| BackgroundTransjugular intrahepatic portosystemic shunt (TIPS) was one of the main treatments for portal hypertension. The clinical efficacy of TIPS had been widely acceptable. In the American Association for the Study of Liver Disease (AASLD) practice guidelines:the role of transjugular intrahepatic portosystemic shunt (TIPS) in the management of portal hypertension which update in 2010, recommended TIPS as the remedies for esophagogastric variceal bleeding who failed in pharmacological and endoscopic therapy, the efficacy was slightly better than surgery. Today, TIPS was one of the most complicated and difficult interventional operations, especially the portal vein puncture was the most difficulty and most likely to cause complications procedure in TIPS, meanwhile, it was also the reason which often caused the operation failure. So there were many portal vein puncture guiding methods had been developing for raise accuracy and avoid the risks.It was reported that wedged hepatic venography using carbon dioxide contrast for targeting the portal vein or ultrasound guidance was the more often-used guiding method in foreign countries. But limited by the conditions in our country, neither way of wedge hepatic venography with CO2 nor ultrasound guidance can be used in clinical work, other methods also had their limitations. percutaneous transhepatic portal vein puncture guiding method was percutaneous transhepatic puncture portal vein by fine-needle and catheter in it for targeting. There had more advantages in operations and guiding effect than other ways, but it was the invasive method. In the old days, the report about portal vein puncture guiding method were mostly based on experience, few contrast in actual guiding effects. Therefore, It is necessary to recognise again for us.PurposeTo investigate the advantages and limitations of percutaneous transhepatic portal vein puncture guiding method, the effect of targeting different branches of portal vein on TIPS. And to discuss its clinical feasibility and application value.Materials and MethodsFrom April 2014 to December 2014,62 patients with portal hypertension and treated by TIPS in our department were included in this study. Of these,48 were male and 14 were female, with a mean age of 49.97 years (range,22-71). The causes of portal hypertension included 43 cases of Hepatitis B cirrhosis,5 cases of alcoholic cirrhosis,4 cases of Hepatitis C cirrhosis,2 cases of congenital hepatic fibrosis,2 cases of Budd Chiari syndrome,1 case of autoimmune hepatitis,1 case of primary biliary cirrhosis and 4 cases of cryptogenic cirrhosis.50 patients had esophagealand gastric variceal bleeding before TIPS,7 had refractory ascites and 5 had obvious portal hypertensive gastropathy. According to Child-Pugh classification, average score was 7.16 (range,5-10). There had 23 cases in A,35 cases in B and 4 cases in C.method of grouping as follows:First, according whether to take percutaneous transhepatic portal vein puncture guiding before TIPS divided all patients into guiding group (group A) and direct puncture group. Second, some one in direct puncture group change into percutaneous transhepatic portal vein puncture guiding during operations just because operator found that portal vein puncture was more difficulty than they expected, and based on this divided direct puncture group into puncture success group (group B) and puncture failure group (group C).The procedure of TIPS as follows:To begin with, all operations of TIPS according to the standard procedure and steps. Next, performed portal vein puncture via hepatic vein after percutaneous transhepatic portal vein puncture guiding in group A, but did it without any guiding in direct puncture group. In the end,change the patients who experience portal vein puncture failure in direct puncture group into percutaneous transhepatic portal vein puncture guiding.SPSS17.0 was used for data analysis. The number of puncture comparing with Independent samples t test (two groups) and One-way ANOVA (more than two groups). The success rate of puncture compared with Chi-square test. Compare preoperative and postoperative results of WBC, HGB, PLT, PT, ALT, AST, ALB, TBIL, DBIL, IBIL and portal pressure applied the Paired sample T test. The change of WBC, HGB, PLT, PT, ALT, AST, ALB, TBIL, DBIL, IBIL and portal pressure among groups (grouping by guiding and grouping by targeting)were analyzed by One-way ANOVA. The operation time among groups (grouping by guiding) were analyzed by One-way ANOVA. Comparations of incidence of hepatic encephalopathy and patency rate of stent among groups (grouping by targeting) by Chi-square test.Results1.Technical success rate, situation of puncture and complication associated with puncture.All patients(n=62) were successfully established the portal-systemic shunt, but one patient had suffered two TIPS procedures because the operation failed at the first time. Fortunately, second operation achieved the success. The total success rate of technique was 98.41%, the success rate of portal vein puncture without any guiding was 96.29%(26/27), and the success rate of portal vein puncture under percutaneous transhepatic portal vein puncture guiding method was 100%(36/36), there had no statistical differences in success rate of portal vein puncture whether guiding or not (Chi-square test, x2=1.355, p=0.244).The mean number of percutaneous transhepatic portal vein puncture by fine-needle was 10 (range,1-33) in group A, and it was 8.6 (range,1-30) in group C. There was no significant differences in statistic between two groups (Independent samples t test, t=0.470, p=0.642). The mean number of portal vein puncture via hepatic vein before