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Congenital intrahepatic portosystemic venous shunts are rare vascular malformations which are incidentally discovered on imaging or once hepatic encephalopathy becomes clinically apparent. Surgical ligation and endovascular embolization are potential treatments.

Portal vein access during transjugular intrahepatic portosystemic shunt creation was examined in 11 patients. Radiation metrics (kerma area product, reference point air kerma, and fluoroscopy times) during portal vein access were significantly greater for conventional versus intravascular US–guided transjugular intrahepatic portosystemic shunt (54.8 mGy ∙ cm2 ± 27.6 vs 8.4 mGy ∙ cm2 ± 5.0, P = .009; 210.4 mGy ± 109.1 vs 29.5 mGy ± 18.4, P = .009; 19.1 min ± 8.6 vs 8.9 min ± 4.6, P = .04). Wedged hepatic venography is a major contributor to radiation exposure. Intravascular US guidance is associated with significantly reduced radiation use.

Purpose To compare and evaluate images of non-contrast enhanced magnetic resonance (MR) portography and hepatic venography acquired with two different fat suppression methods, the chemical shift selective (CHESS) method and short tau inversion recovery (STIR) method. Materials and methods Twenty-two healthy volunteers were examined using respiratory-triggered three-dimensional true steady-state free-precession with two time-spatial labeling inversion pulses. The CHESS or STIR methods were used for fat suppression. The relative signal-to-noise ratio and contrast-to-noise ratio (CNR) were quantified, and the quality of visualization was scored. Results Image acquisition was successfully conducted in all volunteers. The STIR method significantly improved the CNRs of MR portography and hepatic venography. The image quality scores of main portal vein and right portal vein were higher with the STIR method, but there were no significant differences. The image quality scores of right hepatic vein, middle hepatic vein, and left hepatic vein (LHV) were all higher, and the visualization of LHV was significantly better (p Conclusion The STIR method contributes to further suppression of the background signal and improves visualization of the portal and hepatic veins. The results support using non-contrast-enhanced MR portography and hepatic venography in clinical practice.

This study was designed to report our results with a modified technique of three-dimensional (3D) path planning software assisted transjugular intrahepatic portosystemic shunt (TIPS). 3D path planning software was recently developed to facilitate TIPS creation by using two carbon dioxide portograms acquired at least 20° apart to generate a 3D path for overlay needle guidance. However, one shortcoming is that puncturing along the overlay would be technically impossible if the angle of the liver access set and the angle of the 3D path are not the same. To solve this problem, a prototype 3D path planning software was fitted with a utility to calculate the angle of the 3D path. Using this, we modified the angle of the liver access set accordingly during the procedure in ten patients. Failure for technical reasons occurred in three patients (unsuccessful wedged hepatic venography in two cases, software technical failure in one case). The procedure was successful in the remaining seven patients, and only one needle pass was required to obtain portal vein access in each case. The course of puncture was comparable to the 3D path in all patients. No procedure-related complication occurred following the procedures. Adjusting the angle of the liver access set to match the angle of the 3D path determined by the software appears to be a favorable modification to the technique of 3D path planning software assisted TIPS.

Hepatic venoconstriction occurs in rat anaphylactic hypotension. However, the exact venoconstrictive site remains unknown, and we therefore attempted to determine its location by using hepatic venography and histology. Anaphylaxis was induced in anesthetized Sprague-Dawley rats by i.v. administration of ovalbumin antigen. Venography of the portal vein (n = 8) was obtained at baseline and maximal hepatic venoconstriction. We separately examined photomicrographs of the liver sections. Along with systemic hypotension, portal venous pressure increased to a peak of 28 ± 3 cm- H2O at 2 min after antigen injection. Post-antigen portal venography revealed that 40% of portal venuls (76 vessels/total 188 vessels) with diameters from 160 to 300 μm were not visualized, suggesting that stenosis or obliteration occurred distally. The corresponding upstream portal vessels exhibited markedly bulging. Stenosis was also observed in some portal branches with diameters from 180 to 420 μm (9%; 17 vessels/total 188 vessels). Light microscopically, most portal venules with an estimated baseline diameter less than 110 μm showed stenosis, but statistically significant stenosis was found in those with baseline diameters of 20-70 μm. In conclusion, anaphylactic hepatic venoconstriction occurs over a wide range of portal veins with diameters less than 420 μm, and occurs markedly in portal venules with diameters less than 70 μm in anesthetized rats.

