Biomed Imaging Interv J 2006; 2(2):e17
© 2006 Biomedical Imaging and
Ultrasound of living donor liver transplantation
MBBS, FHKAM (Radiology)
Department of Radiology, Queen Mary Hospital, Hong Kong SAR, China
Liver transplantation is the most effective treatment for
various end-stage liver diseases. Living donor liver transplantation (LDLT) was
first developed in Asia due to the severe lack of cadaver graft in this region.
The Liver Transplant Service at Queen Mary Hospital (QMH), Hong Kong, has
pioneered the application of LDLT to patients using both left lobe and right
lobe grafts. The QMH liver transplant programme is the largest of its kind in China
and Southeast Asia.
Ultrasound (US) is often employed in the initial work-up of
potential donor and recipient of LDLT. It is the imaging technique of choice to
assess the early and late complications of LDLT, with colour Doppler ultrasound
being the most useful in the evaluation of post-LDLT vascular complications.
The use of ultrasound contrast agents improves the visualisation of the hepatic
vasculature, possibly delaying or removing the need for more invasive
investigations. Intra-operative ultrasound facilitates the determination of the
resection plane during donor hepactectomy.
Computed tomography (CT) or magnetic resonance imaging (MRI)
can be used as the single imaging modality in the evaluation of LDLT
Ultrasound is most useful as the initial screening test in
detecting hepatic parenchymal abnormalities, while CT or MRI is the modality of
choice in the demonstration of vascular and biliary anatomy of the potential
Biliary complications are more common in LDLT than in
cadaver liver transplantation. The ductal dilatation, resulting from biliary
stricture, is clearly demonstrated by ultrasound. Bilomas can be aspirated
under ultrasound guidance to confirm the diagnosis and to promote healing. Perihepatic
fluid collections and abscesses are also common after LDLT. Intra-hepatic
collections may represent seromas, haematomas or infarction. Ultrasound is a
sensitive means of detecting these collections and can be employed to guide
drainage in suitable patients.
�Transplant-related malignancies include recurrent neoplasia
and post-transplant lymphoproliferative disease (PTLD). Ultrasound
can be used to screen for recurrent disease and to detect PTLD
in the transplanted liver. © 2006 Biomedical Imaging and
Intervention Journal. All rights reserved.
Keywords: ultrasound, living donor, liver,
Liver transplantation is the most effective treatment for various
end-stage liver diseases and sudden, acute liver failure. Due
to the worldwide shortage of cadaveric liver, innovative surgical
techniques, including split liver transplantation and living
donor liver transplantation (LDLT), have been developed. LDLT
was first initiated in Asia to address the severe lack of cadaveric
graft in this region. Over 12 years, more than 1500 cases of
LDLT have been performed in five Asian centres (Kyoto, Tokyo,
Asan, Hong Kong, Taiwan) with 1- and 5-year actuarial patient
survival rates of 78.7%-97.8% and 76.1%-97.8% being achieved,
The Liver Transplant Service at Queen Mary Hospital (QMH), Hong
Kong, has pioneered the application of LDLT to patients using both left lobe
and right lobe grafts. The QMH liver transplant programme is the largest of its
kind in China and Southeast Asia. By the end of December 2003, a total of 321
liver transplants (210 right lobe LDLT) were performed with 1-year and 5-year
survival rates of 84% and 79%, respectively. Successful transplantation
requires a detailed evaluation of the transplant candidate and the potential
Imaging has contributed to the development and success of
LDLT in the selection of patients as well as detection and management of
post-transplant complications. The use of ultrasound in the evaluation of LDLT
patients and assessment of the post-operative complications is discussed in
I. PRE-TRANSPLANT ASSESSMENT
Evaluation in recipients
Pre-transplant imaging plays an important role in
identifying contraindications to transplantation, anatomic abnormalities and
variants that may alter the surgical approach.
i) Liver parenchyma
Ultrasound may show changes of cirrhosis with nodular contours, parenchymal
inhomogeneity, right- lobe atrophy and hypertrophy of lateral
segment and caudate lobe .
Cirrhosis often causes narrowing of the hepatic veins with
loss of the normal phasic waveform. Intra-hepatic vessels may be indistinct.
The caudate lobe can become enlarged and surround the inferior vena cava (IVC),
which is of relevance in cases of living donor transplantation in which IVC is
Colour Doppler Ultrasound may show portal vein flow reversal
or portal collaterals, suggesting the diagnosis of portal hypertension.
ii) Presence and extent of hepatocellular carcinoma
Liver transplantation for the treatment of hepatocellulcar carcinoma (HCC)
provides excellent outcomes with application of the Milan criteria
(single nodule < or = 5cm, or two or three nodules < or
= 3cm) with 5-year survival rates of 70% and low recurrence
A recent study has suggested that currently available selection criteria for
HCC patients can be applicable to LDLT without change of prognostic
Ultrasound is often used to screen HCC in a high risk population.
