经颈静脉肝内门体分流术治疗...癌合并门静脉高压的临床价值_侯昌龙.pdf

介入放射学杂志2023年4月第32卷第4期J Intervent Radiol 2023，Vol32，No4经颈静脉肝内门体分流术治疗肝癌合并门静脉高压的临床价值侯昌龙，熊柏柱，许军，周磊，费一鹏，施长杲，朱先海，谢韬【摘要】目的探讨经颈静脉肝内门体分流术（TIPS）治疗肝癌合并门静脉高压（PHT）患者的临床价值。方法选取2017年5月至2021年5月在中国科学技术大学附属第一医院接受TIPS治疗的肝癌合并PHT患者31例作为研究组，筛选接受保守治疗患者36例作为对照组。根据改良实体瘤疗效评价标准（mRECIST）评估患者疗效，比较两组并发症发生情况和无并发症生存时间。结果TIPS手术成功率为100%。术后门静脉压力平均降低19.57 cmH2O（95%CI=17.8821.26），门静脉直径平均缩小4.25 mm（95%CI=2.855.66），差异有统计学意义（t=23.672、6.178，均P0.05）。术后1年支架畅通率为90%（28/31），2年畅通率为87%（27/31）。研究组、对照组治疗后1年内肝性脑病（HE）发生率差异无统计学意义32%（10/31）、25%（9/36），2=0.432，P=0.510。研究组HE患者12、20个月累积生存率和中位生存时间均高于对照组（78.8%、39.4%和19个月比33.3%、0和8个月，均P0.05）。研究组、对照组中位无并发症生存时间分别为153 d、58 d，30 d和90 d无并发症生存率分别为90.3%和61.3%，77.8%和30.6%，研究组优于对照组（均P0.01）。研究组腹水、再出血发生率均低于对照组（2=16.810、15.085，均P0.01）。研究组、对照组分别有19例、20例患者接受肝癌介入治疗，手术均获得成功。两组不良反应发生率和治疗3个月后肿瘤反应率差异无统计学意义（均P0.05）结论TIPS治疗肝癌合并PHT具有一定的临床应用价值。【关键词】肝癌；门静脉高压；经导管动脉化疗栓塞术；经颈静脉肝内门体分流术中图分类号：R735.7文献标志码：A文章编号：1008-794X（2023）-04-0320-06The clinical value of transjugular intrahepatic portosystemic shunt in the treatment of hepatocellularcarcinoma complicated by portal hypertensionHOU Changlong，XIONG Baizhu，XU Jun，ZHOU Lei，FEI Yipeng，SHI Changgao，ZHU Xianhai，XIE Tao.Department of Intervention of West District，AffiliatedFirst Hospital of University of Science and Technology of China，Hefei，Anhui Province 230031，ChinaCorresponding author：HOU Changlong，E-mail：H【Abstract】ObjectiveTo assess the clinical value of transjugular intrahepatic portosystemic shunt（TIPS）inthetreatmentofpatientswithhepatocellularcarcinoma（HCC）complicated by portal hypertension（PHT）.MethodsThirty-one patients with HCC complicated by PHT，who were admitted to the Affiliated FirstHospital of University of Science and Technology of China to receive TIPS between May 2017 and May 2021，were selected and used as the study group，and other 36 patients who received conservative treatment wereselectedandusedasthecontrolgroup.Modifiedresponseevaluationcriteriainsolidtumor（mRECIST）wasadoptedto evaluate the clinical efficacy，and the incidence of complications and the complication-free survival timewere compared between the two groups.ResultsThe technical success rate of TIPS was 100%.The averagepostoperative portal vein pressure decreased by 19.57 cm H2O（95%CI=17.88-21.26），and the portal vein diameterdecreased by 4.25 mm（95%CI=2.85-5.66），the differences were statistically significant（t=23.672 and t=6.178，both P0.05）.The postoperative one-year stent patency rate was 90%（28/31），and the postoperative 2-year stentpatency rate was 