•
An Angiographic Study of the Pre- and Postoperative Hemodynamics in Patients with Side-to-Side Portacaval Shunts 1
Diagnostic Radiology
Stewart R. Reuter, M.D.,2 Robert N. Berk, M.D.,3 and Marshall J. Orloff, M.D. Hepatic panangiography was performed in 17 patients before and after side-to-side portacaval shunts. Preoperatively, a direct correlation existed between the diameters of the hepatic arteries and the severity of the patient's cirrhosis. Postoperatively, the splenic artery and vein and the hepatic artery dilated further in most patients, reflecting increased blood flow. The greatest increase occurred in those patients with less severe cirrhosis. The liver shrank postoperatively in most patients. The corrected sinusoidal pressure dropped significantly in all patients. A unique pattern of sinusoidal filling at wedged hepatic venography was observed postoperatively in many of the patients. INDEX TERMS:
Arteries, hepatic. Liver, angiography. Liver, cirrhosis. Shunts, porta-
caval Radiology 116:33-39, July 1975
• operatively, as judged by angiographic criteria (14). According to the classification used, the patients were considered to be Stage I cirrhotics if portal pressure was elevated but portosystemic collateral veins identifiable.by angiography had not yet developed. No such patients appear in this material. Patients in whom portosystemic collateral veins had developed but had not reversed the blood flow in the portal vein were placed in Stage II; those in whom the portal vein served as an outflow tract were called Stage III. Since most of the patients fell into Stage II, this group was subdivided according to the length of time contrast medium remained in the portal vein following wedged hepatic venography. If the contrast medium disappeared from the portal vein by 6 seconds from the end of injection, the patient was considered to be Stage IIA. If it remained at the sixth second, the patient was considered to be Stage liB. Although such a division into Stages IIA and liB is empirical, the rate of antegrade drainage of contrast medium from the portal vein radicles should correlate directly with the degree of postsinusoidal fibrosis and resistance to blood flow. Of the 17 patients, 8 were Stage IIA, 7 Stage liB and 2 Stage III. This method of classifying patients with cirrhosis into groups with increasing severity of disease is a simplification of the more complex hemodynamic classification reported by Viamonte et al. (22). With our method, patients with Stage I, II and III disease are separated by major and readily observable hemodynamic events. The subdivision of Stage II cirrhosis also depends on an easily observable event. Wedged hepatic vein catheterization was performed from a femoral vein with the assistance of a manipula-
have evaluated the functional and hemodynamic alterations caused by side-toside portacaval shunts in both humans and experimental animals. Their studies have evaluated changes in hepatic blood flow (1, 7, 8, 10, 17, 18, 23, 24), effects on liver function (11), short- and long-term survival (3-5, 15, 21), extraction ratios and removal rates for oxygen, bromsulphalein (BSP), colloid radiogold, and ammonia (12, 20), and glucose and ammonia metabolism (19). To date, however, no comparison of the pre- and postoperative hemodynamics as detected by angiography in man has been presented. Angiography gives valuable information about both the amount and direction of visceral blood flow. The evaluation of angiograms obtained in the same patient before and after side-to-side portacaval shunts, therefore, should reveal some useful information about the alterations which occur in visceral hemodynamics following a side-to-side portacaval shunt.
M
ANY INVESTIGATORS
PATIENT MATERIAL
Liver panangiography (wedged hepatic venography and pressure measurement together with celiac angiography and, occasionally, splenoportography) was performed as part of the preoperative evaluation of patients prior to emergency side-to-side portacaval shunts at the University of California, San Diego, from early 1971 through 1972. Of these patients, 17 who had tollow-up angiograms four to six months after the shunt operation constitute the material for the present evaluation. For the analysis that follows, the patients were grouped according to the severity of their cirrhosis pre-
1 From the Department of Radiology, University of Michigan, Ann Arbor, Wayne County General Hospital, Eloise, Mich., and the Departments of Radiology and Surgery, University of California, San Diego, Calif. Presented at the Sixtieth Scientific Assembly and Annual Meeting of the Radiological Society of North America, Chicago, III.,Dec. 1-6, 1974. 2 Present address: Department of Radiology, Wayne County General Hospital, Eloise, Mich. 48132. 3 Present address: Department of Radiology, Parkland Memorial Hospital, Dallas, Texas 75235. dk
33
34
STEWART
R. REUTER
tor instrument. Pressures were measured with a water manometer. The corrected sinusoidal pressure was determined by subtracting the inferior vena cava pressure from the wedged hepatic vein pressure. Wedged hepatic venography was performed by injecting 76 % Renografin (methylglucamine diatrizoate) at a rate of 2 mil sec. for 4 seconds. Filming was done at 1 film per second beginning with the start of injection. For celiac angiograms 36 ml of Renografin was injected at a rate of 12 ml/sec. for 3 seconds, Filming was done at a rate of 2 films per second for 4 seconds, 1 per second for 4 seconds, and every third second for 15 seconds. The injection factors were the same for both the preoperative and postoperative angiograms. METHOD OF EVALUATION
The following parameters were evaluated in the preand postoperative angiograms: 1) diameters of the common, proper and right hepatic arteries; 2) degree of tortuosity of the peripheral hepatic artery branches; 3) diameter of the splenic artery; 4) diameter of the splenic vein; 5) liver size; 6) spleen size; 7) sinusoidal filling pattern and direction of portal vein washout at wedged hepatic venography; and 8) corrected sinusoidal pressures. The common hepatic artery diameter was measured 1 cm from the origin of the common hepatic artery so that the data could be compared to the results of Lunderquist (6). Proper and right hepatic artery diameters were measured immediately beyond the origin of the ar-