Background A 3 Tesla (3 T) magnetic resonance (MR) scanner is a promising tool for upper abdominal MR angiography. However, there is no report focused on the image quality of non-contrast-enhanced MR portography and hepatic venography at 3 T. Purpose To compare and evaluate images of non-contrast-enhanced MR portography and hepatic venography with time-spatial labeling inversion pulses (Time-SLIP) at 1.5 Tesla (1.5 T) and 3 T. Material and Methods Twenty-five healthy volunteers were examined using respiratory-triggered three-dimensional balanced steady-state free-precession (bSSFP) with Time-SLIP. For portography, we used one tagging pulse (selective inversion recovery) and one non-selective inversion recovery pulse; for venography, two tagging pulses were used. The relative signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were quantified, and the quality of visualization was evaluated. Results The CNRs of the main portal vein, right portal vein, and left portal vein at 3 T were better than at 1.5 T. The image quality scores for the portal branches of segment 4, 5, and 8 were significantly higher at 3 T than at 1.5 T. The CNR of the right hepatic vein (RHV) at 3 T was significantly lower than at 1.5 T. The image quality scores of RHV and the middle hepatic vein were higher at 1.5 T than at 3 T. For RHV visualization, the difference was statistically significant. Conclusion Non-contrast-enhanced MR portography with Time-SLIP at 3 T significantly improved visualization of the peripheral branch in healthy volunteers compared with1.5 T. Non-contrast-enhanced MR hepatic venography at 1.5 T was better than at 3 T.

Purpose To assess the efficacy, safety and gain in procedure time of the technique of balloon occlusion hepatic venography with iodinated contrast used to target the portal vein during TIPS. The technique is assessed versus wedged hepatic venography. Materials and methods Fifty-eight TIPS were prospectively included. The portal vein was located in 30 cases by the wedged hepatic venography (group 1) and in 28 cases by balloon occlusion hepatic venography (group 2). To compare both techniques a “portogram quality” score was defined using a 5 points scale. The time required to achieve portal puncture was also recorded. The complications of both procedures were assessed and classified in groups as intrahepatic hematoma or intraperitoneal hemorrhage. Results The right portal vein was visualized in a significantly higher number of patients using balloon than with wedged retrograde venography 71.3% (20/28) versus 13.3% (4/30) respectively ( P = 0.002). The quality score for the portogram was significantly higher for balloon hepatic venography 2.21 than for wedged hepatic venography 1.07 ( P = 0.002). The mean time required to puncture the portal vein was significantly shorter when the right branch of the portal vein was visualized 21 min versus 33.5 min ( P = 0.046). We recorded one intrahepatic hematoma (3.3%) and 4 intraperitoneal hemorrhage (13.3%) secondary to wedged hepatic venography. There were no complications with balloon occlusion hepatic venography ( P = 0.053). Conclusion The use of balloon occlusion hepatic venography improves the quality of the retrograde portal venography to target the portal vein and decreases procedure time. The balloon technique is also burdened with fewer complications than the standard wedged hepatic venography.

The purpose of this study was to determine clinical roles for 3D CT hepatic venography in the evaluation of peripheral hepatic venous anatomy during living-donor liver transplantation.Subjects comprised 54 donors (age range, 20-60 years) who had undergone surgery to donate a liver for transplantation. Visualization of each hepatic venous branch and total visualization using 3D CT hepatic venography were evaluated. Maximum venous branch order visualized was graded as nil, first branch, second branch, or third branch or more. The distance between the hepatic surface and the tip of each hepatic venous branch was classified as 0-5 mm, 6-10 mm, 11-15 mm, 16-20 mm, or 21-25 mm. Quality of total 3D CT hepatic venography was evaluated subjectively as poor, good, fair, or excellent. Dominance of large hepatic veins in the right lobe, peripheral branching pattern of the middle hepatic vein, and branching pattern of the vein draining segment IVb were also assessed.Most hepatic venous branches (96.2% [275/286]) were visualized up to at least the second-order branches, and 93.7% (268/286) of branches were within 10 mm of the hepatic surface. As for total visualization, 98% (53/54) of cases were regarded as excellent. The dominant vein in the right lobe was the right hepatic vein in 27 cases, inferior hepatic vein in 25, and middle hepatic vein in one. The branching pattern of the middle hepatic vein was type 1 in 36 cases, type 2 in nine, and type 3 in eight. Segment IVb vein branched from the middle hepatic vein in 20 patients, and from the left hepatic vein in 34.Because 3D CT hepatic venography visualizes peripheral hepatic venous branches in detail, the technique is useful for determining operative indications in living-donor liver transplantation.

