Viatorr覆膜支架在经颈静脉肝内门体分流术中的临床应用

发布时间：2018-05-15 22:25

本文选题：Viatorr支架 + 经颈静脉肝内门腔静脉分流术　；参考：《山东大学》2017年硕士论文

【摘要】：研究背景和目的:经颈静脉肝内门体静脉分流术(transjugular intrahepatic portosystemic shunt,TIPS)是通过利用支架在肝静脉与门静脉之间的肝实质内建立分流通道,从而实现分流门静脉血流、降低门静脉压力的介入治疗技术。该技术1989年Richter首次用于临床,目前已广泛应用于食管胃静脉曲张出血、顽固性腹水、肝性胸水、Budd-Chiari综合征等的门静脉高压症的治疗以及作为肝移植术前过渡阶段而减少致命并发症的发生,并且疗效显著。长期以来,TIPS治疗中远期疗效的主要影响因素一直是TIPS术后分流道的再狭窄或闭塞。据统计其术后分流道再狭窄或闭塞率分别高达5%～64%(术后1年)、33%～70%(术后2年)、60%～85%(术后5年)。自 2004年Viatorr支架专用于TIPS以来,分流道通畅率明显提高,而Viatorr覆膜支架也是目前欧美TIPS指南中的标准支架。2015年10月,Viatorr支架在国内上市,国内的临床报道不多。本研究探讨Viatorr覆膜支架在TIPS治疗肝硬化门静脉高压症的操作技巧及初期疗效。材料和方法:本研究纳入山东省立医院2015年10月-2017年3月10例肝硬化门脉高压合并静脉曲张出血患者采用Viatorr覆膜支架行TIPS治疗,所有患者均术前、术后测定直接门静脉压力,术后1、3、6、12个月定期行血常规、肝功能、凝血功能:行腹部彩色多普勒超声、肝脏增强CT 了解支架通畅情况。对于可疑分流道失功能的患者或行血管造影证实,必要时行介入修正。随访期间观察再出血情况、腹水消退情况及并发症。结果:1.10例患者均一次性操作成功,技术成功率为100%。2.TIPS前后门静脉压力分别为(30.80 ± 4.83)mmHg和(18.20 ± 3.46)mmHg(lmmHg =0.133kPa,配对t检验,t=10.89,P0.001),分流后门静脉压力较分流前平均降低(41.17±8.87)%。3.10例均获随访,随访时间为1～17月(平均218天),随访过程中1例于术后148天腹腔感染死亡;1例术后83天出现自发性腹膜炎并感染性休克,经抗感染治疗后好转;1例术后23天出现阿司匹林致溃疡病出血,停用阿司匹林后,患者黑便消失;其余7例既往反复曲张静脉出血的患者,术后1-3月内复查胃镜均示曲张静脉缓解或消失,随访结束时均未出现呕血、黑便等症状。4.所有患者至随访结束(或死亡前)TIPS分流通道血流通畅,均未出现肝性脑病症状。结论:Viatorr支架以其设计特点能维持分流道的长久通畅,降低再出血率,且术后肝脑并发率低,从而进一步确保了门脉高压症患者行TIPS手术的有效性及安全性。
[Abstract]:Background and objective: Transjugular intrahepatic portosystemic shuntl shunt (TIPSs) is a method of shunt portal blood flow by using stent to establish shunt channels in the hepatic parenchyma between the hepatic vein and the portal vein. Interventional therapy to reduce portal vein pressure. This technique was first used in clinical practice in 1989 and has been widely used in esophageal and gastric variceal bleeding and refractory ascites. The treatment of portal hypertension in patients with Budd-Chiari syndrome and as a transitional stage before liver transplantation reduces the incidence of fatal complications and is effective. For a long time, restenosis or occlusion of shunt after TIPS has been the main influencing factor of mid-and long-term curative effect of tips. According to statistics, the rate of restenosis or occlusion of the shunt after operation was as high as 50.64% (1 year after operation) and 70% (2 years after operation, 60% or 85%) (5 years after operation). Since the Viatorr stent was dedicated to TIPS in 2004, the patency rate of shunt channel has been improved obviously, and the Viatorr stent is also the standard stent in TIPS guidelines in Europe and America. In October 2015, the stents were listed in China, but there are few clinical reports in China. This study was to investigate the operative skills and initial efficacy of Viatorr stent in the treatment of cirrhotic portal hypertension with TIPS. Materials and methods: from October 2015 to March 2017, 10 patients with portal hypertension complicated with varicose vein bleeding were treated with Viatorr stent for TIPS treatment. The direct portal vein pressure was measured before and after operation. Blood routine examination, liver function and coagulation function were performed at 12 months after operation. Abdominal color Doppler ultrasound and hepatic enhanced CT were performed to investigate the patency of stent. For patients with suspected shunt dysfunction or confirmed by angiography, interventional correction is necessary. Rebleeding, ascites regression and complications were observed during follow-up. Results 1. 10 patients were successfully operated at one time. The success rates of portal vein pressure before and after 100%.2.TIPS were 30. 80 卤4.83)mmHg and 18. 20 卤3.46)mmHg(lmmHg / 0.133 KPA, respectively. The paired t test showed that the portal vein pressure after shunt was reduced by 41. 17 卤8. 87 and 3. 10, respectively. The follow-up period ranged from 1 to 17 months (mean 218 days). During the follow-up, 1 case died of abdominal infection on 148 days after operation and 1 case developed spontaneous peritonitis and septic shock on 83 days after operation. After antiinfective treatment, one patient had aspirin induced ulcer bleeding 23 days after operation, the black stool disappeared after stopping aspirin, and the other 7 patients had repeated varicose venous bleeding. Within 1-3 months after operation, gastroscopy showed that the varicose veins were relieved or disappeared, and no symptoms such as hematemesis and black stool were found at the end of follow-up. No hepatic encephalopathy was found in all patients at the end of follow-up (or before death). ConclusionViatorr stent can keep the shunt patency for a long time, reduce the rate of rebleeding, and the complication rate of liver and brain after operation is low, which further ensures the effectiveness and safety of TIPS operation in patients with portal hypertension.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R575.2

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