Hepatic arterioportal shunts not directly related to hepatocellular carcinoma: findings on CT during hepatic arteriography, CT arterial portography and dual phase spiral CT

AIM: To evaluate findings of arterioportal shunts not directly related to hepatocellular carcinoma (HCC) which were seen within third-order portal branches on computed tomography (CT) during hepatic arteriography (CTHA), arterial portography (CTAP), and dual phase spiral CT.MATERIALS AND METHODS: At CTHA in 112 patients, we examined third-order portal vein branches to find arterioportal shunts not directly related to HCC. Six cases were found. We evaluated the findings of these shunts on CTHA and investigated whether CTAP (n = 6) and dual phase spiral CT (n = 5) showed perfusion defects in the corresponding areas on arterioportal shunts. RESULTS: Five of six cases showed abrupt visualization of portal branches without visualization of the proximal portion of CTHA. Five of six cases showed no perfusion defect on CTAP and no hyperattenuating area on CTHA. Four of five cases showed no hyperattenuating area on hepatic arterial phase spiral CT. CONCLUSION: Arterioportal shunts not directly related to HCC and occuring within third-order portal branches mainly showed abrupt visualization of portal branches on CTHA. These occurred frequently without perfusion defects on CTAP and without a hyperattenuating area on CTHA and hepatic arterial phase spiral CT.Park, C. M. (2000). Clinical Radiology55, 465-470.     

Dynamic CT features of arterioportal shunts in hepatocellular carcinoma

Dynamic computed tomographic (CT) findings of 42 patients with hepatocellular carcinoma having angiographically proven arterioportal shunt were reviewed. CT findings related to arterioportal shunt were as follows: early enhancement of the portal vein, which showed a time-density curve similar to that of the aorta, markedly prolonged enhancement of the portal vein, dilated, abnormal intrahepatic vessels often accompanied by irregular, transiently enhanced areas, transient high attenuation of lobar or segmental distribution in the lobe contralateral to the main tumor, and transient wedge-shaped enhancement peripheral to the tumor. Dynamic CT usually detected arterioportal shunts involving larger portal veins as represented by any of the first four findings (14 of 17), whereas detection of arterioportal shunts involving smaller portal veins was lower in frequency (8 of 25), but such a shunt could be demonstrated as transient wedge-shaped enhancement peripheral to the tumor.     

Conformal radiation therapy for hepatoma with portal vein thrombosis

A 43-year-old male patient was diagnosed as having hepatocellular carcinoma with portal vein thrombosis and arterioportal shunts. Three-dimensional conformal radiation therapy (3DCRT) with high focal dose was given to the left portal venous area. Shrinkage of the tumour and thrombus, disappearance of the arterioportal shunts and restoration of the hepatopedal flow of the portal vein was noted 3 months after treatment. The patient received further transarterial embolisation and achieved successful tumour control. No serious complications were encountered. 3DCRT is technically feasible and effective to treat a small volume of liver tissue with a high dose of radiation in this advanced disease.     

Angiographic demonstration of intrahepatic arterio-portal anastomoses in hepatocellular carcinoma.

Hepatic angiograms of 114 patients with hepatocellular carcinoma (HCC) were studied, particularly changes in the portal vein branches. Arterio-portal shunts of varying sizes, evidenced by opacification of intrahepatic portal branches, were seen in 72 cases (63.2%), with retrograde opacification of the portal vein trunk in 29 (25.4%). At least four types of shunts were found: (a) through a tumor thrombus in the portal branch, (b) in a retrograde direction via a peripheral tumor nodule, (c) through a small tumor invading or amputating an artery, and (d) through a tumor located near a major portal vein branch and supplied by a large, coiling artery. Postmortem angiography of the liver in 50 patients with HCC suggests that arterio-portal shunts are the result of the special vasculature in HCC and are highly diagnostic when accompanied by other angiographic changes.     

CT during hepatic arteriography and portography: an illustrative review.

The combination of computed tomography (CT) during arterial portography (CTAP) and CT during hepatic arteriography (CTHA) has been used for evaluation of hepatic neoplasms before partial hepatic resection. Focal hepatic lesions that can be demonstrated with CTAP and CTHA include regenerative nodules, dysplastic nodules, dysplastic nodules with malignant foci, hepatocellular carcinoma, cholangiocarcinoma, hemangioma, and metastases. CTAP is considered the most sensitive modality for detection of small hepatic lesions, particularly small hepatic tumors such as hepatocellular carcinoma and metastatic tumors. CTHA can demonstrate not only hypervascular tumors but also hypovascular tumors and can help differentiate malignant from benign lesions. However, various types of nontumorous hemodynamic changes are frequently encountered at CTAP or CTHA and appear as focal lesions that mimic true hepatic lesions. Such hemodynamic changes include several types of arterioportal shunts, liver cirrhosis, Budd-Chiari syndrome, inflammatory changes, pseudolesions due to an aberrant blood supply, and laminar flow in the portal vein. Familiarity with the CTAP and CTHA appearances of various hepatic lesions and nontumorous hemodynamic changes allows the radiologist to improve the diagnostic accuracy.     

