Imaging of Vascular Complications

8/6/2019 Imaging of Vascular Complications

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Im ag ing o f V ascu la r C om p lica tion sA fte r H epa tic T ransp lan ta tio n

Kenne th D a len1Deborah L . D ay1

Nancy L . A sche rD av id W . H un te r1W illia rn M . Thom pson1

W ilfrido R . C as taneda -Zun iga1Jan is G is se l Le tou rneau1

R ec eiv ed D ece mb er 2 , 19 87 ; a cc ep ted a fte r re -v is io n Jan ua ry 27 , 19 88 .

Th is w ork w as sup po rte d by a re se a rch g ra n t #SM F-5 66 -87 from the M in ne so ta M ed ica l F ou nda -t ion , M in ne apo lis , M N, 5 545 5 .

I D epartm en t o f R ad io log y , U n iv e rs ity o f M in ne -sets Hosp ita l an d C lin ic , Bo x 29 2 UMHC , 42 0 D e l-awa re S t. S E ., M inne apo lis , M N 55455 . Ad dressr ep ri nt r eq u es ts t o J . G . L et ou me au .

2 D epartm en t o f Su rge ry , U n iv e rs ity o f M in ne -s o ta H osp ita l an d C lin ic , M in ne apo lis , M N 55455 .P resen t ad d re ss : D epa rtm en t o f S urg e ry , U nive rs ityo f C a lifo rn ia , Sa n F ran c is co , CA 94143 .AJ R 150:1285-1290, Jun e 19880 36 1 - 80 3X /8 8/ 1 5 06 -1 28 5 Am eric an R oen tgen R ay So c ie ty

Vascu la r com plica tions a fte r hepa tic transp lan ta tion can com prom ise g ra ft and pa tien tsu rv iva l. A ng iog raphy de fines the need fo r re vascu la riza tio n o r re tran sp lan ta tio n , bu tth e va lue o f non in vas iv e im ag ing in th is se thng is no t c lear. T o assess the re la tive m e rito f n on in va siv e im a gin g te chn iques (sonog raphy , sc in tig raphy , C T , and MR ), w e re tro -spect ively re v iewed 19 m a jo r vascu la r com p lic a tions tha t occu r r ed in 1 5 o f 98 hepa ticrec ip ien ts o ve r a 3 /2 -y ea r p er io d . Po rta l v enous th rom bos is w as seen in se ven p atien ts ,dono r ao rt ic o r h epat ic a rte ria l th rom bos is in seven , and in fe rio r v ena cava l th rom bos isin five . S onog raphy p ro v id ed th e In itia l d ia gnos is o f por tal venous th rom bos is in th ree ,a rte ria l c om p ro m is e in five , and cava l obs tru c tion in fou r. C T w as th e f i rs t d iagnos t icexam ina tion to ident i ty po rta l oc c lu sio n in tw o , dono r ao rtlc th rom bos is in one , andin fe rio r vena cava l th rom bos is in one . S c in tig raphy and MR im ag ing p ro v id ed com p le -m en ta ry da ta .

B oth s on og ra ph y and C T ar e use fu l in the eva lu a tio n o f v ascu la r com plic a tio n s th a toccu r a fte r h epatic tra n sp lan ta tio n ; how eve r, n e ith e r is su ffic ie n tly sens itiv e to obv ia teang io g ra ph ic as se ssm en t

Hepa tic transp lan ta tion has becom e an accep ted therapeu tic op tion fo r m anypa tien ts w ith irre ve rs ib le liv e r fa ilu re [1 -3 ]. H oweve r, life - th rea ten ing com plic a tionscan a rise in hepa tic re c ip ien ts , the m ost om inous be ing vascu la r th rom boses , asthey frequen tly requ ire im m ed ia te in te rven tion . C lin ica l s igns o f a rte ria l th rom bos isin c lude feve r, sep ticem ia , e le va ted se rum live r enzym es, and de te r io ra ting coagu -la tion pa ram e te rs [4 , 5 ]. A rte ria l o c c lu s ion can lead to devas ta ting com p lica tions ,such as b ilia ry s tr ic tu re and leaks and pa renchym a l ischem ia o r nec ros is [4 , 6 ].L ikew ise , th rom boses o f the po rta l ve in and in fe rio r vena cava can lead to s ign ifican tp rob lem s , in c lud ing feve r, s ep ticem ia , im pa ired hepa tic func tion , b leed ing in theuppe r gas tro in te s tina l tra c t, a s c ite s , and pe riphe ra l edem a [7 ].

