Portal hypertension due to hepatic sclerosis combined with esophago-gastric varices is a common and frequent disease, which is one of the main diseases that endanger the health of the population, has a high mortality rate and consumes social resources. Currently, the main means of treating esophago-gastric varices are medical treatment, interventional treatment and surgical treatment [1,2].
Interventional treatment of portal hypertension and its complication-esophago-gastric varices are transjugular intrahepatic portosystemic stent shunt (TIPSS) via the jugular route, gastric coronary vein via the TIPSS route- (TIPSS), coronary vein-gastric short vein embolization via the TIPSS route, coronary vein-gastric short vein embolization via the percutaneous transhepatic portal vein route, balloon-occluded retrograde transvenous obliteration (BORTO), splenic artery embolization, and opening of hepatic vein-inferior vena cava obstruction [3-6]. (BORTO), splenic artery embolization, and opening of hepatic-hypophyseal vein obstruction [3-6], etc. In terms of treatment principles, they can be divided into: interventional shunt (e.g., TIPSS), interventional dissection (e.g., embolization of gastric coronary varices), shunt+dissection, reduction of portal blood flow (e.g., abdominal-mesenteric artery perfusion with pressin, splenic artery embolization, etc.), and opening of hepatic-portal vein obstruction. The indications, contraindications and clinical application evaluation of several commonly used interventional techniques are described below.
I. Transjugular route intrahepatic portal-hepatic vein stent shunt
Transjugular intrahepatic portosystemic stent shunt (TIPSS) is an interventional technique developed on the basis of transjugular route liver biopsy, cholangiography and portal angiography. In 1979, Gutierrez, Burgerner performed TIPSS in a canine model of portal hypertension, and the authors again demonstrated the feasibility of the puncture technique, but failed to address In 1982, Colapinto et al. first reported the use of the TIPSS technique in humans, using a simple balloon catheter dilation to establish a shunt between the hepatic and portal veins, and the immediate hypotensive effect was satisfactory, but most of the shunts became occluded within a short period of time (24 h-1 week). However, most of the shunts became occluded within a short period of time (24h-1 week). After Palmaz (1985) and Rosch (1987) demonstrated that endoprostheses could maintain shunt opening in experimental animals, Richter et al. reported the clinical application of TIPSS in 1990, and after that, successful clinical applications were reported in the United States and Japan. After that, successful clinical applications were reported in the United States and Japan [3-5,7-9].
After more than 20 years of relevant basic research, clinical application and technical improvement, there is a relatively consistent understanding of the technical principles, defects and clinical application value of TIPS. Compared with surgical portal-body shunts, TIPS has the advantages of less invasiveness, high technical success rate, reliable reduction of portal vein pressure, control of the diameter of the shunt tract, ability to do simultaneous dissection (embolization of varicose veins), and low complication rate.
I. Indications and contraindications
(A) Indications
1.Esophageal and fundic varices rupture and haemorrhage, after conservative treatment (drug treatment, endoscopic treatment), should be considered.
etc.) are not effective, emergency TIPSS should be considered.
2.Recurrent bleeding even after endoscopic treatment.
3.For patients from remote areas or with limited transportation and emergency measures, prophylactic TIPSS should be considered in the following cases: severe varicose veins without endoscopic treatment, regardless of previous history of varicose vein rupture and bleeding; moderate-to-severe fundic varicose veins with high risk of rupture and bleeding.
4, Recurrent variceal rupture and bleeding after surgical procedures.
5, End-stage liver disease, who need to deal with ruptured variceal bleeding while waiting for liver transplantation.
(II) Controversial indications
1, liver function Child-Pugh grade C, especially serum bilirubin, creatinine and reaction coagulation function of the International
standardized ratio (INR) is higher than the upper limit of normal value, TIPSS should not be selected unless emergency hemostasis is required.
