495

PERCUTANEOUS PORTAL VENOGRAPHYBy DAVID SUTTON, M.D., M.R.C.P., F.F.R.

St. Mary's Hospital, London, W.2

Portal venography by percutaneous injection ofthe spleen was first performed in dogs (Abeaticiand Campi, 195I) and the method was latersuccessfully applied in man (Leger, 1951; Boulvinet al., 195I; Campi and Abeatici, I952).

In the last few years the method has beenroutinely used at a number of centres in the BritishIsles. Atkinson, Barnett, Sherlock and Steiner(I955) have described about 40 cases investigatedat the Hammersmith Hospital. The percutaneoustrans-splenic technique is the method most widelyused, but some workers prefer portal venographyto be performed at laparotomy by injection of amesenteric vein (Green and du Boulay, 1954). Thewriter's personal experience is limited to the trans-splenic method.

TechniqueWe usually perform the investigation under local

anaesthesia, the patient being premedicated by abasal narcotic such as omnopon, 3 gr. given onehour before the examination. The patient liessupine and the spleen is punctured in the mid-axillary line below the costal margin or betweenthe lower ribs. Large spleens are easy to puncture,but normal-sized or small spleens may provedifficult.The needles used are of 19 standard wire gauge

or of I8 standard wire gauge.The skin and subcutaneous tissues are infiltrated

with local anaesthetic and the splenic puncture isthen made through the weal raised in the skin.The needle can often be felt to enter the spleen.If it is correctly sited a backflow of blood isimmediately obtained rather like that resultingfrom a vein puncture. It should be possible todraw back blood easily. Indeed, as most of thecases investigated suffer from portal hypertension,blood will normally drip back through the needlerapidly without any suction being applied to thesyringe. In some cases the blood may be at ex-tremely high pressure. The needle is attached tothe syringe by a plastic connecting tube and onceit is certain that the needle point is correctly sitedin the spleen the contrast examination is pro-ceeded with. Atkinson and Sherlock (I954) have,

in addition, practised measuring the intrasplenicpressure before proceeding to venography. Forthe contrast injection 20 to 50 ml. of the mediumare used and this is injected as rapidly as possible,the procedure being completed within a fewseconds. Diodone 50 or 70 per cent. may be used.We have also used the newer tri-iodated organiciodine compounds, such as Diaginol 70 per cent.Rapid serial films are taken, commencing abouthalfway through the injection of the contrastmedium. With a simple cassette tunnel for thehand changing of films, four films can be taken inabout six seconds. The needle is kept in the spleenfor the minimum period necessary to complete theinjection, usually not more than two to threeminutes. During this period the patient is warnednot to breathe deeply and use only shallow respira-tions in order to prevent undue movement of thespleen with the needle in situ.

If move elaborate apparatus is available, this,of course, is an advantage. The Sch6nander bi-plane apparatus allows films to be taken in twoplanes and therefore provides even more informa-tion, but it should be emphasized that adequatefilms can be obtained by the simpler methoddescribed.

ComplicationsMilnes Walker (I954) has reported a case of

rupture of the spleen requiring splenectomy threedays after a portal venogram. The patient should,therefore, be carefully watched for a few days afterthe investigation if operation is to be delayed.The danger of splenic rupture is claimed to be a

reason for performing the procedure at laparotomyby Green and du Boulay (I954).Another risk is that associated with sensitivity

to the contrast medium, but this is extremely small,being of the same order as that relating to intra-venous pyelograms.

Cases have been recorded where the injectionhas accidentally been made into the peritoneum,and even into the colon; but these accidents,apart from local pain, have had no serious con-sequences.The writer has now injected over 20 cases

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496 POSTGRADUATE MEDICAL JOURNAL October 1956

personally. Successful venograms were obtainedin all cases and no complications were encountered.

IndicationsThe main value of portal venography is in

differentiating between intrahepatic and extra-hepatic portal obstruction where the diagnosis isclinically difficult. Where this problem arises

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FIG. i.-A case of cirrhosis of the liver. The splenic andportal veins are large in calibre and patent through-out. A porto-caval anastomcsis should be possible.(See Fig. 3). Note the retrograde filling of theinferior mesenteric vein and the gastric varices.

