The diseased liver ..a look in pretransplant evaluation

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  • 1. Dr/Ahmed A Bahnassy Consultant Radiologist PSMMC
  • 2. Liver transplantation is the most effective treatment for various end-stage liver diseases. Living donor liver transplantation (LDLT) was first developed in Asia due to the severe lack of cadaveric graft in this region.
  • 3. Evaluation of recipient Pre-transplant imaging plays an important role in identifying contraindications to transplantation, anatomic abnormalities and variants that may alter the surgical approach.
  • 4. Liver parenchyma Ultrasound may show changes of cirrhosis with nodular contours, parenchymal inhomogeneity, right lobe atrophy and hypertrophy of lateral segment and caudate lobe .
  • 5. Doppler US signs of PHT in cirrhosis • P-S collaterals Highly sensitive & specific • Portal vein Dilated PV Decreased mean velocity (< 15 cm/sec) To-and-fro flow /Hepatofugal flow Increased pulsatility (VPI) Arterio-portal fistula • Hepatic vein Compression (Pseudo-portal flow) • Hepatic artery Enlargement & tortuosity Increased RI & PI Harkanyi Z. Ultrasound Clin 2006 ; 1 : 443 – 455.
  • 6. Common spontaneous porto-systemic collaterals More than 20 P-S collaterals described Most common: LGV – PUV – Spleno-renal – Gastro-renal Patnquin1 H et al. Am J Roentgenol 1987 ; 149 : 71 – 76.
  • 7. P-S collaterals / Coronary vein Most prevalent (80-90%) – Most clinically important Sagittal paramedial view Flow in CV directed superiorly & away from splenic vein Sagittal view slightly superior Tortuosity of CV as it extends superiorly toward GE junction Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.
  • 8. P-S collaterals / Gastroesophageal collateral Longitudinal view of left liver lobe Gastroesophageal collateral veins close to diaphragm McGahan J et al. Diagnostic ultrasound, Informa Healthcare, 2nd edition, 2008.
  • 9. Normal umbilical vein anatomy UV communicates with umbilical segment of LPV Travels down anterior abdominal wall toward umbilicus Eventually drains into systemic system via inferior epigastric vein Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.
  • 10. P-S collaterals / Recanalized umbilical vein Longitudinal US of LLL Dilated umbilical vein (10 mm) Similar color Doppler view Hepatofugal flow within UV PUV observed only in hepatic or suprahepatic blockage Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.
  • 11. P-S collaterals / Recanalized umbilical vein Caput medusae Sagittal panoramic view PUV traveling to periumbilical region where it becomes tortuous Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13. N Engl J Med 2005 ; 353 : e19.
  • 12. Cirrhosis & PHT / Diameter of portal vein Longitudinal view of MPV Contoversy on normal PV diameter Up to 13 mm in one study1 Up to 16 mm in another study2 Unusual large PV: good sign of PHT Normal PV size: do not exclude PHT Diameter: 16.9 mm Sign of portal hypertension J et al. Am J Roentgenol 1982 ; 139 : 497 – 499. 2 Goyal AK et al. J Ultrasound Med 1990 ; 9 : 45 – 48. Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13. 1 Weinreb
  • 13. Cirrhosis & PHT / Portal vein velocity Triplex image of PV Controversy on normal PV velocity Difficult to rely on velocity for dg Normal mean velocity: 15 – 18 cm/sec Low velocity: good indicator of PHT Normal velocity: do not exclude PHT Shrunken liver & irregular margin Vmax: 10 cm/s Diagnosis of PHT Swart J et al. Ultrasound Clin 2007 ; 2 : 355 – 375.
  • 14. Portal vein pseudoclot – Incorrect velocity Cirrhotic patient with portal hypertension Velocity scale: 20 cm/s Good flow in HA anteriorly No flow in adjacent PV Velocity scale: 7 cm/s Slower flow in portal vein demonstrated Rubens DJ et al. Ultrasound Clin 2006 ; 1 : 79 – 109.
  • 15. Cirrhosis & PHT / Portal vein flow Normal flow Reversed flow To and fro flow Advanced PHT Advanced PHT Heart failure SOS Arterio-portal fistula Porto-systemic shunt Kok Th et al. Scand J Gastroenterol 1999 ; 34 (Suppl 230) : 82 – 88.
