维也纳总医院和维也纳医科大学为维也纳肝血动力学实验室提供基础设施。维也纳肝血动力学实验室的前任成员和同事应该了解他们的宝贵意见，帮助不断改进我们机构的HVPG测量和血管肝活检方法。此外，我们感谢胃肠病学和肝病科的护士，他们是维也纳血动力学实验室的重要组成部分，并不断为患者提供出色的护理。

此处描述的议定书符合维也纳医科大学人类研究伦理委员会的准则。
1. 准备工作
<ol><li>使用配备数字 X 射线荧光镜系统 （图 1A）、监视器系统 （图1B）、压力记录器和传感器 （图1C）连接到打印机或录制软件以及超声波设备 （图1D）的 X 射线专用/批准程序。此外，确保有足够的空间在患者席旁边有一个无菌工作区（图1E）。</li>
	<li>通过测量HVPG来评估疑似晚期慢性肝病（ACLD）患者。特别是，有以下特征之一的患者可能会接受HVPG测量:血小板减少和150 G/L，横截面成像的端索辅助材料，胃食管变异在启动非选择性β阻断剂治疗之前，阿西特，和肝肿瘤，计划切除。</li>
	<li>在手术中使用以下禁忌症:（一）由于血管或骑兵静脉血栓形成而无法获得血管，（二）临床上明显的出血性疾病（如传播血管内凝血）、（iii）反向肺炎和（iv）显著心律失常。</li>
	<li>在被告知手术的目的和潜在风险后，确保患者被固定并给予书面知情同意。</li>
	<li>说明必须在没有全身麻醉的情况下执行该程序。然而，低剂量的米达佐兰（高达0.02毫克/公斤体重）可能会提供给焦虑的病人。</li>
	<li>使用标准监测系统，通过非侵入性动脉血压测量、脉搏氧化和心电图来监测患者的生命体征。</li>
	<li>在压力袋中使用无菌盐水溶液冲洗压力传感器集。</li>
	<li>校准压力传感器（如果不预先校准，在开始测量之前根据外部压力参考校准，例如使用 13.6 厘米 H2O 等于 10 mm Hg 的水柱）。</li>
	<li>将传感器放在右中庭的水平，瞄准患者的中轴线。</li>
	<li>准备压力记录器/记录软件，以便记录压力跟踪。</li>
	<li>确保所有必要的无菌设备都准备好了（见 材料表）。</li>
	<li>要求病人在病人的长凳上占据一个超高的位置。</li>
	<li>让操作员清洗和消毒她/他的手和前臂。</li>
	<li>戴上手术帽和面罩，无菌手套和无菌外套。</li>
	<li>使用无菌表盖，为中央静脉通道所需的设备准备无菌工作区（图 2A）。</li>
</ol>2. 无菌条件下的中央静脉进入
<ol><li>指示患者将头稍微转向左侧，然后用消毒剂溶液对右前颈和侧颈区域进行消毒。</li>
	<li>将覆盖皮肤的无菌毛巾放在胡萝卜三角形周围。</li>
	<li>使用超声波探针（由无菌的美国探头盖护套覆盖）来识别正确的内部血管和适当的穿刺部位。</li>
	<li>用21G针渗透随后血管进入区域，并应用局部麻醉剂（利多卡因2%，5 mL）。然后，等待1-2分钟的全部效果。</li>
	<li>准备中央静脉通道所需的所有材料（见 材料表）。</li>
	<li>使用 7.5 F 导管导管护套设备，使用超声波引导将针头放在正确的内部血管中，并使用 Seldinger 技术（图 3A）通过针推进导线。 注:如果在HVPG测量后进行血管活检，则必须使用直径较大的10F肝活检介绍套（额外使用18G针头和导线）。</li>
	<li>使用刀片 11 手术刀沿着导线进行 2-3 毫米切口，以方便引入装有扩张器的血管通道护套。</li>
	<li>将装有扩张器的血管通路垂直护套插入导线的内部血管静脉中。</li>
	<li>取出血管通道护套的导线和扩张器。</li>
	<li>确保血管进入护套保持稳定的血管内位置，并将血管进入护套的注射端口定向到侧向（图3B）。 注意:不需要安装或录音。</li>
</ol>3. 将气球导管放置在肝静脉中
<ol><li>准备将气球导管放入肝静脉所需的所有材料（图2B）。</li>
	<li>用对比介质（染料）冲洗气球导管，通过重复的窒息/通缩检查气球的完整性，导管尖浸入盐水溶液中。不应发生气泡。 注意:根据导管本身在 X 射线上的可见性，您也可以仅使用无菌盐水或稀释染料来冲洗导管的血管流明。</li>
	<li>用无菌盐水溶液润湿外面的气球导管，然后将其插入血管通道护套。</li>
	<li>在荧光引导下将气球导管推进到劣质卡瓦静脉 （IVC）中。将气球导管的尖端对准患者背部，导管的轻微旋转通常允许从右中庭推进到 IVC。在某些情况下，指示患者深吸气可能会有所帮助（图3B）。</li>
	<li>将气球导管从 IVC 推进到肝静脉中。尝试通过反复移动与气球导管的尖端面向右向肝静脉和 IVC（图 3C）交界处的可疑区域获得肝静脉。</li>
	<li>确保导管进入一个稳定的位置，允许在2-4厘米的距离内反复测量自由肝静脉压力（FHVP），并有足够的空间在肝静脉的流明膨胀气球，以记录楔形肝静脉压力（WHVP）。</li>
	<li>检查通过充气气球（约2 mL的空气进入气球流明）和对比剂注射（约5 mL进入血管流明）的静脉（楔形位置）的充分遮挡，直到肝静脉消失到膨胀的气球可视化（图3D）。</li>
	<li>观察对比介质的停滞状态，并排除因气球遮挡静脉流明不足或静脉通信存在而冲刷的对比介质。如果观察到显着的对比度介质冲洗，请尝试重新定位气球导管。</li>
	<li>放气气球，用盐水冲洗导管的流明。</li>
</ol>4. 用于评估HVPG的血动力学读数
