Experimental evaluation of portal venous pulsatile flow synchronized with heartbeat intervals: effects of vascular clamping on portal hemodynamics

Purpose

We previously showed that blood flow in the portal vein was pulsatile and influenced by both the inferior vena cava and the arterial system in a complex manner (Nihei et al., 38:141–149, 2011). The objective of the present study is to identify determinants of blood flow and to clarify the source of pulsatile flow in the portal vein.

Methods

Three-breed terminal crossbreed mini-pigs underwent general anesthesia. Pressure and flow in the portal vein, inferior vena cava, hepatic artery, and mesenteric artery were measured simultaneously. Vascular occluders were placed in the inferior vena cava, hepatic artery, and mesenteric artery to examine the effects of clamping on portal venous flow.

Results

Clamping of the mesenteric artery altered pressure and flow waves in the portal vein to waveforms similar to those in the inferior vena cava. Waves resembling those of the inferior vena cava superimposed on portal venous flow appeared later than waves of the inferior vena cava. Clamping of the inferior vena cava promptly altered portal venous pressure and flow. Because clamping of the inferior vena cava led to a sharp rise in portal venous pressure, detailed evaluations were not feasible. Clamping of the hepatic artery had no effect on flow-wave pulsation in the portal vein.

Conclusions

In the hepatic circulation, flow-wave pulsation in the portal vein is influenced by flow in the inferior vena cava via the sinusoids and by flow in the mesenteric artery via the capillary vessels of the intestine.     

Portosystemic collateral vessels in liver cirrhosis: a three-dimensional MDCT pictorial review

Purpose

Portosystemic collateral vessels (PSCV) are a consequence of the portal hypertension that occurs in chronic liver diseases. Their prognosis is strongly marked by the risk of digestive hemorrhage and hepatic encephalopathy.

Materials and methods

CT was performed with a 16-MDCT scanner. Maximum intensity projection and volume rendering were systematically performed on a workstation to analyze PSCV.

Results

We describe the PSCV according to their drainage into either the superior or the inferior vena cava. In the superior vena cave group, we found gastric veins, gastric varices, esophageal, and para-esophageal varices. In the inferior vena cava group, the possible PSCV are numerous, with different sub groups: gastro and spleno renal shunts, paraumbilical and abdominal wall veins, retroperitoneal shunts, mesenteric varices, gallbladder varices, and omental collateral vessels. Regarding clinical consequences esophageal and gastric varices are most frequently involved in digestive bleeding; splenorenal shunts often lead to hepatic encephalopathy; the paraumbilical vein is an acceptable derivation pathway for natural decompression of the portal system.

Conclusion

Knowledge of precise cartography of PSCV is essential to therapeutic decisions. MDCT is the best way to understand and describe the different types of PSCV.     

Investigating the benefit of adding a vena cava filter to anticoagulation with fondaparinux sodium in patients with cancer and venous thromboembolism in a prospective randomized clinical trial

Background

The benefit of adding a vena cava filter to anticoagulation in treating cancer patients with venous thromboembolism remains controversial. We initiated this study as the first prospectively randomized trial to evaluate the addition of a vena cava filter placement to anticoagulation with the factor Xa inhibitor fondaparinux sodium in patients with cancer.

Methods

Sixty-four patients with deep vein thrombosis (86?%) and/or pulmonary embolism (55?%) were randomly assigned to receive anticoagulation with fondaparinux sodium with or without a vena cava filter. Endpoints included rates of complications by treatment arm, recurrent thromboembolism, complete resolution of thromboembolism, and survival rates.

Results

No patient had a recurrent deep vein thrombosis; two (3?%) patients had new pulmonary emboli, one in each randomized cohort. Major bleeding occurred in three patients (5?%). Two patients on the vena cava filter arm (7?%) had complications from the filter. Median survivals were 493?days in the anticoagulation only arm and 266?days for anticoagulation?+?vena cava filter (p?Conclusions No advantage was found for placement of a vena cava filter in addition to anticoagulation with fondaparinux sodium in terms of safety, recurrent thrombosis, recurrent pulmonary embolism, or survival in this prospective randomized trial evaluating anticoagulation plus a vena cava filter in cancer patients. Favorable complete resolution rates of thrombosis were observed on both study arms.     