Contrast enhanced ultrasound greatly increases the sensitivity
in the detection of HCC (Figure 1) .
[View this figure]
|Figure 1 Hepatocellular carcinoma
(HCC) in a 75 year old woman. (a) Baseline US showed
a hypoechoeic lesion at the right hepatic lobe. (b)
Dynamic contrast enhanced US with SonoVue. The early
arterial phase image demonstrated peripheral tumoural
vessels (arrows) with enhancement filling from the
periphery. (c) The arterial phase image showed homogeneous
tumoural enhancement with a small hypoechoic area
(arrow). (d) In the portal phase, the HCC (arrows)
became relatively hypoechoic to the surrounding enhanced
Accurate radiological staging is required to define suitable
HCC candidates for liver transplantation. While either computed
tomography (CT) or magnetic resonance imaging (MRI) can be used,
many studies have found MRI to be superior to detect and characterise
focal hepatic lesions .
iii) Presence of cholangiocarcinoma and other
Known cholangiocarcinoma is a contraindication to liver transplantation due
to a high recurrence rate. The detection of an extra-hepatic
tumour with or without hepatic metastasis also excludes the
patient from transplantation. Ultrasound evaluates the intrahepatic
tumour. Both CT and MRI can also be used to depict extra-hepatic
disease in patients with malignancy, with studies showing MRI
to be superior to helical CT in this regard .
iv) Patency of the portal vein and superior mesenteric
Diffuse thrombosis of the portal and superior mesenteric
vein (SMV) is a contraindication to liver transplantation. Portal vein
thrombosis requires the modification of surgical technique at the time of
transplantation. Ultrasound can be used to assess the vascular patency of a
potential transplant recipient. Contrast enhanced ultrasound improves the
colour and spectral Doppler signal, thereby increasing operator confidence.
However, ultrasound evaluation of the SMV patency remains problematic because
of overlying bowel gas. Contrast enhanced CT or MRI/ MRA (magnetic resonance
angiography) can be employed to evaluate the patency of these vessels.
v) Celiac artery stenosis
Recipients with celiac artery stenosis are at risk of compromised blood flow
to the transplanted organ. Doppler ultrasound has high accuracy
in the diagnosis of high grade splanchnic arterial stenosis,
and can be used as a screening method for celiac artery stenosis
Computed tomography angiography (CTA) is an established method to evaluate
arterial anatomy, aneurysm and stenosis .
Narrowing, mural thrombus and post-stenotic dilatation can
be demonstrated with CTA. Contrast enhanced MRA is the alternate means of
assessing these abnormalities. The detected stenosis is corrected at surgery.
vi) Status of transjugular portosystemic shunt
Some recipients may have undergone placement of a
transjugular portosystemic shunt (TIPS) prior to transplantation. The patency
of the shunt can be assessed with colour Doppler ultrasound, including Power
Doppler. The use of ultrasound contrast readily establishes the patency of the
stent. Migration of the shunt and shunt related stenosis could affect
transplantation in a significant number of patients. The location of the
proximal and distal ends of the shunt can easily be determined by CT.
However, MRI evaluation of graft patency may be limited by metallic stent
Evaluation in liver donors
In addition to detailed clinical examination, informed
consent with the surgical team, cardiopulmonary function assessment and
numerous laboratory and serologic tests, the potential liver donor undergoes
extensive imaging evaluation to identify exclusion criteria for liver donation
and obtain necessary information to ensure success in transplantation.
i) Hepatic artery anatomy to the graft lobe
Detailed anatomic information is required to plan the hepatic-arterial,
portal-venous and hepatic-venous surgical anastomosis in LDLT.
Hepatic angiography is the traditional gold standard in the
preoperative assessment of the vascular anatomy of potential
liver transplant patients. Multi-detector computed tomography
(MDCT) or contrast-enhanced MRI can be used as a non-invasive
Intra-operative ultrasound is performed to direct hepatic
transection in an avascular plane during donor hepactectomy.
The disadvantages of CT include the use of ionising
radiation and injection of potentially nephrotoxic iodinated contrast.
ii) Venous and biliary anatomy
The main branches of the hepatic vein drain into the
inferior vena cava. The portal vein usually bifurcates into the left and right
portal veins, which are easily demonstrated by Doppler ultrasound. The main
portal vein may �trifurcate� with an early branching pattern in the right
hepatic lobe. Accessory right hepatic veins occur in 6% of people and can cause
increased bleeding if unrecognised before surgery.
