Imaging in Liver Transplant

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    22-Jan-2018

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  1. 1. Update on Imaging in Liver Transplantation Dr.Manoj.K.S.MD DNB RD KIMS
  2. 2. Introduction Liver transplantation, first introduced 40 years back, is the recognized treatment of choice for patients suffering from end-stage liver disease, including documented fulminant hepatic failure, decompensated cirrhosis, or hepatocellular carcinoma within defined criteria. Approximately 800-1000 liver transplant surgeries are performed in India annually The number of liver transplantations performed in the United States each year exceeds 6000; however, there are more than 15,000 patients on the waiting list. UNOS National Data Report. http://www.unos.org 2011
  3. 3. History The first human liver transplants were performed in 1963 by a surgical team led by Dr. Thomas Starzl of Denver,at University of Colorado Medical School. Dr.Christian Barnard performed the first Heart transplant on December 3, 1967 in Cape Town, South Africa. https://www.kidney.org/transplantation/transaction/Mileston es-Organ-Transplantation
  4. 4. INDICATIONS Complications of cirrhosis Fulminant hepatic failure Encephalopathy Ascites Hepatocellular carcinoma Refractory variceal hemorrhage Chronic gastrointestinal blood loss due to portal hypertensive gastropathy
  5. 5. INDICATIONS Hepatitis Autoimmune hepatitis Chronic hepatitis B Chronic hepatitis C Chronic cholestatic diseases Primary biliary cirrhosis Primary sclerosing cholangitis Metabolic liver diseases Hemochromatosis Wilson disease
  6. 6. Contraindications Absolute contraindications Active extrahepatic malignancy Diffuse hepatic tumor invasion Thrombosis of the entire portal and SMV system Active or uncontrolled systemic infection Active substance or alcohol abuse Severe cardiopulmonary disease or other comorbid conditions Lack of social support Noncompliance Relative contraindications Age Cholangiocarcinoma Portal vein thrombosis Chronic or refractory infection HIV infection Previous malignancy Active psychiatric disorder Poor social support
  7. 7. Three main types of liver transplantation: cadaveric (DDLT), LDLT, and split-liver grafting The Model for End-Stage Liver Disease (MELD) is a scoring system used to assess the severity of CLD 3-month mortality rate among those with a MELD score of 40 is 100%. For patients with a score of 3039, mortality within 3 months is 83%; for 2029, 76%; for 019, 27%; and for patients with a score of less than 10, 4%.
  8. 8. The imaging requirements for a Liver Transplantation Unit can be considered under these broad Categories . 1.DONOR EVALUATION 2.RECIPIENT EVALUATION 3.INTRA OPERATIVE IMAGING 4. POST TRANSPLANT IMAGING 5. FOLLOW UP
  9. 9. DDLT -Donor evaluation Pre-operative USG /Doppler Intra operative biopsy
  10. 10. DONOR EVALUATION CHEST X-RAY ULTRASOUND ABDOMEN PORTAL/HEPATIC VEIN DOPPLER
  11. 11. Recipient Evaluation Role of Imaging Candidate selection Search for intra and extrahepatic malignancy Surgical planning HCC Staging Assessment of vessel patency: angioinvasion Quantification of diseased liver volume Vascular anatomy Identification of cirrhosis and sequelae of PHTT
  12. 12. RECIPIENT EVALUATION TRIPHASIC CT LIVER & ABDOMEN/PELVIS CT /HRCT CHEST USG/DOPPLER LIVER MRI LIVER & MRCP X-RAY CHEST
  13. 13. RECIPIENT EVALUATION PET SCAN RADIONUCLIDE SCAN MRI Brain MR Angiography cerebral arteries Carotid Doppler Renal artery Doppler LIVER BIOPSY Cardiac Imaging Echo, DSE, Contrast Echo,CAG CT Pulmonary Angio/Lung Perfusion scan
  14. 14. PET SCAN
  15. 15. Recipient Evaluation
  16. 16. Milan & UCSF Criteria Milan criteria : Defined as 1tumor 5cm; or 3 tumors with each tumor 3cm. UCSF criteria Defined as 1tumor 6.5cm or 3 tumors with the largest tumor diameter 4.5cm and total tumor diameter 8cm
  17. 17. Interventional Radiology RFA TACE TARE PTBD PVE TIPS Portal vein thrombectomy Hepatic venous pressure gradient (HVPG)
  18. 18. INTRA OPERATIVE IMAGING Intraoperative Doppler Intraoperative Cholangiography
  19. 19. Intraoperative Cholangiogram
  20. 20. Post Transplant Imaging Post- operative Doppler PORTABLE X-RAY in ICU HIDA Scan for post transplant leak assessment TRIPLE PHASE CT LIVER (optional before discharge)
  21. 21. Post- operative USG/Doppler Structure Comment Liver parenchyma Evaluate parenchymal echogenicity, texture and presence of focal lesions Perihepatic spaces Evaluate for acites, hemorrhage, fluid collections Biliary system Evaluate for ductal dilatation and intraluminal filling defects Vasculature >Evaluate hepatic artery, portal vein, hepatic veins and IVC for patency >Evaluate arterial and venous waveforms and measure arterial resistive indices >Evaluate anastomoses for focal color aliasing and elevated velocities
  22. 22. Post Tx Doppler
  23. 23. Hepatic veins -Normal a wave (atrial systole) S wave Ven systole D wave Ven diastole
