Rescue TIPS 或 Salvage TIPS 中文被称为 挽救性TIPS。挽救是指从危险或不利中救回来。 什么是挽救性TIPS？ 不能控制的食道胃底静脉曲张出血进行TIPS，被称为挽救性TIPS 什么叫不能控制的食道胃底静脉曲张出血？ 门静脉高压食道胃底静脉曲张消化道出血在穷尽内科治疗，包括血管活性药物使用，内镜下的曲张静脉硬化，结扎后仍然持续出血。 什么叫穷尽内科治疗？ 内镜下静脉曲张治疗是硬化治疗还是结扎治疗？一次？还是多次？
VH is one of the most severe and life-threatening complications in cirrhosis patients and constitutes the second most frequent decompensating event after ascites[6].
门静脉高压静脉曲张出血是肝硬化患者最严重和危及生命的并发症之一，是仅次于腹水【6】的第二大最常见的失代偿事件。
About 10%-15% of patients experience treatment failure, warranting repeated endoscopic interventions, with up to 80% mortality【6,7】
约10%-15%的患者经历了治疗失败，需要重复的内镜干预，高达80%的死亡率为[6,7]。
The overall mortality at 6 wk with each episode of VH also remains high at around 15%-25%, despite improvements in therapy[8,9].
尽管在治疗【7,8】方面有所改善，但每发生VH后6周的总死亡率仍然很高，在15%-25%左右。
TIPS is highly effective in reducing the portal pressure, control of bleed, and prevention of early rebleeding.
TIPS在降低门静脉压、控制出血和预防早期再出血方面非常有效。
Due to the increased risk of HE and the absence of survival benefit with the use of uncovered stents, TIPS was traditionally recommended as rescue therapy for uncontrolled bleeding.
由于使用裸支架会增加肝性脑病的风险和缺乏生存获益，TIPS传统上被推荐为不受控制的出血的挽救治疗。
The prognosis of patients undergoing rescue (or salvage) TIPS is dismal, with 35%-55% mortality due to failure to control bleeding or early rebleeding.
接受挽救（或抢救性）TIPS的患者的预后令人沮丧，35%-55%的死亡率是由于未能控制出血或早期再出血。（未能控制出血和早期再出血的原因？）
The time-delay associated with the decision on performing TIPS also contributes to poor outcome[7,10,11].
决定执行TIPS相关的时间延迟也导致了不良的结果[7,10,11]。
A recent large observational study showed a 6-wk mortality of 36% in patients undergoing rescue TIPS[11].
最近的一项大型观察性研究显示，接受抢救性TIPS[11]的患者的6周死亡率为36%。
The model for end-stage liver disease (MELD) and Child–Turcotte-Pugh (CTP) scores were predictive of short- and long-term mortality, respectively, and pre-TIPS intensive care unit stay was independently associated with TIPS failure and mortality at 6 wk and 12 mo.
终末期肝病(MELD)和CTP评分（可以）分别预测短期和长期死亡率，TIPS前重症监护病房住院与6周和12个月TIPS失败和死亡率独立相关。
Rescue TIPS was found futile in patients with CTP score > 13.
CTP评分> 13.患者抢救TIPS无效。
With the advent of e-PTFE–covered stents, the incidence of TIPS dysfunction and recurrence of complications related to PH reduced drastically.
随着覆膜支架的出现，TIPS功能障碍的发生率和PH相关并发症的复发显著降低。
Additionally, it was found that covered TIPS did not significantly increase the frequency and severity of episodes of de-novo HE[3].
此外，研究发现，覆盖的TIPS并没有显著新增肝性脑病[3]发作的频率和严重程度。
Hepatic venous pressure gradient (HVPG), the surrogate marker of portal pressure, is an objective and reproducible measurement.
肝静脉压梯度(HVPG)是门静脉压的替代标志物，是一种客观和可重复的测量方法。
Moitinho et al[12] found that measurement of HVPG in patients with cirrhosis admitted with acute VH provided useful prognostic information, and those with HVPG > 20 mmHg required closer surveillance.
Moitinio等[12]发现，测量急性VH住院的肝硬化患者的HVPG提供了有用的预后信息，而HVPG＞20mmHg患者需要更密切的监测。
Monescillo and colleagues showed that early portal decompression by TIPS placement in those with HVPG > 20 mmHg significantly reduced the risk of treatment failure, prevented recurrent VH, and improved short and long-term survival despite having higher baseline bilirubin levels[13].
