European Journal of Radiology 85 (2016) 1271–1283 Contents lists available at ScienceDirect European Journal of Radiology j ourna l h om epage: www.elsevier.com/locate/ejrad Graft complications following orthotopic liver transplantation: Role of non-invasive cross-sectional imaging techniques Piero Boraschi * , Maria Clotilde Della Pina, Francescamaria Donati 2nd Unit of Radiology—Department of Diagnostic Radiology, Vascular and Interventional Radiology, and Nuclear Medicine, Pisa University Hospital, Via Paradisa 2, 56124 Pisa, Italy a r t i c l e i n f o Article history: Received 1 March 2016 Received in revised form 10 April 2016 Accepted 13 April 2016 Keywords: Liver transplantation Graft complications Multidetector CT MR imaging MR cholangiography Contrast-enhanced MR cholangiography a b s t r a c t Orthotopic liver transplantation is the treatment of choice in adult patients with endstage liver disease. Survival of both graft and patient has progressively improved over time due to improvements in surgical and medical treatment. However, post-transplant complications still have a significant impact on mor- bidity and mortality associated with transplant surgery. The most common adverse events of the graft include vascular (arterial and venous stenosis and thrombosis), biliary (leakage, strictures, stones) and parenchymal complications (hepatitis virus C infection, HCC recurrence, liver abscesses). The diagnosis of these adverse events is often challenging because of the low specificity of clinical and biologic findings. Different diagnostic algorithms have been proposed for the detection of graft complications and, in this setting, radiological evaluation plays a key role in differential diagnosis of graft complications and the exclusion of other adverse events. Ultrasound examination is established the first-line method of iden- tifying adverse events in liver transplant recipients but a normal or a technically unsatisfactory study cannot exclude the presence of biliary, vascular and/or parenchymal complications. In these circum- stances, before planning any treatment, multi-detector CT and/or MR imaging and MR cholangiography should be performed for the evaluation of vascular structures, biliary system, liver parenchyma and fluid collections. The aim of this review is to illustrate the role and state-of-the-art of non-invasive cross- sectional imaging techniques in the diagnosis and management of complications which primarily affect the graft in patients after liver transplantation. © 2016 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Liver transplantation is currently the preferred treatment for patients with acute or advanced chronic liver failure for whom no other treatment option is available [1,2]. Over the last decades, refinement of surgical techniques and advances in periopera- tive management has significantly improved the outcomes of liver transplantation. However, postoperative complications after ortothopic liver transplantation (OLT) still have a significant impact on the morbidity and mortality of recipients. The common adverse events include vascular (arterial and venous stenosis and thrombosis), biliary (leakage, strictures, stones) and parenchymal complications (hepatitis virus C infection, HCC recurrence, liver abscesses) [3]. * Corresponding author at: 2nd Unit of Radiology—Department of Diagnostic Radi- ology, Vascular and Interventional Radiology, and Nuclear Medicine, Pisa University Hospital, Via Paradisa 2, 56124 Pisa, Italy. E-mail addresses: p.boraschi@do.med.unipi.it, p.boraschi@gmail.com (P. Boraschi). Postoperatively, the main goal of diagnostic imaging techniques is to identify early and late complications, thus influencing the man- agement of recipients and significantly contributing to increase graft and patient survival [4]. Knowledge and prompt recognition of post-OLT complications with the most suitable imaging method are crucial for both graft and patient survival. A series of diagnostic and interventional imaging techniques are actually available for the evaluation of liver transplant recipients. Radiologists and clinicians should aware of capabilities and limits of each of them in order to optimize the diagnosis of adverse events, especially in the presence of life- and graft-threatening biliary and vascular complications. The purpose of this review is to illustrate the role and new devel- opments of state-of-the-art non-invasive cross-sectional imaging techniques in assessing and managing complications primarily affecting the graft in patients previously undergoing orthotopic liver transplantation. http://dx.doi.org/10.1016/j.ejrad.2016.04.008 0720-048X/© 2016 Elsevier Ireland Ltd. All rights reserved.