Portal Venography Research Articles

Imaging features and clinical relevance of portal venous systems shown by extrahepatic portal angiography in children with extrahepatic portal venous obstruction

ObjectiveThis study investigated the morphologic changes of portal cavernoma in children with extrahepatic portal venous obstruction and explored the relationship with prognosis. MethodsFrom February 2008 to October 2017, there were 107 patients with cavernous transformation of the portal vein admitted to our hospital. Rex shunts were performed in 99 cases, Warren shunts in 7 cases, and laparoscopic splenic vessel ligation in 1 case. Intraoperative superior mesenteric venography was used to determine the structure of the portal venous system. According to the morphologic features of the portal vein shown by portal venography, groups were assigned as follows: patients with the cotton form of portal cavernoma; patients with visible collateral veins of portal cavernoma; patients with and without a visible left gastric vein; and patients with and without a clearly visible intrahepatic portal vein. The preoperative and postoperative portal pressure, preoperative incidence of esophageal varices, time at onset, incidence of postoperative rebleeding, preoperative and postoperative size of the spleen, and age at time of operation were compared between these groups. ResultsThe preoperative incidence of esophageal varices, time at onset, postoperative size of spleen, and age at time of operation were significantly lower in the group with the cotton form than in those with visible collateral veins (P < .05). There was a significant correlation between the visible left gastric vein and esophageal varices (P = .002). The time at onset, preoperative and postoperative size of the spleen, and age at time of operation were markedly lower in the group with a good visible intrahepatic portal vein than in those without a clearly visible intrahepatic portal vein (P < .05). The visible left gastric vein was notably associated with the performance of a gastroportal shunt (P = .000), and the group with a visible left gastric vein had a higher ratio of children undergoing a gastroportal shunt. ConclusionsThe cotton form, an early-stage manifestation of cavernous transformation of the portal vein, typically occurs in younger children with a shorter time to onset. Children with the cotton form of portal cavernoma typically have a better prognosis after Rex shunt.

Intraoperative stent placement for the treatment of acute portal vein complications in pediatric living-donor liver transplantation

Background: Pediatric living-donor liver transplantation (LDLT) in low weight recipients remains one of the most complex surgical procedures, with portal vein (PV) complications occurring in up to 19% of cases. So far, the Results: of stent placement in PV steno-occlusive disease have been encouraging showing excellent long term patency rates. However, current experience with pediatric PV stenting is mostly focused on PV abnormalities diagnosed long after the transplant, when the percutaneous approach is feasible. We propose this technique as an effective alternative to prevent the frequent and complex problem of PV steno-occlusive disease in pediatric LDLT. Method: The inferior mesenteric vien (IMV) is punctured with a 18-gauge catheter.With a Seldinger technique, the angiocatheter is exchanged for a 5-F sheath over a hydrophilic guidewire. Next, direct portal venography is performed to assess the portal anatomy and detect alterations such as stenosis, torsion of the PV or spontaneous portosystemic shunts. The choice of stent and its subsequent placement is made on the basis of the diameter and length of the donor’s proximal portal vein. Results: Between June 2006 and June 2017, 173 pediatric liver transplants were performed, of which 64 (36.9%) included living donors. Seven of these patients (10.9%) underwent PV stent placement during the transplant or in the immediate (< 24 hs) postoperative setting period. Mean hospital stay was 39 days (range, 15-93) after LDLT. During the mean imaging follow-up period of 1,313 days (range 399-4,255 days), none of the patients showed PV abnormality and PV stent remained patent throughout the post-transplant course. There were no deaths or graft loses during the follow-up period. Conclusion: Intraoperative stenting through the IMV approach may offer both a high feasibility and satisfactory Results, with the potential for excellent long-term primary patency despite continued growth in children.

Iodine load reduction in dual-energy spectral CT portal venography with low energy images combined with adaptive statistical iterative reconstruction.

