CardioVascular Radiology
Cardiovasc. Radiol. 1, 255-259 (1978)
Arterialization of the Portal Vein in Cirrhosis: The Findings at Wedge Hepatic Venography E.C. Martin, ~ D.H. Gordon, 1 and R.J. Adamsons 2 Departments of Radiology I and Surgery, 2 State University of New York, Downstate Medical Center, Brooklyn, New York, USA
Abstract. A new operation for the treatment of cirrhosis and portal hypertension has recently been described involving arterialization of the portal vein in combination with an end-to-side portacaval shunt. We present, for the first time, the appearances at wedge hepatic Venography. No significant change is seen in the wedge hepatic pressure as a result of this technique, and the sinusoidal pattern is preserved. Filling of the portosplanchnic collaterals is not as frequent as after end-to-side shunts alone, and the appearances seem to reflect improved sinusoidal perfusion. The clinical results have been encouraging.
technique, but the radiologic appearance of the arterialized shunts has not previously been reported. We present the findings at wedge hepatic venography and compare them with the descriptions in the literature of the radiologic appearance of end-toside portacaval shunts uncomplicated by arterialization [16]. Materials and Methods Eighteen patients have been given end-to-side portacaval shunts and arterialization of the portal vein at Downstate Medical Center. Seven of these patients were studied with wedge hepatic venography
Key words: Cirrhosis - Portal vein arterialization - Portacaval shunt, end-to-side.
Numerous operations have been devised for the management of portal hypertension, but there has been an increasing dissatisfaction over the last ten years with the long-term results. A new approach to the problem ofportacaval shunting has involved the addition of arterialization of the portal vein to give a dual hepatic perfusion, and approximately 250 patients operated upon, predominantly in Europe, constitute the world experience to date [1, 2, 9-12, 14, 18]. A refined operative technique has been advocated recently and constitutes the United States experience with this type of surgery. It involves a saphenous vein graft interposed between the gastroepiploic artery and the ligated stump of the portal vein combined with an end-to-side portacaval shunt [2, 7] (Fig. 1). Encouraging results have been achieved with this Address reprint requests to: E.C. Martin, M.D., Department of Radiology, Box 1208, Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203, USA
Fig. 1. The arterialization operation. A saphenous vein graft (black arrow) has been interposed between the gastroepiploic artery (white arrow) and the portal vein (open arrow).
0342-7196/78/0001-0255 $01.00 ~ 1978 Springer-Verlag New York Inc.
256
E.C. Martin et al. : Arterialization of the Portal Vein
Tablel: Findings at wedge hepatic venography of patients with end-to-side portacaval shunts and arterialization of the portal vein Patient
l
2 3 4 5 6 7
Wedge hepatic vein pressure (cm of water) Preoperative
Postoperative
35 20 37 12 33 35 45
37 14 43 12 27 30 35
Parenchymal inhomogeneity '~
Portal vein filling
Portosystemic collaterals
Hepatic vein filling Veins filled via sinusoids
Total number filled b
3
-
-
+
4
2 1 2 3 2 3
+ + -
+ + +
+ + + + -
1 2 2 3 2 1
Scale from 1 3 of increasing inhomogeneity
+ + ~
Including hepatic vein injected
Fig. 2A and B. A lnhomogeneous parenchyma, grade I. The distal portal vein fills, as does one hepatic vein (in addition to the hepatic vein injected). B lnhomogeneous parenchyma, grade 3. Portal vein filling can be seen.
from one month to two years after surgery (mean, eight months). In six patients the diagnosis was alcoholic cirrhosis and in one, schistosomiasis. All patients had portal hypertension, complicated by variceal bleeding in six patients and hepatocellular failure in one. In all patients both the portacaval and the arterial shunts were patent and working at the time of the study. Wedge hepatic venograms were performed with a size 7 French, curved, end-hole catheter, using either a femoral or median cephalic vein approach. In one patient we employed a balloon occlusion catheter [13]. Injections were made at 2-3 ml/sec using 10-15 ml of methyglucamine diatrizoate 76% (Hypaque).
