基本技术简介 颈内静脉穿刺 肝静脉导管术 门静脉穿刺技术门静脉侧支循环的栓塞 分流支撑架的释放 即时疗效判定 颈静脉鞘管的拔除
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门静脉侧支循环的栓塞

时间:2021-09-01 08:43来源:www.ynjr.net 作者:杨宁介入医学网
应通过已置入门静脉主支深部的10F导管鞘插入行胃冠状静脉等侧支循环的导管。这是因为导管鞘使导管可自由移动,通过这一导管鞘还可以取出被意外释放的弹簧栓子,而不影响门静脉插管本身。超硬导丝还可通过该10F导管鞘平行于5-6.5F导管插入肠系膜上静脉
Persistence of varices after deployment of TIPS can potentially cause recurrent variceal bleeding, especially in cases where adequate reduction of PSPG could not be achieved.
使用TIPS后持续使用静脉曲张可能导致反复出现静脉曲张出血,特别是在无法充分减少PSPG的情况下。
 
 Few retrospective studies and one RCT have explored this aspect of the TIPS procedure[229-234].
很少有回顾性研究和一项随机对照试验对TIPS在这方面进行了探索[229-234]。
 
 Angiographic filling of varices despite the adequate reduction of PSPG, presence of gastric or ectopic varices, and suboptimal reduction of PSPG after TIPS have been identified as some of the clinical situations in which patients may benefit from concomitant embolization of varices[229].
尽管PSPG充分减少,血管造影显示胃或异位静脉曲张仍然存在,和TIPS后PSPG降低不佳已被确定,某些临床情况,其中患者可能从[229]静脉曲张栓塞中获益。
 
 Recently, a prospective RCT of 106 patients from China compared TIPS alone with TIPS and coronary vein embolization to assess the rates of rebleeding and stent dysfunction[232].
最近,一项来自中国的106例患者的前瞻性随机对照试验比较了单纯TIPS单独与TIPS和冠状动脉栓塞,以评估再出血和支架功能障碍[232]的发生率。
 
 They found that the cumulative rates of recurrent variceal bleeding in the two groups were not significantly different, except at 6 mo, when the bleeding rate in the embolotherapy group was 2.5-fold lower than that in the TIPS group, without any survival advantage.
他们发现,复发性静脉曲张出血累积发生率两组静脉曲张复发出血的累积发生率没有显著差异。当第6个月,当时的TIPS辅助侧支循环栓塞组(复发性出血率)比TIPS组低2.5倍,没有任何生存优势
 
Interestingly, the primary stent patency rates in the adjunctive embolization group were higher than the TIPS group at 6 mo.
有趣的是,辅助栓塞组在6个月时的主要支架通畅率高于TIPS组。
 
 This was attributed to the increased antegrade flow in the TIPS shunt due to the embolization of the varices.
这是由于静脉曲张栓塞导致TIPS分流的顺行血流增加。
 
 However, the incidence of stent dysfunction in the TIPS group in this study at 6 mo (18%) was worse than the 1-year incidence of shunt dysfunction (12.8%) reported by another RCT from Europe in which majority of the patients underwent placement of covered TIPS stents for variceal bleeding.
然而,在本研究中,TIPS组在6个月时支架功能障碍的发生率(18%)比1年分流功能障碍的发生率(12.8%)差,由来自欧洲的另一组RCT研究,多数静脉曲张出血患者进行了覆膜支架TIPS治疗
 
 
 One reason for this discrepancy could be that Fluency® stents, instead of Viatorr®, were used for TIPS creation in the Chinese study, which tends to have a higher rate of dysfunction.
造成这种差异的一个原因可能是,在中国的研究中,使用 Fluency® 支架而不是Viatorr®支架的TIPS,这往往有更高的功能障碍率(18%)。
 
 A meta-analysis of these studies suggested that the incidence of variceal rebleeding was significantly less in the group who underwent concomitant variceal embolization with TIPS[234].
对这些研究的荟萃分析表明,在接受TIPS[234]合并静脉曲张栓塞的组中,静脉曲张再出血的发生率明显较低。

 

It is generally accepted that liquid embolic agents should be used along with coils to achieve effective occlusion of the afferent veins as well as the variceal complex and prevent the persistent filling of varices.
一般普遍认为,液体栓塞剂应与线圈一起使用,以实现传入静脉和静脉曲张复合物的有效闭塞,并防止静脉曲张的持续充盈。
 
 However, many studies have reported the use of coils alone for embolization[229].
然而,许多研究已经报道了单独使用弹簧栓子来栓塞[229]。
 
 Proximal embolization of the afferent vessels using only coils potentially allows persistent variceal perfusion via collaterals and has poor outcomes.
仅使用线圈对传入血管进行近端栓塞,可能允许通过侧支持续进行静脉曲张灌注,且预后较差。
 
 Embolization before TIPS insertion allows for better visualization of collateral vessels, which may decompress after shunt creation.
在TIPS插入前的栓塞可以更好地可视化侧支血管,这可能会在TIPS分流创建后解压。(先TIPS后栓塞侧支循环显示不好影响栓塞效果?)
 
