DOI: 10.1148/rg.244035186
RadioGraphics 2004;24:957-967
© RSNA, 2004
Evaluation of Living Liver Transplant Donors: Method for Precise Anatomic Definition by Using a Dedicated Contrast-enhanced MR Imaging Protocol1
Dushyant Sahani, MD,
Roy D’souza, MD,
Rajagopal Kadavigere, MD,
Martin Hertl, MD,
Jennifer McGowan, RT(R)(CT),
Sanjay Saini, MD and
Peter R. Mueller, MD
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).
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Abstract
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Liver transplantation from a living donor involves removal of part of the donor liver in a fashion that does not endanger its vascular supply or metabolic function. The radiologist plays an important role in evaluation of the living donor to define the conditions under which graft donation is contraindicated and to identify anatomic variations that may alter the surgical approach. In the past, diagnostic work-up of the donor involved costly and invasive tests. Currently, dynamic contrast material–enhanced computed tomography and magnetic resonance (MR) imaging are the imaging tests performed, each of which has advantages and limitations. MR imaging performed with liver-specific and extravascular contrast agents may be used as a single imaging test for comprehensive noninvasive evaluation of living liver transplant donors. MR imaging provides valuable information about variations in the vascular and biliary anatomy and allows evaluation of the hepatic parenchyma for diffuse or focal abnormalities.
© RSNA, 2004
Index Terms: Bile ducts, MR, 76.12143 • Hepatic arteries, MR, 952.12942 • Hepatic veins, MR, 959.12942 • Liver, transplantation, 761.45 • Portal vein, MR, 957.12942
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Introduction
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Living donor liver transplantation in the adult was a new surgical procedure developed to overcome the shortage of available cadaveric livers (1). An exponential increase in the number of patients awaiting liver transplantation in the past decade has led to a scarcity of available cadaveric livers. The surgery for living donor liver transplantation involves removal of part of the liver in a fashion that does not endanger the vascular supply or metabolic function of the remainder of the organ. An understanding of the surgeon’s perspective and the procedure itself is critical so that efficient and pertinent techniques are performed preoperatively. The role of the radiologist in the evaluation of the living donor is to define the conditions in which graft donation is contraindicated and to identify the anatomic variations that may alter the surgical approach. A suboptimal graft that results in recipient complications or necessitates retransplantation takes on greater significance when it originated from a living donor.
Preoperative work-up may involve computed tomography (CT), sonography including Doppler imaging, magnetic resonance (MR) imaging, and catheter angiography. This article discusses the key radiologic information needed for the preoperative imaging work-up of adult liver donors and the role of MR imaging in efficiently providing this information. Specific topics discussed are the surgical perspective, the MR imaging technique, the role of preoperative radiologic imaging, vascular mapping, biliary evaluation, and preoperative evaluation of liver donors with MR imaging.
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Surgical Perspective
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Living related donor transplantation is predominantly undertaken in patients with severe or end-stage liver disease. Patients with early-stage hepatocellular carcinoma have also been found to have a good prognosis after liver transplantation.
In a pediatric recipient, the lateral segment or the entire left lobe of the liver is transplanted, depending on the size and habitus of the recipient. In lateral segment transplantation, segments II and III along with the left hepatic vein, left portal vein, left hepatic artery, and left bile duct go with the graft. The middle hepatic vein and middle hepatic artery (segment IV) are carefully preserved. The allograft is transplanted into the recipient’s hepatic fossa; typically, the left hepatic vein of the donor liver is anastomosed to the recipient’s middle hepatic vein and left hepatic vein trunk, the left portal vein is anastomosed to the main portal vein, and the bile duct is anastomosed to the jejunum via a retrocolic Roux-en-Y limb (2).
In an adult recipient, usually the right lobe of the donor liver is transplanted. The resection typically includes the entire right lobe, right hepatic vein, right portal vein, right hepatic artery, right bile duct, and gallbladder (Fig 1). The middle hepatic artery (segment IV artery) and middle hepatic vein are preserved for the survival of the medial segment.
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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.
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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.
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MR Imaging Technique
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The MR imaging examination protocol for potential living liver donors at our institution is shown in the Table.
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Role of Preoperative Radiologic Imaging
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Preoperative radiologic imaging plays a role in (a) parenchymal evaluation for diffuse liver disease (fatty infiltration) and focal lesion detection, (b) liver volume estimation, and (c) evaluation of the liver vascular (arterial, portal and hepatic venous) and biliary anatomy and variants.
