Search

In 68 patients arterial and portal blood flow were measured by angiodensitometry in the course of routine, indirect splenoportography. Results were compared with those already published, with investigations of a model and with animal experiments. It was shown that, given certain underlying conditions, reliable results can be obtained even in the presence of a pulsatile flow and incomplete contrast mixing. Compared with other procedures, the method has the advantage of providing a complete picture of liver haemodynamics in the course of routine splenoportography in a simple way and without affecting the patient further. As a result the indications for performing a shunt and the choice of the shunt technique can be more accurately determined.

We wanted to use the Ganz thermistor catheter, developed to measure blood flow in human coronary sinuses, to measure portal venous flow, which is greater. We prepared a model circuit with a high flow rate and studied the method for suitability and reproducibility of the measurements. Correlation was close between the measured and calculated flow rates when the thermal indicator was injected at the rate of 48 ml/min. Measurements were highly reproducible. The catheter was then tested clinically. It was inserted into the portal trunk during percutaneous transhepatic catheterization to measure the portal venous flow. Measurements in patients with cirrhosis of the liver were close to those reported by other workers, and were reproducible. The results suggest that this method will be useful for the continuous local measurement of portal venous flow that varies with time, and will provide information about portal circulation in hepatic disease.

Morphology and flow dynamics in the lieno-mesentericoportal territory were investigated in 15 normal persons and 199 patients with pre/intra and intra-hepatic blocks. Indirect (arterial) splenoportography with selective catherization of the splenic artery provided angiograms varying between good and diagnostically useful in 98% of cases. With injection into the truncus coeliacus, this figure falls to 77%. The various types of collateral circulation are stated and discussed. The scope and limits of the methods are shown by comparative surveys between direct splenoportography and indirect splenoportography and portography, using 16 patients. As far as the chronological sequence of angiographical diagnostics in the intrahepatic block is concerned, the indirect method shall precede direct splenoportography, which shall only be employed if the indirect method of examination does not provide sufficient information, the patient has shunt capacity and an operation is to be performed immediately.

This paper reports on the clinical applicability and efficiency of Scintiphotosplenoportography (SPSP) by means of 99mTc Pertechnetate. This diagnostic process permits obtaining the following data: actual route and patency of the portal vein, localizing of collaterals, as well as information on the actual speed of portal flow. By determining the time of transit of the radionuclid via the collateral pathways into systemic circulation, additional assessments as to the hemodynamic functional importance of these collaterals can be made. This process is of particular value for the speedy assessment of the patency of a surgically effected portocaval shunt in cases of shunt-bleeders. In patients without cirrhosis, a stop in the filling along the course of the portal vein indicates portal thrombosis. In cases of manifest cirrhosis, however, the lack of an SPSP image for the proximal portal vein and the liver itself, merely points to the existence of extensive caudal collaterals. Traumatization as the result of intrasplenal application of a volume of less than 1 ml (of tracer) remains minimal. In contrast with radiological splenoportography this methods entails practically no risks. However, as a result of the restricted field of view and the relatively coarse power of resolution, the quality obtainable by szintiphotosplenoportography is somewhat inferior to that of X-ray splenoportography.

Splenoportography still plays today an important role among angiographic examinations used in the study of portal hypertension. The authors arrived at these conclusions after studying the results obtained in more than 500 examinations carried out. In the text, they give a few details of the technic used to improve the photographic result and to reduce the risk of the examination.

The right anterior caudocranial oblique (RACCO) view is proposed for improved depiction of the portal venous system. It is achieved by tilting the image intensifier 25 degrees caudal and 25 degrees-30 degrees to the right and maintaining the patient in the supine position. Transarterial portography with digital subtraction angiography was performed in the RACCO and posteroanterior (PA) views in 22 patients. Comparison of the two views revealed that the RACCO view was superior to the PA view of the left main branch in 15 patients (68%) and of the right posterior lobe branch in 19 patients (86%). The RACCO view will be useful for the evaluation of the portal system in patients with primary and secondary hepatic neoplasms in whom detailed images are important for diagnosis treatment planning.

