Imaging of portal hypertension

1. PORTAL HYPERTENSION-RADIOLOGICAL
DIAGNOSIS
AND INTERVENTIONS
SOURAV TALUKDER
MBBS

2. PORTAL VEIN

3. PORTAL VEIN
PORTAL VEIN
FORMATION-BEHIND-
neck of pancreas
LEVEL- L1-L2 vertebrae
BY- SPLENIC VEIN AND SMV
COURSE
ASCENDS TO PORTA
INTRAHEPATIC INTRASEGMENTAL
COURSE
TERMINATES INTO SINUSOIDS

4. PORTAL VEIN
LENGTH- 6-8 cm
CALIBER- 9-13 mm
FLOW
DIRECTION- HEPATOPETAL
VELOCITY- 15-18 cm/s
PATTERN- UNDULATING; VARIES WITH
RESPIRATION AND CARDIAC
PULSATION

5. PORTAL VEIN
PORTAL VEIN
PRESSURE- 5-10 mm of Hg
TRIBUTARIES-a.
CORONARY VEIN
b. CYSTIC VEIN
c. PYLORIC VEIN
d. PANCREATODUODENAL VEIN

6. PORTAL VEIN ANATOMY

7. PORTAL HYPERTENSION
Hepatic venous pressure gradient
(HVPG)=
wedged hepatic venous pressure(WHVP)-
IVC pressure- > 5 mm of Hg
Splenic vein pressure >15 mm of Hg
Portal vein pressure (measured surgically)
greater than 30 cm of saline

8. CAUSES
Increased resistance to flow
A) PRE-HEPATIC
1- CONGENITAL ATRESIA OR STENOSIS
2- PORTAL VEIN THROMBOSIS
3- SPLENIC VEIN THROMBOSIS
4- EXTRINSIC COMPRESSION

9. CAUSES
INTRAHEPATIC
a. HEPATIC CIRRHOSIS
b. NON-CIRRHOTIC PORTAL FIBROSIS
c. HEPATIC SCHISTOSOMIASIS
d. SARCOIDOSIS
e. LYMPHOMA
f. VENO-OCCLUSIVE DISEASE

10. CAUSES
POST-HEPATIC
.HEPATIC VEIN OBSTRUCTION
.SUPRAHEPATIC IVC OBSTRUCTION
.CONGESTIVE CARDIAC FALIURE
.CONSTRICTIVE PERICARDITIS

11. CAUSES
HYPERKINETIC
A. ARTERIO-PORTAL FISTULA OR
MALFORMATIONS
B. INCREASED SPLENIC FLOW

12. PORTO-SYSTEMIC
COLLATERALS

13. PORTO-SYSTEMIC
COLLATERALS
ENGORGED IN PORTAL HYPERTENSION
A. AT THE LOWER END OF OESOPHAGUS- LGV and
HEMI-AZYGOS VEIN
B. AROUND THE UMBILICUS- PARA-UMBILICAL VEIN
and SUPERIOR and INFERIOR EPIGASTRIC VEINS
C. LOWER RECTUM AND ANAL CANAL- SUPERIOR
RECTAL VEIN AND MIDDLE AND INFERIOR RECTAL
VEINS
D.SPLENO-RENAL COLLATERALS
GASTRO-RENAL COLLATERALS
SPLENO-RETROPERITONEAL COLLATERALS
RETROPERITONEAL PARAVETEBRAL COLLATERALS

14. PORTO-SYSTEMIC COLLATERALS

16. DIAGNOSIS
CLINICAL
RADIOLOGICAL
MODALITIES-a.
B-MODE ULTRASONOGRAPHY
and CDFI
b. CT
c. MRI
d. ANGIOGRAPHY

17. INTRAHEPATIC PORTAL HTN
VASCULAR EVALUATION
PORTAL VEIN DIAMETER
PORTAL FLOW DIRECTION
PORTAL VELOCITY AND WAVEFORMS
PRESENCE OF COLLATERALS
HEPATIC VEIN EVALUATION
HEPATIC AND SM ARTERIES CHANGES

18. PV, SPLENIC VEIN AND SMV DIAMETER
PV DIAMETER > 13 mm
NORMAL PV DIAMETER IS NOT EXCLUSIVE
!!!
SPLENIC AND SMV DIAMETER > 10 mm
< 20% DIAMETER INCREASE WITH
INSPIRATION- SUGGESTIVE

19. FLOW DIRECTION, VELOCITY AND
WAVEFORM
FLOW VELOCITY- DECREASES (<12 cm/s)
AFFECTED BY TYPE OF COLLATERALS
NORMAL FLOW→
MONOPHASIC→BIPHASIC→HEPATOFUGAL

