PORTOGRAFIYA (late lat. [vena] of portae a portal vein + grech, grapho to write, represent; synonym: venoportografiya, portogepatografiya) — a research of portal blood circulation by means of radiological and tracer techniques.
Radiological methods of a portografiya
Rentgenol, research portal vein (see) and its intra hepatic branches carry out in the conditions of their artificial contrasting. Depending on a way of administration of contrast medium distinguish direct, indirect and retrograde the Item. At direct P. a contrast agent is entered directly into a portal vein, into one of the veins making it or into one of its intra hepatic branches. The following techniques of direct P. are developed: transdermal transhepatic, splenoportografiya (see), transumbilikalny and intraoperative (fig. 1). At indirect (arterial) P. a contrast agent is entered into one of large arteries of an abdominal cavity (a celiac trunk, a splenic or upper mesenteric artery), at retrograde P. — into one of small hepatic veins.
Rentgenol, methods P. apply to a research of a portal blood-groove at a wedge, signs portal hypertensia (see) when it is necessary to find out a condition of a portal vein and its intra hepatic branches, localization and the nature of blockade of a portal blood-groove, a condition of collaterals, diameter and passability of the vessels chosen for imposing of a porto-caval anastomosis. To the item it is shown also for differential diagnosis of the diseases which are followed by portal hypertensia at suspicion on anomaly of development or fibrinferments of a portal vein and its roots. In some cases P. apply to establishment of the reason of a splenomegaly, and also to identification of extent of cirrhotic changes in a liver at an atresia of bilious channels or hemolitic anemia at children.
Rentgenol, methods P. are contraindicated at intolerance of drugs of iodine, at acute infectious and mental diseases, dekompensirovanny damages of heart, liver and kidneys, a heavy thyrotoxicosis, hemorrhagic diathesis. Besides, the splenoportografiya is contraindicated at a heart attack, abscess, the suppurated cyst of a spleen and is impossible at an asple-niya and a microsplenia.
Items carry out on an empty stomach in 30 min. after premedication (to the patient subcutaneously enter 1 ml of 1% of solution of Promedolum and 0,3 ml of 0,1% of solution of atropine). The research is conducted under local anesthesia.
Among all techniques of P. the indirect (arterial) P. which is a part rentgenol, researches of large arteries of an abdominal cavity has the leading value. The main advantage indirect P. — a possibility of simultaneous assessment of arterial and venous links of a portal blood-groove. In a splenic artery or an upper mesenteric artery (see. Mezenterikografiya ) or in a celiac trunk (see. Tseliakografiya ) enter 40 — 50 ml of 50 — 76% of solution of a triyodirovanny contrast agent and at once make high-speed serial x-ray shooting during 8 — 12 sec., receiving on the first angiograms the image of arteries of an abdominal cavity — an arterial phase, then parenchyma of a liver and a spleen — a parenchymatous phase, and in 6 — 9 sec. — the image of a portal vein and its roots — a venous phase.
From all techniques of direct P. most widely apply transdermal transhepatic P., at a cut enter a contrast agent by a transdermal puncture of a liver into one of intra hepatic branches of a portal vein. This technique was developed by Shteynbakh (H. Stein-bach, 1953), Hoevelsom (J. Hoevels, 1978) and soavt, and Burkhart (F. Bur-charth, 1979). By means of ultrasonic scanning (see. Ultrasonic diagnosis ) specify the provision of portal fissures. The puncture of a liver is made the needle entered into a thin polyethylene catheter on the average axillary line at the level of portal fissures under X-ray television control (see. Television in medicine. X-ray television ). The needle is taken out, leaving a catheter in a liver. Then the catheter is slowly removed before emergence of blood from it. The provision of the end of a catheter in one of intra hepatic branches of a portal vein confirm 5 ml of a contrast agent by a trial injection. By means of the conductor entered into a catheter it is possible to spend the end of a catheter to the necessary part of portal system, including to the main trunk of a portal vein. A contrast agent in number of 30 — 40 ml is entered with a speed of 8 — 10 ml of 1 sec. and make high-speed serial x-ray shooting (fig. 2).
At a splenoportografiya a contrast agent is entered into a spleen by means of its transdermal puncture.