Venous anatomy is well demonstrated by contrast enhanced CT
or MRI/ MRA.
The biliary system can be evaluated with endoscopic retrograde
cholangiopancreatography (ERCP), CT cholangiography 
and MR cholangiography (MRC). MRC, utilising heavily T2W pulse
sequences, accurately depicts biliary anatomy in potential LDLT
donors and guides the intra-operative management of the biliary
�MRC, enhanced with hepatobiliary agent, is highly accurate in demonstrating
the biliary anatomy in adult living liver donors .
iii) Liver volume
The success of LDLT depends on adequate graft volume. The volumes
of potential donor livers are matched with the volume needed
by the recipient, as calculated according to body surface area.
A minimum of 40% of the normal liver volume is required by the
recipient . At least 30% of the liver
should be left in the donor .
Both CT and MRI can be used to calculate the graft and remnant
liver volume. CT provides accurate and reproducible estimate of liver graft
mass. Hepatic volume, determined by MRI, estimates the degree of fatty
infiltration and evaluates the vascular and biliary anatomy, without the risk
of ionising radiation.
iv) Liver parenchyma
An important donor-related risk factor, associated with poor
recipient outcome after orthotopic liver transplantation, is moderate- to
severe donor steatosis.
Ultrasound, CT and MRI are useful to evaluate focal hepatic
lesions detected in asymptomatic potential donors.
Ultrasound easily detects the presence of fatty infiltration. Severe fatty
infiltration often results in an enlarged liver with diffuse
increase echogenicity .
Acoustic penetration may be reduced with indistinctness of the
blood vessels and the diaphragm. Quantification of the degree of fatty
infiltration may be accomplished with dual energy CT.
Opposed-phase gradient echo MRI can be performed to provide
an objective estimate of the degree of hepatic steatosis. Donor hepatic biopsy
is performed in some institutions to accurately assess the degree of steatosis.
II. INTRA-OPERATIVE EVALUATION
Intra-operative ultrasound is used to determine the optimal plane of resection
during LDLT. The donor liver must be divided along a plane that
avoids major vessels, while leaving both donor and recipient
with sufficient liver volume for proper function. The optimal
resection plane is about 1 cm to the right of the middle hepatic
Our Centre now employs the hepatic venoplasty technique to
facilitate the implantation of the right lobe graft and quarantines
flow in the middle hepatic vein .
Intra-operative ultrasound is most useful to depict venous anatomy for the
surgeon. The hepatic vein branches, from segment V and VIII,
that drain into the right hepatic vein are identified by ultrasound
and marked, because these vessels will be divided during donor
Accessory hepatic veins can also be identified by ultrasound. The right portal
vein should not be divided too close to the portal vein bifurcation,
otherwise a stenosis will be created .
Ultrasound can be used to identify the origin of the right
portal vein during right lobe resection. Intra-operative Doppler
ultrasound also helps detect abnormal hepatic hemodynaemics,
allowing early intervention to ensure better patient outcome
III. NORMAL ULTRASOUND APPEARANCE OF LIVER
A routine post-operative ultrasound of the transplanted
liver includes grey-scale assessment of the liver parenchyma and biliary tree
and Doppler study of the hepatic vasculature. The normal portal vein Doppler
waveform is a continuous flow pattern toward the liver with mild velocity
variations induced by respiration. The normal Doppler appearance of the hepatic
veins and IVC shows a phasic flow pattern.
The normal graft liver has a homogeneous or slightly heterogeneous
pattern at grey-scale imaging . The intrahepatic
biliary ducts should be of normal caliber and appearance. In
the early post-operative period there is usually a small amount
of perihepatic fluid. The normal hepatic artery Doppler waveform
shows a rapid systolic up-stroke with continuous diastolic flow.
The acceleration time should be less than 80 msec, and the resistive
index (RI) should be between 0.5 and 0.7 .
High-resistance flow at the hepatic artery detected on Doppler
ultrasound during the period immediately after transplantation
is a frequent finding and has no prognostic implication .
IV. EVALUATION OF POST-LDLT COMPLICATIONS
Despite the rapid advances in surgical techniques and improvements
in immuno-suppression, various complications still occur after
LDLT, resulting in significant patient morbidity and mortality
[View this table]
|Table 1 Complications
of liver transplantation at Queen Mary Hospital, Hong
Kong (October 1991-December 2003)
Ultrasound is the initial imaging technique of choice to assess
the early and late complications of LDLT. The examination can
be easily performed at the bedside and repeated to follow up
detected abnormalities. Most transplant centres, including ours,
employ colour Doppler Ultrasound in the peri- and post-operative
period for assessing the patency of the hepatic artery, hepatic
veins and portal veins to ensure proper functioning of the liver
Helical computed tomography (CT) is a valuable complement to
ultrasound in the post-operative period and is a safe, accurate
and non-invasive means of detecting post-operative complications
Recipient post-LDLT complications
i) Acute rejection
Acute rejection is the most common and most serious complication affecting
graft survival. The incidence of acute rejection ranges from
17% to 40% and is lower than that of cadveric liver transplantation
with unknown reason .