<ol><li>使用输液线将气球导管的血管流明连接到压力传感器。</li>
	<li>开始记录FHVP与气球的尖端2-4厘米从肝静脉的开口到IVC。曲线的波形必须稳定，不会随着时间而变化。 注:稳定值通常在15岁以后获得。</li>
	<li>充气气球，并继续记录WHVP，直到测量成为一个稳定的水平线，随着时间的推移没有变化。 注:楔形压力的稳定跟踪通常在 >40 s 之后获得。</li>
	<li>重复 FHVG （+15 s） 和 WHVP （+40 s） 的测量至少三次，以获得三倍的高质量读数 （图 3E）。 注:如果单个 FHVP/WHVP 读数之间观察到≥2 mm Hg 存在显著差异，则应进行其他测量。注意潜在人工制品的原因，如咳嗽、移动或在血动力学记录的相应时间点说话。</li>
	<li>记录在 IVC 中的压力在肝静脉的骨质水平以及正确的体外压力 （RAP） 的水平。</li>
	<li>停止录制。</li>
	<li>取出气球导管。</li>
	<li>计算 HVPG（从 WHVP 中减去的 FHVP）为 3 个测量的平均值。 注:如果在按顺序获得的 HVPG 读数之间注意到≥2 mm Hg 的显著差异，则应进行其他测量。</li>
	<li>继续进行血管外活检（步骤 5.1），或从内部血管中取出导管导管护套。 注:插入僵硬的导线可能有助于达到相同的肝内位置，用于随后的血管内肝脏活检。</li>
	<li>使用无菌纱布在内血管静脉血管插入部位顶部施加压力至少5分钟。</li>
</ol>5. 做好血管外肝活检的准备
注:两种不同的活检方法可用于获得血管外肝脏活检:渴望（第6步）或核心活检（第7步）。首先决定使用哪个系统，然后选择适当的活检针介绍护套，然后再进行步骤 5.1 到 5.3）。或者，核心TJBLX集的针头也可以插入到愿望集（注意:使用适当的直径），这导致一个更灵活的核心活检系统，可能更容易引入肝静脉（注意:此方法在这里没有详细描述）。
<ol><li>准备相应的血管肝活检 （TJLBX） 集 （渴望TJLBX:图 4A-B:核心 TJLBX:图 4C:请参阅材料表）。</li>
	<li>用无菌盐水冲洗活检针引针护套，或在血管内呼吸肝活检的情况下，用对比剂进行更好的可视化。</li>
	<li>使用与 3.4 中描述相同的技术，将活检针引入护套推进到肝静脉中。</li>
	<li>根据所使用的活检集，继续为吸入TJBX踩6.1步，或为核心TJBX步骤7.1。</li>
</ol>6. 血管内吸肝活检
<ol><li>使用 10 mL Luer 锁注射器用无菌盐水冲洗吸入性 TJLBX 针头，但在注射器中留下约 3 毫升，以方便吸入。</li>
	<li>通过活检针引入器护套轻轻推进活检针，直到针尖到达介绍者护套的末端。 注意:在推进针头时避免任何力或快速运动。要求患者深呼吸会降低 IVC 和肝静脉之间的角度，以便更容易地推进活检针。</li>
	<li>请病人屏住呼吸。</li>
	<li>使用 10 mL Luer 锁注射器应用吸力，将针头推进肝脏帕伦奇马。</li>
	<li>在仍然使用吸力（负压）时缩回针头。</li>
	<li>建议患者继续正常呼吸。</li>
	<li>取出针头（但不是针头介绍护套），并收获肝脏样本。 注:肝脏样本通常保留在注射器中，而不是针头（图4D）中。</li>
	<li>重复步骤 6.1 到 6.6 额外的针通道，直到获得足够的肝脏标本。</li>
	<li>在导管引入器护套上注入 5-10 mL 的对比介质，以排除肝胶囊穿孔。</li>
	<li>取出活检针引物护套。</li>
	<li>取出 10 F 肝活检套管，使用无菌纱布在内血管血管的血管插入部位顶部施加压力至少 5 分钟。</li>
</ol>7. 血管核心肝活检
<ol><li>通过拉握来加载核心 TJLBX 针头，直到拍摄机制锁定。通过活检针引入器护套轻轻推进核心活检针，直到针尖接近介绍者护套的末端。 注意:在推进针头时避免任何力或快速运动。</li>
	<li>请病人屏住呼吸。</li>
	<li>将针头推进肝脏帕伦奇马。</li>
	<li>通过扣动射击机制的扳机进行核心活检。</li>
	<li>建议患者继续正常呼吸。</li>
	<li>取出针头（但不是针头介绍护套），并收获肝脏样本。小针可能有助于去除肝脏样本（图4D）。</li>
	<li>重复步骤 7.1 到 7.6 额外的针通道，直到获得足够的肝脏标本。</li>
	<li>将5-10 mL的对比介质注射到导管引入器护套的侧端口，以排除肝胶囊穿孔的可能性。</li>
	<li>取出活检针引物护套。</li>
	<li>取出10F肝活检套管，使用无菌纱布在血管内静脉血管插入部位顶部施加压力约5分钟。</li>
</ol>

托马斯·雷贝格尔得到了库克医疗的赠款和物质支持，以及W.L.戈尔和协会讲座的资助和荣誉。菲利普·施瓦布尔、马库斯·佩克-拉多萨夫列维奇和迈克尔·特劳纳对于这份手稿没有什么可透露的。马蒂亚斯 · 曼多弗因从 W. l. 戈尔和同事的讲座而获得荣誉。

虽然HVPG测量需要大量的资源和训练有素的个人与干预技能和专业知识的阅读压力跟踪，它改善预测，并可能指导治疗决定，从而促进个性化的医学。此外，在同一会话中，通过跨性别途径安全获得肝脏活检标本的机会是赞成在三级护理中心实施肝血动力学实验室的另一个论点。事实上，指引支持在拥有足够专业知识和资源的中心使用HVPG测量技术。手术...