Venograms were evaluated for (I) the sinusoidal filling pattern, (2) the number of hepatic veins filled, (3) portal vein filling and the direction of flow, and (4) the presence of hepatosplanchnic collaterals. The wedge hepatic vein pressure was also recorded.
Results
T h e f i n d i n g s at w e d g e h e p a t i c v e n o g r a p h y
are shown
in T a b l e 1. T h e p a t i e n t w i t h s c h i s t o s o m i a s i s
and one
E.C. Martin et al. : Arterialization of the Portal Vein
257
Fig. 3. Portal vein filling. There is a grade 2 inhomogeneous parenchyma. Fig. 4. Portosplanchnic collateral vein. A collateraI vein (arrow) through the gall bladder bed opacifies retrogradely fi-om the portal vein.
other patient had near-normal postoperative wedge pressures, while the other five patients had elevated wedge pressures, ranging from 27 to 43 cm of water. There was no significant change in the mean of the wedge pressures as a result of surgery: the mean preoperative wedge pressure was 31 cm of water, and the mean postoperative wedge pressure was 28 cm of water. Wedge venography demonstrated an inhomogeneous sinusoidal pattern in all seven patients, with a range of inhomogeneity that was arbitrarily graded on a scale of 1 3. One patient had a relatively homogeneous parenchyma, while various degrees of inhomogeneity were seen in the others (Fig. 2); however, there was no true nodular appearance with berrylike protuberances from the hepatic vein, as described after side-to-side portacaval shunts [17]. In two patients the hepatic vein injected was the only one to fill, while in the other patients several other hepatic veins filled via the sinusoids. Contrast flowed through the sinusoids and into the portal vein in the four patients in w h o m the fewest hepatic veins filled (Fig. 3). Flow was hepatopetal in the portal veins outlined, and there seemed to be no relationship between portal vein filling and the hepatic wedge pressure. N o portal vein filling was seen in the other three patients.
In three patients a collateral vein of 1 4 m m ran through the gall bladder bed (Fig. 4). True portosplanchnic shunting with caval opacification was not demonstrated in any of these patients. The wedge pressure was elevated in each instance; however, collateral vein filling was not seen in the other two patients with elevated wedge pressures. No differences in the arterial anastomosis were seen in any of the seven patients when it was separately injected.
Discussion
The technique of the operation has been described in the surgical literature [2, 7]. The objective is to deliver a low flow of arterial blood to the intrahepatic portion of the portal vein in an attempt to ameliorate the adverse metabolic consequences of portosystemic decompression. The mortality rate of the procedure has been acceptable (5.5%), and hepatic encephalopathy has been avoided. Postoperatively, all patients can tolerate an unrestricted protein diet and indeed, one patient has now been operated upon successfully for hepatic encephalopathy alone, uncomplicated by the variceal bleeding that was present in the other six [3, 7]. Liver function, as shown by serum albumin,
258
bilirubin and serum glutamic oxaloacetic transaminase (SGOT) levels, improved in all patients as a result of surgery. The rationale for portal vein arterialization derives from experience with a chronic dog preparation in which observations demonstrated that arterial inflow into the portal vein in amounts varying from 50-100% of normal portal flow is adequate to prevent atrophy of the liver and to abolish the detrimental metabolic consequences of portacaval shunting. Perfusion of the portal vein with arterial blood in these amounts did not damage the microstructure of the liver over an observation period of four years [4 6]. While the technique may well be unable appreciably to alter the pathologic findings in cirrhosis, it m a y affect the rate of change, and it certainly alters the physiology. In end-to-side portacaval shunts the outflow of the liver remains through the hepatic veins, and it is normal for the pressure on the hepatic side of the portal vein to remain elevated [15], although it does fall from preoperative values [6]. This