超声观测副肝静脉(肝短静脉)在Budd-Chiari综合征中的临床意义

目的 评价超声检测Budd-Chiari综合征（Bcs）患者副肝静脉的可行性及价值。方法 运用彩超对31例BCS患者的副肝静脉进行检测和分析。 结果 31例BSC患者中，28例超声检测到副肝静脉，显示率90．3％（28／31）。典型的副肝静脉表现为与下腔静脉相通的异常迂曲的管道，并通过交通支与3支肝静脉相通；肝右后叶内走行无明显迂曲或稍迂曲的副肝静脉主要分布于肝段VI及邻近的肝组织内，与三大肝静脉较少形成交通支。 结论 超声显像在大多数BCS患者中可以直观、动态地观察副肝静脉的形态、侧支循环情况及其血流动力学变化，对病情的诊断、治疗方案的制定和预后判断都有重要意义。     

Sonography in Budd-Chiari syndrome.

OBJECTIVE: The objective of this presentation is to provide an overview of sonographic manifestations of Budd-Chiari syndrome (BCS). METHODS: Patients were scanned with ultrasound systems using mainly a 2- to 5-MHz curvilinear transducer and in some patients a 5- to 12-MHz linear transducer. The patients were asked to fast from the previous night or for at least 6 hours. Color and spectral Doppler sonography was performed in all patients. RESULTS: Commonly seen findings in BCS include inferior vena cava (IVC) webs and thrombi, IVC narrowing, hepatic venous thrombosis, enlarged caudate lobes, ascites, intrahepatic or extrahepatic collaterals, monophasic to absent flow in the hepatic veins, and high flow velocities in areas of stenosis in the IVC or hepatic veins. Inferior vena cava stents used in the treatment of BCS could also be seen. CONCLUSIONS: Budd-Chiari syndrome is an uncommon disorder; outcome is poor in many cases; and the condition is often misdiagnosed or underdiagnosed. Sonography is a noninvasive and effective modality for diagnosis of BCS.     

Budd-Chiari综合征64层CT动态增强扫描强化特征及CT血管成像分析

目的：探讨布-加综合征（Budd-Chiari syndrome,BCS）肝脏64层CT动态强化规律及成像基础,分析CT血管成像技术（CTA）在Budd-Chiari综合征中的应用价值.材料与方法：对1 1例Budd-Chiari综合征病人进行三期增强检查,并对相关血管分别行最大密度投影（MIP）、容积成像（VR）和多平面重建（MPR）,分析Budd-Chiari综合征患者肝脏64层CT动态强化的规律,并观察肝静脉、下腔静脉病变类型及肝内外侧枝循环情况.结果：11例螺旋CT动态增强的BCS患者3例为急性期,8例为慢性期.7例为肝静脉梗阻,4例为下腔静脉梗阻.门脉期肝脏周边强化型4例,中心强化型2例,斑片强化型1例,均匀强化4例.肝内侧支静脉开放6例,其它征象如肝肿大、肝脏尾叶增大、脾大、腹水、肝内外侧枝血管形成等表现也可见到.结论：64层螺旋CT动态增强扫描可无创性显示肝脏血流动力学变化,结合CTA技术,能直观、准确地显示血管梗阻平面及肝内、外侧支循环情况.     

