Pediatric Radiology

https://doi.org/10.1007/s00247-018-4284-8

ORIGINAL ARTICLE

MR angiography and 2-D phase-contrast imaging for evaluation

of meso-rex bypass function
Heather A. Stefek 1,2 & Cynthia K. Rigsby 2,3 & Haben Berhane 2 & Andrada R. Popescu 2 & Shankar Rajeswaran 2 &
Riccardo A. Superina 4,5

Received: 30 June 2018 / Revised: 3 September 2018 / Accepted: 5 October 2018

# Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract
Background The meso-Rex bypass restores blood flow to the liver in patients with extrahepatic portal vein thrombosis. Stenosis
occurs in some cases, causing the reappearance of portal hypertension. Complications such as thrombocytopenia present on a
spectrum and there are currently no guidelines regarding a threshold for endovascular intervention. While Doppler ultrasound
(US) is common for routine evaluation, magnetic resonance (MR) angiography with two-dimensional phase-contrast MRI (2-D
PC-MRI) may improve the assessment of meso-Rex bypass function.
Objectives To determine the feasibility and utility of MR angiography with 2-D PC-MRI in evaluating children with meso-Rex
bypass and to correlate meso-Rex bypass blood flow to markers of portal hypertension.
Materials and methods MR angiography and 2-D PC-MRI in meso-Rex bypass patients were retrospectively analyzed.
Minimum bypass diameter was measured on MR angiography and used to calculate cross-sectional area. Meso-Rex bypass
blood flow was measured using 2-D PC-MRI and divided by ascending aortic flow to quantify bypass flow relative to systemic
circulation. Platelet and white blood cell counts were recorded. Correlation was performed between minimum bypass area, blood
flow and clinical data.
Results Twenty-five children (median age: 9.5 years) with meso-Rex bypass underwent MR angiography and 2-D PC-MRI. The
majority of patients were referred to imaging given clinical concern for complications. Eighteen of the 25 patients demonstrated
>50% narrowing of the bypass cross-sectional area. The mean platelet count in 19 patients was 127 K/μL. There was a significant
correlation between minimum cross-sectional bypass area and bypass flow (rho=0.469, P=0.018) and between bypass flow and
platelet counts (r=0.525, P=0.021).
Conclusion Two-dimensional PC-MRI can quantify meso-Rex bypass blood flow relative to total systemic flow. In a cohort of 25
children, bypass flow correlated to minimum bypass area and platelet count. Two-dimensional PC-MRI may be valuable
alongside MR angiography to assess bypass integrity.

Keywords Children . Magnetic resonance imaging . Meso-Rex bypass . Magnetic resonance angiography . Two-dimensional
phase-contrast

Electronic supplementary material The online version of this article

(https://doi.org/10.1007/s00247-018-4284-8) contains supplementary
material, which is available to authorized users.

* Heather A. Stefek 3
Department of Radiology, Northwestern Memorial Hospital,
heather.stefek@northwestern.edu Chicago, IL, USA
4
Department of Surgery, Northwestern Memorial Hospital,
1
Northwestern University Feinberg School of Medicine, Chicago, IL, USA
420 E. Superior St., Chicago, IL 60611, USA 5
Division of Transplant Surgery,
2
Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago,
Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
Chicago, IL, USA