2. Intractable ascites. Conservative treatment methods should be preferred, such as sodium restriction, diuresis, release of ascites and albumin supplementation. Some scholars in North America believe that recalcitrant ascites due to hepatic sclerosis is one of the indications for TIPSS. A group of multicenter data showed that the survival rates of patients with recalcitrant ascites at 1 and 2 years after treatment with TIPSS were 77% and 59%, respectively, and the survival rates at 1 and 2 years after receiving conventional treatment (ascites pumping + supplemental albumin) were 52% and 29%, respectively. In contrast, recent data from Japanese scholars have shown that although TIPS can relieve ascites due to portal hypertension, there is no significant difference in patient survival compared with conventional treatment. Fewer reports have been made in this regard in China. Because of the differences in the etiology of hepatic sclerosis and the degree of liver tissue destruction and compensation between North America and Southeast Asia, it is not appropriate to consider intractable ascites as the best indication for TIPS [15,16].
3, Budd-Chiari syndrome (BCS). For occlusion of the main trunk of the hepatic vein, absence of larger hepatic venous branches in the liver, poorly established collateral branches, or occlusion of small hepatic veins, TIPSS can be considered when the patient has portal hypertension with variceal rupture and bleeding as the prominent manifestation, and liver transplantation is also an option. Although TIPS can reduce portal vein pressure and improve liver stasis, it has no positive significance in improving the perfusion of liver tissue, and some patients can develop liver failure after surgery [4,17,18].
4, Portal hypertensive gastric disease, who have failed with conservative treatment [3].
5, There are isolated reports of the efficacy of TIPS in hepatic pleural fluid and hepatic-renal syndrome [15].
(C) Conditions not recommended as indications
1, moderate esophageal varices, no history of variceal rupture and bleeding, no tendency to rupture on endoscopy
The majority of scholars believe that a cautious approach should be taken to do prophylactic TIPSS in such patients.
2.Patients with splenomegaly and hypersplenism.
(D) Contraindications: There is no absolute contraindication to TIPSS for the treatment of emergency variceal haemorrhage, but caution should be exercised in the following cases.
1.Severe dysfunction of important organs (heart, lung, liver, kidney, etc.).
2. Coagulation abnormalities that are difficult to correct.
3. Uncontrolled infectious diseases, especially those with biliary infections.
4.Pulmonary hypertension with right heart failure.
5.Recalcitrant hepatic encephalopathy.
6.Parasitic cysts of the liver that cannot be excluded.
(V) Relative contraindications
1.Polycystic liver or multiple liver cysts (easily lead to bleeding in the cystic cavity).
2.hepatocellular carcinoma combined with severe varices. If the liver tumor is well controlled and the location of the tumor does not affect the establishment of shunting tract, it is appropriate to treat it according to conventional TIPS. For those with extensive liver tumor, poor therapeutic effect and ruptured variceal bleeding, TIPSS can be considered when treatment by endoscopic route is ineffective, but embolization of variceal veins should be the main focus and small diameter (diameter <8mm) shunt should be done as appropriate. For patients with portal vein cancer embolism combined with uncontrollable variceal bleeding, TIPSS or percutaneous hepatic puncture route can be used to "squeeze open" the embolus and open the portal vein obstruction, while embolizing the varices.
3.Cavernous degeneration of portal vein. If the portal vein is completely obstructed, the intrahepatic portal vein branches are slender or not visualized, or the difficulty of penetrating the portal vein branches is expected to be very high, TIPS should not be chosen, but if the intrahepatic portal vein branches are well visualized and the portal vein collateral branches are established in the portal area, TIPS can be carefully chosen. The stent should cover the obstructed segment of the portal trunk [19]. In addition, when the portal vein is completely obstructed and the splenic vein is patent, the esophagogastric fundic varices can be embolized by transsplenial puncture through the splenic vein, followed by selective splenic artery embolization to prevent splenic hemorrhage.