The intrasplenic injection of 99mTc-labeled albumin microspheres, followed 30 sec later by an injection of 99mTc-labeled red blood cells with recording of the progression of the two tracers, were performed in 110 patients. This also enabled the plotting of activity versus time curves on splenic, hepatic, cardiac, and pulmonary areas of interest, there by giving access to several hemodynamic variables. Scintillation image demonstrated splenoportal obstruction in 8 cases. Intrahepatic obstruction with reflux via collaterals were observed in 53 cases, 14 with umbilical reflux. In 13 cases, the patency of surgical portacaval anastomoses were verified. The splenoportal blood flow velocity was not significantly different in patients with cirrhosis (V = 10.1 cm per sec +/- 3.0 SD) and in normal subjects (V = 13.2 cm per sec +/- 5.8 SD). The fraction of shunted splenic flow in the case of cirrhosis varied from 0 to 100%; there was no relationship between this percentage and the seriousness of the clinical status. In 3 cases, the presence of intrahepatic shunts was detected. There was a very significant difference between mean transit time (MTT) of red blood cells in patients with cirrhosis (t = 12.2 sec +/- 4.4 SD) and those without cirrhosis (t = 19.9 sec +/- 3.7 SD). Among patients with cirrhosis, those with a history of jaundice had a shorter MTT than those without such a history. On the other hand, the MTT was not significantly different whether the patients with cirrhosis had or did not have hemorrhage, ascites or encephalopathy. There was a positive correlation (P less than 0.01) between MTT and plasma albumin concentration,and between MTT and prothrombin (P less than 0.01). Finally, there was a high negative correlation (P less than 0.001) between MTT and total serum bilirubin. Scintillation splenoportography is a useful technique for assessing hepatic hemodynamics and for demonstrating abnormalities of the intrahepatic circulation.

Digital subtraction angiography (DSA), using a direct arterial route, diminishes the risk of the examination by reducing the contrast dose by about 75%, making the examination more rapid and making it less likely that catheters will have to be changed. At the same time superimposition is avoided, one of the advantages of selective catheterisation. In view of the low contrast dose, it is possible to carry out several examinations at one time and to use additional projections for intracranial and peripheral disease, thereby improving the diagnostic value of the examination. For certain problems, intra-arterial DSA is already able to replace conventional angiography. The small field size and poor spatial resolution still make conventional angiography necessary as the basic form of investigation in most other circumstances.

Repeated direct portography was performed during distal splenorenal shunt in 13 consecutive patients with esophageal varices due to cirrhosis of the liver. The roentgenogram taken at the completion of all operative procedures demonstrated incomplete disconnection between the mesentericoportal and gastrosplenic compartments in four patients. After further disconnection of the veins, the third portogram showed a successful isolation of both systems. The flow state through and the size of the shunt were appropriate in all instances on the roentgenograms. The shunt was patent in all patients, which was confirmed before discharge from the hospital. Hepatic encephalopathy was encountered one year after operation in one patient with the poorest hepatic functions. Esophageal varices disappeared or nearly disappeared at the time of discharge in ten patients. The remaining varices at discharge in another three patients completely disappeared within six months after operation. None of the patients experienced variceal bleeding during the follow-up period of three to 25 months. The results may indicate that repeated intraoperative direct portography is useful in achieving a selective distal splenorenal shunt.

We studied branching of the intrahepatic portal vein and hepatic segment by percutaneous transhepatic portograms in 237 patients with liver, biliary tract, or pancreatic disease. At the hilum, the pattern was normal in 74% of the patients. In the others, branching of the right posterior branch was trifurcated or independent. Caudate branches usually ramified from first-order branches, but sometimes ramified from the right posterior branch. The left portal branch divided into a laterodorsal branch (second-order) and umbilical portion, from which the lateroventral branch (third-order) and several medial branches (fourth-order) arose. It seems to be better to divide the left lobe into anterior segment (supplied by medial and a lateroventral branch) and posterior segments (supplied by a laterodorsal branch) than into the lateral and medial segments. The right anterior branch of 27% of the patients was bifurcated. In the others, there were six other patterns, with four or five fourth-order branches arising from this branch. The anterior segment should be considered having not two subsegments, but four or five small subsegments. Small branches divided off from the main trunk of the right posterior branch. In resection for hepatoma, each such branch can be thought of as one small subsegmental branch.

