The Clinical Characteristics Of Cirrhosis With Portal Vein Thrombosis And The Clinical Application Of Transjugular Intrahepatic Portosystemic Shunt

Background and AimsPortal vein thrombosis(PVT)refers to the thrombosis in the main portal vein and its branches inside and outside the liver.The incidence of PVT in normal people is low,while the probability of PVT in cirrhotic patients is significantly higher.Most PVT patients are in slow progress and have no clinical symptoms.However,some patients,especially those with acute PVT,have a high probability of abdominal pain and other abdominal signs.Chronic PVT often leads to the aggravation of portal hypertension on the basis of liver diseases.Patients with acute PVT often have acute onset and severe symptoms,while patients with chronic PVT have relatively slow clinical symptoms.Once being found,clinical complications have already occurred Portal vein thrombosis is an independent risk factor for the prognosis of cirrhosis.If acute portal vein thrombosis with cirrhosis develops and mesenteric vein is involved,it may lead to intestinal ischemia or even life-threatening intestinal necrosis.Portal vein thrombosis not only affects the prognosis of patients with cirrhosis,but also makes its clinical treatment more complicated.With the clinical application of minimally invasive intervention and special coated stent,TIPS plays a more and more important role in the treatment of portal hypertension in patients with cirrhosis.In recent years,TIPS has also aroused great clinical interests in the treatment of portal hypertension in cirrhotic patients with portal vein thrombosis,and it has been considered as a safe and effective method for the treatment of portal vein thrombosis with cirrhosis.However,there are differences in the extent and degree of portal vein thrombosis.Different views on whether these different thrombus extents,degrees and types affect the clinical outcome and therapeutic effect of TIPS in patients with cirrhosis still exist and need to be further studied.This thesis is divided into two parts.In the first part,303 cirrhotic patients with portal hypertension treated with TIPS were analyzed retrospectively,and the influence of PVT on the clinical characteristics and therapeutic effect of TIPS was observed;in the second part,to prevent the esophageal variceal re-bleeding,165 cirrhotic patients with PVT who had been treated with TIPS were analyzed retrospectively,the different operation of TIPS in patients with different thrombus types and degrees,and the influence of different thrombus types and degrees on the clinical effect and prognosis after TIPS were also analyzed.It provides a clinical basis for the individualized treatment of patients with cirrhosis and PVT,especially those with a history of esophageal and gastric varices bleeding.Part 1 The Influence of Portal Vein Thrombosis on the Clinical Characteristics and Treatment of Patients with CirrhosisAims:This retrospective study aims to analyze the influence of portal vein thrombosis on the clinical characteristics and treatment of patients with cirrhosis.Methods:From December 2009 to December 2017,303 patients with cirrhosis and portal hypertension treated with TIPS in the Eastern Hospital of Shandong provincial hospital were studied retrospectively.There were 184 cases in PVT group,among whom 24 were acute and 160 were chronic,and 119 cases were included in non PVT group.Clinical and laboratory data were collected and followed up to compare the clinical characteristics and treatment effects of the 184 cases in PVT group and 119 cases in non PVT group,and similarly,of the 24 cases in acute PVT group and 160 cases in chronic PVT group.Results:1.The degree of esophageal and gastric varices was higher in cirrhotic patients with PVT(x2=20.514,P<0.001),the proportion of patients with bleeding history was higher(?2=7.587,P=0.006),the proportion of patients with endoscopic and interventional therapy before TIPS was higher(?2=20.514,P<0.001),the pre-operative white blood cell count was higher(t=2.543,P=0.011),the pre-operative platelet count was higher(t=3.957,P<0.001).All were statistically significant.2.Between the two groups of cirrhotic patients with acute and chronic PVT,the pre-operative Child-Pugh score(t=2.615,P=0.010),the Child-Pugh degree(?2=7.072,P=0.021),the incidence of abdominal pain(?2=27.727,P<0.001),the incidence of abdominal distention(?2=6.660,P=0.010),the degree of ascites(?2=12.930,P=0.005),the proportion of