USE OF TRANSSPLENIC INJECTION OF AGITATED SALINE AND

HEPARINIZED BLOOD FOR THE ULTRASONOGRAPHIC DIAGNOSIS

OF MACROSCOPIC PORTOSYSTEMIC SHUNTS IN DOGS

PABLO GóMEZ-OCHOA, FRANCISCO LLABRÉS-Dı́AZ, SERGIO RUIZ, ANDREA CORDA, SAUL PRIETO, IVÁN SOSA,
TOMMASO GREGORI, MANUEL GASCóN, GUILLERMO C. COUTO

We describe the use of ultrasonography-guided percutaneous splenic injection of agitated saline and heparinized
blood for the diagnosis of portosystemic shunts (PSS) in 34 dogs. Agitated saline mixed with 1 ml of heparinized
autologous blood was injected into the spleen of 34 sedated dogs under sonographic guidance. The transducer
was then sequentially repositioned to visualize the portal vein, the caudal vena cava, and the right atrium
through different acoustic windows. It was possible to differentiate between intrahepatic and extrahepatic shunts
depending on the entry point of the microbubbles into the caudal vena cava. Portoazygos shunts and portocaval
shunts could be differentiated based on the presence of microbubbles in the caudal vena cava and/or the right
atrium. In one dog, collateral circulation due to portal hypertension was identified. In dogs with a single
extrahepatic shunt, the microbubbles helped identify the shunting vessel. The technique was also used post-
operatively to assess the efficacy of shunt closure. All abnormal vessels were confirmed by exploratory la-
parotomy or with ultrasonographic identification of the shunting vessel. Ultrasound-guided transsplenic injection
of agitated saline with heparinized blood should be considered as a valuable technique for the diagnosis of PSS;
it is easy to perform, safe, and the results are easily reproducible. r 2010 Veterinary Radiology & Ultrasound,
Vol. 52, No. 1, 2011, pp 103–106.

Key words: agitated saline, dog, portosystemic shunt, spleen, ultrasound.

Introduction transit of microbubbles through the portal system in nor-

C ONGENITAL EXTRAHEPATIC AND intrahepatic macrovas-
cular portosystemic shunts (PSS) affect dogs and cats,
and the various morphologies have been described.1–5 De-
tection and characterization of PSS using diagnostic imag-
ing influences treatment decisions and helps identify the
shunting vessel during surgery.5,6,7
The presumptive diagnosis of a PSS is usually based on a
combination of signalment and history, physical examin-
ation findings, and clinicopathologic abnormalities.8 A de-
finitive diagnosis requires surgical identification, contrast
splenoportography, contrast portal venography, computed
tomography angiography, contrast-enhanced magnetic res-
onance angiography, ultrasonography, or scintigraphy.9,10
Ultrasonography-guided transsplenic injection of agi-
tated saline has been used to evaluate the intravascular
From the Department of Animal Pathology, University of Zaragoza,
Zaragoza, Spain 50013 (Gómez-Ochoa, Ruiz, Sosa, Gregori, Prieto,
Gascón), Davies Veterinary Specialists, Hertfordshire SG5 3HR, UK
(Llabrés-Dı́az), Department of Clinical and Veterinary Pathology, Section
of Animal Internal Medicine, Faculty of Veterinary Medicine, Sassari, Italy
07100 (Corda), and Department of Veterinary Clinical Sciences, Veterinary
Teaching Hospital, College of Veterinary Medicine, OSU Comprehensive
Cancer Center, The Ohio State University, Columbus 43210 (Couto).
Address correspondence and reprint requests to Pablo Gómez-Ochoa,
at the above address. E-mail: pablogomezochoa@gmail.com
Received April 10, 2010; accepted for publication August 25, 2010.
doi: 10.1111/j.1740-8261.2010.01752.x
mal dogs.11 Microbubbles can be followed through the
splenic vein into the portal vein and intrahepatic portal
vasculature. The absence of microbubbles beyond the si-
nusoidal barrier in normal dogs makes transsplenic injec-
tion of agitated saline a useful technique for the diagnosis
of a PSS.11
Our goal was to describe the results of ultrasound-
guided transsplenic injection of agitated saline with he-
parinized blood in dogs with a surgical or ultrasonographic
diagnosis of macroscopic PSS. A secondary objective was
to compare the presurgical vs. the postsurgical pattern of
flow of microbubbles.
Materials and Methods
Thirty-four dogs having a mean age of 2.5 years (range
1–9) and a mean weight of 5.3 kg (range 1–37 kg) with
surgical (26 dogs) or ultrasonographic (eight dogs) confir-
mation of PSS were evaluated between February 2007 and
December 2009.
The microbubble test was always carried out before sur-
gery or ultrasonographic identification of the abnormal
vessel(s). Ultrasound-guided transsplenic injection of
agitated saline was performed as described previously,11
with a slight modification of the technique. The dogs
were sedated with an intramuscular combination of