 Furthermore, a patent TIPS stent represents a potential channel for systemic non-target embolization of misplaced coils or liquid embolic material into the pulmonary circulation.
此外,TIPS支架是弹簧栓子或液体栓塞材料进入肺循环的潜在通道。(但TIPS前栓塞侧支循环潜在导致弹簧栓子或液体栓塞剂进入门静脉,理想的可能是球囊或弹簧栓子阻塞栓塞BRTO,CARTO,PARTO)
 
On the other hand, post-stent embolization allows the operator to determine the effect of PSPG reduction on the filling of varices.
另一方面,支架后栓塞使操作者能够确定PSPG减少对静脉曲张充盈的影响。(PSPG降下来,无论充分与否,静脉曲张充盈理论上都减少,确定后又咋样?还充盈就栓塞,不充盈就不栓塞?)
 
 It is suggested that the use of extensive adjunctive variceal embolotherapy theoretically allows for the use of a smaller shunt diameter, which may lower rates of post-procedure encephalopathy[229].
研究表明,使用广泛的辅助静脉曲张栓塞治疗在理论上允许使用直径较小的分流支架,这可能会降低术后脑病[229]的发生率。(此屁有理)
 
 However, the embolization of varices may lead to an increase in portal pressure necessitating placement of larger shunt for adequate decompression.
然而,静脉曲张的栓塞可能会导致门静脉压力的增加,因此需要放置更大的分流器以进行充分的减压。(骑虎难下,进退无据)
 
 Based on current evidence, adjunctive variceal embolization can be considered in patients in whom the target PSPG reduction could not be achieved after TIPS stent placement or when the persistent filling of variceal channels is noted on completion splenoportogram.
基于目前的证据,对于在TIPS支架放置后无法实现目标PSPG降低或在完成脾门静脉造影术时发现静脉曲张通道持续充盈的患者,可以考虑辅助静脉曲张栓塞。(侧支循环还显影就不栓塞,为嘛?)
 
 It is important to note that the completion splenoportogram should be obtained from the catheter tip at the splenic vein near the splenic hilum to optimally assess the presence or absence of variceal filling after TIPS.
值得注意的是,应从脾门附近的导管尖端获得完整的脾静脉造影,以最佳评估TIPS后是否有静脉曲张填充。
 
 Pre-existing large spontaneous portosystemic shunts can compete with the antegrade flow in the TIPS stent and theoretically lead to early stent dysfunction in addition to increasing the incidence of HE.
先前存在的大型自发性门隙系统分流(胃肾分流?)可以与TIPS支架中的顺行血流竞争,理论上除了增加HE的发生率外,还会导致早期支架功能障碍。
 
 While there are no dedicated studies to assess this aspect of TIPS, it is generally accepted that any large accessible portosystemic shunts should be embolized during TIPS.
虽然没有专门的研究来评估TIPS的这方面,但人们普遍认为在TIPS时的这种分流都应栓塞。







       应通过已置入门静脉主支深部的10F导管鞘,插入行胃冠状静脉等侧支循环的导管。这是因为导管鞘使导管可自由移动,通过这一导管鞘还可以取出被意外释放的弹簧栓子,而不影响门静脉插管本身。超硬导丝还可通过该10F导管鞘平行于5~6.5F导管插入肠系膜上静脉,已保持门静脉插管的稳定。

       选择曲张静脉插管的导管形状取决于其起源静脉的直径(门静脉主支或脾静脉)及侧支起源的方向。胃左静脉栓塞最常使用的导管为Cobra导管(Rosch celiac; 6.5F Cook)。该导管可用于导入Gianturco螺圈(MWCE, Cook)或Amplatzer(下图)[1,2],当使用丙烯酸胶时(Histoacryl blue, B Braun, 德国),用引导同轴微导管。使用任何一种技术都需要经验。最常见的并发症是弹簧栓子放置错误或意外逸出至门静脉或不小心将用于栓塞的胶注入门静脉。因此,应在分流建立完成前栓塞这些病变。避免放置错误的弹簧栓子或丙烯酸胶栓子陷于门脉系统后移至肺部。

 

Amplatzer栓塞门静脉侧支循环[1,2]

TIPS术后显示胃冠状静脉及食道静脉曲张 经导管用1个AVP II 18mm进行胃冠状静脉栓塞 造影显示胃冠状静脉阻塞

 

       巨大分流的栓塞(一些自发脾肾分流)推荐使用反向方案。在分流通道完全以支架支撑后栓塞这些病变。导管应置于侧支深部以免闭塞脾静脉。可使用巨大Gianturco螺圈,联合使用或不使用胶。历史文献的记录中有作者取出可抽出核芯的导丝的长段进行栓塞。积极栓塞门腔侧支的一种可能的禁忌症为即将接受肝移植的病例。缺乏开放的侧支在肝移植手术的无肝期可能导致更为严重的肠道水肿和出血。

1. Pattynama and al, CVIR (2007) 30: 1218-1221.
2. Kessler and al, JVIR (2006) 17: 135-140.

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