肝硬化患者有出现并发症的风险，这些并发症大多与门户高血压（PHT）有关，如胃或食管静脉曲张1、2、3的腹水或出血。肝退补偿的风险与PHT2的程度有关。肝静脉压梯度（HVPG）的测量是估计肝硬化患者门户静脉压力的黄金标准，即评估鼻窦门户高血压4的严重程度。≥6 mm Hg 至 9 mm Hg 的 HVPG 表示门户压力升高（"亚线门户高血压"），而 HVPG ≥10 mm Hg 定义 CSPH。该协议详细描述了设备和流程，并突出了潜在的陷阱，并为故障排除提供了建议。
临床上，HVPG的测量表明（一）建立鼻窦门户高血压的诊断， （二）通过诊断CSPH（HVPG ≥10 mm Hg）来识别有肝病康复风险的患者:（三） 指导静脉出血的初级或二级预防的药理治疗，（四） 评估局部肝切除术后肝衰竭的风险。HVPG 被用作肝纤维化/功能改善和/或恶化的既定代孕标记，因为 HVPG 的减少转化为临床上有意义的益处5，而较高的 HVPG 值则与增加的静脉出血风险6有关。根据对非选择性β阻滞剂（NSBB）或病因疗法下患者HVPG变化的观察，HVPG减少10%被认为是临床上相关的7，8。
迄今为止，没有替代的非侵入性参数反映与HVPG类似的精度门户压力的程度。即使HVPG实际上是一种"间接"的方式来测量门户压力，它强烈相关，从而准确地反映"直接"测量的门户压力在肝硬化患者9。重要的是，HVPG测量应该使用气球导管进行，以最大限度地提高评估的肝帕伦奇马10，11，12。虽然HVPG测量是侵入性的，资源密集型的，需要干预技能和专业知识来解释压力读数的可靠性和合理性，但这种方法是目前诊断和监测肝硬化患者的门户高血压的黄金标准13，14，15。
简单的实验室值，如血小板计数，可能有助于估计CSPH的可能性。然而，血小板计数，或包括血小板计数的非侵入性分数，具有有限的预测值16。在肝硬化患者中显示 splomegaly17 或端粒体抵押品18 的成像模式表明存在 CSPH，但无助于量化门户高血压的实际程度。新型非侵入性成像工具，如肝脏19 和/或脾脏20 的弹性成像，对于排除或排除CSPH的存在是有用的。尽管如此，没有一种可用的方法能够直接测量门户压力21的动态变化。
一些具有里程碑意义的研究强调了HVPG的预测价值， 表明HVPG≥10毫米汞柱（即CSPH）对变异8的形成（以及与门户高血压22相关的并发症的发展）具有预测性，而HVPG的（药理学诱发的）减少则调节了变异生长23和减补偿7的相应风险。HVPG 反应是 NSB 在预防（经常性）静脉出血方面有效性的唯一既定替代。如果HVPG降低到12毫米汞≤值，或在NSBB治疗期间降低≥10-20%，患者可免受静脉出血和存活率增加24，25。同样，HVPG反应也降低了经补偿的肝硬化患者的阿西特和相关并发症的发病率5，26。多项研究已提供证据，支持使用HVPG指导疗法27、28、29、30、31、32。因此，在有足够经验的中心，HVPG反应可以指导治疗决策，为门户高血压患者提供个性化的药物。
此外，HVPG的测量可能作为概念验证研究的替代终点，评估从长凳到床边的肝硬化和/或门户高血压新疗法的有效性，如索拉芬尼布33，34，辛伐他汀35，36，牛磺酸37，或埃里卡桑38。最终，HVPG的测量也可以提供有关HCC39和肝衰竭后肝切除40的风险的重要预测信息。
在二级和三级护理中心应随时提供测量HVPG的基础设施。由于HVPG测量技术需要专门的培训和设备，因此学术和移植中心建立肝动力学实验室，促进门户高血压的最先进的诊断和管理，似乎是合理的。大容量中心每年执行数百次 HVPG 测量。根据我们的经验，在 50-100 次监督的 HVPG 测量之后，通常会获得足够的专业知识来进行准确的 HVPG 测量。