To study the application of using low energy images combined with adaptive statistical iterative reconstruction (ASiR) in dual-energy spectral CT portal venography (CTPV) to reduce iodine load. 41 patients for CTPV were prospectively and randomly divided into two groups. Group A ( n = 21) used conventional 120 kVp scanning protocol with contrast dose at 0.6 gI/kg while group B ( n = 20) used dual-energy spectral imaging with reduced contrast dose at 0.3 gI/kg. The 120 kVp images in Group A and 50 keV images in Group B were reconstructed with 40% ASiR. The contrast-to-noise ratio of portal vein was calculated. The image quality and the numbers of intrahepatic portal vein branches were evaluated by two experienced radiologists using a 5-point scoring system. Group B reduced iodine load by 52% compared to Group A (17.21 ± 3.30 gI vs 35.80 ± 6.18 gI, p < 0.001). All images in both groups were acceptable for diagnosis. CT values and standard deviations in portal veins of Group B were higher than Group A (all p < 0.05); There were no statistical differences in contrast-to-noise ratio, image quality score and the number of observed portal vein branches between the two groups (all p > 0.05), and the two observers had excellent agreement in image quality assessment (all κ > 0.75). The use of 50 keV images in dual-energy spectral CTPV with ASiR reduces total iodine load by 52% while maintaining good image quality. Spectral CT images combined with ASiR can be used in low contrast dose CTPV portal venography to maintain image quality and reduce contrast dose.

Reducing Radiation Dose and Improving Image Quality in CT Portal Venography Using 80 kV and Adaptive Statistical Iterative Reconstruction-V in Slender Patients

To explore the feasibility of reducing radiation dose and improving image quality in CT portal venography (CTPV) using 80 kV and adaptive statistical iterative reconstruction-V(ASIR-V) in slender patients in comparison with conventional protocol using 120 kV and ASIR. Sixty slender patients for enhanced abdominal CT scanning were randomly divided into group A and group B. Group A used the conventional 120 kV tube voltage, 600 mgI/kg contrast dose and reconstructed with the recommended 40% ASIR. Group B used 80 kV tube voltage, 350 mgI/kg contrast dose and reconstructed with ASIR-V from 40% to 100% with 10% interval. The CT values and standard deviation (SD) values of the main portal vein, left branch, and right branch of portal vein, liver, and erector spinae at the same level were measured to calculate the signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR). The image quality was subjectively scored by two experienced radiologists blindly using a 5-point criterion. The contrast dose, volumetric CT dose index, and dose length product were recorded in both groups and the effective dose was calculated. There was no significant difference in general data between the two groups (p > 0.05), the effective dose and contrast dose in group B were reduced by 63.3% (p < 0.001) and 39.7% (p < 0.001), respectively compared with group A. With the percentage of ASIR-V increased in group B, the CT values showed no significant difference, while the SD values gradually decreased and SNR values and CNR values increased accordingly. Compared with group A, group B demonstrated similar CT values (p > 0.05), while the SD values with 80% ASIR-V to 100% ASIR-V were significantly lower than those of 40% ASIR (p < 0.001), and the SNR values and CNR values with 70% ASIR-V to 100% ASIR-V were significantly higher than those of 40% ASIR (p < 0.001). The subjective image quality scores by the two radiologists had excellent consistency (kappa value>0.75, p < 0.001), and the final subjective image quality scores and the subjective scores in each of the 5 scoring categories with 60% ASIR-V to 100% ASIR-V were all significantly higher than those of 40% ASIR, and 80% ASIR-V obtained the highest subjective score among different reconstructions. In CTPV, the application of 80 kV and ASIR-V reconstruction in slender patients can significantly reduce radiation dose (by 63.3%) and contrast agent dose (by 39.7%). Compared with the recommended 40% ASIR using 120 kV, ASIR-V with 80% to 100% percentages can further improve image quality and with 80% ASIR-V being the best reconstruction algorithm. CTPV with 80 kV and ASIR-V algorithm in slender patients can significantly reduce radiation dose and contrast agent dose as well as improve image quality, compared with the conventional 120 kV protocol using 40% ASIR.

Evaluation of Collateral Circulation in Cirrhosis by Computed Tomography Portal Venography

Objective: Cirrhotic portal hypertension can lead to extensive collateral circulation in the portal vein system, and the esophagogastric variceal bleeding (EVB) can easily lead to death. Computed tomography portal venography (CTPV) can display the composition of portal vein noninvasively. The purpose of this study was to investigate the diagnostic value of CTPV in collateral circulation of cirrhosis and to predict the risk of EVB. Methods: A total of 37 patients with cirrhosis in our hospital were analyzed retrospectively. All patients underwent CTPV and gastroscope to observe and classify varicose veins. The consistency of the two methods was analyzed. The diameters of patients with major tributaries of portal vein were compared between the hemorrhagic and non-hemorrhagic patients. The receiver operation characteristic (ROC) curves were used to evaluate the predictive value for EBV. Patients with varicose veins underwent endoscopic esophagogastric variceal ligation. Results: The tributaries of portal vein and the collateral circulation was showed clearly in CTPV. The esophagogastric varices was found in 30 patients, and the Kim grades I, II and III were 8, 10 and 12 respectively. The varicose was found in 28 patients under gastroscope. The CTPV and endoscopy were highly consistent in grading of esophagogastric varices (kappa 0.674). Compared with the non-hemorrhagic patients, the diameter of SMV, LGV and SV in hemorrhagic patients increased significantly. The ROC curves of predicted EBU by these diameters were 0.64, 0.76, and 0.83, respectively. There was no statistical difference between the diameter of portal vein and its tributaries before and after endoscopic variceal ligation. Conclusion: The CTPV can show the collateral vessels of portal vein in patients with cirrhosis, evaluate the degree of varicosity, and determine the risk of varicose rupture.