Introduction
The meso-Rex bypass is considered the intervention of choice
in managing extrahepatic portal vein thrombosis [1]. Initially
described by de Ville de Goyet [2] in 1992, the procedure
utilizes an autologous vein graft, most commonly the internal
jugular vein, to redirect blood from the superior mesenteric
vein to the left portal vein (Fig. 1) [3]. Compared to prior
treatment options for portal vein obstruction, including
portosystemic shunts and variceal banding, the meso-Rex by-
pass offers the advantage of restoring physiological blood
flow to the liver. This allows for more significant normaliza-
tion of liver function following surgery, including improve-
ment in platelet count, international normalized ratio (INR)
and blood ammonia [4, 5]. In addition, patients who undergo
meso-Rex bypass have improved postsurgical weight-for-age
compared to those with splenorenal shunts, highlighting the
importance of adequate liver function in normal pediatric
growth and development [4].
While the majority of bypasses remain patent for years, 10–
17% develop stenosis [1, 6]. Stenosis most commonly occurs
near the left portal vein anastomosis and can occur months to
years after surgery [6]. The sequelae of bypass narrowing are
portal hypertension and hepatic dysfunction, including varice-
al bleeding, hypersplenism and hyperammonemia [3].
Hypersplenism leads to increased sequestration of platelets
and white blood cells and can cause significant splenomegaly.
Endovascular intervention such as angioplasty and/or stent
placement is the mainstay of treatment for meso-Rex bypass
Fig. 1 Diagram of the meso-Rex bypass: inferior vena cava (IVC),
superior mesenteric vein (SMV), inferior mesenteric vein (IMV),
splenic vein (SV), cavernous transformation of the portal vein (CTPV),
right portal vein (RPV), left portal vein (LPV). (Reprinted with
permission [3])
Pediatr Radiol
stenosis. Unfortunately, complications are often unpredictable
and multifactorial, making it difficult to establish definitive
criteria of when intervention should be pursued. There are
no guidelines regarding corrective intervention for complica-
tions related to a meso-Rex bypass; decisions are based on
clinical data and imaging studies.
Follow-up evaluation of the meso-Rex bypass typically
involves serial Doppler ultrasound (US) studies to assess for
adequate blood flow and presence of stenoses [6]. However,
accuracy of flow quantification may be limited by tortuosity
of the bypass, which can preclude adequate views for mea-
surement. In patients with clinical evidence or US findings
suggestive of bypass stenosis, additional evaluation is often
performed with magnetic resonance imaging (MRI). MR an-
giography provides detailed visualization of the meso-Rex
bypass and abdominal vessels, which allows for more precise
measurements and intervention planning. Two-dimensional
phase-contrast MRI (2-D PC-MRI) has been successful in
quantifying portal venous flow in normal subjects and may
likewise prove valuable in assessing meso-Rex bypass blood
flow [7]. The purpose of this study is to determine the utility of
MR angiography with 2-D PC-MRI in evaluating children
with meso-Rex bypasses and to compare blood flow through
the bypass with clinical markers of portal hypertension.
Materials and methods
Patient population and clinical data
The retrospective study is institutional review board (IRB)
approved and HIPAA compliant. Informed consent was
waived by the IRB. A retrospective PACS search identified
all children with a meso-Rex bypass with clinically indicated
abdominal MR angiography with 2-D PC-MRI was per-
formed at Ann and Robert H. Lurie Children’s Hospital
(Lurie Children’s) Hospital between 2013 and 2017. Meso-
Rex bypass and aortic blood flow have been a part of the
clinically indicated MR imaging protocol since 2013. Patient
age, height and weight were recorded on the same day as the
MRI. Platelet count, white blood cell count and blood ammo-
nia level were recorded from the same day as MRI when
available. Relevant clinical history including time from sur-
gery to imaging, complications and study indication were re-
corded from the electronic medical record (Epic, Verona, WI).
Imaging protocol
MR angiography
Abdominal MR angiography was performed at 1.5 T using a
3-D T1 gradient echo sequence with respiratory navigator
triggering at end-expiration and electrocardiography (ECG)
Pediatr Radiol
gating in diastole (T1 fast low angle shot [FLASH], Aera;
Siemens Healthineers, Malvern, PA). Patients fasted for at
least 4 h before the study. General anesthesia was used in 18
patients, and the remaining 7 patients were imaged awake.
MR angiography parameters included: field of view (FOV)