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FIG. 2.-The contrast has been successfully injected intothe spleen but the splenic vein is thrombosed andthe contrast is escaping by means of capsular veinswhich are forming anastomoses with retro-peri-toneal veins and the gastric veins.

portal venography will usually provide a clear cutand unequivocal answer.

If surgery is contemplated it will also provide thesurgeon with extremely valuable information bydemonstrating the size of the portal vein andwhether or not it is possible to anastomose it to theinferior vena cava (Fig. i). It will also show thesize and shape of the splenic vein if the alternativeoperation of a spleno-renal anastomosis is beingconsidered.

Occasionally a case is demonstrated where suchsurgical anastomosis is complicated by the presenceof splenic vein thrombosis (Fig. 2).

Post-operative splenic venograms are occasion-ally performed to demonstrate the patency of asurgical anastomosis (Fig. 3). In one case examin-ed post-operatively by the writer it was thoughtthat an anastomosis was functioning well, but theinvestigation proved conclusively that this was notthe case and that a new portal vein had formedfrom a dilated periportal vein (Figs. 4a and 4b).Radiological Appearances

In cases of portal hypertension due to cirrhosisof the liver or to post-hepatic portal obstructionthe splenic and portal veins are usually welldemonstrated, the latter being large in calibre(Fig. i). The collateral circulation is often wellshown also, and where gastric or oesophagealvarices are present these may be very well outlined.Steiner et al consider that portal venography givesa better and more accurate demonstration ofoesophageal varices than does the simpler examina-tion of barium swallow (Fig. 5). The writer how-ever has seen cases with excellent demonstrationof oesophageal varices by barium swallow where

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FIG. 3.-A post-operative splenic venogram in the caseshown in Fig. i. The portal vein can now be seenemptying into the inferior vena.cava. Note that theneedle point actually lies in a main tributary of thesplenic vein. The inferior mesenteric vein andgastric varices shown in Fig. I are no longer seen.

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October 1956 SUTTON: Percutaneous Portal Venography 497

these have failed to show unequivocally at portalvenography. Distortion of the intrahepatic vas-cular pattern may be seen in cases of cirrhosis, butthis may'be difficult to demonstrate, and is notconstantly shown.The widespread use of percutaneous splenic

venography has demonstrated the existence ofnumerous other collateral channels beside the wellrecognised ones. Thus capsular veins from thespleen are often shown draining into the retroperi-toneal veins to reach the azygos veins (Fig. 2).

Occasionally anastomotic veins are shown inunusual situations and a single huge anastomoticvein may be demonstrated. In such cases opera-

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FIG. 4a.-Splenic venogram showing a patent splenicand portal vein in a case of cirrhosis.

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FIG. 4b.-Post-operative venogram following a porto-caval anastomosis. The anastomosis has been un-successful and the portal tract is filling from enlargedperiportal veins. Note the increased number ofportal systemic anastomotic veins suggestingincreased pressure.

tion may be contra-indicated as there already existsa natural 'shunt'.Doehner et al. (I956) have recently published an

excellent survey based largely on post mortemangiographic studies of the collateral circulation incases of portal obstruction.

In extrahepatic obstruction the portal vein maybe seen to be completely thrombosed and thecirculation to the liver to be carried by smalleranastomotic veins. The so-called condition of'cavernoma' of the portal vein, where the latter isreplaced by a number of small irregular channels,is probably secondary to thrombosis of the portalvein rather than due to an angiomatous malforma-tion.

In cirrhosis of the liver the position may be com-plicated by the fact that thrombosis may occur inthe portal tract as a secondary complication. Thuseven in a known case of cirrhosis it is advisable tohave a venogram performed before operation toensure that the condition is operable. Fig. 2 showsa venogram performed in a woman considered tobe suffering from cirrhosis of the liver. In this

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FIG 5.-Gastric varices demonstrated by bariumswallow.

