经颈静脉肝内门体分流术后门静脉压力下降程度对预后影响的相关进展

保燕青; 王瑜; 张志娇; 郑梦瑶; 黄华; 赵公芳

doi:10.12449/JCH250832

经颈静脉肝内门体分流术后门静脉压力下降程度对预后影响的相关进展

DOI: 10.12449/JCH250832

昆明医科大学第二附属医院消化内科，昆明 650000

基金项目:

云南省“万人计划”名医人才专项 (YNWR-MY-2019-074)

利益冲突声明：本文不存在任何利益冲突。

作者贡献声明：保燕青负责收集文献，论文撰写与修订；王瑜、张志娇负责收集文献，参与论文撰写；郑梦瑶、黄华负责研究思路的设计及论文分析；赵公芳负责立题，拟定写作思路，论文修改及最后定稿。

详细信息

通信作者:
赵公芳， zhaogongfangedu@163.com （ORCID： 0000-0001-9178-1567）

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出版历程
- 收稿日期: 2024-11-24
- 录用日期: 2025-01-20
- 出版日期: 2025-08-25

Research advances in the impact of reduction in portal venous pressure after transjugular intrahepatic portosystemic shunt on prognosis

Department of Gastroenterology，The Second Affiliated Hospital of Kunming Medical University，Kunming 650000，China

Research funding:

Yunnan Province “Ten Thousand Talents Plan” Special Medical Talent Initiative (YNWR-MY-2019-074)

More Information

Corresponding author: ZHAO Gongfang， zhaogongfangedu@163.com （ORCID： 0000-0001-9178-1567）

摘要

摘要: 经颈静脉肝内门体分流术是治疗门静脉高压症的重要手段，门静脉压力下降程度与患者的预后密切相关。门静脉压力降低幅度越大，对肝硬化患者门静脉高压症状的缓解效果越显著，然而也增加了肝性脑病、肝功能衰竭的发生风险。因此，合理控制门静脉压力降低范围对优化治疗效果至关重要。本文就门静脉压力测量方法、影响压力降低的因素、针对不同适应证最佳的降压范围以及不同降压程度对并发症发生的影响作一综述，以期为提高TIPS的治疗效果和改善患者术后预后提供指导。
- 门体分流术，经颈静脉肝内 /
- 门静脉高压症 /
- 门静脉压
Abstract: Transjugular intrahepatic portosystemic shunt （TIPS） is an important intervention for portal hypertension， and the degree of reduction in portal venous pressure is closely associated with the prognosis of patients. While a greater reduction in portal venous pressure may lead to more effective alleviation of portal hypertensive symptoms in cirrhotic patients， it also increases the risk of hepatic encephalopathy and liver failure. Therefore， appropriate control of the degree of reduction in portal venous pressure is essential for optimizing therapeutic outcomes. This article reviews the methods for measuring portal venous pressure， the factors affecting the reduction in portal venous pressure， the optimal range for reduction in different indications， and the impact of varying degrees of pressure reduction on complications， in order to provide guidance for improving the treatment outcome of TIPS and the prognosis of patients after surgery.
- Portasystemic Shunt， Transjugular Intrahepatic /
- Portal Hypertension /
- Portal Pressure

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参考文献(54)