Unfortunately, no imaging modality has proved sensitive or
specific for the diagnosis of rejection. The only reliable means
of diagnosis is by graft biopsy and histologic study .
Imaging studies, including ultrasound, can be used to rule
out other complications that have similar clinical signs and symptoms to acute
rejection. Ultrasound or CT is occasionally used to guide percutaneous biopsy
of the liver graft to confirm the occurrence of acute rejection.
ii) Vascular complications
Vascular complications are reported in about 9% of liver transplant patients
and are the most common significant post-operative complications.
Post-LDLT vascular complications include thrombosis and stenosis
of the hepatic artery, hepatic veins and portal veins as well
as pseudoaneurysm formation. Vascular problems appear to be
more common in the paediatric group of LDLT patients and are
most likely due to the small size of vessels and technical factors
Colour Doppler ultrasound is used as the main screening technique,
while angiography is reserved for confirming ultrasound findings
or when ultrasound findings are equivocal. Doppler spectral
waveform analysis provides excellent screening for the detection
of hepatic allograft arterial stenosis or thrombosis .
The use of ultrasound contrast agents improves visualisation
of the hepatic vasculature and shortens the examination time,
possibly delaying or obviating the need for more invasive investigations
Excellent results have been reported using multi-slice CT angiography
in detecting vascular complications after liver transplantation
. Contrast MRA is another alternative
non-invasive technique for this purpose .
Hepatic artery thrombosis is the most common vascular complication of liver
transplantation. Treatment requires urgent revascularisation
or retransplantation. The diagnosis is established when colour
Doppler ultrasound fails to identify both an arterial colour
Doppler signal and waveform along the anticipated course of
the hepatic artery (Figure 2).
[View this figure]
|Figure 2 Hepatic artery thrombosis
after LDLT. (a) Colour Doppler US showed patent coeliac
artery (arrow). (b) Absence of flow and Doppler signal
seen at the expected location of the hepatic artery
(arrow). PV: Portal vein. (c) Digital subtraction
angiogram of the coeliac axis confirmed thrombosis
of the hepatic artery (arrow).
Protocol Doppler ultrasound with RI measurement, during the
first two weeks after LDLT, is found to predict hepatic artery
The use of contrast enhanced colour Doppler ultrasound may
increase the confidence in excluding arterial thrombosis .
Definitive diagnosis is by angiography. Contrast-enhanced CT or MRI helps in
defining the degree of parenchymal ischaemia in these patients.
Geographic areas of decreased echogencity, with preservation
of the portal tracts, are the early sonographic signs of hepatic
Ultrasound with microbubble contrast enhancement may also
provide confirmation of areas of infarction.
The presence of a tardus-parvus waveform pattern in the Doppler
ultrasound is suggestive of hepatic artery stenosis (Figure
[View this figure]
|Figure 3 Hepatic artery stenosis
after liver transplantation with cholangitic abscess.
(a) Colour Doppler US at post-stenotic segment of
hepatic artery showed turbulent flow and elevated
peak systolic velocity. (b) Tardus-parvus waveform
at pre-stenotic segment of hepatic artery with dampened
flow. (c) Hypoechoic cholangitic abscess at right
lobe liver graft due to hepatic ischaemia (arrows).
Contrast-enhanced ultrasound can easily demonstrate focal stenosis at the hepatic
arterial anastomosis. Angiography with a view to angioplasty
can then be performed. Balloon dilatation of a stenosis is frequently
successful, obviating the need for further surgery and vascular
reconstruction. Coronary stents may also be used .
Hepatic artery pseudoaneurysm is rare after liver
transplantation and occurs in 1% of patients. It may be intra- or extra-hepatic
Ultrasound is the primary technique for detection, but it may
also be seen on contrast-enhanced CT or MRI. Colour Doppler
ultrasound shows a high velocity jet with a swirling pattern
of flow within the cavity (Figure 4). Treatment is by surgery,
coil embolisation or percutaneous thrombin injection .