(F) Efficacy evaluation
TIPS is an important interventional technique for the treatment of ruptured variceal bleeding combined with portal hypertension, which has the advantages of less invasive, simultaneous flow dissection and shunt, wider indications than surgical treatment, high technical success rate and reliable efficacy. In addition, the use of minimally invasive techniques (e.g., balloon-expandable stents, placement of narrowing stents, etc.) can adjust the size of the shunt tract to suit the needs of different individuals, thus avoiding excessive shunts and reducing the incidence of hepatic encephalopathy.
The technical success rate of TIPS is 95% to 99%, the complication rate is 3% to 8%, and the mortality rate directly related to the operation is 0.5% to 1%. In terms of clinical efficacy, TIPSS has an immediate hemostatic success rate of 90% to 99% for emergency variceal rupture bleeding; the efficiency of preventing recurrent bleeding: 85% to 90% in ≤6 months, 70% to 85% in ≤1 year, and 45% to 70% in ≤2 years. The results of a multicenter, double-blind controlled study in the United States showed that the recurrent bleeding rate 1 to 2 years (mean 18 months) after TIPSS was lower than that treated by endoscopic route (ligation, sclerotherapy injection, etc.), but more information is needed to support this view. tIPSS is effective for intractable ascites due to portal hypertension.
The intermediate and long-term (≥1 year) efficacy of TIPS. The 1-year incidence of postoperative rebleeding is 20% to 26%, and the 2-year cumulative recurrent bleeding rate is 32%. The main factor affecting the efficacy is postoperative shunt stenosis or occlusion, which mainly occurs 6-12 months after surgery, and the incidence of clinical follow-up (based on angiography and recurrent bleeding) is 20%-70%, and the incidence of pathological specimens or autopsy is 40%-48%; in recent years, some authors have reported an incidence of shunt stenosis <10% more than 1 year after surgery; the application of overlapping stents to support the shunt can reduce the incidence of stenosis The incidence of stenosis can be reduced with the application of overlapping stents.
[Appendix: About direct percutaneous transhepatic puncture for portal-venous shunt (DIPS)].
DIPS (Direct intra-hepatic portocaval shunt) [4, 5, 10, 24, 25, 26]
Another interventional technique based on the TIPS concept, direct percutaneous transhepatic portocaval shunt (DIPS), has been noted in recent years in three main ways: (1) direct shunt between the caudal lobe of the inferior vena cava and the main trunk of the portal vein, in contrast to the traditional surgical “H ” type portal-luminal shunt is identical. The basic technique: the portal trunk is punctured percutaneously with a 21-23G minimally invasive needle under CT or ultrasound guidance, the portal trunk is punctured percutaneously through the liver, the anterior wall of the caudal lobe encircled inferior vena cava is continued to be punctured posteriorly as appropriate, and a guidewire is introduced into the inferior vena cava (abdominal wall → left lobe of the liver → portal trunk → caudal lobe → inferior vena cava); the guidewire is punctured from the femoral side, the inferior vena cava is pulled to the femoral side, and then dilated with a balloon The “tunnel” between the portal trunk and the inferior vena cava is then dilated with a balloon and a stent is introduced (a laminated stent is available). (2) Establishing a shunt between the left trunk of the portal vein-sagittal and the inferior vena cava, also known as a modified “H” shunt. Basic technique: Minimally invasive percutaneous hepatic puncture of the sagittal part of the portal vein with a CT or ultrasound-guided needle, continued posterior puncture of the anterior wall of the inferior vena cava, as appropriate. (3) At the level of the second hepatic portal, a shunt between the inferior vena cava and the portal branch is established, which is a modified technique of TIPS. Method: When the opening of the hepatic vein cannot be found during TIPS (Budd-Chiari syndrome) or when the distance between the hepatic vein and the main branches of the portal vein is too close for puncturing the portal vein from the hepatic vein, the anterior wall of the inferior vena cava to the liver parenchyma and then the branches of the portal vein can be punctured directly from the level of the second hepatic portal.