Monescillo及其同事发现，在HVPG＞20mmHg患者中，早期放置TIPS减压显著降低了治疗失败的风险，预防了复发性肝性脑病（VH），并改善了短期和长期生存率。
HVPG was found more accurate than the CTP score for 6 wk survival prediction.
HVPG在6周生存预测方面比CTP评分更准确。
This study, however, used endoscopic sclerotherapy in the medical treatment group, and bare stents were used in the early-TIPS group, both of which are not the current standard of care.
然而，本研究使用了内镜硬化治疗，而在早期TIPS使用了裸支架，这两者都不是目前的治疗标准。
To address these issues, a multicentre randomized controlled trial (RCT) was conducted in which patient selection was based on clinical and endoscopic criteria[3].
为了解决这些问题，有人进行了一项多中心随机对照试验(RCT)，其中患者的选择是基于临床和内镜标准[3]。
In this study, early treatment with covered TIPS (within 72 h, and preferably within 24 h) in high-risk patients-defined as CTP score 10-13 points and CTP class B with active bleeding at endoscopy-resulted in significant bleed control and reduction in mortality, without an increase in the risk of HE.
在这项研究中，高危患者早期治疗TIPS（72小时内，最好是24小时内）—— 定义为CTP评分10-13分和内镜活动出血的CTP-B级——可以显著控制出血和降低死亡率，而没有增加HE的风险。
Additionally, the study found lower rates of ascites formation, HRS, and reduced hospital stay.
此外，该研究发现腹水形成率、肝肾综合征（HRS）发生率和住院时间较低。
A retrospective post-RCT surveillance study by the same group found only a trend to improvement in survival when compared with standard medical therapy[14].
同一组的一项回顾性RCT后监测研究发现，与标准药物治疗[14]相比，生存率只有改善的趋势。
The Baveno VI consensus endorsed these findings and recommended that "an early TIPS within 72 h (ideally < 24 h) should be considered in patients at high risk of treatment failure after initial pharmacological and endoscopic therapy"[15].
BavenoVI共识支持这些发现，并建议对于初始药物和内镜治疗后治疗失败的高危患者，应在72小时（理想为24小时）内考虑早期TIPS。
Further, a meta-analysis confirmed the survival benefit offered by early TIPS in high-risk patients[16].
此外，一项荟萃分析证实了早期TIPS在高危患者[16]中提供的生存益处。
The original trial by Garcia-Pagan et al[3] was not powered to conduct appropriate subgroup analyses to identify benefits on survival between CTP B and C groups.
Garcia-Pagan等人[3]的最初试验没有进行适当的亚组分析，以确定CTP-B组和C组之间的生存益处。
Studies conducted later showed that clinical outcomes among CTP-B patients on standard medical treatment were significantly better than that of Child-Pugh C patients without added benefits with early-TIPS[17].
后来进行的研究表明，接受标准药物治疗的CTP-B患者的临床结果明显优于Child-Pugh-C患者，而早期TIPS[17]没有额外的益处。
The re-calibrated MELD score as an alternative to the CTP score was shown to have better prognostic value in patients with acute VH on standard care[18].
重新校准的MELD评分作为CTP评分的替代品，在标准护理[18]的急性VH患者有更好的预后价值。
CTP-C patients with a baseline creatinine ≥ 1 mg/dL (Child C-C1 criteria) were found to have high-risk of death after VH[17].
具有基线肌酐≥1mg/dL(ChildC-C1标准)的CTP-C患者在静脉曲张出血[17]后被发现死亡的高风险。
A recent multicentre study showed that the mortality risk among CTP B compared to CTP class C patients with active bleeding at endoscopy, on the standard of care was lower[17].
最近的一项多中心研究显示，与内镜下活动性出血的CTPC类患者相比，CTPB的死亡风险[17]较低。
The study also identified MELD score ≥ 19 as a high risk for death with standard care alone.
该研究还确定了MELD评分≥19是单独使用标准治疗的死亡的高风险。
This implied that the grouping of Child-Pugh B and Child-Pugh C as high-risk for mortality on standard therapy of acute VH was inaccurate.
这意味着在急性静脉曲张的标准治疗中，Child-Pugh B 和 Child-Pugh C作为高危死亡的分组是不准确的。
Subsequently, observational studies showed that the early use of TIPS was justified in those with MELD ≥ 19 or Child-Pugh class C[19].
随后，观察性研究表明，在MELD≥19或Child-Pugh-C[19]患者中，早期使用TIPS是合理的。
For patients with MELD 12–18 or Child-Pugh B patients, survival benefit could not be uniformly demonstrated.
