Department of Radiology, McMaster University Medical Center, Hamilton Health Sciences, Hamilton, Ontario, Canada.
Radiographics. 2013 Sep-Oct;33(5):1473-96. doi: 10.1148/rg.335125166.
Management of clinically important sequelae of portal hypertension, such as variceal bleeding and ascites, may involve a combination of medical, endoscopic, surgical, and interventional approaches and procedures. Although clinically significant esophageal and rectal varices are typically visible endoscopically, ectopic varices may require multiplanar portal venous phase computed tomography or magnetic resonance imaging for diagnosis. A detailed understanding of individual vascular anatomy, flow dynamics, and patient-related factors such as cardiac and hepatic status is necessary for appropriate treatment selection in patients with complicated portal hypertension. The hepatic venous pressure gradient is the key indirect measurement of portal venous pressure. Transjugular intrahepatic portosystemic shunt (TIPS) placement is regarded as the archetypal intervention for treating complicated portal hypertension by reducing portal pressure. Various modifications, such as direct portocaval shunt, may be used in patients with challenging vascular anatomy. A subset of patients with obstructed hepatic venous outflow or portal venous inflow should be considered for recanalization. Splenic artery embolization may be considered for reduction of portal pressure in selected patients, particularly when hypersplenism or splenic vein occlusion is a prominent feature. Gastric and ectopic varices may bleed even when the portal pressure is low, and balloon-occluded retrograde transvenous obliteration (BRTO) in such patients may lead to equal or improved outcome compared with TIPS placement. BRTO is not limited by poor hepatic reserve or encephalopathy; however, it does not reduce portal pressure and may aggravate esophageal varices. Interventional radiology plays an important role in maintaining the patency of surgically created portosystemic shunts, and it remains at the forefront of new approaches in shunt design and placement. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.335125166/-/DC1.
门脉高压症的临床重要后遗症的管理，如静脉曲张出血和腹水，可能涉及医学、内镜、手术和介入方法和程序的结合。虽然临床上明显的食管和直肠静脉曲张通常可以通过内镜观察到，但异位静脉曲张可能需要多平面门静脉相计算机断层扫描或磁共振成像进行诊断。为了在复杂门脉高压症患者中进行适当的治疗选择，需要详细了解个体血管解剖结构、血流动力学以及与心脏和肝脏状态等患者相关的因素。肝静脉压力梯度是门脉压力的关键间接测量。经颈静脉肝内门体分流术（TIPS）的放置被认为是通过降低门脉压力来治疗复杂门脉高压症的典型干预措施。各种改良方法，如直接门腔分流术，可用于血管解剖结构具有挑战性的患者。部分肝静脉流出道或门静脉流入道阻塞的患者应考虑进行再通。脾动脉栓塞术可用于降低选定患者的门脉压力，特别是当存在脾功能亢进或脾静脉阻塞时。即使门脉压力较低，胃和异位静脉曲张也可能出血，并且在这些患者中，球囊阻塞逆行经静脉闭塞（BRTO）可能与 TIPS 放置具有同等或更好的效果。BRTO 不受肝储备或脑病的限制；然而，它不会降低门脉压力，并且可能会加重食管静脉曲张。介入放射学在维持手术创建的门体分流术的通畅性方面发挥着重要作用，并且它仍然处于分流术设计和放置的新方法的前沿。补充材料可在 http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.335125166/-/DC1 获得。