patients with esophageal and gastric varices bleeding(?2=15.777,P<0.001),white blood cell count(t=4.327,P<0.001),platelet count(t=3.426,P=0.001)were all statistically different.3.Patients with cirrhosis and PVT had higher incidence of hepatic encephalopathy after TIPS(?2=9.498,P=0.002).There was no significant difference in the success rate,survival rate,rebleeding rate and stent stenosis rate between the two groups.In addition,the portal vein pressure of both groups decreased significantly4.There was no significant difference in the success rate of TIPS,survival rate,rebleeding rate,incidence of postoperative hepatic encephalopathy and stent stenosis rate between cirrhotic patients with acute PVT and chronic PVT.In addition,the portal vein pressure of both groups decreased significantlyConclusion:(1)Portal vein thrombosis will aggravate the occurrence of decompensated events such as varicose veins and gastrointestinal bleeding in patients with cirrhosis,and worsen the clinical symptoms of intestinal blood circulation disorders such as abdominal pain.Patients with cirrhosis and acute PVT,in particular,have higher white blood cell count and platelet count and a higher incidence of ischemic bowel diseases such as abdominal pain;(2)The incidence of hepatic encephalopathy in patients with cirrhosis and PVT after TIPS is relatively higher than that of the non-PVT patients,but there is no significant difference in the operation success rate and effect.PVT does not affect the success rate and clinical effect of TIPS.Part 2 Individualized Operation and Clinical Effect of TransjugularIntrahepatic Portosystemic Shunt in Patients with Cirrhosis and Portal VeinThrombosisAims:To analyze the technical requirements of different clinical types of cirrhosis with portal vein thrombosis and different degrees of thrombosis on TIPS,to explore the individualized operation of TIPS in patients with cirrhosis and PVT,and then to observe the influence of different types and degrees of cirrhosis with PVT on the clinical effect and prognosis of TIPS.Methods:From December 2009 to December 2017,165 cirrhotic patients with portal vein thrombosis who had been treated with TIPS because of esophageal and gastric variceal bleeding in the Eastern Hospital of Shandong Provincial Hospital were studied retrospectively.There were 16 patients with acute PVT and 149 with chronic PVT.Based on the previous classification of PVT,combined with the technical requirements of TIPS and the clinical factors which affecting the operation of TIPS,this study proposed a new classification of PVT:(1)Type ?,no occlusion in the main portal vein;occlusion found only in the branch or tributary(including left or right branch of the portal vein inside the liver and superior mesenteric vein or splenic vein outside the liver);(2)Type ?,occlusion only in the main portal vein,no involvement of the branches inside the liver;(3)Type ?,occlusion in the main portal vein and the right branch(?a)or occlusion in the main portal vein and the left branch(?b);(4)Type IV,occlusion in the main portal vein and the right and left branch,no occlusion in the superior mesenteric vein and the splenic vein(?a);or occlusion in the main portal vein and the right and left branch,occlusion in the superior mesenteric vein,and no occlusion in the splenic vein(IVb);(5)Type V,occlusion in the main portal vein and the right and left branch,with occlusion in the splenic vein,no occlusion in the superior mesenteric vein(Va)or occlusion in the main portal vein and the right and left branch,with occlusion in the superior mesenteric vein and the splenic vein(Vb)Choose different treatment options of TIPS according to the different types of PVT:Type I,the first choice is conventional TIPS,which can be successful in portal vein puncture;transcutaneous transhepatic puncture can be used to assist TIPS when portal vein puncture is difficult to carry out.Type ?,the routine TIPS approach is recommended for partial portal vein occlusion;if the portal vein is completely blocked,transcutaneous transhepatic approach can be useful;if this fails again,transcutaneous transsplenic approach is worth a try;Type ?,when it is difficult to operate conventional TIPS,transcutaneous transhepatic puncture in the left branch of the portal vein(?a)or transcutaneous transhepatic puncture in the right branch of the portal vein(?b)can be considered;if this fails,try transcutaneous transsplenic approach;Type IV,the routine TIPS approach is recommended for