肝硬化共识.ppt

TIPS治疗肝硬化门静脉治疗肝硬化门静脉 高压症共识意见高压症共识意见 李安强 甘肃省人民医院 血管外科共识与指南一、一、一、一、TIPSTIPS适应证适应证适应证适应证 急性食管胃静脉曲张破裂出血急性食管胃静脉曲张破裂出血急性食管胃静脉曲张破裂出血急性食管胃静脉曲张破裂出血(EVGB)(EVGB)：6 6周内病死率周内病死率周内病死率周内病死率 约约20%20%。1.1.早期早期早期早期TIPSTIPS：即在大量出血后即在大量出血后72h72h内，将内，将TIPSTIPS作为抢救的一线方案。作为抢救的一线方案。Child-pugh CChild-pugh C级级(13(13 分分)可从早期可从早期TIPSTIPS中获益更多中获益更多优势：优势：成功率成功率95%95%，较药物及内镜更能有效控制致，较药物及内镜更能有效控制致 命大出血及减少再出血，减少重症监护及住院时命大出血及减少再出血，减少重症监护及住院时 间，显著提高生存率。间，显著提高生存率。2.2.补救性补救性补救性补救性TIPSTIPS：是药物联合内镜治疗失败的二线方案。是药物联合内镜治疗失败的二线方案。Bosch J,Abraldes JG,Groszman R.Current management of portal hypertension.J Hepatol.Bosch J,Abraldes JG,Groszman R.Current management of portal hypertension.J Hepatol.2003,38(spple)s54-682003,38(spple)s54-68Garcia-Pagan,J.C.,et al.,Garcia-Pagan,J.C.,et al.,Early use of TIPS in patients with cirrhosis and variceal bleeding.Early use of TIPS in patients with cirrhosis and variceal bleeding.n n engl j med,2010.engl j med,2010.362362(25):p.2370-9.(25):p.2370-9.共识与指南食管胃静脉曲张破裂出血食管胃静脉曲张破裂出血食管胃静脉曲张破裂出血食管胃静脉曲张破裂出血(EGVB)(EGVB)二级预防二级预防二级预防二级预防 急性食管胃静脉曲张出血停止后，患者发生再出血和死急性食管胃静脉曲张出血停止后，患者发生再出血和死亡的风险很大。对于未经治疗的患者，亡的风险很大。对于未经治疗的患者，1-21-2年内平均再出血年内平均再出血率为率为6060，死亡率可达，死亡率可达3333。内镜内镜内镜内镜/药物治疗为二级预防首选方案，药物治疗为二级预防首选方案，药物治疗为二级预防首选方案，药物治疗为二级预防首选方案，TIPSTIPS为二线方为二线方为二线方为二线方案。案。案。案。需要注意：需要注意：需要注意：需要注意：上述前瞻性上述前瞻性RCTRCT中相当一部分中相当一部分TIPSTIPS治疗使治疗使用的是裸支架，且支架直径扩张至用的是裸支架，且支架直径扩张至12mm12mm，而不是目前国内，而不是目前国内外广泛采用的外广泛采用的8-10mm8-10mm聚四氟乙烯聚四氟乙烯(PTFE)(PTFE)覆膜支架。覆膜支架。Luca,A.,et al.,Luca,A.,et al.,TIPS for prevention of recurrent bleeding in patients with TIPS for prevention of recurrent bleeding in patients with cirrhosis:meta-analysis of randomized clinical trials.cirrhosis:meta-analysis of randomized clinical trials.Radiology,1999.Radiology,1999.212212(2):p.411-(2):p.411-21.21.Burroughs,A.K.and M.Vangeli,Burroughs,A.K.and M.Vangeli,Transjugular intrahepatic portosystemic shunt Transjugular intrahepatic portosystemic shunt versus endoscopic therapy:randomized trials for secondary prophylaxis of variceal versus endoscopic therapy:randomized trials for secondary prophylaxis of variceal bleeding:an updated meta-analysis.bleeding:an updated meta-analysis.Scand J Gastroenterol,2002.Scand J Gastroenterol,2002.3737(3):p.249-52(3):p.249-52.共识与指南顽固性腹水顽固性腹水(Refractory ascites)平均生存期平均生存期平均生存期平均生存期6 6个月个月个月个月 肝硬化合并顽固性腹水，肝硬化合并顽固性腹水，TIPSTIPS应作为一线治疗方案。应作为一线治疗方案。应作为一线治疗方案。应作为一线治疗方案。