Venographic appearance of portosystemic collateral pathways


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Venographic appearance of portosystemic collateral pathways

  1. 1. T he British Journal of Radiology, 70 (1997), 1302–1306 © 1997 The British Institute of Radiology Pictorial review Venographic appearance of portosystemic collateral pathways J AHN, MD, J M COOPER, MD, J E SILBERZWEIG, MD and H A MITTY, MD Mount Sinai Medical Center, Department of Radiology, Box # 1234, 1 Gustave L Levy Place, New York, NY 10029, USA Abstract. Many imaging modalities can be used to evaluate various portosystemic collateral pathways seen in patients with portal hypertension. A knowledge of various typical and atypical pathways is essential for a proper understanding of the disease process. Transjugular transhepatic portographic appearance of such pathways are discussed in detail. Introduction drains into the confluence of the SMV and the splenic vein. Portal hypertension is characterized by hepato- fugal flow via various portosystemic collateral Coronary and short gastric venouspathways. Gastrointestinal haemorrhage, one of collateralthe main complications of portal hypertension, may require endoscopic sclerotherapy, transjugular Coronary (left gastric) venous collaterals intrahepatic portosystemic shunt (TIPS) or surgi- (Figure 1) are the most commonly seen porto- cal intervention. The commonest source of bleeding systemic collateral pathways in portal hypertension is oesophagogastric varices and occasionally mes- with a reported incidence of 30–69% [2, 3]. They enteric varices. Other rare sources include peri- are the most important collaterals in cranially stomal and ileal conduit varices. Many less invasive directed hepatofugal flow. Coronary and short imaging modalities, such as Doppler sonography, gastric venous collaterals (Figure 2) are usually CT [1], and MRI are widely advocated to evaluate drained via coexisting oesophageal or paraoeso- these collaterals. Angiographic examination per- phageal varices and occasionally via spontaneous formed during TIPS procedure can also effect- gastrorenal or splenorenal shunts. ively demonstrate these collateral pathways. Angiographic evaluation includes indirect visualiz- Oesophageal or paraoesophageal varicesation of the venous phase via splenic and/or superior mesenteric arteriography and direct vis- These varices (Figure 1) usually arise from ualization via percutaneous transjugular trans- coronary and/or short gastric veins and drain hepatic portography. We present the venographic into azygous and hemiazygous veins. Oesophageal appearances of various collateral pathways demon- varices are the most common source of gastro- strated on transjugular transhepatic portograms. intestinal haemorrhage. Negative angiographic A knowledge of the various collateral pathways is findings on the indirect venous phase does not rule important in the evaluation and follow-up of out oesophageal varices. Endoscopy is the most patients with portal hypertension. reliable diagnostic procedure for detecting oeso- phageal varices. The paraoesophageal varices, however, cannot be detected by endoscopy. TheNormal portal venous anatomy size of the varices depends on the degree of portal The main portal vein is formed by the conflu- hypertension and the presence of other porto- ence of the splenic vein and the superior mesenteric systemic collateral pathways. vein (SMV). The inferior mesenteric vein drains into the splenic vein in two-thirds of individuals Umbilical or paraumbilical varices and the SMV in the remaining third. Other major The recanalized umbilical vein (Figures 3a andtributaries of the splenic vein include short gastric b) originates from the left intrahepatic portal vein,and gastroepiploic veins, and occasionally the left courses vertically in the falciform ligament andgastric (coronary) vein. The coronary vein usually drains into the superficial epigastric veins on the anterior abdominal wall, resulting in the caputReceived 29 May 1997 and in revised form 5 August 1997, accepted 13 August 1997. medusae. The course of the umbilical vein may T he British Journal of Radiology, December 19971302
  2. 2. Pictorial review: Portosystemic collateral pathways mimic that of the portal vein on anteroposterior to keep a TIPS patent and decrease the incidence of encephalopathy [6].projections and cause inadvertent catherization during TIPS procedures. The paraumbilical veins also originate from the left intrahepatic portal vein, Peristomal varices run within the ligamentum teres and course through the falciform ligament. Peristomal varices (Figures 8a–c) are a rare type of portosystemic collateral seen in patients with portal hypertension who have had priorDuodenal varices abdominal surgery. Sites of portosystemic col-Duodenal varices (Figure 4) are relatively lateral communications occur in post-operativecommon collaterals but are rarely a source of adhesions at the peristomal mucocutaneous junc-bleeding due to their deep location in the duodenal tions or at the peritoneal adhesions. While peristo-wall. They usually drain into the inferior vena cava mal varices may bleed, oesophageal varices mayvia retroperitoneal collaterals. coexist and be responsible for the majority of gastrointestinal haemorrhages in such cases. The Gastric and perisplenic varices occurrence rate of haemorrhage from the gastro- oesophageal varices is not significantly differentGastric and perisplenic varices are formed via between the patients with oesophageal varicescoronary and short gastric veins. These varices, alone and peristomal varices with coexisting oeso-however, are not easily differentiated by angiogra- phageal varices. Peristomal varices thus do not actphy. CT may demonstrate these collaterals better as a ‘‘safety valve’’ for oesophageal bleeding [7, 8].due to its