is in contrast to side-to-side shunts, where portal vein pressures equalize with the caval pressure. Under such circumstances of persisting portal hypertension, the development of hepatosplanchnic collaterals is to be expected and was indeed reported by Reuter in all five of his patients studied, though the collaterals became a m a jot source of outflow in only two of the five patients [16]. In contrast to Reuter's findings, wedge hepatic venography demonstrated portosystemic collaterals in only three patients in our group of seven in whom arterialization of the portal vein was added to an end-to-side portacaval shunt. This occurred despite the absence of a significant fall in the wedge pressures postoperatively and with the mainenance of a considerable pressure gradient between the portal vein and the systemic circulation. One explanation is that the hepatopetal portal flow created by the arterialization negates or disguises the effect of the pressure gradient. Yet although no difference in the function of the arterial shunt was seen in any of the patients, in three collaterals were demonstrated, in the fourth there was retrograde filling of the portal vein without portosystemic collateral opacification. The explanation for the different pattern of portal vein opacification is, therefore, not clear, although the radiologic appearance certainly differs notably from that of end-to-side portacaval shunts alone. Bookstein, in an arterial study of 17 patients with end-to-side portacaval shunts alone, noted hepatic artery to portal vein filling in 11. In two instances the outflow was demonstrated to be hepatosplanchnic collateral veins. In the other patients drainage was through the hepatic veins, and the differential obliter-
E.C. Martin et al.: Arterialization of the Portal Vein
ation of the hepatic venous bed in cirrhosis may account for the different paths of drainage [8]. The different number of hepatic veins filled on wedge venography and the apparent inverse relationship between hepatic and portal vein filling m a y well reflect this differential obliteration and further encourages caution in the interpretation of the findings. Again, comparing our findings to Reuter's series, none of our patients had a true nodular pattern on t h e parenchymal phase of the wedge hepatic venogram, and obliteration of the venous bed was not seen to the same degree as in end-to-side shunts alone without arterialization [16]. Certainly, the appearance is totally different from that seen after side-to-side portacaval shunts, where inhomogeneity is the norm and small berries of contrast material are found attached to narrow, feathery hepatic veins [17]. Despite the encouraging findings of less parenchyreal or venous obliteration and less retrograde portal filling and portosplanchnic collateral formation, one should not necessarily conclude that there has been an improvement in sinusoidal perfusion, nor a slowing of the progressive obliteration of the venous bed seen in cirrhosis, and caution should be used in attaching such a significance to these findings. Further investigations of this new technique in the management of cirrhosis and portal hypertension will be rewarding and may come to explain the radiologic appearances. For the moment, it is, however, clear that wedge hepatic venography does not give the same patterns after this operation as in end-to-side shunts alone, and hepatosplanchnic collaterals are not as frequent after arterialization. Neither is viusalization of the portal vein as frequent, and the appearance of the parenchyma on wedge hepatic vein injections may well be better than after the simple operation alone. Since the pathophysiology has been altered by this operation in comparison to end-to-side portacaval shunting alone, it is not surprising that the radiologic appearances differ, but at this stage a logical pathophysiologic explanation is not available. The effects of arterialization, both on the sinusoids and on the venous outflow patterns of the liver, are as yet unknown. When they are revealed, a better correlation with the wedge hepatic vein studies may well be found. For the moment, both the clinical and angiographic results seem to be encouraging.
