Korean J Radiol.  2004 Sep;5(3):199-209. 10.3348/kjr.2004.5.3.199.

Multi-Slice Spiral CT of Living-Related Liver Transplantation in Children: Pictorial Essay

Affiliations
  • 1Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Korea. hwgoo@amc.seoul.kr

Abstract

In pediatric living-related liver transplantation, preoperative evaluation of the recipient is important for surgical planning, while the accurate diagnosis of postoperative complications is essential for graft salvage. Multiplanar and three-dimensional imaging using multi-slice spiral CT can be used for preoperative vascular imaging, as well as for evaluating postoperative complications. In this essay, we describe the usefulness of multi-slice CT, combined with a variety of different reconstruction techniques, for the preoperative evaluation of transplant recipients. In addition, we demonstrate the multi-slice CT findings of postoperative complications, including vascular stenosis or thrombosis, bile duct leak or stricture, and extrahepatic fluid collection.

Keyword

Computed tomography (CT), in infants and children; Computed tomography (CT), multi-detector row; Liver, CT; Liver, transplantation

MeSH Terms

Child
Humans
Liver/*blood supply/*radiography
*Liver Transplantation
*Living Donors
Postoperative Complications/radiography
Preoperative Care
Tomography, Spiral Computed/*methods

Figure

  • Fig. 1 Normal anatomy of the hepatic artery in an 1-year-old girl. Oblique axial maximum intensity projection image shows the right hepatic artery (RHA), left hepatic artery (LHA), splenic artery (SA), and left gastric artery (LGA). Two middle hepatic arteries (arrows) arise from the right hepatic artery.

  • Fig. 2 Replaced right hepatic artery in an 1-year-old girl. Oblique coronal maximum intensity projection (A) and volume rendering (B) images show a replaced right hepatic artery (RHA) arising from the superior mesenteric artery (SMA). Unlike the maximum intensity projection image, the volume rendering image maintains the spatial relationships and depth information and demonstrates the left hepatic artery (long arrow, B) and left gastric artery (short arrow, B) as well.

  • Fig. 3 Replaced left hepatic artery in a 6-year-old girl. Oblique coronal maximum intensity projection images show a replaced left hepatic artery (arrowheads) arising from the left gastric artery (long arrow). Note the artifact (short arrows) resulting from respiratory motion. RHA = right hepatic artery

  • Fig. 4 Celiacomesenteric trunk in a 10-year-old boy. Volume rendering image shows the celiacomesenteric trunk (long arrow). The celiac and superior mesenteric arteries have a common origin. The splenic artery (short arrow) and the left gastric artery (arrowheads) arise from the celiac artery. RHA = right hepatic artery, LHA = left hepatic artery, GDA = gastrointestinal artery

  • Fig. 5 Portal vein stenosis in an 1-year-old girl. Oblique axial maximum intensity projection image shows a small main portal vein (long arrow). Both the right and left portal veins have very small diameters (arrows). Prominent hepatic arteries (*) are noted at the hepatic hilum.

  • Fig. 6 Portal vein thrombosis in a 9-year-old boy. Oblique coronal multiplanar reformatted image shows portal vein thrombosis (arrow) in the right anterior portal branch with irregular periportal enhancement, which was not identified on Doppler sonography.

  • Fig. 7 Anomalies of the inferior vena cava. A. Absent intrahepatic portion of the inferior vena cava in a 2-year-old girl. multiplanar reformatting image shows obliteration of the intrahepatic portion of the inferior vena cava (arrowheads). Note the intact suprahepatic portion of the inferior vena cava (arrow). Recognition of this portion can help in planning hepatic venous reconstruction during transplantation. B. Hypoplastic inferior vena cava in a 14-year-old girl. Curved planar reformatted image shows diffuse narrowing of the suprarenal portion of the inferior vena cava (arrowheads) with engorged hemiazygos veins (arrows).

  • Fig. 8 Esophageal and coronary varices in a 6-year-old girl. Coronal multiplanar reformatting image reveals the presence of a coronary varix (short arrow). The esophageal varix (long arrow) is observed to communicate with the left gastric vein through the gastric fundal varix. L = liver, St = stomach, Sp = spleen

  • Fig. 9 Spontaneous splenorenal shunt in a 6-year-old girl. Oblique coronal maximum intensity projection image shows a prominent splenorenal shunt (arrows). LRV = left renal vein

  • Fig. 10 Perihepatic collaterals in a 7-year-old boy. Oblique coronal maximum intensity projection image shows collateral vessels (arrows) at the perihepatic area. The collateral vessels adjacent to the liver can be ligated during surgery, because otherwise they can cause increased bleeding when the native liver is excised.

