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