Postbiopsy arterioportal fistula in patients with hepatocellular carcinoma: clinical significance in transarterial chemoembolization

OBJECTIVE: The purpose of this study was to determine, retrospectively, the frequency of postbiopsy arterioportal fistula in hepatocellular carcinoma and its significance in transarterial chemoembolization (TACE). MATERIALS AND METHODS: Forty-one patients who underwent percutaneous liver biopsy for diagnosis of hepatocellular carcinoma were referred for TACE. The control population comprised 161 patients referred during the same period who underwent TACE without biopsy. We determined that an arterioportal fistula was present by opacification of the portal vein during the arterial phase of angiography or by opacification with iodized oil during TACE. We considered hepatocellular carcinoma to be responsive to TACE when the sum of iodized oil retention in the tumor and a low-attenuation area on CT was greater than 50% of tumor size. We compared the frequency of arterioportal fistula and the rate of tumor response to TACE in both groups and also evaluated possible factors associated with postbiopsy arterioportal fistula, such as age, sex, Child-Pugh score, tumor size, average number of needle passes, average distance that the needle traversed normal liver before reaching the mass, and average interval between biopsy and TACE. RESULTS: Twenty-three (56.1%) of 41 patients in the biopsy group and 19 (11.8%) of 161 patients in the control group had an arterioportal fistula (p < 0.001). The rate of tumor response to TACE was 87.8% (36/41) in the biopsy group and 87.0% (140/161) in the control group (p = 0.5932). Of the possible related factors, only tumor size correlated negatively with the occurrence of arterioportal fistula. CONCLUSION: Percutaneous liver biopsy in hepatocellular carcinoma patients apparently increases the rate of arterioportal fistula but does not seem to affect the rate of tumor response to TACE.     

Transcatheter arterial embolization for advanced tumor thrombus with marked arterioportal or arteriovenous shunt complicating hepatocellular carcinoma

PURPOSE: To evaluate the efficacy and safety of transcatheter arterial embolization with gelatin sponge immersed in an anti-cancer agent (GIA-TAE) alone or combined with radiation therapy, in hepatocellular carcinoma with portal vein tumor thrombus (PVTT) or hepatic vein tumor thrombus (HVTT) complicated by marked arterioportal or arteriovenous shunts. MATERIALS AND METHODS: GIA-TAE was performed in 15 patients with PVTT and arterioportal shunts to the main portal trunk or first-order branch, and five with HVTT and arteriovenous shunts, adding radiation therapy in suitable cases. Primary efficacy, hemodynamic changes, Child-Pugh score, and survival rates were evaluated. RESULTS: GIA-TAE with or without radiation therapy was effective for tumor thrombus in 11 patients with PVTT and in four with HVTT. Treatment was effective for the main tumor in eight patients with PVTT and three with HVTT. Shunts disappeared in seven of 13 patients available for follow-up. Child-Pugh scores before and after the treatment were not significantly different. Median survival times of PVTT and HVTT groups were 8.7 and 12.2 months, respectively. One-year survival rates for both groups were about 15.6% and 50.0%, respectively. CONCLUSION: TAE with GIA alone or combined with radiation therapy is effective and safe for severe arteriovenous shunts with PVTT or HVTT, and also favors patient survival.     

Portal venous system after portosystemic shunts or endoscopic sclerotherapy: evaluation with Doppler sonography

