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DOI: 10.1148/rg.254045032
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Right arrow Computed Tomography
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Multidetector CT in the Evaluation of Potential Living Donors for Liver Transplantation1

Ana Alonso-Torres, MD, Jaime Fernández-Cuadrado, MD, Inmaculada Pinilla, MD, Manuel Parrón, MD, Emilio de Vicente, MD and Manuel López-Santamaría, MD

1 From the Departments of Radiology (A.A.T., J.F.C., I.P., M.P.) and Pediatric Surgery (M.L.S.), Hospital Universitario La Paz, Paseo de la Castellana 261, Madrid 28046, Spain; and the Department of General Surgery, Hopital Ramón y Cajal, Madrid, Spain (E.d.V.). Presented as an education exhibit at the 2003 RSNA Annual Meeting. Received March 11, 2004; revision requested June 30; final revision received October 27; accepted October 28. All authors have no financial relationships to disclose.


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  		Figure 1.  Drawing illustrates the segmental anatomy of the liver, along with the pattern of hepatic venous drainage, the ramifications of the portal venous system, and the planes of liver transection (dotted line indicates plane of transection in LLS donation, solid line indicates plane of transection in right lobe donation). IVC = inferior vena cava, LHV = left hepatic vein, MHV = middle hepatic vein, MP = main portal vein, R = round ligament, RHV = right hepatic vein.

 


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  		Figure 2.  Three-dimensional volume-rendered (VR) image shows the normal hepatic arterial anatomy. CHA = common hepatic artery, GDA = gastroduodenal artery, LGA = left gastric artery, LHA = left hepatic artery, PHA = proper hepatic artery and its bifurcation (arrow), RHA = right hepatic artery, SA = splenic artery, SMA = superior mesenteric artery.

 


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  		Figure 3.  Anterior VR image shows the normal arterial anatomy with a prominent corkscrew-like gastroduodenal artery (GD) and a filiform distal right hepatic artery (RHA) and left hepatic artery (LHA) (arrows). Because third-order vessels were not visible, the arterial study was considered inadequate, and conventional angiography was performed.

 


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  		Figure 4.  Thick-slab coronal oblique maximum-intensity-projection (MIP) image from CT data shows a replaced RHA (open arrow) arising from the SMA (arrowhead). Note the artery to segment IV (solid arrow) arising from the LHA. This situation is suitable for right lobe donation.

 


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  		Figure 5.  Coronal oblique VR image shows a replaced LHA (arrow) arising from the left gastric artery (arrowhead), a situation that is suitable for LLS donation. GD = gastroduodenal artery, RH = right hepatic artery.

 


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  		Figure 6.  Drawings illustrate the types of RPV branching (11): type A, normal anatomy (92.5% of cases); type B, early bifurcation or trifurcation (2.5%); type C, extraparenchymal branching of the anterior branch from the LPV (2.5%); type D, intraparenchymal branching of the anterior branch from the LPV (1.7%); and type E, an undivided main portal trunk (0.8%). Types B and C result in two venous openings that should be surgically reconstructed in cases of right lobe donation. The chosen technique for reconstruction depends on the distance between the right anterior and posterior branches. Types D and E represent absolute contraindications for right lobe donation. Moreover, the shortness of the transverse portion of the LPV complicates LLS donation.

 


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  		Figure 7.  Thick-slab coronal oblique MIP image shows an accessory LHA (arrow) arising from the left gastric artery. L = left hepatic artery, R = right hepatic artery. This situation would lead to the creation of a dual anastomosis, unless intrahepatic anastomoses, which allow the ligature of the smaller branch, are demonstrated.

 


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  		Figure 8.  Thick-slab axial MIP image shows a complex arterial branching pattern. The CHA trifurcates (solid arrow) into the gastroduodenal artery and two RHAs, from one of which arises the LHA (open arrow) and the artery to segment IV (arrowhead). This situation makes right lobe retrieval extremely difficult.

 


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  		Figure 9.  Thick-slab coronal oblique MIP image shows two LHAs. The proximal artery (arrow) arises at the proper hepatic artery bifurcation, whereas the distal artery (arrowhead) arises from the RHA and has a smaller caliber. The distal LHA should be preserved in cases of right lobe donation to ensure an adequate postsurgical liver volume.

 


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  		Figure 10.  Thin-slab axial MIP image shows the artery to segment IV (arrow) arising from the LHA (arrowhead). This situation is suitable for right lobe donation. Such an artery to segment IV should be transected in LLS donation; however, the consequences are not as relevant as in right lobe donation as long as the remnant liver volume is not significantly compromised.

 


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  		Figure 11.  Coronal VR image shows the artery to segment IV (arrow) arising from the right hepatic artery (R) very close to the proper hepatic artery bifurcation, from which point the left hepatic artery (L) arises.

 


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  		Figure 12.  Thin-slab axial MIP image shows a dual supply to segment IV (arrows) arising from the right (R) and left (L) hepatic arteries. In such cases, if right lobe donation is being considered, it is important to evaluate the dominance of one branch over the other to decide the sacrifice of the smaller one. Graft and remnant liver volumes should also be taken into account.

 


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  		Figure 13.  Thin-slab axial MIP image shows a triple supply to segment IV (arrows). Two vessels arise from the right hepatic artery (R), and a third vessel arises from the left hepatic artery (L).