The Frequency and Significance of Portopulmonary Venous Anastomosis (PPVA) and Transvenous Obliteration for Gastric Varices

A Portopulmonary Venous Anastomosis (PPVA) is a direct vascular connection between the portal venous system and the pulmonary veins, close to the left atrium. We describe a patient with advanced cirrhosis and moderately severe Hepatopulmonary Syndrome (HPS) in whom (PPVA) was demonstrated by a high resolution computed tomographic scan. In order to reduce the symptoms of hypoxia in our patient, we sequentially performed Transjugular Intrahepatic Portosystemic Shunt (TIPS) followed by a catheter based obliteration of the PPVA. The case raised three questions which were addressed through an extensive literature review. Among patients with advanced cirrhosis, what is the frequency of PPVA? Our literature review suggests that the frequency of finding a PPVA in patients with portal hypertension depends on the imaging technique used. Transhepatic or transvenous portal venography may demonstrate PPVA in about 20% of patients with cirrhosis and varices. Limited published experience with contrast enhanced (bubble) echocardiography suggests that PPVA may be present in about 30% of such patients. An increasing number of case reports of PPVA have been published in recent years. This observation indicates that routine use of High Resolution Computed Tomography (HRCT) and magnetic resonance imaging is able to identify PPVA in cirrhotic patients. The visualization of PPVA with HRCT depends on the timing of the contrast injection and the expertise of the viewer. The present report describes three patients with portopulmonary venous anastomosis (PPVA) in whom balloon-occluded retrograde transvenous obliteration (B-RTO) of gastric varices was attempted. No patients had a gastrorenal shunt. In one patient, after an approach from the inferior phrenic vein (IPV), the PPVA was embolized with the use of microcoils. Portopulmonary Venous Anastomosis Detected at Balloon-occluded Retrograde Transvenous Obliteration for Gastric Varices among cirrhotic patients with PPVA, what is the clinical significance of the PPVA? There are multiple causes of clinically significant hypoxia in patients with cirrhosis. A PPVA is a right to left shunt that, theoretically, could be associated with clinically significant systemic arterial hypoxemia or emboli. There is not definitive evidence in the published literature that PPVA alone causes clinically significant hypoxia in cirrhotic patients. PPVA is, however, a documented important risk factor for systemic emboli when needle or catheter techniques are used to treat or prevent bleeding from gastroesophageal varices.

Dual-Energy Spectral Computed Tomography With Adaptive Statistical Iterative Reconstruction for Improving Image Quality of Portal Venography.

The aim of the study was to investigate whether spectral computed tomography (CT) plus adaptive statistical iterative reconstruction (ASIR) could improve imaging quality of computed tomography portal venography (CTPV). Sixty-four patients underwent CTPV, with CT number of portal vein (PV) less than 150 HU in portal phase, were divided into 2 groups A (n = 31), using standard 120-kVp protocol. group B (n = 33), using spectral CT protocol. Standard 120-kVp images were reconstructed with 40% ASIR, and monochromatic images at 60 keV were reconstructed with the following 4 ASIR percentages: 0%, 20%, 40%, and 60%. The CT number, image noise, and contrast-to-noise ratio in main PV were measured. The maximum intensity projection and volume-rendering images were used for subjective evaluation. These 2 kinds of results were statistically analyzed. The contrast-to-noise ratio and subjective scoring of PV increased gradually from 120-kVp images to 60% weight ASIR (3.44 ± 0.95, 4.58 ± 1. 59, 5.26 ± 1.85, 6.18 ± 2.18, and 7.39 ± 2.65 and 4.35 ± 1.17, 6.21 ± 1.29, 6.48 ± 1.35, 6.85 ± 1.28, and 7.00 ± 1.19). There were statistically different for the 5 groups (P < 0.001). The CT number of the PV in the 60-kiloelectron volt spectral images had higher than the 120-kVp images (P < 0.001). The noise of 120 kVp was significantly higher than those of 60% ASIR and significantly lower than those of 0% ASIR (both P < 0.001), and there were no significant differences between 120-kVp, 20% ASIR, and 40% ASIR (P = 0.107 and 1.000, respectively). The diagnostic acceptability was highest at 40% ASIR. Forty-percent ASIR addition to the 60-kiloelectron volt monochromatic image could improve image quality of CTPV comparing with conventional 120-kVp images.

