2023年6月30日,美国肝病研究协会(AASLD)在Hepatology杂志发表了《TIPS、静脉栓塞、逆行性经静脉栓塞治疗曲张出血实践指南2023》。本实践指南首先回顾了门体侧支的解剖结构,这对于理解这些血管内手术的基本原理至关重要。其次介绍了TIPS、逆行(RTO)和顺行经静脉闭塞术(ATO)的技术细节。最后介绍了血管内技术在食管、胃底和异位静脉曲张出血治疗中的临床应用。
2023年6月30日,美国肝病研究协会(AASLD)在Hepatology杂志发表了《TIPS、静脉栓塞、逆行性经静脉栓塞治疗曲张出血实践指南2023》。本实践指南首先回顾了门体侧支的解剖结构,这对于理解这些血管内手术的基本原理至关重要。其次介绍了TIPS、逆行(RTO)和顺行经静脉闭塞术(ATO)的技术细节。最后介绍了血管内技术在食管、胃底和异位静脉曲张出血治疗中的临床应用。
实践指导要点
1. PTFE覆膜TIPS支架应视为标准治疗选择。
2. 当TIPS的适应证是静脉曲张出血(急性出血或预防再出血)时,TIPS应逐级扩张,从8 mm直径开始,逐级扩张至达到PSPG < 12 mmHg时所需的最小直径。
3.对于支架直径扩张到10 mm但PSPG仍未降至12 mmHg以下的患者,应辅以NSBB以进一步降低门静脉压力。
4.无症状的PVT不应被视为TIPS的禁忌证,如若不能完成手术,应考虑转诊至更有经验的医疗机构。
5. 在合并大量自发性门体侧支循环的患者中,可考虑在TIPS操作时进行侧支栓塞,以降低肝性脑病的发生风险。
6. 在接受择期TIPS预防静脉曲张再出血的患者中,推荐TIPS术前14天内开始利福昔明550 mg BID治疗并维持6个月,以降低术后肝性脑病的风险。
7.对于TIPS术后接受最佳药物治疗(乳果糖和利福昔明联合干预)的难治性肝性脑病患者,应考虑经血管内途径缩小TIPS分流道直径。
8.对于适应证为静脉曲张出血的TIPS,推荐在术后1周、3个月、6个月和此后每6个月进行一次多普勒超声随访,以评估TIPS支架通畅性。
9.多普勒超声评估中,当血流为离肝时,门静脉平均最大血流速度(mVPmax)<28 cm/s,或当血流为入肝时,门静脉平均最大血流速度(mVPmax)<39 cm/s,应行静脉造影检查和压力测量,以明确是否发生分流功能障碍。对于反复出现门静脉高压体征或症状的患者,即使上述超声检查结果为阴性,仍可行静脉造影以进一步排除TIPS分流道失功。
实践指导要点
10.对于解剖结构良好的胃部或异位静脉曲张出血(如可通过胃肾分流道进行插管和栓塞),RTO应视为TIPS的替代方案。
11.RTO通过闭塞自发性分流道,将门静脉血流重新导向肝脏,因而会增加门静脉压力梯度。在RTO操作后需密切监测门静脉高压症的并发症发生情况,以判断是否需要补充针对食管静脉曲张的治疗,如TIPS、NSBB或内镜治疗。
12.相较于传统的BRTO或改良BRTO,弹簧圈辅助逆行静脉闭塞术(CARTO)或血管塞辅助逆行静脉闭塞术(PARTO)的并发症更低,因此在经验丰富的中心应作优先推荐。
13. RTO术后72小时内,应行腹部CT或内镜超声检查,以确认胃或异位静脉曲张是否完全闭塞。
14. 应在RTO后1-2个月进行随访内镜检查,以检查食管静脉曲张的预后情况。如果未观察到静脉曲张,则应根据现有指南进行进一步监测。
实践指导要点
15. 经皮经肝、经脾入路或经TIPS入路的 ATO应被推荐作为食管、胃或异位静脉曲张出血伴大型流入静脉或分流或高流量静脉曲张的治疗选择。
16.建议ATO操作时同时完全根除整个曲张静脉巢,以尽量降低曲张静脉再出血风险。栓塞剂或硬化剂的选择应根据操作者的经验及材料的可用性来确定。
17. 应在ATO后72小时内行腹部CT或内镜超声检查,以确认静脉曲张是否完全闭塞。
18. 应在ATO后1-2个月进行随访内镜检查,以评估食管静脉曲张的预后情况。如果未观察到静脉曲张,则应根据现有指南进行进一步监测。
一级预防
19. TIPS不应用于静脉曲张出血的一级预防。
急性出血、早期TIPS
20. 在急性EV/GOV1出血患者中,符合以下任一标准的患者应考虑在首次内镜检查后72小时(理想情况下<24小时)内使用PTFE覆膜支架进行早期TIPS(preemptive TIPS)治疗:Child-Pugh C级10-13分或Child-Pugh B级8-9分,尽管接受了血管活性药物合并治疗,但在首次内镜检查时仍有活动性出血。
挽救、补救TIPS
21. TIPS应用作药物+内镜治疗无法控制的静脉曲张出血(标准治疗失败)患者的挽救治疗措施(Salvage TIPS)。
22. TIPS应用作药物+内镜治疗(标准治疗失败)后早期复发性静脉曲张出血患者的补救治疗措施(Rescue TIPS)。
23. 对于MELD评分>30、乳酸>12 mmol/L或Child-Pugh >13的患者,不应使用挽救/补救TIPS,除非TIPS被用作肝移植的桥接疗法。
二级预防
24. 在急性食管静脉曲张出血已恢复且入院时未经TIPS治疗的患者中,尽管使用NSBB和内镜治疗进行了充分的二级预防,但发生再出血时,TIPS应用作二线治疗选择。
一级预防
25. TIPS或RTO均不应用于胃底静脉曲张出血的一级预防。
急性出血
26. 对于GOV2/IGV1急性出血的患者,氰基丙烯酸酯注射、TIPS或RTO可作为控制出血和预防再出血的一线治疗方案。
27.对于存在TIPS禁忌证的胃底静脉曲张出血患者,RTO是一线血管介入治疗选择。
28.对于同时适合行RTO和TIPS治疗的胃底静脉曲张出血患者,治疗决策取决于血管解剖、临床特征和医疗机构的临床经验:RTO更适用于有显性肝性脑病病史或肝功能差的患者;TIPS更适用于同时合并门静脉高压症其他并发症的患者,如大型食管静脉曲张、显著腹水或合并门静脉血栓。
29. 根据具体情况,TIPS可辅以静脉曲张栓塞术,以降低肝性脑病和再出血的风险。
一级预防
30. 异位静脉曲张的治疗方案应由包括肝病学家、胃肠病学家、介入放射学家和外科医生的多学科团队决定。
31. 疑似异位静脉曲张出血的患者应接受全面的影像学评估,以确定静脉曲张的功能性血管解剖结构,从而制定个体化治疗方案。
32. 如果操作可行,异位静脉曲张的内镜治疗可用作介入治疗的桥接疗法。
33. TIPS是大多数异位静脉曲张的一线治疗,在大多数情况下,应与ATO/RTO一起操作。
34. 对于TIPS不适用的患者或侧支静脉曲张较小的患者,单独使用ATO或RTO亦可充分控制异位静脉曲张出血。
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