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Published online before print June 13, 2002, 10.1148/radiol.2242011340
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(Radiology 2002;224:586-591.)
© RSNA, 2002

Technical Developments

Potential Living Liver Donors: Evaluation with an All-in-One Protocol with Multi–Detector Row CT1

Tobias Schroeder, MD, Silvio Nadalin, MD, Jörg Stattaus, MD, Jörg F. Debatin, MD, MBA, Massimo Malagó, MD and Stefan G. Ruehm, MD

1 From the Departments of Diagnostic Radiology (T.S., J.S., J.F.D., S.G.R.) and Transplantation Surgery (S.N., M.M.), University Hospital Essen, Hufelandstrasse 55, D-45122 Essen, Germany. Received August 7, 2001; revision requested September 28; revision received November 27; accepted January 7, 2002. Address correspondence to T.S. (e-mail: tobias.schroeder@uni-essen.de).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 Materials and Methods
Results
 Discussion
 REFERENCES
 
Multi–detector row computed tomography was performed for the preharvest evaluation of 14 potential living liver donors. Both a biliary contrast agent and a conventional iodinated contrast agent were administered intravenously. This protocol included acquisition of three subsequent scans and allowed accurate assessment of the hepatic parenchymal morphology and volumetrics and a detailed analysis of the biliary and vascular anatomies.

© RSNA, 2002

Index terms: Angiography, comparative studies, 761.1248, 952.12916 • Computed tomography (CT), helical • Computed tomography (CT), three-dimensional, 761.12117 • Liver, transplantation


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
Materials and Methods
Results
 Discussion
 REFERENCES
 
As a reflection of the severe shortage of cadaveric liver transplants, living donor liver transplantation has evolved into a more frequently considered therapeutic option in recent years (1–4). This procedure allows healthy adults to donate a portion of their liver to compatible recipients with end-stage liver disease (5).

After overcoming the psychologic barriers of agreeing to donate part of an organ, the potential liver donor must undergo an extensive and costly preharvest assessment, during which a majority of candidates are eliminated mostly owing to unfavorable hepatic parenchymal, biliary, or vascular morphologies (6). The current evaluation protocol proceeds in a stepwise fashion and includes computed tomography (CT) to accomplish liver planimetry and to exclude parenchymal lesions, endoscopic retrograde cholangiopancreatography (ERCP) to assess the biliary anatomy, and conventional digital subtraction angiography (DSA) to display the hepatic vascular system. Accurate knowledge of the hepatic parenchymal and vascular anatomies is crucial to reduce the frequency of complications during and after transplantation (7–9).

The purpose of our study was to evaluate an all-in-one three-phase dual-enhancement multi–detector row CT approach that combines analysis of the hepatic parenchyma with assessment of the vascular and biliary anatomies.


   Materials and Methods
TOP
 ABSTRACT
 INTRODUCTION
 Materials and Methods
Results
 Discussion
 REFERENCES
 
Patient Population
Between May and July 2001, 14 consecutive potential living liver donors (age range, 20–48 years; mean age, 33 years) (six women [age range, 24–48 years; mean age, 36 years] and eight men [age range, 20–42 years; mean age, 31 years]) underwent evaluation with the three-phase dual-enhancement multi–detector row CT protocol. The study was conducted in accordance with the guidelines of the local ethics committee. Written informed consent was obtained from all patients.

Laboratory analysis had revealed normal liver function for all potential donors before the CT examination. Single-phase multi–detector row CT had already been part of the preharvest assessment protocol of potential liver donors. For ethical reasons, the study protocol with DSA and ERCP was limited to those patients in whom multiphase multi–detector row CT images were deemed insufficient to display the relevant anatomy.

