Transjugular intrahepatic stent portosystemic shunt is developed on the basis of the increasingly mature technology of transjugular portography and percutaneous transjugular liver puncture. The breakthrough of intrahepatic stent portosystemic shunt via jugular vein lies in the popularization and application of metallic stent. The metallic stent was used to support the intrahepatic shunt, which remained unobstructed for a long time (19 ~ 48 weeks), and the inner surface of the stent was covered with a thin intima of 1 ~ 1.5 mm after 4 weeks.
in 198, Eckhauser and others studied the pathological changes of liver to observe the prognosis of surgical shunt, and found that there were mallory bodies in liver biopsy, also known as cherry bodies. The survival rates of cherry bodies at 3 months, 1 year and 5 years after operation were 6%, 1%, 5% and 89.85%, 74.7% and 45.39%, respectively, indicating that cherry bodies has unique value in predicting the prognosis and evaluating the long-term effect after shunt. Cherry bodies can occur in children at all levels, especially in children with alcoholic cirrhosis.
In 1988, German scholar Richter and others first applied intrahepatic stent portosystemic shunt via jugular vein to clinic, and in 1991, 16 cases of successful intrahepatic stent portosystemic shunt via jugular vein were reported. Subsequently, Zemel(1991) and Ring(1992) successively reported the successful results of intrahepatic stent portosystemic shunt via jugular vein. In 1993, intrahepatic stent portosystemic shunt via jugular vein was widely used in various countries.
The devices of transjugular intrahepatic stent portosystemic shunt mainly include transjugular intrahepatic stent portosystemic shunt 1 and RUPS1.
2 operation name
alias of tips 3 tips
transjugular intrahepatic portosystemic shunt; Transjugular intrahepatic stent portosystemic shunt 4 indications
TIPS is suitable for portal hypertension, upper gastrointestinal bleeding, etc.
1. Portal hypertension with gastroesophageal varices bleeding (including acute massive bleeding).
2. Recurrent variceal bleeding and ineffective after medical treatment.
3. Refractory ascites caused by portal hypertension.
4.BuddChiari syndrome.
5. Transitional treatment before liver transplantation. Contraindications < P > Severe cardiac and renal insufficiency, severe hepatitis, and blood coagulation disorder that is difficult to correct, and moderate and severe jaundice are contraindications for intrahepatic stent-portal shunt via jugular vein. Azoulay believes that the transjugular intrahepatic stent portosystemic shunt is relatively noninvasive, but it can increase the hyperdynamic circulatory state of patients with liver cirrhosis. Feoral believes that it is not suitable for patients with ChildPugh score greater than 11 to undergo intrahepatic stent portosystemic shunt via jugular vein. However, some scholars believe that although the hepatic blood flow of Child C patients is seriously impaired, the postoperative hemodynamic state is relatively stable. Therefore, when deciding whether to operate, we must consider it comprehensively.
1. Absolute contraindication? ① Right heart failure with elevated central venous pressure; ② Polycystic lesions of liver; ③ Severe liver function damage. ④ Huge liver cancer invades the hilum, which may hinder the placement of internal stent.
2. Relative contraindications? ① Acute infection in liver or whole body; ② Severe hepatic encephalopathy has not been effectively controlled; ③ Formation of portal vein thrombosis. 6 preparation
1. Laboratory examination? Blood and urine routine, bleeding and clotting time, prothrombin time, liver and kidney function, electrolyte and CO2CP, blood sugar and blood ammonia.
2. Endoscopy or upper gastrointestinal radiography? To understand the degree of esophageal varices and exclude other diseases.
3. 2D and color Doppler ultrasound? To understand the patency of liver, portal, spleen and inferior vena cava, blood flow direction, velocity, collateral circulation and peak velocity of portal vein.
4. Spiral CT or MRI? Understand the anatomy and adjacent relationship of liver and portal vein. Methods
1. Puncture of internal jugular vein? The patient was supine, with his head 15 ~ 2 to the left, exposing the right neck. The upper third of the connecting line from the right ear mastoid to the right sternocleidomastoid muscle was taken as the puncture point, and the puncture needle made an angle of 2 ~ 3 with the skin, and the needle was inserted about 4cm along the sternocleidomastoid muscle lock bone direction. Patients can raise one leg or do Valsava action to promote internal jugular vein filling. Be careful not to go deep into the needle to avoid puncturing the pleura and causing pneumothorax.