[1]	LV Y, FAN DM, HAN GH. Transjugular intrahepatic portosystemic shunt for portal hypertension: 30 years experience from China[J]. Liver Int, 2023, 43( 1): 18- 33. DOI: 10.1111/liv.15313.
[2]	Digestive Minimally Invasive Intervention Collaborative Group, Chinese Society of Gastroenterology, Chinese Medical Association. Consensus on transjugular intrahepatic portosystemic shunt in portal hypertension[J]. Chin J Gastroenterol, 2023, 28( 6): 344- 363. DOI: 10.3969/j.issn.1008-7125.2023.06.004. 中华医学会消化病学分会消化微创介入协作组. 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. DOI: 10.3969/j.issn.1008-7125.2023.06.004.
[3]	ZHAO YH, JIA G, WANG AW, et al. Effect of stent selection and portal pressure gradient on prognosis of TIPS[J]. Int J Dig Dis, 2020, 40( 3): 161- 164. DOI: 10.3969/j.issn.1673-534X.2020.03.006. 赵宇航, 贾光, 王澳文, 等. 支架与门静脉压力梯度对经颈静脉肝内门体静脉分流术后的影响[J]. 国际消化病杂志, 2020, 40( 3): 161- 164. DOI: 10.3969/j.issn.1673-534X.2020.03.006.
[4]	BOSCH J. Reply to:“achieving an effective pressure reduction after TIPS: The need for a new target”[J]. J Hepatol, 2021, 75( 1): 248- 249. DOI: 10.1016/j.jhep.2021.04.009.
[5]	BOSCH J, GARCIA-PAGÁN JC, BERZIGOTTI A, et al. Measurement of portal pressure and its role in the management of chronic liver disease[J]. Semin Liver Dis, 2006, 26( 4): 348- 362. DOI: 10.1055/s-2006-951603.
[6]	Chinese Portal Hypertension Diagnosis and Monitoring Study Group(CHESS), Minimally Invasive Intervention Collaborative Group, Chinese Society of Gastroenterology, Emergency Intervention Committee, Chinese College of Interventionalists, et al. Consensus on clinical application of hepatic venous pressure gradient in China(2018)[J]. J Clin Hepatol, 2018, 34( 12): 2526- 2536. DOI: 10.3969/j.issn.1001-5256.2018.12.008. 中国门静脉高压诊断与监测研究组(CHESS), 中华医学会消化病学分会微创介入协作组, 中国医师协会介入医师分会急诊介入专业委员会, 等. 中国肝静脉压力梯度临床应用专家共识(2018版)[J]. 临床肝胆病杂志, 2018, 34( 12): 2526- 2536. DOI: 10.3969/j.issn.1001-5256.2018.12.008.
[7]	ZHANG PF, CHEN YJ, CAO JL, et al. Value of hepatic venous pressure gradient in preoperative evaluation and prognosis prediction in liver transplant recipients[J]. Organ Transplant, 2023, 14( 1): 154- 159. 张鹏飞, 陈雅洁, 曹经琳, 等. 肝静脉压力梯度对肝移植受者术前评估及预后预测的价值[J]. 器官移植, 2023, 14( 1): 154- 159.
[8]	SAMARASENA JB, CHANG KJ. Endoscopic ultrasound-guided portal pressure measurement and interventions[J]. Clin Endosc, 2018, 51( 3): 222- 228. DOI: 10.5946/ce.2018.079.
[9]	MARTINEZ-MORENO B, MARTÍNEZ MARTÍNEZ J, HERRERA I, et al. Correlation of endoscopic ultrasound-guided portal pressure gradient measurements with hepatic venous pressure gradient: A prospective study[J]. Endoscopy, 2025, 57( 1): 62- 67. DOI: 10.1055/a-2369-0759.
[10]	de FRANCHIS R, BOSCH J, GARCIA-TSAO G, et al. Baveno VII-Renewing consensus in portal hypertension[J]. J Hepatol, 2022, 76( 4): 959- 974. DOI: 10.1016/j.jhep.2021.12.022.
[11]	ATTIA D, RODT T, MARQUARDT S, et al. Shear wave elastography prior to transjugular intrahepatic portosystemic shunt may predict the decrease in hepatic vein pressure gradient[J]. Abdom Radiol(NY), 2019, 44( 3): 1127- 1134. DOI: 10.1007/s00261-018-1795-6.
[12]	XIONG ZX, WANG XZ, YAN YL, et al. A new computational fluid dynamics based noninvasive assessment of portacaval pressure gradient[J]. J Biomech, 2024, 167: 112086. DOI: 10.1016/j.jbiomech.2024.112086.
