RU2660997C2 - Method of using coronary techniques for transjugular intrahepatic portosystemic shunt (tips) - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to surgery and can be used for transjugular intrahepatic portosystemic shunt in cirrhosis of the liver. Coronary conductor 0.014^ʺ is conducted in parallel to rigid conductor 0.035^ʺ from the hepatic vein into the distal bed of the superior mesenteric vein, after which along coronary conductor 0.014^ʺ, bougienage and predilation of the liver meridian between the hepatic vein and portal venous system are performed by a coronary balloon catheter of 2.5×20 mm.

EFFECT: method provides the simplified technique, increased safety of the intervention.

1 cl, 7 dwg

Description

Liver cirrhosis (CP) is a chronic polyetiological progressive liver disease, which is the last stage of development of, as a rule, unfavorable forms of chronic hepatitis, manifested by damage to the parenchymal and interstitial tissue of the organ with a significant decrease in the number of functioning liver cells due to necrosis and degeneration of liver cells, nodular regeneration and diffuse proliferation of connective tissue [1, 2]. Most often, the etiological causes of CP are chronic alcohol intoxication (from 40-50% to 70-80%) and viral hepatitis B, C and D (30-40%) [2, 3, 4]. CPU is one of the ten most common causes of death, killing up to a million people in the world every year.

According to the Federal State Statistics Service, the total mortality from CPU in the Russian Federation in 2013 was registered at 47 thousand people [5]. CP and always accompanying portal hypertension (GH) can cause a number of life-threatening complications: esophageal-gastric bleeding from varicose veins, hepatorenal syndrome, hepatic coma in the outcome of encephalopathy.

Given the high relevance of the problem of prevention and treatment of CP and its complications, the search for optimal methods of surgical treatment of CP remains one of the pressing issues in modern surgical practice. Recently, minimally invasive surgical interventions, including endovascular ones, have become increasingly important in solving this issue. These include primarily the transjugular intrahepatic portosystemic shunt (Transjugular Intrahepatic Portosystemic Shunt - TIPS / TIPS).

The first TIPS operation was proposed in the 1980s. and immediately received widespread clinical use. The aim of this surgical treatment of GHG is to achieve effective portal hypertension. To date, the number of completed TIPS operations exceeds 200 thousand [6, 7, 8, 9].

An analogue of the invention is the operation of transjugular intrahepatic portosystemic shunting. The TIPS procedure involves the creation of a message between the hepatic vein and the portal venous system in order to ensure the outflow of blood from the hepatic sinuses and to reduce portal hypertension. Anesthesia is provided by endotracheal anesthesia. The first stage of the operation is the puncture and catheterization of the internal jugular vein with the aim of inserting a 12.5 F. introducer into it. Further along the guide wire 0.035 ^{/, the} main curved catheter is passed through the superior vena cava, the sinus of the right atrium and the inferior vena cava into the hepatic vein. To perform synchronous reverse portography and phlebography of the right hepatic vein, we catheterize the superior mesenteric artery through the brachial (transbrachial) method using the 5 F introducer sheath and the Headhunter-1 catheter.

Having ascertained the location of the portal vein bifurcation, a special needle is inserted through the catheter into the hepatic vein, with which the liver is punctured. Then, through a puncture needle, a hydrophilic conductor 0.035 ^/ is introduced into the corresponding punctured branch of the portal vein. Thus, access from the hepatic vein to the branch of the portal vein is formed. Using a special 5 F catheter, the hydrophilic conductor is changed to the super-rigid conductor 0.035 ^/ . The puncture parenchymal canal of the liver is sequentially expanded by peripheral balloon catheters of various diameters, most often it is 5-8 mm (Fig. 1). Then, a different type of stent is implanted into the formed channel of the liver. After removal of the stent delivery system, the stent is post-dilated with a balloon catheter of the appropriate diameter. Thus, a message is formed between the portal and systemic blood flow, providing decompression of the portal vein. In order to prevent the development of repeated esophageal-gastric bleeding, if indicated, in some cases embolization of the left gastric and short veins of the stomach with Gianturko spirals is performed.

However, for the analogue method, with severe cirrhotic liver damage, difficulties arise with the inability to conduct a peripheral balloon catheter into the puncture channel of the liver in order to pre-dilate it.

Every year, in connection with the development of medicine and an increase in the total volume of performed surgical interventions, new techniques for performing TIPS operations are improved and created.

The aim of this invention is to simplify the technique of balloon dilatation of the puncture channel of the liver using the coronary technique, which reduces the technical difficulties of its implementation and ensures the safety of surgical intervention, and sometimes the only way to create an optimal liver channel, and, therefore, subsequently form a portocaval shunt.