[View this figure]
|Figure 4 Hepatic artery pseudo-aneurysm
after LDLT. (a) Doppler US detected roundish hypoechoic
lesion close to hepatic artery (arrow). Spectral Doppler
demonstrated elevated peak systolic velocity at neck
of pseudo-aneurysm. (b) Colour Doppler US revealed
turbulent flow within the lesion (arrows). HA: Hepatic
artery, PV: Portal vein. (c) Contrast enhanced CT
showed pseudo-aneurysm (arrows). (d) Digital subtraction
angiogram of celiac axis demonstrated pseudo-aneurysm
[View this figure]
|Figure 5 Hepatic vein stenosis
after LDLT. (a) US showed stenosis of the hepatic
vein (arrow). IVC: Inferior vena cava. (b) Colour
Doppler US demonstrated elevated velocity.
A persistent monophasic wave pattern on Doppler ultrasound images of the hepatic
veins is suggestive of substantial hepatic vein stenosis after
LDLT (Figure 5) . A persistent triphasic
wave pattern on Doppler ultrasound images can exclude the possibility
of substantial stenosis.
Hepatic vein complications, including thrombosis and stenosis, occur in 1.9%
of our patients (Table 1). Hepatic vein thrombosis appears as
absence of flow on colour Doppler ultrasound, and echogenic
thrombus may be seen within the hepatic vein. Ultrasound with
microbubble contrast-enhancement is capable of demonstrating
vascular outflow abnormalities of the hepatic veins and IVC
when standard colour Doppler examination is difficult or the
result is equivocal .
Portal vein abnormalities are uncommon and occur in 1% to 3%
of transplant recipients. Acute portal vein thrombus appears
moderately hypoechoic or isoechoic with absence of Doppler signal
. Partial obstruction of the portal vein
may be caused by thrombus or stenosis at the portal vein anastomosis
(Figure 6). Diffuse low velocities in the portal vein or focally
elevated velocities at the anastomosis are signs of portal vein
stenosis. Transhepatic portal venoplasty or stent insertion
may be performed in significant portal vein stenosis.
[View this figure]
|Figure 6 Portal vein stenosis after
LDLT with subphrenic collection. (a) US showed stenosis
of the portal vein anastomosis (arrow). (b) Colour
Doppler US revealed elevated velocity. (c) Subphrenic
collection also detected by US (arrows).
[View this figure]
|Figure 7 Ductal calculi after LDLT
due to biliary stenosis. (a) US showed echogenic ductal
calculi at right lobe graft (arrows). (b) Non-contrast
CT confirmed hyperdense ductal stone (arrow).
iii) Biliary complications
Bile duct complications are a significant cause of post-transplant
morbidity and mortality , occurring in
24% of our liver transplant recipients (Table 1). Biliary complications
are more common in LDLT than in cadveric liver transplantation
 and include bile leaks, strictures,
calculi (Figure 7) or sludge and dysfunction of sphincter of
Bililary strictures are more frequent in adult LDLT patients
probably due to higher incidence of multiple ducts in right
lobe grafts . Percutaneous transhepatic
cholangiography or endoscopic retrograde cholangiography is
used to diagnose biliary stricture and bile leak. MRC has been
found to be a reliable technique for detecting post-orthotopic
liver transplanatation biliary complications .
Bile leak is caused by technical failure at the duct-to-duct
or biliary-enteric anastomosis, and by hepatic artery thrombosis at
non-anastomotic sites. Biliary obstruction can be divided into anastomotic and
non-anastomotic strictures with causes due to technical failure,
ischemia, calculi, mucocele of the cystic duct remnant and recurrent
Biliary-enteric anastomosis is performed in many LDLT with
the segmental ducts individually anastomosed to a small bowel loop. Anastomotic
stenosis can lead to obstruction of a segmental hepatic duct. The ductal
dilatation, resulting from biliary stricture, is easily demonstrated by ultrasound.
Stricture of the bile duct anastomosis is diagnosed by direct cholangiography,
either endoscopic for end to end biliary reconstruction or percutaneous for
Roux loop biliary reconstruction.
MRC has a role in non-invasive demonstration of the
stricture, reserving the invasive techniques for when intervention is necessary.
Treatment is by percutaneous or endoscopic dilatation with temporary stenting,
while surgery is reserved for recurrent strictures or those not responding to
the less invasive measures.
Bilomas can be aspirated under ultrasound guidance to confirm
the diagnosis, promote healing and preserve graft integrity
(Figure 8) . Should direct cholangiography
confirm a bile leak, then anastomotic stenting may be performed
if the integrity of the hepatic artery has been established.
Radionuclide (Tc 99m HIDA) and MRC are alternative tools in
detecting bile leak. Volumetric mangafodipir-enhanced cholangiography
provides satisfactory evaluation of intra-hepatic biliary anatomy.