For performance by transumbilikalny P. a contrast agent is entered into a portal vein by catheterization of an umbilical vein (see. Catheterization of umbilical vessels ). Theoretically the method is proved by D. G. Doviner (1958), implemented in a wedge. to the practician by Karbalkhes (G. Carbalchaes, 1959) and G. E. Ostroverkhov et al. (1964). By means of the flexible conductor through an umbilical vein and whenever possible in its main trunk carry out a polyethylene catheter to the left branch of a portal vein. Having measured venous pressure and having taken blood for a research of its structure, on a catheter enter 30 — 40 ml of 50 — 76% of solution of a triyodirovan-ny contrast agent with a speed of 10 — 15 ml of 1 sec. and make high-speed serial x-ray shooting. If the end of a catheter is established in the main trunk of a portal vein, then already at the beginning of an injection a contrast agent retrogradno fills a portal vein and is thrown in splenic, left gastric, top and bottom mesenteric veins. On the 3rd second on the roentgenogram the image of all segmented and subsegmented veins of a liver, and by the end of the 4th second — their small branchings is defined. Normal the parenchyma of a liver is most accurately visible on 7 — the 8th second of a research.
Intraoperative P. is for the first time executed in 1945 by Bleykmorom and the Lord (A.N. Blakemore, J.W. Lord), and in the USSR in 1952 P. N. Mazayev et al. A contrast agent by this technique is entered into the main trunk or into one of intra hepatic branches of a portal vein by catheterization of one of small inflows of an upper or lower mesenteric vein. The research is conducted during operation after opening of an abdominal cavity. Because in the operating room it is usually impossible to execute high-speed shooting, P. carry out by means of mobile X-ray equipment that forces to be limited to single pictures. In this case use of X-ray television with the video magnetic record is reasonable.
By one of the first retrograde P.'s technique was proved by O. G. Yugri-nov (1976). By a transdermal puncture of a femoral vein to the patient make catheterization of the lower vena cava. Then the catheter is advanced in one of hepatic veins before its «jamming» and enter a trial dose of a contrast agent. At the correct provision of the end of a catheter enter 50 — 60 ml of 50 — 76% of solution three - the iodated contrast agent with a speed of 20 — 25 ml of 1 sec. and do a series of pictures. In the first pictures inflows of a hepatic vein are defined and oblakovidny contrasting of the site of a parenchyma of a liver is noted, on the subsequent branches of a portal vein and then a parenchyma of a liver come to light.
Mistakes and complications are observed by hl. obr. at a splenoportografiya are also connected with an unsuccessful puncture of a spleen. Bleeding from the place of a puncture of a spleen or its gap demand an urgent operative measure. At transumbilikal-ache P. it is necessary to be careful of a rupture of an umbilical vein during bougieurage. At transdermal transhepatic P.'s carrying out bleeding and a zhelcheistecheniye in an abdominal cavity is possible. For prevention of these complications the puncture channel after removal of a catheter from a liver is subjected by electrothermic coagulations. After carrying out rentgenol, methods P. order to the patient a high bed rest within 1 days.
The radio isotope portografiya
For assessment of portal blood circulation can be used the radio isotope P. which is a version radiotsirkulografiya (see). Radio isotope P. has special value when are contraindicated rentgenol, methods P., napr, at hypersensitivity to drugs of iodine.
Radio isotope P. is carried out by administration of radio pharmaceutical drug (marked albumine) to a vein of front elbow area (an intravenous radioportografiya) or to a spleen by its transdermal puncture (an intra splenic radioportografiya, a radiosplenotsir-kulografiya) with the subsequent record of level of radioactivity over heart and a liver by means of two scintillation counters. At an intravenous radioportografiya curve radioactivity allows to calculate so-called kardioportal-ny time, i.e. a time slice between the maximum rise in activity over heart and a liver, a cut to some extent characterizes the speed of a blood-groove in system of own hepatic artery and portal vein. Normal it makes 20 — 30 sec. Change of this indicator demonstrates hemodynamic disturbances in portal system. The curve radioactivity received by means of an intra splenic radioportografiya allows to determine the speed of a portal blood-groove, resistance of vascular system of a liver at the level of branchings of a portal vein.
Bibliography: Lindenbraten L. D. Radiology of a liver and bilious ways, M., 1980, bibliogr.; The guide to an angiography, under the editorship of. And. X. Rabkina, M., 1977; Yugrinov O. G. Transkaval-naya a portogepatografiya, in book: Wedge, rentgenol., under the editorship of A. I. Pozmogov, page 7-9, Kiev, 1976; Burcharth P. Percutaneous transhepatic portography, Amer. J. Roentgenol., v. 132, p. 177, 1979; Hoevels J., Lunderquist A. Tylen U. Percutaneous transhepatic portography, Acta Radiol. (Diagn.), v. 19, p. 643, 1978.
L. D. Lindenbraten.