1. Global Sonographic Parameters In Portosystemic Shunts In 38 Dogs & Cats E Lindquist, D Casey, J Frank Eric Lindquist DMV, DABVP (Canine & Feline Practice) Director: Sound-Eklin New Jersey Mobile Associates Founder: SonoPath.com

2. To Shunt Or Not To Shunt? That Is The Question. To Shunt Not To Shunt PV/CVC ≥0.75 and PV/AO ≥ 0.8. D‘Anjou et. al. Vet rad and US Vol 45, No 5 2004 102 pqtients

3. Study Premise:  Attempt to stabilize a reliable global and precise sonographic criteria to diagnose or rule out the presence of portosystemic shunting

4. Study Design: Retrospective 5 Sonographers, Trained By 1 Single Evaluator Experienced in Dx Of PSS  33 Dogs & Cats with EHPSS  5 Dogs With Intrahepatic Shunts  Age Range: 2 mo- 12 yr  19/38 Sx Confirmed  Bile Acids: 93-473 umol/L  US Evaluation of Bladder, Kidneys, Liver Size, PV:CVC and PV:AO Ratios

5. Parameter 1: The Bladder Normal: No Calculi Or Sediment Calculi Or Sediment 24/33 (73%) EHPSS Cases. 2/5 IHPSS(40%). 68% overall.

6. Parameter 2: The Kidneys Normal: No Renal Calculi Renal Calculi 32/33 (97%) Of EHPSS Cases. 3/5 for IHPSS(60%). 92% overall

7. Parameter 3: Renomegaly EHPSS 29/33. 88% IHPSS 2/5. 40% 82 % Overall

8. Parameter 3: Liver Size Normal: Subjectively Normal Liver Size Microhepatica 33/33 EHPSS. 5/5 IHPSS. 100% Of Cases Overall

9. Parameters 4 & 5: Normal Portal Hilus; PV:CVC, PV:AO Ratios Normals: PV/CVC ≥0.75 and PV/AO ≥ 0.8. D‘Anjou et. al. Vet Rad US Vol. 45, No 5, 2004. 102 Patients

10. Intrahepatic Shunt Parameters  Bladder Sand/Stones: 2/5  Renal Calculi: 3/5  Renomegaly: 2/5  Microhepatica: 5/5  PV:CVC Ratio: 1:1  PV:AO Ratio: 1:1  CVC:AO Ratio: 1:1

11. Types Of Extrahepatic Shunts: 9 Gastrocaval (Looping), 18 Splenocaval (Short), 6 Splenoazygos (Long minimally curved)

12. Caval Shunts: Increased Vena Cava Volume GastrocavalSplenocaval

13. Scanning Target: Excessive Vena Caval Volume For Gastrocaval & Splenocaval Shunts

14. Caval EHPSS: 9 Gastrocaval & 18 Splenocaval Shunt Ratios (Normals PV/CVC ≥0.75 and PV/AO ≥ 0.8.) Gastrocaval: PV/CVC: 0.4-0.67 PV/AO: 0.4-0.71 Splenocaval: PV/CVC: 0.28- 0.75 PV/AO: 0.4-0.78

15. Azygos EHPSS Shunt Parameters Azygos Shunt Bypasses The Cava Normal CVC:AO Ratio

16. 6 Azygos Shunts: Normal Vena Cava Volume : Ratios: PV/CVC:0.4-0.63 PV/AO: 0.4-0.68 PV Pre/Post Shunt Differential Double Aorta

17. PV/CVC Ratio 38 cases

18. PV/AO Ratio 38 Cases

19. Study Flaws  Published Controls  Non blinded  Urolithiasis is a non specific finding  Microhepatica & renomegaly are subjective parameters  Caval probe pressure creates a variable  Small number of cases (38)

20. Conclusions In this population of 38 dogs and cats, the presence of :  Urinary bladder sand/calculi,  Renal mineralization  Renomegaly  Microhepatica were reliable, non exclusive, positive predictive factors for the presence of PSS, but do not distinguish IHPSS from EHPSS.  Subnormal PV/CVC and PV/AO ratios (0.7 8 or less) are highly reliable indicators of the presence of EHPSS.

21. Any Questions? Questions? Eric.Lindquist@ SonoPath.com