概论 TIPS PARTO DIPS BRTO 经皮胃冠状静脉栓塞术


时间:2021-11-14 08:54来源:www.ynjr.net 作者:杨宁介入医学网
Hepatic cirrhosis is a chronic disease histologically characterized by the presence of regenerative nodules surrounded by diffuse fibrosis(21). 肝硬化是一种慢性疾病,其组织学特征是弥漫性再生结节周围的纤维化(21)。 It is the common final s
Hepatic cirrhosis is a chronic disease histologically characterized by the presence of regenerative nodules surrounded by diffuse fibrosis(21).
 It is the common final stage of several hepatic disorders of different etiologies, as ethylism (ethylism  ['eθɪlɪzəm] 乙醇中毒)and viral chronic hepatitis, besides metabolic, vascular or biliary(13).
The distortion of the hepatic architecture caused by cirrhosis leads to the increase of intrahepatic resistance resulting in portal hypertension(11, 21), being this its major complication with important clinical complications such as ascites, digestive hemorrhage by gastroesophageal varices, hypertensive gastropathy, congestive splenomegaly, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, change in the metabolism of drugs or endogenous substances which are usually eliminated by the liver(2).
Cirrhotic patients with portal hypertension present high prevalence of gastroesophageal varices rupture is one of the most severe and frequent complications being possible to occur in up to 40% of these patients(18).
High digestive bleeding is one of the main death causes in cirrhotic patients(29), with mortality around 30% in the course of acute hemorrhage and from 15% to 20% with adequate treatment.
The risk of rebleeding after the first hemorrhage episode within a year is from 60% to 80% associated with high morbimortality(18).
There are several factors associated with the risk of bleeding, and among them the portal pressure gradient > 12 mm Hg, hepatic dysfunction evaluated by Child-Pugh classification, varices caliber and continuous use of alcoholic drinks(9, 12).
Pressure of ascites, serous albumin < 3. 3g/dL and portal pressure gradient > 18 mm Hg are important risk factors associated with rebleeding(18).
There are many therapeutic options for the treatment of acute and recurrent varices bleeding, which include pharmacological, endoscopic treatment and the surgical portosystemic shunts(9, 11, 12, 23).
The transjugular intrahepatic portosystemic shunt (TIPS) appeared as a non-surgical option as treatment for portal hypertension complications due to the low level of morbimortality, possibility of performance in patients with severe hepatic dysfunction, and for being a minimally invasive procedure that can be carried out without the need of general anesthetics.

TIPS aim is to decompress the portal system, treating or reducing the complications of the portal hypertension.
 The procedure is carried out by intervening radiologic technique, with percutaneous puncture of the internal jugular vein and, creation of an intrahepatic communication between a branch of the portal vein and the hepatic vein with the insertion of an expandable metallic stent in the parenchymatous path(9), and its success rate is approximately 90%(3).
Despite TIPS success in decompressing portal vein, the hepatic function may worsen after the procedure, early mortality reported is from 3% to 44%(5, 20) and the mortality rate in one year is from 10% to 58%(5).
Recent studies show that factors associated with bad prognosis in patients who underwent TIPS include previous encephalopathy, Child-Pugh class C, emergency TIPS and MELD > 18, being these mortality predictors(5, 10, 20, 24, 28).
最近的研究表明,与TIPS患者不良预后相关的因素包括既往曾有肝性脑病发作、Child-Pugh C级、紧急TIPS和MELD>18,是这些死亡率预测因素(5,10,20,24,28)。
TIPS complications divide in those concerning its installation and immediate and late hemodynamic consequences which occur in about 10% of patients being mostly mild(6, 23).
More severe complications occur from 1% to 2% and include hemoperitoneum, sepsis, hemobilia, worsening of hepatic and cardiopulmonary insufficiency(23).
After the procedure, there may occur complications as lung acute edema, pneumonias, adult respiratory distress syndrome and kidney acute insufficiency(4).
Bacteremia or bacterial sepsis may also occur from 1% to 2% of cases, being necessary, before the procedure, perform antibiotic prophylaxis(22).
Among long term complications, the most common are hepatic encephalopathy which occurs in up to 30%(29) and stent dysfunction by stenosis (18% to 78%) or thrombosis (10% to 15%)(3).
 A metanalysis(29) showed that the most common cause of rebleeding in patients with TIPS is stent dysfunction and, that the rebleeding rate is progressive reaching up to 26% in 1 year and 32% in 2 years.
This study aimed at describing the profile, analyzing global and early mortality as well as the complications in cirrhotic patients who underwent TIPS as treatment for digestive hemorrhage by portal hypertension.

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