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498 POSTGRADUATE MEDICAL JOURNAL October 1956

case there was no filling of the splenic or portalvein. The splenic vein was thought to be throm-bosed its circulation being carried by numerouscapsular veins as described above. She wastreated surgically by a submucous resection of thevarices in the lower oesophagus and by splenec-tomy. The presence of cirrhosis of the liver wasconfirmed at laparotomy.Another similar case has been recently examined

and the fact that the portal vein was patent, al-though the splenic vein was thrombosed, wasproved by an operative venogram performedthrough a mesenteric vein.

ConclusionsPercutaneous portal venography is now an

established method for demonstrating the portalcirculation.The technique is not difficult and the method

appears to be safe in competent hands. It provides

an excellent method of differentiating betweenintrahepatic and extrahepatic portal obstructionand of demonstrating the site and nature of anextrahepatic block. Prior to surgery it provides thesurgeon with useful information as to the operativepossibilities. Post-operatively it will demonstratethe patency or inadequacy of a portal shunt. Themethod therefore is of considerable practical valuein the investigation and control of cases of portalhypertension.

BIBLIOGRAPHYABEATICI, S., and CAMPI, L. (I95i), Acta Radiol., 36, 383.ATKINSON, M., and SHERLOCK, S. (I954), Lancet, i, I325.ATKINSON, M., BARNETT, E., SHERLOCK, S., and

STEINER, R. E. (I955), Q. J. Med., 24, 77.BOULVIN, R., CHEVALIER, M., GALLUS, P., and NAGEL, M.

(1951), Acta chir. Belg., 50, 534.CAMPI, L., and ABEATICI, S. (I952), Radiol. med., 38, I.DOEHNER, G. A., RUZICKA, F. F., ROUSSELOT, L. M. and

HOFFMAN, G. (1956), Radiology, 66, 2o6.DU BOULAY, G. H., and GREEN, B. (1954), Brit. J. Radiol., 27,

423.LEGER, L. (I95I), Mem. Acad. chir., Paris, 77, 7I2.WALKER, R. MILNES. (1954), writing in 'Recent Advances in

Surgery', ed. by H. C. Edwards, Churchill, London.

/IdLa"Kacttet4 I/lodeThe following films have been added to the I.C.I.

Film Library:FILMS ON INDUSTRIAL MEDICINE AND

FIRST AID

Artificial RespirationCat. No. FA. 4. Running time: i mins. i6mm.Whatever the cause of asphyxia may be, the

condition must be treated by artificial respiration.In this film the Schafer and Holger Nielsenmethods are described by the General ChemicalsDivision medical officer on wall charts, and bothmethods are then demonstrated by a team of first-aiders on a patient suffering from drowning. Thecombined method with two operators, and the useof the ' Novox ' apparatus is also shown in the film.

Examination of an Unconscious PatientCat. No. FA. 5. Running time: 6 mins. i6mm.The object of this film is to teach first-aiders

to use a systematic method of examination whenthey are confronted with an unconscious patient.A first-aider demonstrates this, and the commen-tary is spoken by a medical officer.Control of HaemorrhageCat. No. FA 6. Running time: 7 mins. I6 mm.The theme of this film is that pressure will

always control bleeding. The general ChemicalsDivision medical officer emphasizes this in an

introduction to the film, and the various methodsof application of pressure are then shown onpatients by two first-aiders. First, a patient witharterial bleeding from a wound in the forearm istreated, and later, the treatment when a foreignbody is present in a wound, the use of ring padsand the important pressure points are demonstra-ted.Removal of Clothing and Treatment ofa FracturedCollar-boneCat. No. FA. 7. Running time: 6 mins. i6mm.A man suffering from a fractured clavicle is

treated by the standard method. Before this canbe applied, however, his jacket and waistcoat haveto be removed. This film shows in detail theeasiest method of removing clothing, followedstep by step with the treatment of the fracture.First Aidfor a Patient with a Fractured SpineCat. No. FA. 8. Running time: 8 mins. i6mm.The victim of an accident involving a fall from a

height is suspected of having fractured his lumbarspine. A team of first-aiders demonstrates thecorrect method of handling and treating such aninjury, from the initial approach to the eventualremoval of the patient on a stretcher. TheGeneral Chemicals Division's medical officerspeaks the commentary and draws attention to theimportant details of treatment.

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