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. 1980 Jun;65(6):1388–1397. doi: 10.1172/JCI109803

Effect of Portal Venous Blood Flow Diversion on Portal Pressure

David S Zimmon 1,2, Richard E Kessler 1,2
PMCID: PMC371477  PMID: 6251112

Abstract

To anticipate the hepatic vascular response to portacaval anastomosis, we studied portal pressure during diversion of portal blood through a temporary extracorporeal umbilical vein to saphenous vein shunt. The relationship of portal pressure to shunted flow was approximately linear. In five schistosomiasis patients (controls) portal diversion to 1,250 ml/min gave portal pressure-shunted flow curve slopes ranging from 0.13 to 0.57 cm water/100 ml per min (0.31±0.18, mean±SD). In 17 cirrhotic patients with portal hypertension a continuum of slopes was observed from within mean±2 SD of control (type A) to larger slopes (type B) indicating failure of portal pressure regulation. When portal flow was augmented by shunting from saphenous vein to portal vein, cirrhotic patients who had slopes less than mean±2 SD of controls during diversion (type A) exhibited a compliant system with small increases in portal pressure, whereas type B patients had significantly greater pressure increases. Selective investigations suggested that changes in portal pressure provoked compensatory changes in hepatic arterial blood flow that tended to maintain portal pressure at a set point. Type B patients demonstrated failure of this mechanism to varying degrees.

After end-to-side portacaval shunt, seven type A cirrhotic patients maintained residual intrahepatic venous pressure unchanged from prior portal pressure, whereas six type B patients had a significant decrease. Residual intrahepatic venous pressure was measured after portacaval shunt in 40 cirrhotic patients who were followed for as long as 9 yr (median survival 4.0 yr). The 13 patients who developed chronic encephalopathy had significantly lower pressure (21.1±4.4 cm, mean±SD) and shorter survival (median 0.6 yr) than the other 27 patients (32.6±5.3 cm, 5.0 yr). The preoperative estimation of portal pressure-diverted portal flow curve slope anticipates the hepatic vascular response to portacaval anastomosis and identifies a group of patients in whom loss of portal blood flow results in a low residual intrahepatic venous pressure that is associated with early death and chronic encephalopathy.

