Hepatic Outflow Insults in Living-Related Liver Transplantation: By Doppler Sonography T.L. Huang, T.Y. Chen, C.L. Chen, Y.S. Chen, C.C. Wang, S.H. Wang, K.W. Chiu, Y.C. Chiang, H.L. Eng, B. Jawan, V.H. de Villa, H.H. Weng, T.Y. Lee, and Y.F. Cheng L IVING related liver transplantation (LRLT) with par- tial left or right liver graft from a living donor has been developed for both children and adult recipients in recent years for treatment of end-stage liver disease. These pro- cedures are different from traditional hepatectomy in that intact hepatic inflow and outflow are necessary in both graft and remnant liver. Hepatic outflow insufficiency remains the major complication in graft failure. 1 In this study, Doppler ultrasound (DUS) was used to predict and monitor hepatic outflow of the partial liver graft during and after transplantation. MATERIALS AND METHODS From June 1994 to March 2001, there were 60 liver transplants at our center, including 48 children and 12 adults, with ages of 0.8 to 50 years (average of children and adult groups to be 3.4 and 43.2, respectively). DUS studies were performed following the sequence of hepatic vein (HV), portal vein, and hepatic artery vascular anastomoses, as well as on abdominal closure and on serial postoperative days. Retrospective review of the measurements of hepatic outflow velocity and waveform revealed two distinct groups. The normal group was defined as a biphasic or triphasic hepatic waveform. The abnormal group was defined as a monopha- sic waveform. The significance of HV peak velocity (Va) was also analyzed between these two groups. RESULTS Of 60 transplants, 53 cases were found to have normal hepatic waveforms (76% of biphasic waveform, and 24% of triphasic waveform) with average velocity of 54 cm/sec and 40.2 cm/sec, respectively. Abnormal monophasic hepatic venous waveform was found in seven cases, six children and one adult) with average velocity of 10.2 cm/sec (range from 3 to 20 cm/sec). Four partial left liver grafts with over- righted rotation that caused venous angulation were found during operation with monophasic waveform and with an average velocity of 6.5 cm/sec. Three of them were cor- rected by graft repositioning with hanging the graft to the left and fixing the falciform ligament to the anterior abdo- men wall. Another case was corrected by putting a Foley balloon catheter behind the graft for releasing the acute venous angulation. The waveforms were changed to bipha- sic or triphasic pattern with and their Va were also changed from 3 to 15 cm/sec to 30 to 78 cm/sec (average of 48 cm/sec). One case with an over-weighted graft and vascular compression was found after abdomen wall closure in a small child. Biphasic HV waveform and normal average velocity (49 cm/sec) were regained after using prosthetic abdomen wall reconstruction. Hepatic venous stenosis was found in two patients after transplants with-presentation of massive ascites. Monophasic waveform and low peak veloc- ity of 15 and 20 cm/sec were found. They were successfully corrected by balloon dilatation and vascular stenting with normal waveforms and Va of 81 cm/sec and 103 cm/sec, respectively. All cases retained normal liver function after transplantation. DISCUSSION The normal waveforms of the hepatic vein are usually multiphasic reflecting the pressure change in the right atrium, causing pulsatile biphasic or triphasic waveform. In the HV outflow insufficiency, the multiphasic pulses could not be transmitted to the hepatic vein; only monophasic waveform could be seen under DUS detection. 2 The veloc- ity of the hepatic vein may also be affected by a number of parameters, including the patency of the outflow tract and the amount of the total inflow. In our experience, when hepatic artery (HA) inflow alone is inadequate, there is little effect on the velocity and waveform of the HV. With inadequate portal vein (PV) inflow, there is only a minor effect on the velocity and waveform of the HV. Otherwise, if the total hepatic inflow is decreased remarkably, both flat monophasic HV waveform and decrease of Va could ap- pear. 3,4 The hemodynamics of the velocity and waveform of the HV, PV, and HA would reveal corresponding changes From the Department of Diagnostic Radiology, (T.L.H., T.Y.C., H.H.W., T.Y.L., Y.F.C.), General Surgery and Liver Transplant Program (C.L.C., Y.S.C., C.C.W., S.H.W., K.W.C., Y.C.C., H.L.E., B.J., V.H.dV.), Chang Gung University and Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, Taiwan. Supported by the grant NO: NSC 89-2314-B-182A-112-M08 from the National Science Council of Taiwan. Address reprint requests to Yu-Fan Cheng, MD, Department of Diagnostic Radiology, Chang Gung Memorial Hospital, Kaohsiung Medical Center, 123, Ta Pei Road, Niao-Sung, Kaohsiung, Taiwan. 0041-1345/01/$–see front matter © 2001 by Elsevier Science Inc. PII S0041-1345(01)02492-7 655 Avenue of the Americas, New York, NY 10010 3464 Transplantation Proceedings, 33, 3464–3465 (2001)