We describe the fatal outcome of an elective TIPS procedure performed in a 43-year-old man with alcoholic cirrhosis. Wedged hepatic venography with CO(2) was the reason for infarction and laceration of liver parenchyma resulting in a subcapsular hematoma and subsequent intra-abdominal bleeding. This is the first report of this complication after the use of CO(2) in a cirrhotic patient.

We evaluated the efficacy and safety of CO(2) wedged hepatic venography (CO(2) WHV) by comparing it with direct transjugular (DP) and indirect arterial portography (IP).Twenty-one CO(2) WHV and IP examinations were performed in 20 patients; 13 of them also underwent DP within 48 h of CO(2) WHV and IP. IP involved the injection of iodinated contrast into the superior mesenteric and splenic arteries. DP was performed from a transjugular approach, during transjugular intrahepatic portosystem shunt placement, with the injection of iodinated contrast into the superior mesenteric or splenic vein. The parameters evaluated were visualization of vessels and varices, portal vein thrombosis detection, and complications.CO(2) WHV depicted the splenic vein in 57%, the superior mesenteric vein in 62%, the main portal vein in 90%, the right portal vein in 95%, and the left portal vein in 90% of patients. It also demonstrated gastroesophageal varices in seven cases, a splenorenal shunt in one case, mesenteric varices in one case, and a recanalized umbilical vein in one case; other varices were also seen.CO(2) WHV is a good and safe technique for demonstrating the portal circulation. It may provide information not obtainable by IP and DP. However, IP provides better demonstration of the variceal network.

Rationale and Objectives. The purpose of this study was to evaluate the utility of CO 2 versus iodinated contrast medium for wedge hepatic venography in identifying portal vein anatomy during transjugular intrahepatic portosystemic shunt (TIPS) procedures. Materials and Methods. Wedge hepatic venograms obtained with CO 2 or iodinated contrast medium and direct portograms of 43 patients undergoing TIPS procedures were analyzed retrospectively. Wedge venography was performed in 23 patients with CO 2 and in 21 with iodinated contrast medium; direct portography was subsequently performed in 42 of 44 patients with iodinated contrast medium and in one with CO 2 . All cases were reviewed systematically to compare portal vein anatomy and completeness of anatomic identification between direct portography and wedge venography, and the results with CO 2 were compared to those with iodinated contrast material. Results. On the basis of opacification of the main portal trunk, branches, or both, the portal vein appearance (definition of the portal bifurcation) was good to excellent in 21 of 23 patients imaged with CO 2 but in only two of 20 patients imaged with iodinated contrast medium. Wedge venograms agreed with direct portograms in 91% (21 of 23) of the CO 2 cases and in 10% (two of 20) of the iodinated contrast medium cases. The two patients with poor opacification using CO 2 had poor delineation of the main portal trunk, branches, and varices. TIPS could not be created in three patients. In two, abnormal morphology was identified at CO 2 venography; in the third, wedge venography was not performed. Conclusion. Wedge hepatic venography with CO 2 compared with iodinated contrast medium has a substantially higher likelihood of correctly and completely identifying the location and anatomy of the portal vein.

PURPOSE To determine the efficacy of CO2 as negative contrast medium compared with iodinated contrast medium in creation and control of TIPS. MATERIAL AND METHODS CO2 was used during TIPS procedures in 33 patients. In 21 patients a wedged hepatic venography was obtained for planning the shunt tract. Additional TIPS-control DSA was performed in 42 cases by direct portal venography to verify the TIPS function and patency. In all cases CO2 gas was used in addition to iodinated contrast medium. RESULTS CO2 produced excellent wedged hepatic venographies in all patients. Visualisation of the portal veins and collaterals was superior to iodinated contrast medium. The TIPS-control DSA performed with CO2 were comparable to those performed with iodinated contrast medium. Complications were not observed in our study. CONCLUSION CO2 is an effective contrast medium for TIPS procedures. In particular the visualisation of portal veins performed by CO2-wedged hepatic venography is superior to iodinated contrast medium.

