About radiology of Liver Transplantation

1. Update on
Imaging in Liver Transplantation
Dr.Manoj.K.S.MD DNB RD
KIMS

2. Introduction
• Liver transplantation, first introduced 40 years
back, is the recognized treatment of choice for
patients suffering from end-stage liver disease,
including documented fulminant hepatic failure, decompensated
cirrhosis, or hepatocellular carcinoma within defined criteria.
• Approximately 800-1000 liver transplant
surgeries are performed in India annually
• The number of liver transplantations performed
in the United States each year exceeds 6000;
however, there are more than 15,000 patients on
the waiting list.
• UNOS National Data Report. http://www.unos.org 2011

3. History
• The first human liver transplants were
performed in 1963 by a surgical team led by
Dr. Thomas Starzl of Denver,at University of
Colorado Medical School.
• Dr.Christian Barnard performed the first Heart
transplant on December 3, 1967 in Cape
Town, South Africa.
• https://www.kidney.org/transplantation/transaction/Mileston
es-Organ-Transplantation

4. INDICATIONS
• Complications of cirrhosis
• Fulminant hepatic failure
• Encephalopathy
• Ascites
• Hepatocellular carcinoma
• Refractory variceal hemorrhage
• Chronic gastrointestinal blood loss due to
portal hypertensive gastropathy

5. INDICATIONS
• Hepatitis
• Autoimmune hepatitis
• Chronic hepatitis B
• Chronic hepatitis C
• Chronic cholestatic diseases
• Primary biliary cirrhosis
• Primary sclerosing cholangitis
• Metabolic liver diseases
• Hemochromatosis
• Wilson disease

6. Contraindications
• Absolute contraindications
• Active extrahepatic malignancy
• Diffuse hepatic tumor invasion
• Thrombosis of the entire portal and SMV system
• Active or uncontrolled systemic infection
• Active substance or alcohol abuse
• Severe cardiopulmonary disease or other comorbid conditions
• Lack of social support
• Noncompliance
• Relative contraindications
• Age Cholangiocarcinoma Portal vein thrombosis Chronic
or refractory infection HIV infection Previous malignancy
Active psychiatric disorder Poor social support

7. Three main types of liver transplantation:
cadaveric (DDLT), LDLT, and split-liver grafting
• The Model for End-Stage Liver Disease (MELD)
is a scoring system used to assess the severity
of CLD
• 3-month mortality rate among those with a
MELD score of 40 is 100%. For patients with a
score of 30–39, mortality within 3 months is
83%; for 20–29, 76%; for 0–19, 27%; and for
patients with a score of less than 10, 4%.

8. The imaging requirements for a Liver Transplantation
Unit can be considered under these broad Categories .
• 1.DONOR EVALUATION
• 2.RECIPIENT EVALUATION
• 3.INTRA OPERATIVE IMAGING
• 4. POST TRANSPLANT IMAGING
• 5. FOLLOW UP

9. DDLT -Donor evaluation
• Pre-operative USG /Doppler
• Intra operative biopsy

10. DONOR EVALUATION
• CHEST X-RAY
• ULTRASOUND ABDOMEN
• PORTAL/HEPATIC VEIN DOPPLER

11. Recipient Evaluation
Role of Imaging
• Candidate selection
• Search for intra and extrahepatic malignancy
• Surgical planning
– HCC Staging
– Assessment of vessel patency: angioinvasion
– Quantification of diseased liver volume
– Vascular anatomy
– Identification of cirrhosis and sequelae of PHTT

12. RECIPIENT EVALUATION
• TRIPHASIC CT LIVER & ABDOMEN/PELVIS
• CT /HRCT CHEST
• USG/DOPPLER LIVER
• MRI LIVER & MRCP
• X-RAY CHEST