T he d iagnos is o f vascu la r th rom bos is a fte r hepa tic transp lan ta tion has re lied onang iog raphy [8 , 9 ]. The ro le o f non in vas ive im ag ing in th is se tting has no t beenex tens ive ly eva lua ted [8 , 1 0]. W e rev iew ed ou r expe rience w ith vascu la r com p li-ca tions in hepa tic re c ip ien ts to de te rm ine the va lue o f non invas ive im ag ing in thesepat ien ts .

M a te ria ls and M ethodsBe tw een Ap ril 1 , 1984 , and Sep tem be r 1 5 , 1987 , 98 o rtho top ic liv e r transp lan ts we re

pe rfo rm ed in 94 pa tien ts (41 adu lts , 53 ch ild ren ) a t the Un ive rs ity o f M inneso ta H osp ita ls .The su rg ica l te chn iques [1 1 ] an d im munosupp ress ive reg im ens [1 2 ] used a re desc rib ed inde ta il e lsew he re . N ine teen pos tope ra tive vascu la r com plic a tions w ere se en in 1 5 pa tien ts(Tab le 1 ). Ind ica tions fo r transp lan ta tion in these 1 5 pa tien ts in c luded ex trahepa tic b ilia rya tres ia (s eve n ) , a lp ha -1 -an t itry ps in de fic ienc y (th ree ), W ils on d isea se (on e ), ch ron ic ac t ivehepa titis (one ), p r im ary b ilia ry c irrhos is (one ), p r im ary hepatom a (one ), and sc le ros ing cho lan -g it is (on e ). T he rad iog rap h ic exam ina tio ns (in c lu d in g sc in t ig raph y , so nog ra ph y, CT , M Rim ag ing , and ang iog raphy) and hosp ita l re co rds o f these pa tien ts we re rev iewed re tro spec-t ive ly .


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1286 DA LEN ET AL . AJA: 150, Jun e 1988

Pa tien ts w e re re fe rred fo r rad io log ic eva lua tion w hen vascu la rocc lus ion was su sp ected becau se of p ers is te nt fe ve r, deter io ra t ingl ive r fu nc tio n, a nd /o r abno rm a l coa gu la t ion pa ram ete rs . F rom thet ime o f transp lan ta tion to th e tim e o f in itia l d iagnos is o f vascu la rth rom bos is , a to ta l o f 1 05 exam ina tions w e re pe rfo rm ed (48 sc in ti-g ram s, 33 sonog ram s, 21 C T scans , and th ree ang iog ram s ). H epa -to bilia ry s cin tig ra ph y w as p erfo rm ed w ith ra pid -se qu en ce ; im m ed ia te ;1 0 -, 20 -, 30 -, 40 -, 50 -, and 60 -m m; and , if necessa ry , de la yed im ag ing.Sonography w as pe rfo rm ed as described e lsewhere ; D op ple r d up le xscann ing techn iques we re used in the la tte r ha l f of th e s tu dy p erio d[1 3- i 5 ]. CT scann ing was pe rfo rm ed w ith IV con tra s t m a te ria l b yus ing bo lus and drip - in fu s ion adm in is tra tion if poss ib le . O u r MRtechn iques fo r de fin itio n o f the uppe r abdom ina l vascu la tu re havea lso been repo rted [1 6 , 1 7]. A ng iog raph ic te chn iques in c luded ab -dom ina l ao rtog raphy ; hepa tic , ce lia c , o r m esen te ric a rte riog raphy ;sp lenopo rtog raphy ; in fe r io r venacavog raphy ; wedged hepa tic yen -ograp hy; a nd tra ns he pa tic p or ta l v en og ra ph y.

F ifteen cases o f vascu la r com plic a tions w ere con f i rmed b y d ir ec texam ina tion , inc lud ing a ng iog rap hy (se ve n ), exp lo ra to ry lap a ro tom y(one ), pos tm ortem exam ina tion (fou r) , o r a com b ina tion o f theseexam ina tions (th ree ). F ou r pa tien ts m erited a d iagnos is o f vascu la rth rom bos is w ith non invas ive im ag ing t ec hn iques a lone ; in c lu s ion inth is s e ries requ ired ev idence fo r th rom bos is on a t leas t tw o non in -v as iv e s tu dio s.