20. PORTO-SYSTEMIC VENOUS
COLLATERALS
LGV- DIAMETER > 7mm→ SEVERE PHTN
SGV- BETWEEN UPPER POLE OF SPLEEN
AND GASTRIC WALL
PARAUMBILICAL VEIN-HIGHLY SPECIFIC
SPLENO-RENAL COLLATERALS- BETWEEN
SPLEEN AND UPPER POLE OF LK
GALLBLADDER WALL- PROMINENT IN
EXTRAHEPATIC CAUSES

21. ARTERIAL EVALUATION
HEPATIC ARTERY RI AND PI - ↑ IN CLD
H.A DIASTOLIC VEL. > PV PEAK VEL.
→ PARENCHYMAL LIVER DS.
IN CIRRHOSIS- NORMAL POST-PRANDIAL ↑
IN RI IS ABSENT
IN CIRRHOSIS-SMA
PI- ↓
POST-PRANDIAL ↓ IN RI- ABSENT
SpA- RI and PI- ↑

22. ARTERIAL EVALUATION
CONGESTIVE INDEX- CROSS
SECTIONAL AREA ⁄ MEAN VEL. OF PV
C.I- > 0.13 cm×sec →PHTN
LIVER VASCULAR INDEX-PV
VEL.⁄ H.A PI
L.V.I- < 12 cm/s → PHTN

23. ARTERIAL EVALUATION
HEPATIC BUFFER INDEX- HA PI MAXIMAL CHANGE ⁄
PV BLOOD VOLUME MAXIMAL CHANGE (IN
RESPONSE TO MEAL)
↓ IN PHTN
PROPOSED BY IWAO et al
PORTAL HYPERTENSION INDEX-
(HA RI×0.69)(SpA RI×0.87) ⁄ PV VEL.
↑ IN PHTN
CUT-OFF- 1.2 SEC/M- PROPOSED BY PISCAGLIA
et al

24. HEPATIC VENOUS EVALUATION
IN CIRRHOSIS- ALTERED WAVEFORMS
WITH FLATTENING OF PHASIC
OSCILLATIONS

25. ORGAN EVALUATION
LIVER
CIRRHOSIS-NCPF-SPLEEN
SPLENOMEGALY
ASCITES

26. ROLE OF CROSS-SECTIONAL IMAGING
DYNAMIC CONTRAST ENHANCED CT-FOR
DETECTION OF VARICES
RETROPERITONEAL AND MESENTRIC
COLLATERALS- BETTER DELINEATED
CTA and MRA- ↑ DELINEATION OF
COLLATERALS

27. PORTAL HYPERTENSION

28. PRE-HEPATIC PORTAL HTN
PV OCCLUSION-NON-
VISUALISATION OF PV
ECHOGENIC INTRALUMINAL MATERIAL
CAVERNOUS TRANSFORMATION
INTRAHEPATIC COLLATERALS
SpV AND SMV OCCLUSION-HEPATOPETAL
FLOW IN PV
COLLATERALS

29. PRE-HEPATIC PORTAL HTN
PV

30. POST-HEPATIC PORTAL HTN
BUDD-CHIARI SYNDROME
SPECIFIC SIGNS-non-
visualisation of veins
fibrous cord
thrombosis
stenosis
IVC web

31. BUDD-CHIARI SYNDROME

32. BUDD-CHIARI SYNDROME
SUGGESTIVE SIGNS
Intra-hepatic ‘comma-shaped’
collaterals
Caudate vein diameter-
3mm or more

33. BUDD-CHIARI SYNDROME
OTHER SIGNS
benign regenerative nodules
caudate lobe hypertrophy
non-homogenous parenchyma
portal thrombosis
recanalised para-umbilical veins
ascites

34. CT FINDINGS
ACUTE BCS-
↓PERIPHERAL
ENHANCEMENT
↑CENTRAL
ENHANCEMENT-FAN-
SHAPED PATTERN
CHRONIC BCS-REGERNERATIVE
NODULES
PATCHY PATTERN OF
ENHANCEMENT

35. MR FINDINGS
CAN DIFFERENTIATE
BET. REGENERATIVE
NODULES (HYPER ON
T1 AND ISO TO HYPO
ON T2) AND HCC
NODULES (HYPO ON T1
AND HYPER ON T2)
R
N