axial imaging ability. Isolated gastric varices resulting from splenic venous occlusion (segmental portal hypertension), will obviously not decompress with TIPS and are usually treated by splenectomy. Mesenteric varices Mesenteric varices (Figures 5a–c and 6) include collaterals originating from the superior mesenteric and inferior mesenteric veins. The reported incidence of gastrointestinal haemorrhage from intestinal varices is 5–6.6% [4]. These varices communicate with systemic veins via the retro- peritoneal and mesenteric venous plexus. Extensive collaterals may develop between branches of the inferior mesenteric vein such as anorectal veins and haemorrhoidal veins which drain into the inferior vena cava via internal iliac veins or gonadal veins. Bleeding mesenteric varices can also be treated successfully with TIPS [5]. Mesenteric varices due to focal venous obstruction (segmental portal hypertension), however, cannot be treated with TIPS. Spontaneous gastrorenal and splenorenal shunts Gastrorenal and splenorenal portosystemic (Figures 7a and b) shunts are occasionally seen in patients with portal hypertension. These shunts divert blood to the inferior vena cava via an enlarged left renal vein. They can decompress the high pressure portal flow and produce a low porto- systemic pressure gradient. Following TIPS pro- Figure 1. Subtracted transjugular transhepatic porto-cedure, these spontaneous shunts can decrease the gram demonstrates a coronary vein (large arrow), feed- effective flow and cause early closure of the newly ing prominent gastric varices (small arrow) which drains created portosystemic shunt. Intentional emboliz- via oesophageal varices (arrowhead). There is a partially inflated Blakemore tube.ation of these spontaneous shunts may be needed T he British Journal of Radiology, December 1997 1303
  3. 3. J Ahn, J M Cooper, J E Silberzweig and H A Mitty Figure 2. Transjugular transhepatic portogram demon- strates a prominent short gastric vein (arrow), feeding gastric varices (arrowhead). A curved arrow indicates a patent splenic vein. Figure 4. Transjugular transhepatic splenoportogram demonstrates duodenal varices (arrow). Also shown are coexisting short gastric varices (arrowhead). (a) (b) Figure 3. Subtracted transjugular transhepatic splenoportogram demonstrates prominent recanalized umbilical vein (arrow in (a)) arising from the intrahepatic left portal vein, continuing as a superficial epigastric vein on the anterior abdominal wall (arrowheads), and draining via bilateral iliac veins (arrows in (b)). Also seen is retrograde filling of the inferior mesenteric vein (curved arrows). T he British Journal of Radiology, December 19971304
  4. 4. Pictorial review: Portosystemic collateral pathways (a) (c) (b) Figure 5. Subtracted (a) and non- subtracted (b) transjugular transhep- atic splenoportograms demonstrate prominent mesenteric varices (open arrows in (a) and (b)) filling retro- gradely from the anorectal branch of the inferior mesenteric vein (arrow- heads in (a) and (b)) and ileocolic branch of the superior mesenteric vein (arrows in (a) and (b)). These mesen- teric varices are drained via right gona- dal vein (curved arrows) which joins the inferior vena cava (arrowheads in (c)), best seen on delayed phase. Figure 6. Subtracted transjugular transhepatic portogram demonstrates prominent inferior mesenteric vein (arrow), forming mesenteric varices (arrowhead) which drain via retroper- itoneal collaterals and into inferior vena cava (curved arrow). (a) (b) Figure 7. Subtracted transjugular transhepatic splenoportogram demonstrates prominent perisplenic varices (arrows in (a) and (b)) draining via oesophageal varices (arrowhead in (a)) and a spontaneous splenorenal shunt (arrowheads in (b)) which drain into the inferior vena cava (large arrow in (b)) via the left renal vein (curved arrow in (b)). T he British Journal of Radiology, December 1997 1305
  5. 5. J Ahn, J M Cooper, J E Silberzweig and H A Mitty (a) (c) (b) Figure 8. Subtracted transjugular portogram demon- strates prominent retrograde filling of the superior mesen- teric vein (arrow in (a)) in a patient with diverticular disease treated with an ileostomy. Unsubtracted (b) and subtracted (c) images of selective injection into the superior mesenteric vein demonstrates prominent peristo- mal varices (arrows in (b) and (c)), draining via the right iliac vein (arrowhead in (c) and eventually into the inferior vena cava (curved arrow in (c)). 5. Katz JA, Rubin RA, Cope C, Holland G, Brass CA. Recurrent bleeding from anorectal varices: Success- ful treatment with a transjugular intrahepaticReferences portosystemic shunt. Am J Gastroenterol 1993;88:1104–7.1. Cho KC, Patel YD, Wachsberg RH, Seeff J. Varices in portal hypertension: Evaluation with CT. 6. Shioyama Y, Matsueda K, Horihata K, et al. Post- TIPS hepatic encephalopathy treated by occlusionRadiographics 1995;15:609–22. 2. Doehner GA, Ruzicka FF Jr, Rousselot LM, balloon-assisted retrograde embolization of a co- existing spontaneous splenorenal shunt. CardiovascHoffman G. The portal venous system: on its patho- logical anatomy. Radiology 1956;66:206–17. Intervent Radiol 1996;19:53–5. 7. Wiesner RH, LaRusso NF, Dozois RR, Beaver3. Rousselot LM, Moreno AH, Panke WF. The clinical and physiopathologic significance of self estab- SJ. Peristomal varices after proctocolectomy in patients with primary sclerosing cholangitis.lished (nonsurgical) portosystemic shunts. Ann Surg 1959;150:384–410. Gastroenterology 1986;90:316–22. 8. Fucini C, Wolff BG, Dozois RR. Bleeding from4. Nunez D, Russell E, Yrizarry J, et al. Portosystemic communications studied by transhepatic portogra- peristomal varices: Perspectives on prevention and treatment. Dis Colon Rectum 1991;34:1073–8.phy. Radiology 1978;127:75–9. T he British Journal of Radiology, December 19971306