Special Radiological Procedures

lecture 7
PORTAL VENOGRAPHY

By
MSc. Zeyad Tareq Al-Dulaimi
3rd.Stage
2023-2024
 PORTAL VENOGRAPHY

Methods
1. Late-phase superior mesenteric angiography
2. Trans-splenic approach (discussed later)
3. Paraumbilical vein catheterization
4. Transjugular transhepatic approach

Indications
1. To demonstrate prior to surgery, the anatomy of the portal system in patients
with portal hypertension
2. To check the patency of a porto systemic anastomosis

Contrast Medium
LOCM 370 mg I mL−1, 50 mL.

Equipment
1. Digital radiography unit
2. Arterial catheter (SMA approach)
3. 10-cm needle (20G) with stilette and outer plastic sheath—e.g. Longdwell
(trans-splenic approach).
Patient Preparation
1. Admission to hospital. A surgeon should be informed in case complications of
procedure .
2. Clotting factors are checked
3. Severe ascites is drained
4. Nil orally for 5 h prior to the procedure
5. Premedication, according to local protocols
Technique
 Superior mesenteric angiography
 Using standard angiographic technique .

For trans-splenic approach

1. With the patient supine, the position of the spleen is percussed or identified
with US. The access point is as low as possible in the midaxillary line,
usually at the level of the tenth or eleventh intercostal space.
2. The region is anaesthetized using a sterile procedure.
3. The patient is asked to hold their breath in mid-inspiration, and the needle is
then inserted inwards and upwards into the spleen (about three-quarters of
the length of the needle is inserted; i.e. 7.5 cm). The needle and stilette are
then withdrawn, leaving the plastic cannula in situ. Blood will flow back
easily if the cannula is correctly sited. The patient is then asked to breathe
as shallowly as possible, to avoid trauma to the spleen from excessive
movement of the cannula.
4. A test injection of a small volume of contrast medium under screening
control can be made to ensure correct siting of the cannula. If it has
transfixed the spleen, simple withdrawal into the body of the spleen is not
acceptable, as any contrast medium subsequently injected would follow the
track created by the withdrawal. A new puncture is necessary.
5. When the cannula is in a satisfactory position, the splenic pulp pressure may
be measured with a sterile manometer (normally 10–15 cm H2O).
 6. A hand injection of 50 mL of contrast medium is made over 5 s and recorded
by rapid serial radiography/digital subtraction angiography. The cannula
should be removed as soon as possible after the injection to minimize
trauma to the spleen.
Images
Rapid serial radiography or digital subtraction runs: 1 image s−1 for 10 s.

Aftercare
1. Blood pressure and pulse—initially quarter-hourly; subsequently 4-hourly.
2. The patient must remain in hospital overnight.

Complications
 Due to the contrast medium
1. Mild: Nausea, vomiting, urticaria.
2. Moderate: Tachycardia, mild bronchospasm, vasovagal reaction, diffuse
erythema.
3. Severe: Seizure, cardiovascular collapse, moderate or severe
bronchospasm, laryngeal oedema, loss of consciousness.

 Due to the technique

1. Haemorrhage
2. Subcapsular injection
3. Perforation of adjacent structures (e.g. pleura, colon)
4. Splenic rupture
5. Infection
6. Pain (especially with an extracapsular injection)

 Due to the catheter

Local
The most frequent complications occur at the puncture site. The
complication rate is lowest for femoral artery punctures:
1. Haemorrhage/haematoma
2. Arterial thrombus
3. Infection at the puncture site
4. Pseudoaneurysm.
5. Arteriovenous fistula—rare.
Distant
1. Peripheral embolus—from stripped catheter thrombus.
2. Atheroembolism—more likely in older subjects.
3. Air embolus. May be fatal in coronary or cerebral arteries.
4. Cotton fibre embolus. Occurs when syringes are filled from a bowl
containing swabs or when a guidewire is wiped with a dry gauze pad.
5. Artery dissection—due to entry of the catheter, guidewire or contrast
medium into the subintimal space.
6. Catheter knotting—more likely during the investigation of complex
congenital heart disease.
7. Catheter impaction:
a) In a coronary artery produces cardiac ischaemic pain
b) In a mesenteric artery produces abdominal pain.
8. Guidewire breakage—less common with modern guidewires

9. Bacteraemia—rarely of clinical significance.

Thank you