Liver Transplantation

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Imaging proof of a patent portal vein is required for a patient to be placed on the liver transplant waiting list. Ultrasound can image the portal vein but is not 100% reliable. When ultrasound fails to adequately visualize the portal vein, 3D CE MRA offers a safe, accurate, and comprehensive assessment of portal venous anatomy without requiring iodinated contrast [16,17]. 3D CE MRA also evaluates the splenic vein, superior mesenteric vein (SMV), inferior mesenteric vein, IVC and potential varices (Fig. 6). Following liver transplantation, rising liver function tests may raise a suspicion of al-

Fig. 3. Spontaneous spleno-renal shunt: 66-year-old woman with progressive toxic-induced hepatic cirrhosis. The patient was referred to MRA for evaluation of the liver. MIP display of a 3D MRA data set acquired the portal venous phase demonstrate a spontaneous splenorenal shunt. The left renal vein is dilated. No gastro-oesophageal varices are identified. Contrast enhanced 3D MRA is ideally suited for non-invasively assessing the portal venous system. Complex vascular morphology is comprehensively depicted owing to the inherent 3-dimensionality of the technique. In this patient the presence of gastro-oesophageal varices can be largely excluded. Most of the portal venous blood appears to be shunted through a spontaneous splenorenal shunt which is well demonstrated

Spontaneous Splenorenal Shunt

Fig. 4a, b. 13-year old female patient with surgical splenorenal shunt due to portalvenous hypertension caused by hereditary liver fibrosis in multicystic kidney disease. The arterial phase image (a) already shows an early enhancement of some venous structures (arrows) which in the portalvenous phase (b) can be identified as the splenic vein (arrow/) connected to the left renal vein (arrowhead. The study confirms patency of the surgical splenorenal shunt without stenosis at the site of anastomosis. Note the enlarged kidneys on both sides due to polycystic kidney disease [Images courtesy of Dr. G. Schneider]

Fig. 4a, b. 13-year old female patient with surgical splenorenal shunt due to portalvenous hypertension caused by hereditary liver fibrosis in multicystic kidney disease. The arterial phase image (a) already shows an early enhancement of some venous structures (arrows) which in the portalvenous phase (b) can be identified as the splenic vein (arrow/) connected to the left renal vein (arrowhead. The study confirms patency of the surgical splenorenal shunt without stenosis at the site of anastomosis. Note the enlarged kidneys on both sides due to polycystic kidney disease [Images courtesy of Dr. G. Schneider]

Splenorenal Shunt
Fig. 5. Different forms of surgical shunts in portalvenous hypertension

Fig. 6 a, b. 51-year-old woman with progressive hepatic failure referred to MRI of the liver to exclude hepatic disease. Oblique map display of the arterial phased 3D data set (a) as well as frontal MIP display of the portal venous 3D data set (b) provide an excellent overview of the vascular anatomy in the abdomen. No anomalies are noted. The superior mesenteric artery is shown to be normal. Similarly, the portal venous system is shown to be normal. All tributaries to the portal venous system such as the splenic vein as well as the superior mesenteric vein are visualized to good advantage. Analysis of the portal venous system should be part of any MR-based evaluation of the liver. For most optimal results the portal venous phase data set should be collected immediately following the arterial phase acquisition. Both 3D data sets should be temporarily separated by a 5-10 sec break during which the patient is asked to breathe. Breath-holding during data acquisition is crucial for optimal image quality

Mra The Spleen

Fig. 6 a, b. 51-year-old woman with progressive hepatic failure referred to MRI of the liver to exclude hepatic disease. Oblique map display of the arterial phased 3D data set (a) as well as frontal MIP display of the portal venous 3D data set (b) provide an excellent overview of the vascular anatomy in the abdomen. No anomalies are noted. The superior mesenteric artery is shown to be normal. Similarly, the portal venous system is shown to be normal. All tributaries to the portal venous system such as the splenic vein as well as the superior mesenteric vein are visualized to good advantage. Analysis of the portal venous system should be part of any MR-based evaluation of the liver. For most optimal results the portal venous phase data set should be collected immediately following the arterial phase acquisition. Both 3D data sets should be temporarily separated by a 5-10 sec break during which the patient is asked to breathe. Breath-holding during data acquisition is crucial for optimal image quality lograft ischemia. Since blood supply to the liver is primarily via the portal vein, this is the most important vessel to evaluate. The most common site of obstruction is at the anastomosis. Usually, anastomoses are easy to identify because of the caliber change between donor and recipient portal veins [18]. Stenosis of the transplant arterial anastomosis may be seen on the arterial phase of a portal venous study, but its smaller size and often folded, tortuous course can make it difficult to assess. Occlusion of the transplant artery is important to detect because it results in ischemia to the donor common bile duct and can lead to biliary strictures and leaks. It is also important to assess the IVC since supra- and infrahepatic IVC anastomoses may also become narrowed and flow limiting.

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