36. ANGIOGRAPHIC FINDINGS
IVC GRAPHY OR
PERCUTANEOUS
HEPATOGRAPHY OR
MR VENOGRAPHY
‘SPIDER-WEB
COLLATERALS’
LONG SEGMENTAL
COMPRESSION OF IVC
BY CAUDATE LOBE
DILATED HEPATIC
ARTERIES
SPIDER WEB
COLLATERALS

37. CONVENTIONAL MODALITIES IN
PHTN
BARIUM
SWALLOW-DEMONSTRATE
OESOPHAGEAL
VARICES

38. INTERVENTIONS IN PORTAL
HYPERTENSION

39. INTERVENTIONS IN PORTAL
HYPERTENSION
INTERVENTIONS THAT REDUCE PORTAL BLOOD
PRESSURE
a. TIPS
b. RECANALISATION OF HEPATIC VENOUS
OUTFLOW
c. RECANALISATION OF OCCLUDED PORTAL
VEINS AND ITS TRIBUTARIES
d. EMBOLISATION OF ARTERIO-PORTAL FISTULA
e. PARTIAL SPLENIC EMBOLISATION
f. REVISION OF OCCLUDED SURGICAL OR
RADIOLOGICAL PORTO-SYSTEMIC SHUNTS

40. INTERVENTIONS IN PORTAL
HYPERTENSION
INTERVENTIONS TO PALLIATE SYMPTOMS RELATED
TO PORTAL HYPERTENSION
a. PERCUTANEOUS TRANSHEPATIC
VARICEAL EMBOLISATION
b. BALLOON RETROGRADE OBLITERA
-TION OF GASTRIC VARICES
c. PERCUTANEOUS PERITONEO-VENOUS
SHUNT

41. TIPS
FIRST PERFORMED
BY RONALD
COLAPINTO AND
CO-WORKERS

42. PRE-TIPS EVALUATION
LIVER AND RENAL FUNCTION TESTS
DOPPLER
CONTRAST ENHANCED CT AND MRI
OF LIVER

43. INDICATIONS
ACUTE INTRACTABLE VARICEAL BLEEDING
SECONDARY PREVENTION OF VARICEAL
BLEEDING
REFRACTORY ASCITES
PORTAL HYPERTENSIVE GASTROPATHY
REFRACTORY HEPATIC HYDROTHORAX
BUDD-CHIARI SYNDROME
VENO-OCCLUSIVE DISEASE

44. CONTRAINDICATIONS
ABSOLUTE
CONGESTIVE CARDIAC FAILURE
SEVERE PULMONARY HTN
SEVERE TRICUSPID REGURGITATION
HEPATIC FAILURE
MULTIPLE HEPATIC CYSTS
UNCONTROLLED SYSTEMIC INFECTIONS
UNRELIEVED BILIARY OBSTRUCTION

45. CONTRAINDICATIONS
RELATIVE
LARGE LIVER TUMOURS
PORTAL VEIN THROMBOSIS
SEVERE COAGULOPATHY
THROMBOCYTOPENIA
MODERATE PULMONARY HYPERTENSION

46. PROCEDURE PROPER
CANNULATION OF
HV
 THROUGH RT
TRANSJUGULAR
APPROACH
 BOTH RHV AND
MHV CAN BE USED
 HEPATIC
VENOGRAPHY

47. PROCEDURE PROPER
NEEDLE PASSAGE
 CARBON-DI-OXIDE
INJECTION TO
DETERMINE LEVEL OF
PV
 INSERTION OF NEEDLE
INTO PV

48. PROCEDURE PROPER
PORTAL
VENOGRAPHY
BALLOON
ANGIOPLASTY
WITH
DILATATION OF
TRACT

49. PROCEDURE PROPER
DEPLOYMENT OF
STENT
TO ENSURE
PATENCY OF
THE TRACT
VIATORR PTFE
COVERED
STENTS

50. PROCEDURE PROPER
PORTAL VENOGRAM
 TO DEMONSTRATE
SHUNT PATENCY AND
NON-VISUALISATION
OF VARICES
 HIGH PORTO-SYSTEMIC
GRADIENT-EMBOLISATION
OF
VARICES

51. SUCCESS RATES
TECHNICAL- 95%
(creation of a patent shunt)
HEMODYNAMIC- 90%
(Reduction of porto-systemic gradient to a
targeted level)
CLINICAL SUCCESS FOR VARICEAL
BLEEDING- 90%
CLINICAL SUCCESS FOR ASCITES- 50-90%