The authors report their experience with 30 adult patients with Budd-Chiari syndrome (BCS), which is a rare and serious disorder, characterized by hepatic outflow obstruction caused by many different conditions. The diagnosis was based on the clinical data, ultrasonography (US), vena cavography and hepatic venography, computed tomography (CT), and liver bi opsy. Behçet's disease (BD) was found in 10 patients with BCS as an underlying disease. Two patients used oral contraceptive drugs, 2 had liver tumor hepato cellular carcinoma and liver lymphoma, and 1 patient had chronic lymphocytic leukemia. Despite full investigation, the authors could not find any obvious un derlying cause in the other 15 patients. The results suggest that (1) BCS must be considered as a possible complica tion in patients with Behçet's disease when they have hepatomegaly even if there were no cardinal manifestations of the disease at the time of admission, and BD is the most common etiologic factor in BCS (33%) in Turkey, where the inci dence of Behçet's disease is relatively high. (2) Anti-aggregant treatment seems to be effective in many instances. (3) There were space-occupying lesion-like appearances in the liver of 7 cases by CT and US examination in the acute stage, and these disappeared on the follow-up CT and US in 5 patients but continued in 2. BCS should thus be differentiated from other liver lesions. (4) There were other great-vessel involvements in 43% of the cases, mostly venous, but only 1 pulmonary arterial occlusion.

Intrahepatic venous collaterals develop in Budd-Chiari syndrome, hepatomas, and other tumors if the hepatic veins are obstructed. In portal hypertension hepatic vein-to-vein anastomoses develop without obstruction of the hepatic veins. In a 53-year-old woman with giant cavernous hemangioma of the liver, hepatic venography demonstrated remarkable hepatic vein-to-vein anastomoses in the periphery of the heaptic veins without venous obstruction, accompanied with low wedged hepatic vein pressure. The hemodynamic change of the liver may cause this abnormality because of the large blood space of the hemangioma. Pathological examination of the resected liver apart from the tumor confirmed numerous deformations and dilatations of the central veins not found in the normal liver, in the area of hepatic vein-to-vein anastomoses shown by venography. Clinically, atypical hepatic resection is possible by maintaining a drainage vein to preserve as much of the normal liver as possible. Hepatic venography, as well as hepatic angiography, gives important information about the liver.

Late hepatic vein and inferior vena cava obstruction after orthotopic liver transplant is unusual. Prolonged venous obstruction may lead to graft failure and reduced patient survival. Direct hepatic venography and pressure studies are essential for diagnosis. We described a patient who developed combined venous outflow obstruction 6 years after liver transplant and was successfully treated with metallic stent placement. Mechanical 'torsion' is a rare cause of venous outflow obstruction.

In the framework of preoperative evaluation of the hepatic venous anatomy in living-donor liver transplantation or oncologic rejections, this paper proposes an automated approach for the 3D segmentation of the liver vascular structure from 3D CT hepatic venography data. The developed segmentation approach takes into account the specificities of anatomical structures in terms of spatial location, connectivity and morphometric properties. It implements basic and advanced morphological operators (closing, geodesic dilation, gray-level reconstruction, sup-constrained connection cost) in mono- and multi-resolution filtering schemes in order to achieve an automated 3D reconstruction of the opacified hepatic vessels. A thorough investigation of the venous anatomy including morphometric parameter estimation is then possible via computer-vision 3D rendering, interaction and navigation capabilities.

A case of Budd-Chiari syndrome (BCS), due to hepatic venous blockage, was initially misinterpreted on CT and ultrasonography (US) as an infiltrating mass of the liver. The irregular enlargement on US and the irregular enhancement with large hypodense areas on CT were believed to be due to an infiltrating mass. US-guided biopsy suggested BCS by showing central liver congestion without any signs of tumor growth. The diagnosis was confirmed by hepatic venography demonstrating collateral veins with a typical spider-web appearance. BCS is a rare, often lethal, condition and in order to reach an early and accurate diagnosis it is essential to be aware of the syndrome.

