645–654_Griffin_hepatic vascular anomalies_AT_14.
qxp_FAB 12/06/2019 14:54 Page 645
Journal of Feline Medicine and Surgery (2019) 21, 645–654
FELINE ABDOMINAL
ULTRASONOGRAPHY: WHAT’S
NORMAL? WHAT’S ABNORMAL?
Hepatic vascular anomalies
Sally Griffin
Compared with disorders of the hepatic parenchyma and biliary tree,
hepatic vascular anomalies are somewhat less common in the cat.
However, as ultrasound technology and image quality continue to
improve and our understanding of vascular abnormalities grows,
recognition of these disorders is gradually increasing.
Colour flow and pulsed-wave Doppler
To fully appreciate the morphology of and blood flow within the various
vascular anomalies that are described in this article, a basic understanding
of the use of colour flow and pulsed-wave Doppler is required. An in-depth
discussion of these modalities is beyond the scope of this article, and for
further information regarding their use and interpretation readers are
referred to Kremkau,1 Nyland and Mattoon,2 and d’Anjou and Penninck.3
Portosystemic shunts
Portosystemic shunts (PSSs) are abnormal vascular connections
between the portal system and systemic venous circulation that allow
blood to bypass the liver.4 They may be congenital or acquired, the
former being more common in cats.
Congenital portosystemic shunts
Although congenital PSSs are a well-recognised cause of hepatic
encephalopathy, they occur far less commonly in cats than in dogs.5
The use of ultrasonography for the diagnosis of PSSs in both species
has been described in detail and only features pertinent to cats are dis-
cussed here.6–11 For further information regarding the expected laboratory
results, options for surgical management and prognosis in cats with a
congenital PSS, readers are referred to two earlier reviews in JFMS by
Tivers and Lipscomb.12,13
Congenital PSSs have been reported in both domestic shorthair cats,
which account for the majority of cases, and purebred cats, particularly
Siamese, Himalayans, Burmese and Persians.5,6,12,14–17 While the majority of
cats are presented for investigation of a suspected shunt when less than
12 months of age,6,18 shunts can remain undetected for many years.12,17
Cats with congenital shunts can be normal in size and stature or small
and in poor condition, and often present with neurological signs.5,6,15,17
Congenital shunts can be subdivided into those that are located outside
the liver (extrahepatic) and those located inside the liver (intrahepatic).
Sally Griffin
BVSc, CertAVP, DipECVDI
Radiology Department,
Willows Veterinary Centre and Referral Service,
Highlands Road, Shirley,
Solihull B90 4NH, UK
Email: sally.griffin@willows.uk.net
DOI: 10.1177/1098612X19856182
© The Author(s) 2019
CLINICAL REVIEW
Practical relevance:  Abdominal
ultrasound plays a vital role in the
diagnostic work-up of many cats
presenting to general and specialist
practitioners. Although hepatic
vascular anomalies are less common
than disorders of the hepatic parenchyma
and biliary tree, our understanding and recognition
of these is gradually increasing with advancements
in ultrasound technology and image quality.
Clinical challenges: Despite ultrasonography
being a commonly used modality, many
practitioners are not comfortable performing an
ultrasound examination or interpreting the resulting
images. Even differentiating between normal
variation and pathological changes can be
challenging for all but the most experienced.
In addition, some views may be obscured by
overlying structures; for example, the termination
of a shunt entering the left phrenic or azygous veins
is often difficut to see due to the high probability of
lung passing between the shunt and the transducer
as the cat breathes.
Equipment: Ultrasound facilities are readily
available to most practitioners, although use
of ultrasonography as a diagnostic tool is highly
dependent on operator experience.
Aim: This review, part of an occasional series on
feline abdominal ultrasonography, discusses the
appearance of various hepatic vascular anomalies.
It is aimed at general practitioners who wish to
improve their knowledge and confidence in feline
abdominal ultrasound and is accompanied by high-
resolution images. Ultrasound of the liver and biliary
tree were discussed in articles published in January
and May 2019, respectively.
Evidence base: Information provided in this article
is drawn from the published literature and the
author’s own clinical experience.
Keywords: Ultrasound; hepatic vascular
anomalies; portosystemic shunt; splenosystemic
shunt; arteriovenous fistula; portal vein thrombosis
JFMS CLINICAL PRACTICE 645
645–654_Griffin_hepatic vascular anomalies_AT_14.qxp_FAB 12/06/2019 14:55 Page 646
R E V I E W / Feline abdominal ultrasonography – hepatic vascular anomalies
Congenital extrahepatic shunts
Single extrahepatic shunts are more common in
cats than intrahepatic shunts, although both
have been reported.9,6,17,19,20 Extrahepatic shunts
in cats can be divided into five subtypes: left
gastrophrenic, left gastrocaval, splenocaval,
left gastroazygous and those arising from the
left colic vein, with the first three accounting
for 92% of shunts in this species (see box below
for imaging guidelines and interpretation).22,23
A shunt arising from the left gastric vein is
recognised on ultrasound as a large vessel
entering the gastrosplenic vein from a cranial
direction, usually close to where the latter
enters the main portal vein. The shunt, which is
often tortuous in nature, can sometimes be fol-
lowed to its termination in the left phrenic vein,
pre- or post-hepatic caudal vena cava (CVC) or
azygous vein. In cats with a left gastrophrenic
shunt (by far the most common subtype), the
anomalous shunting vessel enters the left
phrenic vein at the level of the oesophageal
hiatus.22,24 It may be possible to follow the dilat-
ed left phrenic vein with ultrasound as it travels
lateromedially along the caudal surface of the
Imaging the por tal and vein and tributaries
Regardless of the subtype, most extrahepatic
shunts are usually best seen with a right dorsal
flank or intercostal window.21 With the cat in left
lateral recumbency and the transducer on the
right flank (Figure 1), the portal vein is first iden-
tified at the confluence of the cranial and caudal
mesenteric veins. From here, the portal vein is
followed cranially until the gastrosplenic vein, a
tributary of the portal vein, can be seen entering
the main portal vein from the left (in the far field
of the image). An initial assessment of the size of
the gastrosplenic vein relative to the main portal
vein should be made at this point. Portal vein
tributaries should be smaller in diameter than the
main portal vein. If the gastrosplenic vein is larg-
er than the portal vein, this should immediately
raise suspicion of a shunt.
Figure 1 To image the portal vein starting at the confluence of the cranial
and caudal mesenteric veins, the transducer is placed on the right flank
with the cat in left lateral recumbency
646 JFMS CLINICAL PRACTICE
Shunt nomenclature
By convention, the name of a shunt is derived from the name of the portal
vessel from which it originates and the name of the first systemic vein to
which it joins.25 For example, a left gastrocaval shunt arises from the left
gastric vein and terminates in the post-hepatic caudal vena cava (CVC).
The splenocaval shunt is an exception to this naming convention and, strictly
speaking, arises from the left gastric vein and terminates in the pre-hepatic
CVC at the level of the epiploic foramen. The deviation from the normal
nomenclature is an attempt to differentiate between left gastric shunts that
enter the pre-hepatic CVC and those that enter the post-hepatic CVC.
diaphragm before entering the post-hepatic
CVC.24 In cats with a left gastrocaval shunt,
the anomalous vessel enters the post-hepatic
CVC at the level of the caval foramen, often
via a saccular dilation or ampulla, which may
be recognised ultrasonographically.24 As men-
tioned in the box above, in those cats with a
splenocaval shunt, the shunting vessel termi-
nates in the pre-hepatic CVC at the level of the
epiploic foramen.24,26 Local disruption to flow
resulting in turbulence may be noted in the
cava at the site of entry of a shunt (Figure 3).
Next, using colour flow Doppler and a conven-
A tional colour map (ie, flow towards and away
from the transducer are depicted as red and
gastrosplenic blue, respectively) flow within the gastrosplenic
vein that is vein will normally appear red (Figure 2). As a gen-
eral rule of thumb, flow within portal vein tribu-
larger than the taries should always be directed towards the
portal vein (ie, hepatopetal) under normal cir-
portal vein cumstances. However, when an extrahepatic
should shunt arising from the left gastric vein (a tributary
of the gastrosplenic vein) is present, flow within
immediately the gastrosplenic vein can be continuously or
intermittently directed away from the portal vein
raise suspicion (ie, hepatofugal) and will therefore appear blue
of a shunt. with colour Doppler. This occurs because a large
extrahepatic shunt offers a much lower resis-
tance path than the smaller hepatic sinusoids.
In all ultrasound images, unless stated otherwise,
cranial is to the left and caudal is to the right of the image.
Figure 2 Colour Doppler ultrasound image depicting normal flow in the portal
and gastrosplenic veins. The blue colour in the portal vein confirms that the
direction of blood flow is from caudal to cranial (ie, hepatopetal), or from right
to left in this image. The red colour in the gastrosplenic vein is consistent
with flow towards the transducer and thus flow into the portal vein
645–654_Griffin_hepatic vascular anomalies_AT_14.qxp_FAB 12/06/2019 14:55 Page 647

