经颈静脉肝内门体分流术治疗静脉曲张出血。

The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding.

作者信息

Rössle M, Haag K, Ochs A, Sellinger M, Nöldge G, Perarnau J M, Berger E, Blum U, Gabelmann A, Hauenstein K

机构信息

Medizinische Universitätsklinik, Freiburg, Germany.

出版信息

N Engl J Med. 1994 Jan 20;330(3):165-71. doi: 10.1056/NEJM199401203300303.

DOI:10.1056/NEJM199401203300303

PMID:8264738

Abstract

BACKGROUND

Transjugular placement of an intrahepatic stent is a new technique to establish a portosystemic shunt for treatment of portal hypertension. A puncture needle is advanced in a catheter through the inferior vena cava into a hepatic vein; then an intrahepatic branch of the portal vein is punctured and an expandable stent of metallic mesh is implanted to establish the shunt.

METHODS

We attempted the stent-shunt procedure in 100 of 112 consecutive patients with variceal bleeding due to cirrhosis, who were then followed for a mean (+/- SD) of 12 +/- 6 months. Of the 100 patients, 22 had Child-Pugh class C cirrhosis, 10 were treated on an emergency basis, and 68 had alcoholic cirrhosis. The shunt was established with use of Palmaz stents expanded to 8 to 12 mm in diameter.

RESULTS

Technical success was achieved in 93 percent of the patients. The mean (+/- SD) time for the procedure was 1.2 +/- 0.3 hours. The shunt reduced the portal venous pressure gradient by 57 percent. Major complications were hemorrhage (intraabdominal bleeding in six patients, biliary bleeding in four, and bleeding in the liver capsule in three) and migration of the stent into the pulmonary artery (in two patients). At follow-up, stenosis of the shunt was evident in 21 patients and occlusion in 10 patients; 10 of these 31 patients had variceal rebleeding. Stenoses and occlusions of the shunt were all treated successfully by redilation, thrombolysis, or implantation of an additional stent. Hepatic encephalopathy (stages I to III) developed in 25 percent of the patients. The proportion of patients with shunts who remained free of variceal rebleeding was 92 percent at six months and 82 percent at one year. The 30-day mortality was 3 percent. The cumulative one-year survival was 85 percent.

CONCLUSIONS

These results suggest that the transjugular placement of an intrahepatic portosystemic stent is an effective and safe treatment for variceal hemorrhage in patients with portal hypertension due to cirrhosis.

摘要

背景

经颈静脉肝内支架置入术是一种建立门体分流以治疗门静脉高压症的新技术。穿刺针通过导管经下腔静脉进入肝静脉；然后穿刺门静脉的肝内分支并植入金属网可扩张支架以建立分流。

方法

我们对112例因肝硬化导致静脉曲张出血的连续患者中的100例尝试了支架分流手术，随后对这些患者进行了平均（±标准差）12±6个月的随访。在这100例患者中，22例为Child-Pugh C级肝硬化，10例为急诊治疗，68例为酒精性肝硬化。使用直径扩张至8至12毫米的Palmaz支架建立分流。

结果

93%的患者手术获得技术成功。手术的平均（±标准差）时间为1.2±0.3小时。分流使门静脉压力梯度降低了57%。主要并发症为出血（6例腹腔内出血、4例胆道出血、3例肝包膜出血）和支架移入肺动脉（2例患者）。随访时，21例患者分流明显狭窄，10例患者分流闭塞；这31例患者中有10例发生静脉曲张再出血。分流的狭窄和闭塞均通过再次扩张、溶栓或植入额外支架成功治疗。25%的患者发生肝性脑病（I至III期）。分流患者在6个月时无静脉曲张再出血的比例为92%，1年时为82%。30天死亡率为3%。一年累积生存率为85%。