Xia Jiejun,Liu Zhenyin.Endovascular interventional management of pediatric portal hypertension: an update[J].Journal of Clinical Pediatric Surgery,2026,(02):191-195.[doi:10.3760/cma.j.cn101785-202503009]
儿童门静脉高压血管介入治疗研究进展
- Title:
- Endovascular interventional management of pediatric portal hypertension: an update
- 关键词:
- 儿童门静脉高压; 肝静脉楔入法造影术; 门静脉狭窄球囊血管成形术; 经颈静脉肝内门体分流术; 部分脾动脉栓塞术
- Keywords:
- Pediatric Portal Hypertension; Wedged Hepatic Venography; Balloon Angioplasty; Transjugular Intrahepatic Portosystemic Shunt; Partial Splenic Embolization
- 摘要:
- 儿童门静脉高压在病因及病理生理机制方面与成人存在显著差异,其以肝前型(如门静脉海绵样变)为主,临床需采取个体化治疗策略。近年来,血管介入技术已成为该病的重要治疗手段,本文综述血管介入治疗在儿童门静脉高压中的应用,主要包括: ①肝静脉楔入法造影术,作为评估Rex窝通畅性的金标准,为判断肝外门静脉阻塞是否适宜行肠系膜-Rex分流术提供关键依据; ②门静脉狭窄球囊血管成形术及支架置入术,可用于术后处理桥血管狭窄,其中支架置入(尤其是球囊扩张式支架)在维持远期通畅性方面更具优势; ③部分脾动脉栓塞术,通过部分阻断脾动脉血流,改善脾功能亢进及相关门静脉高压,兼具微创性与安全性; ④经颈静脉肝内门体分流术,适用于肝硬化所致门静脉高压,近年技术改良后成功率达95%,可作为肝移植前的过渡或长期治疗方案。未来应进一步研发适用于儿童的介入器械,并开展多中心临床研究评估各类介入技术的长期疗效。
- Abstract:
- With unique etiopathogenetic mechanisms distinct from adult populations,pediatric portal hypertension is characterized by a predominance of prehepatic portal hypertension,such as cavernous transformation of portal vein.This divergence mandates forming specialized interventional approaches.Recent advances have highlighted the pivotal role of endovascular therapies:Wedged hepatic venography,a gold standard for assessing Rex recessus patency,guides candidacy for Meso-Rex bypass in extrahepatic portal vein obstruction; Balloon angioplasty and stenting for post-procedural portal vein stenosis with stents (particularly balloon-expandable) demonstrating superior long-term patency; Partial splenic embolization (PSE),mitigating hypersplenism and portal hypertension while preserving immune function; Transjugular intrahepatic portosystemic shunt (TIPS),adapted for cirrhotic cases with 95% technical success,serving as a bridge to transplant or definitive therapy.Further development of pediatric-specific devices and multicenter studies are warranted for validating long-term outcomes.
参考文献/References:
[1] Sooraj K,Shivani F,Hassan Khan M,et al.Frequency of causes of portal hypertension in children[J].Cureus,2022,14(6):e25934.DOI:10.7759/cureus.25934.
[2] 中华医学会消化病学分会.中国肝硬化临床诊治共识意见[J].胃肠病学,2023,28(5):275-296.DOI:10.3969/j.issn.1008-7125.2023.05.004. Chinese Society of Gastroenterology,Chinese Medical Association.Chinese Consensus on Clinical Diagnosis and Therapy of Liver Cirrhosis[J].Chin J Gastroenterol,2023,28(5):275-296.DOI:10.3969/j.issn.1008-7125.2023.05.004.
[3] 牛会林,高秋,王凤华,等.64例儿童门静脉高压肝脏病理学分析[J].中华病理学杂志,2020,49(1):68-71.DOI:10.3760/cma.j.issn.0529-5807.2020.01.014. Niu HL,Gao Q,Wang FH,et al.Clinicopathological study of liver biopsy in pediatric portal hypertension:a report of 64 cases[J].Chin J Pathol,2020,49(1):68-71.DOI:10.3760/cma.j.issn.0529-5807.2020.01.014.
[4] Zhang JS,Li L.Rex shunt for extra-hepatic portal venous obstruction in children[J].Children (Basel),2022,9(2):297.DOI:10.3390/children9020297.
