急性和亚急性肠系膜上静脉门静脉血栓的介入治疗

急性和亚急性肠系膜上静脉门静脉血栓的介

入治疗

作者：宋鹏王茂强段峰王志军刘凤永

【摘要】目的评价介入技术治疗急性和亚急性肠系膜上静脉(superior mesenteric vein，SMV)门静脉(portal vein，PV)血栓形成的疗效。方法对21例急性和亚急性SMV PV血栓形成患者进行介入治疗。选择经颈静脉途径经肝穿刺门静脉［即通过经颈静脉肝内门脉系统分流术(transjugular intrahepatic porto systemic shunt approach,TIPS途径)］介入治疗(12例)和经导管肠系膜上动脉(superior mesenteric artery,SMA)溶栓治疗(9例)。结果治疗成功19例，无严重并发症。11例经TIPS途径治疗的患者于治疗结束时造影显示大部分血栓被清除，门静脉系统有血流通过，临床症状缓解。1例虽然SMV PV恢复血流，但12 d后死于腹腔脓肿、MODS。经导管SMA内溶栓治疗9例，术后症状逐渐改善8例，无效1例。结论经TIPS 途径介入技术和经导管SMA溶栓是治疗急性和亚急性SMV PV血栓形成的有效方法。

【关键词】门静脉血栓；肠系膜上静脉血栓；溶栓治疗；介入治疗

Interventional radiological technique for acute and subacute superior mesenteric vein portal vein thrombosis 【Abstract】Objective To assess the efficacy of interventional radiological therapy in the management of acute

and subacute superior mesenteric vein (SMV)portal vein (PV) thrombosis. Methods Twenty one patients with acute or subacute SMV PV thrombosis were treated by interventional radiological therapy. Of all, 12 patients were treated through transjugular intrahepatic portosystemic shunt (TIPS) pathway and 9 by transcatheter intra superior mesenteric artery (intra SMA) thrombolysis. Results Nineteen out of 21 patients obtained satisfactory outcome after interventional radiological therapy, with no occurrence of complication. For patients treated by TIPS, the majority of the thrombus in PV and SMV was cleared away, resulting in flow restoration in the mesenteric vein in 11 patients after the procedure with clinical improvement. One patient died of intra abdominal sepsis and multiple organ failure although SMV PV flow was restored. Clinical improvement was seen in 8 out of 9 patients undergone transcatheter intra SMA thrombolysis. Conclusions Interventional radiological therapy through TIPS pathway and transcatheter intra SMA thrombolysis are effective in managing acute and subacute SMV PV thrombosis.

【Key words】 Portal venous thrombosis; Mesenteric venous thrombosis; Thrombolysis; Interventional therapy

急性和亚急性肠系膜上静脉(superior mesenteric vein，SMV)

门静脉(portal vein，PV)血栓形成是较少见疾病，其临床表现缺乏特征性，如不及时作出明确诊断，10%～15%的患者因侧支血管建立不良而发生肠梗死，病死率较高［1］。近年，介入微创技术开始应用于治疗PV和SMV血栓形成，获得优良效果［2-3］。本文总结了用介入导管技术治疗21例急性和亚急性SMV PV血栓的初步经验。

1 资料和方法

1.1 一般资料

1998年4月至2006年8月我院收治的21例急性和亚急性SMV PV血栓形成患者，其中男13例，女8例；中位年龄46岁(28～68岁)。21例均有不同程度腹痛、腹胀、厌食症状，伴腹泻15例、呕吐6例、腹水8例，腹部均无明显腹肌紧张和反跳痛，心率、血压、体温属正常范围。18例有明确诱因，其中5例1年内行脾切除术，5例近期有胰腺炎病史，6例存在肝硬化门静脉高压症，1例继发于十二指肠创伤修补术后24 h，1例1个月内有阑尾炎手术史。从症状发作至就诊2 d至4周不等，其中1周以内(急性)6例。

PLT高于正常值7例［(500～980)×109/L］，WBC增高8例［(12～20)×109/L］，RBC、Hb正常。肝功能异常10例(AST>40 U/L，ALT>40 U/L，TB>21 μmol/L，DBIL>8.6 μmol/L)，肾功能、血清电解质正常。

Doppler超声波(US)和增强CT确诊17例，增强CT确诊4例。确诊后给予禁食、胃肠减压、抗生素、经外周静脉途径抗凝、溶栓等治疗疗效不显著。4例确诊时因存在静脉溶栓的禁忌证而未进行溶栓