[13]	RIEDEL C, HOFFMANN M, ISMAHIL M, et al. Four-dimensional flow MRI-based computational fluid dynamics simulation for noninvasive portosystemic pressure gradient assessment in patients with cirrhosis and transjugular intrahepatic portosystemic shunt[J]. Radiology, 2024, 313( 1): e232989. DOI: 10.1148/radiol.232989.
[14]	BOIKE JR, THORNBURG BG, ASRANI SK, et al. North American practice-based recommendations for transjugular intrahepatic portosystemic shunts in portal hypertension[J]. Clin Gastroenterol Hepatol, 2022, 20( 8): 1636- 1662. e 36. DOI: 10.1016/j.cgh.2021.07.018.
[15]	TRIPATHI D, STANLEY AJ, HAYES PC, et al. Transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension[J]. Gut, 2020, 69( 7): 1173- 1192. DOI: 10.1136/gutjnl-2019-320221.
[16]	MURA VL, ABRALDES JG, 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. DOI: 10.1002/hep.23612.
[17]	MA L, LIU YZ, YAN ZP, 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. DOI: 10.1007/s00535-023-01977-w.
[18]	REVERTER E, BLASI A, ABRALDES JG, et al. Impact of deep sedation on the accuracy of hepatic and portal venous pressure measurements in patients with cirrhosis[J]. Liver Int, 2014, 34( 1): 16- 25. DOI: 10.1111/liv.12229.
[19]	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. DOI: 10.1053/j.gastro.2017.01.011.
[20]	MA L, MA JQ, ZHANG W, et al. Predictive power of portal pressure gradient remeasured shortly after transjugular intrahepatic portosystemic shunt[J]. Hepatol Int, 2023, 17( 2): 417- 426. DOI: 10.1007/s12072-022-10440-6.
[21]	PITTON MB, WEINMANN A, KLOECKNER R, et al. Transjugular portosystemic stent shunt: Impact of right atrial pressure on portal venous hemodynamics within the first week[J]. Cardiovasc Intervent Radiol, 2022, 45( 1): 102- 111. DOI: 10.1007/s00270-021-03003-z.
[22]	LV Y, WANG QH, LUO BH, 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. DOI: 10.1016/j.jhep.2024.08.007.
[23]	BUCSICS T, SCHODER M, DIERMAYR M, et al. Transjugular intrahepatic portosystemic shunts(TIPS) for the prevention of variceal re-bleeding-A two decades experience[J]. PLoS One, 2018, 13( 1): e0189414. DOI: 10.1371/journal.pone.0189414.
[24]	PRAKTIKNJO M, ABU-OMAR J, CHANG J, et al. Controlled underdilation using novel VIATORR® controlled expansion stents improves survival after transjugular intrahepatic portosystemic shunt implantation[J]. JHEP Rep, 2021, 3( 3): 100264. DOI: 10.1016/j.jhepr.2021.100264.
[25]	HUANG ZZ, YAO QG, ZHU JP, et al. Efficacy and safety of transjugular intrahepatic portosystemic shunt(TIPS) created using covered stents of different diameters: A systematic review and meta-analysis[J]. Diagn Interv Imaging, 2021, 102( 5): 279- 285. DOI: 10.1016/j.diii.2020.11.004.
[26]	GONG JH, XIA ZQ, ZHOU ZD, et al. Effectiveness and prognosis of covered stents with different diameters in transjugular intrahepatic portosystemic shunt: A meta-analysis[J]. Eur J Gastroenterol Hepatol, 2024, 36( 2): 229- 237. DOI: 10.1097/MEG.0000000000002696.
[27]	ZHOU H, YAO X, TANG SH, et al. Influencing factors for hepatic venous pressure gradient in patients with cirrhotic portal hypertension[J]. J Clin Hepatol, 2019, 35( 10): 2205- 2209. DOI: 10.3969/j.issn.1001-5256.2019.10.015. 周昊, 姚欣, 汤善宏, 等. 肝硬化门静脉高压患者肝静脉压力梯度的影响因素分析[J]. 临床肝胆病杂志, 2019, 35( 10): 2205- 2209. DOI: 10.3969/j.issn.1001-5256.2019.10.015.