Advantages of DIPS: (1) the shunt does not contain the hepatic vein, which reduces the incidence of stenosis; (2) the first and second techniques (H-type and modified H-type) have short shunts, especially in the parenchymal segment of the liver, and straighter shunts, so the incidence of stenosis is lower; (3) the difficulty of puncturing the branches of the portal vein with classical TIPS may be overcome.
Defects and technical difficulties of DIPS: (1) the disadvantages of traditional surgical “H” shunt, which is a non-selective shunt and has a high incidence of postoperative hepatic encephalopathy (HE); liver atrophy due to portal vein loss of perfusion; (2) the need for precise positioning of the stent, which should not be extended too far into the main portal vein and inferior vena cava (<5 mm); (3) the need for precise positioning of the stent, which should not be extended too far into the main portal vein and inferior vena cava (<5 mm); and (4) the need for the stent to be inserted into the portal vein. <5 mm); (3) may affect liver transplantation; (4) the rate of intra-abdominal bleeding is higher than that of conventional TIPS; (5) the technical difficulty of simultaneous embolization of the gastric coronary vein/short gastric vein is higher than that of TIPS.
In conclusion, DIPS is only an adjuvant technique and should not be used as a mainstream treatment for portal hypertension combined with varices.
Second, percutaneous transhepatic portal vein route embolization of varicose veins (PTVE) [4, 5, 6]
percutaneous transhepatic variceal embolization
Percutaneous transhepatic variceal embolization (PTVE) has a long history of clinical application and is a simple, inexpensive, and reliable technique for immediate hemostasis, first reported by Swedish scholars Lunderquist and Vang in 1974. It was first reported by Swedish scholars Lunderquist and Vang in 1974 and was the main method of interventional treatment of ruptured gastroesophageal variceal bleeding in the 1980s. With the development of endoscopic treatment techniques and TIPSS, the use of PTVE has tended to decrease gradually, but it is still a proven and practical technique. In recent years, the popular use of micro puncture needle (21-23G) in clinical practice has improved the safety of PTVE.
I. Indications
1.Ruptured bleeding of active varicose veins that cannot be controlled by endoscopic route treatment and drug therapy.
2, recurrent variceal rupture bleeding despite treatment by endoscopy and other conservative measures.
3.There are indications for TIPSS treatment, but the patient refuses TIPSS or the implementation of TIPSS has high risk and technical difficulty; 4.Generally, PTVE is not used as a means to prevent bleeding, but it can be considered for varicose veins of the fundus with inconvenient transportation, limited rescue conditions, and endoscopy suggesting a high risk of rupture.
II. Contraindications
1, there are contraindications to angiography, such as coagulation disorders, bleeding tendency that cannot be corrected after active treatment (including the administration of hemostatic agents, coagulation factors, blood transfusion, etc.), severe cardiac, hepatic and renal insufficiency, etc.
2, portal vein obstruction or sponge-like degeneration.
3, interstitial colon, where the puncture needle cannot avoid the intestinal canal
4, severe cachexia with an expected survival index of <2 weeks
5, unable to cooperate with the examination, especially delirious awakening and failure of psychotic symptoms.
6, people who are allergic to iodine must not use iodine-containing contrast agent, but Gd-DTPA (gadolinium-containing contrast agent) without iodine is available, the latter development is not as clear as iodine, but can meet the treatment; in addition, negative contrast agent CO2 can also be used to guide interventional treatment.
7. Relative contraindications include large amount of ascites, difficulty in avoiding the tumor through the puncture tract, severe hepatic atrophy, etc. When PTVE is really necessary in these cases, ascites should be released, hemostatic agents should be given, and backup emergency measures (such as blood transfusion, selective hepatic artery embolization, etc.) should be taken as appropriate.