Congenital extrahepatic portosystemic shunt: description of four cases and review of the literature

Congenital extrahepatic portosystemic shunt (CEPS), also known as Abernethy malformation, is a rare condition in which the splenomesenteric blood drains directly into a systemic vein, bypassing the liver through a complete or partial shunt. The diagnosis is frequently made during childhood in the setting of neonatal cholestasis, hypergalactosemia, failure to thrive, mental retardation or other congenital defects. In adulthood, CEPS is usually found incidentally during diagnostic work-up for abdominal pain, liver test abnormalities, liver nodules, portopulmonary hypertension, portopulmonary syndrome or portosystemic encephalopathy. The diagnosis depends on imaging and portal venography, but sometimes only liver biopsy can be resolutive, demonstrating the absence of venules within the portal areas. Here we report four recent cases of Abernethy malformation diagnosed in young adults, in which ultrasound (US) was the initial imaging technique and allowed to suspect the diagnosis. Furthermore, we reviewed clinical presentations, associated anomalies and treatment of the 310 cases of CEPS previously reported in the literature.

Catheter-Directed Thrombolysis for Portal Vein Thrombosis in Children: A Case Series

PurposeTo describe safety and efficacy of catheter-directed thrombolysis (CDT) for portal vein thrombosis (PVT) in children. Materials and MethodsRetrospective review was performed of 10 consecutive patients (7 girls, 3 boys; mean age 11.9 y; range, 3–17 y) with PVT undergoing CDT at a single tertiary children’s hospital between August 2005 and March 2016. PVT was categorized by etiology and extent (intrahepatic, extrahepatic, or both). CDT was performed with infusion catheters placed via percutaneous transhepatic (PTH) and/or transjugular intrahepatic (TJ) approaches, with or without the use of adjunctive maneuvers, including balloon maceration and suction and rheolytic thrombectomy. Degree of thrombolysis on portal venography, presence of portal vein thrombus on available follow-up imaging, and complication rates were recorded. ResultsIn 10 patients, 13 CDT procedures were performed for PVT, with 3 patients requiring repeat CDT. Portal access was achieved with PTH (n = 6), TJ (n = 2), or combined (n = 2) approaches. All cases were successful in re-establishing patency and hepatopetal flow on portal venography with complete thrombolysis achieved in 10 of 13 cases (77%). Two major complications (20%) occurred, both with PTH access. Mean follow-up time for 9 patients was 2.6 years (range, 51–1,902 d) with long-term patency achieved in 6 (67%). ConclusionsCDT can be safe and effective for PVT in children. Portal access considerations and early initiation of thrombolysis may further increase safety and efficacy.

Doppler ultrasound surveillance of TIPS-patency in the era of covered stents – retrospective analysis of a large single-center cohort

The purpose of this study was to determine accuracy and necessity of long-term Doppler ultrasound (DU) surveillance of transjugular intrahepatic portosystemic shunt (TIPS) patency after implantation of an ePTFE-covered stent-graft (Viatorr). This single-center retrospective study includes 228 consecutive cirrhotic patients with TIPS implantation due to portal hypertensive complications. Standardized DU surveillance was scheduled 3 - 5 days, 3 months, and 6 months after TIPS implantation and every 6 months thereafter. Portal venography was performed in case of DU findings suspicious of TIPS dysfunction, clinical signs of recurrent portal hypertension, or refractory hepatic encephalopathy. During a mean follow-up of 16.6 ± 23.4 months, 866 DU examinations were performed. Twenty-two cases of TIPS dysfunction were observed in 16 patients with no first dysfunction more than 4 years after implantation. Routine DU in asymptomatic patients had little therapeutic impact (0.75 %). DU and venography were concordant in 39/46 (84.8 %) paired examinations, and 1-, 2-, and 5-year primary TIPS patency was 87.4 %, 83.7 %, and 79.97 %, respectively. Patients with TIPS dysfunction and subsequent successful revision during the first 2 years of follow-up had a significantly higher risk (p = 0.001) of new dysfunction compared to those without TIPS dysfunction. Cumulative 1-, 2-, and 5-year survival was 68.7 %, 61.3 %, and 42.7 %, respectively. Despite acceptable accuracy, scheduled DU surveillance proved to have minor therapeutic impact. Thus, detailed DU surveillance is not useful in asymptomatic patients after 2 years of unremarkable follow-up. In contrast, long-term DU surveilleance should be performed in patients after successful revision of TIPS dysfunction and patients with prothrombotic states (e. g., portal vein thrombosis, Budd-Chiari syndrome).