MR evidence of bile leakage is well demonstrated after intravenous
infusion of the MR hepatobiliary contrast agent, mangafodipir
[View this figure]
|Figure 8 Biloma after LDLT diagnosed
by US guided aspiration. (a) Hypoechoic collection
detected by US at right lobe (arrows). (b) Tip of
needle (arrow) during US guided aspiration (arrow).
(c) Post-aspiration US showed marked decrease in size
of biloma (arrows).
iv) Post-operative collections
Perihepatic fluid collections and abscesses are not uncommon after LDLT. Intra-hepatic
collections appear as cystic or solid masses without internal
vascularity and may represent seromas, haematomas or infarction
Complex lesions with mass effect on surrounding structures
are suggestive of hematomas. Ultrasound detects these collections and can be
used to guide percutaneous drainage in suitable patients.
Infections remain the most significant causes of morbidity in patients undergoing
LDLT , with immuno-suppression being the
most critical predisposing factor. Prophylactic regimens vary
among transplant centres, but some success can be achieved in
reducing the prevalence and severity of peri-operative or long
term infections by various viral, fungal, protozoan, bacterial
and mycobacterial agents. Serologic examinations and bacterial
investigations of blood, sputum, stool, urine and discharge
from drains, as well as antibiotic sensitivity tests, should
be performed when necessary.
vi) Post-transplant malignancies
Approximately 4-5% of liver transplant recipients develop
malignant tumours with a four fold increase in the incidence of lymphoma when
compared with the general population. The majority of these tumours are
non-Hodgkin�s lymphoma. Imaging evaluation and treatment of these diseases
follow the principles of accepted oncological staging criteria.
Post-transplant lymphoproliferative disease (PTLD) represents a spectrum of
B-cell proliferation ranging from lymphoma to a mononucleosis-like
disease. They are found almost exclusively in the paediatric
group of LDLT patients , and 1.9% of our
liver transplant patients are affected (Table 1).
�Imaging features are often non-specific and definitive diagnosis
requires biopsy . Ultrasound may reveal
hypoechoic, poorly vascularized solid masses in the liver of
PTLD patients in addition to the finding of para-aortic lymphadenopathy
(Figure 9) .
[View this figure]
|Figure 9 Post transplant lymphoproliferative
disease after LDLT. (a) US showed hypoechoic lesion
at right lobe graft (arrows). (b) Contrast enhanced
T1W MR image revealed hypovascular tumours (arrows).
[View this figure]
|Figure 10 Recurrent hepatocellular
carcinoma (HCC) after LDLT. (a) US detected large
heterogeneous lesion at liver graft (arrows). (b)
Contrast enhanced arterial CT image showed multifocal
The use of LDLT in the management of HCC remains controversial. Patients transplanted
for HCC are at risk of recurrent disease, with the most frequent
sites being the lung and the liver allograft (Figure 10) .
Ultrasound can be used to screen these patients and contrast-enhanced
ultrasound may increase confidence in difficult cases. Contrast
CT or MRI is also effective in the detection of these recurrent
Donor post-LDLT complications
The overall donor complication rate for 1508 LDLT performed in five Asian transplant
centres was reported to be 15.8%, and 1.1% of donors underwent
The complication rate was higher in right lobe than left
More serious complications also occurred in right lobe donors and included
cholestasis, bile leakage, biliary stricture, portal vein thrombosis,
intra-abdominal bleeding and pulmonary embolism .
Radiological work-up follows the accepted imaging criteria.
The long term outcome of liver donation remains unknown and transplant centres
should continue their follow-up of donors.
Living donor liver transplantation (LDLT) provides a
valuable alternative to cadaveric liver transplantation in the treatment of
acute fulminant liver failure and various end-stage liver diseases.
Ultrasound is the imaging modality of choice in the initial
evaluation of both donor and recipient before and after LDLT.
Despite rapid advances in surgical techniques and
improvement in immuno-suppression, significant complications still occur after
Colour Doppler ultrasound is most useful in the evaluation
of post-LDLT vascular complications, while cholangiography is required in the
diagnosis of biliary complications.
The knowledge of normal and abnormal ultrasound findings
after LDLT is essential for the early detection of post-LDLT complications,
permitting timely intervention and ensuring optimal outcome in these patients.
The author would like to thank K.S. Tai and C. Lam for their
assistance in preparing this manuscript.
Chen CL, Fan ST, Lee SG, et al. Living-donor liver transplantation: 12 years of experience in Asia. Transplantation 2003;75(3 Suppl):S6-11.
Tchelepi H, Ralls PW, Radin R, et al. Sonography of diffuse liver disease. J Ultrasound Med 2002;21(9):1023-32; quiz 1033-4.
