Transjugular Portal Venography and Radiologic Portacaval Shunt: An Experimental Study

Conventional methods of opacifying the portal system are splenic portography (1) and intra-arterial contrast injections into the visceral arteries with delayed films (6). More exotic means reported include translumbar portal vein puncture (4), umbilical vein catheterization (2), hemorrhoidal vein cannulization under spinal anesthesia (7), or laparotomy with cannulization of a mesenteric vein branch (5). All methods produce good to fair opacification of the portal venous system but allow no selectivity of contrast injections or opportunities for manipulative procedures in the venous system. For two years we have performed cholangiography (3) by passing a modified Ross needle and catheter system down the internal jugular vein and superior vena cava, across the right atrium into the inferior vena cava, and then into the hepatic veins in order to puncture the biliary duct system from inside the liver. With this same approach, one of the major branches of the portal vein can be punctured and the catheter inserted into the portal vein. Retrograde injection of the portal venous system is then possible through this catheter. In addition, a short segment of tubing material can be inserted under fluoroscopic control over the catheter to form a shunt from the portal system to the systemic venous system. Technic The right jugular vein of the dog is exposed, and a No. 8 Teflon catheter is introduced. It is maneuvered together with the leading guide wire down into the left hepatic vein via the inferior vena cava. Under fluoroscopic control, one of the draining veins of the left medial hepatic lobe is selected that courses downward and anteriorly. These branches have a close relation to the main left branch of the portal vein, being divided by only a layer of hepatic parenchyma about 5 mm thick. After the position of the catheter tip is checked by a contrast medium injection, a modified 50-cm-long Ross needle (3) is inserted through the catheter until its tip protrudes 2 to 3 cm from the catheter, and the puncture is made. A balloon catheter may be introduced at laparotomy via the splenic vein into the left portal vein for correct aiming, and this assisted us in the first animals. A moderate resistance is felt with the puncture of the wall of the hepatic vein, and later an even greater resistance is experienced with puncture of the portal vein. Small amounts of contrast material are injected to confirm the position of the needle tip. Once a portal vein has been entered, a guide wire is inserted in the direction of the abdominal viscera, and the catheter is passed over the needle and guide wire into the portal system. It is advanced into the portal vein for a distance of about 8 cm. The needle and guide wire are then removed, and contrast material can be introduced, using either hand or pressure injection to outline the portal venous system.