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Evaluation of Living Liver Transplant Donors: Method for Precise Anatomic Definition by Using a Dedicated Contrast-enhanced MR Imaging Protocol¹

¹ From the Departments of Radiology (D.S., R.D., R.K., J.M., S.S., P.R.M.) and Surgery (M.H.), Massachusetts General Hospital, 55 Fruit St, White 270, Boston, MA 02114. Recipient of a Certificate of Merit award for an education exhibit at the 2002 RSNA scientific assembly. Received August 26, 2003; revision requested November 14 and received January 29, 2004; accepted February 4. Address correspondence to D.S. (e-mail: dsahani@partners.org).

View larger version (44K): [in a new window]   Figure 1a.  (a) Drawing of right lobe transplantation shows the transection plane through the liver and the structures that are resected. (b) Photograph of a surgical specimen shows a left lobe liver graft from a donor. Arrow = inferior vena cava, arrowhead = left hepatic duct.

View larger version (145K): [in a new window]   Figure 1b.  (a) Drawing of right lobe transplantation shows the transection plane through the liver and the structures that are resected. (b) Photograph of a surgical specimen shows a left lobe liver graft from a donor. Arrow = inferior vena cava, arrowhead = left hepatic duct.

View larger version (139K): [in a new window]   Figure 2a.  Axial in-phase (a) and opposed-phase (b) GRE images show fatty infiltration of the liver. The decreased signal intensity of the liver on the opposed-phase image (b) indicates that fat is present in the liver. The spleen or paraspinal muscles act as the internal standard. Incidentally noted are two focal lesions in the liver: a hemangioma (arrow) and a cyst (arrowhead).

View larger version (136K): [in a new window]   Figure 2b.  Axial in-phase (a) and opposed-phase (b) GRE images show fatty infiltration of the liver. The decreased signal intensity of the liver on the opposed-phase image (b) indicates that fat is present in the liver. The spleen or paraspinal muscles act as the internal standard. Incidentally noted are two focal lesions in the liver: a hemangioma (arrow) and a cyst (arrowhead).

View larger version (111K): [in a new window]   Figure 3.  Three-dimensional volumetric image created for estimation of the liver volume. Separate volumes for the right and left lobes can be calculated by using available software.

View larger version (162K): [in a new window]   Figure 4.  Coronal contrast material-enhanced MR angiogram shows the normal anatomy of the hepatic artery. CA = celiac axis, CHA = common hepatic artery, LHA = left hepatic artery, RHA = right hepatic artery, SPA = splenic artery.

View larger version (157K): [in a new window]   Figure 5.  Coronal contrast-enhanced MR angiogram shows a normal origin of the artery supplying segment IV (arrow).

View larger version (125K): [in a new window]   Figure 6a.  Variant hepatic artery. Coronal contrast-enhanced MR angiogram (a) and conventional angiogram (b) show a replaced left hepatic artery (arrow in b) arising from the left gastric artery (LGA). CA = celiac axis.

View larger version (105K): [in a new window]   Figure 6b.  Variant hepatic artery. Coronal contrast-enhanced MR angiogram (a) and conventional angiogram (b) show a replaced left hepatic artery (arrow in b) arising from the left gastric artery (LGA). CA = celiac axis.

View larger version (149K): [in a new window]   Figure 7.  Oblique maximum intensity projection (MIP) image from gadolinium-enhanced 3D GRE imaging shows normal branching of the portal vein. Ant = anterior branch of right portal vein, LPV = left portal vein, MPV = main portal vein, Post = posterior branch of right portal vein, RPV = right portal vein, white line = transection plane for transplantation surgery.

View larger version (145K): [in a new window]   Figure 8.  Coronal MIP image from contrast-enhanced MR imaging shows variant anatomy of the portal vein. There is early branching of the right posterior portal vein (white arrow) from the main portal vein (MPV), which subsequently bifurcates into the right anterior branch (black arrow) and left portal vein (LPV).

View larger version (131K): [in a new window]   Figure 9.  Axial MIP image from contrast-enhanced MR imaging shows a normal confluence of the hepatic veins. This view is used to determine the transection plane (white line); for right hepatectomy, the transection plane is located 1 cm to the right of the middle hepatic vein.

View larger version (149K): [in a new window]   Figure 10.  Coronal MIP image from contrast-enhanced MR imaging shows a normal confluence of the hepatic veins at the inferior vena cava. There is also a portal vein anomaly in the form of an additional branch (arrow), which arises from the left portal vein and supplies the right lobe.

View larger version (154K): [in a new window]   Figure 11.  Coronal MIP image shows a large accessory hepatic vein that drains the right lobe (arrow). Its distance from the right hepatic vein is measured for the benefit of the surgeon.

View larger version (104K): [in a new window]   Figure 12a.  Importance of preoperative mapping of accessory hepatic veins. (a) Axial T1-weighted MR image shows an accessory hepatic vein (arrow) that drains the right lobe into the middle hepatic vein. The transection plane (white line) is seen to intersect this accessory vein before the confluence. (b) Postoperative axial T1-weighted MR image shows atrophy of the corresponding liver segment (arrows).

View larger version (146K): [in a new window]   Figure 12b.  Importance of preoperative mapping of accessory hepatic veins. (a) Axial T1-weighted MR image shows an accessory hepatic vein (arrow) that drains the right lobe into the middle hepatic vein. The transection plane (white line) is seen to intersect this accessory vein before the confluence. (b) Postoperative axial T1-weighted MR image shows atrophy of the corresponding liver segment (arrows).

View larger version (180K): [in a new window]   Figure 13a.  (a) Axial T1-weighted MR image shows accessory hepatic veins (arrows). (b) Contrast-enhanced CT image does not show the veins.

View larger version (183K): [in a new window]   Figure 13b.  (a) Axial T1-weighted MR image shows accessory hepatic veins (arrows). (b) Contrast-enhanced CT image does not show the veins.

View larger version (109K): [in a new window]   Figure 14.  Coronal oblique T1-weighted MR cholangiopancreatogram, obtained after injection of mangafodipir trisodium, shows the normal anatomy of the biliary tract.

View larger version (69K): [in a new window]   Figure 15a.  Coronal oblique T1-weighted MR cholangiopancreatogram (a) and intraoperative conventional cholangiogram (b) show a biliary variant in the form of an anomalous left hepatic duct (arrow) arising from the right hepatic duct.

View larger version (164K): [in a new window]   Figure 15b.  Coronal oblique T1-weighted MR cholangiopancreatogram (a) and intraoperative conventional cholangiogram (b) show a biliary variant in the form of an anomalous left hepatic duct (arrow) arising from the right hepatic duct.

View larger version (177K): [in a new window]   Figure 16.  Image shows superimposition of the volumetric model of the right lobe and the model of the hepatic veins. Created from the raw data from CT or MR imaging, such images help in planning the surgical plane for hepatectomy.