References 1. A d a m s o n s , R.J., Moskowitz, H., Lerner, B.: Portacaval shunt with arterialization of the hepatic portion of the portal vein. Curr. Top. Surg. Res. 2:87-92, 1970
E.C. Martin et al. : Arterialization of the Portal Vein 2, Adamsons, R.J., Kinkhabwala, M., Moskowitz, H., Himmelfarb, E., Minkowitz, S., Lern'er, B. : Portacaval shunt with arterialization of the hepatic portion of the portal vein. Surg. Gynecol. Obstet. 135:529 535 , 1972 3. Adamsons, R.J., Levin, D.C.: Hepatic encephalopathy after portosystemic shunt treated by arterialization of intrahepatic portal vein. Surg. Forum 25 : 348, 1974 4. Adamsons, R.J., Arif, S., Babich, A., Butt, K., Lam, A., Minkowitz; S.: Arterialization of the liver in combination with a portacaVal shunt in the dog. Surg. Gynecol. Obstet. 140: 594-600, 1975 5. Adamsons, R.J., Arif, S., Babich, A., Butt, K., Ikramuddin, S., Lam, A.: The effect of arterialization of the portal vein on the prevention of atrophy of the hepatic parenchyma in dogs with portacaval shunt. Enr. Surg. Res. Abstr. 8 (Supplement) : 16, 1976 6. Adamsons, R.J., Arif, S., Babich, A., Butt, K., Lam, A., lkramuddin, S., Minkowitz, S. : Hemodynamic basis of long-term survival of dogs with portacaval shunt and arterialization of the liver. Abstract No. 43, Fourth World Congress Collegium Internationale Chirurgie Digestivae (DICD). Davos, Switzerland, September 1976 7. Adamsons, R.J., Butt, K., Swaminath, I., DeRose, J., Dennis, C.R., Kinkhabwala, M.: Portacaval shunt with arterialization of the portal vein by means of a low flow arterio-venous fistula. Presented at the American College of Surgery, Dallas, Texas, October 1977 8. Bookstein, J., Boijsen, E., Olin, T., Vang, J.: Angiography after end-to-side portacaval shunt: Clinical laboratory and pharmacoangiographic observations. Invest. Radiol. 6:101 - 109, 1971 9. Burlui, D., Ratin, O., Maneseo, G., T~ju, G.: Art6rialisation
259 portale par la veine ombilicale r6perm6abilis6e. La Presse M6dicale 76: 581-584, 1968 10. Fritsch, A., Funovics, J., Gangl, A., Horak, W., Grabner, G , Kohl, P.: Die kontrollierte Arterialisation der Leber. II. Klinische Ergebnisse Langenbecks. Arch. Chir. 336:67-69, 1974 11. Maillard, J.N., Rueff, B., Prandi, D., Sicot, C. : Hepatic arterialization and portacaval shunt in hepatic cirrhosis: An assessment. Arch. Surg. 108:315-320, 1974 1'2, Matzander, U.: Methode und Technik der druckadaptierten Leberarterialisation mit portacavaler Anastomose. Chirurg 45:226, 1974 13. Novak, D., Biitzow, G. H., Becket, K. : Hepatic occlusion venography with a balloon catheter in portal hypertension. Radiology 122:623, 1977 14. Otte, J.B., Lambott, L., Kestens, P.M. : Hepatic arterialization and portacaval shunt in hepatic cirrhosis. Abstract No. 42, Fourth World Congress of Collegium lnternationale Chirurgie Digestivae (CICD). Davos, Switzerland, September 1976 15. Redeker, A.G., Geller, H.M., Reynolds, T.B.: Hepatic wedge pressure, blood flow, vascular resistance and oxygen consumption in cirrhosis before and after end-to-side portacaval shunt. J. Clin. Invest. 37:606-618, 1958 16. Reuter, S.R., Orloff, M.J. : Wedged hepatic venography in patients with end-to-side portacaval shunts. Radiology 111 : 563 566, 1974 17. Reuter, S.R., Berk, R.N., Orloff, M.J.: An angiographic study of the pre- and postoperative hemodynamics in patients with side-to-side portacaval shunts. Radiology 116:33 39, 1975 t8. Von Buerger, K., Zimmermann, H.B., Huebner, R., Hagemann, E., Muenchow, R., Tausch, W.: Zusfitzliche Arterialisation der Leber bei portosystemischen Shuntoperationen. Der iliko-portale Saphenabypass. Zentralbl. Chir. 98:558 561, 1973
Cardiovasc. Radiol. 1, 255-259 (1978)
Arterialization of the Portal Vein in Cirrhosis: The Findings at Wedge Hepatic Venography E.C. Martin, ~ D.H. Gordon, 1 and R.J. Adamsons 2 Departments of Radiology I and Surgery, 2 State University of New York, Downstate Medical Center, Brooklyn, New York, USA
Abstract. A new operation for the treatment of cirrhosis and portal hypertension has recently been described involving arterialization of the portal vein in combination with an end-to-side portacaval shunt. We present, for the first time, the appearances at wedge hepatic Venography. No significant change is seen in the wedge hepatic pressure as a result of this technique, and the sinusoidal pattern is preserved. Filling of the portosplanchnic collaterals is not as frequent as after end-to-side shunts alone, and the appearances seem to reflect improved sinusoidal perfusion. The clinical results have been encouraging.