TIPS TIPS不仅降低门静脉压力，缓解腹水，更重要是改善尿纳排泄和肾不仅降低门静脉压力，缓解腹水，更重要是改善尿纳排泄和肾脏功能脏功能。TIPS TIPS改善肝硬化合并顽固性腹水生存率优于腹腔穿刺放液改善肝硬化合并顽固性腹水生存率优于腹腔穿刺放液 (LVP)(LVP)。Rossle,M.and A.L.Gerbes,Rossle,M.and A.L.Gerbes,TIPS for the treatment of refractory ascites,hepatorenal TIPS for the treatment of refractory ascites,hepatorenal syndrome and hepatic hydrothorax:a critical update.syndrome and hepatic hydrothorax:a critical update.Gut,2010.59(7):p.988-1000.Gut,2010.59(7):p.988-1000.Salerno,F.,et al.,Salerno,F.,et al.,Randomized controlled study of TIPS versus paracentesis plus albumin Randomized controlled study of TIPS versus paracentesis plus albumin in cirrhosis with severe ascites.in cirrhosis with severe ascites.Hepatology,2004.40(3):p.629-35.Hepatology,2004.40(3):p.629-35.Salerno,F.,et al.,Salerno,F.,et al.,Transjugular intrahepatic portosystemic shunt for refractory ascites:a Transjugular intrahepatic portosystemic shunt for refractory ascites:a meta-analysis of individual patient data.meta-analysis of individual patient data.Gastroenterology,2007.133(3):p.825-34.Gastroenterology,2007.133(3):p.825-34.共识与指南 顽固性肝性胸水顽固性肝性胸水顽固性肝性胸水顽固性肝性胸水(Refractory hepatic hydrothorax)(Refractory hepatic hydrothorax)胸腔穿刺放胸水及利尿限盐等内科治疗是肝性胸水的主要治疗方法，胸腔穿刺放胸水及利尿限盐等内科治疗是肝性胸水的主要治疗方法，然而当患者进展为顽固性肝性胸水时上述手段往往无效并可能造成严重然而当患者进展为顽固性肝性胸水时上述手段往往无效并可能造成严重并发症。并发症。TIPS TIPS可缓解顽固性肝性胸水并减少需要行胸腔穿刺的次数。可缓解顽固性肝性胸水并减少需要行胸腔穿刺的次数。顽固性肝性胸水的有效治疗手段有限，顽固性肝性胸水的有效治疗手段有限，TIPSTIPS仍被视为是难治性肝性胸水的重要治疗手段。仍被视为是难治性肝性胸水的重要治疗手段。仍被视为是难治性肝性胸水的重要治疗手段。仍被视为是难治性肝性胸水的重要治疗手段。Gordon,F.D.,et al.,Gordon,F.D.,et al.,The successful treatment of symptomatic,refractory hepatic The successful treatment of symptomatic,refractory hepatic hydrothorax with transjugular intrahepatic portosystemic shunt.hydrothorax with transjugular intrahepatic portosystemic shunt.Hepatology,1997.Hepatology,1997.2525(6):p.1366-1369.(6):p.1366-1369.Siegerstetter,V.,et al.,Siegerstetter,V.,et al.,Treatment of refractory hepatic hydrothorax with Treatment of refractory hepatic hydrothorax with transjugular intrahepatic portosystemic shunt:long-term results in 40 patients.transjugular intrahepatic portosystemic shunt:long-term results in 40 patients.European European journal of gastroenterology&hepatology,2001.journal of gastroenterology&hepatology,2001.1313(5):p.529-534.