  • Fig. 11 Hemorrhoidal vein in a 6-month-old girl. Volume rendering image well delineates its continuation with the inferior mesenteric vein (arrowheads). Diffuse narrowing of the portal vein (arrows) is noted. RGV = right gastric vein, LGV = left gastric vein, SV = splenic vein, PEV = paraesophageal vein, SMV = superior mesenteric vein, IVC = inferior vena cava

  • Fig. 12 Hepatocellular carcinoma in a 2-year-old boy. A. Arterial-phase CT scan shows a hypervascular mass (arrow) in the right lobe of the liver. The underlying liver reveals a cirrhotic change. B. Portal-phase CT scan at the same level shows wash-out of contrast agent from the tumor. Based on characteristic enhancement pattern of the mass on CT, hepatocellular carcinoma was diagnosed, and the diagnosis was confirmed on histopathology.

  • Fig. 13 Hepatic artery stenosis in an 11-year-old girl, 18 days after living-related liver transplantation to treat fulminant hepatitis. A. Coronal multiplanar reformatting image shows severe multifocal stenoses of the hepatic artery at the anastomosis sites (arrowheads). B. Hepatic arteriogram demonstrates the hepatic artery stenoses (arrowheads) with distal sluggish flow. Compared with conventional angiography, CT angiography seems to overestimate the stenosis. C. Axial CT scan reveals multiple peripheral, wedge-shaped low-attenuation lesions due to hepatic infarction.

  • Fig. 14 Pseudoaneurysm of the hepatic artery in an 8-year-old boy, 3 years after living-related liver transplantation to treat biliary cirrhosis. Oblique axial maximum intensity projection image (A) and angiography (B) show a pseudoaneurysm (arrow) of the S3 segmental artery in the transplanted liver. We regarded this lesion as a pseudoaneurysm rather than a true aneurysm, because presurgical hepatic CT angiography of the donor was negative. The lesion probably developed as a result of a previous liver biopsy. Another saccular enhancing lesion (arrowhead) near the anastomosis site of the hepatic artery was detected and considered to be another pseudoaneurysm on CT angiography, but it was later identified as a focal varix in the right gastric vein (*, B) on the angiography. A portal vein stent is also noted on the angiography.

  • Fig. 15 Portal vein stenosis in a 2-year-old girl, 4 months after living-related liver transplantation to treat biliary atresia. A. Oblique axial maximum intensity projection image obtained 5 days after transplantation shows an anastomosis site (arrows) of the portal vein and provides a baseline study for later comparison. B. Oblique axial maximum intensity projection image performed 4 months later reveals the development of a severe anastomotic stenosis (arrows) of the portal vein. Based on this CT finding, a portal vein stent was placed for the treatment of the portal vein stenosis.

  • Fig. 16 Portal vein obstruction in a 7-year-old girl, 7 years after living-related liver transplantation to treat biliary atresia. Volume rendering image shows complete obstruction of the main portal vein (arrowheads). Multiple collateral vessels (*) arising from the superior mesenteric vein (SMV) reconstituted the intrahepatic portal veins (arrows). SV = splenic vein

  • Fig. 17 Evaluation of the patency of portal vein stents. A. Patent portal vein stent in a 9-year-old boy, 4 years after living-related liver transplantation to treat biliary cirrhosis. Curved planar reformatted image simultaneously demonstrates the patency of the proximal (*) and distal (arrows) portions of the stent. B. Stenosis of the portal vein stent in an 1-year-old girl, 9 days after living-related liver transplantation to treat biliary atresia. Oblique axial multiplanar reformatting image shows the stenosis (arrow) of the portal vein stent. We were able to evaluate the patency of the stent, because portions of the portal vein distal to the stenosis were enhanced.

  • Fig. 18 Compression of the inferior vena cava caused by fluid collection in a 7-year-old boy, 18 days after living-related liver transplantation to treat biliary atresia. Oblique coronal multiplanar reformatting images show inferior vena cava compressed (arrows) by localized fluid collections (F).

  • Fig. 19 Stenosis of the hepatic vein anastomosis in a 7-year-old boy, 22 days after living-related liver transplantation to treat biliary atresia. A. Oblique coronal multiplanar reformatting image obtained 5 days after transplantation shows the anastomosis site (arrows) between the hepatic vein and the IVC and provides a baseline study for later comparison. B. Initial postoperative Doppler sonography shows a pulsatile monophasic pattern of hepatic venous flow, which provides a baseline flow pattern of the hepatic vein for later comparison. C. Follow-up Doppler sonography performed 22 days after transplantation reveals absence of previous pulsatility in the hepatic venous flow pattern. This sonographic finding and the observed increase in the amount of intraperitoneal fluid led to the diagnosis of hepatic vein stenosis. After confirming the significant trans-stenotic pressure gradient (14 mmHg) on catheter venography, a stent was successfully placed at the hepatic vein stenosis. D. Oblique coronal multiplanar reformatting image after the placement of the hepatic vein stent demonstrates the patency of the placed stent (arrow).