The literature concerning accidents and complications of transcutaneous splenoportography is examined and compared with personal experience. The technique used is discussed and some of its advantages with respect to selective arteriography of the coeliac tripod are stressed. It is concluded transcutaneous that splenoportography is free from any particular risk and has no equal in the detailed study of certain alterations of the splenoportal trunk.

A fullterm newborn infant two weeks of age, suffering from congestive heart failure due to a large patent ductus arteriosus, deteriorated suddenly presenting with a paralytic ileus. Radiographically diffuse intestinal pneumatosis and gas in the portal vein system could be shown. A mechanical reason was excluded by laparotomy shortly after which the infang died. Out of blood Klebsiella pneumonia could be grown. A survey of the literature on the syndrome of pneumatosis intestinalis and gas embolization into the portal vein system in the neonatal age group disclosed 41 cases. Based on this material etiology radiological features, differential diagnosis, prognosis and treatment is discussed in detail.

The function of polygonal liver cells can be estimated by using liver specific dyes such as labelled BSP or bengalrosa and labelled X-ray contrast media. Various methods are available: clearance with blood counting or external monitoring, whole body clearance and retention measurement. These tests are of value for following the course of liver diseases. Blood flow measurements either with labelled colloids or 133 Xe are mainly used for scientific purposes. Portosystemic shunts can be detected by injection of labelled microspheres in the spleen and lung monitoring or scanning. With the dynamic scintigraphy portosystemic shunts can be visualized ( radionuclide splenoportography). The measurement of the praecordial appearance time after rectal instillation of 133 Xe permits the functional evaluation of a surgical portosystemic shunt. Dynamic scintigraphy makes possible the estimation of the arterial part of liver blood flow after i.v. injection of 99m Tc and this together with the radionuclide splenoportography allows the assessment of disturbed blood flow in patients with portal hypertension. I. v. applied parathyroid hormone increases the arterial hepatic blood flow. Preliminary results indicate that patients with portal hypertension and a good response to parathyroid hormone seem to have a good prognosis after shunt operation. The determination of red cell survival with 51 Cr is helpful in the differential diagnosis of jaundice. The specificity of liver scanning with labelled colloids for malignant diseases can be reasonably increased by additional 67 Ga-scintigraphy. In the diagnosis of hepatoma with both colloid and Galliumscan and the evaluation of alpha-fetoprotein a 90% accuracy can be achieved. The hepatobiliary transport can easily be visualized with 99m Tc labelled IDA-compounds and also in patients with severe jaundice where the X-ray cholangiopathy is impossible. This examination is indicated in patients with bile duct observations (also intrahepatic), after cholecystectomy, for the differential diagnosis of jaundice, for the demonstration of refluxes etc. The most important radioimmunological in vitro methods for the investigation of liver diseases are only briefly described.

Over 45 months, 119 angiographic examinations were performed in 95 patients prior to liver transplantation, and 53 examinations in 44 patients after transplantation. Transplantation feasibility was influenced by patency of the portal vein and inferior vena cava. Selective arterial portography, wedged hepatic venography, and transhepatic portography were used to assess the portal vein if sonography or computed tomography was inconclusive. Major indications for angiography after transplantation included early liver failure, sepsis, unexplained elevation of liver enzyme levels, and delayed bile leakage, all of which may be due to hepatic artery thrombosis. Other indications included gastrointestinal tract bleeding, hemobilia, and evaluation of portal vein patency in patients with chronic rejection who were being considered for retransplantation. Normal radiographic features of hepatic artery and portal vein reconstruction are demonstrated. Complications diagnosed using results of angiography included hepatic artery or portal vein stenoses and thromboses and pancreaticoduodenal aneurysms. Intrahepatic arterial narrowing, attenuation, slow flow, and poor filling were seen in five patients with rejection.

The relationships among collateral veins, gastroesophageal varices, extrahepatic shunting, and free portal pressure were studied by percutaneous transhepatic portography in 57 patients with cirrhosis of the liver. The size of esophageal varices was related to the size of the coronary and short gastric veins and to the portal pressure. The size of gastric varices was related to cephalad collaterals from the spleen and splenic vein, but not to portal pressure. Portosystemic shunting was associated with collaterals in the lower abdomen, but not with varices or portal pressure.