Seo TS, Oh JH, Lee DH, et al. Radiologic anatomy of the rabbit liver on hepatic venography, arteriography, portography, and cholangiography. Invest Radiol 2001;36:186-192.The radiologic anatomy of rabbit liver has received little study but is important in many experimental investigations.Twenty-four rabbits were studied by using hepatic venograms, aortograms, hepatic arteriograms, cholangiograms, and portograms.In all cases, the right, middle, and left hepatic veins drained into the inferior vena cava just below the diaphragm, and the caudate lobe hepatic vein drained more inferiorly. The proper hepatic artery was a branch of the common hepatic artery in 96%. The first branch of the proper hepatic artery was the caudate lobe artery. The remaining main hepatic artery was divided into the right and left hepatic arteries. The left hepatic artery was further divided into the medial and lateral segmental branches in 95%. The anatomy of the portal vein or bile duct was the same as the hepatic artery in 100% of cases.Knowledge of the normal patterns and variations of the vessels and bile duct will be helpful for experiments of the rabbit liver in future studies.

Balloon occlusion hepatic venography using carbon dioxide (CO2) is proposed as a safer yet simpler alternative to wedged catheter techniques that have caused hepatic lacerations during the transjugular intrahepatic portosystemic shunt (TIPS) procedure. The image quality of CO2 wedged catheter and balloon occlusion venograms was comparable in our small series, with no venographic-related complications occurring in the balloon occlusion group.

Purpose: on the basis of 89 different vascular interventions performed in the livers of 39 rabbits, we attempted to establish the feasibility and technical limitations of these procedures. Material and Methods: Forty-five selective hepatic artery catheterizations were carried out using 0.66-mm and 1.0-mm catheters, including superselective proper hepatic catheterizations (n=14) using a specially designed 0.66-mm introducer/catheter system. the portal system was investigated with both direct (n=5) and indirect (arterial) (n=4) portography. Hepatic vein catheterizations were performed in 22 cases. Results: with the 0.66-mm system, spasm occurred in one of 11 cases in the proper hepatic artery, and no spasm was observed in the common hepatic and celiac arteries. Both arterial portography and hepatic venography were easily performed and were a precise and repeatable method. Conclusion: the 0.66-mm system has proved to be advantageous over the 1.0-mm catheterization in avoiding arterial spasm. Direct portography as well as catheterization of the hepatic vein from a jugular approach are hazardous, leading to serious complications including the death of the animal.

Purpose To assess the usefulness of percutaneous transhepatic hepatic venography (PTHV) in planning interventional radiologic treatment of Budd-Chiari syndrome (BCS). Materials and Methods Six patients aged 14–56 years under-went examination for BCS. After preliminary transfemoral inferior vena cavography and selective hepatic venography failed in determining the extent of venous obstruction, PTHV was performed. Results PTHV completely depicted the proximal and distal extent of hepatic venous occlusion. Intraluminal thrombus in the right and middle hepatic veins shown in one patient was treated with fibrinolytic infusion and balloon thrombectomy. Central obstruction of the right hepatic vein shown in two patients was treated with venoplasty or venoplasty and stent placement. In three patients, PTHV showed a “spider web” appearance of diffuse obliteration of the normal intrahepatic venous architecture; a transjugular intrahepatic portosystemic shunt was placed in two of these patients. Conclusion PTHV provides information not available with conventional venography that is useful in planning the treatment of BCS.

肝内性門脈圧亢進症における肝静脈造影および逆行性門脈造影の診断的意義について検討した.変数選択型判別分析による正診率は,肝硬変症(以下LCとする)159例中151例95%,乙'型肝硬変症7例中6例86%,原発性胆汁性肝硬変症6例中5例83%,特発性門脈圧亢進症は21例中12例57%であった.誤診例を詳細に分析すると本法はきわめて忠実に肝病変を反映するため,肝生検,肝表面像を含め総合評価することにより,より正確な門脈圧亢進症の形態診断に到達しうると考えられた.LCの造影所見を成因別に検討するとアルコール性LCは非アルコール性LCに比較して壁不整,屈曲・蛇行の著明なI型が有意に少なく,これはアルコール性LCの再生結節径が他群に比較して有意に小さなことを反映した造影上の相違と推測され,造影所見の検討が成因を考える上で有力な一手段となりうることが示唆された.

