Indirect Portography Research Articles

Synchronous hybrid procedure combining interventional radiology and endoscopy for esophagogastric varices with large gastro-renal shunt.

Successful treatment of esophagogastric varices (EGV) with giant portal-systemic shunt is challenging. To explore the feasibility and safety of a novel hybrid procedure involving interventional radiology and endoscopy in the same sitting.Three cases clinically diagnosed to have decompensated cirrhosis and EGV with giant gastrorenal shunt (GRS) on contrast-enhanced computed tomography (CT) were included. The hybrid procedures included: indirect portography, hepatic vein pressure gradient (HVPG) measurement, HVPG-based partial splenic embolization (PSE), retrospective GRS balloon occlusion, endoscopic histoacryl injection (EHI), balloon catheter radiography and withdrawal. All the procedures were done in the same operation room. Main outcomes measurements included operation time, complications, and re-bleeding events.Hybrid interventions were performed successfully in 3 cases with a mean operation time of 63.3 minutes without any major intra- and post-operation complications. No rebleeding occurred at 6-month follow-up.Synchronous hybrid intervention combining radiology and endoscopy is feasible and safe for patients with EGV and giant GRS, preliminary study with limited cases deserves further exploration.

Techniques and long-term effects of transjugular intrahepatic portosystemic shunt on liver cirrhosis-related thrombotic total occlusion of main portal vein

Portal vein hypertension (PVH) in liver cirrhosis complicated with portal venous thrombosis (PVT) has been mainly treated with transjugular intrahepatic portosystemic shunt (TIPS). The clinical effects of TIPS have been confirmed, however, no large-scale studies have been focused on technical analyses and a long-term follow-up, especially on thrombotic total occlusion of main portal vein (MPV). To demonstrate critical techniques and clinical outcome of TIPS on liver cirrhosis-related thrombotic total occlusion of MPV, 98 patients diagnosed with liver cirrhosis related thrombotic total occlusion of MPV and treated with TIPS from January 2000 to January 2010 were retrospectively analyzed. Twenty-three (23.5%) patients had MPV (single site) thrombosis, 55 (56.1%) had multiple site-thrombosis (MPV and other), 17 (17.3%) had cavernous transformation of portal vein, and 3 (3.1%) had post-transplant thrombosis. The successful rate of TIPS was 90.7%, without any procedure-related deaths or severe complications. Mean portal pressure was dropped from 33.08 ± 1.38 mmHg preoperatively to 20.18 ± 0.83 mmHg postoperatively (p < 0.001). Collectively, TIPS is safe and effective in treating liver cirrhosis-related thrombotic total occlusion of MPV. This complex procedure requires combination of indirect portography and percutaneous transhepatic portal techniques to increase the rate of success.

Abstract No. 231: Comparison of technical success of transjugular intrahepatic portosystemic shunt between patients with and without indirect portography

Abstract No. 231: Comparison of technical success of transjugular intrahepatic portosystemic shunt between patients with and without indirect portography

Transsinusoidal Portal Vein Embolization with Ethylene Vinyl Alcohol Copolymer (Onyx): A Feasibility Study in Pigs

PurposePortal vein embolization is performed to increase the future liver remnant before liver surgery in patients with liver malignancies. This study assesses the feasibility of a transsinusoidal approach for portal vein embolization (PVE) with the ethylene vinyl alcohol copolymer, Onyx.MethodsIndirect portography through contrast injection in the cranial mesenteric artery was performed in eight healthy pigs. Onyx was slowly injected through a microcatheter from a wedged position in the hepatic vein and advanced through the liver lobules into the portal system. The progression of Onyx was followed under fluoroscopy, and the extent of embolization was monitored by indirect portography. The pigs were euthanized immediately (n = 2), at 7 days (n = 4), or at 21 days postprocedure (n = 2). All pigs underwent necropsy and the ex vivo livers were grossly and histopathologically analyzed.ResultsTranssinusoidal PVE was successfully performed in five of eight pigs (63%). In 14 of 21 injections (67%), a segmental portal vein could be filled completely. A mean of 1.6 liver lobes per pig was embolized (range 1–2 lobes). There were no periprocedural adverse events. Focal capsular scarring was visible on the surface of two resected livers, yet the capsules remained intact. Histopathological examination showed no signs of recanalization or abscess formation. Mild inflammatory reaction to Onyx was observed in the perivascular parenchyma.ConclusionsThe porcine portal vein can be embolized through injection of Onyx from a wedged position in the hepatic vein. Possible complications of transsinusoidal PVE and the effect on contralateral hypertrophy need further study.