R E V I E W / Feline abdominal ultrasonography – hepatic vascular anomalies

The presence of a large diameter vessel adja-

cent to the aorta in the craniodorsal abdomen,
containing cranially directed blood flow, is con-
sistent with a left gastroazygous shunt.9 It should
be noted that the normal azygous vein is not
seen on ultrasound in cats.10 It is often difficult
to see the termination of a shunt entering the left
phrenic or azygous veins due to their inherently
cranial location within the abdomen and the
high probability of lung passing between the
shunt and the transducer as the cat breathes.
The left colic vein is a tributary of the caudal
mesenteric vein. Shunts arising from the left
colic vein can be identified on ultrasound by
the presence of a large vessel containing
hepatofugal flow that enters a distended Figure 3 Ultrasound image showing altered flow within the caudal vena cava at the level of
caudal mesenteric vein (Figure 4).23 An inter- shunt entry. A colour flow Doppler window has been applied over the cava. In the right side
esting feature of left colic shunts is that they of the window, flow in the cava is depicted as being blue, indicating that flow is away from
the transducer and therefore from right to left (or caudal to cranial) in the image, as expected.
often travel caudally before making a 180º In the left side of the window, the solid blue colour has been replaced with a mosaic of several
turn to enter the systemic venous circulation colours including red, yellow, blue and cyan. According to the colour map on the left side of the
image, this indicates that flow is directed both towards and away from the transducer, which is
via either the CVC or common iliac vein.23 the typical appearance of turbulence