A barium sulphate-gelatine mixture was injected into the veins in the left lobe of 50 human livers which were then x-rayed. The radiographs were compared with the pathological and anatomical findings and enlargements were studied and compared with the histology. A correlation was found between the venogram and the macroscopic and microscopic changes, particularly in various forms of cirrhosis of the liver. The scope and limitations of hepatic venography were studied with respect to solitary and diffuse liver metastase.

Webs of the hepatic veins have been rarely described. Two patients presented with intractable ascites in whom hepatic venography demonstrated this unusual finding. Liver biopsies from both patients showed variable patterns of perivenular fibrosis. Transvenous balloon dilatation of the web was effective in abolishing the pressure gradient across the obstruction and improving hepatic venous outflow. Both patients showed a dramatic clinical improvement following the procedure, with complete resolution of ascites in one patient and considerable improvement in the other with symptoms not recurring over 18 months of follow-up. The histological features that help to distinguish hepatic venous outflow obstruction from other causes of perivenular fibrosis are described.

Hepatic venographies were performed selectively in 42 patients with hepatocarcinoma. The findings were evaluated from anterior and lateral views. Thirty-nine right hepatic v. could be identified and the existence of one branch as the first ramification was found in 36 cases (92.3%). The first branches of the right hepatic v. could be classified into veins (V7) running from segment VII and those (V8) running from segment VIII. A V7 was identified in 26 cases (72.8%) and a V8 was identified in 10 cases (27.8%). The vena hepatica dorsalis [6] (V8) running from Segment VIII was recognised in 10 cases. The middle and left hepatic v. Were identified in 31 cases and 33 cases respectively. Two main types of middle vein (one with no Principal branching and the other with a branching) were found in 11 cases (37.9%) and 12 cases (41.4%) respectively. The first branch of the middle hepatic v. (V8) running from segment VIII was identified in 10 cases (32.3%). These results indicate that anatomical consideration of the hepatic v. in each patient is necessary when performing hepatic resection.

The authors report the case of a 45 year old woman in whom the diagnosis of nodular regenerative hyperplasia of the liver was made by needle biopsy of the liver, laparoscopy and hepatic venography. The patient did not have any underlying disorders and had not ingested any of the many drugs and chemicals which may produce the lesion. Clinical manifestations were hepatosplenomegaly, portal hypertension and iron deficiency anaemia, and her condition remains unchanged 5 years after diagnosis.

Although necessity for angiography has been reduced somewhat because of the development of newer imaging modalities, such as ultrasound and CT, celiac or hepatic arteriography, portography, and hepatic venography often prove useful in the diagnosis of liver disease. They can be utilized for therapeutic purposes as well in certain vascular abnormalities.

Total and selective hepatic vein angiographies were performed preoperatively and 6 weeks after 70 per cent liver resection in 6 dogs. The alterations in the hepatic vein system, increased diameter and elongation of the remaining lobar veins and their major tributaries plus increased angle between the radicles, are consistent with the findings earlier described by angiography of the hepatic arterial and portal venous system after major hepatic resection in dogs.

Three-lumen, two-balloon catheterを試作し,雑種犬において肝静脈造影を行なうとともに,その安全性について検討した.肝静脈開口部の上下で下大静脈を確実に閉塞できれば,鮮明な肝静脈造影およびsinusoidal filingを得る事ができる.2つの別のcatheter(一方は先端をballoon間に来る様に下大静脈に留置し,他方は門脈にcatheterを留置する)で,造影時および単に上下のballoonで下大静脈を閉塞させた時の圧をmonitorした.balloon間の圧および門脈圧は極めてよく相関して変動した.balloon間に加わる圧はsinusoidを通じて門脈に逃げ,広い門脈系で緩衝されると推察された,従来の方法に比べ更に小さいtumor, cysteの発見およびfibrosisの程度が診断可能であり,比較的安全な検査法と思われる.

