Sterling K M, Darcy M D
Division of Vascular and Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO 63110, USA.
AJR Am J Roentgenol. 1997 Jan;168(1):239-44. doi: 10.2214/ajr.168.1.8976952.
The purpose of this study was to define the incidence, nature, and presentation of stenoses that develop in patients with transjugular intrahepatic portosystemic shunts (TIPS) and to assess the efficacy of treatment that prolongs shunt patency.
TIPS were successfully created in 108 patients over a 43-month period. Of the 93 patients with adequate radiologic or pathologic follow-up, 60 had no shunt problems and 33 developed shunt stenoses or occlusions. Follow-up of these 93 patients included sonography, venography, and/or pathologic confirmation. Presentations of stenoses, types of therapy, and patency after treatment were evaluated in all patients.
In the cohort group, 35% of the patients had shunt problems (mean time to presentation, 7.4 months after TIPS). Forty stenoses and eight occlusions occurred in the 33 patients. Of the 48 shunt problems, 35 (73%) were detected with routine radiologic screening, 12 (25%) presented with recurrent symptoms, and one (2%) was confirmed by pathologic evaluation. Of the 33 patients with stenoses and occlusions, 21 had one reintervention, six had two reinterventions, three had three reinterventions, one had four reinterventions, and two received no therapy. These reinterventions included 30 restentings, 11 angioplasties, four new shunts, and one thrombolysis alone. Of the 31 primary reinterventions, 23 (74%) were restentings, six (19%) were angioplasties, and two patients received a new TIPS. Of the 10 secondary reinterventions, six were restentings, three were angioplasties, and one was a new TIPS. Of the four tertiary reinterventions, one was a restenting, two were angioplasties, and one was thrombolysis. Kaplan-Meier survival analysis revealed the primary patency of the shunt to be 67% at 6 months, 48% at 1 year, and 26% at 2 years. The primary-assisted patency of the shunt was 96% at 6 months and 87% at 3 years. The secondary patency was 99% at 1 year and 89% at 3 years.
Stenoses are common after TIPS procedures and frequently can be detected on routine screening studies. Shunt revision can effectively extend the patency of TIPS. Restenting is generally required for hepatic vein stenoses. Angioplasty should be the first line of therapy for intrashunt stenoses, as only 44% of patients will require restenting.
本研究旨在明确经颈静脉肝内门体分流术（TIPS）患者中发生的狭窄的发生率、性质及表现，并评估延长分流道通畅性的治疗效果。
在43个月期间，108例患者成功接受了TIPS手术。在93例有充分影像学或病理学随访的患者中，60例无分流道问题，33例出现分流道狭窄或闭塞。对这93例患者的随访包括超声检查、静脉造影和/或病理学证实。评估了所有患者狭窄的表现、治疗类型及治疗后的通畅情况。
在队列组中，35%的患者出现分流道问题（出现问题的平均时间为TIPS术后7.4个月）。33例患者中发生了40处狭窄和8处闭塞。在48例分流道问题中，35例（73%）通过常规影像学筛查发现；12例（25%）出现复发症状；1例（2%）经病理学评估证实。在33例发生狭窄和闭塞的患者中，21例接受了1次再次干预，6例接受了2次再次干预，3例接受了3次再次干预，1例接受了4次再次干预，2例未接受治疗。这些再次干预包括30次支架植入、11次血管成形术、4次新的分流术和1次单纯溶栓治疗。在31例初次再次干预中，23例（74%）为支架植入，6例（19%）为血管成形术，2例患者接受了新的TIPS。在10例二次再次干预中，6例为支架植入，3例为血管成形术，1例为新的TIPS。在4例三次再次干预中，1例为支架植入，2例为血管成形术，1例为溶栓治疗。Kaplan-Meier生存分析显示，分流道的初次通畅率在6个月时为67%，1年时为48%，2年时为26%。分流道的初次辅助通畅率在6个月时为96%，3年时为87%。二次通畅率在1年时为99%，3年时为89%。
TIPS术后狭窄常见，且常可在常规筛查研究中发现。分流道修复可有效延长TIPS的通畅性。肝静脉狭窄通常需要支架植入。血管成形术应作为分流道内狭窄的一线治疗方法，因为只有44%的患者需要支架植入。