The essence of our proposed method is as follows: a 0.014 '' coronary conductor is conducted parallel to a 0.035 '' conductor from the hepatic vein to the distal channel of the superior mesenteric vein. After that, bougienage and dilatation of a narrow “channel of the liver” by a coronary balloon catheter is performed (Fig. 2). Then, peripheral balloon catheters of various diameters are passed through a 0.035 '' rigid conductor into the already pre-diluted “liver channel” and further dilatation to optimal sizes is performed.

The method is as follows:

Under aseptic conditions, under endotracheal anesthesia, a puncture and catheterization of the internal jugular vein is performed to insert an 12.5 F insertion sheath. Further along the guide wire 0.035 ^{/, the} main curved catheter is passed through the superior vena cava, the sinus of the right atrium and the inferior vena cava into one of most suitable hepatic veins. In parallel, puncture of the right brachial artery is performed in order to install the introducer sheath. An introducer sheath 5 F with a hemostatic valve is installed. In order to prevent angiospasm of the brachial artery intraarterially through the introducer is introduced a solution of Nitroglycerin 100 μg and 20 ml of physical. mortar in accordance with existing standards. A catheter “Headhunter-1” - 5 F to the mouth of the superior mesenteric artery is inserted through the inserted introducer at 0.035 ^/ guide. In order to determine the anatomy of the vessels of the liver, synchronous return portography and phlebography of the right hepatic vein are performed.

The portal vein is punctured with a stylet-catheter traction. Through a puncture needle, a hydrophilic conductor 0.035 ^/ is inserted into the corresponding punctured branch of the portal vein. Next, a coronary conductor of 0.014 '' is parallel to the 0.035 '' conductor from the hepatic vein to the distal channel of the superior mesenteric vein. After that, a narrow “liver channel” is blocked and dilated by a coronary balloon catheter. Using a special 5 F catheter, the hydrophilic conductor is changed to a super-rigid 0.035 ^' conductor. Then the puncture parenchymal canal of the liver is sequentially expanded by peripheral balloon catheters of various diameters, followed by implantation of a self-expanding nitinol stent into it. After removal of the stent delivery system, it is post-dilated with a balloon catheter of the appropriate diameter.

Surgery ends with the alternate removal of catheters, introducers. Manual hemostasis of puncture sites is performed by finger pressing, after which an aseptic pressure dressing is applied for 24 hours.

The advantages of this method:

The use of coronary technique in TIPS operations, when difficulties arise in carrying out instruments through the formed “liver channel” due to severe cirrhotic liver damage, is practically the only solution for the successful outcome of this operation.

The method was tested in GBUZ "KKB number 2", Krasnodar. In the period from January 2014 to 2016, using coronary technique during TIPS operations, treatment was performed in two of fourteen patients with cirrhotic liver damage of various origins. There were no complications in this group of patients. The postoperative period after endovascular occlusion in all patients averaged 7 days.

Clinical example

Patient K., 65 years old. Ds: Cirrhosis of the liver of mixed origin (toxic + viral C), Child B grade class B (9 points), complicated by portal hypertension syndrome (splenomegaly, varicose veins of the esophagus I-II degree, mini-hydroperitoneum), hepatic cell failure (coagulopathy , hypercholesterolesterolemia), hypersplenism (pancytopenia), mild hepatic encephalopathy. Received in September 2016 in a planned manner to perform surgical intervention TIPS. At the time of admission, the patient complained of general weakness, lack of appetite, memory impairment. Anamnestically, the patient considers herself a patient since 2005, when she was diagnosed with chronic viral hepatitis C. The deterioration came in 2010, when she began to notice an increase in the abdomen, nausea, general weakness. For what purpose, a cirrhosis of the liver of viral etiology was examined and established. She underwent conservative treatment with a gastroenterologist, an infectious disease specialist. In 2015, when performing FGDS, varicose veins of the esophagus 2 tbsp. During the period from 2015 to 2016, three episodes of esophageal bleeding were noted, two of them required endoscopic ligation.

Upon admission according to ultrasound of the abdominal organs, ultrasound signs of cirrhotic transformation of the liver, portal hypertension (splenomegaly, hydroperitoneum, diffuse changes in the pancreas) are determined. According to laboratory research methods: leukocytopenia, mild normochromic anemia, severe thrombocytopenia, hypercholesterol anesthesia, pancytopenia, other indicators are within normal values.

In September 2016, the patient underwent planned TIPS surgery. Intraoperatively, the patient received 5000 units of heparin intravenously. Under combined anesthesia, the right brachial artery was punctured, the introducer sheath 5F Prelude (MeritMedical) was installed. Then, the superior mesenteric artery is selectively catheterized with an HH1-5F catheter. Then, a puncture of the right internal jugular vein was performed, a 10F conduction sheath (Optimed) was inserted, which was inserted into the right hepatic vein. Performed synchronous reverse portography and phlebography of the right hepatic vein to determine the anatomy of the vessels of the liver (Fig. 3).