  • 16. Cirrhosis & PHT / To-and-fro flow in PV Cardiac cycle Duplex US of LPV during suspended respiration Hepatopetal & hepatofugal with each heart beat Seen before frank hepatofugal flow Wachsberg RH et al. RadioGraphics 2002 ; 22 : 123 – 140.
  • 17. Cirrhosis & PHT / To-and-fro flow in PV Respiratory cycle Transverse color Doppler US of left portal vein Hepatopetal flow Hepatofugal flow On real-time US, these alterations corresponded to respiratory cycle Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.
  • 18. Causes of to-and-fro flow - Portal hypertension - Tricuspid regurgitation - Right heart failure - Aerterio-portal vein fistula Exaggerated pulsatility Minimum velocity below baseline Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.
  • 19. Cirrhosis & PHT / Reversed flow of PV Severe PHT – Rare Hepatopetal flow in HA & hepatofugal flow in PV Not pathognomonic feature of cirrhosis Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.
  • 20. Cirrhosis & PHT / Reversed flow in PV branches Color Doppler of peripheral liver Duplex Doppler of same area Hepatopetal flow in HA Hepatofugal flow in PV Arterial flow above baseline Portal venous below baseline Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.
  • 21. Patency of the portal vein and superior mesenteric vein Ultrasound can be used to assess the vascular patency of a potential transplant recipient. Diffuse thrombosis of the portal and superior mesenteric vein (SMV) is a relative contraindication to liver transplantation. Portal vein thrombosis requires the modification of surgical technique at the time of transplantation.
  • 22. PV thrombosis
  • 23. take care Partial thrombosis of portal vein Black & white ultrasound Color & pulsed Doppler Partial echogenic thrombus Complete filling of main PV obscuring the clot Swart J et al. Ultrasound Clin 2007 ; 2 : 355 – 375.
  • 24. No PV! Portal cavernoma Gray-scale ultrasound Color & pulsed Doppler
  • 25. Superior mesenteric vein thrombosis Transverse image of SMA & SMV SMA SMV http://www.ultrasoundcases.info
  • 26. Status of transjugular portosystemic shunt Some recipients may have undergone placement of a transjugular portosystemic shunt (TIPS) prior to transplantation. The patency of the shunt can be assessed with colour Doppler ultrasound, including Power Doppler. thrombosis
  • 27. Cirrhosis & PHT / Prominent hepatic artery Enlarged HA with tortuous or ‘‘corkscrew’’ appearance Increased flow in HA to compensate decreased flow in PV Swart J et al. Ultrasound Clin 2007 ; 2 : 355 – 375.
  • 28. Cirrhosis & PHT / Changes of hepatic artery flow Normal flow Normal in most patients Decreased diastolic flow Reversed diastolic flow ESLD Kok Th et al. Scand J Gastroenterol 1999 ; 34 (Suppl 230) : 82 – 88. ESLD
  • 29. Cirrhosis often causes narrowing of the hepatic veins with loss of the normal phasic waveform. Intrahepatic vessels may be indistinct.
  • 30. Cirrhosis & PHT / Changes of hepatic vein flow Triphasic Biphasic Cirrhosis Budd-Chiari syndrome Metastases Ascites Healthy subjects Monophasic Cirrhosis Budd-Chiari syndrome Metastases Ascites Healthy subjects Kok Th et al. Scand J Gastroenterol 1999 ; 34 (Suppl 230) : 82 – 88.
  • 31. Damping index of HV waveform Damping index = Minimum velocity of downward HV Maximum velocity of downward HV Normal value: < 0.6 Severe portal hypertension: ≥ 0.6 Severe portal hypertension : HVPG > 12 mmHg Kim MY et al. Liver International 2007 ; 27 : 1103 – 1110.
  • 32. Damping index of HV waveform in cirrhosis DI: 0.26 HVPG: 7 mmHg DI: 0.72 HVPG: 15 mmHg DI of 0.6: Sen 76%, Sp 82, & AUC 0.86 for severe PHT Kim MY et al. Liver International 2007 ; 27 : 1103 – 1110.
  • 33. Caudate lobe The caudate lobe can become enlarged and surround the inferior vena cava (IVC), which is of relevance in cases of living donor transplantation.
  • 34. focal mass Presence and extent of hepatocellular carcinoma Liver transplantation for the treatment of hepatocellular carcinoma (HCC) provides excellent outcomes with application of the Milan criteria (single nodule < or = 5cm, or two or three nodules < or = 3cm) with 5-year survival rates of 70% and low recurrence