Indirect Doppler ultrasound abnormalities of significant portal vein stenosis after liver transplantation.

To determine indirect Doppler ultrasound (DUS) abnormalities associated with significant portal vein (PV) stenosis (PVS) in recipients of liver transplantation (LT). This retrospective study was approved by our institutional review board. Between February 2006 and May 2017, 41 LT recipients were diagnosed with significant PVS, defined as having more than 50% narrowing of PV diameter for any reason, including thrombosis or flow disturbance associated with prominent collateral vessels on portal venography. We reviewed the DUS findings of hepatic arteries (HAs) as well as PVs of them, before and after treatment of PVS, and in comparison, with a one-to-one case-matched control. Inter-group comparison of frequency in DUS abnormalities was performed using Chi square (χ2)with Fisher's exact test and McNemar's test. Diagnostic values of each abnormal DUS finding and combinations were also evaluated. DUS of significant PVS showed "no demonstrable color flow," either at recipient PVs or anastomoses (26.7%), and showed turbulence (66.7%) and hepatofugal portal flow (HFPF; 20.0%) at the graft PVs. HFPF was more frequently observed in those with "no demonstrable color flow" at recipient PVs or anastomoses (p = 0.006). DUS of graft HAs revealed tardus-parvus waveforms (20.9%) and prolonged systolic acceleration times (16.3%), more commonly in the "no demonstrable color flow" group (p = 0.012). These indirect DUS abnormalities disappeared and resolved on follow-up DUS after treatment. In the control group, such Doppler abnormalities were less frequently shown than in the PVS group (p ≤ 0.01, respectively). When one of the portal-blood flow velocity (PFV)-related index abnormalities (such as increased time average velocity [TAV] at anastomosis and TAV ratio between recipient PV and anastomosis) or "no demonstrable color flow" were shown in DUS as well as one of the indirect DUS abnormalities, sensitivity, and specificity was 71.11 and 97.78%, respectively. In addition to PFV-related abnormalities, DUS occasionally shows "no demonstrable color flow" either at recipient PVs or anastomoses, and indirect Doppler abnormalities such as turbulence, HFPF at graft PVs, and abnormal waveforms at graft HAs in LT recipients with significant PVS. The combination of PFV-related abnormalities and indirect DUS abnormalities would be helpful for diagnosis of PVS.

Clinical Efficacy of Percutaneous Transhepatic Portal Vein Angioplasty for Late-onset Portal Vein Stenosis in Pediatric Liver Transplant Patients.

Stenosis of the portal vein (PV) is a rare complication after liver transplantation (LT) in pediatric patients, and it adversely affects outcomes. We reviewed the safety and efficacy of percutaneous transhepatic balloon angioplasty (PTBA) as a treatment for post-LT late-onset PV stenosis (PVS). Three hundred eighteen patients between the ages of 0 and 21 years received an LT from 2001 to 2016 at this tertiary center. Twenty-one children were evaluated for PVS using percutaneous portal venography. Of the 21, 19 patients (7 female, 12 male) with a median age of 12 years (7-15 years) were diagnosed with PVS and received PTBA. Two patients were excluded: one did not have PVS, and one received shunt surgery. Median time between LT and PTBA was 83 months (interquartile range, 49-138). For patients in whom pressure could be accurately measured (n = 9), mean PV pressure gradient was 6.3 mm Hg (SD, 5.0) preprocedure and 0.9 mm Hg (SD, 1.2) postprocedure. Mean percentage improvement in gradient across the stenotic region was 86.2% (SD, 15.9%; P < 0.01). At 12-month postprocedure, there was a mean improvement (pre-PTBA vs post-PTBA means) in bilirubin by 28.2% (0.6 mg/dL vs 0.4 mg/dL, P = 0.07), aspartate aminotransferase by 31.2% (116.3 IU/L vs 28.1 IU/L, P = 0.04), alanine aminotransferase by 40.7% (140.3 IU/L vs 28.6 IU/L, P = 0.07), γ-glutamyltransferase by 29.0% (337.2 IU/L vs 38.0 IU/L, P = 0.06) and platelets by 62.1% (128.3 vs 191.1 × 10/L, P = 0.03). The PV patency was successfully maintained in 18 of 19 patients for a median of 16 months (interquartile range, 5-35). One patient received a successful repeat procedure for restenosis at 6 weeks. Angioplasty for PVS after pediatric LT is a safe and effective treatment with good patency and improved clinical outcomes. Longer follow-up studies are required.