  24. 24. Post Tx Doppler
  25. 25. Post Transplant Doppler Artery In a post-transplant patient, the normal hepatic arterial RI ranges from 0.55 to 0.80
  26. 26. Post Tx Doppler
  27. 27. DONOR EVALUATION LIVER STEATOSIS ASSESSMENT CT ANGIO LIVER CT VOLUMETRY
  28. 28. DONOR EVALUATION MRCP MRI Liver LIVER FIBROSIS assessment with Ultrasound or MR elastography
  29. 29. DONOR EVALUATION Mammography USG pelvis USG Thyroid Doppler lower limb arteries/veins
  30. 30. CT Imaging
  31. 31. MR Imaging
  32. 32. LIVER FAT ASSESSMENT Liver Attenuation Index (LAI). The LAI is the difference between mean hepatic attenuation and mean splenic attenuation (i.e. average density of liver average density of spleen on non-contrast scan). Liver attenuation is calculated by placing the circular region of interest (ROI) of at least 1 cm area at multiple places in the liver, covering all the hepatic segments
  33. 33. Liver Attenuation Index Average attenuation of liver parenchyma on non- contrast CT images varies between 50 and 65 HU and is generally 8-10 HU greater than that of spleen. Limanond et al. found in their study that LAI > 5 HU correctly predicted the absence of significant macrovesicular steatosis. LAI values of -10 to 5 HU were suggestive of mild to moderate steatosis (6-30%), while LAI values of less than -10 HU were suggestive of moderate to severe hepatic steatosis (i.e. 30% fat) with a specificity of 100%. Limanond P, Raman SS, Lassman C, Sayre J, Ghobrial RM, Busuttil RW, et al. Macrovesicular hepatic steatosis in living related liver donors: Correlation between CT and histologic findings. Radiology 2004;230:276-80
  34. 34. MR Fat Quantification In Phase-Opposed phase 3 Point Dixon MR Spectroscopy SVS with PRESS
  35. 35. LDLT The most common LDLT technique in adults is right hemihepatectomy, whereby segments V- VIII are harvested, leaving the middle hepatic vein (MHV) with the donor. Right hemi-liver along with its artery, portal vein, bile duct, and the draining hepatic veins is implanted into the recipient.
  36. 36. LDLT In pediatric liver transplants, left lateral sectionectomy is the standard method, whereby segments II and III are harvested In certain situations of adult LDLT, where either the remnant liver volume in donor is inadequate or there is complex portal venous or biliary anatomy, a right posterior sectionectomy can also be performed by harvesting only segments VI and VII with their posterior sectional hepatic artery, portal vein, bile duct, and right hepatic vein (RHV)
  37. 37. Arterial reconstruction The conventional hepatic arterial fish-mouth anastomosis is an end-to-end anastomosis reconstructed between the donor and recipient arterial anastomotic sites, usually between the splenic artery and common hepatic artery For cadaveric donors, the donor hepatic artery is harvested at the level of the celiac axis with a patch of the aorta. The aortic patch is then anastomosed to the recipient hepatic artery near the gastroduodenal artery take-off. For living donors, the arterial anastomosis is to the right, left or proper hepatic artery
  38. 38. PV/IVC/BILIARY A portal vein anastomosis is usually an end-to-end anastomosis between the two portal veins. The piggyback technique is the standard technique IVC .An end-to-side anastomosis is made between the donor IVC and the common stump of recipient hepatic vein Biliary anastomosis is an end-to-end anastomosis between the donor common bile duct and the recipient common hepatic duct after a cholecystectomy
  39. 39. SEGMENTAL ANATOMY
  40. 40. ARTERIAL ANATOMY
  41. 41. PORTAL VEIN -3D MIP
  42. 42. Hepatic Veins -3D MIP
  43. 43. Total volume
  44. 44. RIGHT & LEFT LOBE VOLUME
  45. 45. Partial volumes
  46. 46. DONOR MRCP
  47. 47. DONOR MRCP
  48. 48. DONOR MRCP
  49. 49. DONOR MRCP
  50. 50. DONOR MRCP
  51. 51. DONOR MRCP
  52. 52. DONOR MRCP
  53. 53. DONOR MRCP
  54. 54. DONOR MRCP
  55. 55. DONOR MRCP
  56. 56. DONOR MRCP
  57. 57. DONOR MRCP
  58. 58. DONOR MRCP
  59. 59. DONOR MRCP
  60. 60. DONOR MRCP
  61. 61. DONOR MRCP
  62. 62. DONOR MRCP
  63. 63. DONOR MRCP
  64. 64. DONOR MRCP
  65. 65. DONOR MRCP
  66. 66. FOLLOW UP /COMPLICATIONS DOPPLER & ULTRASOUND SCAN MRI & MRCP CT ABDOMEN /CHEST CT ANGIOGRAPHY MR ANGIOGRAPHY DSA SCINTIGRAPHY -HIDA ERCP LIVER BIOPSY CONTRAST ULTRASOUND INTERVENTIONAL RADIOLOGY PET-CT/ BONE SCAN
  67. 67. IR in LT Complications Vascular Biliary General Vascular Hepatic Artery Stenosis/Thrombosis (HAS/HAT), Portal/Hepatic vein,IVC stenosisi Biliary leak, strictures Drainage of collections, Pleural effusion etc
  68. 68. Combined Liver-Kidney Transplantation
  69. 69. First Pediatric LT at KIMS Second Pediatric CLKT at KIMS
  70. 70. Special Thanks to Dr. B.Venugopal Dr.Madhavan Unni Dr.Shabeer Ali Dr.L.Jayasree Dr.R C Sreekumar Dr.Manoj Pillai Dr.Suresh Babu Dr.Manish Yadav Dr.Malini Dr.Shiraz Mr Judson Mr Siraj Liver Transplant Team KIMS IMA Trivandrum THANKS TO TCCI IMA,APS ,SCOG DEPT OF RADIOLOGY, HPB&LT,KIMS