肝移植术后肝静脉和下腔静脉梗阻的诊断及介入治疗

目的 探讨肝移植术后肝静脉、下腔静脉梗阻的诊断及介入治疗技术.方法 在831例原位肝移植(OLT)、26例活体肝移植(LDLT)患者中,共有11例在移植术后2～111 d经血管造影证实为肝静脉、下腔静脉梗阻并进行了介入治疗.其中肝静脉吻合口狭窄或闭塞5例、下腔静脉吻合口狭窄5例、肝静脉狭窄伴下腔静脉吻合口狭窄1例.11例中,5例为成人OLT、4例为LDLT、2例为儿童减体积OLT,介入治疗前9例接受了肝脏CT、2例接受了MR增强扫描.术后随访患者肝肾功能指标、临床症状及肝静脉、下腔静脉血流状况.对11例患者的影像资料、介入治疗技术要点和治疗效果进行回顾性分析.介入治疗前后梗阻两端静脉压力差比较,采用配对t检验.结果 11例患者,CT或MR检查均可明确显示肝脏淤血范围、肝静脉或下腔静脉梗阻部位及程度;其中4例肝静脉梗阻和5例下腔静脉梗阻者行支架植入治疗,1例肝静脉梗阻者行经皮腔内血管球囊扩张术(PTA),1例肝静脉伴下腔静脉梗阻者,行肝静脉PTA和下腔静脉支架植入,介入治疗手术均成功.术后检测梗阻两端静脉压力差为(2.9±1.7)mm Hg(1 mm Hg=0.133 kPa),较术前(16.5±4.1)mm Hg明显下降(t=11.5,P＜0.01).术后10例患者临床症状改善,肝肾功能恢复;1例肝功能恶化,于术后第9天死于多器官功能衰竭.患者术后随访9～672 d,2例肝静脉PTA治疗者术后1个月内发生血管再狭窄,支架植入治疗者未发生再狭窄,无严重并发症发生.结论 支架植入是治疗肝移植术后肝静脉和下腔静脉梗阻安全、有效的方法;术前CT或MR对明确肝淤血范围及静脉梗阻具有重要价值.     

上腔静脉综合征多排螺旋CT诊断价值

目的 探讨多排螺旋CT血管成像在上腔静脉综合征(SVCS)中的诊断价值.方法 46例上腔静脉综合征行颈胸部多排螺旋CT平扫及增强扫描,发送工作站后处理(包括VR、MPR、MIP、CPR)作出诊断,并与手术或穿刺病理作对比分析.结果 46例中肺癌所致SVCS 36例、恶性淋巴瘤5例、胸腺癌3例,慢性纵隔炎1例,甲状腺癌伴颈内静脉及上腔静脉癌栓形成1例.奇静脉入口以上梗阻31例,奇静脉入口以下梗阻4例,奇静脉人口上下同时阻塞者11例.轻～中度梗阻16例,重度梗阻21例,完全梗阻9例.结论 多排螺旋CT是诊断SVCS理想的检查手段.对临床进一步治疗具有重大指导作用.     

四肢主要动脉创伤性假性动脉瘤的外科治疗

目的 总结四肢主要动脉创伤性假性动脉瘤的外科治疗和疗效。方法 1998～2004年收治四肢主要动脉创伤性假性动脉瘤31例，均采用手术治疗，其中直接修补6例，端-端吻合5例，大隐静脉移植16例。人造血管移植3例，血管结扎1例。获随访23例，随访时间6个月～5年（平均18个月）。结果 28例一期治愈出院，其余3例术后血管闭塞二期再行自体静脉移植治愈。随访未见假性动脉瘤复发和肢体缺血症状。结论 四肢主要血管创伤性假性动脉瘤应强调尽早手术治疗；术中阻断动脉远近端血流是手术成败的关键；损伤血管直接或间接重建具有较好的治疗效果。     

小儿肝移植术后流出道梗阻的血管内治疗

目的 评价小儿肝移植术后流出道梗阻(HVOO)血管内治疗的效果.方法 搜集2008年1月至2013年1月肝移植术后小儿流出道梗阻患儿10例,均经下腔静脉及肝静脉造影证实,并行经皮血管成形术(PTA)和(或)经皮血管内支架成形术治疗.肝静脉流出道梗阻发生时间为术后10～ 455 d,根据梗阻发生时间分为早发型(肝移植术后1个月内)和迟发型(肝移植术后1个月以上),分析10例患儿血管内治疗的效果.结果 10例共进行21次血管内治疗,1次治疗无效,技术成功率为95.2％(20/21),首次治疗临床成功率为70.0％(7/10).早发型3例,1例扩张无效行手术治疗成功,1例反复流出道梗阻复发,最后植入支架,1例发生急性排斥反应死亡.迟发型7例,经球囊扩张或内支架治疗成功.结论 PTA和支架成形术治疗小儿肝移植术后HVOO,结果是安全有效的.早发型或肝静脉合并下腔静脉流出道梗阻应尽早植入支架,迟发型流出道梗阻和单纯肝静脉狭窄球囊扩张可获得较好结果.     