Disabling portosystemic encephalopathy in a non-cirrhotic patient: Successful endovascular treatment of a giant inferior mesenteric-caval shuntviathe left internal iliac vein

Hepatic encephalopathy is suspected in non-cirrhotic cases of encephalopathy because the symptoms are accompanied by hyperammonaemia. Some cases have been misdiagnosed as psychiatric diseases and consequently patients hospitalized in psychiatric institutions or geriatric facilities. Therefore, the importance of accurate diagnosis of this disease should be strongly emphasized. A 68-year-old female patient presented to the Emergency Room with confusion, lethargy, nausea and vomiting. Examination disclosed normal vital signs. Neurological examination revealed a minimally responsive woman without apparent focal deficits and normal reflexes. She had no history of hematologic disorders or alcohol abuse. Her brain TC did not demonstrate any intracranial abnormalities and electroencephalography did not reveal any subclinical epileptiform discharges. Her ammonia level was > 400 mg/dL (reference range < 75 mg/dL) while hepatitis viral markers were negative. The patient was started on lactulose, rifaximin and low-protein diet. On the basis of the doppler ultrasound and abdomen computed tomography angiography findings, the decision was made to attempt portal venography which confirmed the presence of a giant portal-systemic venous shunt. Therefore, mechanic obliteration of shunt by interventional radiology was performed. As a consequence, mesenteric venous blood returned to hepatopetally flow into the liver, metabolic detoxification of ammonia increased and hepatic encephalopathy subsided. It is crucial that physicians immediately recognize the presence of non-cirrhotic encephalopathy, in view of the potential therapeutic resolution after accurate diagnosis and appropriate treatments.

Non-Cirrhotic Hepatic Encephalopathy Presenting as a Spontaneous Intrahepatic Porto-systemic Shunt

Hepatic encephalopathy (HE) is a common manifestation of cirrhosis, which is treated medically. Cirrhotic patients who require TIPS may also develop HE. Spontaneous porto-systemic shunts are a rare occurrence. In patients without liver disease they can be either congenital or spontaneous. Many go undetected if patients are asymptomatic. We present a case of a non-cirrhotic patient with a spontaneous intrahepatic porto-systemic shunt presenting with encephalopathy. A 58-year-old female presented with acute onset encephalopathy and concern for seizures. She underwent an EEG which was consistent with complex partial status epilepticus. She had an ammonia level of 56 but ranged as high as 110 mcmol/L. Liver function tests, PT/INR were within normal limits. She had no prior history of liver disease. She was not on any medications to cause hyperammonemia. She was started on AEDs and lactulose but continued to have cognitive deficits, trouble with short-term memory, concentration and balance. An LP was performed and revealed pleocytosis. Neurology felt her presentation and symptomology was consistent with autoimmune/paraneoplastic encephalitis and she was placed on IV steroids. A paraneoplastic antibody panel was unrevealing. She was referred to Hepatology for evaluation of persistent hyperammonemia. Workup revealed a large porto-hepatic shunt on CT scan. Chronic liver disease workup was unremarkable. Symptoms persisted despite medical treatment for hyperammonemia. She was referred to Interventional Radiology for embolization of her spontaneous intrahepatic porto-systemic shunt as there was suspicion that her symptoms and presentation were due to non-cirrhotic hepatic encephalopathy secondary to the intrahepatic shunt. She underwent a successful embolization. Her ammonia levels normalized. She has had an improvement in her symptoms and has been without overt encephalopathy. She also remains seizure free. Further follow up will be needed to assess for concurrent autoimmune/paraneoplastic encephalitis versus symptoms entirely due to her porto-systemic shunt. Spontaneous intrahepatic porto-systemic shunts are rare with many patients being asymptomatic. Mildly symptomatic patients are initially managed conservatively with medications and dietary modifications, however if symptoms persist or are severe enough, they may require intervention such as IR guided embolization to redistribute blood flow within the portal system.Figure: large shunt between the right portal and hepatic veins.Figure: Portal venography demonstrating large portal vein-hepatic vein shunt with poor parenchymal opacification of the liver giving preferential flow through the shunt rather than into native intrahepatic portal veins.Figure: Following embolization there was near complete occlusion of the shunt itself with preferential flow into the intrahepatic portal veins. Following shunt embolization marked improvement in the degree of hepatic parenchymal opacification was noted.