Successful curative extracorporeal hepatic resection for far-advanced hepatocellular carcinoma in an adolescent patient

Hepatectomy is the principal treatment for hepatocellular carcinoma (HCC); however, some HCCs are not resectable by conventional hepatic resection. In such apparently incurable cases, extracorporeal hepatic resection (ECHR) may offer an option for survival. We recently encountered a juvenile patient with faradvanced HCC who was successfully treated by ECHR with favorable long-term survival. A 17-year-old woman was referred to our hospital with a huge liver mass and was admitted for evaluation. She had no history of serious illness, surgery, or hospitalization and no notable family history. Of the serum tumor markers examined, a-fetoprotein (335.5 ng/mL, normal < 20 ng/mL) and des-c-carboxy prothrombin (1988 mAU/mL, normal < 40 mAU/mL) were elevated. She was serologically negative for anti– hepatitis C virus antibody and hepatitis B surface antigen, but she was positive for hepatitis B core antigen. Computed tomography with contrast enhancement showed an 18 cm 12 cm tumor in the center of the liver (Fig. 1a). One intrahepatic metastatic tumor was found in the left lateral segment of the liver. The first left branch of the portal vein was completely involved in the liver. The inferior vena cava (IVC) and the right hepatic vein (RHV) were completely surrounded by the tumor and were remarkably dislocated to the anterior side of the body (Fig. 1b,c). Celiac arterial angiography and indirect portography revealed an intact hepatic artery and the portal vein of the right posterior branch (Fig. 1d,e). The estimated remnant liver volume after left trisegmentectomy was 508 mL, which corresponded to 52.6% of the patient’s standard liver volume (Fig. 1f). On the basis of these findings, standard in situ hepatic resection was considered unfeasible, and ECHR was planned instead. Laparotomy revealed that the liver was severely enlarged because of the huge tumor, but the nontumorous liver parenchyma seemed to be normal. After the division of the proper hepatic artery and the common bile duct, the total liver was detached from the diaphragm. Intraoperative ultrasound was used to determine the cutting line at the back table. Vascular clamps were then applied, and this was followed by division of the portal vein and the suprahepatic and infrahepatic IVC, after which total hepatectomy was performed (Fig. 2a). A pump-driven portosystemic venovenous bypass was established from the portal vein and the left saphenous vein to the left axillary vein. The explanted liver was flushed with University of Wisconsin solution. The hepatic parenchymal dissection was performed with a Cavitron ultrasonic surgical aspirator (Valleylab, Inc., Boulder, CO), and the vessels were divided with ligations or clips. The IVC was completely dissected from the tumor and the dorsal liver. Extended left lobectomy with the caudate lobe was performed at the back table. After hepatic resection, vascular and biliary leakage tests were performed by the injection of University of Wisconsin solution, and the leakage points were repaired with fine sutures. The actual weight of the explanted liver was 2050 g (Fig. 2d), and the weight of the liver autograft

Assessment of Portal Venous System Patency in the Liver Transplant Candidate: A Prospective Study Comparing Ultrasound, Microbubble-Enhanced Colour Doppler Ultrasound, with Arteriography and Surgery

AIM: To determine the role of microbubble-enhanced colour Doppler ultrasound (CDUS) in assessing portal venous patency prior to liver transplantation. MATERIALS AND METHODS: Over a 2-year period, all patients with chronic liver disease undergoing routine pre-transplant CDUS examination in whom the portal venous system was inadequately demonstrated were recruited to the study. CDUS was performed in 368 patients and 33 patients (9%) were recruited. A repeat CDUS examination following an intravenous bolus injection of the microbubble contrast agent Levovist® (Schering Healthcare AG, Berlin, Germany) was performed. Diagnostic confidence was recorded on a free linear analogue scale for both examinations. Findings were compared with indirect portography and surgery. RESULTS: Of the 33 patients with sub-optimal baseline examinations, improvement in portal vein visualization was achieved in 31 patients (94%). Median diagnostic confidence increased from 50% (interquartile range 30–60) to 90% (interquartile range 75–98) (P<0.001) following administration of Levovist®. Overall accuracy of portal vein assessment using microbubble-enhanced CDUS in 15 patients in whom a definitive diagnosis was made within 2 months was 87%. CONCLUSION: Microbubble-enhanced CDUS is a simple, inexpensive adjunct to standard pre liver transplant screening of the portal vein. It is particularly helpful in patients with end-stage cirrhosis who are at high risk of portal vein thrombosis and in whom the conventional examination is sub-optimal.Marshall, M. M.et al. (2002). Clinical Radiology57, 377–383.

Integral role of interventional radiology in the development of a pediatric liver transplantation program.