AND OTHERS
July 1975
tery. In each patient, the measurements were made at an identical position on the artery on both the pre- and .postoperative angiograms. The diameter of the splenic artery was also measured 1 cm from the origin of the vessel; the diameter of the splenic vein was measured in the midportion where it was best visualized. The evaluation of the degree of tortuosity of the peripheral hepatic arteries was a subjective estimate based upon the appearance of the vessels at angiography. Spleen and liver size were judged by the area visualized during the parenchymal phase and by the distribution of the hepatic or splenic artery. In the liver the hepatogram phase better delineated the outline of the right lobe of the liver, while the extent of the hepatic artery branchings proved more reliable for estimating the left lobe. Measurements were made with a compensating polar planimeter. The area on the anteroposterior film was chosen for the pre- and postoperative comparison to allow the use of single numbers for liver and spleen size instead of using individual measurements of length and width. Statistical analysis was performed to test if the measurements before and after surgery were significant. The average difference and the corresponding standard deviation were calculated for each postoperative change for Groups IIA and liB. (Group III was not used because of the small sample size.) A paired T-test was then applied to test the hypothesis that the average differences did not show any change. The corresponding levels of rejecting this hypothesis (and thus concluding that change was demonstrated) were then calculated. RESULTS
o ~
Average
q:J
Average Stage :2A CirrhoticS Before S-S P-C Shunt
(it
I I 15",,,,
Entire GrouP Before S-S P-C Shunt
II
..
..
II
II
After
II
II
Average Stage 28 Cirrhotics It
II
..
Averege Stage 3 •
II
II
II
II
..
..
After
II
II
..
Before S-S P-C ShUlt After
n
II
II
Cirrhotics Before S-S P-C Shunt n Aftar II " ](
ro
I
Q
tl
An Angiographic Study of the Pre- and Postoperative Hemodynamics in Patients with Side-to-Side Portacaval Shunts 1
Diagnostic Radiology
Stewart R. Reuter, M.D.,2 Robert N. Berk, M.D.,3 and Marshall J. Orloff, M.D. Hepatic panangiography was performed in 17 patients before and after side-to-side portacaval shunts. Preoperatively, a direct correlation existed between the diameters of the hepatic arteries and the severity of the patient's cirrhosis. Postoperatively, the splenic artery and vein and the hepatic artery dilated further in most patients, reflecting increased blood flow. The greatest increase occurred in those patients with less severe cirrhosis. The liver shrank postoperatively in most patients. The corrected sinusoidal pressure dropped significantly in all patients. A unique pattern of sinusoidal filling at wedged hepatic venography was observed postoperatively in many of the patients. INDEX TERMS:
Arteries, hepatic. Liver, angiography. Liver, cirrhosis. Shunts, porta-
caval Radiology 116:33-39, July 1975
• operatively, as judged by angiographic criteria (14). According to the classification used, the patients were considered to be Stage I cirrhotics if portal pressure was elevated but portosystemic collateral veins identifiable.by angiography had not yet developed. No such patients appear in this material. Patients in whom portosystemic collateral veins had developed but had not reversed the blood flow in the portal vein were placed in Stage II; those in whom the portal vein served as an outflow tract were called Stage III. Since most of the patients fell into Stage II, this group was subdivided according to the length of time contrast medium remained in the portal vein following wedged hepatic venography. If the contrast medium disappeared from the portal vein by 6 seconds from the end of injection, the patient was considered to be Stage IIA. If it remained at the sixth second, the patient was considered to be Stage liB. Although such a division into Stages IIA and liB is empirical, the rate of antegrade drainage of contrast medium from the portal vein radicles should correlate directly with the degree of postsinusoidal fibrosis and resistance to blood flow. Of the 17 patients, 8 were Stage IIA, 7 Stage liB and 2 Stage III. This method of classifying patients with cirrhosis into groups with increasing severity of disease is a simplification of the more complex hemodynamic classification reported by Viamonte et al. (22). With our method, patients with Stage I, II and III disease are separated by major and readily observable hemodynamic events. The subdivision of Stage II cirrhosis also depends on an easily observable event. Wedged hepatic vein catheterization was performed from a femoral vein with the assistance of a manipula-
have evaluated the functional and hemodynamic alterations caused by side-toside portacaval shunts in both humans and experimental animals. Their studies have evaluated changes in hepatic blood flow (1, 7, 8, 10, 17, 18, 23, 24), effects on liver function (11), short- and long-term survival (3-5, 15, 21), extraction ratios and removal rates for oxygen, bromsulphalein (BSP), colloid radiogold, and ammonia (12, 20), and glucose and ammonia metabolism (19). To date, however, no comparison of the pre- and postoperative hemodynamics as detected by angiography in man has been presented. Angiography gives valuable information about both the amount and direction of visceral blood flow. The evaluation of angiograms obtained in the same patient before and after side-to-side portacaval shunts, therefore, should reveal some useful information about the alterations which occur in visceral hemodynamics following a side-to-side portacaval shunt.