<table><tbody><tr><td>10 mL Luer-Lock syringe</td><td>Braun</td><td>REF 4617100V, LOT 17G03C8</td><td>Luer-Lock Syringe for connection with the aspiration biopsy set</td></tr><tr><td>10 mL Syringe 2x</td><td>Braun</td><td>REF 4606108V</td><td>Snonpyrogenic, nontoxic 10 mL syringe</td></tr><tr><td>10 F liver biopsy&amp;nbsp; introducer sheath set</td><td>Cook Medical</td><td>REF RCFW-10.0-38, REF G07600</td><td>Percutaneous Sheath Introducer Set (TJBX), 10F Port, 13cm, Check-Flo Performer Introducer</td></tr><tr><td>18 G needle for biopsy introducer sheat</td><td>Arrow International</td><td>REF AN-04318</td><td>Introducer Needle for TJBX Set, 18 G, 6.35 cm</td></tr><tr><td>21 G needle</td><td>Henke Sass Wolf</td><td>REF 0086, Fine-Ject 21Gx2&quot;</td><td>Sterile injeciton needle, 21 Gx2&quot;, 0.8 x 50 mm, for local anesthesia</td></tr><tr><td>3-way channels</td><td>Becton Dickinson</td><td>BD Connecta Luer-Lok, REF 39402</td><td>Three way channel with Luer-Lok connection system</td></tr><tr><td>7.5 F catheter introducer sheath set</td><td>Arrow International</td><td>REF SI_09875-E</td><td>Percutaneous Sheath Introducer Set, 7.5 F Port</td></tr><tr><td>Aspiration TJLBX set</td><td>Cook Medical</td><td>REF RMT-16-51.0-TJL, REF G20521</td><td>TJ Liver Access and Biopsy Needle Set (Aspiration Set), 9 F-45 cm, 16 G-50.5 cm</td></tr><tr><td>Balloon catheter</td><td>Gerhard Pejcl Medizintechnik Austria</td><td>REF 500765B</td><td>Ferlitsch HVPG Catheter, 7F-65cm, Balloon:2.5mL, Pressure 50-90 kPa, GW: 0.032&quot;</td></tr><tr><td>Blade 11 scalpel</td><td>Medi-Safe Surgicals</td><td>MS Safety Scalpel REF /Batch 18012424</td><td>11 blade safety scalpels, retractable, single use, 10 scalpels per package</td></tr><tr><td>Blunt tip fill needle</td><td>Becton Dickinson</td><td>REF 303129</td><td>Sterile blunt tip fill needle, single use</td></tr><tr><td>Contrast media (dye)</td><td>Dr. Franz K&amp;ouml;hler Chemie GmbH, Bensheim, GER</td><td>ZNR 1-24112</td><td>Peritrast 300 mg Iod/mL, 50 mL, contrastmedia</td></tr><tr><td>Core TJLBX set</td><td>Cook Medical</td><td>REF RMT-14XT-50.5-LABS-100, REF G08285</td><td>TJ Needle Introducer and Bx-Needle 7 F-53.5 cm, 14 G-53.5 cm/20 mm, 18 G-60 cm</td></tr><tr><td>Digital x-ray fluoroscope system</td><td>Siemens</td><td>Model No 07721710</td><td>ARCADIS Varic, mobile x-ray fluoroscope system</td></tr><tr><td>Disinfectant solution</td><td>Gebro Pharma</td><td>1-20413</td><td>Isozid-H</td></tr><tr><td>Face mask</td><td>MSP Medizintechnik GmbH</td><td>REF HSO36984</td><td>Surgical face mask from double fleece, with tie, 50 pieces</td></tr><tr><td>Guide wire for biopsy introducer sheat</td><td>Arrow International</td><td>REF AW-14732</td><td>Marked Spring-Wire Guide, TJBX Set, 0.032&quot;, 0.81 mm, 68 cm</td></tr><tr><td>Infusion line</td><td>Rosstec Medical Products b Cardea GmbH &amp;amp; Co</td><td>REF 220010, 100m</td><td>Infusion line, Luer-Lok for connection of balloon catheter and pressure transducer</td></tr><tr><td>Lidocaine 2%</td><td>Gebro Pharma</td><td>Xylanaest, ZNR 17.792, 20mg/1mL (2%)</td><td>Sterile vials Xylanest including 2% Lidocain hydrochloride for local anesthesia</td></tr><tr><td>Midazolame</td><td>Roche</td><td>Dormicum, ZNr 1-18809, Midazolam 5mg/5mL</td><td>Sterile vials Dormicum including Midazolam for sedation</td></tr><tr><td>Monitor system</td><td>Datex-Ohmeda by GE</td><td>Type F-CMREC1</td><td>Patient monitoring system</td></tr><tr><td>Patient bench</td><td>Silerlen-MAQET</td><td>Model No 7474.00A</td><td>Mobile patient bench for x-ray fluoroscopy</td></tr><tr><td>Pressure bag</td><td>Ethox Corp</td><td>REF 4005</td><td>Pressure Infuser Bag 500 mL</td></tr><tr><td>Pressure recorder</td><td>Edwards Lifesciences</td><td>Ref T001631A, Lot 61202039</td><td>TruWave 3 cc/150 cm</td></tr><tr><td>Pressure transducer</td><td>Edwards Lifesciences TM</td><td>REF T001631A</td><td>Pressure Monitoring Set (1x), 3 cc/150 cm, TruWave TM</td></tr><tr><td>Recording software&amp;nbsp;</td><td>Datex Ohmeda by GE</td><td>Software S/5 is property of Instrumentarium Corp of Datex-Ohmeda TM</td><td>Datex-Ohmeda S/5TM Collect - Software to record pressure tracings of the patient monitor system</td></tr><tr><td>Sterile coat</td><td>Lohmann &amp;amp; Rauscher International GmbH &amp;amp; Co</td><td>REF 19351</td><td>Surgical Gown, Different sizes, e.g. L-130 cm</td></tr><tr><td>Sterile gauze</td><td>Hartmann</td><td>REF 401798, 10x10cm gauze</td><td>10 x 10 cm sterile gauze, 10 pieces per package</td></tr><tr><td>Sterile gloves</td><td>Meditrade</td><td>REF 9021</td><td>Gentle Skin sterile gloves, different sizes, e.g. 7.5</td></tr><tr><td>Sterile saline solution</td><td>Fresenius Kabi</td><td>NaCl 0.9%, B009827 REV 03</td><td>Physiologic Saline Solution 0.9% NaCl, 309 mosmol/L, pH-Wert: 4.5-7.0</td></tr><tr><td>Sterile saline vessel</td><td>KLS Martin</td><td>REF K8A,&amp;nbsp; 18/10 Jonas</td><td>Sterilizable Metal Vessel for sterile saline</td></tr><tr><td>Sterile table cover</td><td>Hartmann</td><td>REF 2502208</td><td>Table Cover, Foliodrape 150 x 100 cm</td></tr><tr><td>Sterile towel</td><td>BARRIER by M&amp;ouml;lnlycke Health Care</td><td>REF 706900</td><td>Adhesive OP-Towel, 100 x 100 cm</td></tr><tr><td>Sterile US probe cover sheath</td><td>Websinger</td><td>REF 07014</td><td>Sterile ultrasound probe cover, 20 x 60 cm, inluding two sterie adhesive tapes</td></tr><tr><td>Stiff guidewire</td><td>Cook Medical</td><td>REF TSMG-35-180-4-LES, G46729</td><td>Lunderquist Extra Stiff Wire Guide, 0.035&quot;-.89 mm, 180 cm, 4 cm flexible tip</td></tr><tr><td>Surgical cap</td><td>BARRIER by M&amp;ouml;lnlycke Health Care</td><td>REF 620500, PCS 100, Colour Green</td><td>Surgical Cap</td></tr><tr><td>Ultrasound device</td><td>FUJIFILM SonoSite</td><td>Model M-Turbo, REF P17000-17</td><td>Mobile ultrasound system</td></tr></tbody></table>