300 × 280 mm, slice thickness reconstructed at 1.3 mm, repe-
tition time (TR) 3.3 ms and echo time (TE) 1.27 ms. All
examinations were performed following contrast: 20 patients
received 0.03 mmol/kg gadofosveset trisodium (Ablavar;
Lantheus Medical Imaging, North Billerica, MA), two re-
ceived 2.5 mg/kg ferumoxytol (Feraheme; AMAG
Pharmaceuticals, Waltham, MA), two received 0.1 mmol/kg
Gadavist (Bayer HealthCare, Whippany, NJ) and one received
0.1 mmol/kg Dotarem (Guerbet, France). For exams using a
blood pool contrast, images were acquired in the steady state
following contrast administration. For those performed with
extracellular gadolinium-based contrast agents, our protocol
consists of an initial bolus injection followed by a slow con-
tinuous contrast infusion.
MR angiography image analysis
Minimum diameter of the meso-Rex bypass was measured in
two orthogonal planes on MR angiography using Vitrea (Vital
Images, Minnetonka, MN). Minimum cross-sectional area
(π x r1 x r2) was calculated and normalized to body sur-
face area (BSA). This area was compared to the cross-
sectional area of the mid-bypass to quantify the extent
of narrowing as a percentage. Vitrea software was used
to generate 3-D reconstructions of the MR angiography to
aid visualization of the bypass. Spleen lengths were re-
corded from the MR angiography images and compared
to normative values [8].
Phase-contrast imaging
Retrospectively ECG-gated 2-D PC-MRI was acquired
perpendicular to the long axis of the bypass in the mid
portion of the meso-Rex bypass with plane placement to
avoid any stenosis. The following parameters were used
for meso-Rex bypass 2-D PC-MRI: repetition time
TR 5.8 ms, TE 3.5 ms, velocity encoding of 40–80 cm/s
and a spatial resolution of at least 4 pixels across the
meso-Rex bypass diameter. Blood flow in the aortic root
was also quantified to report meso-Rex bypass flow as a
percentage of total systemic arterial flow. For the aortic 2-
D PC-MRI sequence, retrospectively ECG-gated 2-D PC-
MRI was obtained perpendicular to the long axis of the
aortic root with the following parameters: TR 5.7–5.8 ms,
TE 2.1–4.4 ms and velocity encoding of 150–200 cm/s to
avoid aliasing.
Phase-contrast imaging data analysis
Two-dimensional PC-MRI meso-Rex bypass and aortic root
blood flow sequences were post-processed in Qflow (Medis,
The Netherlands) by an imaging technologist with >5 years of
experience. Data were reviewed by one of two attending pe-
diatric radiologists (C.K.R. with 18 years of experience and
A.P. with 10 years of experience). Meso-Rex bypass flow was
divided by flow in the aortic root to obtain a ratio of bypass-to-
systemic blood flow, representing the percentage of systemic
blood flow being transported by the meso-Rex bypass. Meso-
Rex bypass flow was compared to normal portal vein flow
using published data for fasting healthy children [9].
Statistical methods
Regression analysis was performed in SPSS (IBM, Armonk,
NY) to correlate the minimum cross-sectional area of the
meso-Rex bypass, blood flow and clinical data including
platelet and white blood cell (WBC) count. Pearson’s coeffi-
cient was calculated for variables with a normal data distribu-
tion; Spearman’s rho was calculated for variables with abnor-
mal data distribution. P<0.05 was considered statistically
significant.
Results
Demographics
The final cohort included 25 patients (12 female, 13 male)
with a median age of 9.5 years (interquartile range [IQR]:
8.0–12.6 years). Imaging was performed at a median of
53 months (IQR: 19–64 months) following meso-Rex bypass
surgery, with all patients imaged 9 or more months following
surgery (Table 1). An additional patient was not included in
this final cohort as imaging had been performed in the imme-
diate postoperative period to evaluate for postsurgical compli-
cations. Original meso-Rex bypass was constructed using an
internal jugular vein autograft in 22 of 25 patients. In the
remaining three patients, the inferior mesenteric vein was used
to form the bypass as preoperative evaluation demonstrated
inadequate or absent internal jugular vein. Two patients addi-
tionally required incorporation of a Gore-tex (Gore Medical,
Flagstaff, AZ) graft in either initial or revision surgery.
MRI was performed as part of routine follow-up in asymp-
tomatic patients in 11 of 25 studies. In these cases, MRI was
used to assess the function of the meso-Rex bypass both 1 year
following placement as well as 5 years later, in order to deter-
mine discharge from routine follow-up at Lurie Children’s.
Fourteen patients had additional indications for the MRI, in-
cluding elevated ammonia (n=1), worsening thrombocytope-
nia and/or progression of splenomegaly (n=6), history of