Caudal mesenteric vein

PV
Shunt Cranial mesenteric vein
Shunt

a b

c d

Figure 4 Ultrasound images from a 5-month-old male entire domestic

longhair cat with an extrahepatic shunt originating from the left colic vein
and terminating in the caudal vena cava (CVC). (a) Image acquired at the level
of the confluence of the cranial and caudal mesenteric veins. The diameter of
the shunting vessel is much greater than that of the portal vein (PV). (b) Colour
Doppler image at the same level as (a) shows abnormal hepatofugal flow in
the portal vein cranial to the shunt and within the shunting vessel itself, as
denoted by the arrows. As the shunt was followed caudally (c,d), it formed
a large, tortuous vessel containing hepatofugal flow (ie, directed from left
to right in the images). (e) Focal dilation of the CVC (arrows) at the entry site
of the shunt

JFMS CLINICAL PRACTICE 647

645–654_Griffin_hepatic vascular anomalies_AT_14.qxp_FAB 12/06/2019 14:55 Page 648

R E V I E W / Feline abdominal ultrasonography – hepatic vascular anomalies

Ultrasound Congenital intrahepatic shunts
As previously stated, intrahepatic shunts
can be used occur less commonly than extrahepatic shunts
in the cat. Most intrahepatic shunts in cats
preoperatively are left divisional, although both right- and
to accurately central-divisional shunts have also been
reported.18 Ultrasound can be used preopera-
characterise tively to accurately characterise intrahepatic
shunts as left, right or central divisional.18
intrahepatic As in the dog, left-divisional shunts in
shunts as left, cats are thought to represent a patent ductus
venosus and arise from the left branch of
right or central the intrahepatic portal vein, forming a large-
divisional. diameter vessel, initially travelling cranio-
laterally through the left side of the liver
before coursing medially to drain into the CVC
via the left hepatic vein.18,27 Right-divisional
shunts in the cat can similarly present as a
large tortuous vessel but are located within
the right side of the liver, rather than the left.27
In dogs, central-divisional shunts are usually
formed from a foramen between the intrahep-
atic portions of the portal vein and CVC,
whereas in the cat they take the form of a tor-
tuous intrahepatic vessel.27 The use of a right
or left craniodorsal intercostal and/or sub-
costal approach is often necessary to identify
the intrahepatic shunt ultrasonographically.9
The ability to identify and follow any shunt-
ing vessel will depend not only on operator
experience but also on patient cooperation
and the extent of any gas within the gastro-
intestinal tract, which can obscure important
anatomy. Therefore, while the ‘shunt hunt’
can be performed with the patient conscious,
it is often preferable to use sedation.

Findings supporting a suspicion of congenital PSS

Interpretation of portal flow
If a shunting vessel cannot be identified directly with ultra-
sound, further information regarding the likely presence of a
shunt can be gained by assessing portal vein size and flow
speed, direction and character using colour flow and pulsed-
wave Doppler. Ideally, flow speed should be measured using
a Doppler angle <60º to avoid incurring excessive errors in the
calculation of flow speed, although in practice this is not always
possible to achieve.1 In cats, a ratio of the diameters of the por-
tal vein and aorta of 0.7–1.25 and a mean portal flow speed of
10–18 cm/s at the porta hepatis is considered normal.9,10 An
extrahepatic shunt may be suspected in cats with a reduced
(<0.65) portal vein to aortic size ratio.9 The mean diameter of the
portal vein at the porta hepatis in normal cats is 0.44 cm com-
pared with only 0.27 cm in cats with an extrahepatic PSS.9
Portal flow in normal cats is usually smooth and uniform
(ie, non-pulsatile). This is because the portal vein is connect-
ed to the intestinal capillaries caudally and hepatic sinu-
soids cranially and hence portal flow is not exposed to the
systolic and diastolic pressures of the systemic circulation.
When a congenital intra- or extrahepatic shunt is present,
portal flow may become variable due to the abnormal direct
connection with the systemic circulation.6,9 Measurement of
portal flow is usually easier in cats with intrahepatic rather
than extrahepatic shunts due to the small size of the portal
vein at the porta hepatis in the latter.9

Secondary findings less commonly in cats than in dogs and is only seen in
The identification of certain abnormalities on ultrasound, around 22–50% of cats with a congenital PSS.9,6,17,18
such as microhepatica, renomegaly and ammonium urate ✜ Reduced intrahepatic portal vasculature (ie, reduced size
urolithiasis, can support a clinical suspicion of a congenital and/or number of intrahepatic portal branches due to
PSS.9 This is particularly useful if an anomalous vessel decreased intrahepatic portal flow) is also a less common
cannot be seen directly. finding in cats with shunts than in
✜ Microhepatica occurs due to dogs (as are renomegaly and
reduced delivery of hepatotroph- ammonium urate urolithiasis – see
ic factors, such as insulin, to the below).6 In two studies, only 21%
liver in the presence of a congen- and 50% of cats with a congeni-
ital PSS.4 On ultrasound, a small tal shunt had a reduction in intra-
liver is suspected when there is hepatic portal vasculature.6,19
a reduction in the volume of ✜ Renomegaly in dogs − and like-
liver parenchyma between the ly also in cats − with a PSS occurs
diaphragm and the stomach.28 due to an increase in glomerular fil-
A gall bladder that appears tration rate.29 Normal renal length
abnormally large relative to in the cat ranges from approxi-
the volume of liver tissue can mately 3.0–4.5 cm, although a
also indicate microhepatica, renal length >5 cm has been
although care should be taken reported in healthy Ragdolls.30–32
not to overinterpret a large gall The association of renomegaly
bladder in a cat that has not Figure 5 Medullary rim sign (arrows) in the kidneys of a 4-month- with a medullary rim sign (Figure
old female entire cat with a left gastrocaval portosystemic
eaten recently.28 Interestingly, shunt. A medullary rim sign is a hyperechoic band within 5) has been reported in <50% of
microhepatica is recognised the medulla that parallels the corticomedullary junction cats with a congenital PSS.17,19
Continued on page 649