[5] 张金山.浅析Rex手术的技术难点及实施条件[J].临床小儿外科杂志,2025,24(1):86-90.DOI:10.3760/cma.j.cn101785-202208033-016. Zhang JS.Technical challenges and implementation considerations for Rex shunt[J].J Clin Ped Sur,2025,24(1):86-90.DOI:10.3760/cma.j.cn101785-202208033-016.
[6] Natali GL,Cassanelli G,Paolantonio G,et al.Pediatric liver cirrhosis interventional procedures:from biopsy to transjugular intrahepatic portosystemic shunt[J].Pediatr Radiol,2023,53(4):727-738.DOI:10.1007/s00247-022-05492-7.
[7] Flores-Calderón J,Morán-Villota S,Rouassant SH,et al.Guidelines for the diagnosis and treatment of extrahepatic portal vein obstruction (EHPVO) in children[J].Ann Hepatol,2013,12(S1):S3-S24.DOI:10.1016/S1665-2681(19)31403-6.
[8] 中华医学会小儿外科学分会肝胆外科学组.儿童肝外门静脉梗阻临床诊断和治疗中国专家共识(2023版)[ J].中华小儿外科杂志,2023,44(6):484-492.DOI:10.3760/cma.j.cn421158-20230117-00014. Section of Hepatobiliary Surgery,Branch of Pediatric Surgery,Chinese Medical Association.Chinese Expert Consensus on Diagnosing and Treating Extrahepatic Portal Venous Obstruction in Children (Edition 2023)[J].Chin J Pediatr Surg,2023,44(6):484-492.DOI:10.3760/cma.j.cn421158-20230117-00014.
[9] Wu HY,Zhou N,Lu LW,et al.Value of preoperative computed tomography for meso-Rex bypass in children with extrahepatic portal vein obstruction[J].Insights Imaging,2021,12(1):109.DOI:10.1186/s13244-021-01057-8.
[10] 吴慧莹,周宁,鹿连伟,等.CT与楔入法门静脉造影术在儿童Rex术前诊断价值的比较[J].实用放射学杂志,2022,38(4):629-633.DOI:10.3969/j.issn.1002-1671.2022.04.028. Wu HY,Zhou N,Lu LW,et al.Comparison of the preoperative diagnostic value of CT and WHVP in pediatric Rex surgery[J].J Pract Radiol,2022,38(4):629-633.DOI:10.3969/j.issn.1002-1671.2022.04.028.
[11] Bertocchini A,Falappa P,Grimaldi C,et al.Intrahepatic portal venous systems in children with noncirrhotic prehepatic portal hypertension:anatomy and clinical relevance[J].J Pediatr Surg,2014,49(8):1268-1275.DOI:10.1016/j.jpedsurg.2013.10.029.
[12] 王增萌,李志强,彭春辉,等.楔入法经肝静脉逆行门静脉造影辅助儿童肝外门静脉梗阻手术决策制定[J].中华小儿外科杂志,2023,44(6):493-500.DOI:10.3760/cma.j.cn421158-20230320-00092. Wang ZM,Li ZQ,Peng CH,et al.Application of wedged hepatic venous portography for assisting surgical decision-making in children with extrahepatic portal vein obstruction[J].Chin J Pediatr Surg,2023,44(6):493-500.DOI:10.3760/cma.j.cn421158-20230320-00092.
[13] 刘珍银,温哲,蒋贻洲,等.楔入法门静脉造影在儿童门静脉海绵样变中的应用价值[J].中华小儿外科杂志,2017,38(1):46-50.DOI:10.3760/cma.j.issn.0253-3006.2017.01.011. Liu ZY,Wen Z,Jiang YZ,et al.Value of portal wedged venography in pediatric cavernous transformation of portal vein[J].Chin J Pediatr Surg,2017,38(1):46-50.DOI:10.3760/cma.j.issn.0253-3006.2017.01.011.
[14] Chang XP,Liu L,Wang JQ,et al.Effectiveness of preoperative intrahepatic portal venous classification system in guiding preoperative surgical decisions and predicting hypotensive effects after meso-rex bypass for children with EHPVO[J].J Pediatr Surg,2025,60(2):161990.DOI:10.1016/j.jpedsurg.2024.161990.