2. Send the 1F long sheath through the guide wire to the level of hepatic vein opening of inferior vena cava. This step should be carried out under X-ray monitoring, and the action should be gentle. ECG monitor should be equipped, some patients may have transient atrial premature beats, and once frequent arrhythmia occurs, the operation should be suspended.
3. Hepatic venography was performed by introducing 5F catheter through guide wire to understand the anatomy of hepatic vein and its adjacent position to inferior vena cava, and to determine the puncture point. Most patients choose 2 ~ 3 cm from the right side of the opening level of inferior vena cava-hepatic vein (right hepatic vein or middle hepatic vein) as the puncture point. For patients with portal vein blood flow away from the direction of liver and poor liver function, hepatic vein wedge radiography can clearly show the portal vein and its branches, and assist in locating puncture. At this time, 5F catheter can be embedded in the distal end of hepatic vein for angiography of 5ml/25ml (volume/total amount per second).
4. Send the puncture needle protected by the outer sleeve to the puncture site, adjust the direction of the puncture needle so that the puncture needle points in the direction of the main branch of portal vein (generally the right branch of portal vein 2cm away from the branch of portal vein), instruct the patient to hold his breath, puncture, draw blood back, inject contrast agent for observation, and switch the 18cm Amplatz guide wire to the splenic vein or superior mesenteric vein after confirming that the puncture of portal vein is successful.
5. introduce 5F side hole angiography catheter (or pigtail tube) to portal vein main angiography (15ml/45ml), and then measure portal vein pressure and inferior vena cava pressure.
6. Send a balloon catheter with a diameter of 1mm and a length of 6mm to expand the puncture path in the liver. At this time, concave marks on the wall of the liver and portal vein can be seen. Ask the patient to hold his breath and mark the two concave marks on the skin in vitro so as to locate when releasing the stent. Repeatedly expand until the concave marks disappear and withdraw the balloon (Figure 1).
7. The stent is introduced along Amplatz guide wire for release. During release, the wall of liver and portal vein should be 1cm more than the other to ensure the support of the whole shunt. If the wall of hepatic vein cannot be supported, another stent can be released by overlapping the original stent. Generally, as long as the positioning is accurate, a stent with a length of 6cm is enough to support the whole shunt. If the stent is not fully opened after release, it can be expanded with a balloon (Figure 2).
8. Repeat portography (15ml/45ml) and pressure measurement.
9. postoperative treatment? After transjugular intrahepatic portosystemic shunt, we should pay attention to the blood ammonia level, limit the protein intake (4g/d) to prevent hepatic encephalopathy, and take orally 12 ~ 16mg/d of dipyridamole or aspirin, or take imported ticlopidine for a long time, so as to reduce the maximum platelet aggregation rate from normal to 2% ~ 3%, or INR (prothrombin). In addition, we should pay attention to the monitoring of liver and kidney function and establish a regular and comprehensive follow-up system (one week, one month, three months and six months after operation).
1. Complications and management after intrahepatic stent portosystemic shunt via jugular vein
(1) Stenosis and occlusion? It is the cause of rebleeding and ascites, and it is also the main factor affecting the long-term curative effect after intrahepatic stent portosystemic shunt via jugular vein. The stenosis and occlusion rate after intrahepatic stent portosystemic shunt via jugular vein is more than 3%. Freedman's long-term observation reports that the stenosis and occlusion rate can reach 75%. Stenosis and occlusion after intrahepatic stent portosystemic shunt via jugular vein are related to improper operation, such as failure to open the whole shunt when stent is released, angulation distortion after stent release, frequent puncture of liver and portal vein wall or improper anticoagulation, resulting in thrombosis and pseudointimal hyperplasia.
(2) hepatic encephalopathy? The incidence rate is 5% and most of them can be controlled clinically. Conn believes that maintaining a certain portal vein gradient pressure and the characteristics of hepatic shunt after intrahepatic stent portosystemic shunt via jugular vein can reduce the absorption of harmful substances in the intestine and help prevent hepatic encephalopathy, while Larberge believes that the occurrence of hepatic encephalopathy has nothing to do with the direction of blood flow.
(3) Complications related to operation include hepatic artery injury, hepatic infarction, hepatic capsule injury, intra-abdominal hemorrhage, biliary tract injury, pneumothorax, pericardial tamponade, etc. Other complications include ARDS, renal failure, hepatic failure, sepsis, stent wandering, etc., but the incidence of such complications is low. 8 precautions
operational precautions.