Multi–Detector Row CT Protocol
CT imaging was performed with a four–detector row CT scanner (Volume-Zoom; Siemens Medical Systems, Erlangen, Germany). The multi–detector row CT protocol consisted of three image sets of the liver that were collected in succession with the following parameters: 120 kVp, 150–180 mAs, section thickness of 4 mm, collimation of 1 mm, feed rotation of 6 mm, rotation time of 0.5 second, and reconstruction increment of 1 mm. Each image set was collected over 20–25 seconds. The in-room time was closely monitored.

The first CT image set was acquired at 25 minutes ± 5 (mean ± SD) after infusion of 100 mL of a biliary contrast agent (Biliscopin; Schering, Berlin, Germany) at a rate of approximately 0.1 mL/sec through a 20-gauge catheter placed in an antecubital vein. The agent was administered to delineate the biliary system, which contained the excreted contrast agent. Thus, the first image set provided a detailed view of the contrast material–enhanced intra- and extrahepatic biliary tree. Infusion of the biliary contrast agent was tolerated well by all 14 patients. No adverse reactions were observed.

Subsequently, CT angiography was performed to display the hepatic arterial anatomy. For this purpose, 140 mL of an iodinated contrast agent (Imeron 350; Bracco, Milan, Italy) was administered intravenously with an automated injector (CT9000; Liebel-Flarsheim, Cincinnati, Ohio) at a rate of 5 mL/sec. Automated bolus tracking with bolus detection at the level of the ascending aorta ensured accurate timing of the arterial phase. To display the portal and hepatic venous anatomy, a third CT image set was acquired at 20 seconds following the arterial data. The in-room time ranged between 7 and 12 minutes (mean, 10 minutes). The total examination time, including preparation of the patients and slow infusion of the biliary contrast agent outside the scanner room, was between 25 and 35 minutes.

Image Analysis
Analysis of the image data was based on source images and three-dimensional postprocessed images (maximum intensity projections and shaded surface displays for instant overview of the biliary and vascular morphologies, and volume renderings for the final assessment and documentation). All data were postprocessed with a commercially available workstation (Virtuoso; Siemens Medical Systems). To provide a more realistic three-dimensional impression, the data were also reviewed in stereo mode, including visual enhancement with artificial coloring (10,11). All data were reviewed and evaluated by two radiologists (T.C., S.G.R.) in conjunction with at least one transplantation surgeon (M.M.), with consensus. Only relevant findings were documented on film. Image analysis was focused on the following aspects.

Assessment of CT study as diagnostic versus nondiagnostic.—The study was regarded as diagnostic when the biliary and vascular structures were sufficiently enhanced to allow reliable determination or exclusion of anatomic variants, particularly with respect to the surgical procedure.

Exclusion of focal liver lesions.—The hepatic parenchyma was assessed for the presence of masses on the basis of all three collected image sets. Similarly, other organs were assessed for concomitant disease.

Size of hepatic lobes.—Hepatic volumes were determined by manually tracing the contours of the entire liver and the right hepatic lobe on the venous image set. To facilitate calculation of hepatic volumes, the sections were divided into 10-mm-thick intervals by using a planimeter (12–15). By subtracting the volume of the right hepatic lobe from the total liver volume, the volume of the left hepatic lobe was determined.

Morphology of the biliary system.—The biliary anatomy as displayed on the initial image set was analyzed and assessed for anatomic variants according to Couinaud (16).

Morphology of the hepatic arterial system.—The celiac trunk, splenic artery, common hepatic artery, proper hepatic artery, gastroduodenal artery, right and left hepatic arteries beyond the level of the first bifurcation, and the superior mesenteric artery were assessed on the second image set. Each vessel was assessed for the presence of vascular disease, including stenoses, aneurysms, or arterial anatomic variants characterized according to the classification of Michels (17).

Morphology of the portal and hepatic veins.—The portal venous system was evaluated on the third image set by separately analyzing the splenic and superior mesenteric veins, the portal vein, and the right and left portal branches. On the same images, the three hepatic veins were examined.

Image analysis on the basis of both source images and manually optimized postprocessed images, including manual planimetry of hepatic volumes and detailed assessment of the biliary and vascular morphology, required between 40 and 60 minutes.

