| Objective: Transjugular intrahepatic portosystemic shunt(TIPS)is widely used in the treatment of cirrhotic portal hypertension.This method is especially suitable for patients who cannot tolerate surgery,portal hypertension,refractory thoracic/ascites,or patients with esophageal varices bleeding.Shunt or hepatic vein stenosis or occlusion is a common short-and medium-term complication after TIPS surgery,which can lead to recurrence of life-threatening clinical symptoms.Although the widespread use of stent grafts in recent years has greatly reduced the incidence of TIPS complications,the evaluation of postoperative shunt function remains the focus of attention.Color Doppler ultrasound(CDUS)is the routine preferred method for monitoring the function of shunt in patients with TIPS.However,whether previous methods and diagnostic criteria for evaluating the dysfunction of bare stents are applicable to the stent graft have been questioned by many scholars.Meanwhile,whether the sensitivity of ultrasound diagnosis is higher than clinical indications(ascites,gastrointestinal bleeding)is also questioned.Therefore,it is still of great significance to explore the ultrasound methodology or parameters for evaluating the function of the stent graft.In this study,the application value of ultrasound and clinical indicators in evaluating the functional status of shunt was compared using angiographic results as the gold standard.At the same time,this study compared the application value of convex array probe and phased array probe in judging the dysfunction of stent graft.Methods: A total of 226 patients with cirrhotic portal hypertension who underwent TIPS surgery in the First Affiliated Hospital of Anhui Medical University were enrolled.Retrospective analysis was performed on 226 patients who underwent CDUS and clinical laboratory tests at one week,one month,three months,six months,and one year after surgery.According to clinical symptoms recurrence and/or abnormal ultrasound parameters,56 patients with suspected shunt dysfunction were screened for DSA angiography.The indicators of clinical symptoms include recurrent ascites and/or variceal hemorrhage.Abnormalities of ultrasound parameters include: partial filling loss of blood flow signal in the shunt;no blood flow signal in the shunt;local blood flow velocity of the shunt is greater than 190cm/s or less than 90cm/ s.Stent dysfunction was considered when venous angiography showed a stenosis or a portal pressure gradient(PPG)> 12 mm Hg.1.DSA angiography results were used as the control standard to calculate the diagnostic performance of clinical symptoms and ultrasound in the evaluation of shunt dysfunction.2.According to the ultrasonic judgment standard,analyze the sensitivity of the convex array probe and the phased array probe in diagnosing the dysfunction of the shunt.3.At the same time,observe the prognosis of patients,compare the changes in various biochemical indicators before and after surgery.Results: 1.For TIPS patients with abnormal angiographic results,the sensitivity of ultrasound and clinical indicators for predicting shunt dysfunction was 74.3% and77.1%,respectively(p > 0.05),while the specificities were 95.2% and 66.7%,respectively(p < 0.05).2.Through statistical analysis,the area under the ROC curve of the phased array probe is much larger than the area under the ROC curve of the convex array probe(0.95 vs 0.88,p=0.01).Of the 40 cases with abnormal ultrasound parameters of the convex array probe,5 phased array probe scan images showed good filling blood flow in the lumen of the stent.These 5 cases were finally excluded from the malfunctioned stent queue.3.The average follow-up was 31 ± 16 months.Of the226 surgical patients,a total of 27 patients died(total survival rate 88.1%)and 35 patients with shunt dysfunction(the total incidence was 15.5%).Compared with the preoperative mean portal vein flow velocity(21 cm/s),the mean peak flow velocity of the portal vein increased to 36 cm/s;the average flow velocity of the hepatic aorta increased from 69 cm/s before surgery to 120 cm/s after surgery.The differences were statistically significant.The levels of serum TBi L,ALT,and AST one week after surgery were higher than those before surgery,but gradually returned to preoperative levels three to six months after surgery.The blood ammonia concentration of the patients increased after surgery,but those gradually decreased with the postoperative time(P < 0.05).During long-term follow-up after surgery,the peak velocity of the shunt decreased slightly over time.Conclusion: Ultrasound combined with two probe modes,compared with the recurrence of clinical symptoms,had a higher specificity for judging the dysfunction of TIPS shunt,but its sensitivity is slightly lower.So clinical symptoms should be noted during clinical follow-up to improve the diagnosis sensitivity of the shunt dysfunction.The phased array probe CDFI mode can display the whole blood flow signal in the shunt more accurately than the convex array probe CDFI mode.And its predicted value in diagnosing dysfunctional shunt is significantly higher than that of convex array probe. |
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