Identification and accurate quantification of diffuse liver disease like fatty infiltration (Fig 2) or hemochromatosis is critical for both the donor as well as the recipient. The presence of diffuse liver disease may result in inaccurate liver volume estimation, and the residual functional liver may be suboptimal for donor survival (3). Focal lesions like adenomas, focal nodular hyperplasia, and hemangiomas may be incidentally detected in a healthy adult (Fig 2) and may be multiple. The presence of these lesions and their location may increase surgical morbidity or contraindicate liver surgery.
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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).
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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).
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Accurate preoperative estimation of the donor’s liver volume (Fig 3) is critical for satisfactory recipient and donor outcome. Provided there is no diffuse liver disease such as fatty infiltration, a remaining liver volume of 30%–40% of the total liver volume is sufficient for the donor to survive (4). The aim is to transplant a donor organ that is similar in size to the native organ. The recipient’s habitus, the amount of ascites, and the severity of the liver disease also have to be considered. The minimum graft-to–recipient body weight (GRBW) ratio is usually considered to be 0.8% if corrected for the degree of steatosis or other diffuse liver disease. A donor liver up to 20% larger than the estimated optimal volume is acceptable.
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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.
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Vascular Mapping
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The major difference between a graft obtained from a living donor and one from a cadaveric donor is the more limited length of vessels available for anastomosis in the former.
Hepatic Arteries
Knowledge of the exact arterial supply to the liver (Fig 4) is of utmost importance to the surgeon when planning an arterial reconstruction because variations in the hepatic arterial anatomy occur in approximately 45% of patients (5). The origin and location of the artery supplying segment IV of the liver should be identified preoperatively (Fig 5). In some cases, variant hepatic arterial anatomy is encountered during imaging (Fig 6); the commonest variant is a replaced right hepatic artery, which is seen in 11% of cases according to the Michels classification (6). When the lateral segment and right lobe graft are harvested, the segment IV artery should be left intact in the donor to prevent parenchymal damage to the medial segment of the liver. The segment IV artery, which is usually a branch of the left hepatic artery, originates from the common hepatic artery in 25% of individuals.
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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.
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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.
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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.
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Portal Vein
Function of the transplanted liver in the recipient as well as its regeneration are dependent on the patency of the donor and recipient vessels. The normal pattern is for the main portal vein to divide into the right and left portal branches (Fig 7). Abnormal configurations of the portal vein are known (7). Venous anomalies in the form of early branching or trifurcation of the portal vein (Fig 8) can make surgery difficult, as more vascular anastomosis is then required with the recipient portal vein. At times, a portal venous anomaly may be complicated enough to contraindicate transplant surgery.
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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.
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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).
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It is important to recognize cases where the right anterior portal vein branches from the left portal vein at a distance from the bifurcation. In this case, if the left portal vein is resected at the bifurcation, segment IV as well as segments V and VIII will be deprived of portal perfusion, resulting in devascularization (8). Therefore, the resection has to be distal to the origin of the right anterior portal vein. The transection line of the left portal vein may be located inside the hepatic parenchyma, leading to an extraparenchymal length insufficient for anastomosis to the recipient’s portal vein. In these cases, an interpositioned venous graft, usually the donor’s greater saphenous vein, may be required. Tokunaga et al (9) reported a branch patch technique in 1994. Portal vein trifurcation is considered a contraindication to living related liver transplantation of segments V–VIII. Absence of the right portal vein excludes the patient from a liver transplantation procedure. Exclusion of potential liver donors from surgery because of portal vein variants appears to be as high as 20% (10). The estimation of the portal vein diameter is also important and should be measured in the area of expected anastomosis.
Hepatic Veins
Preoperative mapping of the hepatic venous system is indispensable to the success of living related liver transplantation, as the transection plane is determined by the anatomic distribution of the hepatic veins (Figs 9, 10) (11). The function of a new liver in the recipient and its regeneration depend on the inflow and outflow of the graft, respectively, and therefore the supplying and draining vessels are to be left intact (12). The size, number, and patency of the hepatic veins should be documented.
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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.
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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.