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Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. BRADLEY S. E., CHILDS A. W., COMBES B., COURNAND A., WADE O. L., WHEELER H. O. The effect of exercise on the splanchnic blood flow and splanchnic blood volume in normal man. Clin Sci. 1956 Aug;15(3):457–463. [PubMed] [Google Scholar]
  2. Burchell A. R., Moreno A. H., Panke W. F., Nealon T. F., Jr Hemodynamic variables and prognosis following portacaval shunts. Surg Gynecol Obstet. 1974 Mar;138(3):359–369. [PubMed] [Google Scholar]
  3. Burchell A. R., Moreno A. H., Panke W. F., Nealon T. F., Jr Hepatic artery flow improvement after portacaval shunt: a single hemodynamic clinical correlate. Ann Surg. 1976 Sep;184(3):289–302. doi: 10.1097/00000658-197609000-00006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. DE FREITAS F. M., FARACO E. Z., DE AZEVEDO D. F., ZADUCHLIVER J., LEWIN I. BEHAVIOR OF NORMAL PULMONARY CIRCULATION DURING CHANGES OF TOTAL BLOOD VOLUME IN MAN. J Clin Invest. 1965 Mar;44:366–378. doi: 10.1172/JCI105150. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Daoud F. S., Reeves J. T., Schaefer J. W. Failure of hypoxic pulmonary vasoconstriction in patients with liver cirrhosis. J Clin Invest. 1972 May;51(5):1076–1080. doi: 10.1172/JCI106899. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. EDWARDS E. A. Functional anatomy of the porta-systemic communications. AMA Arch Intern Med. 1951 Aug;88(2):137–154. doi: 10.1001/archinte.1951.03810080005002. [DOI] [PubMed] [Google Scholar]
  7. FERGUSON D. J. HEMODYNAMICS IN SURGERY FOR PORTAL HYPERTENSION. Ann Surg. 1963 Sep;158:383–386. doi: 10.1097/00000658-196309000-00007. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Fuchs W. A., Preisig R., Voegeli E., Bircher J. Hepatic arteriography in cirrhosis of the liver and portal hypertension. Correlation between angiographic and functional data. Invest Radiol. 1972 Sep-Oct;7(5):369–377. doi: 10.1097/00004424-197209000-00003. [DOI] [PubMed] [Google Scholar]
  9. Gitlin N., Grahame G. R., Kreel L., Williams H. S., Sherlock S. Splenic blood flow and resistance in patients with cirrhosis before and after portacaval anastomoses. Gastroenterology. 1970 Aug;59(2):208–213. [PubMed] [Google Scholar]
  10. Greenway C. V., Stark R. D. Hepatic vascular bed. Physiol Rev. 1971 Jan;51(1):23–65. doi: 10.1152/physrev.1971.51.1.23. [DOI] [PubMed] [Google Scholar]
  11. HALES M. R., ALLAN J. S., HALL E. M. Injection-corrosion studies of normal and cirrhotic livers. Am J Pathol. 1959 Sep-Oct;35:909–941. [PMC free article] [PubMed] [Google Scholar]
  12. Imanaga H., Yamamoto S., Kuroyanagi Y. Surgical Treatment of Portal Hypertension According to State of Intrahepatic Circulation. Ann Surg. 1962 Jan;155(1):42–50. doi: 10.1097/00000658-196201000-00005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Jackson F. C., Perrin E. B., Felix W. R., Smith A. G. A clinical investigation of the portacaval shunt. V. Survival analysis of the therapeutic operation. Ann Surg. 1971 Oct;174(4):672–701. doi: 10.1097/00000658-197110000-00012. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. KELTY R. H., BAGGENSTOSS A. H., BUTT H. R. The relation of the regenerated hepatic nodule to the vascular bed in cirrhosis. Proc Staff Meet Mayo Clin. 1950 Jan 18;25(2):17-26, illust. [PubMed] [Google Scholar]
  15. KONTOS H. A., SHAPIRO W., MAUCK H. P., PATTERSON J. L., Jr GENERAL AND REGIONAL CIRCULATORY ALTERATIONS IN CIRRHOSIS OF THE LIVER. Am J Med. 1964 Oct;37:526–535. doi: 10.1016/0002-9343(64)90066-x. [DOI] [PubMed] [Google Scholar]
  16. Kessler R. E., Amadeo J. H., Tice D. A., Zimmon D. S. Filtration of schistosomes in unanesthetized man. JAMA. 1970 Oct 19;214(3):519–524. [PubMed] [Google Scholar]
