2023单纯门静脉再通术治疗非肝硬化性慢性肝外门静脉阻塞引起的重度门静脉高压.docx
2023单纯门静脉再通术治疗非肝硬化性慢性肝外门静脉阻塞引起的重度门静脉高压非肝硬化性慢性肝外门静脉阻塞(CNC-EHPVo)是一种罕见的肝脏疾病，有发生肝前性门静脉高压及其相关并发症的风险，包括胃肠道(GI)出血、门脉胆管病、腹痛、腹水、血栓蔓延或复发(Intagliatazetal.Gastroenterology.2019,156,1582-1599.e1;NoronhaFerreirazetal.Hepatology.2016z63z1640-1650;Hernandez-Geazetal.JournalofHepatology.2019z71z175-199;Khannazetal.JournalofHepatology.2014z60z421-441;Rodriguesfetal.AlimentaryPharmacologyandTheraPeUtics.2019,49,20-30)o同时，约40%的CNC-EHPVO患者伴有肌少症(Lattanzizetal.LiverInternational.2019z39z1937-1942)o肝硬化患者中，经颈静脉肝内门体分流术(TIPS)后门静脉高压的改善与肌少症的好转相关(Artruzetal.AlimentaryPharmacologyandTherapeutics.2020z52,1516-1526;Tsienzetal.EuropeanJournalofGastroenterologyandHepatology.2013z25,85-93;Gioiazetal.LiverInternational.2021,41,2965-2973)o在急性门静脉血栓患者中，门静脉再通术(PVR)会导致不良事件，这可能是因为在这种情况下常需联合局部或全身溶栓(VallazLiverInternational.2020z40(Suppl.1)z142-148;Hall,etal.WorldJournalofSurgery.2011l35,2510-2520;Thornburg,etal.JournalofVascularandInterventionalRadiology.2017,28z1714-1721.e2)o然而，鉴于CNC-EHPVO的血栓性质，不宜行溶栓治疗。有几项研究报道了肝硬化或非肝硬化患者行TIPS联合肝外门静脉阻塞再通术的良好结局，并证实了该方法的可行性(Kallini,etal.Hepatology.2016,63z1387-1390;Marotzetal.DiagnosticandInterventionalImaging.2019z100z147-156;Senzolo,etal.AlimentaryPharmacologyandTherapeutics.2006z23,767-775;Sarin,etal.Gastroenterology.2016z151,574-577.e3;Knightzetal.Hepatology.2021f74t2735-2744)o然而，对于无明显肝纤维化的窦性门静脉高压患者，辅助TIPS治疗可能是没必要的(Habib,etal.JournalofVascularandInterventionalRadiology.2015,26,499-506)oJHEPReports于2022年8月正式发表了一篇题为单纯门静脉再通术治疗非肝硬化性慢性肝外门静脉阻塞引起的重度门静脉高压的文章，该研究旨在评估CNC-EHPVO患者在未行TIPS的情况下进行PVR的长期预后，并确定PVR失败和支架闭塞的预测因素。ArtrU等纳入了2000年至2019年期间的31例接受了PVR而未行TIPS的CNC-EHPVo患者(平均年龄：50岁；中位随访时间：52个月)。主要操作步骤包括：经皮经肝穿刺进入门静脉，将导管插入肝内门静脉分支，使用0.035英寸J形刚性亲水性导丝再通阻塞血管，在阻塞段放置球囊和自扩张银钛诺支架将其扩张至6mm。术前、术后在肠系膜/脾静脉处测量门静脉压力，并行门静脉造影。当经肝途径不可行时，尝试经脾途径。结果显示，27例患者成功放置支架，6例发生不良事件，未发生死亡。在手术成功的患者中，5年首次通畅率为73%,其与1年后肌肉质量改善(P=O.007)和脾脏体积减小(P=O.01)相关。此外，21例(78%)PVR技术成功的患者在5年内未发生门静脉高压并发症。总的来说，对于既往发生过门静脉高压并发症或处于高风险的CNC-EHPVo三,仅行PVR是安全可行的。重要研究结果分析及其临床意义1.