Evaluation of efficacy
The advantages of PTVE include low technical difficulty, short operation time, low cost, minimal impact on liver function, and high success rate of emergency hemostasis (75%-95%), which is a good emergency tool for patients with emergency bleeding who do not have endoscopic treatment or poor endoscopic treatment, and who do not have indications for bypass (including TIPS) or dissection. There is no evidence-based medical evidence on whether PTVE can be used as a measure to prevent ruptured varices from bleeding. For severe fundic varices with a high risk of rupture and limited emergency care, PTVE can be considered for those who do not consider other treatment measures (bypass, dissection, TIPSS, BORTO, etc.).
The disadvantage of PTVE is that it does not reduce portal vein pressure, and most patients have varying degrees of elevated portal vein pressure (5-10 cmH2O) after embolization of varices, the latter of which can lead to postoperative ascites, re-establishment of side branches, and formation of new varices. In addition, the recurrent bleeding rate after PTVE is high, and the literature reports rebleeding rates of 55%, 66%, 80%, and 90% at 6 months, 1, 2, and 3 years after surgery. Combining PTVE with partial splenic artery embolization can reduce portal vein pressure, decrease the incidence of postoperative recurrent bleeding, and improve the symptoms of hypersplenism; combining PTVE with transendoscopic approach to varicose veins can also improve the hemostatic effect.
Third, retrograde occlusion of varicose veins (BORTO) is performed under the obstruction of a balloon catheter [27-32].
Balloon-occluded retrograde transvenous obliteration
Balloon-occluded retrograde transvenous obliteration (BORTO) is performed by using a transvenous route (femoral or jugular vein) into the inferior vena cava and retrograde through side branches such as the gastric-adrenal vein shunt, splenic-renal shunt, and left subphrenic vein. into the portal vein geniculate branches for occlusion of varicose veins. The basic techniques and clinical applications of retrograde varicose vein occlusion via the gastro-renal shunt are described below.
I. Indications
1.BORTO can be considered in the presence of gastro-renal shunt or splenic-renal shunt and moderate to severe varices in the fundus, regardless of the history of variceal rupture and bleeding.
2.In the presence of gastric-renal shunt or splenic-renal shunt, although there is no fundic-esophageal varices, but there is hepatic encephalopathy (HE), HE can be relieved or eliminated after using embolization of spontaneous shunt tract.
Second, contraindications
1.The shunt can not be completely blocked by balloon.
2.When blocking the spontaneous shunt tract, the retrograde injection of contrast agent is obvious to the portal vein reflux, and cannot avoid accidental embolization of portal vein.
3.Under the blocking of spontaneous shunt, the fundic-esophageal varices cannot be confirmed after retrograde injection of contrast agent.
4.Other: such as renal insufficiency (hemolysis and hemoglobinuria after BORTO may cause renal failure), left renal vein thrombosis, and the presence of contraindications to angiography.
Evaluation of efficacy
BORTO is a relatively simple interventional technique with the advantages of low impact on liver function, no postoperative HE complications, and less damage, etc. The technical success rate is 60%-90%, and the clinical efficiency is 50%-80%.
BORTO as a means of emergency hemostasis has certain limits, such as the combination of BORTO with splenic artery embolization, treatment of esophageal varices via endoscopic route, percutaneous transhepatic puncture portal vein route embolization of fundic varices, etc., can improve the efficacy. If a huge gastric-renal shunt or splenic-renal spontaneous shunt is found during TIPSS, embolization of the gastric coronary vein and short gastric vein under the blocked spontaneous shunt tract by BORTO technique can avoid the embolic agent from entering the inferior vena cava.