Sixty-four transhepatic portograms performed before transhepatic obliteration of varices in patients with variceal hemorrhage have been reviewed. Sixty-two patients had coronary gastroesophageal vessels feeding gastric and esophageal varices and other major collateral circulation was seen in 25 patients. There was no relationship between the presence of major collateral circulation and the height of portal pressure or the severity of hemorrhage from gastroesophageal varices. Failure to opacify the intrahepatic portal venous system was seen in 11 patients and was strongly associated with portal-systemic encephalopathy. In addition to transhepatic portography, 35 patients had a splenic portogram, and 27 patients had coeliac axis angiography. There was poor agreement between the findings of these three techniques. Transhepatic portography was markedly superior in demonstrating the portal-systemic collateral circulation. Because of the excellent anatomical definition obtained, transhepatic portography is a superior technique for visualizing the portal system. However, even this technique may occasionally fail to demonstrate gastroesophageal collateral circulation in patients with endoscopically documented variceal hemorrhage.

Conventional arteriography and intra-arterial DSA were compared in 243 individuals for examination of the liver, kidney, lower extremity and portal vein. There was no significant difference in the diagnostic value of these methods. DSA suffers from a poorer spatial resolution in the periphery of vessels, but this has not resulted in a loss of clinically relevant information.

Segmental angiography of the liver with laparoscopy and electro-coagulation has high diagnostic value. The circulatory systems of the liver may be studied selectively or in various combinations. Morphologic lesions as well as functional disturbances of liver arteries and veins, the portal vein and to a certain degree lymph vessels can be visualized precisely. An improved indication for shunt operations and a more reliable prognosis may be achieved by direct transhepatic pressure measurements, especially within the hepatic artery and portal vein. An early diagnosis of the Budd-Chiari-Syndrome is enabled by the combined segmental veno- and portography which could not be achieved by the known techniques so far. Complications are rarely seen. In 1070 examinations there was one suspicion for bilihemia, one case of hemobilia, and one case of a subcapsular hematoma. Twice a liver lobe was perforated. There was never a permanent damage to the patient. Biochemical and nuclear medicine studies are suggested.

Retrograde portography is carried out through a trans-jugular route. Contrary to previously available techniques of trans-juglar portography, the method does not inflict any trauma on the parenchyma or vessels. Demonstration of the portal system is achied by reserved flow through the liver sinusoids. Together with arterial hepatography and indirect splenic and mesenteric portography, the method provides additional information in various forms of pre-, intra- and post-hepatic block without submitting the patient to any additional risk.

A cine-portogram is a new diagnostic modality in portal system. The main purpose of this study is to assess the clinical significance of cine-portogram in patients with portal hypertension. Portal hemodynamics have been evaluated by cine-portogram in 28 patients with portal hypertension. Portal hemodynamics have been analysed in the following five main diagnostic findings: portal hepatic perfusion, hemodynamics of coronary vein, dominance of gastric vein or short gastric vein, extension of varices in lower esophago-proximal gastric region, and route of draining vein of esophageal varices. The grade of portal hepatic perfusion has been evaluated in all cases by cine-portogram. Hemodynamics of coronary vein have been evaluated in 78% of patients. Dominance of the left gastric vein or short gastric vein has been evaluated in 84% of patients. Extension of varices in lower esophago-proximal gastric lesion and route of draining vein of esophageal varices have been evaluated by only cine-portogram. In conclusion, the cine-portogram is a new and useful diagnostic modality for the evaluation of portal hemodynamics in patients with portal hypertension.

A summary of several techniques for visualization of the portal venous system, developed in the last four decades, is given. The various methods are divided into direct and indirect techniques. Indirect arterial portography is the method of choice in patients with cirrhosis of the liver, being the most physiologic technique, visualizing the total portal venous system including arterial supply and having a low complication risk.

Percutaneous transhepatic portography was performed in 28 patients with HCC and PTPE was attempted in 9 of them. Displacement of the portal vein was found in 37% of 52 HCCs. Other portographic findings were: encasement (19%), avascular area (19%), occlusion (10%), narrowing (4%), neovascularization (4%), tumor staining (2%). Frequency of the tumor-related portography findings was found to be increased in relation to tumor size. TAE followed by PTPE with stainless steel coil (6 cases) or microcapsule form of MMC (3 cases) was performed on 9 cases. PTPE appears to be a promising adjuvant to conventional TAE.