进行分类和探讨常见PSCV的临床意义。目的:肝硬化门脉高压患者经TIPS途径行门脉属支置管门脉DSA造影,观察PSCV的表现,并探讨常见PSCV开放的临床意义。材料和方法:材料:回顾性收集2015年8月至2017年2月就诊于我院并经临床确诊的肝硬化门静脉高压患者,所有患者均为失代偿期并行TIPS术治疗,共入选274例,其中男性232例,女性42例。年龄51.29±12.63(16-79)岁。肝功能Child-Pugh分级A级32例,B级175例,C级67例。方法:1、经TIPS途径置管到门脉属支,即肠系膜上静脉和脾静脉,分别行门静脉DSA造影。2、观察PSCV的显示情况,并对PSCV进行描述性的研究。3、观察常见PSCV的特点并结合临床指标分析其临床意义。搜集患者TIPS术前肝功能、腹水程度、术前门静脉主干压力等临床指标,结合PSCV情况,经统计分析判断这些PSCV与术前门静脉压力(portal venous pressure,PVP)、肝功能Child分级及腹水程度的关系。计量资料用均数±标准差(x±s)表示,计数资料组间比较应用X2检验,趋势卡方检验说明变量间线性关系。结果:274例患者均成功经脾静脉主干及肠系膜上静脉主干完成门静脉造影及常规TIPS手术,技术成功率100%。6例患者右侧颈内静脉狭窄或闭塞,经左侧颈内静脉穿刺置管。门静脉造影后无操作相关的并发症发生,如过敏、腹腔出血、穿刺点出血等。1、DSA下PHT失代偿期患者PSCV的描述性研究根据PSCV在门脉系统的起始部位,可分为:(1)门静脉分支型(2.55%);(2)门静脉主干型(23.35%);(3)门静脉属支型(包括肠系膜上、下静脉和脾静脉)(12.77%);(4)混合型(61.31%),即PSCV起源上述2个或2个以上的部位。不同起源PSCV出现情况如下:1.1门静脉分支起源75例(1)门静脉左支:附脐静脉开放42例(15.33%),门静脉左支-膈下/胃静脉分流4例(1.46%)。(2)门静脉末梢:肝内广泛门肝静脉末梢分流29例(10.58%)。1.2门静脉主干起源216例胃左静脉曲张216例(78.83%)。1.3门静脉属支起源188例(1)胃短/后静脉曲张172例(62.77%)。(2)肠系膜上静脉:肠系膜上静脉-腹膜后静脉曲张1例(0.36%),肠系膜上静脉-胃底区静脉曲张1例(0.36%),胃网膜静脉曲张5例(1.82%)。(3)肠系膜下静脉:直肠静脉曲张2例(0.73%)。(4)脾(胃)肾分流23例(8.39%)。1.4混合型起源168例混合型起源的胃左静脉合并其他血管141例(51.46%),胃短/后静脉合并其他血管130例(47.45%)及附脐静脉、门静脉末梢、脾(胃)肾分流等上述静脉的2个或2个以上起源。2、PHT失代偿期患者常见PSCV的临床意义(1)胃左静脉、胃短/后静脉及脐静脉在不同肝功能分级、PVP等级及腹水程度中,出现率的差异有统计学意义(P0.05)。(2)脾(胃)肾分流在不同肝功能分级、PVP及腹水程度出现率的差异没有统计学意义(P0.05)。(3)肝内广泛门肝静脉末梢分流在不同PVP等级及腹水程度中出现率的差异没有统计学意义(P0.05),但这种分流仅出现在肝功能B、C级患者中。结论:1、在TIPS术中完成门静脉造影是安全和可行的。2、通过门脉DSA造影,根据PSCV的起源,可将其分为门静脉分支型、门静脉主干型、门静脉属支型及混合型。多数患者为混合型(61.31%),且可发生肝内广泛门肝静脉末梢分流。3、胃左静脉、胃短/后静脉及附脐静脉的出现率与PVP、肝功能分级及腹水程度均呈正相关。4、脾(胃)肾分流和肝内广泛门体静脉末梢分流出现率与PVP、肝功能分级及腹水程度无相关性。5、肝内广泛门体静脉末梢分流可能常出现在肝功能相对较差的(肝功能B、C级)肝硬化门静脉高压患者中。
[Abstract]:Background: in patients with liver cirrhosis and portal hypertension (portalhypertension, PHT) patients, often exists between portosystemic collateral vessels (portosystemic collateral, vessels, PSCV) is open, the blood flow is usually from the hepatic blood flow. With the development of portal hypertension, the number of PSCV and.PSCV increased blood flow is an important reason for bleeding and the occurrence of hepatic encephalopathy, clear PSCV and part of the inflow outflow recognition has important significance for clinical diagnosis and treatment. The present research on PSCV imaging is mainly to enhance the CT of PSCV, and has studied a variety of classification. But the enhancement of CT can not accurately display the hemodynamic status of PSCV. Is not the gold standard. The literature, a systematic study of DSA angiography showed no direct PSCV. Therefore, this research through the TIPS pathway catheter to the portal vein branches (superior mesenteric vein and splenic vein) Direct observation of portal vein angiography DSA, PSCV display, and classification and clinical significance of common PSCV. Objective: Patients with liver cirrhosis and portal hypertension by TIPS pathway for portal vein branches of portal vein catheterization DSA angiography, observe the performance of PSCV, and to explore the clinical significance of common PSCV. Materials and methods materials: retrospectively collected from August 2015 to February 2017 in our hospital for treatment of the patients with liver cirrhosis and portal hypertension clinical diagnosis, patients with decompensated parallel TIPS treatment, 274 patients were enrolled, of which 232 were male, 42 were female. Age 51.29 + 12.63 (16-79) years old. 32 cases of liver function Child-Pugh grade a, grade B 175 cases, C grade 67 cases. Methods: 1, after TIPS catheterization to the portal vein branches, namely the superior mesenteric vein and splenic vein, portal vein angiography were performed DSA.2 display of PSCV was observed, and the research on.3 descriptive observation of common PSCV, PSCV The characteristics and clinical data collected to analyze its clinical significance. The liver function in patients with TIPS ascites before operation, preoperative portal vein pressure and other clinical indicators, combined with PSCV, by statistical analysis to judge the PSCV and preoperative portal vein pressure (portal venous, pressure, PVP), the relationship between Child classification of liver function and ascites. The mean and standard deviation of measurement data (x + s) said the count data between groups were compared using X2 test, chi square test shows that the linear relationship between variables. Results: 274 patients were successful by splenic vein and superior mesenteric vein complete portal vein angiography and conventional TIPS surgery, the technical success rate of 100%.6 cases patients with right internal jugular vein stenosis or occlusion of the left internal jugular vein catheterization. Portal vein angiography after operation related complications occurred, such as allergies, abdominal hemorrhage, hemorrhage and.1, DSA PHT in decompensated patients 鑰匬SCV鐨勬弿杩版，

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