  • Fig. 20 Pneumobilia in a 3-year-old girl, 11 months after living-related liver transplantation to treat biliary cirrhosis. Oblique sagittal minimum intensity projection image demonstrates pneumobilia in the transplanted liver. An anastomosed site (arrow) with jejunum (J) is delineated in this patient.

  • Fig. 21 Localized bile duct dilatation in a 5-year-old boy, 4 years after living-related liver transplantation to treat fulminant hepatitis. minimum intensity projection images show localized bile duct dilatations (arrows) in the transplanted liver. Secondary parenchymal atrophy of the involved segment of the transplanted liver is noted.

  • Fig. 22 Localized fluid collection - extrahepatic bile leak in a 7-year-old boy, 1 day after living-related liver transplantation to treat biliary atresia. Localized fluid collection (F) in the perihepatic space was confirmed as resulting from an extrahepatic bile leak. Hepatic venous infarction (arrows) is noted along the resection margin of the transplanted liver as a geographic low density lesion.


Reference

1. Hashikura Y, Kawasaki S, Terada M, et al. Long-term results of living-related donor liver graft transplantation: a single-center analysis of 110 transplants. Transplantation. 2001. 72:95–99.
2. Unsinn KM, Freund MC, Ellemunter H, et al. Spectrum of imaging findings after pediatric liver transplantation: part 1, posttransplantation anatomy. AJR Am J Roentgenol. 2003. 181:1133–1138.
3. Unsinn KM, Freund MC, Ellemunter H, et al. Spectrum of imaging findings after pediatric liver transplantation: part 2, posttransplantation complications. AJR Am J Roentgenol. 2003. 181:1139–1144.
4. Cheng YF, Chen CL, Jawan B, et al. Multislice computed tomography angiography in pediatric liver transplantation. Transplantation. 2003. 76:353–357.
5. Molmenti EP, Pinto PA, Klein J, Klein AS. Normal and variant arterial supply of the liver and gallbladder. Pediatr Transplant. 2003. 7:80–82.
6. Pannu HK, Maley WR, Fishman EK. Liver transplantation: preoperative CT evaluation. RadioGraphics. 2001. 21:S133–S146.
7. De Carlis L, Del Favero E, Rondinara G, et al. The role of spontaneous portosystemic shunts in the course of orthotopic liver transplantation. Transpl Int. 1992. 5:9–14.
8. Tatekawa Y, Asonuma K, Uemoto S, Inomata Y, Tanaka K. Liver transplantation for biliary atresia associated with malignant hepatic tumors. J Pediatr Surg. 2001. 36:436–439.
9. Wozney P, Zajko AB, Bron KM, Point S, Starzl TE. Vascular complications after liver transplantation: a 5-year experience. AJR Am J Roentgenol. 1986. 147:657–663.
10. Heffron TG, Pillen T, Welch D, Smallwood GA, Redd D, Romero R. Hepatic artery thrombosis in pediatric liver transplantation. Transplant Proc. 2003. 35:1447–1448.
11. Katyal S, Oliver JH 3rd, Buck DG, Federle MP. Detection of vascular complications after liver transplantation: early experience in multislice CT angiography with volume rendering. AJR Am J Roentgenol. 2000. 175:1735–1739.
12. Diem HV, Evrard V, Vinh HT, et al. Pediatric liver transplantation for biliary atresia: results of primary grafts in 328 recipients. Transplantation. 2003. 75:1692–1697.
13. Rollins NK, Sheffield EG, Andrews WS. Portal vein stenosis complicating liver transplantation in children: percutaneous transhepatic angioplasty. Radiology. 1992. 182:731–734.
14. Rossi AR, Pozniak MA, Zarvan NP. Upper inferior vena caval anastomotic stenosis in liver transplant recipients: Doppler US diagnosis. Radiology. 1993. 187:387–389.
15. Millis JM, Cronin DC, Brady LM, et al. Primary living-donor liver transplantation at the University of Chicago: technical aspects of the first 104 recipients. Ann Surg. 2000. 232:104–111.
16. Keogan MT, McDermott VG, Price SK, Low VH, Baillie J. The role of imaging in the diagnosis and management of biliary complications after liver transplantation. AJR Am J Roentgenol. 1999. 173:215–219.
17. Ametani F, Itoh K, Shibata T, Maetani Y, Tanaka K, Konishi J. Spectrum of CT findings in pediatric patients after partial liver transplantation. RadioGraphics. 2001. 21:53–63.
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