ResultsH e p a tic A rte ry /D o n o r A o rta T h ro m b o s is

A rte ria l th rom bos is (hepa tic a rte ry in th ree cases and dono rao rta in fou r) w as obse rved in s ix ch ild ren and one adu lt. A llpa tien ts unde rw en t hepa tob ilia ry d iso fen in sc in tig raphy ,w h ich show ed foca l a reas o f decreased up take in tw o . Th rom -bos is was firs t d iagnosed by sonog raphy in th ree pa tien ts(F ig . 1 ), C T in one (F ig . 2 ), ang iog raphy in one , lapa ro tom y inone , and pos tm o rtem exam ina tion in one (T ab les 2 and 3 ).F iv e cases o f a rte r ia l o cc lu s ion w e re con firm ed by ang iog ra -phy , su rge ry , o r pos tm o rtem exam ina tion . In one pa tien t, C T ,sonog raphy , and M R im ag ing we re be lie ved to be de fin itiv e

and ang iog raphy w as no t pe rfo rm ed . In one ped ia tr ic pa tien t,C T w as fa lse ly nega tiv e fo r th rom bos is , and ang iog raphy wasused to m ake the in itia l d iagnos is w ith in 3 days . F ive ch ild renw ith a rte ria l th rom bos is have d ied ; the m ean in te rva l fromtransp lan ta tion to d iagnos is w as 4 w eeks (range , 1 .5 w eeksto 2 m on ths). T he m ean su rv iva l o f these ch ild ren was 73days (range , 1 0-240 ). O f the tw o pa tien ts su rv iv ing a rte ria lo c c lu s ion , the in te rva l from transp lan ta tion to d iagnos is w asm uch g reate r (51 /2_38 m on ths).

P orta l V ein T h ro m bo s isSeven cases o f po rta l venous th rom bos is w e re iden tifie d

(Tab les 2 and 3 ). R educed uptake /de la yed ex tra c tion onhepa tob ilia ry sc in tig raphy w as seen in th ree pa tien ts . Thed iagnos is o f th rom bos is w as firs t iden tifie d by sonog raphy inth ree pa tien ts (F ig . 3 ), C T in tw o , ang iog raphy in one , andlapa ro tom y in one . S ix o f the seven pa tien ts had ve rific a tiono f th rom bos is by e ither ang iog raphy o r pos tm o rtem exam i-na tion . O ne fa lse -nega tive sonog ram w as iden tified a fte r an -g iog raphy la te r the sam e day show ed po rta l ve in occ lu s ion .T he m ean in te rva l from transp lan ta tion to d iagnos is w as 2 .3w eeks (range , 1 -6 w eeks). Th ree ch ild ren have d ied , w h ileth ree ch ild ren and one adu lt have su rv iv ed .

In fe rio r V e n a C av a l T h ro m bo s isIn fe r io r vena cava l th rom bos is w as seen in fiv e pa tien ts

(Tab les 2 and 3 ); the d iagnos is w as firs t m ade by sonographyin fou r (F ig . 4 ) and by C T in one . S u rg ica l o r pos tm o rtemve rifica tion was ava ilab le in th ree . Hepa tob ilia ry sc in tig raphyshow ed decreased excre tion in a ll fiv e pa tien ts . Th ree pa tien ts(tw o adu lts , one ch ild ) expe rienced cava l th rom bos is w ith in 2days o f transp lan ta tion and dea th w as im m inen t (m ean su r-v iva l, 8 days a fte r transp lan ta tion ; range , 7 -9). T he d iagnos iso f cava l th rom bos is w as m ade la te r in the tw o su rv ivo rs (1

TABLE 1: H epa tlc T ransp lan t V ascu la r Comp l ic a t ions

c:e Transp lant(years )

L oc atio n o f T hro m bo sis Non inva : i v e Diagnos t ic

1 40 D ono r ao rta NM , sonog raphy , CT , M R2 3V2 D onor ao rta , in fe rio r venacavaN M, s on og ra ph y, CT

3 5 H epa tic a rte ry NM4 3 D ono r ao rta NM , sonog raphy , CT5 4 Po rta l v e in , h epa tic a rte ry NM6 71 /2 D on or a orta NM , sonog raphy , CT7 1 3 Po rta l v e in NM , sonog raphy , CT8 1# {189 } Por ta l v e in NM , so nograp hy , CT9 37 In fe r io r vena cava NM , sonog raphy , CT1 0 2 Po rta l v e in , in fe r io r vena cava NM , sonog raphy , C T1 1 # {190 } P o rta l v e in NM , sonog raphy , C T12 1V 2 P orta l v e in , h ep a tic a rte ry NM , so no gra ph y, C T1 3 49 Po rta l v e in NM , sonog raphy , C T14 43 In fe r io r vena c ava NM , sonog raphy , C T1 5 1 V2 In fe rio r ve na cava NM , so no gra ph y

Note -NM = n uc le ar m e da cin e (h e pa to b il ia ry s ci nt ig ra p hy ).