technique, but the radiologic appearance of the arterialized shunts has not previously been reported. We present the findings at wedge hepatic venography and compare them with the descriptions in the literature of the radiologic appearance of end-toside portacaval shunts uncomplicated by arterialization [16]. Materials and Methods Eighteen patients have been given end-to-side portacaval shunts and arterialization of the portal vein at Downstate Medical Center. Seven of these patients were studied with wedge hepatic venography
Key words: Cirrhosis - Portal vein arterialization - Portacaval shunt, end-to-side.
Numerous operations have been devised for the management of portal hypertension, but there has been an increasing dissatisfaction over the last ten years with the long-term results. A new approach to the problem ofportacaval shunting has involved the addition of arterialization of the portal vein to give a dual hepatic perfusion, and approximately 250 patients operated upon, predominantly in Europe, constitute the world experience to date [1, 2, 9-12, 14, 18]. A refined operative technique has been advocated recently and constitutes the United States experience with this type of surgery. It involves a saphenous vein graft interposed between the gastroepiploic artery and the ligated stump of the portal vein combined with an end-to-side portacaval shunt [2, 7] (Fig. 1). Encouraging results have been achieved with this Address reprint requests to: E.C. Martin, M.D., Department of Radiology, Box 1208, Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203, USA
Fig. 1. The arterialization operation. A saphenous vein graft (black arrow) has been interposed between the gastroepiploic artery (white arrow) and the portal vein (open arrow).
0342-7196/78/0001-0255 $01.00 ~ 1978 Springer-Verlag New York Inc.
256
E.C. Martin et al. : Arterialization of the Portal Vein
Tablel: Findings at wedge hepatic venography of patients with end-to-side portacaval shunts and arterialization of the portal vein Patient
l
2 3 4 5 6 7
Wedge hepatic vein pressure (cm of water) Preoperative
Postoperative
35 20 37 12 33 35 45
37 14 43 12 27 30 35
Parenchymal inhomogeneity '~
Portal vein filling
Portosystemic collaterals
Hepatic vein filling Veins filled via sinusoids
Total number filled b
3
-
-
+
4
2 1 2 3 2 3
+ + -
+ + +
+ + + + -
1 2 2 3 2 1
Scale from 1 3 of increasing inhomogeneity
+ + ~
Including hepatic vein injected
Fig. 2A and B. A lnhomogeneous parenchyma, grade I. The distal portal vein fills, as does one hepatic vein (in addition to the hepatic vein injected). B lnhomogeneous parenchyma, grade 3. Portal vein filling can be seen.
from one month to two years after surgery (mean, eight months). In six patients the diagnosis was alcoholic cirrhosis and in one, schistosomiasis. All patients had portal hypertension, complicated by variceal bleeding in six patients and hepatocellular failure in one. In all patients both the portacaval and the arterial shunts were patent and working at the time of the study. Wedge hepatic venograms were performed with a size 7 French, curved, end-hole catheter, using either a femoral or median cephalic vein approach. In one patient we employed a balloon occlusion catheter [13]. Injections were made at 2-3 ml/sec using 10-15 ml of methyglucamine diatrizoate 76% (Hypaque).