The aim of this study was to examine the role of interventional radiology (IR) in the pretransplant evaluation of potential living-related liver transplantation (LRLT) donors and in the post-transplant management of pediatric liver transplant recipients. Medical records and procedural reports were reviewed of 12 potential donors and five recipients for left lateral segment liver transplants. Procedures performed by the IR Division, clinical indications, and complications were tabulated. Retrospective calculation of radiation exposure to the skin and gonads of the donors and recipients were made. Three-dimensional ultrasound (3D US) was used in all 12 potential donors to screen for the donor with the most appropriately sized left lateral segment. The four optimal donor candidates underwent contrast angiography in order to measure the diameter and screen for variant arterial supply to the left lateral segment. Pretransplantation, one recipient underwent mesenteric angiography with indirect portography to confirm thrombosis of the portal vein and to prove patency of the splenomesenteric venous confluence. Three children underwent LRLT and two children received split livers from cadaveric donors. Thirty-two IR procedures were performed after transplantation (Tx) in the four transplant survivors (one child died following Tx). These IR procedures included: ultrasound-guided percutaneous liver biopsy to evaluate the pathologic cause of liver dysfunction (seven); placement of nasal jejunal feeding tubes (three) or a peripherally inserted central catheter (four) for nutritional and pharmacologic support; large-volume diagnostic and therapeutic paracentesis (two) and thoracentesis (one); percutaneous catheter drainage of symptomatic large pleural effusions (two), large-volume chylous ascites (one) (with later drain removal [one]), and a large biloma (one); percutaneous biliary drain placement (three), biliary drain replacement (two), and balloon cholangioplasty (four) to relieve obstructive jaundice from biliary enteric anatomic strictures; and mesenteric arteriography (one) for suspected thrombosis of the hepatic artery. No complications occurred. Mean skin and gonadal radiation doses were 193 mGy and 27 mGy, respectively, for donors, and 164 mGy and 60 mGy, respectively, for recipients. Even in a program such as this, with a limited series of pediatric liver Txs, it is apparent that IR plays an integral role in optimizing the clinical outcome and use of resources. Specific benefits included: selection of optimal donors; accurate mapping of the donor and occasionally recipient hepatic vasculature; and, most importantly, providing relatively safe minimally invasive procedures for nutritional support and diagnosis and management of untoward events after Tx. When possible, ultrasound guidance should be used to avoid excessive cumulative fluoroscopic exposure to recipients.

The Usefulness of CO2 Indirect Portography in Transjugular Intrahepatic Portosystemic Shunt(TIPS)

Purpose : To determine the usefulness of carbon dioxide() indirect portography during TIPS procedure.Materials and Methods : We evalvated eight patients who had undergone TIPS due to variceal hemorrhage or ascites caused by portal hypertension. All patients but one with complete situs inversus underwent wedged right hepatic venography for visualization of the portal vein using . For indirect portal venography, 50cc of was injected by hand without prior injection of a small amount of . In three patients a 5-F angiographic catheter was wedged into the right hepatic vein, and in the other five a 9-F sheath from a Ring’s transjugular access set was adjunctively wedged into the right hepatic vein over the 5-F catheter. The time requiredfor portal vein puncture was defined as the time between the indirect portal venography procedure and the first procedure after successful portal vein puncture.Results : All patients successfully underwent TIPS without any immediate complication. The portal vein was visualized by in 7 of 8 patients (87.5%). Two of three patients who underwent indirect portography withonly a 5-F catheter wedging demonstrated opacification of the right portal vein; in the remaining patient the portal venous system was not visualized. Of the five patients who underwent indirect portography with an adjunctive 9-F sheath wedged in the right hepatic vein, four showed opacification from the peripheral to themain portal vein, and in the other, the only right peripheral portal vein was opacified. The mean time for portal vein puncture was 20.5 minutes.Conclusion : For visualization of the portal venous system during TIPS procedure, the use of indirect portography is feasible.

Contrast Bolus Dynamic Computed Tomography for the Measurement of Solid Organ Perfusion