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AJA:150, June 1988 COMPL IC AT IO NS AFTER HEPAT IC TRANSP LANT 1287

F ig . 1 .-c as e 1 2 : 1 /2 -y ea r-o ld g irl w ith seps is an d abnorm al c oagu la t ion p aram ete rs im med ia te ly a fte r tran sp lan ta tion . H epa tic ne cro s is w as susp ec te dclinically.

A, Tran sv ers e dup le x so nogram of live r reve a ls abs en ce o f h ep atic a rte ria l flow and inh om og en eous hepa tic pa renchym a .B , A bdom ina l a o r tog ram show s occ lus ion a t an as tom o s is o f na tive he pa tic a rte ry w ith do no r ce lia c ax is ( ar r ow) .C, P ercu ta ne ou s cho la ng iog ram re vea ls n um erou s in trah epa tic b il ia ry s tric tu res (lo ng a rr ow s) an d m ult ip le a re as o f ex trad uc ta l co n tras t m ate ria l ( shorta r r o w s ) com pa t ib le w ith b ile le ak .

F ig . 2 .-C as e 1 : 4 3 -y ea r-o ld w om an with ab dom ina l fu lln es s and e lev a te d liv er en zym es 38 m onths a fte r h ep at ic tra nsp la n ta tio n .A, C T s ca n th ro ug h m id ab dom en s ho w s lo w -a tte nu atio n th ro m bu s in dono r ao rtic g ra f t ( arrows) .B, T ra nsv erse 1 2-w eig hte d M R sc an at sa me le ve l a ls o sh ow s h ig h-s ig na l-in ten sity a ortic g ra ft th ro mb us ( ar r ows ) .C , C oro na l T i-w eig hte d M R im ag e sh ow s in te rm ed ia te so ft-t is su e-d en sity s ig na l o f th ro mb us in dono r ao rta n ea r its a nas tom os is w ith iliac a rte ry

( arrows) .

and 6 m on ths). O ne o f these pa tien ts deve loped cava l th rom -bos is 2 weeks a fte r dono r ao rta th rom bos is , and the o the rdeve loped cava l th rom bos is a fte r po rta l th rom bos is .

Discuss ionIm p roved su rv iv a l a fte r hepa tic transp lan ta tion is a ttr ibu t-

ab le to m o re e ffe c tive im m unosupp ress ion , su rg ica l ad -vances , and m e tic u lous pos tope ra tive ca re . N eve rthe les s , anum be r o f pos ttransp lan ta tion com p lic a tions occu r tha t o ftenp resen t w ith nonspec ific sym p tom s and labo ra to ry abno r-

m a litie s . The re fo re , d iffe ren tia tion o f causes o f g ra ft d ys func-tion (ischem ic in ju ry , b ilia ry obs tru c tion , re je c tion , o r in fe c tion )is o ften d ifficu lt w ithou t rad io log ic eva luation [1 0 , 1 8, 19 ].

R ad io log ic eva luation o f the hepa tic a llog ra ft frequen tlyin vo lves the use o f seve ra l te chn iques . D iso fen in sc in tig raphyp rim a rily assesses hepa toce llu la r func tion and b ilia ry excre -tion [1 0 , 1 1 , 1 9]. S onog raphy can be used to eva lua te thehepa tic pa renchym a , and the add ition o f dup le x scann ingcapab ilitie s pe rm its d iffe ren tia tion be tween vascu la r and b ili-a ry s tru c tu res and re liab ly docum en ts vascu la r in teg rity [10 ,1 3, 1 4, 20 ]. C T prov ides a m eans o f de te rm in ing the g ross


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1288 DALEN ET AL . AJA:150, June 1988

F ig . 3 .-C as e 13 : 4 9 -y ea r-o ld m an 10 daysa f te r t r an s p l an t a ti o n , w ith b le ed in g f rom gas t r o -eso ph agea l va r ice s a nd increa s in g se rum live renzymes.

A, Transve rs e so nog ram w ith dup le x sc an -n in g shows no por ta l v en ou s flow .

