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VASCULAR IMAGING OF THE LIVER

VASCULAR IMAGING OF THE LIVER. Edward G. Grant M. D. Dept. of Radiology University of Southern California Keck School of Medicine. Normal Vascular Anatomy. 3 separate vascular systems PV, HA, HV’s PV 70 - 75% blood / O 2  liver Hepatic artery subordinate

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VASCULAR IMAGING OF THE LIVER

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  1. VASCULAR IMAGING OF THE LIVER Edward G. Grant M. D. Dept. of Radiology University of Southern California Keck School of Medicine

  2. Normal Vascular Anatomy • 3 separate vascular systems • PV, HA, HV’s • PV 70 - 75% blood / O2 liver • Hepatic artery subordinate • Essential in LTX selectively  biliary tree • 3 normal hepatic veins  IVC • Recognize by anatomy, spectral patterns

  3. Normal Celiac Axis

  4. Normal Vascular Anatomy: Hepatic Artery

  5. Normal Vascular Anatomy:Portal Vein

  6. Normal Vascular Anatomy:Hepatic Veins

  7. Congenital Anomalies &Normal Variants • Normal variants • HA: • Accessory, replaced, separate LHA’s • Commonly arises from SMA, posterior to PV • PV: • Length of extrahepatic PV • HV’s • Inferior/ accessory RHV • Innumerable variations of branching

  8. Congenital Anomalies & Normal Variants • PV aneurysms • HA / PV fistulae • High pressure HA  low pressure PV • Symptomatic  severe portal HTN • HV / PV fistulae • Low pressure HV  low pressure PV • Asymptomatic unless huge  encephalopathy • HV / IVC webs ( BCS)

  9. Portal Vein Aneurysm

  10. HA / PV fistulae

  11. HA / PV fistulae

  12. Hemangioendothelioma

  13. HV / PV fistulae

  14. Portal Vein Thrombosis • Color Doppler sonography • Sensitivity = 98%, specificity = 92% • Accuracy = 92% • Negative predictive value = 98% • Good screening technique • Negative Doppler study = no further w/u • Low flow (severe portal HTN)  false + • Adjust color sensitivity, use power Doppler Tessler et al. AJR 1991;157:293

  15. Portal Vein: Thrombosis

  16. Portal Vein: Thrombosis

  17. Portal Vein: Thrombosis

  18. Portal Vein Thrombosis

  19. Portal Vein Thrombosis & HCC Pozniak et al. Radiology 1991;180:663

  20. Cavernous Transformation

  21. Cavernous Transformation

  22. Portal Hypertension

  23. Portal Hypertension

  24. Portal Hypertension

  25. Portal Hypertension:Collaterals: Coronary Vein

  26. Portal Hypertension:Collaterals - PUmb Vein

  27. Portal Hypertension:Collaterals - Splenorenal

  28. Porto-Systemic Shunts • Porto-caval •  Portal flow  encephalopathy • Selective • Distal spleno-renal (Warren) • Mesocaval • Mesoatrial • Transjugular intrahepatic portosystemic shunt -- TIPS Grant et al.AJR 1990;154:393

  29. Porto-systemic Shunts

  30. TIPS • R / M hepatic vein  portal bifurcation •  flow, bile leak  neointimal hyperplasia  stenosis • High failure rate (at HV end) • Routine US surveillance • Q 3 months • Focal  flow velocity at stenosis • General  velocity in shunt = HV stenosis Dodd et al. AJR 1995;164:1119 Kantermann et al. AJR 1997; 186:467

  31. TIPS

  32. TIPS - Left Portal Vein

  33. TIPS

  34. TIPS Thrombosis

  35. Post TIPS Thrombosis

  36. TIPS - HV Stenosis

  37. TIPS - HV Stenosis

  38. TIPS HV Stenosis

  39. TIPS Reversed MHV

  40. TIPS / US Contrast Furst et al. AJR 1998;170:1047

  41. The Pulsatile Portal Vein • Abnormal portal vein communications • Porto-systemic shunts • HV / PV fistulae • HA / PV fistulae (more arterialized) • Transmitted cardiac pathology • Right heart failure • Tricuspid regurgitation Duerinckx et al. Radiology 1990; 176:655 Abu-Yousef et al. AJR 1990: 155:785

  42. The Pulsatile Portal Vein

  43. The Pulsatile Portal Vein

  44. Budd - Chiari Syndrome • Hepatomegaly, abdominal pain, ascites • Gray scale = vein, color ≠ flow (50%) • Gray scale ≠ vein, color ≠ flow (50%) • Intrahepatic collaterals: “spider web” • Bicolor vein, capsular, portal vein reversed • Blockage ≠ all 3 veins (selective) • PV thrombosis = 20%, IVC blocked = 80% Millener et al. AJR 1993; 161:307

  45. Budd - Chiari Syndrome

  46. Budd - Chiari Syndrome

  47. Budd - Chiari Syndrome

  48. Budd Chiari Syndrome

  49. Budd Chiari Syndrome

  50. Budd - Chiari Syndrome Bargallo X. et al. AJR 2003; 181:1641

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