(5):p.529-534.Spencer,E.B.,D.T.Cohen,and M.D.Darcy,Spencer,E.B.,D.T.Cohen,and M.D.Darcy,Safety and efficacy of transjugular Safety and efficacy of transjugular intrahepatic portosystemic shunt creation for the treatment of hepatic hydrothorax.intrahepatic portosystemic shunt creation for the treatment of hepatic hydrothorax.Journal of vascular and interventional radiology,2002.Journal of vascular and interventional radiology,2002.1313(4):p.385-390.(4):p.385-390.共识与指南布加综合征（布加综合征（布加综合征（布加综合征（Budd-Chiari SyndromeBudd-Chiari Syndrome，BCSBCS）BCSBCS指因肝静脉流出道狭窄或闭塞导致肝后性指因肝静脉流出道狭窄或闭塞导致肝后性门静脉高压和门静脉高压和/或下腔静脉高压为特点的临床症候群。或下腔静脉高压为特点的临床症候群。TIPS TIPS降低门静脉压力并改善肝脏充血，从而改降低门静脉压力并改善肝脏充血，从而改善肝功能并延长生存期。若无法顺利插管至肝静脉，善肝功能并延长生存期。若无法顺利插管至肝静脉，可经肝后段下腔静脉行直接可经肝后段下腔静脉行直接TIPSTIPS。TIPS TIPS 适于内科治疗或血管成形术无效的患者。适于内科治疗或血管成形术无效的患者。Garcia-Pagan,J.C.,et al.,Garcia-Pagan,J.C.,et al.,TIPS for Budd-Chiari syndrome:long-term TIPS for Budd-Chiari syndrome:long-term results and prognostics factors in 124 patients.results and prognostics factors in 124 patients.Gastroenterology,2008.Gastroenterology,2008.135135(3):p.808-15.(3):p.808-15.Seijo S,Plessier A,Hoekstra J,.et al.Good long term outcome of Seijo S,Plessier A,Hoekstra J,.et al.Good long term outcome of Budd Chiari syndrome with a step wise management.Hepatology Budd Chiari syndrome with a step wise management.Hepatology,2013,57(5):1962-1968,2013,57(5):1962-1968共识与指南共识与指南二、二、TIPS禁忌证禁忌证TIPS绝对禁忌症绝对禁忌症 未被证实的肝硬化门脉未被证实的肝硬化门脉高压症高压症TIPS相对禁忌症相对禁忌症 1）广泛的原发性肝脏肿瘤；）广泛的原发性肝脏肿瘤；2）胆道梗阻；）胆道梗阻；3）多囊性肝病；）多囊性肝病；4）门静脉海绵样变；）门静脉海绵样变；5）严重凝血障碍（）严重凝血障碍（INR5）；）；6）Child-Pugh评分评分13分；分；7）中度）中度肺动脉高压；肺动脉高压；8）严重的右心功能衰竭。）严重的右心功能衰竭。共识与指南共识与指南三、三、TIPS规范化操作流程规范化操作流程.CO2楔入法肝静脉造影楔入法肝静脉造影 确认肝静脉位置后，交换球囊导管，充盈球囊以肝静脉血流后经导管注入40-60ml CO2，即可清晰显示门静脉。操作时避免球囊导管插入肝静脉过深，以致肝包膜破裂或肝包膜下血肿形成。经验丰富的医师也可以普通导管楔入肝实质行CO2造影。共识与指南共识与指南门静脉穿刺解剖要点门静脉穿刺解剖要点 门脉右支一般在肝右静脉的前方，肝中静脉后方；而门脉左支则位于肝中静脉前方，肝左静脉后方。根据术前影像学检查和术前CO2造影可明确肝静脉、门静脉相对关系，指导门静脉穿刺方向。共识与指南共识与指南支架植入支架植入 国外普遍采用国外普遍采用PTFE覆膜覆膜Viatorr支架支架为为TIPS专用支架，其通畅性明显优于裸支专用支架，其通畅性明显优于裸支架。国内尚无架。国内尚无Viatorr支架，可以选用支架，可以选用PTFE覆膜覆膜Fluency支架。支架。TIPS术后术后HVPG，一般应下降至，一般应下降至12mmHg或较基线值下降或较基线值下降25%。（。（1 mmHg=0.133kpa)。共识与指南共识与指南四、四、四、四、TIPS TIPS 拓展技术拓展技术拓展技术拓展技术TIPSTIPS辅以曲张静脉血管内栓塞辅以曲张静脉血管内栓塞辅以曲张静脉血管内栓塞辅以曲张静脉血管内栓塞经下腔静脉直接门脉分流（经下腔静脉直接门脉分流（经下腔静脉直接门脉分流（经下腔静脉直接门脉分流（Direct intrahepatic Direct intrahepatic portocaval shunt,DIPS)portocaval shunt,DIPS)经肝段下腔静脉直接穿刺，经肝尾状叶实质穿刺门静脉。经肝段下腔静脉直接穿刺，经肝尾状叶实质穿刺门静脉。