Intraoperative Comparisons
Findings at multi–detector row CT regarding biliary and vascular morphologies were compared with intraoperative findings, which were available in four of the 14 donors. The predicted transplant volumes and the intraoperatively determined transplant weight were compared on the basis of a 1:1 conversion factor (15).

Postoperative Follow-up
Postoperatively, the donors remained under clinical observation for 15 days ± 2. Daily clinical examination and blood analysis were performed as part of the clinical routine. In combination with liver function tests, abdominal CT or magnetic resonance (MR) imaging was performed routinely at 10 days, 1 month, and 3 months postoperatively to document the altering liver size.


   Results
TOP
 ABSTRACT
 INTRODUCTION
 Materials and Methods
Results
Discussion
 REFERENCES
 
All 14 examinations were deemed fully diagnostic regarding display of the biliary and vascular morphologies, thereby obviating DSA, ERCP, or both.

Liver Parenchyma and Liver Volume
In all 14 patients, the liver parenchyma was visualized with high spatial resolution. Eleven patients did not have any parenchymal abnormalities. One patient had a 2.0 x 2.5 x 2.0-cm hemangioma in segment 8. In a second patient, a 1.5 x 2.0 x 2.0-cm lesion with early arterial enhancement and of undetermined origin was identified in segment 6. Diagnostic biopsy revealed an adenoma. One patient had multiple small cysts (<4 mm) in the right hepatic lobe.

The total liver volumes ranged between 1,040 and 1,716 mL (mean, 1,349 mL). The volume of the right lobe ranged between 626 and 1,040 mL (mean, 851 mL), which corresponds to 57.4% and 71.4% (mean, 63.1%) of the total liver volume, respectively.

Intraoperative assessment of the resected transplant volumes showed a mean difference of 9% ± 2 compared with the values predicted with multi–detector row CT by both overestimating (n = 2) and underestimating (n = 2) the transplant volume.

Biliary System
The biliary tree was clearly visualized to the third and frequently to the fourth level of intrahepatic branches (Figs 1–3). Standard anatomy according to the Couinaud classification (16), including a simple bifurcation at the upper biliary confluence, was seen in six patients (Fig 1). Eight patients had biliary variants, including trifurcation at the upper biliary confluence (n = 3), drainage of an additional right hepatic duct into the left hepatic duct (n = 2), drainage of an additional right hepatic duct into the common hepatic duct (n = 1), and direct drainage of a small left lobe duct into the right hepatic duct (n = 3). One patient had sludge in the gallbladder. Intraoperative assessment (n = 4) confirmed the following CT findings: normal biliary anatomy (n = 1), a small left lobe duct that drained into the right hepatic duct (n = 2), and an additional right hepatic duct that drained into the common hepatic duct (n = 1).



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  		Figure 1. Oblique coronal three-dimensional CT cholangiogram is normal, with bifurcation of the common hepatic duct into the right and left hepatic ducts at the upper confluence (arrow).

 


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  		Figure 2. Transverse CT cholangiographic source image shows a trifurcation of the biliary ducts at the upper confluence (arrow) as a normal variant.

 


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  		Figure 3. Oblique coronal three-dimensional CT cholangiogram obtained in the same patient as in Figure 2 shows a trifurcation at the upper confluence (arrow) and a small branch (arrowhead) from segment 4 that drains into the middle right hepatic duct.