[15] 王杰钦,温哲,宁禹,等.Rex手术治疗儿童肝外门静脉梗阻128例远期疗效分析[J].中华小儿外科杂志,2023,44(6):501-507.DOI:10.3760/cma.j.cn421158-20230331-00137. Wang JQ,Wen Z,Ning Y,et al.Long-term efficacy analysis of extrahepatic portal vein obstruction in children undergoing Rex surgery:a report of 128 patients[J].Chin J Pediatr Surg,2023,44(6):501-507.DOI:10.3760/cma.j.cn421158-20230331-00137.
[16] 张金山,李龙.Rex术后再发生上消化道出血的治疗策略探讨[J].中华小儿外科杂志,2017,38(9):676-680.DOI:10.3760/cma.j.issn.0253-3006.2017.09.007. Zhang JS,Li L.Therapeutic strategies for recurrent upper gastrointestinal hemorrhage in children undergoing Rex shunting[J].Chin J Pediatr Surg,2017,38(9):676-680.DOI:10.3760/cma.j.issn.0253-3006.2017.09.007.
[17] Lautz TB,Kim ST,Donaldson JS,et al.Outcomes of percutaneous interventions for managing stenosis after meso-Rex bypass for extrahepatic portal vein obstruction[J].J Vasc Interv Radiol,2012,23(3):377-383.DOI:10.1016/j.jvir.2011.11.030.
[18] Wang JQ,Ning Y,Ren HF,et al.Medium-to long-term outcomes of Rex shunt in 105 children with extrahepatic portal vein obstruction in China[J].J Pediatr Surg,2025,60(2):161930.DOI:10.1016/j.jpedsurg.2024.161930.
[19] 刘珍银,温哲,刘涛,等.门静脉海绵样变Rex手术后桥血管吻合口狭窄球囊扩张术初步探讨[J].临床小儿外科杂志,2019,18(12):999-1003.DOI:10.3969/j.issn.1671-6353.2019.12.003. Liu ZY,Wen Z,Liu T,et al.Clinical application of balloon dilatation for anastomotic stenosis after meso-Rex bypass for cavernous transformation of the portal vein[J].J Clin Ped Sur,2019,18(12):999-1003.DOI:10.3969/j.issn.1671-6353.2019.12.003.
[20] Spogis J,Tsiflikas I,Sch?fer JF,et al.TIPS and interventional radiology management of portal hypertensive complications in pediatric population[J].Dig Dis Interv,2024,8(2):156-166.DOI:10.1055/s-0044-1782148.
[21] Shim DJ,Ko GY,Sung KB,et al.Long-term outcome of portal vein stent placement in pediatric liver transplant recipients:a comparison with balloon angioplasty[J].J Vasc Interv Radiol,2018,29(6):800-808.DOI:10.1016/j.jvir.2017.11.019.
[22] Kyaw L,Lai NM,Iyer SG,et al.Percutaneous transhepatic interventional therapy of portal vein stenosis in paediatric liver transplantation:a systematic review of efficacy and safety[J].Pediatr Transplant,2022,26(2):e14187.DOI:10.1111/petr.14187.
[23] Sare A,Chandra V,Shanmugasundaram S,et al.Safety and efficacy of endovascular treatment of portal vein stenosis in liver transplant recipients:a systematic review[J].Vasc Endovascular Surg,2021,55(5):452-460.DOI:10.1177/1538574421994417.
[24] Ghibes P,Gr?zinger G,Hartleif S,et al.Balloon angioplasty versus stent placement for the treatment of portal vein stenosis in children:a single center experience[J].Pediatr Radiol,2023,53(9):1885-1893.DOI:10.1007/s00247-023-05674-x.
[25] Yeh YT,Chen CY,Tseng HS,et al.Enlarging vascular stents after pediatric liver transplantation[J].J Pediatr Surg,2017,52(12):1934-1939.DOI:10.1016/j.jpedsurg.2017.08.060.
[26] 韩晓华,吴琳.脾动脉栓塞术在儿科临床实践中的应用[J].中华小儿外科杂志,2019,40(5):475-478.DOI:10.3760/cma.j.issn.0253-3006.2019.05.019. Han XH,Wu L.Application of splenic arterial embolization in clinical pediatric practices[J].Chin J Pediatr Surg,2019,40(5):475-478.DOI:10.3760/cma.j.issn.0253-3006.2019.05.019.
