TIPS术后降低门静脉压力“最佳平衡点”选择的现状与展望

摘要/Abstract

摘要： 经颈静脉肝内门体分流术(TIPS)可有效控制肝硬化门静脉高压相关并发症,但分流程度不足可能导致出血或腹水复发,分流过度则可能增加显性肝性脑病及肝功能恶化风险。TIPS术后门静脉压力梯度(亦常以门腔压力梯度表述)是评价分流效果和血流动力学反应的关键指标,但其最佳目标值、测量时机及策略仍存在争议。本文结合国内外相关研究和指南共识,从术后压力梯度的测量时机与位置、不同适应证下的目标范围、支架类型与扩张策略、患者选择及临床决策等方面进行综述,旨在为TIPS术后压力管理的临床实践及后续研究提供参考。

关键词: 经颈静脉肝内门体分流术, 门静脉压力梯度, 门腔压力梯度, 肝性脑病, 腹水

何阳, 周粟, 傅青春. TIPS术后降低门静脉压力“最佳平衡点”选择的现状与展望[J]. 肝脏, 2026, 31(4): 466-469.

/ 推荐

参考文献

[1] 中华医学会肝病学分会,中华医学会感染病学分会.慢性乙型肝炎防治指南(2022年版)[J].中华肝脏病杂志,2022,30(12):1309-1331.
[2] de Franchis R D, Bosch J, Garcia-Tsao G, et al. Baveno Ⅶ-renewing consensus in portal hypertension[J]. J Hepatol. 2022,76(4):959-974.
[3] Lv Y, Wang Q, Luo B, et al. Identifying the optimal measurement timing and hemodynamic targets of portal pressure gradient after TIPS in patients with cirrhosis and variceal bleeding[J]. J Hepatol. 2025;82(2):245-257.
[4] Silva-Junior G, Turon F, Baiges A, et al. Timing affects measurement of portal pressure gradient after placement of transjugular intrahepatic portosystemic shunts in patients with portal hypertension[J]. Gastroenterology. 2017,152(6):1358-1365.
[5] Ma L, Liu Y, Yan Z, et al. Comparing the predictive ability of portoatrial and portocaval gradient after transjugular intrahepatic portosystemic shunt creation for variceal rebleeding[J]. J Gastroenterol 2023,58(5):494-502.
[6] La Mura V, Abraldes J G, Berzigotti A, et al. Right atrial pressure is not adequate to calculate portal pressure gradient in cirrhosis: a clinical hemodynamic correlation study[J]. Hepatology. 2010,51(6):2108-2116.
[7] Groszmann R J, Bosch J, Grace N D, et al. Hemodynamic events in a prospective randomized trial of propranolol versus placebo in the prevention of a first variceal hemorrhage[J]. Gastroenterology. 1990,99(5):1401-1407.
[8] Feu F, García-Pagán J C, Bosch J, et al. Relation between portal pressure response to pharmacotherapy and risk of recurrent variceal haemorrhage in patients with cirrhosis[J]. Lancet. 1995,346:1056-1059.
[9] Abraldes J G, Tarantino I, Turnes J,et al. Hemodynamic response to pharmacological treatment of portal hypertension and long-term prognosis of cirrhosis[J]. Hepatology. 2003,37:902-908.
[10] Groszmann R J, Garcia-Tsao G, Bosch J, et al. Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis[J]. N Engl J Med. 2005,353:2254-2261.
[11] Xia Y, Tie J, Wang G, et al. Individualized portal pressure gradient threshold based on liver function categories in preventing rebleeding after TIPS[J]. Hepatol Int. 2023,17(4):967-978.
[12] Roccarina D, Saltini D, Adotti V, et al. End-procedural adherence to recommended hemodynamic targets does not improve the outcome of elective TIPS in patients with cirrhosis[J]. Hepatology. 2025,82(5):1155-1171.
[13] Queck A, Schwierz L, Gu W, et al. Targeted decrease of portal hepatic pressure gradient improves ascites control after TIPS[J]. Hepatology. 2023,77(2):466-475.
[14] Xia Y, Tie J, Wang G, et al. Optimal threshold of portal pressure gradient for patients with ascites after covered TIPS: a multicentre cohort study[J]. Hepatol Int. 2025,19(1):199-211.
[15] Kabelitz M A, Hartl L, Schaub G, et al. Identification of optimal portal pressure decrease to control ascites while minimizing HE after TIPS: a multicenter study[J]. Hepatology. 2025,82(5):1172-1186.
[16] Zhu P, Dong S, Sun P, et al. Expanded polytetrafluoroethylene (ePTFE)-covered stents versus bare stents for transjugular intrahepatic portosystemic shunt in people with liver cirrhosis[J]. Cochrane Database Syst Rev. 2023,8(8):CD012358.
[17] Pieper C C, Jansen C, Meyer C, et al. Prospective evaluation of passive expansion of partially dlated transjugular intrahepatic portosystemic shunt stent grafts-a three-dimensional sonography study[J]. J Vasc Interv Radiol. 2017,28(1):117-125.
[18] Deltenre P, Zanetto A, Saltini D,et al. The role of transjugular intrahepatic portosystemic shunt in patients with cirrhosis and ascites: recent evolution and open questions[J]. Hepatology. 2023,77(2):640-658.
[19] Zhang W, Zhang M, Xiao J, et al. Efficacy of 6-mm and 8-mm transjugular intrahepatic portosystemic shunt for variceal bleeding: a randomized controlled trial[J]. Clin Gastroenterol Hepatol. 2026,24(1):161-171.e3.
[20] 唐承薇,张春清,诸葛宇征,等.经颈静脉肝内门体静脉分流术治疗门静脉高压专家共识[J].胃肠病学, 2023, 28(6):344-363.