Endoscopic Ultrasound-Guided Direct Portal Pressure Measurement Using a Digital Pressure Wire with Real-Time Remote Display: A Survival Study.

Portal hypertension is necessary for the development of most clinical complications of cirrhosis. We recently reported a novel, endoscopic ultrasound (EUS)-guided technique for direct portal pressure measurements using a digital pressure wire. The aims of this study were to (1) evaluate safety in an animal survival model and (2) compare direct portal vein (PV) versus transhepatic access of a first-order venule. Yorkshire pigs, weighing 40-55 kg. Procedures were performed under general anesthesia. PV was identified using a linear array echoendoscope and accessed with a 22-G fine needle aspiration needle preloaded with a digital pressure wire. Access was confirmed by portal venography. Mean digital pressure measurements were recorded over 30 seconds, and again after accessing a first-order portal venule in a transhepatic manner. Procedure times and video logs were maintained throughout. Animals were survived for 2 weeks. Repeat portal pressure measurements were performed before euthanasia and necropsy. EUS-guided portal pressure measurements ranged from 3 to 11 mm Hg (mean 6.1) and were performed in a mean time of 214 seconds. There was no difference in measurement between the PV and first-order venule, or between baseline and 2-week follow-up. Five of 5 animals survived without incident. On necropsy, there was no evidence of thrombus or hemorrhage. This study represents the first survival study after EUS-guided direct portal pressure measurements using a digital pressure wire. This method appears safe, straightforward, and precise. Measurements of the PV and a first-order portal venule appear equivalent, and serial measurement seems feasible.

Abstract No. 69 - Persistent variceal filling on portal venography after transjugular intrahepatic portosystemic shunt creation and the risk of post-TIPS variceal hemorrhage

Abstract No. 69 - Persistent variceal filling on portal venography after transjugular intrahepatic portosystemic shunt creation and the risk of post-TIPS variceal hemorrhage

Application of low concentration contrast medium in spectral CT imaging for CT portal venography.

To investigate the effect of low-concentration contrast medium on spectral computed tomography (CT) image quality for portal venography CT. 150 patients with suspected portal diseases were divided into three groups and had spectral CT examination using aGE Discovery CT 750 HD scanner. The patients in three groups were injected with different concentrations of iodine (350 mgI/mL, 315 mgI/mL and 280 mgI/mL) at an injection rate of 4.0-5.0 mL/s with 1.2 mL/kg (body weight) of contrast medium, respectively. During the portal vein imaging phase, 0.625 mm-slice-thickness monochromatic images and optimal monochromatic images were obtained. Optimal keV mono-energy was achieved using the optimal contrast-to-noise ratio (CNR) in the portal vein relative to the erector spinae muscle. Volume rendering and maximum intensity projection methods were applied to generate portal venography. The CT values and standard deviations were measured at the portal vein, the erector spinae muscle, and the abdomen fat, respectively. These values were used to calculate the signal-to-noise ratio (SNR); while CNR was calculated using CT values of the portal vein and erector spinae muscle. The overall imaging quality was evaluated on afive-point scale by two radiologists with at least five years' experience. Comparisons among the three groups were performed using One-Way ANOVA test. Monochromatic images at 50-53 keV demonstrated the best CNR for both the portal vein and erector spinae muscle. SNR and CNR of images with different contrast medium concentrations were similar (P > 0.05). The five-point scores were also similar (P > 0.05) for the three groups. The total iodine intake at 280 mgI/mL was 25.4% lower than that at 350 mgI/mL. Spectral CT with monochromatic images at 50-53 keV allows significant reduction in iodine load while improving portal vein signal intensity and maintaining image quality.