measurement of the hepatic venous pressure gradient and transjugular liver biopsy

在这里，我们提供了一个详细的协议，描述肝静脉压梯度（HVPG）测量在晚期慢性肝病患者的临床过程，然后指导血管活检。在局部麻醉和超声波指导下，导管引入器护套放置在正确的内部血管中。使用荧光引导，气球导管被推进到劣质的静脉卡瓦（IVC），并插入一个大的肝静脉。通过注射对比介质来保证导管的正确和足够的楔形位置，同时气球会阻断罐式肝静脉的外流。校准外部压力传感器后，通过楔形肝静脉压力 （WHVP） 和自由肝静脉压力 （FHVP） 的三重记录获得连续压力记录。FHVP 和 WHVP 之间的差异称为 HVPG，值≥10 mm Hg 表示临床上显著的门户高血压 （CSPH）。在取出导管之前，记录 IVC 中在同一级别获得的压力读数以及正确的体外压力。
最后，可以通过相同的血管途径进行血管外肝活检。不同的系统可用:然而，核心活检针比吸入针更受欢迎，尤其是对于心律失常的肝脏。同样，在荧光镜指导下，活检针引体护套被推进到肝静脉中。接下来，通过介绍者护套轻轻推进血管活检针:（i） 在吸入活检的情况下，针头在吸入下进入肝帕伦奇马，然后快速取出，或（ii）在核心活检的情况下，切割机制在帕伦奇马内触发。可以通过变性活检安全地进行几个单独的通道，以获得足够的肝脏标本。在有经验的手中，这些程序的组合大约需要30-45分钟。

在肝功能保存完好的补偿患者（即没有任何肝退化史，如腹腔或静脉出血）中，测量的HVPG值可能是正常的，或在亚线门户高血压（HVPG 6-9 mm Hg）范围内。然而，补偿的患者可能会发展CSPH（HVPG≥10毫米汞柱），这表明开发变异或肝退补偿的风险增加。反过来，食管或胃静脉曲张的患者，HVPG通常在CSPH的范围，如果不是患者应评估门户静脉血栓的存在或其他原因的预肝/前体门户高血压。在有食管静脉...

Watch this Scientific Journal Video about Measurement of the Hepatic Venous Pressure Gradient and Transjugular Liver Biopsy at JoVE.com

Measurement of the Hepatic Venous Pressure Gradient and Transjugular Liver Biopsy

在这里，我们提出了一个测量肝静脉压梯度（HVPG）的协议，这是诊断临床上显著门户高血压的黄金标准。此外，我们描述了如何在同一会话内进行血管内肝脏活检。

肝静脉压梯度和转性肝活检测量

Here we provide a detailed protocol describing the clinical procedure of hepatic venous pressure gradient (HVPG) measurement in patients with advanced ...

measurement-hepatic-venous-pressure-gradient-transjugular-liver

Universidad de Cartagena UDEC

Research

JoVE Journal

Medicine

19.4K 次观看.  Medical University of Vienna. 在这里，我们提出了一个测量肝静脉压梯度（HVPG）的协议，这是诊断临床上显著门户高血压的黄金标准。此外，我们描述了如何在同一会话内进行血管内肝脏活检。

视频: Measurement of the Hepatic Venous Pressure Gradient and Transjugular Liver Biopsy

Monitoring of Systemic and Hepatic Hemodynamic Parameters in Mice

The use of mouse models in experimental research is of enormous importance for the study of hepatic physiology and pathophysiological disturbances. However, due to the small size of the mouse, technical details of the intraoperative monitoring procedure suitable for the mouse were rarely described. Previously we have reported a monitoring procedure to obtain hemodynamic parameters for rats. Now, we adapted the procedure to acquire systemic and hepatic hemodynamic parameters in mice, a species ten-fold smaller than rats. This film demonstrates the instrumentation of the animals as well as the data acquisition process needed to assess systemic and hepatic hemodynamics in mice. Vital parameters, including body temperature, respiratory&#160;rate&#160;and heart&#160;rate were recorded throughout the whole procedure. Systemic hemodynamic parameters consist of carotid artery pressure (CAP) and central venous pressure (CVP). Hepatic perfusion parameters include portal vein pressure (PVP), portal flow rate as well as the flow rate of the common hepatic artery (table 1). Instrumentation and data acquisition to record the normal values was completed within 1.5 h. Systemic and hepatic hemodynamic parameters remained within normal ranges during this procedure.
This procedure is challenging but feasible. We have already applied this procedure to assess hepatic hemodynamics in normal mice as well as during 70% partial hepatectomy and in liver lobe clamping experiments. Mean PVP after resection (n= 20), was 11.41&#177;2.94 cmH2O which was significantly higher (P&#60;0.05) than before resection (6.87&#177;2.39 cmH2O). The results of liver lobe clamping experiment indicated that this monitoring procedure is sensitive and suitable for detecting small changes in portal pressure and portal flow rate. In conclusion, this procedure is reliable in the hands of an experienced micro-surgeon but should be limited to experiments where mice are absolutely needed.