 
Hepatic Arteries
CT angiography accurately depicted the arterial supply of both hepatic lobes in all 14 patients (Fig 4). Five patients had standard arterial anatomy with both lobes supplied by single arteries that originated from the celiac trunk through the common and proper hepatic arteries (17–19). Arterial variants were identified in the remaining nine patients, including solitary arterial supply of the right lobe from the superior mesenteric artery (n = 2), supplemental arterial branches to the right lobe that originated from the superior mesenteric artery (n = 2), solitary arterial supply of the left lobe from the left gastric artery (n = 1), supplemental arterial branches to the left lobe supplied by the left gastric artery (n = 5), and doubled left hepatic arteries that originated from the proper hepatic artery (n = 1). In one patient, the left gastric and common hepatic arteries originated from the aorta. In another patient, the left lobe was supplied by small branches that were fed by both the left gastric and common hepatic arteries, with the latter originating from the superior mesenteric artery. Arterial anatomic findings were confirmed intraoperatively in the four patients who had undergone harvest: normal arterial supply (n = 2), complete arterial supply of the right lobe and partial arterial supply of the left lobe by the superior mesenteric artery with another left lobe artery coming from the left gastric artery (n = 1), and a supplemental arterial branch to the left lobe coming from the left gastric artery (n = 1).



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  		Figure 4. Oblique coronal three-dimensional CT arteriogram in the same patient as in Figure 2 shows a doubled left hepatic artery (thin arrows) coming from the common or proper hepatic arteries. The biliary system is still contrast enhanced and shows the trifurcation at the upper confluence (thick arrow) and the topographic relationship of both branches of the systems. A doubled renal artery (arrowhead) is depicted posterior to the splenic vein.

 
Portal and Hepatic Veins
CT in the portal or hepatic venous phases was diagnostic in all 14 patients (Fig 5). Eleven patients had normal anatomy. Variants in the remaining three patients included a portal venous branch to the dorsolateral liver segments that originated directly from the portal bifurcation, a short (<1-cm) stem of the right portal vein, and a doubled right portal vein.



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  		Figure 5. Oblique coronal three-dimensional CT angiogram in the portal or hepatic venous phases in the same patient as in Figure 2. The right and middle hepatic veins fuse (arrow) proximal to the inferior vena cava. The biliary system is still contrast enhanced and shows the topographic relationship of both systems.

 
Similarly, the hepatic veins were accurately demonstrated (Fig 5). Venous anatomy was rated normal in 13 patients, including common drainages into the inferior vena cava in five patients, and detection of a high confluence between the right main and right dorsolateral branches in two. In addition, an accessory communication was seen between the left and middle hepatic veins. The following findings were also verified intraoperatively: standard anatomy (n = 2), accessory communication between the left and middle hepatic veins (n = 1), and functional trifurcation of the portal vein (n = 1).

Other Findings
Other findings that were not relevant for the preoperative assessment included renal cysts (n = 2) and doubled renal arteries (n = 7). Our findings are summarized in the Table.


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  		Summary of CT Findings in 14 Consecutive Potential Living Liver Donors

 
Postoperative Complications
Within the 3-month postoperative follow-up, none of the four donors had a complication that required additional imaging studies or therapeutic intervention.


   Discussion
TOP
 ABSTRACT
 INTRODUCTION
 Materials and Methods
Results
 Discussion
REFERENCES
 
This three-phase dual-enhancement multi–detector row CT protocol provides a comprehensive preharvest analysis of living related liver donors. The protocol permits assessment of the hepatic parenchymal morphology and volumetrics, in conjunction with a detailed and accurate analysis of the biliary and vascular anatomy, thereby obviating arterial DSA or ERCP as part of the preharvest protocol. The examination is well tolerated and easily performed.

Essentially, this approach is based on the simultaneous application of two contrast agents in combination with multi–detector row CT and advanced image postprocessing. This three-phase protocol proved to be efficient, robust, and accurate. The examination was well tolerated, examination times never exceeded 35 minutes, and no technical failures occurred. The spatial resolution was sufficient to allow assessment of the underlying parenchymal, biliary, and vascular morphologies most accurately as evidenced by the excellent intraoperative correlation in all four available cases. Since the transplantation surgeons were comfortable with the information provided with the three-phase multi–detector row CT protocol, correlative DSA and ERCP examinations were not performed for ethical reasons. The excellent correlation with intraoperative findings is mirrored in recent reports that demonstrate complete agreement between CT angiography and DSA and between CT cholangiography and ERCP (20–23).