13. RECIPIENT EVALUATION
• PET SCAN
• RADIONUCLIDE SCAN
• MRI Brain
• MR Angiography cerebral arteries
• Carotid Doppler
• Renal artery Doppler
• LIVER BIOPSY
• Cardiac Imaging –Echo, DSE, Contrast Echo,CAG
• CT Pulmonary Angio/Lung Perfusion scan

22. PET SCAN

23. Recipient Evaluation

24. Milan & UCSF Criteria
• Milan criteria :
Defined as 1 tumor ≤5 cm; or ≤3 tumors with
each tumor ≤3 cm.
• UCSF criteria
Defined as 1 tumor ≤6.5 cm or ≤3 tumors with
the largest tumor diameter ≤4.5 cm and total
tumor diameter ≤8 cm

25. Interventional Radiology
• RFA
• TACE
• TARE
• PTBD
• PVE
• TIPS
• Portal vein thrombectomy
• Hepatic venous pressure gradient (HVPG)

26. INTRA OPERATIVE IMAGING
• Intraoperative Doppler
• Intraoperative Cholangiography

27. Intraoperative Cholangiogram

28. Post Transplant Imaging
• Post- operative Doppler
• PORTABLE X-RAY in ICU
• HIDA Scan for post transplant leak assessment
• TRIPLE PHASE CT LIVER (optional before
discharge)

29. Post- operative USG/Doppler
Structure Comment
Liver parenchyma Evaluate parenchymal echogenicity,
texture and presence of focal lesions
Perihepatic spaces Evaluate for acites, hemorrhage, fluid
collections
Biliary system Evaluate for ductal dilatation and
intraluminal filling defects
Vasculature >Evaluate hepatic artery, portal vein,
hepatic veins and IVC for patency
>Evaluate arterial and venous
waveforms and measure arterial
resistive indices
>Evaluate anastomoses for focal color
aliasing and elevated velocities

30. Post Tx Doppler

31. Hepatic veins -Normal
a wave (atrial systole)
S wave
Ven systole
D wave
Ven diastole

32. Post Tx Doppler

33. Post Transplant Doppler –Artery
In a post-transplant patient, the normal hepatic
arterial RI ranges from 0.55 to 0.80

34. Post Tx Doppler

37. DONOR EVALUATION
• LIVER STEATOSIS ASSESSMENT
• CT ANGIO LIVER
• CT VOLUMETRY

38. DONOR EVALUATION
• MRCP
• MRI Liver
• LIVER FIBROSIS assessment with Ultrasound or
MR elastography

39. DONOR EVALUATION
• Mammography
• USG pelvis
• USG Thyroid
• Doppler lower limb arteries/veins

40. CT Imaging

41. MR Imaging

42. LIVER FAT ASSESSMENT
• Liver Attenuation Index (LAI).
• The LAI is the difference between mean hepatic
attenuation and mean splenic attenuation (i.e.
average density of liver − average density of
spleen on non-contrast scan).
• Liver attenuation is calculated by placing the
circular region of interest (ROI) of at least 1 cm²
area at multiple places in the liver, covering all
the hepatic segments

43. Liver Attenuation Index
• Average attenuation of liver parenchyma on non-
contrast CT images varies between 50 and 65 HU and is
generally 8-10 HU greater than that of spleen.
• Limanond et al. found in their study that LAI > 5 HU
correctly predicted the absence of significant
macrovesicular steatosis.
• LAI values of -10 to 5 HU were suggestive of mild to
moderate steatosis (6-30%), while LAI values of less
than -10 HU were suggestive of moderate to severe
hepatic steatosis (i.e. ≥30% fat) with a specificity of
100%.
• Limanond P, Raman SS, Lassman C, Sayre J, Ghobrial RM, Busuttil RW, et al. Macrovesicular hepatic
steatosis in living related liver donors: Correlation between CT and histologic findings. Radiology
2004;230:276-80

44. MR Fat Quantification
• In Phase-Opposed phase
• 3 Point Dixon
• MR Spectroscopy –SVS with PRESS

48. LDLT
• The most common LDLT technique in adults is
right hemihepatectomy, whereby segments V-
VIII are harvested, leaving the middle hepatic
vein (MHV) with the donor. Right hemi-liver
along with its artery, portal vein, bile duct, and
the draining hepatic veins is implanted into
the recipient.