M
ANY INVESTIGATORS
PATIENT MATERIAL
Liver panangiography (wedged hepatic venography and pressure measurement together with celiac angiography and, occasionally, splenoportography) was performed as part of the preoperative evaluation of patients prior to emergency side-to-side portacaval shunts at the University of California, San Diego, from early 1971 through 1972. Of these patients, 17 who had tollow-up angiograms four to six months after the shunt operation constitute the material for the present evaluation. For the analysis that follows, the patients were grouped according to the severity of their cirrhosis pre-
1 From the Department of Radiology, University of Michigan, Ann Arbor, Wayne County General Hospital, Eloise, Mich., and the Departments of Radiology and Surgery, University of California, San Diego, Calif. Presented at the Sixtieth Scientific Assembly and Annual Meeting of the Radiological Society of North America, Chicago, III.,Dec. 1-6, 1974. 2 Present address: Department of Radiology, Wayne County General Hospital, Eloise, Mich. 48132. 3 Present address: Department of Radiology, Parkland Memorial Hospital, Dallas, Texas 75235. dk
33
34
STEWART
R. REUTER
tor instrument. Pressures were measured with a water manometer. The corrected sinusoidal pressure was determined by subtracting the inferior vena cava pressure from the wedged hepatic vein pressure. Wedged hepatic venography was performed by injecting 76 % Renografin (methylglucamine diatrizoate) at a rate of 2 mil sec. for 4 seconds. Filming was done at 1 film per second beginning with the start of injection. For celiac angiograms 36 ml of Renografin was injected at a rate of 12 ml/sec. for 3 seconds, Filming was done at a rate of 2 films per second for 4 seconds, 1 per second for 4 seconds, and every third second for 15 seconds. The injection factors were the same for both the preoperative and postoperative angiograms. METHOD OF EVALUATION
The following parameters were evaluated in the preand postoperative angiograms: 1) diameters of the common, proper and right hepatic arteries; 2) degree of tortuosity of the peripheral hepatic artery branches; 3) diameter of the splenic artery; 4) diameter of the splenic vein; 5) liver size; 6) spleen size; 7) sinusoidal filling pattern and direction of portal vein washout at wedged hepatic venography; and 8) corrected sinusoidal pressures. The common hepatic artery diameter was measured 1 cm from the origin of the common hepatic artery so that the data could be compared to the results of Lunderquist (6). Proper and right hepatic artery diameters were measured immediately beyond the origin of the ar-
AND OTHERS
July 1975
tery. In each patient, the measurements were made at an identical position on the artery on both the pre- and .postoperative angiograms. The diameter of the splenic artery was also measured 1 cm from the origin of the vessel; the diameter of the splenic vein was measured in the midportion where it was best visualized. The evaluation of the degree of tortuosity of the peripheral hepatic arteries was a subjective estimate based upon the appearance of the vessels at angiography. Spleen and liver size were judged by the area visualized during the parenchymal phase and by the distribution of the hepatic or splenic artery. In the liver the hepatogram phase better delineated the outline of the right lobe of the liver, while the extent of the hepatic artery branchings proved more reliable for estimating the left lobe. Measurements were made with a compensating polar planimeter. The area on the anteroposterior film was chosen for the pre- and postoperative comparison to allow the use of single numbers for liver and spleen size instead of using individual measurements of length and width. Statistical analysis was performed to test if the measurements before and after surgery were significant. The average difference and the corresponding standard deviation were calculated for each postoperative change for Groups IIA and liB. (Group III was not used because of the small sample size.) A paired T-test was then applied to test the hypothesis that the average differences did not show any change. The corresponding levels of rejecting this hypothesis (and thus concluding that change was demonstrated) were then calculated. RESULTS
o ~
Average
q:J
Average Stage :2A CirrhoticS Before S-S P-C Shunt
(it
I I 15",,,,
Entire GrouP Before S-S P-C Shunt
II
..
..
II
II
After
II
II
Average Stage 28 Cirrhotics It
II
..
Averege Stage 3 •
II
II
II
II
..
..
After
II
II
..
Before S-S P-C ShUlt After
n
II
II
Cirrhotics Before S-S P-C Shunt n Aftar II " ](
ro
I
Q
tl