Table 1 Demographics and
clinical data for the final study Number
cohort
Age
Gender
Time between surgery and MRI
Platelet count
White blood cell count
previous stenosis, angioplasty or modification (n=6) and as-
sessment of stenosis identification on US (n=1). Eleven pa-
tients in the cohort had more than one MRI examination per-
formed; the most recent study was used in each case.
Clinical data
Nineteen patients had laboratory data evaluated on the day of
MRI with measurement of platelets, WBC count and ammo-
nia levels. In this group, the mean platelet count was 127,000
per microliter (K/μL) (±56 K/μL) with 14 children below the
normal range of 150-450 K/μL. Mean WBC count was 4.8 K/
μL (±1.7 K/μL) with 6 children below the normal range of
4.5-10 K/μL. Median ammonia was 33 μmol per liter
(μmol/L) (IQR: 23–43 μmol/L), with 9 children above the
normal level of 11–35 μmol/L.
MR angiography and phase-contrast MRI
Median indexed minimum cross-sectional area of the bypass
was 22 mm2/m2 with values ranging from 1 to 62 mm2/m2
(IQR: 10–37 mm2/m2). In comparing the narrowest bypass
segment to the patent mid-bypass, 7 patients had <50% de-
crease in cross-sectional area, 10 patients had 50–80% de-
crease in area and 8 patients had >80% decrease in cross-
sectional area. Stenosis occurred near the upstream of the left
portal vein anastomosis in all but one patient, who demonstrat-
ed a narrowing of the mid-bypass. Two patients in the group
had severe stenosis measuring less than 1 mm with exact mea-
surements difficult to discern due to the small diameter and
spatial resolution of the MR study. They were assigned a min-
imum diameter of 1×1 mm for the purposes of this study.
Of 26 patients initially imaged, phase-contrast MRI suc-
cessfully measured aortic root and meso-Rex bypass flow in
all but 1 patient (96%) A single case was excluded from the
final cohort for technically inadequate ascending aortic flow
sequence. On average, phase-contrast imaging of the bypass
lasted 103 s (±56 s) and that of the ascending aorta lasted 98 s
(±49 s). In the final cohort, mean blood flow through the
meso-Rex bypass was 13% (±5.9%) of systemic blood flow
with values ranging from 1.2% to 25%. Notably, in 20 of 25
patients, the bypass transported less than 18.3% of systemic
flow (Fig. 2). Eighteen percent of systemic flow represents
normal portal vein flow in healthy children [9]. Twenty-one
Pediatr Radiol
n=25 patients
Median: 9.5 years (range: 2.5–19 years)
12 female, 13 male
Median: 53 months (range: 9–109 months)
Mean: 127×103/μL (normal: 150–450×103/μL)
Mean: 4.8×103/μL (normal: 4.5–10×103/μL)
of 25 patients had splenomegaly; 1 patient was post-
splenectomy.
Three cases are selected to highlight the range of outcomes
encountered in meso-Rex bypasses. The first was a 7-year-old
boy seen 5 years after surgery. Imaging demonstrated a patent
bypass transporting 21% of systemic circulation, reassuring
for continued adequacy of function (Fig. 3). Another patient
in the cohort, also a 7-year-old boy, underwent MRI 19 months
after surgery due to signs of compromised portal flow, with
thrombocytopenia to 74 K/μL and elevated ammonia at
94 μmol/L. While imaging confirmed bypass patency, only
5% of the systemic circulation was being transported by the
bypass. This compromised forward flow likely contributed to
the formation of varices (Fig. 4). A third patient, a 14-year-old
girl, was found to have a stenosis near the left portal vein
anastomosis (Fig. 5). She underwent angioplasty and follow-
up MR angiography demonstrated improvement in patency as
well as increased blood flow from 10 to 19% of systemic
circulation (Fig. 5).
Regression analysis
Indexed minimum cross-sectional bypass area was signifi-
cantly correlated to blood flow through the bypass, with a
larger area corresponding to higher flow (Spearman
rho=0.469, P=0.018, Fig. 6). In addition, in the 19 patients
Fig. 2 Meso-Rex bypass flow with each bar representing one patient. The