 


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  		Figure 14.  Anterior VR image shows the normal portal venous anatomy. The left (L), main (M), and right (R) portal veins are well visualized. SMV = superior mesenteric vein, SV = splenic vein.

 


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  		Figure 15.  Thick-slab coronal MIP image shows a trifurcation of the main portal vein (M) into the anterior right (A), posterior right (P), and left (L) portal veins. In cases of right lobe donation, this variant would lead to the creation of two venous openings that should be reconstructed.

 


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  		Figure 16.  Coronal VR image shows extraparenchymal branching of the anterior branch (A) from the left portal vein (L) close to the bifurcation of the main portal vein (M). In cases of right lobe donation, this situation allows the reconstruction of the two venous openings into a single orifice. Dotted line indicates the transection plane for LLS retrieval, leaving a short portal vein for reconstruction. R = right portal vein.

 


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  		Figure 17.  Coronal VR image shows extraparenchymal branching of the anterior branch (A) from the left portal vein (L) far (18 mm) from the bifurcation of the main portal vein (M). Nevertheless, the right lobe was harvested and the portal vein was reconstructed with a Y-shaped graft. R = right portal vein.

 


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  		Figure 18.  Drawings illustrate anatomic variants that result in two venous openings being either joined together to make a single orifice (venoplasty) (A), anastomosed separately to the LPV and RPV of the recipient (B), or connected to a Y-shaped vascular graft for a single anastomosis (C). D = donor, G = graft, R = recipient.

 


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  		Figure 19.  Coronal VR image shows a vein (arrow) arising from the main portal vein (MPV) and supplying the LLS. Note the extraparenchymal branching of the right anterior branch (A) from the left portal vein (L). R = right portal vein. In this case, the coincidence of two distinct portal variants led to the selection of a more suitable candidate.

 


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  		Figure 20.  Thick-slab axial MIP image shows the normal hepatic venous anatomy. The left hepatic vein (L) forms a common trunk with the middle hepatic vein (M), whereas a large right hepatic vein (R) drains independently. There are no other small branches that drain independently into the IVC.

 


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  		Figure 21.  Thick-slab coronal oblique MIP image shows the normal hepatic venous anatomy of the middle (M) and left (L) hepatic veins, which join to form a common trunk. Note the early confluence of two branches (arrows) to form the main middle hepatic vein, a "safe" anatomy for right lobe donation.

 


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  		Figure 22.  Coronal VR image shows a large accessory inferior RHV (arrow) draining into the IVC. The distance to the RHV (arrowhead) must be carefully measured in cases of right lobe donation.

 


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  		Figure 23.  Thick-slab axial MIP image shows a branching pattern of the middle hepatic vein (M) consisting of an early confluence of two branches (arrows) to form the main venous trunk (arrowhead). In cases of right lobe donation, this situation allows safe transection to the right of the MHV.

 


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  		Figure 24.  Thick-slab axial MIP image shows the late confluence of two branches (straight solid arrows) to form the middle hepatic vein (M) very close to the IVC (open arrow). Note the two branches to segment IV (curved arrows) draining into the left hepatic vein (L). These two branches would be transected in cases of LLS retrieval.

 


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  		Figure 25a.  Dominance of the MHV over the RHV. (a) Thick-slab axial MIP image shows a large middle hepatic vein (M) that drains the anterior segments and segment VII (straight arrows). Several RHVs (arrowheads) drain the posterior segments. Note the large vein that drains segment IV independently into the IVC (curved arrow). (b) Thick-slab coronal MIP image shows the RHV (open arrow) draining segment VI into the IVC (arrowhead) 33 mm below the MHV (solid arrow).

 


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  		Figure 25b.  Dominance of the MHV over the RHV. (a) Thick-slab axial MIP image shows a large middle hepatic vein (M) that drains the anterior segments and segment VII (straight arrows). Several RHVs (arrowheads) drain the posterior segments. Note the large vein that drains segment IV independently into the IVC (curved arrow). (b) Thick-slab coronal MIP image shows the RHV (open arrow) draining segment VI into the IVC (arrowhead) 33 mm below the MHV (solid arrow).

 


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  		Figure 26.  Thick-slab coronal MIP image shows the branch of segment III (arrowhead) draining into the middle hepatic vein (M). The branch of segment II drains independently into the IVC.

 


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  		Figure 27.  Anterior 3D VR image obtained in a potential living donor of an LLS shows the calculated volume of the graft (195.1 cc [cm3]).

 


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  		Figure 28a.  Liver regeneration after right lobe donation. (a) Axial CT scan obtained before donation shows the LPV (arrow) dividing the left lateral segment (LLS) from segment IV, when calculated total liver volume was 1,768 cm3 and graft volume was 1,082 cm3. (b) Axial CT scan obtained 14 months after donation shows hypertrophy of the remnant liver (estimated volume, 1,505 cm3). This volume represented 85% of the previous total liver volume and 139% of the graft volume. LLS = left lateral segment, arrow indicates the LPV.

 


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  		Figure 28b.  Liver regeneration after right lobe donation. (a) Axial CT scan obtained before donation shows the LPV (arrow) dividing the left lateral segment (LLS) from segment IV, when calculated total liver volume was 1,768 cm3 and graft volume was 1,082 cm3. (b) Axial CT scan obtained 14 months after donation shows hypertrophy of the remnant liver (estimated volume, 1,505 cm3). This volume represented 85% of the previous total liver volume and 139% of the graft volume. LLS = left lateral segment, arrow indicates the LPV.

 




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