CAJ | 학술논문

目的探讨经皮脾穿刺门静脉插管(PTSPC)技术的可行性.方法 30例门静脉高压症患者接受经PTSPC行食管胃底曲张静脉栓塞术,其中2例同时接受门静脉支架植入术.病例纳入标准:门静脉主干阻塞(癌栓或血栓)和肝硬化严重肝萎缩患者;排除标准:凝血酶原时间(PT)＞20 s的严重凝血功能不良患者.17例患者为原发性肝癌合并门静脉主干癌栓、13例为肝硬化合并严重肝萎缩和(或)小至中量腹水.30例患者术前均有食管胃底静脉曲张破裂出血病史;术前凝血功能正常(PT＜14 s)16例,轻度降低(PT 14～17 s)10例,中度降低(PT 18～20 s)4例;均接受上腹部CT增强检查,并依据CT结果确定脾静脉分支的穿刺位置、方向及深度.术后回顾性分析PTSPC要点、并发症及临床应用价值.结果 30例患者,28例成功应用PTSPC进行门静脉插管;2例插管未成功者均为脾静脉脾内分支细小.发生与PTSPC相关并发症6例(20.0%),均为不同程度血红蛋白浓度下降(15～50 g/L);其中4例需要输血治疗,包括1例腹腔大出血,在术后2 h出现血压严重下降,经输入4个单位红细胞和补充血容量后好转.PTSPC成功的28例均行食管胃底曲张静脉栓塞术,其中2例在栓塞曲张静脉的基础上放置门静脉覆膜支架.28例患者术后中位随访时间6个月(1～42个月),死亡16例,其中14例为肝癌患者在术后1～12个月死亡,2例肝硬化患者分别在术后14、23个月死于肝功能衰竭.随访期间,发生静脉曲张再出血4例,累积再出血率为14.3%.结论 PTSPC是可行的,为经导管门静脉腔内治疗提供了一条新路径,但穿刺部位出血应引起足够重视.
목적 탐토경피비천자문정맥삽관(PTSPC)기술적가행성.방법 30례문정맥고압증환자접수경PTSPC행식관위저곡장정맥전새술,기중2례동시접수문정맥지가식입술.병례납입표준:문정맥주간조새(암전혹혈전)화간경화엄중간위축환자;배제표준:응혈매원시간(PT)＞20 s적엄중응혈공능불량환자.17례환자위원발성간암합병문정맥주간암전、13례위간경화합병엄중간위축화(혹)소지중량복수.30례환자술전균유식관위저정맥곡장파렬출혈병사;술전응혈공능정상(PT＜14 s)16례,경도강저(PT 14～17 s)10례,중도강저(PT 18～20 s)4례;균접수상복부CT증강검사,병의거CT결과학정비정맥분지적천자위치、방향급심도.술후회고성분석PTSPC요점、병발증급림상응용개치.결과 30례환자,28례성공응용PTSPC진행문정맥삽관;2례삽관미성공자균위비정맥비내분지세소.발생여PTSPC상관병발증6례(20.0%),균위불동정도혈홍단백농도하강(15～50 g/L);기중4례수요수혈치료,포괄1례복강대출혈,재술후2 h출현혈압엄중하강,경수입4개단위홍세포화보충혈용량후호전.PTSPC성공적28례균행식관위저곡장정맥전새술,기중2례재전새곡장정맥적기출상방치문정맥복막지가.28례환자술후중위수방시간6개월(1～42개월),사망16례,기중14례위간암환자재술후1～12개월사망,2례간경화환자분별재술후14、23개월사우간공능쇠갈.수방기간,발생정맥곡장재출혈4례,루적재출혈솔위14.3%.결론 PTSPC시가행적,위경도관문정맥강내치료제공료일조신로경,단천자부위출혈응인기족구중시.
Objective To evaluate the feasibility of percutaneous transsplenic portal vein catheterization (PTSPC). Methods Thirty patients with portal hypertension underwent gastroesophageal variceal embolization via PTSPC route, 2 of which simultaneously underwent portal vein stenting. This study included the patients with portal venous obstruction ( tumor embolus or thrombus) or the patients with serious liver atrophy caused by liver cirrhosis. The patients who had severe coagulation insufficiency (with prothrombin time ＞ 20 s) were excluded. Of the 30 patients, 17 had primary hepatocellular carcinoma with main portal venous tumor embolus, 13 had cirrhosis with severe liver atrophy and(or) slight or moderate ascite. Before this study, all of 30 patients had a history of variceal bleeding, and 16 patients had a normal coagulation level, 10 patients had a mildly prolonged prothrombin time (14-17 s), 4 patients had a moderately prolonged prothrombin time (18-20 s). All of 30 patients underwent upper abdomen CT enhanced scanning before this procedure, and the site, direction, and depth of splenic vein branch puncture were decided by CT images. The technology of PTSPC, procedure-related complications, and its clinical application were retrospectively analyzed. Results PTSPC was performed successfully in 28 of 30 patients. Two cases failed because of a small intrasplenic vein. Procedure-related complications occurred in 6 patients (20. 0% ), which had decrease of hemoglobin concentration ( 15-50 g/L). Four of them needed blood transfusion. In the six patients, one patient (3.3%) with abdominal cavity hemorrhage had a serious drop of blood pressure 2 hours after procedure, whose clinical symptoms were relieved after four units of packed RBC and a great quantity of fluid were transfused. Twenty-eight patients whose PTSPC were successfullyperformed underwent variceal embolization, 2 of them were placed with portal vein covered stents. During a median follow-up period of 6 months (range: one to forty-two months), 14 patients died of hepatocellular carcinoma 1 to 12 months after procedure, and 2 patients died of hepatic failure caused by liver cirrhosis at fourteen months and twenty-three months after procedure, respectively. Variceal rebleeding was observed in 4 patients, the cumulative rebleeding rate at 1 year was 14.3%. Conclusion PTSPC is a feasible procedure, which provides a useful route for endovascular treatment of portal vein. However, hemorrhage at the puncture site after procedure should be noticed.