肝移植术后血管胆道并发症的介入治疗

目的:评价介入治疗对肝移植后胆道、血管并发症的价值。材料和方法:18例肝移植患者接受了介入治疗。其中肝动脉狭窄8例,行肝动脉造影及溶栓治疗;下腔静脉及肝静脉狭窄2例,行内支架置入术;胆瘘及胆道狭窄8例,行PTCD治疗。结果:胆道并发症8例,PTCD治疗后症状消失;肝动脉狭窄8例,溶栓后肝动脉完全开放6例,1例血流部分开放,1例肝动脉血流未恢复再次肝移植治疗;下腔静脉及肝静脉狭窄2例内支架置入术后下腔静脉梗阻及肝肿大症状消失。结论:介入治疗是治疗肝移植后胆道血管并发症的有效方法。     

上腔静脉梗阻:DSA的评价

上腔静脉(SVC)梗阻是一种不常见的但产生严重症状的综合征,需紧急处理。常规静脉造影难于显示梗阻部位。作者采用IVDSA上腔静脉造影替代常规静脉造影。用18或21号蝶形针置于任一上肢外周静脉,以每秒5ml速度注入20ml60％泛影葡胺,同时于上臂加压150普西(psi),用9或12吋屏,包括上纵隔及肩部以1帧/秒摄片,造影剂充盈静脉后增加到3帧/秒。特别注意观察静脉梗阻的部位、侧支通路及梗阻以远的中央静脉。作者检查6例男性,4例女性,年龄23—63岁,临     

锁骨下血管损伤的救治

目的 探讨锁骨下血管损伤的有效治疗方法。方法 对15例锁骨下血管损伤的救治进行回顾性分析,本组6例行血管修补,3例行人造血管移植,2例行大隐静脉桥接,1例行直接端一端吻合。结果 手术修复成功12例,静脉修复后均无明显肢体肿胀,动脉修复术后1年随访,均可清晰地触及桡动脉搏动。其中2例并发臂丛神经损伤,术后1年随访未完全恢复。死亡3例。结论 对锁骨下血管损伤应做到诊断迅速,快速有效止血,及时补充血容量和纠正休克。手术修复应根据具体情况选择适当切口,严格遵循显微外科技术,针对不同的情况选择血管吻合、修补、自体静脉或人造血管移植。     

支架治疗上腔静脉综合征32例疗效分析

目的:评价支架治疗上腔静脉综合征的疗效。方法:经股静脉造影确诊32例肿瘤患者并发上腔静脉综合征,然后在上腔静脉、无名静脉狭窄段植入支架治疗。结果:32例造影均显示静脉血流恢复,术后患者上腔静脉梗阻症状缓解。结论:支架植入治疗上腔静脉综合征安全有效,并发症少,能有效提高患者生活质量。     

经皮上腔静脉成型术治疗上腔静脉阻塞综合征

目的　探讨经皮上腔静脉支架成型术治疗上腔静脉阻塞综合征的方法及临床价值。方法　上腔静脉阻塞综合征患者 1 5例 ,包括肺癌伴纵隔淋巴结转移 1 0例 ,非霍奇金淋巴瘤 3例 ,食管癌伴纵隔淋巴结转移 2例 ,均先行右锁骨下静脉或肘静脉穿刺插管至阻塞上段作造影、测压 ,显示阻塞的部位、程度、侧支循环及有无血栓等情况 ,再经右侧股静脉穿刺入路置放上腔静脉支架。结果　 1 5例患者均 1次成功地植入上腔静脉支架 ,1例患者因狭窄范围超过 1 0cm而导入 2枚支架 ,其余均置入 1枚支架。术后造影显示血流恢复通畅 ,手术前后梗阻远端测压从术前的 (30 .5± 2 .3)cmH2 O降到术后的 (8.8±1 .5 )cmH2 O(均为卧位测压 ) ,差异有显著性 (P <0 .0 1 )。术后造影侧支静脉不再显影 ,上腔静脉阻塞症状明显改善 ,随访 6个月 ,除 1例患者因合并血栓经局部溶栓、球囊扩张治疗后症状改善 ,其余患者均无阻塞症状复发。结论　经皮上腔静脉成型术创伤小、恢复快、疗效确切 ,是治疗上腔静脉阻塞综合征的有效方法。     