partial portal vein occlusion,transcutaneous transhepatic approach for complete portal vein occlusion and transcutaneous transsplenic approach is recommended if the former fails to achieve portal vein puncture;Type V,conventional TIPS is recommended for partial occlusion of the main portal vein;if the main portal vein is completely blocked,transcutaneous transhepatic approach can be used;if it fails to achieve portal vein puncture,transcutaneous transsplenic approach with thrombectomy can be tried when there is fresh and loose thrombusThe clinical and laboratory data of patients were analyzed retrospectively and follow-up was carried out.To observe respectively the influence of clinical stages and degrees of thrombosis on the clinical characteristics and TIPS treatment in cirrhotic patients with PVT and esophagogastric varices bleeding.To summarize new clinical types of PVT which can guide the individualized operation of TIPS,and to discuss the clinical characteristics of different clinical types and the therapeutic effect and prognosis of TIPS.Results:1.According to the extent and degree of thrombus,a total of 165 cirrhotic patients with PVT and gastrointestinal hemorrhage treated by TIPS were reviewed.There are 20 cases of Type I,among whom 18 were of successful TIPS,14 of routine TIPS and 4 of transcutaneous transhepatic approach;32 cases of Type II,among whom 29 of successful TIPS,18 of routine TIPS,7 of transcutaneous transhepatic approach and 4 of transcutaneous transsplenic approach;42 cases of Type III,among whom 42 were of successful TIPS,27 of routine TIPS,15 of transcutaneous transhepatic approach;27 cases of Type IV,25 were successfully treated with TIPS,11 of conventional TIPS,11 of transcutaneous transhepatic approach and 3 of transcutaneous transsplenic approach;44 cases of Type V,35 were successfully treated with TIPS,13 of conventional TIPS,20 of transcutaneous transhepatic approach and 2 of transcutaneous transsplenic approach.There were significant differences among the five groups in the success rate of TIPS(?2=10.49,P=0.0313),the way of portal vein puncture(?2=19.377,P=0.013),and the proportion of transcutaneous transhepatic or transcutaneous transsplenic puncture(?2=11.559,P=0.021).2.After the implementation of TIPS in the five types of patients,the pressure of portal vein decreased significantly.I-type baseline PVP 30.1 ± 6.2mmHg,postoperative PVP 18.2±3.6mmHg(t=9.771,P<0.001);?-type baseline PVP 28.5±6.0mmHg,postoperative PVP 18.9±5.8mmHg(t=12.818,P<0.001);?-type baseline PVP 26.2±7.OmmHg,postoperative PVP 17.0±5.7 mmHg(t=10.491,P<0.001);IV-type baseline PVP 29.1±5.8mmHg,postoperative PVP 19.7±5.0 mmHg(t=9.4,P<0.001);V-type baseline PVP 28.2±5.9mmHg,postoperative PVP 15.5±6.7mmHg(t=10.305,P<0.001).There were significant differences in absolute value of decline(F=2.449,P=0.050)and percentage of PVP decrease(F=2.449,P=0.050)among the five types of patients,and the absolute value and percentage of PVT decrease in V type patients were the highest.3.After the successful implementation of TIPS,there was no significant difference in survival rate(?2=1.610,P=0.807),rebleeding rate(?2=2.778,P=0.596),incidence of postoperative hepatic encephalopathy(?2=1.470,P=0.832),and stent stenosis rate(?2=5.274,P=0.260).Conclusion:(1)In this study,patients with cirrhosis and PVT were divided into five clinical types according to the different operation schemes of TIPS and different operation methods were adopted according to different clinical types.The difficulty of TIPS operation gradually increased from Type I to Type V,and the operation success rate of V-type(diffuse portal vein thrombosis)patients was the lowest.(2)There was no significant difference in the postoperative survival rate,rebleeding rate,incidence of hepatic encephalopathy and stent stenosis rate among the five clinical types of patients.But after the successful implementation of TIPS,all the five clinical types of patients could achieve a significant reduction in portal vein pressure,especially V-type patients who were with the most severe portal vein occlusion had the largest decrease in portal vein pressure.(3)According to the clinical classification of this study,cirrhotic patients with PVT and esophageal and gastric variceal bleeding can realize the individualized operation of TIPS and achieve a higher success rate.V-type patients with a relatively low success rate can still benefit from the successful implementation of TIPS comparing to other clinical types.