对于MELD12-18患者或Child-Pugh B患者，生存获益不能得到一致的证明。
An RCT from a single center in China reported improved control of bleeding and rebleeding and better transplant-free survival (TFS) at 6 wk and one year with early TIPS[20].
来自中国一个单一中心的一项随机对照试验报告称，在6周和一年的早期TIPS[20]时，对出血和再出血的控制有所改善，以及更好的无移植生存期(TFS)。
The benefit was seen in all groups regardless of active bleeding or stage of liver disease.
无论活动性出血或肝病分期如何，所有组均有获益。
There was no difference in the incidence of HE.
肝性脑病的发生率无差异。
Besides, the actuarial probability of remaining free from new or worsening ascites was higher in the early TIPS group than in the control group at one year.
此外，早期TIPS未出现新发腹水或原有腹水的恶化概率高于对照组。
A slight increase of median bilirubin levels and the international normalized ratio at 1 and 3 mo was observed in the early-TIPS group, which improved after 6 mo.
早期TIPS组在1个月和3个月时，中位胆红素水平和国际标准化比值略有升高，6个月后有所改善。
Similarly, median MELD scores were significantly higher at 1 and 3 mo in the TIPS group disappearing after 6 mo.
同样，TIPS组在6个月后消失，MELD评分在1个月和3个月后显著升高。
Notably, all patients with Child-Pugh class B and class C disease were included irrespective of active bleeding, and 75% had a chronic hepatitis-B infection.
值得注意的是，所有Child-PughB类疾病和C类疾病患者均无活动性出血，75%患有慢性乙型肝炎感染。
Therefore, antiviral therapy could have influenced the outcome.
因此，抗病毒治疗可能会影响治疗结果。
Another recent RCT from the United Kingdom reported that early-TIPS reduced rebleeding without survival benefit and higher incidence of HE in those undergoing early TIPS[21].
英国最近的另一项随机对照试验报告称，早期TIPS减少了[21]患者的再出血，但没有生存获益，而HE的发生率更高。
However, out of the 29 patients enrolled in the TIPS-arm of this study, only 13 underwent TIPS stent placement within 72 h of index bleeding, making it underpowered to derive any conclusions.
然而，在本研究纳入TIPS组的29例患者中，只有13例在出血后72小时内放置了TIPS支架，这使得它无法得出任何结论。
Despite the contradictory results shown by these two recent RCTs, there is enough evidence now (Table (Table1)1) to recommend early TIPS in patients with Child-Pugh class C disease and MELD > 19; however, the upper limit of MELD requires confirmation.
尽管最近这两项随机对照试验的结果相互矛盾，但现在有足够的证据（表(表1)1）建议Child-Pugh-C类疾病和MELD患者的早期TIPS，但MELD的上限需要确认。
Even though the question of survival benefit in patients with Child-Pugh class B and MELD score of 12-18 remains open to debate, the reduction in rebleeding and ascites, without increasing the risk or severity of HE could also justify the use of early TIPS in this subgroup of patients.
尽管Child-Pugh-B类和MELD评分为12-18的患者生存获益的问题仍存在争议，但再出血和腹水的减少，而不增加风险或严重程度，也可以证明在这一亚组患者中使用早期TIPS。
In keeping with this, the British society of interventional radiology and British association of the study of the liver recommends that "in patients who have Child’s C disease (C 10-13) or MELD ≥ 19, and bleeding from esophageal varices (EV) or GOV1 and GOV2 gastric varices (GV) and are hemodynamically stable, early or pre-emptive TIPS should be considered within 72 h of a variceal bleed where local resources allow"[22].
与此相一致的是，英国介入放射学协会和英国肝脏研究协会建议，对于患有CTP-C(C10-13)或MELD≥19、食管静脉曲张(EV)或GOV1和GOV2胃静脉曲张(GV)的患者，血流动力学稳定，应在当地资源允许和[22]的静脉曲张出血后72小时内考虑早期或先发制人（抢先或优先）的TIPS。
Despite these recom-mendations, the rate of implementation of early TIPS in a real-world situation is dismal, with only 6%-13% of eligible candidates undergoing the procedure according to two recent large multicentre observational studies[23,24].
尽管进行了这些修正，但在现实世界中，早期TIPS的实施率令人沮丧，根据最近的两项大型多中心观察性研究[23,24]，只有6%-13%的合格候选人接受了该手术。
幸福的树叶子掉了可以挽救吗？ |