87%（27/31）.The difference in the incidence of hepatic encephalopathy（HE）within one yearafter treatment between the study group and the control group was not statistically significant（32%versus25%，DOI：103969jissn1008794X202304003作者单位：230031安徽合肥中国科学技术大学附属第一医院（安徽省立医院）西区介入科（侯昌龙、许军、周磊、费一鹏、施长杲、朱先海、谢韬）；蚌埠医学院（熊柏柱）通信作者：侯昌龙E-mail：H 血管介入Vascular intervention 320介入放射学杂志2023年4月第32卷第4期J Intervent Radiol 2023，Vol32，No42=0.432，P=0.510）.The postoperative12-month and 20-month cumulative survival rates and the mediansurvival time in the study group were higher than those in the control group（78.8%versus 33.3%versus 39.4%。and 19 months versus 8 months；all P0.05）.The median complication-free survival time in the study groupand the control group was 153 d and 58 d respectively；the complication-free survival rates at 30 d and 90 d inthe study group were 90.3%and 77.8%respectively，which were better than 61.3%and 30.6%respectively in thecontrol group（all P0.01）.The incidences of ascites and rebleeding in the study group were remarkably lowerthan those in the control group（2=16.810 and 2=15.085 respectively，both P0.01）.Nineteen patients in thestudy group and 20 patients in the control groups received interventional treatment of HCC，and the operation wassuccessful.There were no statistically significant differences in the incidence of adverse effect and the post-TIPS3-month tumor response rate between the two group（both P0.05）.ConclusionFor the treatment of HCCcomplicated by PHT，TIPS has certain clinical application value.（J Intervent Radiol，2023，32：320-325）【Keywords】hepatocellularcarcinoma；portalhypertension；transarterialchemoembolization；transjugular intrahepatic portosystemic shunt肝癌80%90%发生于肝硬化基础上，肝硬化或肝癌进展会引起一系列与门静脉高压（portalhypertension，PHT）相关的临床并发症，PHT引起的上消化道出血约占肝癌死亡原因的15%1-2。PHT治疗很有必要，可为进一步肿瘤治疗提供可能，并可能会延长患者生存期3。经颈静脉肝内门体分流术（transjugular intrahepatic portosystemic shunt，TIPS）已被明确是治疗PHT的有效手段。本研究回顾性对比分析TIPS治疗肝癌合并PHT的临床价值。1材料与方法1.1一般资料选取2017年5月至2021年5月因原发性肝癌合并PHT在中国科学技术大学附属第一医院接受TIPS治疗患者31例（研究组，其中有19例同期或术后接受肝癌介入治疗）及保守治疗患者36例（对照组，经筛选并与研究组匹配）。纳入标准：符合原发性肝癌诊疗规范（2019版）诊断标准；术前评估拟行TIPS的穿刺路径不经肝癌病灶；影像学、实验室、内镜检查或临床症状符合PHT表现；存在PHT相关症状和体征，腹水和/或上消化道出血。排除标准：肝功能Child-Pugh分级C级；肝癌远处转移，如肺或其他脏器；术前发生肝性脑病（hepatic encephalopathy，HE）。两组患者基线特征比较差异无统计学意义（P0.05），见表1。1.2治疗方法TIPS术：在美国GE公司Innova 3100型DSA机引导下，采用Seldinger法穿刺右颈内静脉，插入TIPS穿刺套装（美国Cook公司），经过上腔静脉、下腔静脉上段后，由右肝静脉穿刺肝内门静脉，穿刺成功后造影并测定门静脉压力；根据患者食管胃底静脉曲张情况选择性插管并栓塞胃冠状静脉等分流静脉；常规使用7 mm80 mm球囊（美国强生公司）扩张分流道，于DSA图像测量分流道长度，植入不同规格TIPS专用血管覆膜支架（美国Gore公司）或覆膜支架联合/不联合裸支架（美国Bard公司）；再行门静脉压力测定并造