dashed line marks 18.3% of systemic flow, which is the normal calculated
ratio of portal vein (PV) to total systemic blood flow [9]
Pediatr Radiol
Fig. 3 Three-dimensional MR angiography reconstruction in a 7-year-
old boy with meso-Rex bypass placed at the age of 2 years. There is
minimal narrowing of the patent meso-Rex bypass near the left portal
vein anastomosis (arrow). By 2-D phase-contrast MRI, the bypass
transported 21% of the systemic blood flow. These findings were
reassuring of continued adequacy of function
with laboratory data, flow significantly correlated to the plate-
let count with lower flow corresponding to a lower platelet
count (r=0.525, P=0.021, Fig. 7). There was a trend toward
lower WBC count in patients with decreased blood flow, but
the correlation was not statistically significant (r=0.380,
P=0.109).
Discussion
In this study, 2-D PC-MRI successfully quantified blood flow
through the meso-Rex bypass and ascending aorta in 96% of
patients, a promising success rate that suggests future larger-
scale application. Two-dimensional PC-MRI has several ad-
vantages over Doppler US in measuring flow. Obtaining
views for accurate flow measurement is less technically chal-
lenging with 2-D PC-MRI than with Doppler US, especially
in tortuous bypasses. In addition, MRI avoids the limi-
tations of bowel gas artifact and technologist variability
that can impact US studies. Furthermore, MR angiogra-
phy provides 3-D visualization of the bypass that can be
valuable in assessing intervention feasibility. Inclusion
of phase-contrast imaging adds little time to MR exams;
on average, measurement of ascending aortic and bypass
flow requires less than 2 min each.
By quantifying meso-Rex bypass and ascending aortic
flow volumes in the same exam, flow through the meso-Rex
bypass can be quantified relative to total cardiac output. This
provides a means of “normalizing” flow volumes to the pa-
tient’s own blood volume. The fraction of systemic circulation
Fig. 4 Three-dimensional MR angiography reconstruction in a 7-year-
old boy presenting 19 months after meso-Rex bypass surgery with
clinical signs of compromised portal flow. MR angiography
demonstrates a patent meso-Rex bypass (short arrow) transporting 5%
of the systemic blood flow. A dominant gastric varix (long arrow) was
visualized originating from the portal vein and leading to a network of
varices, likely secondary to decreased forward flow through the bypass
transported through the meso-Rex bypass is important in
assessing bypass function. Flow through a well-functioning
meso-Rex bypass should be the equivalent of flow within a
normal portal vein. Based on reported values for blood flow in
healthy children, the portal vein transports 18.3% of systemic
blood flow [9]. Compromised portal venous flow leads to
complications such as portal hypertension and hepatic
dysfunction, and restoring adequate flow to the liver
ameliorates these complications. For example, thrombo-
cytopenia in patients with portal vein stenosis or cirrho-
sis improves following treatment with angioplasty or
liver transplant, respectively [10, 11]. Similar improve-
ment is seen after endovascular correction of meso-Rex
bypass stenosis [6]. However, the threshold to intervene
can be unclear, especially in patients with comorbidities
or history of recurrent stenosis. Further characterizing
the relationship between bypass blood flow and clinical
complications may clarify the need for intervention.
Following placement of a meso-Rex bypass, routine
follow-up includes physical examination and a complete
blood count as well as serial Doppler US studies, typically
performed at 1, 3, 6 and 12 months after surgery [6]. In
addition, MRI is often routinely performed 1 year after
surgery as well as 5 years after surgery, at which point
successful cases are transitioned to less frequent follow-
up. Patients are also referred for MRI if there are US

