Doppler Sonography to Diagnose Venous Congestion in a Modified Right Lobe Graft After Living Donor Liver Transplantation
So Yeon Kim1,
Kyoung Won Kim1,
Seung Soo Lee1,
Gi-Won Song2,
Shin Hwang2,
Pyo Nyun Kim1 and
Sung Gyu Lee2
1 Department of Radiology and Research Institute of Radiology, Asan Medical
Center, University of Ulsan College of Medicine, 388-1, Pungnap-2 dong,
Songpa-ku, Seoul 138-736, Korea.
2 Department of Surgery, Asan Medical Center, University of Ulsan College of
Medicine, Seoul, Korea.
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Fig. 1A —31-year-old man who underwent living donor liver
transplantation using modified right lobe graft. Volume-rendered images with
oblique axial (A) and coronal (B) projections parallel to course
of middle hepatic vein (MHV) show two tributaries of MHV in paramedian sector
of segments V (V5) and VIII (V8).
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Fig. 1B —31-year-old man who underwent living donor liver
transplantation using modified right lobe graft. Volume-rendered images with
oblique axial (A) and coronal (B) projections parallel to course
of middle hepatic vein (MHV) show two tributaries of MHV in paramedian sector
of segments V (V5) and VIII (V8).
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Fig. 1C —31-year-old man who underwent living donor liver
transplantation using modified right lobe graft. Intraoperative photograph
shows that both tributaries (V5, V8) were anastomosed to inferior vena cava
using interposition vein graft (arrows). Small area of bluish
discoloration (arrowheads), suggestive of congestion, is also noted
in paramedian sector of graft despite outflow reconstruction.
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Fig. 2A —51-year-old man in hepatic venous congestion group after
undergoing living donor liver transplantation using modified right lobe graft.
Gray-scale sonography image on postoperative day 1 shows hyperechogenicity in
paramedian sector of segment VIII relative to right posterior hepatic segment.
Straight border of involved hepatic parenchyma (arrowheads) abuts
anterior segmental branch of portal vein (arrow).
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Fig. 2B —51-year-old man in hepatic venous congestion group after
undergoing living donor liver transplantation using modified right lobe graft.
Color Doppler sonography image on postoperative day 1 shows no
Doppler-detectable blood flow of middle hepatic vein (MHV) tributary
(arrowheads) in segment VIII with velocity scale adjusted down to
± 8.6 cm/s.
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Fig. 2C —51-year-old man in hepatic venous congestion group after
undergoing living donor liver transplantation using modified right lobe graft.
Axial contrast-enhanced CT scan obtained during portal venous phase on
postoperative day 1 shows marked low attenuation in approximately half of
segment VIII corresponding to draining territory of MHV. Straight border of
involved hepatic parenchyma (arrowheads) abuts anterior segmental
branch of portal vein (arrow). Vertex of wedge-shaped,
low-attenuation area points to inferior vena cava. Also noted is that there is
no opacification of MHV tributary in that area.
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Fig. 2D —51-year-old man in hepatic venous congestion group after
undergoing living donor liver transplantation using modified right lobe graft.
Venogram obtained on postoperative day 1 shows focal stenosis at anastomosis
site (arrowhead) between MHV tributary in segment VIII and
interposition vein graft, with pressure gradient of 13 mm Hg.
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Fig. 3A —57-year-old man in non–hepatic venous congestion group
based on CT. Patient underwent living donor liver transplantation using
modified right lobe graft. Color Doppler sonography image on postoperative day
1 shows no Doppler-detectable blood flow of middle hepatic vein (MHV)
tributary (arrowheads) in segment VIII next to right hepatic vein
(RHV) (arrow), with velocity scale adjusted down to ± 8.6
cm/s. On Doppler sonography, hepatic venous congestion was diagnosed.
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Fig. 3B —57-year-old man in non–hepatic venous congestion group
based on CT. Patient underwent living donor liver transplantation using
modified right lobe graft. Contrary to color Doppler sonography findings,
axial contrast-enhanced CT scan obtained during portal venous phase on
postoperative day 7 shows that there is no definite hepatic venous congestion,
with opacified MHV tributary (arrowheads) in segment VIII next to
RHV. Patient belonged to non–hepatic venous congestion group based on CT
findings. This is example of false-positive case of Doppler sonography.
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Fig. 4A —47-year-old man in non–hepatic venous congestion group
after undergoing living donor liver transplantation using modified right lobe
graft. Color Doppler sonography image on postoperative day 1 shows reversed
flow of middle hepatic vein (MHV) tributary in segment V
(arrowheads), which is seen as red instead of blue.
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Fig. 4B —47-year-old man in non–hepatic venous congestion group
after undergoing living donor liver transplantation using modified right lobe
graft. Axial contrast-enhanced CT scan obtained during portal venous phase on
postoperative day 7 shows that there is no definite hepatic venous congestion.
MHV tributary (arrow) in that area is partially opacified but does
not extend to resection margin.
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Fig. 5A —22-year-old woman in hepatic venous congestion group after
undergoing living donor liver transplantation using modified right lobe graft.
Color Doppler sonography image on postoperative day 1 shows no
Doppler-detectable blood flow in middle hepatic vein (MHV) tributary
(arrowheads) in segment V, with velocity scale adjusted down to
± 8.6 cm/s.
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Fig. 5B —22-year-old woman in hepatic venous congestion group after
undergoing living donor liver transplantation using modified right lobe graft.
Color Doppler sonography image on postoperative day 1 shows hepatofugal flow
of corresponding segmental portal vein (arrows), seen as blue instead
of red.
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Fig. 5C —22-year-old woman in hepatic venous congestion group after
undergoing living donor liver transplantation using modified right lobe graft.
Axial contrast-enhanced CT scan obtained during portal venous phase on
postoperative day 2 shows area of low attenuation in segment V that
corresponds to draining territory of MHV. Straight border of involved hepatic
parenchyma (arrowheads) abuts anterior segmental branch of portal
vein (long arrow). Vertex of wedge-shaped, low-attenuation area
points to inferior vena cava. Also noted is that there is no opacification of
MHV tributary (short arrow) in that area.
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