We sought to determine the usefulness of duplex Doppler sonography in the assessment of blood flow and clot formation in the portal vein in 44 patients with portal hypertension and bleeding esophageal varices who had undergone either endoscopic sclerotherapy (28 cases) or portosystemic shunt procedures (16 cases). The main, left, and right portal veins (collectively referred to as intrahepatic portal veins), superior mesenteric vein, splenic vein, and shunt were assessed for flow direction, presence of thrombi, and collaterals. Patent shunts were visualized in 12 (75%) of the 16 cases. Clot was detected in 27 (69%) of 39 intrahepatic portal veins in patients with end-to-side shunts, in six (67%) of nine intrahepatic portal veins in patients with distal splenorenal shunts, and in five (5%) of 92 intrahepatic portal veins in patients who had had endoscopic sclerotherapy. Flow in the main portal vein was hepatopetal in two (15%) of 13 patients with patent shunts (one end-to-side portacaval shunt and one distal splenorenal shunt). Flow in the main portal vein was hepatopetal in 26 (93%) of 28 patients who had had endoscopic sclerotherapy. Our data suggest endoscopic sclerotherapy preserves antegrade portal flow and results in fewer portal vein clots than surgical portosystemic shunts do. Patterns of thrombosis and flow direction vary unpredictably from patient to patient. Shunt patency should not be inferred without direct visualization of the shunt.     

Non-tumorous enhancement caused by cholecystic venous inflow shown on biphasic CT hepatic arteriography: comparison with hepatocellular carcinoma

The haemodynamics in non-tumorous abnormalities on CT arterial portography (CTAP) owing to cholecystic venous direct inflow to the liver were compared with the haemodynamics in hepatocellular carcinoma. 53 patients who simultaneously underwent CTAP and CT during hepatic arteriography (CTHA) to detect hepatocellular carcinoma had the late phase added to CTHA. Changes in size, shape and pattern of 47 non-tumorous enhancement abnormalities on the liver around the gall bladder or in the dorsum of segment IV between the early and late phases on biphasic CTHA as well as of 60 tumorous lesions were determined. Enhancement on biphasic CTHA was seen in all 47 lesions with a non-tumorous portal defect (early phase alone, n=8; late phase alone, n = 3; both, n = 36). In these 47 lesions, the size and the shape of enhancement changed in 63.8% and 51.1%, respectively, between the early and late phases on CTHA; the pattern of enhancement did not change in 72.3%. On the other hand, the size of enhancement on biphasic CTHA changed in only 16.7% of 60 tumours, and the shape in only 5%, although the enhancement pattern changed in a large proportion (80%). In conclusion, owing to the difference in haemodynamics, non-tumorous abnormalities caused by cholecystic venous inflow and tumours are clearly delineated on biphasic CTHA. Thus, adding the late phase to previous single phase CTHA (i.e. performing biphasic CTHA) is useful in differentiating the two entities.     

Arterioportal shunts on dynamic computed tomography

Thirty-two patients, 20 with hepatocellular carcinoma and 12 with liver cirrhosis, were examined by dynamic computed tomography (CT) using intravenous bolus injection of contrast medium and by celiac angiography. Dynamic CT disclosed arterioportal shunting in four cases of hepatocellular carcinoma and in one of cirrhosis. In three of the former, the arterioportal shunt was adjacent to a mass lesion on CT, suggesting tumor invasion into the portal branch. In one with hepatocellular carcinoma, the shunt was remote from the mass. In the case with cirrhosis, there was no mass. In these last two cases, the shunt might have been caused by prior percutaneous needle puncture. In another case of hepatocellular carcinoma, celiac angiography but not CT demonstrated an arterioportal shunt. Thus, dynamic CT was diagnostic in five of six cases of arteriographically demonstrated arterioportal shunts.     

Congenital and acquired anomalies of the portal venous system.

Knowledge of the normal anatomy, most frequent variants, and congenital and acquired anomalies of the portal venous system is of great importance for liver surgery and interventional procedures such as creation of transjugular intrahepatic portosystemic shunts. Radiologic studies of the portal venous system include color Doppler ultrasonography (US), computed tomography (CT), magnetic resonance imaging, and arterial or direct portography. Among the most common branching variants of the portal vein are trifurcation, right anterior portal branch arising from the left portal vein, and right posterior portal branch arising from the main portal vein. Agenesis of the right or left portal vein is the most frequently reported congenital anomaly. Venous collateral vessels due to portal hypertension and cavernous transformation of the portal vein are best evaluated with cross-sectional imaging. Intrahepatic portosystemic, arterioportal, and arteriosystemic fistulas and associated perfusion anomalies have characteristic features at dual-phase helical CT. Color Doppler US is the single most useful tool for demonstration of aneurysms of the portal venous system and bland or neoplastic portal vein thrombosis. CT is also the best means of evaluating gas in the portal venous system, which is no longer an ominous sign and must be differentiated from aerobilia.     