多层螺旋CT血管成像评价肝移植受者移植前后血管结构

背景:多层螺旋CT具有先进的扫描技术和强大的图像后处理功能,其亚秒级的扫描速度及各向同性的成像功能,在血管成像上有很多优势.目的:探讨多层螺旋CT血管成像技术对肝移植受者移植前后血管结构评价的应用价值.设计、时间及地点:回顾性分析,以肝移植受者肝脏血管为观察对象,自身对照观察,于2003-10/2006-12在中山大学附属第五医院放射科完成.对象:选择拟行原位肝移植患者27例,年龄31～67岁,男17例,女10例.方法:轴位螺旋扫描范围为膈顶上方2 cm至双肾下极以下.电压120 kV,动脉期准直0.75 mm,平扫、门脉期、肝静脉期准直1.5 cm;使用非离子型对比剂优维显,注射速度为3 mL/s,三期增强扫描延迟时间分别为20～25 s,50～55 s,75～80 s.重建增强的薄层图像序列,动脉期层厚1 mm,间隔0.7 mm;门脉期、肝静脉期层厚2 mm,间隔1 mm.将图像序列传入后处理工作站,以MIP、VR等方式显示腹腔干系、门脉系、肝静脉及下腔静脉血管的三维结构.主要观察指标:肝移植前后患者血管三维结构.结果:移植前所有患者腹腔干系均得到良好显示,21例肝动脉走形正常,6例患者肝动脉变异,其中门静脉海绵样变2例,门脉多发血栓1例,因不适宜手术此3例未进行肝移植.24例患者第二肝门及下腔静脉肝内段血管结构显示清楚,肝右静脉单独汇入下腔静脉、肝左静脉和肝中静脉先汇合后再注入下腔静脉18例,肝有静脉、肝中静脉及肝左静脉分别单独汇入下腔静脉6例,下腔静脉肝后段狭窄2例.17例肝移植后CT血管成像发现肝动脉吻合口部狭窄2例,门脉高压侧支迂曲缓解10例,另7例患者因检查费用问题选择B超检查.结论:多层螺旋CT血管成像能够清晰显示肝移植患者移植前后血管结构,对适宜手术的病例筛选、指导手术方案及移植后血管结构的评价具有重要意义.     

Transjugular liver biopsy using ultrasonographic guidance for jugular vein puncture and an automated device for hepatic tissue sampling: a retrospective analysis of 200 consecutive cases

Background

We retrospectively evaluated the value of the combination of ultrasonographic guidance for jugular vein puncture and an automated biopsy device for transjugular liver biopsy.

Methods

Transjugular liver biopsy was performed with ultrasonographic guidance for right internal jugular vein puncture and an automated device for hepatic tissue sampling (Quick-Core^®) in 200 consecutive patients in whom percutaneous transhepatic biopsy was contraindicated. Histopathologic specimens were reviewed for adequacy and complications related to the procedure were analyzed.

Results

Biopsies were technically successful in 198 of 200 (99%) patients. The two cases of technical failure were due to an acute angle between right hepatic vein and inferior vena cava (1%). Adequate gross hepatic tissue specimens (mean length, 11. 0 mm ± 5.3; range, 5.0–20.0 mm) were obtained in 198 (99%) patients, allowing definitive histological diagnosis in 196 of 198 patients, for an overall success rate of 98%. Neither cases of inadvertent injury of the carotid artery nor life-threatening intraperitoneal bleeding were observed. Minor complications were noted in 24/200 (12%) patients.

Conclusion

The combination of ultrasonographic guidance for jugular vein puncture and an automated biopsy device for tissue sampling is recommended for transjugular liver biopsy as it results in a safe, well-tolerated, and efficient technique.     

3.0T MR门静脉和下腔静脉血管成像对腹部肿瘤血管侵犯的评价

[目的]探讨阴道镜检查在宫颈病变诊断中的临床价值.[方法]2007年6月至2009年6月诊治275例宫颈病变患者,对其宫颈阴道镜及镜下活检结果进行分析.[结果]经病理确诊为慢性宫颈炎221例,宫颈上皮内瘤变（CIN） 39例 （CIN Ⅰ10例、CINⅡ16例、CIN Ⅲ13例）,宫颈癌15例.阴道镜检查对CIN的灵敏度为69%,特异度为94%,阳性预测值为64.3%,阴性预测值为94.8%,阳性似然比为10.89,阴性似然比为0.33,诊断符合率为90.18%.阴道镜检查对宫颈癌的灵敏度为67%,特异度为98%,阳性预测值为71.4%,阴性预测值为98.1%,阳性似然比为43.33,阴性似然比为0.34,诊断符合率为96.73%.[结论]阴道镜检查对宫颈癌尤其是癌前病变的早期诊断有重要的临床价值.     

