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经颈静脉肝内门体分流术植入Viatorr支架预防高危食管胃底静脉曲张再出血

Preventive effect of Viatorr stent implantation in TIPS in cirrhotic patients with esophagogastric varices at high re-bleeding risk

    摘要
  • 摘要:
    目的 比较采用经颈静脉肝内门体分流术（transjugular intrahepatic portosystemic shunt，TIPS）Viatorr覆膜支架植入或内镜联合药物治疗两种方法对伴有内镜治疗失败高危因素肝硬化食管胃底静脉曲张患者再出血的预防效果。
    方法 回顾性分析2015年11月至2018年12月复旦大学附属中山医院收治的240例肝硬化食管胃底静脉曲张伴有内镜治疗失败高危因素（肝静脉压力梯度≥20 mmHg、门静脉血栓、胃肾分流或腔道外侧支静脉）患者的临床资料。98例患者行TIPS（Viattor覆膜支架植入）治疗（TIPS组），142例患者接受内镜联合药物治疗（内镜组）。根据高危因素类型，2组进一步分为TIPS组1~4亚组和内镜组1~4亚组。采用Kaplan-Meier曲线和log-rank检验分析2组患者术后再出血率、肝性脑病发生率及生存情况，用Cox回归分析模型进行预后预测因素分析。
    结果 TIPS组患者2年无再出血累计生存率明显高于内镜组（94%vs 70%，P < 0.001）。TIPS组1~4亚组患者2年无再出血累计生存率分别为89%、92%、96%、92%，内镜组1~4亚组为68%、76%、67%、67%，2组各对应亚组间差异均有统计学意义（P < 0.05）。2组及各对应亚组间患者肝性脑病发生率、生存情况差异均无统计学意义。
    结论 对于合并肝静脉压力梯度≥20 mmHg、门静脉血栓、胃肾分流或腔道外侧支静脉的肝硬化食管胃底静脉曲张患者，植入Viatorr覆膜支架的TIPS预防再出血的效果优于内镜联合药物治疗，同时不增加肝性脑病的发生。

     

    Abstract:
    Objective To compare the preventive effect of transjugular intrahepatic portosystemic shunt (TIPS) using Viatorr stent with endoscopic therapy plus non-selective β-blockers (NSBBs) for gastroesophageal variceal bleeding (GEVB) in cirrhotic patients with high-risk factors of endoscopic treatment failure.
    Methods Between November 2015 and December 2018, 240 consecutive cirrhotic patients with a history of GEVB and high factors which included the hepatic vein pressure gradient (HVPG) ≥ 20 mmHg, portal vein thrombosis (PVT), gastro-renal shunt (GRS), or extraluminal para-gastric veins (ep-GVs), were diagnosed and treated. Totally, 98 patients underwent TIPS with Viatorr-covered stent (group A) and 142 patients received endoscopic therapy combined with NSBBs (group B). According to the above high-risk factors, both groups were stratified into 4 paired subgroups (A1-A4, B1-B4). Variceal rebleeding rate, overt hepatic encephalopathy (HE) rate, and overall survival were compared between the two groups and paired subgroups by Kaplan-Meier curve and log-rank detection.
    Results The 2-year cumulative survival rate of patients without variceal rebleeding was higher in group A than that in group B (94% vs 70%, P < 0.001). The 2-year cumulative survival rate of patients without variceal rebleeding was 89%, 92%, 96%, and 92%, respectively in the A1-A4 subgroups, and 68%, 76%, 67%, and 67%, respectively in the B1-B4 subgroups, and there were differences between the corresponding subgroups (P < 0.05). There were no significant differences between the two groups and corresponding subgroups in HE and survival rates.
    Conclusions Compared to secondary prophylaxis with endoscopic therapy plus NSBBs, TIPS with Viatorr-covered stent could significantly reduce the variceal rebleeding rate in cirrhotic patients with HVPG ≥ 20 mmHg, PVT, GRS, or ep-GVs, without increasing the incidence of hepatic encephalopathy.

     

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