648 JFMS CLINICAL PRACTICE

645–654_Griffin_hepatic vascular anomalies_AT_14.qxp_FAB 12/06/2019 14:55 Page 649

R E V I E W / Feline abdominal ultrasonography – hepatic vascular anomalies

Diagnostic sensitivity of ultrasound

The overall sensitivity of ultrasound for the detection and
characterisation of congenital shunts in cats is high,
although this is greatly operator dependent.19 An accuracy
of 100% for the diagnosis of congenital PSSs using ultra-
sonography has been reported in a case series of 24 cats
in which ultrasonography was performed by experienced
radiologists.6 The accuracy is likely to be lower for less
experienced operators.

Acquired portosystemic shunts

Acquired shunts are pre-existing embryonic
vessels that open up and dilate in response to
chronic portal hypertension to allow blood to a
bypass the liver and enter the systemic circu-
lation directly. The prevalence of acquired
portosystemic shunting in cats as a result of
portal hypertension is low and only occasion-
al reports exist.35–42 This may be at least in part
attributable to the relatively low prevalence of
cirrhosis in this species, which is a common
cause of acquired shunts in the dog.39 Acquired
shunts have been reported to occur in cats in
association with several conditions including
hepatic fibrosis,39,41 arterioportal fistulae,37,43
portal vein thrombosis37 and chronic diaphrag- b
matic herniation,40 and also as a sequela to
Figure 7 (a,b) Colour flow Doppler images showing the typical ultrasonographic
surgical attenuation of a congenital PSS.44,45 appearance of acquired shunts that have formed secondarily to portal
Although reports of the ultrasonographic hypertension. Small vessels such as these are usually best appreciated with
appearance of secondary acquired shunts in colour flow Doppler and can be surprisingly difficult to identify in B-mode grey
scale images
cats are also rare, acquired shunt morphology
appears to mirror that seen in dogs. Acquired from the portal vein close to the splenic vein
shunts can take the form of one or more has also been described in two cats with clinical
plexuses of small tortuous vessels in the signs of hepatic encephalopathy.41 In both cases,
retroperitoneal space close to one or both liver histology revealed congenital hepatic fibro-
kidneys or between the portal vein and CVC sis, a condition that arises due to congenital bil-
(Figure 7).39,40 A peritoneal effusion of variable iary cystic lesions and has previously been
volume is also commonly found in cats with linked with polycystic kidney disease in cats.46
acquired PSSs.39 The authors of the case report concluded that
The presence on ultrasound of an acquired the congenital liver disease most likely result-
shunt taking the form of a solitary abnormal ves- ed in portal hypertension and the formation
sel containing hepatofugal flow that originated of acquired portosystemic collaterals.41

Continued from page 648

✜ Ammonium urate urolithiasis may be observed in ani-
mals with a congenital shunt due to reduced hepatic con-
version of ammonia to urea, leading to increased excretion
of ammonia in the urine.4,33 This occurs alongside
decreased uric acid metabolism, the final result of which
can be the development of ammonium urate stones.33
Since ammonium urate uroliths are usually radiolucent,
ultrasound is particularly useful for their detection
(Figure 6).5 Cats with urate uroliths and a concurrent PSS
are typically younger than cats with uroliths and no PSS
(2 years vs 7 years).34 However, urolithiasis may not be a
sensitive indicator of a congenital PSS – in one study of six
Figure 6 Ammonium urate uroliths (arrows) present within the urinary
cats with a congenital shunt, none had evidence of bladder (same cat as Figure 5). The hyperechoic interface and strong distal
nephroliths or bladder calculi.19 acoustic shadowing are typical of mineralised calculi

