DIPS（Direct Intrahepatic Portacaval Shunt）是“直接经肝门腔静脉分流术”的英文缩写。它是为了减少传统TIPSS（Transjugular intrahepatic portosystemic stent shunt）操作的缺陷而设计的一种改良介入技术。
传统TIPSS的技术成功率高（可达95%～99%），并发症发生率低（3%～8%），操作相关的死亡率低（0.5%～1%）。对急诊静脉曲张破裂出血的即刻止血成功率可达90%～99%；不同文献对预防复发出血6个月、1年和2年的有效率分别为85%～90%，70%～85%和45%～70%。TIPSS术后1～2年（平均18个月）复发出血率低于经内镜下治疗，而且对门静脉高压症所致的顽固性腹水有一定疗效[1~12]。
但TIPSS的中远期（≥1年）疗效并不理想。术后再出血1年、2年的发生率分别为为20%～26%，和32%~41%。影响长期疗效的主要因素是术后分流道狭窄或闭塞，75%是发生在支撑架在肝静脉出口位置[4,8,15,23,26,42,43]的狭窄，导致整个肝内分流通道慢性失效。若以复发出血或/和影像学检查为依据，术后6个月、12个月内发生率分别为为17%～25%和23~87%不等[11~21]、而病理标本或尸检的发生率为40%～48%。
为了防止TIPSS术后支撑架内再狭窄，有关技术改进一直在进行[8，22]。以介入放射学角度主要采取两种策略：（1）覆盖分流通道（Covering the shunt），即植入覆膜支撑架到分流通道内，减少传统裸支撑架内膜增生引起的支撑架内狭窄；（2）避开或减少分流通道内肝实质部分（Avoiding the liver），避开肝静脉建立直接的门-腔静脉分流。DIPS和经皮腹膜后脾肾静脉分流术（Percutaneous Retroperitoneal Splenorenal Shunt，PRESS）、经皮肝外门腔分流术（Percutaneous Extrahepatic Portocaval Shunt，PEPS）以及经静脉肝外门腔分流术（Transvenous Extrahepatic Portocaval Shunt，TEPS）一样是基于后一种策略考虑。
DIPS技术是传统TIPSS技术的改良，主要是在肝后段下腔静脉（Retrohepatic segmental of inferior vena cava，RHSIVC）紧邻肝静脉出口的地方与门静脉或门静脉分支之间直接建立低阻力的分流通道，将部分门静脉血流分流到下腔静脉，以达到降低门静脉压力。由于避免传统TIPS经肝静脉建立分流通道，从而减少分流通道的狭窄或闭塞的发生率，把持支撑架相对长期的通畅性[36]。下腔静脉是人体直径最大的静脉，其直径远超过肝静脉，理论上下腔静脉作为门腔静脉分流的出口将改善经肝门腔静脉分流术的通畅率[24~28]。目前主要应用于TIPS术中缺乏肝静脉开口（Budd-Chiari Syndrom[26]）或肝硬化肝脏缩小导致肝静脉与门静脉主要分支之间角度过小，不宜从肝静脉穿刺门静脉[25,29]，以及前次TIPSS阻塞时[30]。除了扩大TIPSS的适应症，最希望达到的目的是希望获得更为稳定和长期的分流通道开通率。
肝硬化病人，肝静脉引流到下腔静脉几乎是直角或由于严重的肝硬化，门静脉的水平提高几乎与肝静脉水平接近。临床上RUPS-100穿刺组件以产品设计的角度难以经肝静脉穿刺进入门静脉[24]。比较传统的TIPSS，DIPS从门静脉分流到腔静脉的角度小，符合门静脉血流动力学分布，静脉流出道阻塞或狭窄的触发因素比TIPSS少[39]，所以分流通道潜在开放的时间比TIPSS长。
就解剖而言，肝硬化患者左叶代偿肥大，为穿刺点的选择和超声引导提供方便[38]。
DIPS的主要缺点和包括外科手术一样属于非选择性分流，术后可因门静脉灌注下降导致进行性肝功能衰竭以及肝性脑病；手术要求置入支架定位精确，支撑架两端不宜在门静脉主干和下腔静脉内伸入过长；有潜在增加肝移植的困难程度；发生腹腔内出血的比例高于常规TIPS；与TIPSS比较增加栓塞胃冠状静脉/胃短静脉的技术难度。
DIPS穿刺技术[34,35]
首先将血管内超声探头从右股静脉前进到肝内段下腔静脉。RUPS-100经颈静脉入路引入到下腔静脉（需增加弯度[26]。血管内超声引导下引导穿刺针从下腔静脉进入门静脉最近的分支。超声引导下的DIPS的主要优点是穿刺门静脉时可以直接看到穿刺针的进入轨迹，避免了传统TIPSS盲穿门静脉的缺点，潜在改善了这一位置操作的安全性和有效性。
时利民[40]，罗剑军[41]等曾研究肝后段下腔静脉建立肝内分流的影像学研究。周云[37]等人报告采用二维超声引导下穿刺获得成功。
Direct Intrahepatic Portacaval Shunt -DIPS
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| 超声引导下门静脉穿刺 |
超声引导下穿刺针进入门静脉时情形 |
穿刺门静脉成功后，5F猪尾巴导管进入门静脉实施门静脉造影。撤出猪尾巴导管置换直径6mm，长6cm球囊扩张导管（Opta 5; Cordis, Miami Lakes, Fla）位于腔静脉与门静脉之间。扩张球囊可以显示近端切迹为下腔静脉壁，远端切迹为门静脉壁。两个切迹之间是的距离是门静脉和下腔静脉之间的肝实质通道的长度，也是支撑架的覆膜部分的最小长度。
测量好切迹间的距离后，充分扩张球囊至两个球囊切迹消失，收缩球囊沿导丝撤出球囊后置换10F鞘管进入门静脉，在透视和血管超声监测下植入覆膜血管支撑架完成直接分流的建立，并造影证实。植入覆膜支撑架是由于以前的研究证实PTFE覆膜支撑架由于裸金属支撑架，可以减少胆汁瘘和肝实质通道内狭窄[31~33]
除了经肝后下腔静脉直接穿刺肝内静脉，也有考虑经皮经肝门静脉穿刺肝后段下腔静脉[38]。
(未完待续）
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