腔静脉恶性梗阻的内支架治疗

恶性肿瘤致上腔或下腔静脉阻塞 ,因病情危重通常患者一般情况差 ,无法耐受较大创伤的治疗 ,使临床治疗十分困难 ,本组 30例腔静脉恶性梗阻的患者经血管内支架治疗 ,取得了较好的近期疗效 ,现报道如下。材料和方法一、资料患者 30例 ,男 2 1例 ,女 9例 ,年龄 36～ 73岁 ,平均 5 7岁。上腔静脉综合征 12例 ,其中肺癌 8例 ,纵隔淋巴结转移癌 4例 (甲状腺癌 1例 ,原发灶不明癌 1例 ,食管癌 1例 ,乳腺癌 1例 ) ,主要表现 :颈静脉怒张、颜面及颈部浮肿、呼吸困难。下腔静脉综合征 18例 ,其中原发性肝癌 15例 ,后腹膜肿瘤 3例 ,主要表现 :腹壁静脉…     

Collateral pathways observed by radionuclide superior cavography in 70 patients with superior vena caval obstruction.

Schematic representations of collateral pathways that have developed in association with superior vena caval obstruction have been established in studies using radionuclide superior cavography (RNSC). However, these were hampered by the poor resolution of earlier scintillation cameras. Using a modern scintillation camera, we performed RNSC in 70 patients with obstruction of the superior vena caval system, and examined the differences in collateral pathways in the presence or absence of obstruction of the azygos vein. RNSC visualized the site of obstruction and collateral pathways far more readily than in prior studies. When the orifice of the azygos vein was not obstructed, collateral flow drained into the azygos system. When it was obstructed, however, the collaterals drained into the inferior vena caval system. An important collateral pathway comprising the contralateral brachiocephalic vein and the jugular venous arch was also found, which has not previously been reported. Our diagrams of collateral circulation may provide a means of determining the site of obstruction in the superior vena caval system by RNSC.     

Superior vena cava obstruction: a venographic classification

Analysis of venacavograms in 27 patients with superior vena caval obstruction revealed the following four patterns of venous collateral return: type I, partial obstruction (up to 90% stenosis) of the superior vena cava with patency of the azygos vein; type II, near-complete to complete obstruction (90-100%) of the superior vena cava with patency and antegrade flow through the azygos vein and into the right atrium; type III, near-complete to complete obstruction (90-100%) of the superior vena cava with reversal of azygos blood flow; type IV, complete obstruction of the superior vena cava and one or more of the major caval tributaries, including the azygos system. These patterns correlate well with the patients' clinical courses and can be used to identify patients who are at risk of developing cerebral and airway compromise and therefore would benefit from superior vena cava bypass surgery.     

MRI visualization of the aortic nipple

The aortic nipple, a small “pseudotumor” adjacent to the aortic arch, is the left superior intercostal vein. In our series of 40 patients it was demonstrated in six; all had a right upper thoracic mass and four had a superior vena caval syndrome. Coronal magnetic resonance, images (MRI) of the thorax were superior to all other imaging methods in demonstrating the nipple. It is concluded that in patients with masses in the right upper chest, coronal MR chest examinations are valuable in demonstrating an aortic nipple, a sign of impending present superior vena caval or innominate, vein obstruction.     

Cavo-portal shunting in superior and inferior vena caval obstruction

Focal radionuclide accumulation of Tc-99m sulfur colloid (SC) and tc-99m macroaggregated albumin (MAA) in the liver has been reported in both inferior and superior vena caval obstruction. We studied a patient with uniform radionuclide accumulation of Tc-99m MAA in the liver during lung scintigraphy. In this patient, both the superior vena cava (SVC) and the inferior vena cava (IVC) were obstructed. Most of the systemic venous return appeared to be passing through the liver on its way to the heart, through the anastomoses between the systemic veins and the portal vein. The the best of our knowledge, uniform hepatic uptake in vena caval obstruction is not reported in the literature.     

The normal and abnormal left superior intercostal vein.

A study of 500 normal erect posteroanterior chest radiographs was undertaken to determine the incidence of visualization and size of the left superior intercostal vein in normal individuals. The vein produces a small "nipple" lateral to the aortic knob on 1.4% of normal erect posteroanterior chest films; its diameter can be up to 4.5 mm in normal patients. Dilatation of the vein beyond 4.5 mm is a useful sign of a circulatory abnormality warranting further study. Dilatation may be due to absence of the inferior vena cava, hypoplasia of the left innominate vein, congestive failure, portal hypertension, Budd-Chiari syndrome, or superior or inferior vena caval obstruction. The differential diagnosis of an enlarged left superior intercostal vein includes mediastinal mass, especially lymphadenopathy, and aneurysm of the arch of the aorta.     