肝癌合并肝动脉-门静脉分流影响门静脉血流动力学的定量研究

目的　通过门静脉系统置管直接测定肝动脉 门静脉分流 (APS)栓塞前后门静脉压力的改变 ;定量分析门静脉压力与门静脉高压症之间的变化关系。方法　对 18例肝癌合并中央型APS患者APS栓塞和肝动脉化疗栓塞术 (TACE) ,同时行经皮门静脉穿刺置管 ,测定APS分流道闭塞前后门静脉压力 ;术前及术后 2周行肝脏彩超及胃镜检查。结果　 18例患者术后门静脉主干压力显著降低 ,下降幅度为 5 .4 %～ 33.3% ,平均降幅为 2 0 .1% ;栓塞后门静脉直径缩小 ,血流速度加快 (P <0 .0 1) ;13例门静脉主干呈离肝血流患者 ,术后有 7例转为向肝方向。APS栓塞后 ,18例患者门静脉高压症状均有改善 ,在门静脉压下降幅度超过 2 0 %的 10例患者中 ,门静脉高压症有明显改善 ;门静脉压力下降在 2 0 %以下的8例患者中 ,门静脉高压症改善不明显。结论　栓塞APS能显著降低门静脉压力 ,平均降幅达 2 0 %以上 ;当门静脉压力降低 2 0 %及以上时可有效地改善腹水、上消化道出血和顽固性腹泻症等一系列门静脉高压症状     

Hepatic arteriography under temporary hepatic venous occlusion]

Hepatic arteriography with and without temporary segmental hepatic vein occlusion was performed in 10 patients, five of whom had chronic liver injury. Hepatic arteriograms obtained during hepatic venous obstruction demonstrated significantly more peripheral and definite arterial branches in the occluded area and fewer peripheral branches in the non-occluded segment. A prolonged, dense hepatogram (sinusoidogram) showing hepatofugal opacification of the portal vein was obtained in the occluded area. Only one case with a large veno-venous anastomosis did not show these findings. Hepatic arteriograms in two cases with hepatocellular carcinoma provided clear visualization of peripheral portal branches that could act as efferent tumor vessels during regional temporary hepatic vein occlusion. Temporary hepatic venous occlusion may cause a sudden increase of hepatic arterial flow in the occluded area and transsinusoidal arterioportal communication there. This method can be useful for the diagnosis and arterial infusion or embolization therapy of hepatic diseases.     

Iodized oil in the portal vein after arterial embolization

Transcatheter embolization with a relatively large amount (average, 17 mL) of iodized oil and doxorubicin hydrochloride with or without gelatin sponge particles was performed in 50 patients with hepatocellular carcinoma and in eight patients with liver metastases. After an intraarterial hepatic injection of an emulsion of iodized oil and doxorubicin hydrochloride, iodized oil was seen in the portal vein; the amount correlated with the amount that was injected, despite the lack of arterioportal shunting. Prominent portal vein appearances were seen in six of 21 cases (29%) given 10 mL or less of iodized oil, in 14 of 21 cases (67%) with 10-20 mL, and in 18 of 21 cases (86%) with more than 20 mL. Iodized oil may enter the portal vein through an arterioportal communication after pooling in the sinusoids.     

肝癌伴门静脉癌栓血流动力学变化的CT表现

目的:探讨肝癌合并门静脉癌栓的血流动力学变化及其CT表现,为肝癌的诊治及预后提供帮助。方法:经临床证实的原发性肝癌合并门静脉癌栓患者34例为研究组,不伴门静脉癌栓的25 例为对照组。所有病例均行螺旋CT三期增强扫描。结果:研究组34例中24例出现动脉期高灌注,9 例出现门脉期低灌注,研究组与对照组间肝实质灌注异常的差异具有显著性意义;研究组肝动静脉瘘发生率明显增加;门静脉主干癌栓常并发门静脉海绵样变性、胆囊静脉曲张及胆旁静脉丛扩张;CT可显示门脉高压的侧支循环。结论:原发性肝癌门静脉癌栓可引起肝脏血流动力学变化,正确认识其CT表现对指导临床具有重要意义。     

多层螺旋CT门静脉成像对门脉高压侧支循环血管的研究

目的:评价多层螺旋CT门静脉成像(MDCTP)在门脉高压侧支循环血管显示中的价值。方法:31例经临床检查确诊的门静脉高压患者行MDCTP检查,采用MIP、MPR、VR等重建技术进行图像后处理,获得门静脉系统及侧支血管图像,两名医师分别判断侧支血管显示情况。结果:MDCTP不仅显示肝内门静脉3~4级分支,还显示了整个门脉侧支血管系统。31例患者中,胃左静脉曲张28例,食管或食管旁静脉曲张27例,脾静脉曲张21例,胃短/胃后静脉曲张7例,脾-肾分流血管1例,脐静脉曲张伴腹壁静脉曲张2例,门静脉栓塞4例,肠系膜上静脉血管闭塞2例。结论:MDCTP能显示门静脉高压侧支血管开放的部位、范围及程度,有助于对门脉高压患者治疗方案的选择,是一种有重要临床价值的无创性门脉检查方法。     