52. COMPLICATIONS
TIPS DYSFUNCTION
THROMBOSIS
NEO-INTIMAL HYPERPLASIA
TRANSCAPSULAR PUNCTURE
INTRAPERITONEAL BLEED
HEPATIC INFARCTION
FISTULAE
HAEMOBILIA
SEPSIS
HEMOLYSIS
ENCEPHALOPATHY
STENT MIGRATION

53. RECANALISATION OF OCCLUDED
PV AND TRIBUTARIES
IN EXTRA-HEPATIC OBSTRUCTION OF
PV OR ITS BRANCHES
PERCUTANEOUS RECANALISATION
AND STENTING IS DONE
RESULTS ARE MORE ENCOURAGING
IN PV THAN IN BRANCH VESSELS

54. RECANALISATION OF SMV
V
A
RI
C
E
S

55. EMBOLISATION OF ARTERIO-PORTAL
FISTULAS
INVOLVEMENT- HA>SpA>SMA> IMA
CAUSES - CONGENITAL, TRAUMATIC,
IATROGENIC, ATHEROSCLEROTIC, IN
MALIGNANCY
DIAGNOSIS- ARTERIOGRAPHY

56. EMBOLISATION OF ARTERIO-PORTAL
FISTULAS
TREATMENT- SELECTIVE AND
SUPERSELECTIVE CATHETERISATION AND
EMBOLISATION OF FEEDING ARTERIES
USING COILS, BALLOONS, GELFOAMS AND
ISOBUTYL-2-ACRYLATE OR N-BUTYL
CYANOACRYLATE
MORE PROMISING RESULTS FOR SMALL
FISTULAS

57. PARTIAL SPLENIC EMBOLISATION
TO DIMINISH INFLOW OF BLOOD INTO THE
PORTAL VEIN
SUPERSELECTIVE CATHETERISATION
THROUGH FEMORAL ROUTE AND
EMBOLISATION OF INTRASPLENIC
ARTERIAL BRANCHES WITH POLYVINYL
ALCOHOL PARTICLES
FEW COMPLICATIONS AND PROMISING
RESULTS

58. REVISION OF SHUNTS
PERCUTANEOUS TRANSLUMINAL
ANGIOPLASTY IN OCCLUDED SHUNTS
PROPER SIZE OF BALLOON TO PREVENT
SHUNT RUPTURE

59. HEPATIC VENOUS OUTFLOW
RECANALISATION
AIM- TO RESTORE PHYSIOLOGICAL
FLOW IN BUDD-CHIARI SYNDROME
SHORT SEGMENT STENOSIS-BALLOON
ANGIOPLASTY AND
STENTING
LONG SEGMENT STENOSIS-PORTO-
CAVAL SHUNTING
TIPS-OPENS INTO IVC

60. IVC RECANALISATION
I
V
C
RHV
P
O
S
T-S
T
E
N
TI
N
G

61. PERCUTANEOUS TRANSHEPATIC
VARICEAL EMBOLIZATION
FIRST DESCRIBED BY LUNDERQUIST AND
VANG IN 1974
CATHETERISATION OF PV BY
PERCUTANEOUS TRANSHEPATIC
APPROACH AND EMBOLISATION OF
GASTRIC VEINS
COMPLICATIONS- REBLEEDING
PV THROMBOSIS

62. BALLOON-OCCLUDED RETROGRADE
TRANSVENOUS OBLITERATION OF
VARICES (BRTO)
TO TREAT BLEEDING GASTRIC
VARICES
TECHNIQUE-a.
ADVANCING CATHETER TO GASTRO-RENAL
SHUNT THROUGH FV
b. OCCLUSION OF SHUNT AND INJECTION OF
SCLEROSANTS
c. OVERNIGHT INFLATION OF BALLOON
d. ASPIRATION OF SCLEROSANTS AND
WITHDRAWAL OF CATHETER

63. BALLOON-OCCLUDED RETROGRADE
TRANSVENOUS OBLITERATION OF
VARICES (BRTO)
ADVANTAGES-a.
GOOD CONTROL OF GASTRIC VARICEAL
BLEEDING
b. AUGMENTATION OF PORTAL BLOOD FLOW
AND
REDUCED INCIDENCE OF HEPATIC
ENCEPHALOPATHY
DISADVANTAGES-WORSENING
OF ESOPHAGEAL VARICES

64. ACKNOWLEDGEMENTS
AIIMS-MAMC-PGI IMAGING SERIES-DIAGNOSTIC
RADIOLOGY-GASTROINTESTINAL
AND
HEPATOBILIARY IMAGING-3RD EDITION
DIAGNOSTIC ULTRASOUND-4TH
EDITION
GOOGLE