"Hot spot" on hepatic scintigraphy and radionuclide venacavography.

Seven patients showing a localized area of increased uptake (hot spot) on 99mTc sulfur colloid liver scans are described. Four also had dynamic studies. In five patients the hot spot was associated with superior vena caval obstruction, in one it was associated with inferior vena caval obstruction, and in one with a hepatoma. Although a hot spot on static liver images usually indicates superior vena caval obstruction, the addition of radionuclide venacavography is recommended to confirm the diagnosis. A hot spot in the liver area in a radionuclide venogram of the lower limbs suggests inferior vena caval obstruction with collaterals via the liver.     

Superficial collateral veins on abdominal CT: findings in cirrhosis and systemic venous obstruction

Inspection of the superficial veins of the abdominal wall has long been a routine part of the physical examination. To date, radiologists have given such veins rather scant attention, even though they are elegantly demonstrated by CT. We have performed a study of 21 patients with cirrhosis, 7 patients with caval obstruction and 28 normal control counterparts in order to determine whether superficial veins were more numerous in these two clinical conditions. The 7 patients with caval obstruction included 4 with superior and 3 with inferior vena cava obstructions. Electronic data from the CT examinations of these 28 cases and 28 controls were analysed on a viewing console. Superficial veins were significantly more numerous in patients with cirrhosis (mean maximum=5, p<0.01) and caval obstruction (mean maximum=9.1, p<0.01) than in the normal controls (mean maximum=2.1). The combination of too many superficial veins and a large superior mesenteric vein is a pointer towards cirrhosis. The presence of excessive superficial veins is yet another clue to the presence of underlying disease when analysing abdominal CT.     

上腔静脉狭窄及阻塞的介入性开通治疗：附六例报告

报告６例上腔静脉狭窄及阻塞的介入治疗结果，旨在探讨有关技术问题及评价临床疗效。６例中，男５例，女１例，年龄４８￣７４岁，均表现为上腔静脉综合征，５例为肺癌伴纵隔淋巴结转移所致，１例为纵隔淋巴瘤压迫上腔静脉。４例造影表现为重度狭窄，２例为完全性阻塞。介入治疗时，先用导丝通过梗阻段，继而用球囊导管扩张，最后导入金属内支架。结果：６例均开通成功，无重要并发症，术后临床症状明显改善，侧支静脉消失，梗阻远侧     

Gianturco self-expanding stents: Clinical experience in the vena cava and large veins

Twenty-five patients with stenosis of the vena cava (21) and other large veins (4) have been treated with self-expanding Gianturco metallic stents. Eighteen patients had superior vena cava syndrome. In 17, the stricture was due to malignant superior vena cava compression recurrent after maximum tolerance radiotherapy and/or chemotherapy. In 16 of these patients there was early symptomatic relief. In 1 patient with a benign posttraumatic superior vena cava stricture, the stenosis was not relieved, and occlusion occurred after 1 month. Stenoses associated with dialysis shunts were relieved in 2 other patients. Two malignant and one benign inferior vena cava stenoses were relieved either until death, or in the benign case, for 30 months. One malignant subclavian vein obstruction occluded after 24 h due to stent misplacement and another with extrinsic mediastinal compression remained patent until death, extensive thrombus having been lysed prior to stent placement. The results of this short series suggest that the Gianturco self-expanding stent in the vena cava and large veins is easy and safe to place, and in most cases produces almost immediate palliation of the distressing effects of venous obstruction, often in a preterminal and inoperable patient.     

Reflections on the etiology of hot spots on liver scans

Liver scintigraphy demonstrated areas of increased radiocolloid uptake in three cases with obstruction of the superior vena cava and extensive collateral circulation through the veins of the thoracic wall. The pattern of the hyperactive zones is indicative of predominant vascularization of the liver via the umbilical vein, with high colloid particle deposition in the quadrate lobe and adjacent part of the right lobe. These liver regions vascularized by the first intrahepatic branches of the umbilical vein as demonstrated by postmortem angiography, probably extract a great portion of the tracer dose, resulting in localized hyperactivity. An identical liver scan image was, however, found in a fourth case without evident superior vena cava syndrome. In this patient, presenting with a bronchus carcinoma with paratracheal metastatic lymph nodes, there is no explanation (collateral circulation without vena caval obstruction?) for the abnormal tracer distribution within the liver.