The collateral circulations of the spermatic veins (author's transl)

The frequency and appearance of anastomoses between the spermatic veins and the inferior vena cava and portal vein, are analyzed in a series of 171 patients examined by retrograde spermatic phlebography. Spermatocaval anastomoses are divided into those that occur above the scrotum: direct (spermatocaval and iliospermatic) and indirect (perivertebral and ureteric); and those seen at the level of the scrotum (with the scrotal veins, veins of the vas deferens, and those from the contralateral scrotal area). Spermatoportal anastomoses are frequent but difficult to confirm because of the existence of proximal valves. Three cases are also reported which give examples where the spermatic vein played an important part in the collateral circulation (inferior vena cava thrombosis, left renal vein thrombosis, portal hypertension).     

三维对比剂增强MR血管成像诊断布加综合征的价值

目的观察三维对比剂增强MR血管成像（3DCEMRA）上布加综合征（BCS）的各种表现,并初步评价该项新技术的价值。方法33例BCS患者行3DCEMRA检查。23例为继发性BCS,分别继发于肝细胞癌（21例）、右肾上腺癌（1例）或血栓性静脉炎（1例）。10例为原发性BCS。观察肝静脉、下腔静脉（IVC）和门静脉的开放性,观察有无肝内外侧支、肝实质病变和门静脉一体静脉间曲张静脉。10例患者行下腔静脉造影术,2例行肝右静脉穿刺造影术,把3DCEMRA所获的诊断结果与造影相对照。结果3DCEMRA可显示BCS的各种表现。肝静脉表现包括：癌栓形成（19例）、肿瘤压迫（2例）、肝静脉未显示（4例）和局限性狭窄（4例）。IVC表现为严重狭窄或闭塞（10例）、肿瘤直接侵犯（2例）、癌栓形成（3例）、血栓性静脉炎（1例）和隔膜形成（3例）。9例显示肝内侧支形成,其中2例显示“蜘蛛网”征象。所见的肝外侧支包括扩张的奇静脉和半奇静脉（13例）,以及左肾一膈下一心包膈静脉侧支（2例）形成。2例患者发现门静脉左支闭塞,10例患者发生门静脉．体静脉间静脉曲张。3DCEMRA发现的肝实质病变有：尾叶增大（7例）、不均匀强化（18例）和并发肿瘤（18例）。12例3DCEMRA诊断结果均与造影结果一致。结论3DCEMRA能显示BCS的各种征象,并能帮助提供正确诊断。     

Budd-Chiari syndrome: CT observations

The authors describe four patients with Budd-Chiari syndrome in whom contrast material-enhanced computed tomographic (CT) scans demonstrated low-density venous thrombosis in three sites not, to our knowledge, previously described with this modality. Thrombosis was seen in the portal circulation, the hepatic veins, and the intrahepatic inferior vena cava. It is known that concomitant portal vein thrombosis may be seen in 20% of patients with Budd-Chiari syndrome. Three of the four patients in the current study had this finding, one with extensive thrombosis of portal, mesenteric, and splenic veins and the other two with portal vein branch involvement. In one patient hepatic vein thrombosis was demonstrated with CT, and in three inferior vena cava clot was demonstrated. All four patients had the distinctive hepatic parenchymal contrast enhancement pattern seen in this condition, which the authors think may be at least partially caused by associated portal thrombosis. The presence of portal venous thrombosis should prompt the observer to consider the diagnosis of Budd-Chiari syndrome. Detection of hepatic vein clot confirms the diagnosis and may be seen in this condition in association with inferior vena cava thrombus.     

Hepatoma, arterioportal shunting, and hyperkinetic portal hypertension: therapeutic embolization

Four patients with hepatocellular carcinoma, shunting of blood from the hepatic artery to the portal vein, and hyperkinetic portal hypertension were treated by transcatheter embolization of the hepatic artery. In three acutely bleeding patients variceal hemorrhage was controlled by the embolization. Following embolization hepatofugal portal venous flow became hepatopetal in all four patients. No serious complications were encountered. When hepatoma is complicated by arterioportal shunting and hyperkinetic portal hypertension, occlusion of the fistula by transcatheter embolotherapy can reduce the portal pressure.