This film demonstrates how to acquire systemic and hepatic hemodynamics in mice. The whole monitoring includes acquisition of vital parameters, systemic blood pressure, central venous pressure, common hepatic artery flow rate, and portal vein pressure as well as the portal flow rate in mice.

全身及肝脏血流动力学参数的监测小鼠

The use of mouse models in experimental research is of enormous importance for the study of hepatic physiology and pathophysiological disturbances. ...

科研

医学

Technique of Porcine Liver Procurement and Orthotopic Transplantation using an Active Porto-Caval Shunt

The success of liver transplantation has resulted in a dramatic organ shortage. Each year, a considerable number of patients on the liver transplantation waiting list die without receiving an organ transplant or are delisted due to disease progression. Even after a successful transplantation, rejection and side effects of immunosuppression remain major concerns for graft survival and patient morbidity. 
Experimental animal research has been essential to the success of liver transplantation and still plays a pivotal role in the development of clinical transplantation practice. In particular, the porcine orthotopic liver transplantation model (OLTx) is optimal for clinically oriented research for its close resemblance to human size, anatomy, and physiology. 
Decompression of intestinal congestion during the anhepatic phase of porcine OLTx is important to guarantee reliable animal survival. The use of an active porto-caval-jugular shunt achieves excellent intestinal decompression. The system can be used for short-term as well as long-term survival experiments. The following protocol contains all technical information for a stable and reproducible liver transplantation model in pigs including post-operative animal care.

Experimental animal research plays a pivotal role in the development of clinical transplantation practice. The porcine orthotopic liver transplantation model (OLTx) closely resembles human conditions and is frequently used in clinically oriented research. The following protocol contains all information for a reliable porcine OLTx model using an active porto-caval-jugular shunt.

使用Active波尔图腔静脉分流术猪肝脏采购和原位移植技术

The success of liver transplantation has resulted in a dramatic organ shortage. Each year, a considerable number of patients on the liver transplantation ...

Ex Vivo Hepatic Perfusion Through the Portal Vein in Mouse

Metabolic diseases such as diabetes, pre-diabetes, non-alcoholic fatty liver disease (NAFLD), and nonalcoholic steatohepatitis (NASH) are becoming increasingly common. Ex vivo liver perfusions allow for a comprehensive analysis of liver metabolism using nuclear magnetic resonance (NMR), in nutritional conditions that can be rigorously controlled. As in silico simulations remain a primarily theoretical means of assessing hormone actions and the effects of pharmaceutical intervention, the perfused liver remains one of the most valuable test beds for understanding hepatic metabolism. As these studies guide basic insights into hepatic physiology, results must be accurate and reproducible. The greatest factor in the reproducibility of ex vivo hepatic perfusion is the quality of surgery. Therefore, we have introduced an organized and streamlined method to perform ex vivo mouse liver perfusions in the context of in situ NMR experiments. We also describe a unique application and discuss common issues encountered in these studies. The overall purpose is to provide an uncomplicated guide to a technique we have refined over several years that we deem the golden standard for obtaining reproducible results in hepatic resections and perfusions in the context of in situ NMR experiments. The distance to the center of the field for the magnet as well as the inaccessibility of the tissue to intervention during the NMR experiment makes our methods novel.

Ex Vivo Hepatic Perfusion Through the Portal Vein in Mouse

The protocol describes a straightforward method of resectioning an intact mouse liver for metabolic studies through portal vein perfusion.

离体 小鼠通过门静脉进行肝灌注

Metabolic diseases such as diabetes, pre-diabetes, non-alcoholic fatty liver disease (NAFLD), and nonalcoholic steatohepatitis (NASH) are becoming ...

生物化学

Method of Direct Segmental Intra-hepatic Delivery Using a Rat Liver Hilar Clamp Model

Major hepatic surgery with inflow occlusion, and liver transplantation, necessitate a period of warm ischemia, and a period of reperfusion leading to ischemia/reperfusion (I/R) injury with myriad negative consequences. Potential I/R injury in marginal organs destined for liver transplantation contributes to the current donor shortage secondary to a decreased organ utilization rate. A significant need exists to explore hepatic I/R injury in order to mediate its impact on graft function in transplantation. Rat liver hilar clamp models are used to investigate the impact of different molecules on hepatic I/R injury. Depending on the model, these molecules have been delivered using inhalation, epidural infusion, intraperitoneal injection, intravenous administration or injection into the peripheral superior mesenteric vein. A rat liver hilar clamp model has been developed for use in studying the impact of pharmacologic molecules in ameliorating I/R injury. The described model for rat liver hilar clamp includes direct cannulation of the portal supply to the ischemic hepatic segment via a side branch of the portal vein, allowing for direct segmental hepatic delivery. Our approach is to induce ischemia in the left lateral and median lobes for 60 min, during which time the substance under study is infused. In this case, pegylated-superoxide dismutase (PEG-SOD), a free radical scavenger, is infused directly into the ischemic segment. This series of experiments demonstrates that infusion of PEG-SOD is protective against hepatic I/R injury. Advantages of this approach include direct injection of the molecule into the ischemic segment with consequent decrease in volume of distribution and reduction in systemic side effects.