B , Dynam ic abdom in a l C T scan show si n h omogeneou s dens i t y in p orta l ve in ( ar r ows ) ,co nfirm in g so no gra ph ic find in gs . Incom ple te oc -c lu s io n o f por ta l ve in w as sub stan t ia ted ang ie -graph ic a l l y 3 w eeks la te r w hen dup lex sonogra -ph y a lso sh ow ed reco nstitu tio n o f flow w ith invessel.

TAB LE 2 : Con fIrm ed Pos topera t iv e V ascu la r Com plica tio n s A fte r L iv e r T ransp lan ta tionC om p lic a tion : M eans o f s b uen t C onfirm ationCase No . D iagnos is u T im e a fte rTransp lanta t ion S ta tus a tFo l low-up

H ep atic a rte ry /d on or a orta th ro mb os is :2 S onog raphy CT , ang iog raphy 5V2 m on th s A liv e3 Au topsy None 1 1/2 w eeks D ied4 Ang iog raphy Su rge ry , au topsy 2 m on ths D ied5 Su rge ry A u topsy 2 w eeks D ied6 Sonog raphy Ang iog raphy , au topsy 2 w eeks D ied1 2 Sonog raphy Ang iog raphy 6 w ee ks D iedP o rt al v ei n t hr om b os is :5 S u rge ry A u topsy 2 w eeks D ied7 CT Sonog raphy , ang iog raphy 3 w eeks D ied8 Ang iog raphy In fe r io r venacavog raphy 1 w eek Al ive1 0 Sonog raphy CT , ang iog raphy 1 V 2 w eeks A liv e

1 2 Sonograph y Ang io g raph y 6 w eeks D ied1 3 Sonog raphy C T , ang iog raphy 1 V 2 w eeks A liveIn fe rio r v en a c av a th ro m bo sis :9 S onog raphy In fe r io r venacavog raphy 2 days D ied1 4 Sonog raphy Su rge ry 2 days D ied1 5 Sonog raphy Au topsy 1 day D ied

TABLE 3 : V ascu la r Com plic a tio ns A fte r L iv er T ransp lan ta tio n w ith ou t A ng iog rap h ic , S u rg ica l, o r P ostm ortem C onf irm atio nCaseN o. C om lca t nI 10 M eans o fDiagnos is Corrobora t iveStud ies T im e a fte rTransp lan t a t ion S ta tus a tFo l low -up

1 D ono r ao rta th rom bos is C T S onog raphy , M R 38 m onths Al ive2 In fe rio r v en a c ava th ro mb os is S onog raphy C T 6 m onths A live1 0 In fe r io r vena cava th rom bos is C T 2D echoca rd iog raphy 1 m onth A liv e

1 1 Po rta l ve in th rom bos is C T S onog raphy 1 w eek Al iveNote . - 2D = two - d imens iona l .

s tru c tu ra l in teg rity o f the hepa tic a llog ra ft [1 0 , 1 9-21 ] and thepa tency o f m ajo r vascu la r s truc tu res [21 , 22 ]. M R appea rs tobe m os t va luab le fo r docum en ting the pa tency o f the g ra ftvascu la tu re [1 6 , 1 7, 23 ]. H ow eve r, the ro le o f these non in -vas ive tes ts in the d iagnos is o f vascu la r com plic a tions a fte r

hepa tic transp lan ta tion has no t been de fined p rec ise ly [8 , 10 ,20].

Th rom bo tic phenom ena a re pa rticu la rly c ritica l to g ra ft func-tion because co lla te ra l c ircu la tion is no t re cons tru c ted andm ay take m on ths o r yea rs to deve lop . The true ra te o f


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AJR:150, Jun e 1988 COMPL IC AT IONS AFTER HEPAT IC TRANSPLANT 1289

F ig . 4 .-C ase 9 : 3 7 -y ea r-o ld w om an with 7 .5 -k g w e igh t ga in 2 d ay s a fte r h ep atic tra nsp la n ta -t ion .

A , Long itu d in a l so nog ram revea ls a re a o f in -c re as ed e ch og en ic ity a t in fr ah ep atic c av al a na s-to mo sis w Ith o blite ra tio n o f lu m en ( ar r ows ) .