103
104 Go¤MEZ-OCHOA ET AL
acetylpromazine and butorphanolw and positioned in
right recumbency. A General Electric P6,z a LogicE,y and
a Philips ATL HDI 3500z were used. A wide-range mi-
croconvex transducer was used to locate the spleen. The
microbubble solution injected into the splenic pulp was
composed of a weight-related volume of 0.9% saline mixed
with 1 ml of heparinized autologous blood taken from the
jugular vein. The mixture was agitated back and forth be-
tween two syringes connected at right angles to each other
by a three-way stopcock. The total volume of the injectate
was 6 ml for dogs between 1 and 10 kg of body weight, 8 ml
for dogs between 10 and 20 kg, and 10 ml for dogs up to
20 kg. A 22 G, 1.5 in. needle, attached to the three-way
stopcock via a flexible extension tube, was positioned in the
splenic parenchyma under ultrasonographic guidance.
Maintaining the needle in the splenic pulp, the transducer
was then repositioned to sequentially visualize three differ-
ent acoustic windows.
The first acoustic window had the transducer positioned
just caudal to the xiphoid process. Through this window,
longitudinal images of the portal vein at the level of the
porta hepatis were obtained. Subsequently, and maintain-
ing the transducer caudal to the xiphoid process, transverse
images were obtained to evaluate the caudal vena cava and
hepatic veins.
The second acoustic window was used to evaluate the
right and dorsal aspects of the abdomen. With the patient
still in right recumbency, the transducer was positioned
under the right side of the patient, behind the last rib, and
with a slight cranial orientation. A cutout window of the
table or a sliding technique where the transducer runs be-
tween the table and the right side of the patient was used
for this purpose. Longitudinal images of the caudal vena
cava from the level of the right kidney cranially were
obtained from this second acoustic window.
The third acoustic window allowed for a standard echo-
cardiographic right parasternal long-axis view and a stan-
dard right ventricular outflow tract short-axis view to be
obtained. Longitudinal and transverse images were
obtained and reviewed, paying particular attention to the
right atrium.
At this point, the agitated saline was injected, divided
into three boluses. Each bolus was injected in o3 s during
the examination of every acoustic window.
In eight dogs with an extrahepatic shunt that underwent
surgical correction, ultrasound-guided transsplenic injec-
tion of agitated saline was repeated 1 month after surgery
to compare the distribution of microbubbles with the pre-
surgical findings.
Calmo Neosan, Pfizer, New York, NY.
wTorbugesic, Fort Dodge, Madison, NJ.
zGeneral Electric, Fairfield, CT.
yGeneral Electric, Fairfield, CT.
zAmsterdam, the Netherlands.
2011
Results
Three patterns of microbubble distribution were identified
(Table 1). The first was identified in eight dogs with a single
intrahepatic shunt each; two had a patent ductus venosus
and six had a right divisional shunt. The microbubbles were
seen clearly in the portal vein or involved portal vein branch,
the intrahepatic shunt, and in a dilated hepatic vein and/or in
the caudal vena cava (Fig. 1) (Video S1). However, they
could not be found in the caudal vena cava before the
shunting vessel entered the hepatic parenchyma. Following
the microbubble transit, either in the intrahepatic portal
veins or in the caudal vena cava, the shunting vessel was
characterized further sonographically. In these eight dogs,
microbubbles were also seen in the right atrium.
The second pattern was found in 23 dogs with a single
extrahepatic portocaval shunt and one dog with cirrhosis.
The microbubbles were detected in the caudal vena cava
before it entered the hepatic parenchyma (Fig. 2). The
technique helped localize the entry point of the shunting
vessel (Video S1), but the specific origin was impossible to
discriminate. Microbubbles were seen in the right atrium in
all of these dogs (Video S2). In the dog with cirrhosis, a
long splenorenal vessel was identified and this was con-
firmed during laparotomy.
The third microbubble pattern was seen in two dogs with
a single portoazygos shunt. The microbubbles could only
be found in the right atrium (Fig. 3). No information about
the entrance point of the shunting vessel could be deter-
mined in these dogs, although scanning the region of the
abdominal azygos vein along the aorta to determine the
location of shunt termination is recommended in cases with
a caudal entry point.
In seven of eight dogs with a single congenital extrahe-
patic shunt evaluated again postoperatively, no Doppler
signal was seen in the shunting vessel and no microbubbles
were seen in the caudal vena cava or the right atrium. In
one dog, microbubbles were seen in the caudal vena cava
and the right atrium.
No complications were detected in any dog, and the
echo pattern at the injection site reverted to the pre-injec-
tion state within 5 min of injection.
Table 1. Summary of the Three Microbubble Patterns
Presence of Microbubbles
Extrahepatic Hepatic Veins and
CVC Intrahepatic CVC RA
Extrahepatic PCS Yes Yes Yes
