LIVER TRANSPLANT AND

WHAT RADIOLOGISTS
SHOULD KNOW
Liver Transplant Basics
◦ 3 sites of potential complications:
◦ Parenchyma
◦ Blood vessels
◦ Biliary ducts

◦ Common images:
◦ US
◦ CT
◦ HIDA
◦ MRCP
Anastomotic Sites
Examples of What You Should Be Looking For
Even More Examples of What You Should Be
Looking For
Complications
Hepatic Artery Thrombosis
◦ Start off with Doppler US.
◦ If you see a flow, great, you’re done!
◦ If you DON’T see a flow, POSSIBLY thrombosis.
◦ Order either CT angiography or MR angiography
◦ CT may show low attenuation foci in the parenchyma representing infarction
Example below
Examples of Images looking at Hepatic Artery
for Thrombosis
More pics of what happens with Hepatic Artery
Thrombosis
Hepatic Artery Stenosis
◦ Doppler US findings:
◦ Low resistive index
◦ Long systolic acceleration time
◦ Tardus-Parvus waveform distal to the stenosis
◦ INCREASED peak systolic velocity at the site of stenosis (>200)

◦ If findings significant, confirm with CT angiography, NOT MR angiography

Examples of Hepatic Artery Pseudoaneurysm
Portal Vein Stenosis
◦ Peak anastomotic velocity > 125 OR anastomic:preanastomotic velocity 3:1
◦ IF narrowing is due to size discrepancy between donor and recipient portal
veins, do hepatic portography!
◦ If pressure gradient >5 mm, it’s stenosis!
Portal Vein Stenosis
Portal Vein Thrombosis
IVC/Hepatic Vein Stenosis and Thrombosis
◦ IVC Stenosis/Thrombus:
◦ US: 3-4X higher than normal velocity! Also see distended hepatic veins, and loss of
phasicity
◦ CT venography and MR venography: Filling defects

◦ Hepatic Vein Stenosis/Thrombus

◦ LOW resistive index and monophasic waveforms
Hepatic Vein Waveforms
Hepatic Vein Waveforms WITH THROMBUS
And Yet Even More Pics
And Yet Even More Pics
Biliary Complications
◦ Can range from bile duct obstruction, stenosis, stricture choledocholithiasis,
bile leak, biloma, necrosis.
◦ If a pt has T tube in place, ORDER T-TUBE CHOLANGIOGRAPHY OVER
MRCP.
◦ BETTER ANATOMY AND FUNCTIONAL ANALYSIS THAN MRCP.
◦ Otherwise, if no T tube, MRCP
Bile Duct Obstruction
◦ Choledocholithiasis
◦ MRCP: Well-define margins of the filling defects unlike the castlike appearance of
sludge
◦ BE CAREFUL, PNEUMOBILIA MAY APPEAR SIMILAR!!!
◦ So then how to differentiate between the two: dependent vs nondependent positions
◦ Bile Duct Stricture
◦ Either at the site of anastomosis, or elsewhere
◦ Sometimes, CT may not show dilatation even with stricture present.
◦ If you STILL suspect stricture, MRCP, ERCP, or transhepatic cholangioraphy
Pictures of Bile Duct Obstruction
Even More Pics of Bile Duct Obstruction
Bile Duct Leakages
◦ Usually at one of two locations: biliary anastomotic sites OR T-tube exit sites
◦ Can be either extravasation into the peritoneal cavity, or biloma

◦ Best nondiagnostic test to check for bile leak: cholescintigraphy

◦ Collection that does NOT conform to the expected shape of a bowel is a leak.
Bile Duct Leakages
In Summary
◦ Knowing the anatomy and the potential complications for liver transplant can
help you navigate through the appropriate studies.
◦ Knowledge of the potential sites of complication can help you better predict
and even prevent further complications.