B, In fe rio r v enaca vo gram show s com p le te oc -c lu s io n o f in fe rio r v en a ca va a t d is ta l in fe r io rv en a c av al a na st om o si s (w hite a rr o ws ) w it h c cl-la te ra l f low through hemlazygous system ( b l a c karrows) an d ref lux into re na l v ein s.

occu rrence o f a rte r ia l th rom bos is is unknown , bu t ra te s of3 .4 -1 2% in adu lts and 1 1 .8 -42% in ch ild ren have beenrepo rted [4 , 20 ]. In ou r se r ie s , 2 .3% o f adu lt and 1 0.9% ofped ia tric re c ip ien ts (ove ra ll o ccu rrence ra te , 7 .1 % ) deve lopeda rte r ia l c om p rom ise . If th rom bos is occu rs ea r ly in the pos t-transp lan ta tion pe riod , the p rognos is is g r im and re transp lan -ta tion m ay be ind ica ted ; if it deve lops la te r, su rv iva l is m o relik e ly and poss ib ly is enhanced by the deve lopm en t o f co lla t-e ra l c irc u la to ry pa thw ays [4 , 20 ]. In ou r s tudy , a rte ria l th rom -bos is w as firs t d iagnosed by non invas ive im ag ing techn iquesin fou r (57% ) o f seven pa tien ts . B ecause sonog raph ic and CTexam inations can be fa ls e ly nega tiv e , agg ress ive ang io -g raph ic eva lua tion m ay be requ ired . T he sens itiv ity and spec -ific ity o f each non invas ive im ag ing m ethod canno t, un fo rtu -na te ly , be de te rm ined from ou r se rie s , because de fin itiveang iog raphy , su rge ry , o r au topsy w as no t pe rfo rm ed in eve ryhepa tic re c ip ien t du r ing the s tudy pe riod .

P orta l ve in th rom bos is is a ls o assoc ia ted w ith s ign ifican tpos ttransp lan ta tion m o rb id ity and m o rta lity . The 7 .1% fre -quency repo rted in ou r se r ie s is s im ila r to the 9% frequencyo f po rta l v enous th rom bos is reported by C ien fuegos e t a l.[1 9 ]. N on invas ive techn iques p rov ided the prim a ry d iagnos iso f porta l ve in th rom bos is in five (71 % ) o f seven ins tances andw e re fa lse ly nega tive in one case . In fe rio r vena cava l th rom -bos is was d iagnosed in fiv e (5 .1 % ) o f 98 cases , and itsd iagnos is w as firs t sugges ted by non invas ive m eans in a llfive . In one case (case 1 0) the deve lopm en t o f im pa iredvenous d ra inage w as an tic ipa ted a t the tim e o f transp lan ta -tion , because venous recons tru c tion was d iffic u lt ow ing toazygous con tinua tion o f the in fe r io r vena cava .

Ind ire c t e v idence o f vascu la r occ lu s ion can a lso be obta inedfrom sonog raphy and C T when foca l parenchym a l abno rm a l-itie s sugges tive o f ischem ia o r necros is a re seen . S uch w asthe case in th ree (1 6% ) o f 1 9 com p lica tions , in c lud ing tw ohepa tic a rte ry th rom boses and one po rta l ve in th rom bos is . Inthese pa tien ts de fin itive assessm en t o f these com p lica tionsw as m ad e a ng io gra ph ica lly .

In summary , non in vas ive im ag ing is va luab le in d iagnos ingvascu la r com p lica tions a fte r hepa tic transp lan ta tion . T he h ighfa ta lity ra te (60% in ou r se r ie s ) assoc ia ted w ith vascu la rcom p lic a tions a fte r hepa tic transp lan ta tion em phas izes theim po rtance o f p rom p t and accu ra te d iagnos is fo r de te rm ina -tion o f app rop ria te trea tm en t. In ou r s tudy , 1 4 (74% ) o f 19in s tances o f vascu la r th rom bos is we re in itia lly d iagnosed bynon invas ive techn iques , 1 0 (53% ) by sonog raphy and fou r(2 1 % ) by CT . H oweve r, tw o exam ina tions in ou r se rie s w e refa lse ly nega tive , and the d iagnos is u ltim a te ly was m ade byang iog raphy in bo th . O u r da ta re in fo rce the ro le s c ited byseve ra l au tho rs o f sc in tig raphy , sonog raphy , and C T asscreen ing too ls in de te rm in ing w h ich pa tien ts need m o reagg ress ive in te rven tiona l e va lua tion [8 , 1 0, 1 5, 21 ]. The useo f M R fo r eva lua ting uppe r abdom ina l vascu la tu re has exc itingim p lica tions in the eva lua tion o f these pa tien ts ; re finem en tsin M R m ay p rec lude ang iog raphy in ce rta in cases .

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