Ghaneh Fananapazir (editor) - Transplantation Imaging
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This book describes the multimodality imaging of cardiac, lung, liver, kidney, pancreas, and small bowel transplants in donors and recipients. The volume of transplantation of solid organs has increased substantially and has become common practice in medicine. Radiological evaluation of transplanted organs such as the heart, lungs, liver, pancreas, and kidneys is critical, both in potential donors (as is the case in liver and kidney transplantation) and in preoperative and postoperative evaluations of recipients. Understanding the often complex surgical anastomoses and unique pathology is necessary to inform radiologic interpretation. This book provides radiologists with the knowledge of the normal appearance of a transplanted organ, an understanding of imaging modalities that are best suited to answering clinical questions, an overview of the pathologies related to such organs and their appearance on various modalities, vascular and nonvascular complications, and techniques related to image-guided transplant interventions.
Ghaneh Fananapazir (editor): author's other books
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Ghaneh Fananapazir (editor)
Judith P. Swazey
Marie-Andrée Jacob
Yinghong Wang (editor)
Thomas H. Berquist
Philippe Jouvet (editor)
Patrizia Burra (editor)
Michael S. Torbenson MD
Thorsten Johnson Christian Fink Stefan O. Schönberg
Emilio Quaia
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Springer International Publishing AG, part of Springer Nature 2018
Ghaneh Fananapazir and Ramit Lamba (eds.) Transplantation Imaging1. Preoperative Imaging Evaluation of Living Liver Transplant Donors
Kristine S. Burk 1
(1)
Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
Kristine S. Burk (Corresponding author)
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Dushyant Sahani
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Keywords
Liver donor imaging Liver transplant imaging Hepatic vasculature anatomy and variants Biliary anatomy and variantsIntroduction
Liver transplantation is a lifesaving treatment for patients with end-stage liver disease and is in high demand with 14,619 candidates on the waiting list as of November 2016 [].
Partial liver transplantations, particularly from living related donors, offer substantially increased challenges to both the surgeon and the radiologist. For these operations, imaging plays a crucial role in candidate selection and surgical planning. Contrast-enhanced CT and MRI are the standard imaging modalities utilized in the evaluation, as these provide complete assessment of the liver parenchyma, biliary system, and vascular anatomy. Imaging protocols are highly tailored and routinely utilize techniques for iron and fat quantification, volumetric analysis, and 3D reformations. In addition to understanding these imaging techniques and anatomy, diagnostic radiologists must also understand the nuances of donor and recipient selection and have a knowledge of the transplant operations themselves.
This chapter will review the different types of transplant operations, discuss the imaging modalities and protocols most commonly utilized in this clinical setting, and provide an in-depth discussion of the evaluation of a potential LDLT donor.
Transplant Operations
There are three types of liver transplants performed today: the whole-liver cadaveric transplant, the split-liver cadaveric transplant, and the living donor liver transplant.
Whole-Liver Cadaveric Transplant
The most common type of transplant performed in the USA is the whole-liver cadaveric transplant, in which a complete donor liver is transplanted into the recipient []. In this procedure, the native liver and gallbladder are removed and an entire donor liver is put in its place. Anastomoses are required at the hepatic artery, at the portal vein, at the hepatic veins to the inferior vena cava (IVC), and at the common bile duct. The advantage of this operation is the relative technical simplicity and large amount of healthy liver given to the recipient. However, this operation alone cannot meet the demands of the waiting list population. This has led to the development of other transplant operations.
Split-Liver Cadaveric Transplant
Split-liver cadaveric transplants are the least common type of transplant operation, accounting for only 1.0% of transplants performed in 2014 []. 