Llovet JM, Schwartz M, Mazzaferro V. Resection and liver transplantation for hepatocellular carcinoma. Semin Liver Dis 2005;25(2):181-200.
Hwang S, Lee SG, Joh JW, et al. Liver transplantation for adult patients with hepatocellular carcinoma in Korea: comparison between cadaveric donor and living donor liver transplantations. Liver Transpl 2005;11(10):1265-72.
Nicolau C, Vilana R, Bru C. The use of contrast-enhanced ultrasound in the management of the cirrhotic patient and for detection of HCC. Eur Radiol 2004;14 Suppl 8:P63-71.
Rode A, Bancel B, Douek P, et al. Small nodule detection in cirrhotic livers: evaluation with US, spiral CT, and MRI and correlation with pathologic examination of explanted liver. J Comput Assist Tomogr 2001;25(3):327-36.
Low RN, Semelka RC, Worawattanakul S, et al. Extrahepatic abdominal imaging in patients with malignancy: comparison of MR imaging and helical CT in 164 patients. J Magn Reson Imaging 2000;12(2):269-77.
Lim HK, Lee WJ, Kim SH, et al. Splanchnic arterial stenosis or occlusion: diagnosis at Doppler US. Radiology 1999;211(2):405-10.
Guven K, Acunas B. Multidetector computed tomography angiography of the abdomen. Eur J Radiol 2004;52(1):44-55.
Schroeder T, Malago M, Debatin JF, et al. "All-in-one" imaging protocols for the evaluation of potential living liver donors: comparison of magnetic resonance imaging and multidetector computed tomography. Liver Transpl 2005;11(7):776-87.
Alonso-Torres A, Fernandez-Cuadrado J, Pinilla I, et al. Multidetector CT in the evaluation of potential living donors for liver transplantation. Radiographics 2005;25(4):1017-30.
Sahani D, D'souza R, Kadavigere R, et al. Evaluation of living liver transplant donors: method for precise anatomic definition by using a dedicated contrast-enhanced MR imaging protocol. Radiographics 2004;24(4):957-67.
Wang ZJ, Yeh BM, Roberts JP, et al. Living donor candidates for right hepatic lobe transplantation: evaluation at CT cholangiography--initial experience. Radiology 2005;235(3):899-904.
Kim RD, Sakamoto S, Haider MA, et al. Role of magnetic resonance cholangiography in assessing biliary anatomy in right lobe living donors. Transplantation 2005;79(10):1417-21.
Ayuso JR, Ayuso C, Bombuy E, et al. Preoperative evaluation of biliary anatomy in adult live liver donors with volumetric mangafodipir trisodium enhanced magnetic resonance cholangiography. Liver Transpl 2004;10(11):1391-7.
Lo CM, Fan ST, Liu CL, et al. Minimum graft size for successful living donor liver transplantation. Transplantation 1999;68(8):1112-6.
Fan ST, Lo CM, Liu CL, et al. Safety of donors in live donor liver transplantation using right lobe grafts. Arch Surg 2000;135(3):336-40.
Bassignani MJ, Fulcher AS, Szucs RA, et al. Use of imaging for living donor liver transplantation. Radiographics 2001;21(1):39-52.
Liu CL, Zhao Y, Lo CM, et al. Hepatic venoplasty in right lobe live donor liver transplantation. Liver Transpl 2003;9(12):1265-72.
Chong WK. Ultrasound evaluation of liver transplants. Abdom Imaging 2004;29(2):180-8.
Marcos A, Fisher RA, Ham JM, et al. Right lobe living donor liver transplantation. Transplantation 1999;68(6):798-803.
Someda H, Moriyasu F, Fujimoto M, et al. Vascular complications in living related liver transplantation detected with intraoperative and postoperative Doppler US. J Hepatol 1995;22(6):623-32.
Cheng YF, Huang TL, Chen CL, et al. Intraoperative Doppler ultrasound in liver transplantation. Clin Transplant 1998;12(4):292-9.
Crossin JD, Muradali D, Wilson SR. US of liver transplants: normal and abnormal. Radiographics 2003;23(5):1093-114.
Garcia-Criado A, Gilabert R, Salmeron JM, et al. Significance of and contributing factors for a high resistive index on Doppler sonography of the hepatic artery immediately after surgery: prognostic implications for liver transplant recipients. AJR Am J Roentgenol 2003;181(3):831-8.
Ho MC, Wu YM, Hu RH, et al. Surgical complications and outcome of living related liver transplantation. Transplant Proc 2004;36(8):2249-51.
