经颈静脉肝内门体分流术后分流道失功再通肝硬化患者预后影响因素分析

张晓丰; 张玮; 于之源; 诸葛宇征

doi:10.3969/j.issn.1001-5256.2020.02.021

经颈静脉肝内门体分流术后分流道失功再通肝硬化患者预后影响因素分析

DOI: 10.3969/j.issn.1001-5256.2020.02.021

1. 南京大学医学院
2. 南京大学医学院附属鼓楼医院消化科

基金项目:

国家自然科学基金(8157040652)；

详细信息

中图分类号: R575.2
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出版历程
- 收稿日期: 2019-09-06
- 出版日期: 2020-02-20

Prognostic and risk factors for patients undergoing recanalization due to shunt dysfunction after transjugular intrahepatic portosystemic shunt

Nanjing University Medical School

Research funding:

摘要

摘要:
目的探讨影响经颈静脉肝内门体分流术（TIPS）后分流道失功行再通的肝硬化患者的预后及危险因素分析。方法回顾性分析2013年1月-2019年2月南京大学医学院附属鼓楼医院收治的因肝硬化食管胃底静脉曲张破裂出血行TIPS术,且术后因分流道失功行再通的69例患者的临床资料,包括患者初次TIPS和再通术中、术前及术后资料;支架参数、门静脉压力梯度、门静脉穿刺部位、实验室指标等。Kaplan-Meier曲线评估再通后患者的累积分流道失功率和生存率,2组间累积通畅率比较采用logrank检验。Cox回归模型分析影响再通患者术后发生分流道再失功和生存的影响因素。结果 69例患者再通术后28例（40. 6%）发生再失功,15例（21. 7%）死亡。再失功中位时间11. 3个月。患者1、2、3、5年再失功的累积发生率分别为29. 8%、41. 6%、48. 0%、52. 7%,累积生存率分别为96. 9%、94. 8%、83. 0%和62. 6%。单纯行支架内球囊扩张术患者与行支架置入术患者累积通畅率比较差异有统计学意义（χ2=9. 494,P=0. 009）。初次TIPS前肝功能CTP分级、初次手术支...
- 肝硬化 /
- 门体分流术,经颈静脉肝内 /
- 预后
Abstract:
Objective To investigate the prognostic and risk factors for cirrhotic patients undergoing recanalization due to shunt dysfunction after transjugular intrahepatic portosystemic shunt( TIPS). Methods A retrospective analysis was performed for the clinical data of 69 cirrhotic patients who were admitted to Affiliated Drum Tower Hospital of Nanjing University Medical School from January 2013 to February2019 and underwent TIPS due to esophagogastric variceal bleeding and recanalization due to shunt dysfunction after TIPS. Related clinical data included preoperative,intraoperative,and postoperative data of TIPS and recanalization,stent parameters,hepatic venous pressure gradient,site of puncture of the portal vein,and laboratory markers. The Kaplan-Meier curve was used to evaluate the cumulative rate of shunt dysfunction and cumulative survival rate after recanalization,and the log-rank test was used for comparison of cumulative patency rate between two groups. The Cox regression model was used to investigate the influencing factors for secondary shunt dysfunction and survival after recanalization. Results Of all patients undergoing recanalization,28( 40. 6%) experienced secondary shunt dysfunction and 15( 21. 7%) died. The median time to secondary shunt dysfunction was 11. 3 months. The 1-,2-,3-,and 5-year cumulative incidence rates of secondary shunt dysfunction were 29. 8%,41. 6%,48. 0%,and 52. 7%,respectively,and the 1-,2-,3-,and 5-year cumulative survival rates were 96. 9%,94. 8%,83. 0%,and 62. 6%,respectively. There was a significant difference in cumulative patency rate between the patients undergoing balloon dilatation of stent alone and those undergoing stent implantation( χ2= 9. 494,P = 0. 009).Child-Turcotte-Pugh( CTP) grade before first TIPS,stent diameter for first surgery,and international normalized ratio( INR) and prothrombin time( PT) before recanalization were associated with secondary shunt dysfunction( all P < 0. 05),and an increase in INR before recanalization was an independent risk factor for secondary shunt dysfunction( hazard ratio [HR]= 4. 398,95% confidence interval [CI]:1. 848-10. 467,P = 0. 001),while stent implantation during recanalization was an independent protective predictor against secondary shunt dysfunction( HR = 0. 370,95% CI: 0. 194-0. 704,P = 0. 002). CTP grade before first TIPS and Model for End-Stage Liver Disease( MELD) score were associated with patients' survival after recanalization( both P < 0. 05),and an increase in MELD score was the only independent risk factor for death after recanalization( HR = 1. 293,95% CI: 1. 054-1. 627,P = 0. 026). Conclusion For patients undergoing recanalization due to shunt dysfunction after TIPS,stent implantation during recanalization is a reasonable choice,while an increase in MELD score is associated with poor prognosis of patients.
- liver cirrhosis /
- portasystemic shunt,transjugular intrahepatic /
- prognosis

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参考文献(24)

[1] YANG LY. Attention to the surgical treatment of portal hypertension in China[J]. Chin J Dig Surg,2018,17(10):971-975.(in Chinese)杨连粤．重视我国门静脉高压症外科治疗的问题[J]．中华消化外科杂志，2018,17(10):971-975.

[2] GARCIA-TSAO G,ABRALDES JG,BERZIGOTTI A,et al.Portal hypertensive bleeding in cirrhosis:Risk stratification,diagnosis,and management:2016 practice guidance by the American Association for the study of liver diseases[J]. Hepatology,2017,65(1):310-335.