[28]	CHEN LX. Construction of predictive model and prognostic value analysis of post-TIPS portal pressure gradient in cirrhotic patients[D]. Chengdu: Sichuan University, 2021. 陈柳香. 肝硬化患者TIPS术后PPG的预测模型构建及预后价值分析[D]. 成都: 四川大学, 2021.
[29]	HE JH, LI JY, FANG CX, et al. The relationship and changes of liver blood supply, portal pressure gradient, and liver volume following TIPS in cirrhosis[J]. Can J Gastroenterol Hepatol, 2022, 2022: 7476477. DOI: 10.1155/2022/7476477.
[30]	RÖSSLE M, SIEGERSTETTER V, OLSCHEWSKI M, et al. How much reduction in portal pressure is necessary to prevent variceal rebleeding? A longitudinal study in 225 patients with transjugular intrahepatic portosystemic shunts[J]. Am J Gastroenterol, 2001, 96( 12): 3379- 3383. DOI: 10.1111/j.1572-0241.2001.05340.x.
[31]	WANG XZ, LUO XF, YANG L. Achieving an effective pressure reduction after TIPS: The need for a new target[J]. J Hepatol, 2021, 75( 1): 246- 248. DOI: 10.1016/j.jhep.2021.02.010.
[32]	CHUNG HH, RAZAVI MK, SZE DY, et al. Portosystemic pressure gradient during transjugular intrahepatic portosystemic shunt with Viatorr stent graft: What is the critical low threshold to avoid medically uncontrolled low pressure gradient related complications?[J]. J Gastroenterol Hepatol, 2008, 23( 1): 95- 101. DOI: 10.1111/j.1440-1746.2006.04697.x.
[33]	BOSCH J. Small diameter shunts should lead to safe expansion of the use of TIPS[J]. J Hepatol, 2021, 74( 1): 230- 234. DOI: 10.1016/j.jhep.2020.09.018.
[34]	LUO SH, ZHOU MM, CAI MJ, et al. Reduction of portosystemic gradient during transjugular intrahepatic portosystemic shunt achieves good outcome and reduces complications[J]. World J Gastroenterol, 2023, 29( 15): 2336- 2348. DOI: 10.3748/wjg.v29.i15.2336.
[35]	XIA YF, TIE J, WANG GC, 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. DOI: 10.1007/s12072-023-10489-x.
[36]	ZHAO LH, TIE J, WANG GC, et al. Efficacy of TIPS plus extrahepatic collateral embolisation in real-world data: A validation study[J]. BMJ Open Gastroenterol, 2024, 11( 1): e001310. DOI: 10.1136/bmjgast-2023-001310.
[37]	BIAN HL, LI JS, LIU C, et al. An excerpt of AASLD practice guidance on the use of TIPS, variceal embolization, and retrograde transvenous obliteration in the management of variceal hemorrhage in 2023[J]. J Clin Hepatol, 2023, 39( 11): 2564- 2568. DOI: 10.3969/j.issn.1001-5256.2023.11.008. 卞恒露, 李家速, 刘翠, 等.《2023年美国肝病学会实践指导: 经颈静脉肝内门体分流术、静脉曲张栓塞术和逆行经静脉闭塞术治疗静脉曲张出血》摘译[J]. 临床肝胆病杂志, 2023, 39( 11): 2564- 2568. DOI: 10.3969/j.issn.1001-5256.2023.11.008.
[38]	LV Y, CHEN H, LUO BH, et al. Transjugular intrahepatic portosystemic shunt with or without gastro-oesophageal variceal embolisation for the prevention of variceal rebleeding: A randomised controlled trial[J]. Lancet Gastroenterol Hepatol, 2022, 7( 8): 736- 746. DOI: 10.1016/S2468-1253(22)00087-5.
[39]	LV Y, CHEN H, LUO BH, et al. Concurrent large spontaneous portosystemic shunt embolization for the prevention of overt hepatic encephalopathy after TIPS: A randomized controlled trial[J]. Hepatology, 2022, 76( 3): 676- 688. DOI: 10.1002/hep.32453.
[40]	BAI YW, LIU JC, WU WL, et al. Transjugular intrahepatic portosystemic shunt(TIPS) with variceal embolization reduces rebleeding risk for patients with portal pressure gradient over 12 mmHg: A long-term follow-up study[J]. Eur J Radiol, 2024, 181: 111740. DOI: 10.1016/j.ejrad.2024.111740.