Fig. 1.1
Ex vivo split-liver cadaveric transplant the right tri-segment graft was transplanted into an adult recipient with HCC, while the left lateral segment graft went to an infant with fulminant hepatic failure. Adapted from Burk KS, Singh AK, Vagefi PA, Sahani D, Pretransplantation imaging workup of the liver donor and recipient. Radiology Clinics of North America 2016; 54(2):185197
Living Donor Liver Transplant
In a living donor liver transplant , a part of the donors liver is removed and transplanted into the recipient (Fig. ]. 
Fig. 1.2
Right lobe living donor liver transplant. ( a ) Preoperative donor image. ( b ) Intraoperative photograph after liver parenchymal division but prior to vascular division. ( c ) Postoperative donor image showing growth in the remnant left hepatic lobe. Adapted from Burk KS, Singh AK, Vagefi PA, Sahani D, Pretransplantation imaging workup of the liver donor and recipient. Radiology Clinics of North America 2016; 54(2):185197
For a pediatric liver graft recipient, the left lateral segmentectomy technique is most popular. In this operation, the transection plane runs just to the right of the falciform ligament, and segment IV and the MHV are left in the donor (Fig. ]. 
Fig. 1.3
( a ) The left lateral segmentectomy LDLT plane runs to the left of the MHV. ( b ) The right lobe LDLT plane connects the gallbladder fossa and IVC and runs 1 cm to the right of the MHV. Adapted from Burk KS, Singh AK, Vagefi PA, Sahani D, Pretransplantation imaging workup of the liver donor and recipient. Radiology Clinics of North America 2016; 54(2):185197
The overall risk of postoperative complication for the partial liver donor is 40%, and the risk of postoperative death is 0.150.20%. Though this overall complication rate seems high, 95% of these complications are minor in severityClavien grade I or II. These require only conservative, medical management, or at most a percutaneous intervention [].
Imaging Techniques
CT and MRI are the modalities most commonly used to evaluate liver donors and recipients in the preoperative setting. Indeed, with the advent of biliary contrast agents and imaging post-processing techniques, older modalities including conventional angiography, ERCP, and intraoperative cholangiography have largely been replaced. Though MRI can be used as a sole imaging modality for preoperative evaluation, CT and MRI are more commonly used together as their strengths are complimentary to one another [].
CT/CTA
CT/CTA has superior spatial resolution compared to MRI and is therefore better at delineating small segmental hepatic arteries and accessory hepatic veins [). However, it is no longer performed as the biliary excreted iodinated contrast agent was removed from the US market a few years ago. Biliary evaluation is now performed via MRCP. 
Fig. 1.4
3D reformatted image of a CT cholangiogram showing the common bile duct and intrahepatic biliary ducts
Since liver donors are often young and healthy without other medical comorbidities, reduction in radiation dose for these exams is important. Methods to reduce radiation dose routinely used at our institution include limiting the field of view to the abdomen on arterial phase images, using iterative reconstruction and weight-based kVp techniques (80 kVp if <150 bs, 100 kVp if 150200 lbs, 120 kVp if >200 lbs) on portal/hepatic venous phase images, and using dual energy techniques (140 and 80 kVp) on only a limited number of thick slices (24 slices depending on liver size) for steatosis evaluation.
MRI/MRCP
MRI/MRCP with and without a hepatobiliary contrast agentGd-BOPTA (MultiHance) or Gd-EOB-DTPA (Eovist)is the second examination performed at our institution for evaluation of liver donors. Fat and iron deposition is assessed with Dixon sequences. The biliary system is evaluated with traditional T2-weighted non-contrast-enhanced 3D MRCP images in the coronal plane, T2-weighted SSFSE images in the coronal and axial planes, T1-weighted post-contrast biliary-phase images in the coronal and axial planes, and/or a 20-min delayed post-contrast 3D MRCP. Additionally, focal liver lesions are characterized with traditional T2, T1 pre-contrast, and T1 post-contrast images in the arterial, portal venous, and delayed phases []. For all the above, fast pulse sequences such as spoiled gradient echo and parallel imaging techniques are utilized to decrease image acquisition time and minimize motion artifacts.
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