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1
Department of Radiology, Abdominal Imaging Section, Beth Israel Deaconess
Medical Center and Harvard Medical School, 330 Brookline Ave., Boston, MA
02215.
2
Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
02215.
3
Present address: Institute of Liver Transplantation, Lahey Clinic Medical
Center, 41 Mall Rd., Burlington, MA 01805.
Received May 8, 2000;
accepted after revision June 21, 2000.
Presented at the annual meeting of the American Roentgen Ray Society,
Washington, DC, 2000.
Abstract
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SUBJECTS AND METHODS. Forty consecutive potential donors were included in the study. There were 26 men and 14 women, (age range, 18-57 years; mean, 37 years) We performed CT using a multidetector scanner, after IV injection of 180 mL of contrast material at 5 mL/sec. Arterial phase images were acquired at 18 sec (collimation, 1.25 mm; table speed, 7.5) and portal phase images, at 60 sec (collimation, 2.5 mm; table speed, 15). Postprocessing was performed on a commercially available workstation. CT data included dual-energy assessment of liver parenchyma for fatty infiltration; depiction of arterial, portal venous, and hepatic venous anatomy and identification of important vascular variants; and determination of total and lobar liver volume.
RESULTS. Of the 40 potential liver donors evaluated, 15 patients (37.5%) were excluded on the basis of CT findings, with most exclusions a result of portal vein anomalies (n = 8). Fatty infiltration resulted in four exclusions (10%), and small liver volume resulted in three exclusions (7.5%).
CONCLUSION. Multidetector multiphase CT provided comprehensive parenchymal, vascular, and volumetric preoperative evaluation of potential donors undergoing living adult right lobe liver transplantation. This information had a major impact on patient selection because it was used to stratify patients. It allowed the surgeons to plan their surgical approach, and this planning may reduce postoperative complications.
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Because of the complexity of the hepatic resection, preoperative imaging plays an important role in patient selection and surgical planning. The main goal of presurgical imaging is to provide a vascular arterial and venous "road map," which is critical for surgical guidance. In addition, the donor's liver parenchyma must be examined for size, shape (of right and left lobes), incidental lesions, fatty infiltration, or other abnormalities. Knowledge of total and segmental liver volume is equally important to avoid donor-recipient volume mismatch, which may cause graft failure [6]. In potential donors, sufficient left lobe liver volume must be maintained to permit metabolic function during regeneration. Also, the resected right lobe should be large enough to meet the recipient's metabolic demand.
Multidetector CT is a technologic advance that permits high-speed and high-resolution helical imaging of the entire liver volume during a single breath-hold. Rapid helical data acquisition has resulted in increased body coverage, decreased motion artifact, better use of contrast bolus, and multiphase organ scanning that allows accurate vascular mapping. The combination of fast helical scanning and image processing in three-dimensional (3D) and multiplanar reconstructions has resulted in dr1amatic improvement of image quality and the ability to depict fine anatomic vascular detail.
Prior work has described optimization of multidetector multiphase CT in preoperative liver donor examination [7]. We describe our recent experience with the complete preoperative donor examination including the following: assessment of liver parenchyma for fatty infiltration; depiction of arterial, portal venous and hepatic venous anatomy and identification of important vascular variants; accurate measurement of total and segmental liver volume; and definition of a curved virtual hepatectomy plane that provides volumes to satisfy the metabolic demands of both donors and recipients.
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CT Protocol
CT was performed with a LightSpeed scanner (General Electric Medical
Systems, Milwaukee, WI) with interleaved multidetector capability, described
in a prior study [7]. To assess
fatty infiltration, two axial (5-mm collimation) images were acquired at
different kilovoltage settings (80 and 140 kVp) at a fixed level along the mid
right lobe of the liver [8].
Multiphase scanning was then performed after IV injection of 180 mL of
ioversol 68% (Optiray; Mallinckrodt, St. Louis, MO) at a rate of 5 mL/sec.
Arterial dominant phase images were acquired at 18 sec (collimation, 1.25 mm;
table speed, 7.5; kVp, 120; mA, 240-280). Images were obtained from a level 2
cm below the dome of the diaphragm to 2 cm below the origin of the superior
mesenteric artery. Portal dominant phase images were acquired at 60 sec
(collimation, 2.5 mm; table speed, 15; kVp, 120; mA, 240-280). Images were
obtained through the entire liver.
Image Processing
Axial images were reconstructed with a standard algorithm, and
postprocessing was performed on a commercially available workstation
(Advantage Windows 3.1, General Electric Medical Systems). Major vessels were
visualized with volume rendering and shaded-surface display. Three-dimensional
models of the vascular structures were also generated, and visual enhancement
was achieved by artificial color assignment of the vascular models.