JFMS CLINICAL PRACTICE 649

645–654_Griffin_hepatic vascular anomalies_AT_14.qxp_FAB 12/06/2019 14:55 Page 650
R E V I E W / Feline abdominal ultrasonography – hepatic vascular anomalies
Splenosystemic shunts
A separate category of shunt that has been
described in predominantly older, spayed
female cats is the splenosystemic shunt.47 It is
thought that splenosystemic shunts most like-
ly represent either acquired shunts resulting
from previous or current portal hypertension
or they are congenital shunts of uncertain clin-
ical significance.47
On ultrasound, a splenosystemic shunt usu-
ally takes the form of a single anomalous ves-
sel that originates from the splenic vein and
follows a tortuous course either caudal to the
left kidney before entering the left renal vein
or CVC adjacent to the renal vein, or contin-
ues medial to the left kidney. In some cats,
while the shunt may start and end as a single
Cross-sectional imaging
Like ultrasound, computed tomography angiography (CTA)
is a non-invasive diagnostic modality frequently used for the
detection of shunts in both human and veterinary medi-
a b
Ao
CVC
PV
c d
Stomach
Ao
CVC
Shunt
e f
CVC
Shunt
GB
650 JFMS CLINICAL PRACTICE
vessel, it can also form a plexus of smaller ves-
sels at some point along the way. Of 33 cats
with a splenosystemic shunt identified using
ultrasound, 42% also had a hepatopathy that
could potentially have resulted in portal
hypertension.47 Three cats had hepatopetal
portal flow with a flow speed <10 cm/s and
one cat had hepatofugal portal flow, sugges-
tive of portal hypertension. Ascites was also
identified in 10 cats.
Splenosystemic shunts have additionally
been observed in abdominal radiographs of
cats and create what is now referred to as a
‘spaghetti sign’.48 The typical radiographic
appearance is that of a well-defined, tortuous,
tubular structure of soft tissue opacity within
the left mid-abdominal cavity, lateral to the
left kidney and caudal to the spleen.48
cine.49 However, unlike ultrasound, which only enables a
small region of the abdomen to be imaged at any given time,
CTA provides the user with a global overview of the shunt(s)
within the abdomen, allowing shunt
anatomy, course and position relative
Stomach to other organs and vessels to be
accurately determined and easily
Ao
understood (Figure 8). CTA is consid-
CVC
ered to be the gold standard in human
medicine for the evaluation of PSSs
PV
and is preferred by surgeons when
planning their surgical approach.50,51
It has been shown to be superior
Shunt
to ultrasound for the detection and
characterisation of PSSs in dogs52 and
the same may also be true in cats;
however, it is likely that ultrasound
will always remain useful, particularly
in smaller cats with minimal intra-
abdominal fat.
CVC Figure 8 Selected transverse plane computed
tomography angiography (CTA) images of the
abdomen of a 4-month-old domestic shorthair
cat with an extrahepatic left gastrophrenic
portosystemic shunt. All images are displayed
in a soft tissue window (window level 40;
Shunt window width 440), were acquired following the
administration of iodinated intravenous contrast
and are presented in caudal-to-cranial order.
The patient’s right-hand side is to the left of the
image. (a) Within the cranial abdomen, the portal
vein (PV) is visible in the normal location ventral
to the caudal vena cava (CVC), just to the right
of midline. (b) A short distance cranial to this,
the gastrosplenic vein joins the PV from the left
(not shown). A large vessel (the shunt) emerges
from the gastrosplenic vein at the expected
location of the left gastric vein and is located
to the left of the PV at this level. Note that the
CVC shunt is much larger in diameter than the PV.
(c,d) The shunting vessel travels cranially and
slightly dorsally within the abdomen, medial
to the gastric fundus. (e,f) At the level of the
Left phrenic vein diaphragm, the shunt joins with the left phrenic
vein, which runs along the abdominal side of the
GB diaphragm before draining into the post-hepatic
CVC. Additional findings identified in the same
CTA study included microhepatica and
urolithiasis. GB = gall bladder; Ao = aorta
645–654_Griffin_hepatic vascular anomalies_AT_14.qxp_FAB 12/06/2019 14:55 Page 651

R E V I E W / Feline abdominal ultrasonography – hepatic vascular anomalies

Portal vascular abnormalities Intrahepatic arterioportal fistulae are extreme-

ly rare in the cat and only three cases have
Arterioportal fistulae been reported to date.37,42,43 The ultrasono-
An intrahepatic arterioportal fistula is an graphic appearance appears to be very similar
abnormal communication between a hepatic to that seen in dogs with the same condition
artery and a portal vein within the liver and (Figure 9).37,42,53 All three cats were 18 months
can be congenital or, less commonly, acquired.42 of age or younger at the time of diagnosis.

a b

c d

e f

*
* *

Secondary acquired shunts

Figure 9 (a) Ultrasound image of a large tortuous vessel representing a congenital arterioportal fistula in the liver of a 4-month-old Golden Retriever puppy. The vessel
could be traced from the coeliac artery to the point where it joined the left branch of the portal vein. (b) Colour flow Doppler confirms the presence of blood flow within
the vessel, which in this case is directed towards the transducer. (c) In a different region of the liver, a plexus of multiple tiny vessels is present within the hepatic
parenchyma below the fistula. These were barely visible on B-mode grey scale images. The gall bladder is visible in the bottom right of the image. (d) Colour flow and
pulsed-wave Doppler interrogation of the portal vein shows that flow is hepatofugal (ie, away from the liver), turbulent, pulsatile and travelling at a higher speed than normal.
(e) Multiple loops of a dilated anomalous blood vessel within the liver of a 2-month-old Labrador Retriever puppy that also had a congenital arterioportal fistula. (f) Single
slice transverse plane computed tomography angiography image through the cranial abdomen of the same dog as in (e). The image is displayed in a soft tissue
window (window level 40; window width 440) and was acquired following the administration of iodinated intravenous contrast. Multiple loops of a large tortuous
vessel representing an arterioportal fistula are observed within the cranial abdomen (asterisks) and liver. Throughout the abdomen, numerous plexuses of much
smaller tortuous vessels are present, consistent with the formation of secondary acquired shunts. A moderate volume of peritoneal fluid is also visible and likely
to be the result of portal hypertension

JFMS CLINICAL PRACTICE 651

645–654_Griffin_hepatic vascular anomalies_AT_14.qxp_FAB 12/06/2019 14:55 Page 652

R E V I E W / Feline abdominal ultrasonography – hepatic vascular anomalies

Abdominal ultrasonography was performed

on two cats and in both cases revealed ascites
and dilation of an intrahepatic portal vein
branch containing turbulent pulsatile flow on
colour Doppler images.37,42 In one of the cats,
an enlarged coeliac artery could be followed
with ultrasound from its origin at the aorta to
its communication with the dilated portal
vein branch.37 Doppler interrogation of this Portal
cat revealed hepatofugal pulsatile flow of vein
abnormally high speed within the main portal
vein, which was dilated.37 Portal flow with
these characteristics can be explained by the
presence of high-pressure arterial blood flow-
ing into the low-pressure portal system,
increasing pressure in the latter and ultimate-
ly resulting in portal hypertension. Acquired
PSSs arising secondarily to portal hyperten-
sion and involving the left renal vein were
also identified in both cats.37,42

