Percutaneous retroperitoneal splenorenal shunt : an experimental study in swine

TIPS（经颈静脉肝内门体分流术）是治疗静脉曲张的有效方法，但有一些并发症。尤其是肝性脑病是严重的并发症之一。我们开发了经皮腹膜后脾肾分流术（PRESS）作为一种新的程序，建立门体分流无肝性脑病，并进行了实验研究在猪。首先，我们做了一个特殊的穿刺装置。我们使用覆膜金属支架通过经股动脉途径建立了一个脾肾分流术。在急性研究中，我们成功地建立了分流，没有任何并发症。脾静脉和IVC之间的压力梯度在分流建立后立即降低。在慢性研究中，大多数动物的分流管阻塞或严重狭窄1 - 4周。大体检查显示所有覆膜支架均位于腹膜后腔，无腹腔内出血。PRESS相对容易完成，在本研究中未观察到重大并发症。所有的实验程序仅通过荧光透视引导，但在临床环境中，超声引导可用于避免穿透胰腺实质。在肝硬化的情况下，脾静脉穿刺可能更容易，因为脾静脉宽，相对接近左肾静脉。我们已经表明，PRESS在技术上是可行的，是一个潜在的新的治疗门静脉高压症。PRESS是否能长期有效缓解门脉高压，是否能替代TIPS，尚需进一步的实验研究。

TIPS (Transjugular intrahepatic portosystemic shunt) is well known as an effective method for varices, but it has several complications. Especially hepatic encephalopathy is one of serious complications. We developed percutaneous retroperitoneal splenorenal shunt (PRESS) as a new procedure creating porto-systemic shunt without hepatic encephalopathy, and performed an experimental study in swine. First we made a special puncture set. We created a spleno-renal shunt through the retroperitoneal cavity by the transfemoral approach using a covered metallic stent. In the acute study we successfully created the shunt without any complications. Pressure gradient between the splenic vein and the IVC decreased immediately after the shunt creation. In the chronic study the shunt was obstructed or severely narrowed in most of the animals for 1 to 4 weeks. Gross inspection revealed that all stent-grafts were located in the retroperitoneal cavity and there was no intraperitoneal hemorrhage. PRESS was done with relative ease, and no major complication was observed in this study. All experimental procedures were guided only by fluoroscopy, but in a clinical setting ultrasonographic guidance could be used to avoid the penetration of the pancreatic parenchyma. In the case with liver cirrhosis the puncture of the splenic vein might be easier, because the splenic vein is wide and relatively close to the left renal vein.We have shown that PRESS is technically feasible and is a potential new treatment for portal hypertension. Further experimental studies are necessary to evaluate if PRESS is effective in long term relief of portal hypertension and if it can be an alternative or replacement of TIPS.