  17. Kessler R. E., Santoni E., Tice D. A., Zimmon D. S. Effect of lymph drainage on portal pressure and bleeding esophageal varices. Gastroenterology. 1969 Mar;56(3):538–547. [PubMed] [Google Scholar]
  18. Kessler R. E., Tice D. A., Zimmon D. S. Effect of umbilico-systemic shunting on portal pressure and bleeding varices. Surg Forum. 1969;20:376–377. [PubMed] [Google Scholar]
  19. Kessler R. E., Tice D. A., Zimmon D. S. Retrograde flow of portal vein blood in patients with cirrhosis. Radiology. 1969 Apr;92(5):1038–1042. doi: 10.1148/92.5.1038. [DOI] [PubMed] [Google Scholar]
  20. Kessler R. E., Tice D. A., Zimmon D. S. Value, complications, and limitations of umbilical vein catheterization. Surg Gynecol Obstet. 1973 Apr;136(4):529–535. [PubMed] [Google Scholar]
  21. Kessler R. E., Zimmon D. S. Umbilical vein angiography. Radiology. 1966 Nov;87(5):841–844. doi: 10.1148/87.5.841. [DOI] [PubMed] [Google Scholar]
  22. Kew M. C., Brunt P. W., Varma R. R., Hourigan K. J., Williams H. S., Sherlock S. Renal and intrarenal blood-flow in cirrhosis of the liver. Lancet. 1971 Sep 4;2(7723):504–510. doi: 10.1016/s0140-6736(71)90435-1. [DOI] [PubMed] [Google Scholar]
  23. Koppel M. H., Coburn J. W., Mims M. M., Goldstein H., Boyle J. D., Rubini M. E. Transplantation of cadaveric kidneys from patients with hepatorenal syndrome. Evidence for the functionalnature of renal failure in advanced liver disease. N Engl J Med. 1969 Jun 19;280(25):1367–1371. doi: 10.1056/NEJM196906192802501. [DOI] [PubMed] [Google Scholar]
  24. Kreel L., Gitlin N., Sherlock S. Hepatic artery angiography in portal hypertension. Am J Med. 1970 May;48(5):618–623. doi: 10.1016/0002-9343(70)90012-4. [DOI] [PubMed] [Google Scholar]
  25. Lunzer M., Newman S. P., Sherlock S. Skeletal muscle blood flow and neurovascular reactivity in liver disease. Gut. 1973 May;14(5):354–359. doi: 10.1136/gut.14.5.354. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. MURRAY J. F., DAWSON A. M., SHERLOCK S. Circulatory changes in chronic liver disease. Am J Med. 1958 Mar;24(3):358–367. doi: 10.1016/0002-9343(58)90322-x. [DOI] [PubMed] [Google Scholar]
  27. Malt R. A., Nabseth D. C., Orloff M. J., Stipa S. Occasional notes. Portal hypertension, 1979. N Engl J Med. 1979 Sep 13;301(11):617–618. doi: 10.1056/NEJM197909133011124. [DOI] [PubMed] [Google Scholar]
  28. Moreno A. H., Burchell A. R., Rousselot L. M., Panke W. F., Slafsky F., Burke J. H. Portal blood flow in cirrhosis of the liver. J Clin Invest. 1967 Mar;46(3):436–445. doi: 10.1172/JCI105545. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Peto R., Pike M. C., Armitage P., Breslow N. E., Cox D. R., Howard S. V., Mantel N., McPherson K., Peto J., Smith P. G. Design and analysis of randomized clinical trials requiring prolonged observation of each patient. I. Introduction and design. Br J Cancer. 1976 Dec;34(6):585–612. doi: 10.1038/bjc.1976.220. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Peto R., Pike M. C., Armitage P., Breslow N. E., Cox D. R., Howard S. V., Mantel N., McPherson K., Peto J., Smith P. G. Design and analysis of randomized clinical trials requiring prolonged observation of each patient. II. analysis and examples. Br J Cancer. 1977 Jan;35(1):1–39. doi: 10.1038/bjc.1977.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Price H. L., Deutsch S., Marshall B. E., Stephen G. W., Behar M. G., Neufeld G. R. Hemodynamic and metabolic effects of hemorrhage in man, with particular reference to the splanchnic circulation. Circ Res. 1966 May;18(5):469–474. doi: 10.1161/01.res.18.5.469. [DOI] [PubMed] [Google Scholar]