The portal vein is punctured with a stylet catheter. The hydrophilic conductor 0.035 '' Aquatrack (Cordis) blocked the “liver channel” with a Bern-4F hydrophilic catheter (MeritMedical), which was inserted into the gastric vein. A phlebography of the gastric vein was carried out, according to which varicose veins of the stomach and esophagus along the entire length, the presence of antegrade blood flow in them (a source of esophageal bleeding) were determined. FIG. 4. Embolization was performed in the proximal third of the gastric vein with “MReye” spirals 15 × 15 mm, 8 × 5 mm (COOK) FIG. 5

Further, the Bern-4F catheter was inserted into the superior mesenteric vein along the 0.035 '' hydrophilic conductor. Conductor changed to 0.035 '' Amplatz Super Stiff hard conductor. Numerous attempts to conduct Armada 5.0 × 60 mm (Abbott), Empira 4.0 × 40 mm (Cordis) balloon catheters along the “canal of the liver” through a rigid guide were unsuccessful, and therefore it was decided to use coronary technique. The coronary conductor 0.014 '' Pilot 150 - 300 mm (Abbott) is run parallel to the 0.035 '' conductor from the hepatic vein into the distal channel of the superior mesenteric vein. After that, bougienage and dilatation of the narrow “liver channel” was performed with a Trek 2.5 × 20 mm balloon catheter (Abbott). FIG. 6, which made it possible to conduct balloon catheters with a diameter of 5.0 × 80 mm, 6.0 × 80 mm, 7.0 × 20 mm into the “channel of the liver” along a rigid conductor of 0.035 ”and dilate to the optimal size. Next, a Pigtail-5F catheter is inserted into the portal vein along a 0.035 '' Amplatz Extra Support rigid conductor. The portal vein phlebography was performed to determine the length of the stent. After that, a self-expanding nitinol stent “Egis” 10 × 60 mm (S&G Biotech Inc.) was implanted, followed by post-dilution with an Armada 10 × 40 mm balloon catheter (Abbott). On the control venography: port-caval anastomosis (TIPS) is functioning, the discharge of the contrast medium into the right atrium is adequate, there are no signs of stent and spiral dislocation, occlusion of the embolized gastric vein Fig. 7.

In the postoperative period, I felt satisfactory, no deterioration was observed, was discharged on the seventh day in satisfactory condition under the supervision of a gastroenterologist at the place of residence.

Medical and social effectiveness:

This method of treatment in patients with portal hypertension is highly effective and less traumatic, it allows for effective decompression of the portal system, prevention of recurrent bleeding from varicose veins of the esophagus and stomach, ascites syndrome, and significantly improves the quality of life of patients. The use of the coronary technique "simplifies" the technique of bougienage of the "liver channel", reduces the duration of surgery and the frequency of intraoperative complications, and sometimes it is the only way to create the optimal liver channel. The use of coronary technique in TIPS operations, when difficulties arise in carrying out instruments through the formed “liver channel” due to severe cirrhotic liver damage, is practically the only solution for the successful outcome of this operation. TIPS is an alternative to surgical methods of treating portal hypertension and has several advantages over rather traumatic surgical bypass operations: the application of portocaval angio- and organoanastomoses.

Brief Description of the Drawings:

FIG. one

The puncture parenchymal canal of the liver is dilated by a peripheral balloon catheter (indicated by arrows)

FIG. 2

The puncture parenchymal canal of the liver is dilated by a coronary balloon catheter (indicated by black arrows), parallel to the 0.035 '' conductor

FIG. 3

Synchronous return portography and phlebography of the right hepatic vein - the hepatic vein is indicated by white arrows, the portal vein by black

FIG. four

White arrows indicate the hydrophilic catheter Bern-4F, black arrows indicate a varicose vein of the stomach

FIG. 5

The result of embolization: arrows indicate the complete reduction of blood flow in the gastric vein

FIG. 6

Arrows indicate dilatation of the “liver channel” with a Trek balloon catheter 2.5 × 20 mm

FIG. 7

Control venography: white arrows indicate port-caval anastomosis (TIPS), black - embolized gastric vein.

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Claims (1)

The method of transjugular intrahepatic portosystemic shunting for cirrhosis of the liver, which consists in sequentially expanding the puncture parenchymal canal of the liver with peripheral balloon catheters of various diameters, characterized in that the coronary conductor 0.014 ^ʺ is parallel to the rigid conductor 0.035 ^ʺ from the hepatic vein to the distal superior mesentery, after which the superior mesentery coronary conductor 0.014 ^ʺ perform bougienage and predilation of the liver channel between the hepatic vein and portal venous with a 2.5 × 20 mm coronary balloon catheter system.

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