Intrahepatic PCS No Yes Yes
Extrahepatic PAS No No Yes
Scanning the region of the abdominal azygos vein along the aorta to
identify the shunt termination in cases with an abdominal entry point is
recommended.CVC, caudal vena cava; RA, right atrium; PCS, port-
ocaval shunt; PAS, portoazygos shunt.
Vol. 52, No. 1 TRANSSPLENIC INJECTION OF AGITATED SALINE IN PORTOSYSTEMIC SHUNT
Fig. 1. Great Pyrenees dog with intrahepatic shunt. The portal vein (PV)
and the caudal vena cava (CVC) can be visualized filled with microbubbles.
Discussion
This technique is based on the fact that agitated saline
microbubbles do not cross the sinusoidal barrier, whereas
microbubbles can reach the systemic circulation bypassing
the liver in case of a macroscopic PSS. The three shunting
patterns described in the results can be easily and objec-
tively identified using standard ultrasound equipment.
Moreover, the addition of a small volume of blood makes
the ultrasonographic identification of the microbubbles
easier than when only agitated saline is used.11 This is
a fairly relevant point because the negative effect of the
dilution of the agitated saline in case of a small shunt en-
tering into a large vessel, like the caudal vena cava, is
avoided. As an example, this study includes cases where we
identified shunting vessels of 2–3 mm diameter and where
the microbubbles were still easily identified in the caudal
vena cava and/or in the right atrium.
Fig. 2. Longitudinal view of the caudal vena cava (CVC). The entrance
point can be easily identified (arrow) in this extrahepatic shunt.
105
Fig. 3. Microbubbles inside the right atrium and right ventricle of a dog
with a portoazygos shunt.
The diagnosis of PSS in small animals is often challeng-
ing.5 Advanced imaging techniques are being used increas-
ingly to define the number and morphology of PSS, but
these techniques are not widely available. Sonography is
used commonly for PSS detection, but this technique is
heavily operator- and equipment dependent. The reported
accuracy of ultrasonography for shunt detection has in-
creased through the improved quality of the equipment
and the routine use of color Doppler.5 Ultrasound-guided
transsplenic injection of agitated saline and heparinized
blood may provide for a further increase in the accuracy of
ultrasound for shunt detection.
Agitated saline is safe, even when injected into a pe-
ripheral vein.12 In humans, a link between injection of ag-
itated saline and mild cerebral ischemic events has been
suggested.13 The addition of a small volume of blood to the
saline possibly decreases microbubble surface tension and
promotes bubble aggregation, thereby increasing their sta-
bility and longevity in solution.12
Peritoneal extravasation can result in nondiagnostic
studies when using transsplenic portal scintigraphy14 or
with iodinated contrast splenoportography, whereas in the
transsplenic injection of agitated saline and heparinized
blood, extravasation does not interfere with or affect the
results of the test when subsequent splenic injections are
performed.
No attempt was made to calculate the sensitivity, spec-
ificity, and accuracy of this technique. The main objective
of the study was to describe the different patterns of mi-
crobubble identification obtained in this population of
dogs with PSS.
This technique may represent a good screening test to
differentiate between intrahepatic and extrahepatic shunts
but comparing it with advanced imaging techniques are
needed to determine its accuracy. Moreover, ultrasono-
graphy-guided transsplenic injection of agitated saline
106 Go¤MEZ-OCHOA ET AL
allows discrimination between portocaval shunts and port-
oazygos shunts, and provides information about the entry
point in portocaval shunts and a qualitative assessment of
shunting vessel closure/attenuation following surgery.
There are several limitations to this technique. The mi-
crobubbles should follow the pressure gradient and end up
in the caudal vena cava or azygos vein to be detected.
Therefore, a shunt not involved in the microbubble path-
way will likely be missed. This limitation is shared with
contrast splenoportography15,16 and with transsplenic por-
tal scintigraphy.14 Many collateral and plexus-like acquired
shunts are outside the pathway of the injected microbub-
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Supporting Information
Additional Supporting Information may be found in the
online version of this article:
Video S1. Microbubbles’ transit through an intrahepatic
shunt (arrow). Localization of the entrance point (arrow)
in a 1 kg Yorkshire Terrier with extrahepatic shunt.
CVC ¼ caudal vena cava, PV ¼ portal vein.
Video S2. Longitudinal view of the caudal vena cava in a
dog with an extrahepatic shunt. Microbubbles inside the
right side of the heart (right parasternal long axis view and
right ventricular outflow tract from right parasternal short
axis view).
Please note: Wiley-Blackwell are not responsible for the
content or functionality of any supporting materials sup-
plied by the authors. Any queries (other than missing ma-
terial) should be directed to the corresponding author for
the article.