[27] Ahmadzade M,Akhlaghpoor S,Rouientan H,et al.Splenic artery embolization for variceal bleeding in portal hypertension:a systematic review and metanalysis[J].Emerg Radiol,2025,32(1):79-95.DOI:10.1007/s10140-024-02299-x.
[28] 谭斌.部分脾动脉栓塞术的现状及进展[J].实用放射学杂志,2023,39(4):667-670.DOI:10.3969/j.issn.1002-1671.2023.04.037. Tan B.Research status and recent advances of partial splenic embolization[J].J Pract Radiol,2023,39(4):667-670.DOI:10.3969/j.issn.1002-1671.2023.04.037.
[29] Leideck P,Nkontchou G,Elkrief L,et al.The role and evolution of partial splenic embolization over three decades:a multicentric retrospective single cohort study of 90 patients from French nationwide experience[J].Clin Res Hepatol Gastroenterol,2024,48(6):102355.DOI:10.1016/j.clinre.2024.102355.
[30] Vittorio J,Orellana K,Martinez M,et al.Partial splenic embolization is a safe and effective alternative in the management of portal hypertension in children[J].J Pediatr Gastroenterol Nutr,2019,68(6):793-798.DOI:10.1097/MPG.0000000000002332.
[31] Talwar A,Gabr A,Riaz A,et al.Adverse events related to partial splenic embolization for the treatment of hypersplenism:a systematic review[J].J Vasc Interv Radiol,2020,31(7):1118-1131.e6.DOI:10.1016/j.jvir.2019.08.015.
[32] 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. Chinese College of Interventionalists.CCI Clinical Practice Guidelines.Management of TIPS for Portal Hypertension (Edition 2019)[J].J Clin Hepatol,2019,35(12):2694-2699.DOI:10.3969/j.issn.1001-5256.2019.12.010.
[33] Di Giorgio A,Agazzi R,Alberti D,et al.Feasibility and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in children[J].J Pediatr Gastroenterol Nutr,2012,54(5):594-600.DOI:10.1097/MPG.0b013e3182490c05.
[34] Sanín E,Suárez-Galvis M,?lvarez S,et al.Transjugular intrahepatic portosystemic shunt creation in children weighing <10 kg using an unconventional technique[J].J Vasc Interv Radiol,2023,34(6):1070-1074.DOI:10.1016/j.jvir.2023.01.037.
[35] Bertino F,Hawkins CM,Shivaram G,et al.Technical feasibility and clinical effectiveness of transjugular intrahepatic portosystemic shunt creation in pediatric and adolescent patients[J].J Vasc Interv Radiol,2019,30(2):178-186.e5.DOI:10.1016/j.jvir.2018.10.003.
[36] 夏杰军,徐翼,牛传强,等.TIPS术治疗4岁儿童肝窦阻塞综合征1例[J].中华介入放射学电子杂志,2022,10(4):456-458.DOI:10.3877/cma.j.issn.2095-5782.2022.04.020. Xia JJ,Xu Y,Niu CQ,et al.Application of TIPS for the treatment of hepatic sinus obstruction syndrome in a 4-year-old child:one case report[J].Chin J Intervent Radiol (Electron Ed),2022,10(4):456-458.DOI:10.3877/cma.j.issn.2095-5782.2022.z04.020.
[37] Wang YZ,Ma B,Li PW,et al.Feasibility and clinical effectiveness of transjugular intrahepatic portosystemic shunt creation in pediatric and adolescent patients:a meta-analysis[J].Pediatr Surg Int,2022,38(3):377-387.DOI:10.1007/s00383-022-05066-6.
[38] Izaaryene J,Tradi F,Vidal V,et al.Transjugular intrahepatic portosystemic shunt placement in an infant weighing less than 22 pounds[J].Diagn Interv Imaging,2020,101(10):685-687.DOI:10.1016/j.diii.2020.03.012.
[39] Ghannam JS,Cline MR,Hage AN,et al.Technical success and outcomes in pediatric patients undergoing transjugular intrahepatic portosystemic shunt placement:a 20-year experience[J].Pediatr Radiol,2019,49(1):128-135.DOI:10.1007/s00247-018-4267-9.
备注/Memo
收稿日期:2025-3-3。
基金项目:广州医科大学科研提升项目(02-410-2302148XM)
通讯作者:刘珍银,Email:361476011@qq.com