经皮经肝门静脉穿刺支架置入经皮经肝门静脉穿刺支架置入经皮经肝门静脉穿刺支架置入经皮经肝门静脉穿刺支架置入 Petersen B,Binker C.Intravascular ultrasound Petersen B,Binker C.Intravascular ultrasound guided direct intrahepatic portacaval guided direct intrahepatic portacaval shunt:midterm follow up.J Vasc Interv shunt:midterm follow up.J Vasc Interv Radiol.2004,15(9):927-938Radiol.2004,15(9):927-938 Fidelman N,Kwan SW,LaBerge JM,et al.The Fidelman N,Kwan SW,LaBerge JM,et al.The transjugular intrahepatic portosystemic shunt:an transjugular intrahepatic portosystemic shunt:an update.AJR Am J Roentgenol,2012,199(4):746-update.AJR Am J Roentgenol,2012,199(4):746-755755共识与指南共识与指南五、五、TIPS并发症的防治和管理并发症的防治和管理 TIPS的并发症包括操作相关、分流相关的并发症 操作相关的并发症操作相关的并发症 肝包膜穿刺伤最为常见，误穿肝动脉、肝内胆管及胆囊等偶有发生，大多并发症多可通过对症处理逐渐缓解，死于TIPS操作相关并发症的几率非常小（0.6%-4.3%）。Boyer TD,IIaskal ZJ.American Association for the study Boyer TD,IIaskal ZJ.American Association for the study of liver diseases.The role of transjugular intrahepatic portosystemic of liver diseases.The role of transjugular intrahepatic portosystemic shunt(TIPS)in the management of portal shunt(TIPS)in the management of portal hypertension:update.Hepatology,2010,51(1):306hypertension:update.Hepatology,2010,51(1):306共识与指南共识与指南TIPSTIPS术后常见并发症术后常见并发症术后常见并发症术后常见并发症 主要是分流道失效和肝性脑病主要是分流道失效和肝性脑病主要是分流道失效和肝性脑病主要是分流道失效和肝性脑病。1.1.分流道失效分流道失效分流道失效分流道失效多种原因可以造成多种原因可以造成TIPSTIPS分流道分流道阻塞或狭窄阻塞或狭窄 致分流道失效，包括支架内急性血栓致分流道失效，包括支架内急性血栓的形成和假性内膜增生。的形成和假性内膜增生。支架内假性内膜过度增生是导致支架狭窄的支架内假性内膜过度增生是导致支架狭窄的主要原因主要原因，病理结果显示狭窄，病理结果显示狭窄/闭塞的支架被上皮闭塞的支架被上皮细胞及富含胶质的基质所覆盖，其机制尚不完全明细胞及富含胶质的基质所覆盖，其机制尚不完全明确。一般认为与分流道表面不光滑，高速血流对肝确。一般认为与分流道表面不光滑，高速血流对肝实质和肝静脉的长期刺激和损伤，以及支架本身的实质和肝静脉的长期刺激和损伤，以及支架本身的生物相容性差有关。生物相容性差有关。Ducoin,H.,et al.,Ducoin,H.,et al.,Histopathologic analysis of transjugular Histopathologic analysis of transjugular intrahepatic portosystemic shunts.intrahepatic portosystemic shunts.Hepatology,1997.Hepatology,1997.2525(5):p.(5):p.1064-9.1064-9.共识与指南共识与指南2.肝性脑病肝性脑病 分流道增加外周血氨的浓度，导致分流相关肝性脑病（HE）的发生。TIPS术后新发或肝性脑病加重的概率为20-50%。只有术后严格的限制蛋白摄入，保持大便通畅可能会适当的减少HE的发生。Riggio,O.,et al.,Riggio,O.,et al.,Pharmacological prophylaxis of hepatic Pharmacological prophylaxis of hepatic encephalopathy after transjugular intrahepatic portosystemic encephalopathy after transjugular intrahepatic portosystemic shunt:a randomized controlled study.shunt:a randomized controlled study.J Hepatol,2005.J Hepatol,2005.4242(5):p.(5):p.674-9.674-9.谢谢谢谢