Portal vein aplasia
Portal vein abnormalities are uncommon in
the cat. A single case of congenital absence
of the portal vein has recently been reported
in a 9-month-old female neutered domestic
shorthair cat. While this was suspected on
abdominal ultrasound, CTA was necessary for
confirmation of the diagnosis.54
Figure 10 Echogenic thrombus (arrows) obstructing the portal vein of a 4-year-old male
neutered Siamese cat with lymphoma
may be missed without the use of colour flow
Doppler.57 A chronic thrombus, on the other
hand, is more likely to be visible with B-mode
ultrasound due to its echogenic appearance
relative to blood (Figure 10).57

Portal vein thrombosis

Thrombosis of the portal vein can result from
vascular stasis, damage to the vessel endothe-
lium or a hypercoagulable state and is a rare
cause of portal hypertension in the cat.55 To
date, only seven cases of portal vein throm-
bosis in cats have been reported in the litera-
ture.37,56 Six had evidence of hepatobiliary
disease and the remaining cat had raised
liver enzymes and hyperthyroidism.37,56
Abdominal ultrasonography was performed
in all seven cases. In five cats, the portal vein
thrombus had an echogenic appearance on
ultrasound, and in the sixth cat reduced blood
flow was identified in the renal, splenic and
portal veins.56 In the remaining cat, a hypo-
echoic mass, presumed to be a thrombus, was
identified within the main portal vein;37 the
mass completely filled the lumen of the portal
vein and caused mild focal dilation of the ves-
sel. In four of these cats, colour flow Doppler
was also used to confirm reduced or absent
flow within the portal vein thrombus, and in
two cats small plexuses of tortuous vessels,
representing secondary acquired shunts, were
visible in the region of the portal vein or left
kidney.37,56
Thrombi vary in echogenicity depending
upon their age and this could explain the vari-
ation in appearance of the portal vein thrombi
described in these cats. A recently formed
thrombus can appear almost anechoic and
KEY POINTS
✜ Extrahepatic portosystemic shunts are more common than
intrahepatic shunts in cats. The majority arise from the left gastric
vein and are best appreciated using a right flank or intercostal
window.
✜ Most intrahepatic shunts in the cat are left divisonal and form
a large tortuous vessel that runs through the left side of the liver
and drains into a hepatic vein.
✜ Acquired shunts are rare in the cat, but when they do occur they
often take the form of a retroperitoneal plexus of tiny vessels that
directly links the portal and systemic venous systems. Colour flow
and/or power Doppler are usually necessary to confirm their
presence on ultrasound.
✜ Splenosystemic shunts are typically found in older female cats
and present as a long vessel containing hepatofugal flow, running
between the splenic vein and a systemic vein − usually either the
left renal vein or the CVC.
✜ Arterioportal fistulae are extremely rare in the cat but should be
suspected if a large tortuous vessel is identified within the liver
(the main differential being a congenital intrahepatic shunt).
Typical features on ultrasound include pulsatile hepatofugal flow
of high velocity within the portal vein, ascites and multiple
acquired shunts.
✜ Portal vein thrombosis has been reported in the cat.
The ultrasound appearance depends on the age of
the thrombus, with chronic thrombi typically having
an echogenic appearance.