The authors have investigated the aortic responses to various intravenous bolus injections of nonionic and ionic contrast media and have presented data illustrating the potential of ultrafast computed tomography (CT) to quantify perfusion in the kidney, liver, and spleen. Bolus Dynamics Study: Performed in 3 healthy dogs (weight: 35 kg to 36 kg). In 2 dogs, 15 mL of the nonionic agent iohexol and the ionic agent sodium-meglumine diatrizoate were injected at 5, 10 and 20 mL/sec via a venous catheter placed in the superior vena cava; the order of injection was alternated between the 2 dogs. In the third dog, 25 mL of iohexol 300 mg I/mL was compared with diatrizoate 370 mg I/mL with injection rates of 10 and 20 mL/sec. Computed tomography scanning at the level of the midabdominal aorta was performed using an ultrafast CT scanner. Time-density curves were drawn for regions of interest over the aorta, and gamma-variate fits performed. Perfusion Studies: Dynamic perfusion scans of the upper abdomen were performed in more than 50 patients. A dose of 25 mL of iohexol 300 mg I/mL was injected at 10 mL/sec via an intravenous cannula in the antecubital fossa, followed immediately by 25 mL of saline, at the same rate. Scanning was performed at a single level using an ultrafast CT scanner. Regions of interest were drawn and gamma-variate fits were applied to the vascular time-density curves. Bolus Dynamics: Excellent curve fits for aortic time-density curves were obtained. A 10-mL/sec versus a 5-mL/sec bolus produced an 8% higher peak density. Nonionic contrast increased the peak density by a mean of 6%, increased the area under the corrected time-density curve by a mean of 22%, and lengthened the increase time by a mean of 21%. Perfusion Studies: Values obtained were reproducible and correlated well with values predicted from inert gas washout techniques. Changes in the CT number in a region after an intravenous injection of contrast medium may be used to calculate blood flow per unit volume of tissue. Ultrafast CT offers sufficient data points for accurate calculation. The quality of the aortic bolus is of great importance. Nonionic media offer several important advantages: hemodynamic perturbation is minimized, and they are better tolerated at the high injection rates needed. Low-osmolality nonionic agents produce "better" curves than conventional high-osmolality ionic agents, all other factors being equal. The resulting data are relevant to intravenous digital subtraction angiography and indirect portography as well as to perfusion measurement. The technique of quantitative dynamic CT is theoretically applicable to any cross-sectional modality, notably magnetic resonance.

Comparison of portal CT and indirect portography in hepatic masses

Comparison of portal CT and indirect portography in hepatic masses

Localization of the Portal Vein for Transjugular Catheterization: Percutaneous Placement of a Metallic Marker with Real-Time US Guidance

Transjugular catheterization of the portal vein can be used to form a portosystemic shunt. Conventionally, the passage of a needle from the hepatic vein into the portal vein is performed with fluoroscopic monitoring only. Several methods to target the portal vein have been previously reported, including transhepatic venous catheterization, indirect portography (arterial catheterization), or skin marking based on ultrasound (US) mapping of portal landmarks. The authors used realtime US guidance to percutaneously place a small marking wire in the parenchyma next to the portal bifurcation. A 0.018-inch-diameter, 5-mm-long platinum wire is delivered through a 22-gauge echo-tipped needle placed adjacent to the right portal vein. This marking wire enabled rapid entry into the portal vein, helped avoid extrahepatic puncture, and was useful during stent deployment and positioning.

Comparative analysis of pulsed doppler ultrasonography of portal vein vs indirect portography

Comparative analysis of pulsed doppler ultrasonography of portal vein vs indirect portography

Digital indirect portography.

Thirty-eight patients underwent digital indirect portography with arterial injections of dilute contrast medium. The portal system was seen in 37 patients. Compared with conventional portography, the technique offers many advantages, including increased sensitivity and earlier visualization of the portal venous system, lower contrast loads, and lack of need for vasodilators. Digital indirect portography is an excellent method for evaluating the portal venous system.

Protean manifestations of pylethrombosis. A review of thirty-four patients.

Thirty-four adult patients with portomesenteric venous occlusion (PVO) were reviewed. In 11 with hepatic cirrhosis, PVO was usually heralded by worsening ascites often with varix hemorrhage; mortality was high. Four with isolated portal block had varix hemorrhage without ascites. All of these patients survived despite recurrent hematemesis when portal decompression was not feasible in two patients. Eight others (5 agnogenic and 3 with hypercoagulability), experienced sudden abdominal pain with a clot typically propagated into mesenteric tributaries with ileojejunal infarction; survival was related to the promptness of operation and the extent of bowel ischemia. Of five patients with intraabdominal sepsis and pylephlebitis, only one survived. In the final six patients, PVO occurred with intraabdominal carcinoma. Five had progressive ascites, cachexia, and an early death. Imaging techniques included plain and contrast roentgenograms, ultrasonography, and for definitive diagnosis direct portography (operative or splenoportogram), indirect portography (splanchnic arteriovenogram), and computed tomography. Thirteen of 34 patients had ascites, and in nine of 11 patients examined, protein concentration of ascitic fluid was extremely low (less than 0.6 g/dl). Clinical presentation of PVO varies, depending on acuteness and extent of visceral venous blockade, severity of portal hypertension, auxiliary venous collateralization, and regional lymph flow. Inciting factors include endothelial damage and blood hypercoagulability from trauma, infection, stagnant circulation, blood dyscrasia, and malignancy. Improved imaging now allows early diagnosis.

Trans-jugular retrograde portography. Preliminary communication

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.