Portal ven dallanma varyantları

Özet

Portal ven dallanma varyantı, ana portal venin karaciğer içindeki sektör ve segment dallarına beklenenden farklı sırada ayrılmasıdır; damarlar çoğunlukla açık kalır. Kontrastlı BT’nin üç boyutlu rekonstrüksiyonları, portal ven dallarının kökenlerini ve karaciğer segmentleriyle ilişkilerini değerlendirmeye yardımcı olur. Varyant haritası özellikle karaciğer rezeksiyonu, canlı vericili transplantasyon ve portal ven embolizasyonu planlanırken önem kazanır. Dallanmayı standart kabul etmek, hedeflenen segment yerine başka bir karaciğer alanının damarının bağlanması ya da embolize edilmesiyle sonuçlanabilir.

Faz ve pencere

Portal tanısal

Kontrastlı BT’nin üç boyutlu rekonstrüksiyonlarında sağ posterior portal ven dallanması bifurkasyon, loop veya diğer örüntüler olarak değerlendirilebilir.

Önerilen pencereler: Batın (G 400 / M 50), Karaciğer (G 150 / M 30), Anjiyo (G 600 / M 150).

BT bulguları

• Trifurkasyon: ana portal ven tek bir sağ portal gövde oluşturmadan sol portal, sağ anterior ve sağ posterior dallara ayrılır.
• Erken sağ posterior dal: VI ve VII segmentlerine giden dal, ana portal venin ilk ayrımı olarak çıkar; sağ anterior dal ile sol portal dal daha sonra ayrılır.
• Sağ posterior portal dalın kökeni ve segmental pediküllerle ilişkisi, kontrastlı BT’nin üç boyutlu rekonstrüksiyonlarında değerlendirilir.
• Segment V ve VIII dalları sağ anterior portal pediküle; VI ve VII dalları sağ posterior pediküle doğru izlenir.
• Sol portal venin yatay ve kistik bölüm seyri sırasında, sağ portal venin sol portal venden köken alması gibi ekstrasplenomeyal dallanma varyantları değerlendirilir.
• Portal ven dallanma varyantları, kontrastlı BT’de damarların kökenleri ve karaciğer segmentleriyle ilişkilerine göre tanımlanır.
• Daha seyrek örüntülerde segment VI veya VII dalı ayrı köken alabilir; her dalın beslediği alan ve ana gövdeyle ilişkisi ayrı tanımlanır.

Ölçütler ve sınıflamalar

Covey portal ven dallanma sınıflaması

Tip I standart sağ-sol dallanmadır. Tip II ana portal ven trifurkasyonunu, tip III sağ posterior dalın ana portal venden erken çıkışını tanımlar. Tip IV ve V, sırasıyla sağ portal venden segment VII ve segment VI’ya giden ayrı dalların bulunduğu örüntülerdir.

Normalde

Standart portal ağaçta ana portal ven sağ ve sol dallara ayrılır; sağ portal ven de V/VIII segmentlerini besleyen anterior ve VI/VII segmentlerini besleyen posterior dallara bölünür. Portal ven dallanma örüntülerini, ana ve sağ portal ven dallarının kökenleri ile karaciğer segmentleri ve portal pediküllerle ilişkilerine göre karşılaştır.

Ayırıcı tanı

Portal ven trombozu, portal venöz faz görüntülemede intraluminal dolum defekti şeklinde görülebilir; kronik olgularda kavernöz dönüşümle kollateral damarlar eşlik edebilir.

Portal ven stenozu

daralan segmentte akım hızlanması ve transstenotik basınç gradyanı izlenir; tıkanıklık yokken varyantta damarın lümeni boyunca patenta devam eder.

Kavernöz dönüşümde tıkalı portal veni baypas etmek üzere kollateral ven ağı gelişir ve bu ağ porta hepatis çevresinde izlenebilir.

Aberrat hepatik arter

arteriyel fazda yoğunlaşır ve superior mezenterik veya çeliak trunktan köken alarak portal venin arka yüzünden geçebilir; portal ven dallarından farklı olarak karaciğer arteriyel sistemine bağlanır.

Hepatik ven

segmentlerden toplanarak vena kava inferiora drene olur; portal ven aksının tersine porta hepatis'ten parankime doğru değil, parankimden merkeze doğru akar.

Tuzaklar

• Tek aksiyel kesitte damarın yönüne göre segment tahmini yapmak; yüksek varyant sıklığı nedeniyle damarın parankim içindeki gerçek seyri ve ulaştığı segmental bölge üç boyutlu yeniden yapılandırmalarla doğrulanmalıdır.
• Yetersiz portal kontrastlanma veya erken faz görüntüleme, küçük bir portal dala geçici hepatik attenuans farkı (THAD) yaratarak trombozu taklit edebilir; bunun için tüm fazların ve diğer damarların opaklaşma düzeyleri karşılaştırılmalıdır.
• Trifurkasyonda ortak sağ portal gövde bulunmayabilir; sağ anterior ve posterior dalları var olmayan bir gövde üzerinden tarif etmek anatomik haritayı yanlış gösterir.
• Portal dallanma varyantı safra yolu varyantıyla birlikte bulunabilir; ameliyat öncesi incelemede yalnız damar ağacını değil, hiler safra kanallarının ayrılma düzenini de raporla.

Kendini dene

1. Portal faz BT'de ana portal ven sağ anterior, sağ posterior ve sol dallara tek noktada ayrılıyor; ortak sağ gövde görülmüyor. Bu örüntü hangisidir?

   • Portal trifurkasyon
   • Erken posterior dal
   • Kavernöz dönüşüm
   • Portal ven stenozu
   Cevabı göster

   Portal trifurkasyon. Üç ana dalın aynı ayrım düzeyinden çıkması trifurkasyondur. Erken posterior dalda VI-VII dalı ana ayrımdan önce çıkar. Kavernöz dönüşümde kollateral ven ağı gelişir; portal ven stenozunda darlık boyunca akım hızı ve basınç gradyanı artabilir.

2. Ana portal venin ilk dalı VI-VII segmentlerine uzanıyor; sol ve sağ anterior dallar daha sonra ayrılıyor. En uygun adlandırma nedir?

   • Erken sağ posterior dal
   • Portal trifurkasyon
   • Portal ven trombozu
   • Kavernöz dönüşüm
   Cevabı göster

   Erken sağ posterior dal. İlk çıkan dalın sağ posterior sektöre ve VI-VII segmentlerine gitmesi erken sağ posterior dal örüntüsüdür. Trifurkasyonda üç ana dal aynı düzeyde çıkar; tromboz lümeni dolduran defekt veya kesilme yapar, kavernöz dönüşüm çoklu kollaterallerle karakterizedir.

İlgili konular

• Arterioportal şant ve geçici hepatik atenüasyon farkı (THAD)

Kaynaklar

Bu sayfadaki 42 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 16 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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