A unique rat liver hilar clamp model was developed for studying the impact of pharmacologic molecules in ameliorating ischemia-reperfusion injury. This model includes direct cannulation of the portal supply to the ischemic liver segment via a branch of the portal vein, allowing for direct hepatic delivery.

直接节段性肝内交付使用大鼠肝门部夹具模型方法

Major hepatic surgery with inflow occlusion, and liver transplantation, necessitate a period of warm ischemia, and a period of reperfusion leading to ...

Contrast-Enhanced Subharmonic Aided Pressure Estimation (SHAPE) Using Ultrasound Imaging with a Focus on Identifying Portal Hypertension

Noninvasive, accurate measurement of pressures within the human body has long been an important but elusive clinical goal. Contrast agents for ultrasound imaging are gas-filled, encapsulated microbubbles (diameter &#60; 10 &#956;m) that traverse the entire vasculature and enhance signals by up to 30 dB. These microbubbles also produce nonlinear oscillations at frequencies ranging from the subharmonic (half of the transmit frequency) to higher harmonics. The subharmonic amplitude has an inverse linear relationship with the ambient hydrostatic pressure. Here an ultrasound system capable of performing real-time, subharmonic aided pressure estimation (SHAPE) is presented. During ultrasound contrast agent infusion, an algorithm for optimizing acoustic outputs is activated. Following this calibration, subharmonic microbubble signals (i.e., SHAPE) have the highest sensitivity to pressure changes and can be used to noninvasively quantify pressure. The utility of the SHAPE procedure for identifying portal hypertension in the liver is the emphasis here, but the technique has applicability across many clinical scenarios.

Contrast-Enhanced Subharmonic Aided Pressure Estimation SHAPE Using Ultrasound Imaging with a Focus on Identifying Portal Hypertension

A protocol for noninvasively estimating ambient pressures utilizing subharmonic ultrasound imaging of infused contrast microbubbles (following appropriate calibration) is described with examples from human patients with chronic liver disease.

使用超声成像的对比增强次谐波辅助压力估计 （SHAPE），重点是识别门静脉高压症

Noninvasive, accurate measurement of pressures within the human body has long been an important but elusive clinical goal. Contrast agents for ultrasound ...

生物工程

Rat Model of the Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) Procedure

Recent clinical data support an aggressive surgical approach to both primary and metastatic liver tumors. For some indications, like colorectal liver metastases, the amount of liver tissue left behind after liver resection has become the main limiting factor of resectability of large or multiple liver tumors. A minimal amount of functional tissue is required to avoid the severe complication of post-hepatectomy liver failure, which has high morbidity and mortality. Inducing liver growth of the prospective remnant prior to resection has become more established in liver surgery, either in the form of portal vein embolization by interventional radiologists or in the form of portal vein ligation several weeks prior to resection. Recently, it was shown that liver regeneration is more extensive and rapid, when the parenchymal transection is added to portal vein ligation in a first stage and then, after only one week of waiting, resection performed in a second stage (Associating Liver Partition and Portal vein ligation for Staged hepatectomy = ALPPS). ALPPS has rapidly become popular across the world, but has been criticized for its high perioperative mortality. The mechanism of accelerated and extensive growth induced by this procedure has not been well understood. Animal models have been developed to explore both the physiological and molecular mechanisms of accelerated liver regeneration in ALPPS. This protocol presents a rat model that allows mechanistic exploration of accelerated regeneration.

Rat Model of the Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy ALPPS Procedure

Inducing rapid liver hypertrophy using Associating Liver Partition and Portal vein ligation for a Staged hepatectomy (ALPPS) has been proposed for resection of borderline resectable liver tumors. This model may elucidate mechanisms involved in rapid hypertrophy and allows testing of drugs that promote or block the acceleration of regeneration.

肝分型与门静脉结扎大鼠分期肝切除 (ALPPS) 手术模型的建立

Recent clinical data support an aggressive surgical approach to both primary and metastatic liver tumors. For some indications, like colorectal liver ...

Invasive Hemodynamic Characterization of the Portal-hypertensive Syndrome in Cirrhotic Rats

This is a detailed protocol describing invasive hemodynamic measurements in cirrhotic rats for the characterization of portal hypertensive syndrome. Portal hypertension (PHT) due to cirrhosis is responsible for the most severe complications in patients with liver disease. The full picture of the portal hypertensive syndrome is characterized by increased portal pressure (PP) due to the increased intrahepatic vascular resistance (IHVR), hyperdynamic circulation, and increased splanchnic blood flow. Progressive splanchnic arterial vasodilation and increased cardiac output with elevated heart rate (HR) but low arterial pressure characterizes the portal hypertensive syndrome.
Novel therapies are currently being developed that aim to decrease PP by either targeting IHVR or increased splanchnic blood flow &#8212; but side effects on systemic hemodynamics may occur. Thus, a detailed characterization of portal venous, splanchnic, and systemic hemodynamic parameters, including measurement of PP, portal venous blood flow (PVBF), mesenteric arterial blood flow, mean arterial pressure (MAP), and HR is needed for preclinical evaluation of the efficacy of novel treatments for PHT. Our video article provides the reader with a structured protocol for performing invasive hemodynamic measurements in cirrhotic rats. In particular, we describe the catheterization of the femoral artery and the portal vein via an ileocolic vein and the measurement of portal venous and splanchnic blood flow via perivascular Doppler-ultrasound flow probes. Representative results of different rat models of PHT are shown.

Here we describe a detailed protocol for invasive measurements of hemodynamic parameters including portal pressure, splanchnic blood flow, and systemic hemodynamics in order to characterize the portal hypertensive syndrome in rats.