Total liver volume was measured by hand tracing the liver outline on the axial portal venous phase images. We then generated a 3D model of the liver with the "paintbrush" method, using the commercially available software. Using the liver and hepatic vein models for guidance, we defined a curved plane in a manner simulating the anticipated surgical incision to the right of the middle hepatic vein in the superior portion of the liver and avoided major vessels traversing the plane between the right and left lobes. This relatively avascular plane traverses the gallbladder fossa and extends inferiorly to the portal bifurcation.
Image Interpretation
The technique was considered technically adequate if there was
visualization of the vascular structures in all phases sufficient to permit
image reconstruction. Arterial phase images should allow complete
opacification of tertiary order branches, particularly the artery to segment
IV. Portal venous phase images should allow complete opacification of the
small vessels (less than 3 mm), particularly accessory inferior right hepatic
veins. All axial images were evaluated to assess hepatic morphology for
evidence of fatty infiltration and the presence of incidental liver lesions.
The resulting two-dimensional reformations and 3D models of the hepatic
arteries, hepatic veins, and portal veins were also evaluated. In all cases,
reconstructed models were carefully reviewed and compared with the axial
source images to ensure that no important vascular structures were
inadvertently deleted from the vascular model. Electronic calipers were used
to provide distances between important vascular structures. If the artery to
segment IV arose from the right hepatic artery, the distance between its
origin and the origin of the right hepatic artery was measured. If an
accessory inferior right hepatic vein was identified, its size and the
distance between it and the right hepatic vein were measured in the coronal
plane.
Each study was evaluated for possible anatomic exclusion criteria. These criteria included variants in the portal venous anatomy that preclude surgery, fatty infiltration of the liver, and insufficient liver volume both to leave behind in the healthy donor and to sustain metabolic function in the recipient. In 12 patients with no anatomic exclusions, preoperative conventional celiac and superior mesenteric angiograms were obtained in the arterial and portal venous phases. The objectives of obtaining an angiogram were to define arterial and venous anatomy, to identify important vascular variants, to identify the origin and course of the artery to segment IV, and to identify unexpected vascular abnormalities of the liver. Angiograms were interpreted independently, with reviewers not made aware of the CT findings. Correlation between findings on CT and on angiography was performed by consensus of all authors, including the radiology and surgical transplantation teams.
Image Display
All images, including two-dimensional reformations and 3D reconstructed
models, were sent to a picture archiving and communication system (PACS)
workstation, which permits interactive analysis.
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Of the 40 patients evaluated, only 23 (57.5%) had no anatomic exclusions. To date, 12 surgeries have been performed, and five are pending. In the remaining six patients, surgery was not performed because the recipients had contraindications to liver transplantation, including the presence of hepatoma or portal vein thrombosis. Fifteen patients (37.5%) were excluded from surgery because of anatomic exclusions based on CT findings. Portal vein variants that precluded surgery resulted in eight exclusions, fatty infiltration resulted in four exclusions, and insufficient liver volume resulted in three exclusions. Two potential donors deferred surgery.
We evaluated each potential donor for evidence of fatty infiltration by taking CT attenuation measurements from the center of the right and left lobes in the two images obtained at different kilovoltage settings [8]. Of all 40 patients examined, four (10%) had evidence of mild fatty infiltration and were excluded from surgery. These patients had liver attenuation measuring below 58-60 H at 80 kVp that dropped by 6-8 H at 140 kVp.
Incidental liver lesions included simple cysts or hemangiomas (n = 8). One patient had incidental polycystic liver disease and was excluded from surgery. Incidental extrahepatic lesions included renal cysts or stones (n = 5), gallstones (n = 2), and an adrenal adenoma (n = 1). These lesions had no impact on patient selection.
The hepatic arteries, identified to their tertiary branches in all patients, were best displayed in the oblique coronal plane along the porta hepatis. Table 1 shows the different arterial vascular variants. None of these variants were considered an exclusion from surgery. Tertiary order branches, as small as 1 mm in diameter, were well visualized in both lobes of the liver in all patients. The dominant artery supplying segment IV was identified in 39 of the 40 patients. It arose from the right hepatic artery in 25 patients (62.5%). In one patient the artery to segment IV could not be visualized. A celiac angiogram was not obtained in this patient because the recipient had a hepatoma, and the donor was excluded from surgery. CT findings were compared with those seen on angiography performed preoperatively (Fig. 1A,1B). Of the 12 angiographic examinations performed, the branching pattern of the right and left hepatic artery seen on CT was confirmed on angiography. CT correctly identified and angiography confirmed the dominant artery supplying segment IV in all 12 patients. Angiography showed no additional unsuspected vascular findings missed on CT.