[41]	The Chinese College of Interventionalists. CCI clinical practice guidelines: Management of TIPS for portal hypertension(2019 edition)[J]. J Clin Hepatol, 2019, 35( 12): 2694- 2699. DOI: 10.3969/j.issn.1001-5256.2019.12.010. 中国医师协会介入医师分会. 中国门静脉高压经颈静脉肝内门体分流术临床实践指南(2019年版)[J]. 临床肝胆病杂志, 2019, 35( 12): 2694- 2699. DOI: 10.3969/j.issn.1001-5256.2019.12.010.
[42]	QUECK A, SCHWIERZ L, GU WY, et al. Targeted decrease of portal hepatic pressure gradient improves ascites control after TIPS[J]. Hepatology, 2023, 77( 2): 466- 475. DOI: 10.1002/hep.32676.
[43]	GU WY, QUECK A, TREBICKA J, et al. Reply: Targeted decrease of portal hepatic pressure gradient immediately after TIPS improves ascites control and prognosis[J]. Hepatology, 2023, 77( 5): E101. DOI: 10.1097/hep.0000000000000276.
[44]	WU JQ. Relationship between portal pressure gradient and complications after TIPS with 7mm stent[D]. Kunming: Kunming Medical University, 2023. 吴佳沁. 7 mm分流道下门静脉压力梯度与TIPS术后并发症关系的研究[D]. 昆明: 昆明医科大学, 2023.
[45]	XIA YF, TIE J, WANG GC, 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. DOI: 10.1007/s12072-024-10742-x.
[46]	WANG B, WANG MM, ZHU YJ, et al. Comparison of the clinical efficacy of 8 mm and 10 mm covered stents in patients with cirrhosis and refractory ascites[J]. Clin J Med Offic, 2024, 52( 11): 1119- 1122, 1128. DOI: 10.16680/j.1671-3826.2024.11.04. 汪博, 汪檬檬, 祝叶静, 等. 8 mm与10 mm直径覆膜支架在治疗肝硬化合并难治性腹水患者中临床效果比较研究[J]. 临床军医杂志, 2024, 52( 11): 1119- 1122, 1128. DOI: 10.16680/j.1671-3826.2024.11.04.
[47]	FRIIS KH, THOMSEN KL, LALEMAN W, et al. Post-transjugular intrahepatic portosystemic shunt(TIPS) hepatic encephalopathy-a review of the past decade’s literature focusing on incidence, risk factors, and prophylaxis[J]. J Clin Med, 2023, 13( 1): 14. DOI: 10.3390/jcm13010014.
[48]	TONG H, GAN C, WEI B, et al. Risk factors for overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunt creation in patients with liver cirrhosis[J]. J Dig Dis, 2021, 22( 1): 31- 40. DOI: 10.1111/1751-2980.12957.
[49]	ELSAID MI, RUSTGI VK. Epidemiology of hepatic encephalopathy[J]. Clin Liver Dis, 2020, 24( 2): 157- 174. DOI: 10.1016/j.cld.2020.01.001.
[50]	LI WY, DUAN YY, LIU ZK, et al. Clinical value of hemodynamic changes in diagnosis of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt[J]. Scand J Gastroenterol, 2022, 57( 6): 713- 718. DOI: 10.1080/00365521.2022.2029938.
[51]	LUCA A, MIRAGLIA R, MARUZZELLI L, et al. Early liver failure after transjugular intrahepatic portosystemic shunt in patients with cirrhosis with model for end-stage liver disease score of 12 or less: Incidence, outcome, and prognostic factors[J]. Radiology, 2016, 280( 2): 622- 629. DOI: 10.1148/radiol.2016151625.
[52]	YAO YH, SATAPATHY SK, FERNANDES ESM, et al. Hepatic venous pressure gradient(HVPG) predicts liver failure after transjugular intrahepatic portal shunt: A retrospective cohort study[J]. Ann Transl Med, 2022, 10( 20): 1122. DOI: 10.21037/atm-22-4737.
[53]	TUIFUA TS, PARTOVI S, REMER EM, et al. Assessment of clinical outcomes, clinical manifestations, and risk factors for hepatic infarction after transjugular intrahepatic portosystemic shunt placement(TIPS): A retrospective comparative study[J]. Cardiovasc Intervent Radiol, 2022, 45( 10): 1512- 1523. DOI: 10.1007/s00270-022-03219-7.
[54]	RAJESH S, GEORGE T, PHILIPS CA, et al. Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update[J]. World J Gastroenterol, 2020, 26( 37): 5561- 5596. DOI: 10.3748/wjg.v26.i37.5561.