The hepatic venography and wedged hepatic venous pressure measurement were performed in 35 patients with portal hypertension using a balloon catheter, and the results were compared with those obtained by the conventional method. It was revealed that the balloon catheter visualized a broader area of the liver and showed more accurate wedged hepatic venous pressure than the conventional catheter, thereby demonstrating that this is an excellent diagnostic tool for patients with portal hypertension.

Vascular radiology of the rat was undertaken to study the feasibility of various diagnostic procedures for the demonstration of liver and renal anatomy. Wedged retrograde hepatic venography could not be performed. The demonstration of the hepatic veins occurred only in shocked animals or after pericardial puncture. The venous system of the rat could be visualized from a penile vein injection and this could be repeated at frequent intervals. By this means the arterial system was shown moderately well using simple radiographic apparatus. For the best demonstration of the arterial system a left-sided cardiac puncture was required, but this procedure was neither reliable, repeatable nor safe. The size, shape, calibre, and position, of various components of the venous and arterial systems are described and illustrated as seen radiographically. Further improvements in their visualization should be possible by using more powerful and sophisticated equipment.

In six cases of Budd-Chiari syndrome, wedged hepatic venography and inferior vena cavography were performed, and hepatic arteriography was carried out in two of these cases. Specific patterns on the wedged hepatic venogram seen only in this condition are described. Narrowing of the upper end of the inferior vena cava is demonstrated radiographically in this condition. This may be associated with intrinsic filling defects thought to be due to thrombus formation in the upper end of the inferior vena cava. On hepatic arteriography there is marked narrowing of the vessels and these appear bowed. The spider's-web network pattern as well as actual occlusion of a hepatic vein, is considered to be pathognomic of the Budd-Chiari syndrome.

Benign hepatic tumors and peliosis hepatis developed in a patient who had received androgen therapy for three years. The tumors were identified by arteriography. Peliosis hepatis was diagnosed by wedged hepatic venography: to our knowledge, this method has not been previously used to diagnose this condition. Wedged venography, performed four months after withdrawal of androgen therapy and after liver function had nearly returned to normal, demonstrated morphologic improvement as well. On the basis of this case and other histologic descriptions of peliosis hepatis, we believe that wedged hepatic venography is a simple, sensitive, and specific diagnostic modality.

Hepatic arteriography, venography, and histopathology were reviewed in 20 patients with hepatic venous occlusion. The hepatic histologic materials (14 patients) were carefully examined in retrospect and correlated with the angiographic findings. Hepatic arteriographic findings were usually nonspecific but revealed neoplasms in all six patients studied and collaterals in four. Collateral channels that were recognized angiographically in 15 patients were extrahepatic, intrahepatic-interlobar, and indeterminate. The intrahepatic type was found in the partial Budd-Chiari syndrome, whereas other patterns were present in both diffuse and localized forms of hepatic venous occlusive disease. Histologically, the centrilobular sinusoids were congested and distorted in association with parenchymal destruction and compression. Hepatic venography correlated poorly with histopathologic findings.

Intrahepatic communications between hepatic veins can be demonstrated in hepatic venography and in anatomic and autopsy studies [1 -.3]. However, to our knowledge the presence of an intrahepatic collateral pathway between the right and left hepatic veins bypassing an obstruction of the inferior vena cava has not been reported. We describe a case of complete caval occlusion resulting in this unique pathway.

Free and wedged hepatic venography were carried out in 37 patients with idiopathic portal hypertension (IPH) and the findings compared with those in 88 patients with cirrhosis of the liver. Characteristic changes in IPH included frequent vein-to-vein anastomoses, narrower angles between large veins and their tributaries, smooth and wavy middle-sized to large branches (giving a general "weeping willow" appearance), homogeneous sinusoidal filling, and minimal to absent filling of the portal venous system on wedged retrograde portography. In cirrhosis, by contrast, changes included rare vein-to-vein anastomoses, wide angles between veins and tributaries, irregular stenoses of large veins and branches at various levels, spotty sinusoidal filling, and frequent retrograde flow in the portal venous system. Hepatic venography is helpful in differentiating IPH from cirrhosis.

The transjugular technique facilitates various diagnostic and therapeutic procedures in the liver. Even in patients with defective hemostasis, severe ascites, or marked obesity, liver biopsy or cholangiography can be performed with relative safety. It also provides an alternative route for entry into the portal system.