1. Puncture of internal jugular vein is very difficult when the internal jugular vein is deformed or the hematoma is caused by wrong puncture of carotid artery. Generally, the puncture lasts more than 1 minutes. It is considered to introduce a long guide wire from femoral vein for positioning, so as to reduce complications and shorten the operation time. Buckley provided intrahepatic stent portosystemic shunt via the left internal jugular vein, which can be considered when the angle between the right hepatic vein and the inferior vena cava is small and Rups1 is difficult to pass. Larberge reported the case of establishing shunt between right inferior hepatic vein and right portal vein through femoral vein.
2. The difficulty of intrahepatic stent portosystemic shunt via jugular vein is the puncture between liver and portal vein. In the early stage, the liver underwent portography before operation, and the Dormia basket was placed in the portal vein to mark it, but it was abandoned because it was time-consuming and increased the probability of intra-abdominal bleeding. Through superior mesenteric artery or splenic artery and hepatic venography, the adjacent relationship between liver and portal vein can be well determined. Because of the disorder of blood circulation in liver during cirrhosis, indirect portal venography can inject papaverine 3 ~ 6 mg or prostaglandin E intravenously to dilate blood vessels and improve the imaging effect. Wedge venography of hepatic vein is inaccurate when portal blood flow is in the direction of liver, and there is some damage. Chet reported that CO2 was used as contrast agent in transjugular intrahepatic stent portosystemic shunt, which greatly reduced the amount of contrast agent. Especially in hepatic vein wedge radiography, the low viscosity of gas made it pass through hepatic microvascular bed in large quantities and quickly, and the 5F catheter could get good imaging even in the state of incomplete insertion. Three-dimensional CT and MRI can clearly show the relationship between liver and portal vein anatomy and adjacent organs, and exclude space-occupying lesions, which is a non-invasive examination. Jesus reported 41 cases of transjugular intrahepatic stent portosystemic shunt under the guidance of B-ultrasound. The successful puncture took less than 7 minutes, the total operation time was 45 ~ 15 minutes, and the dosage of contrast agent was less than 1ml. The successful experience is worth learning. Puncture is usually between the upper branch of the right hepatic vein (middle hepatic vein) and the right branch of portal vein, but sometimes it is necessary to choose other locations, such as the right (middle) liver to the bifurcation of portal vein, to the left portal vein, from the left hepatic vein to the left portal vein, and from the lower branch of the right hepatic vein to the right portal vein (left femoral vein approach). The puncture direction is generally from back to front and down. Du Xiangke and others observed 7 specimens of human hepatic vein and portal vein, and thought that the better puncture point of intrahepatic stent portosystemic shunt via jugular vein was about 4.9cm from the posterior segment of inferior vena cava to the right hepatic vein on average, and then about .55cm from the posterior segment to the upper segment of the right posterior lobe of portal vein to establish a channel. During liver cirrhosis, great changes have taken place in the course of blood vessels in the liver, and the choice of the best puncture point and route should be determined according to specific cases. If you choose the bifurcation puncture, be sure to confirm whether it is in the liver parenchyma. Scott reported 31 autopsies, and 48.4% of the bifurcation of portal vein was outside the liver. The puncture direction of other points also needs to be confirmed whether it is in the liver. The inferior branch of the right hepatic vein is generally not used as a puncture site, because it enters the liver below the portal vein level, resulting in puncture through the lower wall of the portal vein. Eduard reported a case in which a mooring guide wire was fixed and guided by the superior branch of the right hepatic vein, collateral circulation, inferior branch of the right hepatic vein and the inferior vena cava under the variation of the tiny superior branch of the right hepatic vein and the thick inferior branch of the right hepatic vein.
3. The size of shunt follows the standard of surgical shunt, which is generally 1mm or 12mm in diameter, and the portal pressure is less than 2.45kPa(25cmH2O). Sometimes, a single shunt is not enough to provide sufficient blood pressure reduction effect, so it needs to be realized by double shunt. According to Larberge's report, about 1% patients have established a double shunt, and some patients still have obvious varicose veins when the portal pressure is less than 1.96kPa(2cmH2O), so varicose veins can be embolized at the same time. When the portal pressure is less than 2.45kPa(25cmH2O), it is theoretically appropriate to put aside varicose veins or undergo endoscopic sclerosis (not embolizing for observation).