Venograms were evaluated for (I) the sinusoidal filling pattern, (2) the number of hepatic veins filled, (3) portal vein filling and the direction of flow, and (4) the presence of hepatosplanchnic collaterals. The wedge hepatic vein pressure was also recorded.
Results
T h e f i n d i n g s at w e d g e h e p a t i c v e n o g r a p h y
are shown
in T a b l e 1. T h e p a t i e n t w i t h s c h i s t o s o m i a s i s
and one
E.C. Martin et al. : Arterialization of the Portal Vein
257
Fig. 3. Portal vein filling. There is a grade 2 inhomogeneous parenchyma. Fig. 4. Portosplanchnic collateral vein. A collateraI vein (arrow) through the gall bladder bed opacifies retrogradely fi-om the portal vein.
other patient had near-normal postoperative wedge pressures, while the other five patients had elevated wedge pressures, ranging from 27 to 43 cm of water. There was no significant change in the mean of the wedge pressures as a result of surgery: the mean preoperative wedge pressure was 31 cm of water, and the mean postoperative wedge pressure was 28 cm of water. Wedge venography demonstrated an inhomogeneous sinusoidal pattern in all seven patients, with a range of inhomogeneity that was arbitrarily graded on a scale of 1 3. One patient had a relatively homogeneous parenchyma, while various degrees of inhomogeneity were seen in the others (Fig. 2); however, there was no true nodular appearance with berrylike protuberances from the hepatic vein, as described after side-to-side portacaval shunts [17]. In two patients the hepatic vein injected was the only one to fill, while in the other patients several other hepatic veins filled via the sinusoids. Contrast flowed through the sinusoids and into the portal vein in the four patients in w h o m the fewest hepatic veins filled (Fig. 3). Flow was hepatopetal in the portal veins outlined, and there seemed to be no relationship between portal vein filling and the hepatic wedge pressure. N o portal vein filling was seen in the other three patients.
In three patients a collateral vein of 1 4 m m ran through the gall bladder bed (Fig. 4). True portosplanchnic shunting with caval opacification was not demonstrated in any of these patients. The wedge pressure was elevated in each instance; however, collateral vein filling was not seen in the other two patients with elevated wedge pressures. No differences in the arterial anastomosis were seen in any of the seven patients when it was separately injected.
Discussion
The technique of the operation has been described in the surgical literature [2, 7]. The objective is to deliver a low flow of arterial blood to the intrahepatic portion of the portal vein in an attempt to ameliorate the adverse metabolic consequences of portosystemic decompression. The mortality rate of the procedure has been acceptable (5.5%), and hepatic encephalopathy has been avoided. Postoperatively, all patients can tolerate an unrestricted protein diet and indeed, one patient has now been operated upon successfully for hepatic encephalopathy alone, uncomplicated by the variceal bleeding that was present in the other six [3, 7]. Liver function, as shown by serum albumin,
258
bilirubin and serum glutamic oxaloacetic transaminase (SGOT) levels, improved in all patients as a result of surgery. The rationale for portal vein arterialization derives from experience with a chronic dog preparation in which observations demonstrated that arterial inflow into the portal vein in amounts varying from 50-100% of normal portal flow is adequate to prevent atrophy of the liver and to abolish the detrimental metabolic consequences of portacaval shunting. Perfusion of the portal vein with arterial blood in these amounts did not damage the microstructure of the liver over an observation period of four years [4 6]. While the technique may well be unable appreciably to alter the pathologic findings in cirrhosis, it m a y affect the rate of change, and it certainly alters the physiology. In end-to-side portacaval shunts the outflow of the liver remains through the hepatic veins, and it is normal for the pressure on the hepatic side of the portal vein to remain elevated [15], although it does fall from preoperative values [6]. This