guiding in group C was 5.5 (range,2-12) which failed puncture into portal vein. If ignore it, the mean number of portal vein puncture via hepatic vein was 4.9 (range,2-20) in group C, while it was 3.9 (range,1-13) in group A and 4.5 (range,1-12) in group B. There were no significant differences in statistic among groups (One-way ANOVA, p>0.05).If we defined the number of portal vein puncture which under minimum average as success. The success rate of group A was 61.1%, and it was 42.3% in group B and 55.6% in group C respectively. The success rate among groups had no statistical differences (Chi-square test,x2=1.664, p=0.435). But we found that the success rate which under guiding was significantly increased than without any guiding (58.3% vs 25.6%), and there was a significant differences in statistic between them (Chi-square test, x2=8.722, p=0.003).The complications associated with puncture as follows:In group A, one patient occured percutaneous transhepatic needle-tract bleeding after remove the catheter that used for thrombolysis; another patient diagnosed with intra-abdominal bleeding based on discovered ascites by ultrasound examination and obvious decreased of hemoglobin after TIPS. In group B, one patient appeared abrupt dizziness, limb tic and significantly decrease of blood pressure, considered intra-abdominal hemorrhage caused by extrahepatic portal vein puncture; another one diagnosed with intra-abdominal bleeding under bloody ascites. In group C, two patients diagnosed hematobilia because they all pass black stool after TIPS; other two patients found right pleural effusion by chest X-ray examination, considered caused by percutaneous transhepatic puncture.2.Laboratory examinationThe laboratory examinations in three days after TIPS showed that WBC, PT, ALT, AST, TBIL, DBIL, IBIL were on the rise while HGB and ALB showed downward trends. In addition, they all had significant differences in statistic (Paired sample T test, p< 0.05). Only PLT didn’t have significant differences in statistic (Paired sample T test, t=1.318, P=0.192). According to Child-Pugh classification, average score that after TIPS was 8.47 (range,5-12).the variations of WBC, HGB, PT, ALT, AST, ALB, TBIL, DBIL and IBIL among groups (grouping by guiding) didn’t had significant differences in statistic (One-way ANOVA, p>0.05) except the IBIL between group A and group C (One-way ANOVA, p=0.033).Blood ammonia level and renal function before TIPS were not be record. Blood ammonia mean level after TIPS was 60.60μmol/L(range,12.2-133.5).3.The effect of targeting different branches of portal vein and variation of Portal pressureThere were 30 cases puncture targeted on portal vein bifurcation; 15 cases targeted on portal trunk; 9 cases targeted on left portal branch and 8 cases targeted on right portal branch. Mean use number of covered stent was 1.10 (range,1-2), and the bare stent was 0.77 (range,0-2). The mean pressures of portal vein before TIPS were 38.03 cm H2O (range,17-51), and they descend into 22.87 cm H2O (range,5-34) after TIPS. There were significant differences before and after TIPS (Paired sample T test, t=-17.119, P=0.000). The mean drop of portal pressure were 15.16 cm H2O, but there had no statistical difference (One-way ANOVA, p> 0.05) between groups (grouping by guiding).If we grouping based on puncture target of portal vein, the variation of PT, ALT, AST, ALB, TBIL, DBIL, IBIL, portal pressure and blood ammonia level did not had statistical difference among groups (One-way ANOVA, p>0.05).4.Operation timeThe total operation time from jugular vein puncture or percutaneous transhepatic portal vein puncture to last angiography were mean 90.3 minutes (range,47-194). There were mean 96.8 minutes in group A (range,51-138),71.9 minutes in group B (range,47-113) and 110.5 minutes in group C (range,66-194). The operation time of group B was much shorter than group A as well as group C, and they all had statistical differences (One-way ANOVA, p=0.003 and p=0.001). The operation time of group A and group C did not had statistical differences (One-way ANOVA, p=0.448).5.Hepatic encephalopathy and shunt dysfunctionTo the end of follow-up. There had 7 patients were diagnosed hepatic encephalopathy, the incidence were 11.3%. According to grouping by puncture target of portal vein, the incidence were 16.7%、6.7%、0% and 12.5% in each team, there had no statistical differences(Chi-square test, x2=2.343, p=0.504). Shunt dysfunction had happened in 3 cases, the total stent patency rate was 95.2%. As well as grouping by puncture target of portal vein, the stent patency rate of each team were 93.3%, 93.3%,100% and 100%, there also did not had statistical differences (Chi-square test, x2=1.191, p=0.755). One patient died of septic shock combined multiple organ dysfunction.Conclusion1.Percutaneous transhepatic portal vein puncture guiding method was simple, safety and easy to grasp, it was feasible in clinical;2.The accuracy of portal vein puncture via hepatic vein will be improved when adopt percutaneous transhepatic portal vein puncture guiding method, and it ensured the success rate;3.Percutaneous transhepatic portal vein puncture under DSA needed much more numbers of puncture and also had a certain degree of risk. And the operation time will be longer. Indeed, portal vein puncture via hepatic vein without any guiding also keep a higher success rate. So, Whether to taken guiding must be consideration of experience of operator, imaging evaluation before TIPS4.The different puncture target of portal vein had no effect on shunting efficacy, liver function and incidence of hepatic encephalopathy. |
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