肝硬化大鼠门脉高压综合征的侵袭性血流动力学特征

This is a detailed protocol describing invasive hemodynamic measurements in cirrhotic rats for the characterization of portal hypertensive syndrome. ...

Assessment of Plasma Coagulation on Liver Tissue in a Large Animal Model In Vivo

Plasma coagulation as a form of electrocautery is used in liver surgery for decades to seal the large liver cut surface after major hepatectomy to prevent hemorrhages at a later stage. The exact effects of plasma coagulation on liver tissue are only poorly examined. In our porcine model, the coagulation effects can be examined close to the clinical application. A combined laser Doppler flowmeter and spectrophotometer documents microcirculation changes during coagulation at 8 mm tissue depth noninvasively, providing quantifiable information about hemostasis beyond the subjective clinical impression. The temperature at coagulation site is assessed with an infrared thermometer prior and post coagulation and with a thermographic camera during coagulation, a measurement of the gas beam temperature is not possible due to the upper threshold of the devices. The depth of coagulation is measured microscopically on hematoxylin/eosin stained sections after calibration with an object micrometer and gives an exact information about the power setting-coagulation depth-relation. The sealing effect is examined on the bile ducts as it is not possible for a plasma coagulator to seal larger blood vessels. Burst pressure experiments are carried out on explanted organs to rule out blood pressure related effects.

Assessment of Plasma Coagulation on Liver Tissue in a Large Animal Model In Vivo

Here we present a protocol to experimentally assess plasma coagulation in liver tissue in vivo. In a porcine model, microcirculation is examined by laser Doppler, coagulation depth is measured histologically, temperature at coagulation site by infrared thermometer and thermographic camera, and duct sealing effect is documented by burst pressure experiments.

大动物模型肝组织血浆凝固的评价

Plasma coagulation as a form of electrocautery is used in liver surgery for decades to seal the large liver cut surface after major hepatectomy to prevent ...

用于绵羊静脉依从性评估的 3D 血管造影

Quantifying Inferior Vena Cava Compliance and Distensibility in an In Vivo Ovine Model Using 3D Angiography

Synthetic vascular grafts overcome some challenges of allografts, autografts, and xenografts but are often more rigid and less compliant than the native vessel into which they are implanted. Compliance matching with the native vessel is emerging as a key property for graft success. The current gold standard for assessing vessel compliance involves the vessel's excision and ex vivo biaxial mechanical testing. We developed an in vivo method to assess venous compliance and distensibility that better reflects natural physiology and takes into consideration the impact of a pressure change caused by flowing blood and by any morphologic changes present. 
This method is designed as a survival procedure, facilitating longitudinal studies while potentially reducing the need for animal use. Our method involves injecting a 20 mL/kg saline bolus into the venous vasculature, followed by the acquisition of pre and post bolus 3D angiograms to observe alterations induced by the bolus, concurrently with intravascular pressure measurements in target regions. We are then able to measure the circumference and the cross-sectional area of the vessel pre and post bolus. 
With these data and the intravascular pressure, we are able to calculate the compliance and distensibility with specific equations. This method was used to compare the inferior vena cava's compliance and distensibility in native unoperated sheep to the conduit of sheep implanted with a long-term expanded polytetrafluorethylene (PTFE) graft. The native vessel was found to be more compliant and distensible than the PTFE graft at all measured locations. We conclude that this method safely provides in vivo measurements of vein compliance and distensibility.

作者聚焦:先天性心脏病研究中新生血管发育的改进成像

This protocol allows for the in vivo quantification of venous compliance and distensibility using catheterization and 3D angiography as a survival procedure allowing for a variety of potential applications.

使用 3D 血管造影量化体内绵羊模型中的下腔静脉顺应性和扩张性

Synthetic vascular grafts overcome some challenges of allografts, autografts, and xenografts but are often more rigid and less compliant than the native ...

肝静脉压梯度和转性肝活检测量

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全身及肝脏血流动力学参数的监测小鼠

使用Active波尔图腔静脉分流术猪肝脏采购和原位移植技术

离体小鼠通过门静脉进行肝灌注

直接节段性肝内交付使用大鼠肝门部夹具模型方法

使用超声成像的对比增强次谐波辅助压力估计（SHAPE），重点是识别门静脉高压症

肝分型与门静脉结扎大鼠分期肝切除 (ALPPS) 手术模型的建立

肝硬化大鼠门脉高压综合征的侵袭性血流动力学特征

大动物模型肝组织血浆凝固的评价

使用 3D 血管造影量化体内绵羊模型中的下腔静脉顺应性和扩张性

使用 3D 血管造影量化体内绵羊模型中的下腔静脉顺应性和扩张性

肝静脉压梯度和转性肝活检测量

摘要

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此视频中的章节

全身及肝脏血流动力学参数的监测小鼠

使用Active波尔图腔静脉分流术猪肝脏采购和原位移植技术

离体 小鼠通过门静脉进行肝灌注

直接节段性肝内交付使用大鼠肝门部夹具模型方法

使用超声成像的对比增强次谐波辅助压力估计 （SHAPE），重点是识别门静脉高压症

肝分型与门静脉结扎大鼠分期肝切除 (ALPPS) 手术模型的建立

肝硬化大鼠门脉高压综合征的侵袭性血流动力学特征

大动物模型肝组织血浆凝固的评价

使用 3D 血管造影量化体内绵羊模型中的下腔静脉顺应性和扩张性

使用 3D 血管造影量化体内绵羊模型中的下腔静脉顺应性和扩张性

离体小鼠通过门静脉进行肝灌注

使用超声成像的对比增强次谐波辅助压力估计（SHAPE），重点是识别门静脉高压症