Application value of split-bolus spectral computed tomography in the portal venography

Objective To investigate the effect of split-bolus spectral computed tomography(CT) on the portal venography and radiation dose. Methods The prospective study was adopted. The clinical data of 119 patients who underwent spectral CT at China-Japan Union Hopital from September 2014 to March 2015 were collected. Patients were randomly divided into the portal venography with split-bolus spectral CT single-phase enhanced scan group and portal vein multi-phase scan group by random sequence method. In the portal venography with split-bolus spectral CT single-phase enhanced scan group, the spectral CT was used with the method of split-bolus single phase imaging, and in the portal vein multi-phase scan group, standard spiral CT was used to perform three-phase scan. Two observers evaluated CT portal venography subjectively and objectively, measured CT values, contrast to noise ratio (CNR), signal noise ratio (SNR), and calculated radiation dose. Observed indices included (1) choice of optimal monochromatic images. (2) CT values of portal veins, measurement of CNR and SNR. (3) Subjective scoring of portal venography quality. (4) Comparison of radiation dose. Measurement data with normal distribution were presented as±s, comparison between groups was analyzed by independent sample t test. Comparison of count data was analyzed by chi-square test. Results The 113 patients were screened for eligibility, including 59 in the portal venography with split-bolus spectral CT single-phase enhanced scan group and 54 in the portal vein multi-phase scan group. (1) Choice of optimal monochromatic images: optimal monochromatic images were abstracted at 60 keV from spectral CT portal venography. (2) CT values of portal veins and measurement of CNR and SNR: the CT values of intrahepatic portal vein, extrahepatic portal vein and branches of portal vein were (319±44)HU, (328±53)HU, (294±45)HU in the reconstructed images at the energy level of 60 keV in the portal venography with split-bolus spectral CT single-phase enhanced scan group and (213±41)HU, (228±49)HU, (210±41)HU in the portal vein multi-phase scan group, with significant differences between the 2 groups(t=8.04, 6.34, 6.82, P 0.05). The SNR of intrahepatic portal vein, extrahepatic portal vein and branches of portal vein were 31±6, 29±6, 27±6 in the portal venography with split-bolus spectral CT single-phase enhanced scan group and 29±7, 28±9, 26±6 in the portal vein multi-phase scan group, respectively, with no significant differences (t=-0.688, 0.615, 0.600, P>0.05). (3) Subjective scoring of portal venography quality: the subjective score of image quality of portal venography was 14.3±1.0 in the portal venography with split-bolus spectral CT single-phase enhanced scan group and 12.5±1.8 in the portal vein multi-phase scan group, with a significant difference (t=12.43, P<0.05). (4) Comparison of radiation dose: the radiation dose was (8.1±1.1)mSv of patients in the portal venography with split-bolus spectral CT single-phase enhanced scan group and (17.4±7.5)mSv in the portal vein multi-phase scan group, with a significant difference (t=24.14, P<0.05). Conclusion Spectral CT portal vein imaging combined with split-bolus protocol can achieve better manifestations of portal vein and its branches, and reduce radiation dose in the scanning process. Key words: Liver diseases; Portal vein; Spilt-bolus; Tomography, X-ray computed; Spectral imaging; Radiation dose

Endoscopic ultrasound and multi-slice spiral CT portal venography in diagnosis and treatment of portal hypertension

Endoscopic ultrasound and multi-slice spiral CT portal venography in diagnosis and treatment of portal hypertension

Dual Energy CT (DECT) Monochromatic Imaging: Added Value of Adaptive Statistical Iterative Reconstructions (ASIR) in Portal Venography.

ObjectiveTo investigate the effect of the adaptive statistical iterative reconstructions (ASIR) on image quality in portal venography by dual energy CT (DECT) imaging.Materials and MethodsDECT scans of 45 cirrhotic patients obtained in the portal venous phase were analyzed. Monochromatic images at 70keV were reconstructed with the following 4 ASIR percentages: 0%, 30%, 50%, and 70%. The image noise (IN) (standard deviation, SD) of portal vein (PV), the contrast-to-noise-ratio (CNR), and the subjective score for the sharpness of PV boundaries, and the diagnostic acceptability (DA) were obtained. The IN, CNR, and the subjective scores were compared among the four ASIR groups.ResultsThe IN (in HU) of PV (10.05±3.14, 9.23±3.05, 8.44±2.95 and 7.83±2.90) decreased and CNR values of PV (8.04±3.32, 8.95±3.63, 9.80±4.12 and 10.74±4.73) increased with the increase in ASIR percentage (0%, 30%, 50%, and 70%, respectively), and were statistically different for the 4 ASIR groups (p<0.05). The subjective scores showed that the sharpness of portal vein boundaries (3.13±0.59, 2.82±0.44, 2.73±0.54 and 2.07±0.54) decreased with higher ASIR percentages (p<0.05). The subjective diagnostic acceptability was highest at 30% ASIR (p<0.05).Conclusions30% ASIR addition in DECT portal venography could improve the 70 keV monochromatic image quality.