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Hepatic veins were displayed in the axial and coronal planes. The axial plane revealed best the early branching and early bifurcation of the middle hepatic vein, which may alter the plane for right hepatectomy (Fig. 2A,2B). Three (7.5%) of the 40 patients had an early bifurcation. An accessory inferior right hepatic vein (Fig. 3A,3B) was seen in 21 patients (52.5%), and two or more veins were seen in six patients (15%).
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Portal venous anatomy was best displayed in the coronal plane and had excellent correlation to the 12 preoperative venograms obtained during the venous phase of celiac angiography (Fig. 4A,4B). Variations in portal vein anatomy that may affect the selection criteria for potential donors were well displayed. These variations included a separate origin of the posterior right portal vein from the main portal vein (Fig. 5). The right portal vein was absent in eight patients (20%), six (15%) of whom had a trifurcation and one (2.5%) of whom had a quadrifurcation. In one patient (2.5%), the right posterior portal vein arose from the main portal vein.
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Measurement of liver volume was performed by hand tracing the edge of the liver on the axial images of the portal venous phase of enhancement to isolate the liver from the surrounding soft tissues of similar attenuation. Three-dimensional models were generated, and the resultant liver volume was automatically calculated. Total liver volume ranged from 1336 to 2505 mL (mean, 1791 mL). Models for the hepatic veins and for the liver were superimposed (Fig. 6) and were used to generate the hepatectomy plane between the right and left lobes (Fig. 7).
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The use of multidetector technology has dramatically increased the speed of data acquisition, resulting in decreased motion artifact and better contrast-bolus use. These factors have resulted in consistent depiction of two-dimensional slab reformations and 3D models of small vessels. The most critical aspect of imaging potential liver donors is the accurate depiction of the origin and course of the artery to segment IV. Unlike currently available conventional helical scanners, multidetector CT results in 1.25-mm resolution. If the acquisition parameters and timing of the contrast bolus are optimized, this resolution allows consistent depiction of this tiny artery (Fig. 1A,1B), shown in our comparison with conventional angiographic findings. The anatomic details are exquisitely clear in all planes without the multitude of traditional discontinuities that arise from nonhelical and even unidetector technology. The precise relationship between vascular anatomy and liver parenchyma is clearly defined. The arteries, veins, and segments are displayed in an anatomic orientation that can be easily evaluated by the surgeon. Branching points to relevant arteries and veins and their relation to the proposed site of incision can be viewed with minor interruption in adjacent slabs or with no interruption in 3D models. This technique is useful in delineating vascular anatomy of the liver in a highly visual fashion by assigning a specific color to each vessel. This delineation is of increasing importance, especially with the advances in hepatic resection techniques.
In all 40 patients multidetector CT provided adequate opacification of the vascular structures. This technical success may be the result, in part, of the high bolus-injection rate of 5 mL/sec. All arterial phase images were acquired at 18 sec and portal venous phase images, at 60 sec after contrast injection. This timing has worked consistently well for all our patients, and we have not required a test injection that some institutions use [9].
Fatty infiltration of the liver is associated with a variety of conditions including diabetes mellitus, obesity, and alcohol or other substance abuse. Detection of fatty infiltration of the liver preoperatively is critical because it may be associated with impaired function and possible failure of the implanted graft [10]. CT is sensitive in detecting fatty infiltration. of the liver [11, 12], whereas dual-energy CT may be used to quantify the degree of fatty infiltration [8]. When scanned with 80 and 140 kVp, fatty livers exhibit a drop of attenuation compared with that of normal livers. Mild fatty infiltration (< 25%) is associated with a drop of 6 H. Moderate (50%) and severe (>75%) fatty infiltration is associated with a drop of 11 and 20 H, respectively. In our study we were careful to measure homogeneous regions of the liver, and paired measurements were identical in size and location of measurements. Because fatty infiltration may be focal, two measurements were taken in the right and left lobes. To avoid erroneous measurements related to volume averaging, density measurements did not include the periphery of the liver. Four patients (10%) had fatty infiltration and were excluded from surgery.
The complex vascular anatomy of the liver and the high incidence of normal vascular variants reinforce the need for accurate pre-operative vascular imaging. Variations in the hepatic arterial anatomy occur in approximately 45% of patients [13]. Replacing angiography in many institutions, CT angiography is a fast and minimally invasive procedure for delineating the hepatic arterial anatomy [14, 15]. Variations in hepatic venous anatomy are also common and have been reported in approximately 30% of patients [16]. These variations have been revealed on sonography [17] and on CT during arterial portography [18]. Variations in the portal venous anatomy occur in 20% of patients and have also been revealed on sonography [19, 20] and on CT during arterial portography [18]. More recently, helical CT angiography has been widely used for various abdominal applications [14, 15, 21,22,23,24,25,26]. However, the technique with conventional helical scans was limited to major vessels and coverage was not uniform.
