CLINICAL AND TRANSLATIONAL RESEARCH Hepatic Venous Drainage: How Much Can We Learn From Imaging Studies? Anatomic-Functional Classification Derived From Three-Dimensional Computed Tomography Reconstructions Arnold Radtke, 1,2,5 Georgios C. Sotiropoulos, 1 George Sgourakis, 1 Ernesto P. Molmenti, 1 Tobias Schroeder, 3 Fuat H. Saner, 1 Susanne Beckebaum, 1 Christoph E. Broelsch, 1 Dieter C. Broering, 1,2 and Massimo Malago 1,4 Background. The knowledge of “venous dominance” is essential to prevent serious venous congestion in live donor liver transplantation and extended liver resections. Aims. The purpose of our study was to delineate our proposed anatomic-functional classification of hepatic venous drainage. Methods. One hundred forty consecutive live liver donor candidates underwent three-dimensional computed tomog- raphy reconstructions and three-dimensional virtual hepatectomies. Five different venous dominance types were defined on drainage volumes or territories. “Risky” configurations were identified and classified. Results. The right hepatic vein (RHV) was dominant for the entire liver and right hemiliver (RHH) in most (83.5%) cases irrespective of the presence of inferior (accessory) hepatic veins (IHVs). The middle hepatic vein (MHV) was dominant for the total liver (TL) in 15.5% of cases and for the RHH in 27% of cases. The left hepatic vein was almost always (92%) dominant for the left hemiliver. When associated with a large IHV drainage volume, a RHV/IHV complex dominant for the TL led to a RHH dominant MHV (mean 59.5%RHH) if the IHV was not reconstructed. Conclusions. Our proposed anatomic-functional classification provides a valuable insight into hepatic vein dominance patterns. RHH venous drainage patterns at “high risk” for venous congestion include (1) a dominant MHV for the TL and (2) a dominant RHV/IHV complex with a large IHV drainage volume. Keywords: Liver surgery, Living donor liver transplantation, Liver anatomy, three-dimensional reconstruction, 3D CT, Liver imaging, Liver venous drainage, Hepatic vein anatomy, Hepatic vein dominance, Hepatic vein classification. (Transplantation 2010;89: 1518–1525) T he site of the transection plane in major liver resections and adult live donor liver transplantation (LDLT) re- mains a subject of debate (1, 2). Such controversy originates in the “discrepancy” between a bifid portoarterial inflow (Pringle-demarcation line) and a venous outflow with three major hepatic veins (HV) (3). This uneven pattern leads to an anatomical physiologic “competition” among the left and right hemilivers (LHH and RHH, respectively) for the middle HV (MHV). Given the potentially limited functional volumes of both graft and remnant livers, the optimal management of the MHV constitutes a dilemma because it can be retained only on one side (4). Thus, liver partitioning has to respect individual territories and preserve the MHV drainage in the medial sectors of either hemiliver (Couinaud segments IVa/b, V, and VIII) (2). Neumann et al. (5) investigated the MHV drainage in segments V and VIII of the right grafts in relation to the anatomic classification and observed a wide range of drainage volumes. The drawbacks of the existing anatomic classifications together with the venous outflow variants in both graft and remnant livers prompted an anatomic- functional redefinition (6). This work was supported by a grant from the German Society for Research (117/1-1:A2.2). The authors declare no conflict of interest. 1 Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany. 2 Department of General and Thoracic Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Germany. 3 Department of Diagnostic and Interventional Radiology, University Hos- pital Essen, Essen, Germany. 4 Department of Hepatobiliary Surgery, Royal Free University Hospital, Uni- versity of London, London, United Kingdom. 5 Address correspondence to: Arnold Radtke, M.D., Department of General and Thoracic Surgery, University Hospital of Schleswig-Holstein, Cam- pus Kiel, Germany. E-mail: arnold.radtke@uksh-kiel.de A.R. participated in the writing of the manuscript and in research design; G.C.S. and E.P.M. participated in the writing of the manuscript; G.S. and F.H.S. participated in data analysis; T.S. contributed new reagents or analytic tools; S.B. participated in manuscript revision; and M.M. and C.E.B. participated in research design. Received 10 September 2009. Revision requested 23 October 2009. Accepted 11 March 2010. Copyright © 2010 by Lippincott Williams & Wilkins ISSN 0041-1337/10/8912-1518 DOI: 10.1097/TP.0b013e3181dd6bac 1518 | www.transplantjournal.com Transplantation • Volume 89, Number 12, June 27, 2010