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Of particular relevance is the site of drainage of the middle hepatic vein—either directly into the inferior vena cava or as a common trunk with the left hepatic vein. If the patency of the segment IV vein in a left lobe graft is not preserved, venous congestion will occur, resulting in hepatofugal flow in the segment IV portal vein and leading ultimately to atrophy of this segment (13,14). The draining veins of segment IV can be highly variable. They might be multiple in number and very small in caliber, usually draining into the middle hepatic vein. Similarly, information on the presence of accessory hepatic veins, their size, and their distance from the main hepatic veins is crucial to the transplantation surgeon (Fig 11), as their inadvertent transection can cause bleeding and atrophy of the supplied segment of the liver (Fig 12). A large collateral vein in the graft may also need an additional anastomosis with the recipient’s hepatic vein or inferior vena cava. The hepatic veins are sometimes better appreciated on T1-weighted MR images (Fig 13).
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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.
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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).
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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).
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Biliary Evaluation
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The prevalence of anastomotic biliary complications in adult liver transplantation is as high as 40% (15). Biliary complications are the commonest cause for long-term morbidity in liver transplant recipients. To prevent these complications, the transplant surgeon needs a preoperative map of the biliary tree and an idea of the presence of branching variants. The traditional method of mapping the biliary anatomy for transplant surgery is intraoperative cholangiography. When detected at the time of surgery, the presence of biliary variants may significantly influence the type of biliary anastomosis (16). Two types of biliary reconstruction, namely choledocho-choledochotomy and hepatico-jejunostomy with a Roux-en-Y loop, have been accepted as standard anastomotic procedures. The surgeon prefers a single duct-to-duct anastomosis if the anatomy permits. Preoperative mapping of the biliary anatomy helps the surgeon plan the anastomosis.
The normal anatomy of the biliary ducts is as follows: The common hepatic duct is formed by the union of the right and left hepatic ducts (Fig 14). The common hepatic duct joins the cystic duct coming from the gallbladder to form the common bile duct. The union of the medial duct (from segments V and VIII) and the lateral duct (from segments VI and VII) forms the right hepatic duct. Importance is given to the variations in the drainage of the hepatic ducts (Fig 15), most notably the right lateral duct (17). The presence and location of any accessory hepatic ducts also need to be identified. The presence of variant biliary anatomy by itself may not contraindicate transplant surgery but helps make a decision when other possibly detrimental factors are also present. This can be possible only if the information is available prior to surgery.
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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.
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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.
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Preoperative Evaluation of Liver Donors with MR Imaging
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MR imaging of the liver has evolved in recent years mainly due to the development of fast imaging techniques that provide superior-quality, high-resolution images in a breath hold (18). A comprehensive MR imaging examination has the potential to serve as the sole preoperative imaging modality for a living adult-to-adult liver donor (19,20). A complete MR imaging examination involves use of hepatobiliary contrast material (mangafodipir trisodium) for parenchymal assessment and T1-weighted MR cholangiography (21) and extracellular contrast material (gadopentetate dimeglumine) for angiography/venography and lesion characterization. MR angiography is an excellent noninvasive tool for evaluation of the patency and size of the portal and hepatic veins (22,23). T1-weighted MR cholangiopancreatography is a noninvasive procedure to map a nondilated biliary system. Biliary ductal branching anomalies and variants can be demonstrated and accessory ducts can be identified with MR cholangiography (24,25). Likewise, liver volume estimation is equally as accurate as with CT and can be undertaken in any plane.
Studies by Goyen et al (26) and Cheng et al (27) have evaluated MR imaging as the single imaging modality in potential living donors for liver transplantation and its practicability to replace CT, catheter angiography, and endoscopic retrograde cholangiopancreatography in this patient subset. A comprehensive assessment of the hepatic parenchyma, biliary ductal system, and hepatic arterial, portal, and hepatic venous systems can be accomplished by using contrast-enhanced MR imaging and MR cholangiography. Conventional angiography is then required in suboptimal studies, and intraoperative cholangiography is performed only when biliary ductal variants are encountered. MR imaging is superior to CT due to the ability to demonstrate the biliary tree in a noninvasive manner. Some authors have used iodinated biliary contrast agents to map the biliary tree during CT, but these agents are associated with a high risk of complications. Motion artifacts can now be reduced by using fast imaging techniques such as fast spin-echo, breath-hold GRE, and echo-planar imaging.
