Doppler Ultrasound in Living Donor Liver

Transplantation: Role of Portal Venous Flow

Eisele RM, Schumacher G, Settmacher U, Neuhaus P

Department of General, Visceral and Transplantation Surgery,

Charitè Campus Virchow Klinikum, University of Berlin, Germany

Department of General and Visceral Surgery,

Friedrich-Schiller-University, Jena, Germany

Disclosure of any financial interest or hazard is provided by the author on behalf of the study group

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Doppler Ultrasound in Living Donor Liver Transplantation: Role of Portal Venous Flow

• Excellent results if selection of donor and recipient is proper and strict

• Scheduled procedure

• Donor is known previously and available for hemo- dynamic in house- examinations

Living Donor Liver Transplantation in Adults

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• Right Liver Lobe (Segments V - VIII)

• One Hepatic Artery

• One Portal Venous Branch

• Right Hepatic Vein, occasionally with

Reconstruction of the Middle

or Inferior Right Hepatic Vein

Doppler Ultrasound in Living Donor Liver Transplantation: Role of Portal Venous Flow

The Segmental Liver Graft: Anatomical Considerations

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Doppler Ultrasound in Living Donor Liver Transplantation: Role of Portal Venous Flow

The Segmental Liver Graft: Intraoperative View

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Doppler Ultrasound in Living Donor Liver Transplantation: Role of Portal Venous Flow

The Segmental Liver Graft: Hemodynamic Properties

• Small for Size Graft

• Reduced Total Vascular Cross-Sectional Area

• Portal Hyperperfusion

• Unknown clinical impact

Marcos A et al.: Transplantation 2000;7012:1697-1703

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Doppler Ultrasound in Living Donor Liver Transplantation: Role of Portal Venous Flow

Different Methods of Hemodynamic Assessment: Pros and Cons

• Direct intraoperative way:• Advantage: valid examination

• Disadvantage: invasive

• Indirectly using Doppler ultrasound:• Disadvantage: many chances to fail

• Advantage: repeatedly appliable

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• correct acquisition of

the Doppler signal

• precisely corrected

angle of flow direction

• exact determination

of vessels‘ diameters

Doppler Ultrasound in Living Donor Liver Transplantation: Role of Portal Venous Flow

Preconditions for Assessing Flow Volume

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Doppler Ultrasound in Living Donor Liver Transplantation: Role of Portal Venous Flow

Doppler Ultrasound and Hepatic Artery Flow

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Doppler Ultrasound in Living Donor Liver Transplantation: Role of Portal Venous Flow

Study Design

Donor

Recipient

Donor ultrasound regarding portal venous and hepatic arterial branches supply-ing the donor‘s right lobe (=graft)

Donor Procedure, Living Donor Liver Transplantation

Doppler ultra-sound of the recipient‘s graft within the first 24 h following reperfusion

Doppler ultra-sound of the recipient‘s graft within the first 48 h following reperfusion

Doppler ultra-sound of the recipient‘s graft within the first 72 h following reperfusion

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Treatment of end stage liver disease in

5 cases of ethyltoxic Cirrhosis

4 cases of Malignancy (2 CCC, 2 HCC)

3 cases of posthepatitic Cirrhosis (HCV)

2 cases of Primary Sclerosing Cholangitis

4 miscellaneous cases (Budd-Chiari-Syndrome, AIH,

Polycystic Degeneration, Primary Biliary Cirrhosis)

Doppler Ultrasound in Living Donor Liver Transplantation: Role of Portal Venous Flow

Living Donor Liver Transplantation in Adults

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Doppler Ultrasound in Living Donor Liver Transplantation: Role of Portal Venous Flow

Portal Venous Flow

0

500

1000

1500

2000

2500

3000

3500

4000

ml/min

Pretx. Posttx.

Maximum

Mean

Minimum

p < 0.001

(T-test)

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Doppler Ultrasound in Living Donor Liver Transplantation: Role of Portal Venous Flow

Hepatic Artery Flow FollowingLiving Donor Liver Transplantation

0

20

40

60

80

100

120

140

Timepoints

ml/min

HDF (n=8) LDF (n=6)

p < 0.01 (U-test)

Intra-individual analysis:

Inter-individual analysis:

p < 0.005 (T-test)

p < 0.001 (T-test)

No signifi-cance in preopera- tive values

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Doppler Ultrasound in Living Donor Liver Transplantation: Role of Portal Venous Flow

0

200

400

600

800

1000

1200

1400

1600

1 2 3 4

hdf ldf

ml/min

Timepoints

HDF (n=8) LDF (n=6)

p < 0.05 Wilcoxon for HDF

p < 0.05 Friedmanfor HDF No signi-

ficances in inter-

individual analysis

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• No possible explanation in GBWR, immunosuppres-sion, or medical

treatment with vasotropic agents

• No influence upon• survival and outcome (2 deaths, 1 successful ReTx., 2 cases of ReTx. and

subsequent death)

• vascular complications (1 HAT in a HDF pat.)

• other complications (ascitis, renal insufficiency, variceal bleeding in one HDF

pat.)

Doppler Ultrasound in Living Donor Liver Transplantation: Role of Portal Venous Flow

Clinical Implications

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Doppler Ultrasound in Living Donor Liver Transplantation: Role of Portal Venous Flow

Summarizing the Results

• Two subgroups could be distinguished in time

course of hepatic arterial flow following living donor

liver transplantation in adults

• Portal venous hyperperfusion - whereas common

in both groups - obviously does not lead to the

same hepatic arterial flow pattern in each patient.

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Doppler Ultrasound in Living Donor Liver Transplantation: Role of Portal Venous Flow

Conclusions

• Portal venous flow did not emerge to be a predictor

of arterial flow following living donor liver

transplantation in adults

• There seems to be a tendency towards a slower

portal venous flow recovery in patients with typical

hepatic arterial hypoperfusion following living donor

liver transplantation