In the current study, we identified important vascular variants that have impacted patient selection and surgical planning, such as portal vein trifurcation. Arterial vascular variants occurred in 30% of patients, compared with 45% of patients reported by Michels [13]. CT may not depict clinically insignificant accessory arteries included in Michels' classification. None of the arterial variants were considered a contraindication to donor hepatectomy. However, providing the surgeon with a preoperative intra- and extrahepatic vascular road map was considered essential to the technical success of the procedure. Because segment IV is spared during surgery, identifying the artery supplying this segment is critical. If the artery to segment IV arises from the right hepatic artery, the distance between its origin and the origin of the right hepatic artery is important because it provides reference for the surgeon during graft harvesting. In one patient the artery to segment IV could not be identified by multi-detector CT. Because no conventional angiogram was obtained in that patient, it is not known whether the artery was nondominant or not optimally depicted. Angiography performed in 12 patients showed no arterial or venous variants missed on CT. Therefore, it is suggested that angiography may be performed only if the artery to segment IV is not identified or if there were technical difficulties in obtaining an arterial phase scan.
Variations in branching and confluence of the middle hepatic vein are important because they may affect the hepatectomy plane, which is usually located to the right of the middle hepatic vein along the gallbladder fossa. Early confluence to the right was present in three patients (7.5%). This may result in a small graft size, which may not be sufficient to maintain the recipient's metabolic function. Alternatively, accurate depiction of this vein allows the surgeon to localize, transect, and reconstruct the vein to the right hepatic vein at the time of surgery. Special attention was paid to the presence of an accessory inferior right hepatic vein, and, if present, its distance from the right hepatic vein was measured in the coronal plane. If the distance between the right hepatic vein and the accessory inferior right hepatic vein is more than 4 cm, it may be difficult to surgically implant both veins with a single partially occluding clamp on the recipient's inferior vena cava. Accessory right inferior hepatic veins were detected in 27 patients (67.5%). When present, these veins should be preserved to reduce the risk of graft malfunction, especially if they are larger than 3 mm in maximum diameter. Up to three accessory hepatic veins were identified, and these are important because their presence can significantly increase operative time.
Certain variations in portal venous anatomy are considered contraindications to surgery, including absence of the right portal vein trunk, which was seen in eight patients (20%). When a right hepatectomy is performed, it results in more than one portal vein anastomosis being required, with an increased risk of postoperative portal vein thrombosis in donors.
When the donor is being evaluated, lobar and total liver volumes must be known before transplantation. It has been estimated that the minimum graft volume required to provide sufficient functional hepatocytes to the recipient is approximately 40% of the standard liver mass [10], calculated with the body surface area [27]. Another approximation is 1% of the recipient's body weight [28]. Small-for-size grafts are prone to dysfunction, not only because of inadequate functional hepatic mass but also because the graft may sustain injury related to the excessive portal perfusion [6]. Minimizing morbidity to the donor is also a major concern because the donor is left with only the left lobe of the liver. Therefore, the critical volume and the quality of the remnant liver are important considerations in patient selection. Liver-remnant volume of 30-40% of the total liver volume is sufficient for the donor to survive, provided that the liver parenchyma is normal with no evidence of fatty infiltration [10].
Without the use of biliary contrast agents, conventional and multidetector CT is not useful for depicting nondilated intrahepatic bile ducts. Although contrast agents have been developed to opacify the biliary tree [29,30,31,32,33,34,35], their use is associated with increased risk of adverse reactions due, in part, to the iodine content. If preoperative knowledge of the biliary anatomy is considered necessary by transplantation surgeons, an intraoperative cholangiogram could be obtained. MR imaging provides an alternative technique that could reveal both the hepatic vasculature and the biliary tree.
Sonography is useful in identifying arterial and venous anatomy and vascular variants [17, 19, 20]. We could not reliably identify the artery to segment IV using sonography, and our surgeons prefer to have CT scans readily available in the operating room. Sonography is also useful for evaluating liver parenchyma for features suggestive of fatty infiltration and for identifying incidental liver lesions. An essential role is played during surgery by intraoperative sonography, used to guide the surgical incision. However, in our experience sonography has not been useful for measuring total and segmental liver volumes, data that are essential during preoperative planning.
In conclusion, multidetector multiphase CT provides comprehensive and accurate preoperative examination of potential donors undergoing living adult right lobe liver transplantation. This information has a major impact on patient selection and allows better planning of a safer surgical approach, which can be expected to reduce postoperative complications.
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