Multi–detector row CT protocols have previously been advocated for preharvest assessment of potential liver donors (24,25). The documented strategies had been limited, however, to analysis of the hepatic parenchyma and vascular supply. This three-phase dual-enhancement protocol goes one step further: It includes a detailed depiction of the biliary tree within the same examination. A similarly comprehensive approach has recently been proposed on the basis of MR imaging (26) that permits depiction of the biliary tree on heavily T2-weighted images. While MR cholangiography has been shown to be accurate regarding the detection of intra- or extrahepatic ductal dilation (27,28), the spatial resolution is frequently insufficient to depict the normal biliary system beyond the hepatic bifurcation (29,30). This insufficiency represents a considerable drawback in the preoperative assessment of potential liver donors.

Failure to recognize even minor anatomic variants of the biliary tree can result in severe postoperative leaks and other complications (31). The fact that only six of 14 patients had normal biliary anatomy emphasizes the value of preoperative CT cholangiography. Similarly, the high number of vascular variations detected in this limited number of potential donors demonstrates the profound demands on preoperative imaging and serves as an indication of the high spatial and temporal resolutions achievable with multi–detector row CT techniques (32).

Beyond its inherent noninvasiveness, this multi–detector row CT protocol provides the advantage of three-dimensional depiction of the imaged structures, which results in an immediate understanding of vascular or biliary variants. Even though the source images provided all required anatomic information, the image analysis was considerably more time consuming, and the perception of the anatomy was less intuitive. The simultaneous display of biliary and vascular structures in stereo mode and, thus, the depiction of topographic relationships was considered most helpful by transplantation surgeons. This display increased the understanding of the underlying hepatic anatomy, which considerably facilitated the surgical planning process.

However, this three-phase dual-enhancement protocol harbors potential risks. Thus, administration of the biliary contrast agent requires normal hepatic function or a bilirubin level below 35–70 µmol/L (33–35). Since only patients with normal hepatic laboratory parameters enter the donor program, this does not represent a true limitation. More important, the biliary agents are known to be associated with considerable side effects, ranging from mild and self-resolving symptoms like sensation of warmth, unpleasant taste, nausea, vomiting, and erythema to moderate and severe systemic adverse reactions that can lead to shock syndrome and death (20). The agent was well tolerated in this limited group of potential donors, but further experience needs to be gained. In the United States, however, the use of Biliscopin is restricted since it has not yet been approved by the U.S. Food and Drug Administration. Another potential weakness of this protocol relates to the uptake of biliary contrast agent into the hepatic parenchyma. The resultant enhancement of normal parenchyma may mask fatty infiltration of the liver. Since the value of CT scans for this indication is already a matter of controversy (24,36), all preharvest evaluation protocols include a diagnostic liver biopsy.

We conclude that this three-phase dual-enhancement multi–detector row CT strategy, which includes CT cholangiography and CT angiography, has the potential to replace the combinations of various partially invasive diagnostic procedures listed in the donor evaluation protocols. This strategy might increase patient acceptance, reduce costs, and increase acceptance of the pretransplantation survey by potential donors (37).


   FOOTNOTES
 
Abbreviations: DSA = digital subtraction angiography, ERCP = endoscopic retrograde cholangiopancreatography

Author contributions: Guarantors of integrity of entire study, S.G.R., M.M.; study concepts, S.G.R., T.S.; study design, T.S., S.G.R., M.M.; literature research, T.S., S.N.; clinical studies, T.S., S.G.R., M.M., S.N., J.S.; data acquisition and analysis/interpretation, T.S., J.S., S.G.R.; statistical analysis, J.S., S.N.; manuscript preparation, T.S.; manuscript definition of intellectual content, S.G.R., J.F.D., T.S.; manuscript editing, T.S.; manuscript revision/review, J.F.D., S.G.R.; manuscript final version approval, all authors.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 Materials and Methods
Results
 Discussion
 REFERENCES
 

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