[3] LV Y,QI X,HE C,et al. Covered TIPS versus endoscopic band ligation plus propranolol for the prevention of variceal rebleeding in cirrhotic patients with portal vein thrombosis:A randomised controlled trial[J]. Gut,2018,67(12):2156-2168.

[4] SANYAL AJ,FREEDMAN AM,LUKETIC VA,et al. The natural history of poral hypertension after transjugular intrahepatic portosystemic shunts[J]. Gastroenterology,1997,112(3):889-898.

[5] TAN HK,JAMES PD,SNIDERMAN KW,et al. Long-term clinical outcome of patients with cirrhosis and refractory ascites treated with transjugular intrahepatic portosystemic shunt insertion[J]. J Gastroenterol Hepatol,2015,30(2):389-395.

[6] RÖSSLE M. TIPS:25 years later[J]. J Hepatol,2013,59(5):1081-1093.

[7] PERARNAU JM,LE GOUGE A,NICOLAS C,et al. Covered vs. uncovered stents for transjugular intrahepatic portosystemic shunt:A randomized controlled trial[J]. J Hepatol,2014,60(5):962-968.

[8] DING ZF,YIN SW. Application of Viatorr covered stent in transjugular intrahepatic portosystemic shunt[J]. J Clin Hepatol,2018,34(5):1007-1110.(in Chinese)丁智锋，殷世武．Viatorr覆膜支架在经颈静脉肝内门体分流术中的应用现状[J]．临床肝胆病杂志，2018,34(5):1107-1110.

[9] HAN G,QI X,HE C,et al. Transjugular intrahepatic portosystemic shunt for portal vein thrombosis with symptomatic portal hypertension in liver cirrhosis[J]. J Hepatol,2011,54(1):78-88.

[10] NICOLAS C,D’ALTEROCHE L,PERARNAU JM. Reply to:“Shunt dysfunction:Is it suitable as the primary end point in transjugular intrahepatic portosystemic shunt trials?”[J]. J Hepatol,2015,62(1):247-248.

[11] CHEN Q,ZHANG Y,YUE ZD,et al. Clinical efficacy of transjugular intrahepatic portosystemic shunting for recurrent portal hypertension after liver transplantation[J]. Chin J Dig Surg,2018,17(10):1013-1017.(in Chinese)陈权，张裕，岳振东，等．经颈静脉肝内门体分流术治疗肝移植术后再发门静脉高压症的临床疗效[J]．中华消化外科杂志，2018,17(10):1013-1017.

[12] KHAN S,TUDUR SC,WILLIAMSON P,et al. Portosystemic shunts versus endoscopic therapy for variceal rebleeding in patients with cirrhosis[J]. Cochrane Database Syst Rev,2006(4):CD000553.

[13] SAXON RR,MENDEL-HARTVIG J,CORLESS CL,et al. Bile duct injury as a major cause of stenosis and occlusion in transjugular intrahepatic portosystemic shunts:Comparative histopathologic analysis in humans and swine[J]. J Vasc Interv Radiol,1996,7(4):487-497.

[14] SZE DY,VESTRING T,LIDDELL RP,et al. Recurrent TIPS failure associated with biliary fistulae:Treatment with PTFEcovered stents[J]. Cardiovasc Intervent Radiol,1999,22(4):298-304.

[15] DUCOIN H,EL-KHOURY J,ROUSSEAU H,et al. Histopathologic analysis of transjugular intrahepatic portosystemic shunts[J]. Hepatology,1997,25(5):1064-1069.

[16] TRIPATHI D,HELMY A,MACBETH K,et al. Ten years’follow-up of 472 patients following transjugular intrahepatic portosystemic stent-shunt insertion at a single centre[J]. Eur J Gastroenterol Hepatol,2004,16(1):9-18.

[17] JIRKOVSKY V,FEJFAR T,SAFKA V,et al. Influence of the secondary deployment of expanded polytetrafluoroethylene–covered stent grafts on maintenance of transjugular intrahepatic portosystemic shunt patency[J]. J Vasc Interv Radiol,2011,22(1):55-60.

[18] THEN EO,ARE VS,LOPEZ-LUCIANO M,et al. Elevated international normalized ratio:A risk factor for portal vein thrombosis in cirrhotic patients[J]. Gastroenterology Res,2019,12(3):135-140.

[19] GOU YY,HE S,WU KL,et al. Clinical features and treatment of 160 cases of liver cirrhosis with portal vein thrombosis[J].Chin J Dig,2018,38(7):455-460.(in Chinese)苟园园，何松，吴开玲，等．肝硬化门静脉血栓160例的临床特点和治疗分析[J]．中华消化杂志，2018,38(7):455-460.

[20] HARDING DJ,PERERA MT,CHEN F,et al. Portal vein thrombosis in cirrhosis:Controversies and latest developments[J].World J Gastroenterol,2015,21(22):6769-6784.

[21] LV Y,HE C,WANG Z,et al. Association of nonmalignant portal vein thrombosis and outcomes after transjugular intrahepatic portosystemic shunt in patients with cirrhosis[J]. Radiology,2017,285(3):999-1010.

[22] WANG Q,LV Y,BAI M,et al. Eight millimetre covered TIPS does not compromise shunt function but reduces hepatic encephalopathy in preventing variceal rebleeding[J]. J Hepatol,2017,67(3):508-516.

[23] REVERTER E,TANDON P,AUGUSTIN S,et al. A MELDbased model to determine risk of mortality among patients with acute variceal bleeding[J]. Gastroenterology,2014,146(2):412-419.

[24] CASADABAN LC,PARVINIAN A,ZIVIN SP,et al. MELD score for prediction of survival after emergent TIPS for acute variceal hemorrhage:Derivation and validation in a 101-patient cohort[J].Ann Hepatol,2015,14(3):380-388.

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