is in contrast to side-to-side shunts, where portal vein pressures equalize with the caval pressure. Under such circumstances of persisting portal hypertension, the development of hepatosplanchnic collaterals is to be expected and was indeed reported by Reuter in all five of his patients studied, though the collaterals became a m a jot source of outflow in only two of the five patients [16]. In contrast to Reuter's findings, wedge hepatic venography demonstrated portosystemic collaterals in only three patients in our group of seven in whom arterialization of the portal vein was added to an end-to-side portacaval shunt. This occurred despite the absence of a significant fall in the wedge pressures postoperatively and with the mainenance of a considerable pressure gradient between the portal vein and the systemic circulation. One explanation is that the hepatopetal portal flow created by the arterialization negates or disguises the effect of the pressure gradient. Yet although no difference in the function of the arterial shunt was seen in any of the patients, in three collaterals were demonstrated, in the fourth there was retrograde filling of the portal vein without portosystemic collateral opacification. The explanation for the different pattern of portal vein opacification is, therefore, not clear, although the radiologic appearance certainly differs notably from that of end-to-side portacaval shunts alone. Bookstein, in an arterial study of 17 patients with end-to-side portacaval shunts alone, noted hepatic artery to portal vein filling in 11. In two instances the outflow was demonstrated to be hepatosplanchnic collateral veins. In the other patients drainage was through the hepatic veins, and the differential obliter-
E.C. Martin et al.: Arterialization of the Portal Vein
ation of the hepatic venous bed in cirrhosis may account for the different paths of drainage [8]. The different number of hepatic veins filled on wedge venography and the apparent inverse relationship between hepatic and portal vein filling m a y well reflect this differential obliteration and further encourages caution in the interpretation of the findings. Again, comparing our findings to Reuter's series, none of our patients had a true nodular pattern on t h e parenchymal phase of the wedge hepatic venogram, and obliteration of the venous bed was not seen to the same degree as in end-to-side shunts alone without arterialization [16]. Certainly, the appearance is totally different from that seen after side-to-side portacaval shunts, where inhomogeneity is the norm and small berries of contrast material are found attached to narrow, feathery hepatic veins [17]. Despite the encouraging findings of less parenchyreal or venous obliteration and less retrograde portal filling and portosplanchnic collateral formation, one should not necessarily conclude that there has been an improvement in sinusoidal perfusion, nor a slowing of the progressive obliteration of the venous bed seen in cirrhosis, and caution should be used in attaching such a significance to these findings. Further investigations of this new technique in the management of cirrhosis and portal hypertension will be rewarding and may come to explain the radiologic appearances. For the moment, it is, however, clear that wedge hepatic venography does not give the same patterns after this operation as in end-to-side shunts alone, and hepatosplanchnic collaterals are not as frequent after arterialization. Neither is viusalization of the portal vein as frequent, and the appearance of the parenchyma on wedge hepatic vein injections may well be better than after the simple operation alone. Since the pathophysiology has been altered by this operation in comparison to end-to-side portacaval shunting alone, it is not surprising that the radiologic appearances differ, but at this stage a logical pathophysiologic explanation is not available. The effects of arterialization, both on the sinusoids and on the venous outflow patterns of the liver, are as yet unknown. When they are revealed, a better correlation with the wedge hepatic vein studies may well be found. For the moment, both the clinical and angiographic results seem to be encouraging.