652 JFMS CLINICAL PRACTICE

645–654_Griffin_hepatic vascular anomalies_AT_14.qxp_FAB 12/06/2019 14:55 Page 653
R E V I E W / Feline abdominal ultrasonography – hepatic vascular anomalies
Conflict of interest
The author declares no potential
conflicts of interest with
respect to the research,
authorship, and/or publica- THE LIVER
tion of this article. ‘Feline abdominal ultrasonography: What’s
normal? What’s abormal? The liver’ appeared in
Funding the January 2019 issue of JFMS.
THE BILIARY TREE
The author received no finan- ‘Feline abdominal ultrasonography:
cial support for the research, What’s normal? What’s abormal?
authorship and/or publication The biliary tree’ appeared in the
of this article. May 2019 issue of JFMS.
References
1 Kremkau FW. Doppler principles. In: Kremkau
FW (ed). Sonography principles and instruments.
9th ed. St Louis, MO: Elsevier, 2016, pp 131–182.
2 Nyland TG and Mattoon JS. Fundamentals of
diagnostic ultrasound. In: Nyland TG and
Mattoon JS (eds). Small animal diagnostic ultra-
sound. 3rd ed. St Louis, MO: Elsevier, 2015,
pp 1–49.
3 d’Anjou MA and Penninck D. Practical physi-
cal concepts and artifacts. In: d’Anjou MA and
Penninck D (eds). Atlas of small animal ultra-
sonography. 2nd ed. Iowa: John Wiley & Sons,
2015, pp 1–18.
4 Martin RA. Congenital portosystemic shunts
in the dog and cat. Vet Clin North Am Small
Anim Pract 1993; 23: 609–623.
5 Weisse C and Berent AC. Hepatic vascular
anomalies. In: Ettinger SJ, Feldman EC and
Côte E (eds). Textbook of veterinary internal
medicine: diseases of the dog and cat. 8th ed.
St Louis, MO: Elsevier, 2017, pp 1639–1658.
6 Lamb CR, Forster-van Hijfte MA, White RN,
et al. Ultrasonographic diagnosis of congenital
portosystemic shunts in 14 cats. J Small Anim
Pract 1996; 35: 205–209.
7 Lamb CR. Ultrasonography of portosystemic
shunts in dogs and cats. Vet Clin North Am
Small Anim Pract 1998; 28: 725–753.
8 Lamb CR. Ultrasonographic diagnosis of con-
genital portosystemic shunts in dogs: results
of a prospective study. Vet Radiol Ultrasound
1996; 37: 281–288.
9 d’Anjou MA, Penninck D, Cornejo L, et al.
Ultrasonographic diagnosis of portosystemic
shunting in dogs and cats. Vet Radiol Ultrasound
2004; 45: 424–437.
10 d’Anjou MA. The sonographic search for
portosystemic shunts. Clin Tech Small Anim
Pract 2007; 22: 104–114.
11 Szatmari V, Rothuizen J, van den Ingh TS, et al.
Ultrasonographic findings in dogs with
hyperammonemia: 90 cases (2000–2002). J Am
Vet Med Assoc 2004; 224: 717–727.
12 Tivers M and Lipscomb V. Congenital portosys-
temic shunts in cats: investigation, diagnosis and
stabilisation. J Feline Med Surg 2011; 13: 173–184.
13 Tivers M and Lipscomb V. Congenital porto-
systemic shunts in cats: surgical management
and prognosis. J Feline Med Surg 2011; 13:
185–194.
14 Rothuizen J, van den Ingh TS, Voorhout G, et al.
Congenital portosystemic shunts in sixteen
dogs and three cats. J Small Anim Pract 1982;
23: 67–81.
15 Tillson DM and Winkler J. Diagnosis and
treatment of portosystemic shunts in the cat.
Vet Clin North Am Small Anim Pract 2002; 32:
881–899.
16 Hunt GB. Effect of breed on anatomy of
portosystemic shunts resulting from congeni-
tal diseases in dogs and cats: a review of 242
cases. Aust Vet J 2004; 82: 749–749.
17 Blaxter AC, Holt PE, Pearson GR, et al.
Congenital portosystemic shunts in the cat:
a report of nine cases. J Small Anim Pract 1988;
29: 631–645.
18 White RN, Forster-van Hijfte MA, Petrie G, et al.
Surgical treatment of intrahepatic portosystemic
shunts in six cats. Vet Rec 1996; 139: 314–337.
19 Santilli RA, Gerboni G, Olivieri M, et al.
Ultrasonographic diagnosis of portosystemic
communications in dogs and cats: retrospec-
tive study of 51 cases [article in Italian].
Veterinaria 2003; 17: 13–23.
20 Berger B, Whiting PG, Breznock EM, et al.
Congenital feline portosystemic shunts. J Am
Vet Med Assoc 1986; 188: 517–521.
21 Santilli RA and Gerboni G. Diagnostic imaging
of congenital porto-systemic shunts in dogs
and cats: a review. Vet J 2003; 166: 7–18.
22 White RN, Shales C and Parry AT. New perspec-
tives on the development of extrahepatic por-
tosystemic shunts. J Small Anim Pract 2017; 58:
669–677.
23 White RN and Parry AT. Morphology of con-
genital portosystemic shunts involving the
left colic vein in dogs and cats. J Small Anim
Pract 2016; 57: 247–254.
24 White RN and Parry AT. Morphology of con-
genital portosystemic shunts emanating from
the left gastric vein in dogs and cats. J Small
Anim Pract 2013; 54: 459–467.
25 Payne JT, Martin RA and Constantinescu GM.
The anatomy and embryology of portosys-
temic shunts in dogs and cats. Semin Vet Med
Surg (Small Anim) 1990; 5: 76–82.
26 White RN and Parry AT. Morphology of
splenocaval congenital portosystemic shunts
in dogs and cats. J Small Anim Pract 2016; 57:
28–32.
27 Lamb CR and White RN. Morphology of con-
genital intrahepatic portacaval shunts in dogs
and cats. Vet Rec 1998; 142: 55–60.
28 Nyland TG, Larson MM and Mattoon JS. Liver.
In: Mattoon JS and Nyland TG (eds). Small ani-
mal diagnostic ultrasound. 3rd ed. St Louis,
MO: Elsevier Saunders, 2015, pp 332–399.