Fig. 5 A 14-year-old girl imaged
9 months after surgery was noted
to have a stenosis of the meso-
Rex bypass (a) near the left portal
vein anastomosis (arrow). Two-
dimensional PC-MRI quantified
the meso-Rex bypass transporting
10% of the systemic blood flow. b
The patient subsequently
underwent angioplasty and
follow-up imaging demonstrates
improvement of patency (arrow)
and increased blood flow to 19%
findings suggestive of stenosis and/or symptoms of portal hy-
pertension. Greater than 50% bypass narrowing was present in
18 of 25 patients, with 8 of these patients demonstrating >80%
bypass narrowing. This rate of stenosis was much higher than
the incidence of bypass stenosis in all meso-Rex patients,
which is reported to be 10–17% [1, 6]. At our institution,
US is preferred for routine bypass surveillance and many of
the patients in our cohort underwent MRI to assess complica-
tions initially suspected on US imaging. This composition of
our cohort was reflected in phase-contrast imaging, with 80%
of the cohort calculated to transport less blood flow through
the meso-Rex bypass than through a normal portal vein.
Clinical data in the cohort mirrored phase-contrast findings,
with 14 patients displaying clinical thrombocytopenia, 6 with
leukopenia and 9 with elevated blood ammonia at the time of
the MRI study.
Smaller minimum indexed area of the bypass was sig-
nificantly correlated to decreased blood flow, affirming
that stenoses impact flow. However, deciding when to
intervene on stenoses can be difficult in clinical practice.
Clinical complications are multifactorial and mirror those
Fig. 6 A scatterplot shows the relationship between the minimum cross-
sectional meso-Rex bypass area and blood flow by 2-D phase-contrast
MRI
Pediatr Radiol
initially present due to extrahepatic portal vein thrombo-
sis, which may not completely normalize following by-
pass. Furthermore, the degree of stenosis noted on imag-
ing may be disparate from the clinical picture. No objec-
tive guidelines dictate the threshold for intervention and
decisions are based on clinical trends and imaging [3].
At our institution, the decision to intervene is made when
there is radiographic evidence of bypass stenosis as well
as an overall decline in the clinical picture, including
sequelae of hypersplenism such as splenomegaly and
thrombocytopenia. However, we lack definitive guide-
lines and cutoffs to define adequate bypass function
and decisions are made on a case-by-case basis. In our
cohort, decreased blood flow measured by phase-contrast
imaging was significantly correlated to worsening throm-
bocytopenia and trended to lower WBC counts. For this
reason, it may be valuable to consider blood flow as a
biomarker when assessing function of the bypass and
intervention threshold.
The utility of 2-D PC-MRI in clinical care was further
made evident in the consideration of individual patients in
Fig. 7 A scatterplot shows the relationship between the bypass flow by 2-
D phase-contrast MRI and platelet count
Pediatr Radiol
the cohort. Imaging can be valuable to track long-term
function of the meso-Rex bypass and may, in turn, help
characterize predictors of positive outcomes. It can clarify
the etiology of bypass failure and, as discussed above,
play a role in optimizing the timing of interventions for
bypass stenoses. Future research avenues should aim to
incorporate imaging and clinical data into concrete clini-
cal decision-making to optimize intervention timing for
meso-Rex bypass stenosis. In addition, characterizing pre-
dictors of bypass stenosis could help inform initial surgi-
cal management of portal vein thrombosis.
Study limitations include the small number of patients un-
dergoing MRI to evaluate meso-Rex bypasses and the resul-
tant selection bias of patients with clinical suspicion of a com-
plication. Understanding the physiological correlation be-
tween diameter and blood flow could be strengthened by in-
cluding a larger number of patients, especially those with a
low concern for complications. In addition, larger cohorts are
needed to determine optimal flow cutoff for intervention.
Additional avenues for future research include correlation of
MRI data to US data to further characterize bypass stenoses as
well as tracking long-term outcomes in children with meso-
Rex bypasses.
Conclusion
This study demonstrates the ability of 2-D PC-MRI to
quantify blood flow through the meso-Rex bypass relative
to systemic blood flow. Furthermore, bypass flow corre-
lated significantly to the narrowest bypass diameter and
platelet count, suggesting that meso-Rex flow may be a
valuable parameter to assess meso-Rex bypass integrity
and to aid in timing interventions related to meso-Rex
bypass complications.
Acknowledgements A special thanks to 3-D analyst Brian Reilly from
Ann & Robert H. Lurie Children’s Hospital of Chicago for his contribu-
tion of 3-D MR angiography reconstructions.
Compliance with ethical standards
Conflicts of interest None
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