A comprehensive MR imaging examination includes parenchymal assessment for focal or diffuse abnormalities; MR angiography for delineating the vascular anatomy and variants; and MR cholangiography for biliary branching anomalies. Diffuse liver diseases like fatty infiltration and hemochromatosis, which can affect graft outcome, can be diagnosed at MR imaging due to the signal intensity changes they produce with the different pulse sequences. It is possible to quantify fatty infiltration by using in-phase and opposed-phase GRE sequences. Assessment for fatty infiltration is done on the basis of signal loss relative to the spleen on opposed-phase T1-weighted GRE images when compared with in-phase images (28). MR imaging offers an accurate means of determining adult liver volume (29). When MR imaging is used to calculate liver volume, care has to be taken to cover the entire liver in one acquisition.
Use of 3D breath-hold contrast-enhanced MR angiography enables acquisition of a large volume data set in the coronal plane within a breath hold during the first pass of contrast material (30). However, visualization of the terminal arterial branches like the segment IV artery may be difficult to achieve with MR angiography due to in-plane saturation, phase dispersion, and longer acquisition times.
MR venography after administration of gadolinium contrast material is highly accurate in mapping the venous anatomy and identifying venous anomalies. The accuracy of delineating the anatomy is increased by using multiplanar reconstruction (22). MR venography can be considered an alternative to invasive angiography and/or portography in small children for pretransplantation evaluation (23). When displayed in a 3D fashion, the images have good correlation with images from traditional imaging modalities and operative findings.
MR cholangiography can provide quality images of the biliary tree in a noninvasive manner (24,25). The continual improvement in MR imaging software and hardware makes MR cholangiography a potential replacement for intraoperative cholangiography. T2-weighted MR cholangiopancreatography is useful to delineate a dilated biliary system. However, like all T2-weighted sequences, the resolution is comparatively less than that of a T1-weighted sequence and may not adequately demonstrate a nondilated biliary system. On the other hand, T1-weighted MR cholangiopancreatography with a hepatobiliary contrast agent has good contrast resolution to map the biliary tree in a "normal" liver donor population. These T1-weighted MR cholangiopancreatography sequences are GRE sequences and can be performed in a breath hold (25).
At our institution, all donors undergo contrast-enhanced MR imaging with a 1.5-T magnet and a phased-array torso coil (Table). The entire study including unenhanced MR imaging, imaging after administration of mangafodipir trisodium, and dynamic imaging after administration of gadopentetate dimeglumine can be completed in approximately 45 minutes in a single imaging session.
Detection and characterization of hepatic masses rely on T1- and T2-weighted imaging and dynamic contrast-enhanced T1-weighted imaging with interpolated 3D spoiled GRE sequences.
For vascular anatomy, postprocessing of the raw data images is performed on a commercially available workstation. By using MIP and the shaded surface display technique, multiplanar and 3D maps of the hepatic arteries, portal vein, and hepatic veins are generated from the axial data set (Fig 16).
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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.
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For the biliary tree, MIP images are reconstructed from the 3D T1-weighted GRE sequence performed after administration of mangafodipir trisodium. The images are rotated in the desired planes.
Liver volumes are calculated by manually tracing an electronic cursor around the margins of the hepatic parenchyma on an axial section of the 3D spoiled GRE sequence. Subsequently, a 3D model of the liver volume is isolated, and the liver volume is computed with available commercial software (14). By using the same tracing technique, the lateral segment, medial segment, and right lobe of the liver are outlined and subsequently segmental or lobar volumes are calculated independently.
By superimposing the liver and hepatic vein models, virtual hepatectomy models are generated (Fig 16). Using these models for guidance, we manually trace a hepatectomy border, avoiding major vascular structures traversing between the right and left lobes.
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Conclusions
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MR imaging, as a single imaging technique, allows a comprehensive preoperative evaluation of potential liver donors. It provides valuable information about variations in vascular and biliary anatomy and allows examination of the liver parenchyma for diffuse or focal abnormalities. CT can provide all of this information but fails to demonstrate the biliary anatomy. All of this information is important in donor selection and preoperative planning. By using the generated data, 3D reconstructed images of the liver and its vascular anatomy can be created and a virtual hepatectomy can be performed. The transplant surgeon is prepared with all the required information and knows what to expect at the time of surgery.
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Footnotes
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Abbreviations: GRE = gradient-echo,
MIP = maximum intensity projection,
3D = three-dimensional
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A. Alonso-Torres, J. Fernandez-Cuadrado, I. Pinilla, M. Parron, E. de Vicente, and M. Lopez-Santamaria
Multidetector CT in the Evaluation of Potential Living Donors for Liver Transplantation
RadioGraphics,
July 1, 2005;
25(4):
1017 - 1030.
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Abstract
Introduction