患者的主要基线特征Tablr1.MainClurMtcrfetkso(the11IMtkmgWbounderwentEjIWlkItkMlPrOCcdiltVforCNC-BIPVOwKhPHT.No.9t×CNC-EHPVOCMCIndkJtkmo(rrcjMiwtk>nDeUybetween(MagiwKandrccjuliMton(mooch)Mcordbig(0Sirtnet;,/Mjr(rtetM"typesExtmN>10mrwaterk/spknkveinsSuccmLPrimMy(Mten<y4PHTco<nplkJCk>nJfUrSuccrttlblrecauiiMt>nMSyeirs145.MAfterUvefSUfeRyRroirrcnCGlb/edingO>NoneYesYesNo246.MAflrrpMret«urg«yRHrjctoryjsctMdncnhjemrr!ugicFHT1nMesemencYesYesNo3b5,MChronicPanCratItbBeforeSUrgF2Meemen:andSPknKY«NoNo44B.MAfterPanmJtiCairg«yRecunencClbedingOnSplenicYesY«NoSb4S.FAfterPanmJtkMgcyRecurrencClbleeding1mMeemrrrandp)enYesY«Wst6。0MlOthramboticdisorder:FllAndFVcompositeKetaOzymmRecurrentClblredingJndchronicJbdOfnlIUIPjtn1283/2NoneYcsY«No7*».MChronicPAnCre*!kBeforeSUrIery25中MedrnCandlcnYcsYCNo8v50.MSuspectedumdmti6cdpro(KromboticdisorderBcfbrrUlrXefy873RMremrrrandSPknKY«YcsNo9lQ.FSuspectedUnidentiMpr<MKrombotdisorderRecurrentClbedinf19WMescntrncandSPknKYesYCNo10*».MNecroticMcrcafQsRecurrentGlbcdint2WMescmerrandsp)cnYesYesNo11»5B.MChronicfMt×rcMtBR>talChCUnfQathy83RMesenierrandSp)CnXYesNO¥n12*26.MRodiromboUcdsorde:aniphosptx>bpdsyndromeExirnsionofthrombosisunderm(×OdfuUnigjW493/2XtesentercandSPIenKYesYesNo13*6D.MChronicPtlnCreMNbRecurrentGlbedinc353MttemercJndsplenNaOWlnXtoMtfrjhepMicexIrrvaanNMWA14Q.FAfterpanmjtagFScwreClbleedingO1/1MeemerYesY«No1574MChronicponcreMitsIbrtalchdjnDpjthO3/2MeieniercYCYeNo1628.MAftercolonicsurgeryChromeAbdomnilpain73MesemencJndsplenicNaowing10HUrjhepjocexIrnaanNMWA!731.MOthramboncdisorder:antiphcptM)bpdsyrdrcmeChrome>bdmnjiMn23/3MnenterKYesNo18S3.MChrankpjncrejtitsChrantCJbdOmmapain3MnenlerYesNoWs1978.MAfterCDlonicsurgeryRecurrentGlbeding33/2MncnlrrcY«YeiNo2070.FThrombotkdisorder:ParaneopUsticTrousscausyndrome(ENToncercurativecmtrd4yearsbdoceGIblrcdn)SewreClbleeding481/1Hnemrri:YesYesNo213.MThrombotkdisorder:antIptaphobptdsyndromeChromcabdomnalpn151/1McscmerrYesNoWs2271.MAllerUVefSitffnyChrome4bdommpainandbcites151/2NoneNaowintontrjh11xexIensanN/AWA2321.FAfterPAncreaticUHgerySevereefMkMcopccPHT733/2MeientencJndIP)CfuCYesYesNo2457.MChronicPJnaeMItiISevereQbleeding1inMttenleri:JndSPknKYesYesNo2573.MChrcnicpancrejtHBBeforesurvey33/1MesemecandSPknKYesY«NO26?42.FSuspededUrudenliftedProthromboticdisorderSevereendoscopicPHT116311MttemencY«YesNo(conontMtfonntxragf)1.lble1(c<mnu<d)No.e.KXCNC-EHPVOCMCIndkMkmofIvcanalKitionDelaybetween<U<nosttandrecjfulution(month)CUssMcjt