References 1. A d a m s o n s , R.J., Moskowitz, H., Lerner, B.: Portacaval shunt with arterialization of the hepatic portion of the portal vein. Curr. Top. Surg. Res. 2:87-92, 1970
E.C. Martin et al. : Arterialization of the Portal Vein 2, Adamsons, R.J., Kinkhabwala, M., Moskowitz, H., Himmelfarb, E., Minkowitz, S., Lern'er, B. : Portacaval shunt with arterialization of the hepatic portion of the portal vein. Surg. Gynecol. Obstet. 135:529 535 , 1972 3. Adamsons, R.J., Levin, D.C.: Hepatic encephalopathy after portosystemic shunt treated by arterialization of intrahepatic portal vein. Surg. Forum 25 : 348, 1974 4. Adamsons, R.J., Arif, S., Babich, A., Butt, K., Lam, A., Minkowitz; S.: Arterialization of the liver in combination with a portacaVal shunt in the dog. Surg. Gynecol. Obstet. 140: 594-600, 1975 5. Adamsons, R.J., Arif, S., Babich, A., Butt, K., Ikramuddin, S., Lam, A.: The effect of arterialization of the portal vein on the prevention of atrophy of the hepatic parenchyma in dogs with portacaval shunt. Enr. Surg. Res. Abstr. 8 (Supplement) : 16, 1976 6. Adamsons, R.J., Arif, S., Babich, A., Butt, K., Lam, A., lkramuddin, S., Minkowitz, S. : Hemodynamic basis of long-term survival of dogs with portacaval shunt and arterialization of the liver. Abstract No. 43, Fourth World Congress Collegium Internationale Chirurgie Digestivae (DICD). Davos, Switzerland, September 1976 7. Adamsons, R.J., Butt, K., Swaminath, I., DeRose, J., Dennis, C.R., Kinkhabwala, M.: Portacaval shunt with arterialization of the portal vein by means of a low flow arterio-venous fistula. Presented at the American College of Surgery, Dallas, Texas, October 1977 8. Bookstein, J., Boijsen, E., Olin, T., Vang, J.: Angiography after end-to-side portacaval shunt: Clinical laboratory and pharmacoangiographic observations. Invest. Radiol. 6:101 - 109, 1971 9. Burlui, D., Ratin, O., Maneseo, G., T~ju, G.: Art6rialisation
259 portale par la veine ombilicale r6perm6abilis6e. La Presse M6dicale 76: 581-584, 1968 10. Fritsch, A., Funovics, J., Gangl, A., Horak, W., Grabner, G , Kohl, P.: Die kontrollierte Arterialisation der Leber. II. Klinische Ergebnisse Langenbecks. Arch. Chir. 336:67-69, 1974 11. Maillard, J.N., Rueff, B., Prandi, D., Sicot, C. : Hepatic arterialization and portacaval shunt in hepatic cirrhosis: An assessment. Arch. Surg. 108:315-320, 1974 1'2, Matzander, U.: Methode und Technik der druckadaptierten Leberarterialisation mit portacavaler Anastomose. Chirurg 45:226, 1974 13. Novak, D., Biitzow, G. H., Becket, K. : Hepatic occlusion venography with a balloon catheter in portal hypertension. Radiology 122:623, 1977 14. Otte, J.B., Lambott, L., Kestens, P.M. : Hepatic arterialization and portacaval shunt in hepatic cirrhosis. Abstract No. 42, Fourth World Congress of Collegium lnternationale Chirurgie Digestivae (CICD). Davos, Switzerland, September 1976 15. Redeker, A.G., Geller, H.M., Reynolds, T.B.: Hepatic wedge pressure, blood flow, vascular resistance and oxygen consumption in cirrhosis before and after end-to-side portacaval shunt. J. Clin. Invest. 37:606-618, 1958 16. Reuter, S.R., Orloff, M.J. : Wedged hepatic venography in patients with end-to-side portacaval shunts. Radiology 111 : 563 566, 1974 17. Reuter, S.R., Berk, R.N., Orloff, M.J.: An angiographic study of the pre- and postoperative hemodynamics in patients with side-to-side portacaval shunts. Radiology 116:33 39, 1975 t8. Von Buerger, K., Zimmermann, H.B., Huebner, R., Hagemann, E., Muenchow, R., Tausch, W.: Zusfitzliche Arterialisation der Leber bei portosystemischen Shuntoperationen. Der iliko-portale Saphenabypass. Zentralbl. Chir. 98:558 561, 1973