JFMS CLINICAL PRACTICE 653
645–654_Griffin_hepatic vascular anomalies_AT_14.qxp_FAB 12/06/2019 14:55 Page 654
R E V I E W / Feline abdominal ultrasonography – hepatic vascular anomalies
29 Deppe TA, Center SA, Simpson KW, et al.
Glomerular filtration rate and renal volume in
dogs with congenital portosystemic vascular
anomalies before and after surgical ligation.
J Vet Intern Med 1999; 13: 465–471.
30 Walter PA, Feeney DA, Johnston GR, et al.
Feline renal ultrasonography: quantitative
analyses of imaged anatomy. Am J Vet Res 1987;
48: 596–599.
31 Debruyn K, Paepe D, Daminet S, et al. Renal
dimensions at ultrasonography in healthy
Ragdoll cats with normal kidney morphology:
correlation with age, gender and bodyweight.
J Feline Med Surg 2013; 15: 1046–1051.
32 Nyland TG, Widmer WR and Mattoon JS.
Urinary tract. In: Mattoon JS and Nyland TG
(ed). Small animal diagnostic ultrasound. 3rd
ed. St Louis, MO: Elsevier Saunders, 2015, pp
557–607.
33 Berent AC and Tobias KM. Portosystemic vas-
cular anomalies. Vet Clin North Am Small Anim
Pract 2009; 39: 513–541.
34 Dear JD, Shiraki R, Ruby AL, et al. Feline urate
urolithiasis: a retrospective study of 159 cases.
J Feline Med Surg 2011; 13: 725–732.
35 Morandi F, Sura PA, Sharp D, et al.
Characterization of multiple acquired por-
tosystemic shunts using transplenic portal
scintigraphy. Vet Radiol Ultrasound 2010; 51:
466–471.
36 Burton CA and White RN. Portovenogram
findings in cases of elevated bile acid concen-
trations following correction of portosystemic
shunts. J Small Anim Pract 2001; 42: 536–540.
37 McConnell JF, Sparkes AH, Ladlow J, et al.
Ultrasonographic diagnosis of unusual portal
vascular abnormalities in two cats. J Small
Anim Pract 2006; 46: 338–343.
38 Bertolini G. Acquired portal collateral circula-
tion in the dog and cat. Vet Radiol Ultrasound
2010; 51: 25–33.
39 Langdon P, Cohn LA, Kreeger JM, et al.
Acquired portosystemic shunting in two cats.
J Am Anim Hosp Assoc 2002; 38: 21–27.
40 Barfield DM, Gibson AD and Lipscomb VJ.
Multiple acquired portosystemic shunts in
a cat secondary to chronic diaphragmatic
rupture. JFMS Open Rep 2015; 1. DOI:
10.1177/2055116915585020.
41 Zandvliet MM, Szatmari V, van den Ingh T, et
al. Acquired portosystemic shunting in 2 cats
secondary to congenital hepatic fibrosis. J Vet
Intern Med 2005; 19: 765–767.
42 Uemura A, Haruyama T, Nakata M, et al.
Hybrid technique coil embolisation for intra-
hepatic arterioportal fistula in a cat: case
report. JFMS Open Rep 2016; 2. DOI:
10.1177/2055116916642256.
Available online at jfms.com
Article reuse guidelines: sagepub.co.uk/journals-permissions
For reuse of images only, contact the author
654 JFMS CLINICAL PRACTICE
43 Legendre AM, Krahwinkel D, Carrig CB, et al.
Ascites associated with intrahepatic arterio-
venous fistula in a cat. J Am Vet Med Assoc 1976;
168: 589–591.
44 Vogt JC, Krahwinkel DJ, Jr, Bright RM, et al.
Gradual occlusion of extrahepatic portosys-
temic shunts in dogs and cats using the
ameroid constrictor. Vet Surg 1996; 25: 495–502.
45 VanGundy TE, Boothe H and Wolf A. Results of
surgical management of feline portosystemic
shunts. J Am Anim Hosp Assoc 1990; 26: 55–62.
46 Bosje JT, van den Ingh TS and van der Linde-
Sipman JS. Polycystic kidney and liver disease
in cats. Vet Q 1998; 20: 136–139.
47 Palerme JS, Brown JC, Marks SL, et al.
Splenosystemic shunts in cats: a retrospective
of 33 cases (2004–2011). J Vet Intern Med 2013;
27: 1347–1353.
48 Specchi S, Panopoulos I, Adrian AM, et al.
A ‘spaghetti sign’ in feline abdominal radio-
graphs predicts spleno-systemic collateral cir-
culation. Vet Radiol Ultrasound 2018; 59: 13–17.
49 Matsuura T, Takahashi Y, Yanagi Y, et al.
Surgical strategy according to the anatomical
types of congenital portosystemic shunts in
children. J Pediatr Surg 2016; 51: 2099–2104.
50 Henseler KP, Pozniak MA, Lee FT, Jr, et al.
Three-dimensional CT angiography of spon-
taneous portosystemic shunts. Radiographics
2001; 21: 691–704.
51 Achiwa S, Hirota S, Kako Y, et al. Radiological
anatomy of spontaneous splenorenal shunts
in patients with chronic liver disease. Jpn J
Radiol 2017; 35: 206–214.
52 Kim SE, Giglio RF, Reese DJ, et al. Comparison
of computed tomographic angiography and
ultrasonography for the detection and charac-
terization of portosystemic shunts in dogs.
Vet Radiol Ultrasound 2013; 54: 569–574.
53 Bailey MQ, Willard MD, McLoughlin MA, et al.
Ultrasonographic findings associated with
congenital hepatic arteriovenous fistula in
three dogs. J Am Vet Med Assoc 1988; 192:
1099–1101.
54 Holloway A, Groot L and van der Schaaf K.
Congenital absence of the portal vein in
a cat. JFMS Open Rep 2018; 4. DOI: 10.1177/
2055116917749079.
55 Kumar DR, Hanlin E, Glurich I, et al. Virchow's
contribution to the understanding of thrombo-
sis and cellular biology. Clin Med Res 2010; 8:
168–172.
56 Rogers CL, O’Toole TE, Keating JH, et al. Portal
vein thrombosis in cats: 6 cases (2001–2006).
J Vet Intern Med 2008; 22: 282–287.
57 Zwiebel WJ. Sonographic diagnosis of hepatic
vascular disorders. Semin Ultrasound CT MR
1995; 16: 34–48.