Saing H, Fan ST, Tam PK, et al. Surgical complications and outcome of pediatric liver transplantation in Hong Kong. J Pediatr Surg 2002;37(12):1673-7.
Quiroga S, Sebastia MC, Margarit C, et al. Complications of orthotopic liver transplantation: spectrum of findings with helical CT. Radiographics 2001;21(5):1085-102.
Boraschi P, Donati F. Complications of orthotopic liver transplantation: imaging findings. Abdom Imaging 2004;29(2):189-202.
Dodd GD 3rd, Memel DS, Zajko AB, et al. Hepatic artery stenosis and thrombosis in transplant recipients: Doppler diagnosis with resistive index and systolic acceleration time. Radiology 1994;192(3):657-61.
Berry JD, Sidhu PS. Microbubble contrast-enhanced ultrasound in liver transplantation. Eur Radiol 2004;14 Suppl 8:P96-103.
Brancatelli G, Katyal S, Federle MP, et al. Three-dimensional multislice helical computed tomography with the volume rendering technique in the detection of vascular complications after liver transplantation. Transplantation 2002;73(2):237-42.
Kim BS, Kim TK, Jung DJ, et al. Vascular complications after living related liver transplantation: evaluation with gadolinium-enhanced three-dimensional MR angiography. AJR Am J Roentgenol 2003;181(2):467-74.
Kaneko J, Sugawara Y, Akamatsu N, et al. Prediction of hepatic artery thrombosis by protocol Doppler ultrasonography in pediatric living donor liver transplantation. Abdom Imaging 2004;29(5):603-5.
Sidhu PS, Marshall MM, Ryan SM, et al. Clinical use of Levovist, an ultrasound contrast agent, in the imaging of liver transplantation: assessment of the pre- and post-transplant patient. Eur Radiol 2000;10(7):1114-26.
Cook GJ, Crofton ME. Hepatic artery thrombosis and infarction: evolution of the ultrasound appearances in liver transplant recipients. Br J Radiol 1997;70:248-51.
Sidhu PS, Ellis SM, Karani JB, et al. Hepatic artery stenosis following liver transplantation: significance of the tardus parvus waveform and the role of microbubble contrast media in the detection of a focal stenosis. Clin Radiol 2002;57(9):789-99.
Denys AL, Qanadli SD, Durand F, et al. Feasibility and effectiveness of using coronary stents in the treatment of hepatic artery stenoses after orthotopic liver transplantation: preliminary report. AJR Am J Roentgenol 2002;178(5):1175-9.
Patel JV, Weston MJ, Kessel DO, et al. Hepatic artery pseudoaneurysm after liver transplantation: treatment with percutaneous thrombin injection. Transplantation 2003;75(10):1755-57.
Ko EY, Kim TK, Kim PN, et al. Hepatic vein stenosis after living donor liver transplantation: evaluation with Doppler US. Radiology 2003;229(3):806-10.
Maluf DG, Stravitz RT, Cotterell AH, et al. Adult living donor versus deceased donor liver transplantation: a 6-year single center experience. Am J Transplant 2005;5(1):149-56.
Boraschi P, Braccini G, Gigoni R, et al. Detection of biliary complications after orthotopic liver transplantation with MR cholangiography. Magn Reson Imaging 2001;19(8):1097-105.
Shaw AS, Ryan SM, Beese RC, et al. Ultrasound of non-vascular complications in the post liver transplant patient. Clin Radiol 2003;58(9):672-80.
Bridges MD, May GR, Harnois DM. Diagnosing biliary complications of orthotopic liver transplantation with mangafodipir trisodium-enhanced MR cholangiography: comparison with conventional MR cholangiography. AJR Am J Roentgenol 2004;182(6):1497-504.
Scarsbrook AF, Warakaulle DR, Dattani M, et al. Post-transplantation lymphoproliferative disorder: the spectrum of imaging appearances. Clin Radiol 2005;60(1):47-55.
Ferris JV, Baron RL, Marsh JW Jr, et al. Recurrent hepatocellular carcinoma after liver transplantation: spectrum of CT findings and recurrence patterns. Radiology 1996;198(1):233-8.
Lo CM. Complications and long-term outcome of living liver donors: a survey of 1,508 cases in five Asian centers. Transplantation 2003;75(3 Suppl):S12-5.
|Received 25 November 2005; received in revised form 26 February 2006; accepted 9 March 2006
Correspondence: Department of Radiology, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, China. Tel: (852) 2855 3692; Fax: (852) 2819 3591; E-mail: email@example.com (Lilian Leong).
Please cite as: Leong L, Ultrasound of living donor liver transplantation, Biomed Imaging Interv J 2006;2(2):e17
This article has been viewed 37338 times.