  32. Price J. B., Jr, Voorhees A. B., Jr, Britton R. C. Operative hemodynamic studies in portal hypertension. Significance and limitations. Arch Surg. 1967 Nov;95(5):843–852. doi: 10.1001/archsurg.1967.01330170151019. [DOI] [PubMed] [Google Scholar]
  33. REDEKER A. G., GELLER H. M., REYNOLDS T. B. Hepatic wedge pressure, blood flow, vascular resistance and oxygen consumption in cirrhosis before and after end-to-side portacaval shunt. J Clin Invest. 1958 Apr;37(4):606–618. doi: 10.1172/JCI103643. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. REDEKER A. G., KUNELIS C. T., YAMAMOTO S., REYNOLDS T. B. ASSESSMENT OF PORTAL AND HEPATIC HEMODYNAMICS AFTER SIDE-TO-SIDE PORTACAVAL SHUNT IN PATIENTS WITH CIRRHOSIS. J Clin Invest. 1964 Jul;43:1464–1471. doi: 10.1172/JCI105022. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. REYNOLDS T. B., GELLER H. M., KUZMA O. T., REDEKER A. G. Spontaneous decrease in portal pressure with clinical improvement in cirrhosis. N Engl J Med. 1960 Oct 13;263:734–739. doi: 10.1056/NEJM196010132631505. [DOI] [PubMed] [Google Scholar]
  36. REYNOLDS T. B., REDEKER A. G., GELLER H. M. Wedged hepatic venous pressure; a clinical evaluation. Am J Med. 1957 Mar;22(3):341–350. doi: 10.1016/0002-9343(57)90090-6. [DOI] [PubMed] [Google Scholar]
  37. Rappaport A. M., Schneiderman J. H. The function of the hepatic artery. Rev Physiol Biochem Pharmacol. 1976;76:129–175. doi: 10.1007/BFb0027689. [DOI] [PubMed] [Google Scholar]
  38. Reynolds T. B. The role of hemodynamic measurements in portosystemic shunt surgery. Arch Surg. 1974 Mar;108(3):276–281. doi: 10.1001/archsurg.1974.01350270010003. [DOI] [PubMed] [Google Scholar]
  39. SCHENK W. G., Jr, McDONALD J. C., McDONALD K., DRAPANAS T. Direct measurement of hepatic blood flow in surgical patients: with related observations on hepatic flow dynamics in experimental animals. Ann Surg. 1962 Sep;156:463–471. doi: 10.1097/00000658-196209000-00013. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. SHALDON S., CHIANDUSSI L., GUEVARA L., CAESAR J., SHERLOCK S. The estimation of hepatic blood flow and intrahepatic shunted blood flow by colloidal heat-denatured human serum albumin labeled with I-131. J Clin Invest. 1961 Jul;40:1346–1354. doi: 10.1172/JCI104365. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. TYGSTRUP N., WINKLER K., MELLEMGAARD K., ANDREASSEN M. Determination of the hepatic arterial blood flow and oxygen supply in man by clamping the hepatic artery during surgery. J Clin Invest. 1962 Mar;41:447–454. doi: 10.1172/JCI104497. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Takahashi T., Tezuka F. Hepatic arteries and arterial circulation in liver cirrhosis. Tohoku J Exp Med. 1974 Jun;113(2):113–128. doi: 10.1620/tjem.113.113. [DOI] [PubMed] [Google Scholar]
  43. Viallet A., Joly J. G., Marleau D., Lavoie P. Comparison of free portal venous pressure and wedged hepatic venous pressure in patients with cirrhosis of the liver. Gastroenterology. 1970 Sep;59(3):372–375. [PubMed] [Google Scholar]
  44. Viamonte M., Jr, Warren W. D., Fomon J. J., Martinez L. O. Angiographic investigations in portal hypertension. Surg Gynecol Obstet. 1970 Jan;130(1):37–53. [PubMed] [Google Scholar]
  45. WILLIAMS R., ZIMMON D. S., THOMPSON E., SHERLOCK S. THE ESTIMATION OF SEGMENTAL HEPATIC VENOUS FLOW IN MAN. Gastroenterology. 1964 May;46:525–530. [PubMed] [Google Scholar]
  46. Zimmon D. S., Kessler R. E. The portal pressure-blood volume relationship in cirrhosis. Gut. 1974 Feb;15(2):99–101. doi: 10.1136/gut.15.2.99. [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Zimmon D. S. The hepatic vasculature and its response to hepatic injury: a working hypothesis. Yale J Biol Med. 1977 Sep-Oct;50(5):497–506. [PMC free article] [PubMed] [Google Scholar]

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