中国河南地区布加氏综合征患者肝内静脉及侧支循环的超声表现分析

目的：探讨中国河南地区布加氏综合征（Budd-Chiari syndrome, BCS）患者肝内静脉及侧支循环的超声影像表现特点。方法：分析567例BCS患者肝内静脉及侧支循环的超声图像资料。结果：①肝左静脉（LHV）病变507例,肝中静脉（MHV）病变517例,肝右静脉（RHV）病变418例。LHV、MHV以膜性闭塞性病变最多,RHV以条索状闭塞最多。②567例BCS患者副肝静脉（AHVs）扩张403例,病变27例,AHVs有病变与无病变在下腔静脉（IVC）是否病变方面差异有统计学意义（P=0.000,连续校正法）。③肝内侧支循环类型8种。④567例BCS患者中395例肝内形成侧支循环,尾叶静脉与肝右后静脉在与主肝静脉（MHVs）形成侧支方面有统计学差异（P=0.000）。⑤病变的LHV、MHV、RHV形成侧支循环例数分别为331、319、104例,三者在形成侧支循环方面有统计学差异（P=0.000）,两两比较：LHV与MHV在形成侧支循环方面无统计学差异（P=0.234）,LHV与RHV及MHV与RHV在形成侧支循环方面有统计学差异（P=0.000）。结论：①中国河南地区BCS患者MHVs病变发生率高,多伴有副肝静脉代偿扩张及侧支循环形成。②BCS患者肝内侧支循环类型丰富,尾叶静脉与MHVs形成侧支循环数量明显多于肝右后静脉;LHV、MHV侧支循环形成数量多于RHV,MHVs病变主要类型与侧支循环形成多少有关。③AHVs有一定的病变率,IVC病变不是AHVs病变的主要诱因。     

B-TFE与3D DCE-MRA联合应用在布加综合征诊断中的价值

目的探讨B-TFE与3D DCE-MRA联合应用在布加综合征（BCS）诊断中的价值。材料与方法搜集经DSA证实的布加综合征患者32例,其中8例为单纯下腔静脉阻塞,2例为单纯肝静脉阻塞,22例为下腔静脉阻塞伴肝静脉阻塞。32例患者均行B-TFE和3D DCE-MRA检查,分析两种方法及联合应用时对BCS及其侧支循环的显示情况。结果 B-TFE正确诊断8例下腔静脉阻塞、18例下腔静脉阻塞伴肝静脉阻塞和2例肝静脉阻塞,总检出率为87.5%（28/32）;3D DCE-MRA正确诊断8例下腔静脉阻塞、19例下腔静脉阻塞伴肝静脉阻塞和1例肝静脉阻塞,总检出率为93.8%（30/32）。B-TFE共显示个193侧支循环,3DDCE-MRA则显示248个侧支循环。两者结合准确诊断全部BCS及其肝内外侧支循环。结论联合应用B-TFE和3DDCE-MRA是诊断BCS的理想方法。I     

Budd-Chiari syndrome: hepatic venous obstruction by an elevated diaphragm

We describe two cases of Budd-Chiari syndrome detected by magnetic resonance imaging that resulted from compression of the inferior vena cava by an elevated right hemidiaphragm. Magnetic resonance images demonstrated elevation of the right hemidiaphragm and medial deviation of the inferior vena cava with short segmental narrowing. The hepatic veins and inferior vena cava were patent but discontinuous. Hepatic venous drainage was assisted by multiple large intrahepatic collaterals. Received: 13 April 1998/Accepted: 3 June 1998     

Classification of hepatic venous outflow obstruction: ambiguous terminology of the Budd-Chiari syndrome

Severe hepatic venous outflow obstruction and its manifestations often are recorded under the label "Budd-Chiari syndrome." Unfortunately, this label is ambiguous; it does not clearly identify the site of the lesion (hepatic veins versus inferior vena cava), its morphologic features (thrombotic versus nonthrombotic), or its cause. In the literature, implied or expressed definitions vary. Use of a standardized topographic and pathogenetic classification of hepatic venous outflow obstruction would enable investigators to group patients with comparable conditions, as required for therapeutic trials, prognostic evaluations, and studies of pathogenetic pathways. Review of our own cases revealed that hepatic venous outflow obstruction involving large hepatic veins is usually thrombotic and that isolated obstruction of the inferior vena cava or of small hepatic veins is usually nonthrombotic. Application of such a classification seems feasible and may yield useful results.     