49. LDLT
• In pediatric liver transplants, left lateral
sectionectomy is the standard method, whereby
segments II and III are harvested
• In certain situations of adult LDLT, where either
the remnant liver volume in donor is inadequate
or there is complex portal venous or biliary
anatomy, a right posterior sectionectomy can also
be performed by harvesting only segments VI and
VII with their posterior sectional hepatic artery,
portal vein, bile duct, and right hepatic vein (RHV)

50. Arterial reconstruction
•
The conventional hepatic arterial “fish-mouth”
anastomosis is an end-to-end anastomosis reconstructed
between the donor and recipient arterial anastomotic
sites, usually between the splenic artery and common
hepatic artery
For cadaveric donors, the donor hepatic artery is harvested at the
level of the celiac axis with a patch of the aorta. The aortic patch is
then anastomosed to the recipient hepatic artery near the
gastroduodenal artery take-off. For living donors, the arterial
anastomosis is to the right, left or proper hepatic artery

51. PV/IVC/BILIARY
• A portal vein anastomosis is usually an end-to-end
anastomosis between the two portal veins.
• The piggyback technique is the standard technique
IVC .An end-to-side anastomosis is made between
the donor IVC and the common stump of recipient
hepatic vein
• Biliary anastomosis is an end-to-end anastomosis
between the donor common bile duct and the
recipient common hepatic duct after a
cholecystectomy

52. SEGMENTAL ANATOMY

53. ARTERIAL ANATOMY

54. PORTAL VEIN -3D MIP

55. Hepatic Veins -3D MIP

56. Total volume

57. RIGHT & LEFT LOBE VOLUME

58. Partial volumes

99. DONOR MRCP

100. DONOR MRCP

101. DONOR MRCP

102. DONOR MRCP

103. DONOR MRCP

104. DONOR MRCP

105. DONOR MRCP

106. DONOR MRCP

107. DONOR MRCP

108. DONOR MRCP

109. DONOR MRCP

110. DONOR MRCP

111. DONOR MRCP

112. DONOR MRCP

113. DONOR MRCP

114. DONOR MRCP

115. DONOR MRCP

116. DONOR MRCP

117. DONOR MRCP

118. DONOR MRCP

119. FOLLOW UP /COMPLICATIONS
• DOPPLER &
ULTRASOUND SCAN
• MRI & MRCP
• CT ABDOMEN /CHEST
• CT ANGIOGRAPHY
• MR ANGIOGRAPHY
• DSA
• SCINTIGRAPHY -HIDA
• ERCP
• LIVER BIOPSY
• CONTRAST ULTRASOUND
• INTERVENTIONAL
RADIOLOGY
• PET-CT/ BONE SCAN

120. IR in LT Complications
• Vascular
• Biliary
• General
• Vascular – Hepatic Artery Stenosis/Thrombosis
(HAS/HAT), Portal/Hepatic vein,IVC stenosisi
• Biliary leak, strictures
• Drainage of collections, Pleural effusion etc

121. Combined Liver-Kidney Transplantation

122. First Pediatric LT at KIMS
Second Pediatric CLKT at KIMS

123. Special Thanks to
• Dr. B.Venugopal
• Dr.Madhavan Unni
• Dr.Shabeer Ali
• Dr.L.Jayasree
• Dr.R C Sreekumar
• Dr.Manoj Pillai
• Dr.Suresh Babu
• Dr.Manish Yadav
• Dr.Malini
• Dr.Shiraz
• Mr Judson
• Mr Siraj
• Liver Transplant Team KIMS
• IMA Trivandrum
THANKS TO
TCCI
IMA,APS ,SCOG
DEPT OF
RADIOLOGY,
HPB&LT,KIMS