IV. Splenic artery embolization in the treatment of complications of portal hypertension [5,33-36]
Transcatheter Splenic Arterial Embolization for Management of Portal Hypertension Variceal Bleeding
Splenic arterial embolization was first reported by Maddison et al. in 1973 for cirrhosis combined with hypersplenism, and patients treated had a shrinking spleen and rapid improvement in peripheral blood picture after the procedure, but the incidence of serious complications such as splenic abscess, acute pancreatitis, and systemic infection after total splenic embolization was high (5%-8%) due to the limitations of the technique and inexperience in postoperative management at that time. In 1979, Spigos et al. reported the treatment of hypersplenism with selective, partial splenic artery embolization, which resulted in a lower incidence of serious postoperative complications and partial postoperative preservation of splenic function. in 1985, Jonasson et al. reported a large group of embolized splenic artery cases with 1-8 years of follow-up after embolization of the spleen with gelatin sponge particles, which confirmed the safety and efficacy of partial splenic embolization. Currently, selective splenic artery embolization has become a safe and effective interventional technique used clinically in the treatment of various diseases such as splenic injury without an indication for emergency surgery, portal hypertension, splenic aneurysm, splenic tumor, pre-surgical embolization, and certain hematologic diseases. This section focuses on the application of splenic artery embolization in the treatment of portal hypertension.
I. Indications and contraindications of splenic artery embolization
(A) Indications.
1, portal hypertension with a history of ruptured bleeding from upper gastrointestinal varices when other treatment methods (such as ligature or injection of sclerosing agent via endoscopy, hepatic vein-portal vein stent shunt [TIPSS] via jugular vein route, percutaneous liver puncture portal vein for gastric coronary vein embolization, etc.) cannot be performed or treatment fails.
2. those with splenomegaly complicated by hypersplenism due to various causes and with indications for traditional surgical treatment
3.Primary hepatocellular carcinoma combined with cirrhosis, splenomegaly and hypersplenism resulting in blood cell reduction, which affects the implementation of treatment for the tumor (such as chemotherapy or hepatic artery chemoembolization via catheter).
4. Other cases requiring embolization of the splenic artery, such as hematopenia caused by certain hematological diseases with bleeding tendency that cannot be corrected by other treatments; splenic artery aneurysm; tumors adjacent to the spleen invading the splenic artery resulting in bleeding; splenic artery steal syndrome after liver transplantation, etc.
(II) Contraindications.
1.Severe infection that fails to be controlled, with a high risk of splenic abscess after doing splenic embolization.
2.Severe decompensation of liver function (Child-Pugh grade C), unless necessary, splenic artery embolization should not be done.
3, secondary hypersplenism, whose primary disease has reached end-stage, with cachexia and organ failure
4, coagulation dysfunction, need to correct the coagulation function before interventional treatment.
5, other indications for conventional interventions, such as severe cardiac, pulmonary and renal insufficiency, allergy to iodine (can be replaced with CO2, gadolinium-containing contrast agent), etc.
(C) Efficacy evaluation
Transcatheter splenic artery embolization is a simple and easy method, which can reduce portal venous blood flow (40%-70%), lower portal venous pressure, reduce varicose veins or even disappear after the procedure, and improve hypersplenic symptoms at the same time. The drawback is that it cannot immediately occlude the rupture of varicose veins, and has certain limits for treating emergency hemorrhage, so it is not suitable as the first-line interventional treatment. In addition, the recurrence rate of varicose veins after embolization of splenic artery alone is high due to the existence of extensive collateral circulation between splenic artery and surrounding organs, so it is not suitable as a measure to prevent variceal bleeding.
When other methods (such as endoscopic ligature or injection of sclerosing agent, TIPSS, PTVE, etc.) cannot be performed or cannot control variceal bleeding, embolization of splenic artery is still a life-saving measure; combining splenic artery embolization with PTVE can stop bleeding immediately, reduce portal vein pressure, and lower the incidence of recurrent bleeding after surgery; combining splenic artery embolization with variceal treatment by endoscopic route can also improve hemostasis. The combination of splenic artery embolization and transendoscopic treatment of varicose veins can also improve the hemostatic effect.