Embryogenetic malformations of the inferior vena cava, and their manifestations in adults

Five male patients with congenital anomalies of the inferior vena cava aged 20 to 43 were examined. The diagnosis and the level of aplasia were established on the basis of complex instrumental examination (duplex scanning of inferior extremity veins, pelvic veins, and retroperitoneal veins; computed and magnetic resonance tomography of the abdominal cavity; pelvic phlebography; retrograde cavagraphy). Together with inferior vena cava anomalies, other malformations such as pulmonary arterial stenosis or duplication of renal collector system were diagnosed in two patients. In three or 60% of the patients the disease had first manifested by the clinical picture of peripheral thrombosis (shin and femoral edema); fever, chill and subsequent edema of both legs had been first manifestations in two patients. Aplasia of the infrarenal segment of the inferior vena cava was revealed in two patients; in other two patients aplasia of the infrarenal, renal, and partly suprarenal segments of this magistral vessel was found; in one patient the whole vein was aplastic except a small part of the suprarenal segment, where the hepatic veins and the right suprapolar renal vein flew into. To establish an early diagnosis of a congenital inferior vena cava anomaly, the protocol of examination of patients with venous diseases should include ultrasound mapping of the suprarenal and infrarenal segments of the vena cava; in cases of agenesia it should include computed and magnetic resonance tomography and retrograde cavagraphy.     

下腔静脉血经肝回流入右心房：布—加氏综合征的一种特殊类型

目的 回顾性研究一种特殊类型的布－加氏综合征：下腔静脉肝回流入右心房。方法 彩多多普勒超声检查１１４例布－加氏综合征患者,观察下腔静脉和三支肝静脉的走行、入口和血流方向以及肝内外交流支。结果 共５例布－加氏综合征患者呈现特殊循环方式,表现为肝段下腔静脉血经一支肝静脉入肝,通过肝内交通支 另一支肝静脉回流右心房。诊断均经介入手术证实。结果 下腔静脉血经肝加 型布－加氏综合征是一种少见类型,其特点是下     

节段性狭窄闭塞布-加综合征的介入治疗

目的　探讨布 加综合征 (BCS)下腔静脉节段性狭窄、闭塞合并肝静脉阻塞的介入治疗。方法　 2 8例节段性狭窄、节段闭塞患者 ,多数合并 1～ 3支肝静脉闭塞 ,无合并下腔静脉血栓形成。应用球囊导管或房间隔穿刺针行下腔静脉开通术 ,下腔静脉开通后用 2 .0～ 2 .3cm球囊扩张后放入金属内支架。术后抗凝治疗 2年。结果　 2 7例患者成功进行了经皮穿刺球囊破膜扩张 ,即经皮腔内血管成形术 (PTA)和血管内支架植入治疗。闭塞肝静脉多数扩张下腔静脉后同时开通。患者肝、脾缩小 ,腹水吸收。 1例穿破下腔静脉急诊手术止血。随访 2～ 36个月未见复发及消化道出血。结论　下腔静脉狭窄者注意有肝静脉闭塞 ;下腔静脉闭塞破膜后 ,2 0例肝静脉闭塞者 19例随之开放 ,无需特殊处理 ;安放支架时注意保护肝静脉入口。     

Budd-Chiari syndrome associated with liver cirrhosis: A case report

BACKGROUNDBudd-Chiari syndrome (BCS) is a rare heterogeneous liver disease characterized by obstruction of the hepatic venous outflow tract. The incidence of BCS is so low that it is difficult to detect in general practice and difficult to include within the scope of routine diagnosis. The clinical manifestations of BCS are not specific; hence, BCS tends to be misdiagnosed.CASE SUMMARYWe report the case of a 33-year-old Chinese woman who presented with progressive distension in the upper abdomen. She was initially misdiagnosed with liver cirrhosis (LC) due to abnormalities on an upper abdominal computed tomography scan. Although she was taking standard anti-cirrhosis therapy, her symptoms did not improve. Magnetic resonance imaging showed caudate lobe hypertrophy; and dilated lumbar and hemiazygos veins. Venography revealed membranous obstruction of the inferior vena cava owing to congenital vascular malformation. A definitive diagnosis of BCS was made. Balloon angioplasty was performed to recanalize the obstructed inferior vena cava and the patient’s symptoms were completely resolved.CONCLUSIONBCS lacks specific clinical features and can eventually lead to LC. Clinicians and radiologists must carefully differentiate BCS from LC. Correct diagnosis and timely treatment are vital to the patient''s health.     

FIESTA序列对Budd-Chiari综合征下腔静脉病变的诊断价值

目的：探讨FIESTA序列对Budd-Chiari综合征(BCS)下腔静脉病变的诊断价值。材料与方法回顾性分析51例临床诊断为BCS的患者的下腔静脉病变情况,以DSA为诊断金标准,评估FIESTA序列对下腔静脉病变的诊断能力,包括检出静脉病变的敏感度、特异度、诊断准确度,显示下腔静脉血栓、下腔静脉瘤的能力。结果 MRI诊断准确有41例,灵敏度为97.61%、特异度为55.56%、准确度为90.20%;发现下腔静脉血栓8例,下腔静脉瘤样扩张4例。结论 FIESTA序列在显示BCS的下腔静脉中具有直观、准确率较高、无需对比剂的优点,可作为诊断BCS下腔静脉病变的常规序列。     

布-加综合征介入治疗前后血流动力学变化的彩色多普勒研究

目的 搪塞布－加综合征（ＢＣＳ）介入治疗前后特征性异学血管形态及血流动力学变化。方法 对１８６例ＢＣＳ分别于治疗前及治疗后一周进行彩色多普勒检测。结果 １８６例ＢＣＳ中,下腔静脉狭窄或阻塞者,远下腔静脉扩张,肝狭窄或阻塞者,其血流通过肝内侧支至未闭的肝静脉,或通过副肝静脉流处下腔静脉。治疗后可见知流通过开通的肝静脉及下腔静脉,内支架形状清晰可见。结论彩色多普蚵准确观察ＢＣＳ特异性为其诊断及随访的主     

Guidewire localization by transthoracic echocardiography during central venous catheter insertion: a periprocedural method to evaluate catheter placement

Purpose

To evaluate the feasibility of guidewire detection in right cardiac cavities by transthoracic echocardiography (TTE) in order to detect catheter misplacement and to optimize central venous catheter (CVC) positioning. Ultrasonic control for catheter tip positioning was compared to that by chest X-ray (CXR).

Methods

We conducted a monocentric prospective observational study (January–November 2010). All consecutive patients undergoing CVC insertion were included. The puncture was performed using the landmark method or ultrasound guidance. TTE was performed during the procedure to follow the arrival of the guidewire in the right cardiac cavities. Catheter misplacement was defined as an aberrant position on the postprocedural CXR (catheter positioning in ipsilateral or contralateral veins). The primary endpoint was the prediction of catheter misplacement by guidewire detection in the cardiac cavities. The secondary endpoint was the optimization of the catheter tip placement in the superior vena cava.

Results

A total of 98 patients received 101 CVC. The guidewire was visualized in 92 cases. In five cases, the guidewire was not seen in the right cardiac cavities and CXR showed catheter misplacement. In four cases, poor echogenicity led to the ultrasound examination being abandoned. Catheter misplacement was detected by TTE with a sensitivity of 96 % (CI 90–98 %), a specificity of 83 % (CI 44–97 %), a positive predictive value of 98 %, and a negative predictive value of 55 %. Likelihood ratios were LR+ 5.7 (CI 0.96–34.4) and LR? 0.05 (CI 0.02–0.14). Guidewire removal under TTE avoided an excessively distal position of the catheter tip in all cases.

Conclusion

TTE is a reliable tool to detect catheter misplacement and to optimize catheter tip positioning during the procedure of CVC insertion.