Three-dimensional computed tomography scan analysis of hepatic vasculatures in the donor liver for living donor liver transplantation

Abstract

Because hepatic vasculatures exhibit variations, a preoperative evaluation of the vascular anatomy and an estimation of the volume of the liver graft are essential for successful adult living donor liver transplantation. Using 3-dimensional (3D) computed tomography (CT), we analyzed the volumetric and anatomical relationship of the hepatic vasculatures of liver grafts. The livers of 223 potential donors were analyzed by 3D CT. Volumetric analysis was performed for each hepatic vein and its tributaries. The anatomy of the portal vein and hepatic artery was assessed along with the biliary system via intraoperative cholangiography in 110 recipients. On the basis of the anatomical presentation of the inferior right hepatic vein (IRHV), the hepatic veins were classified as follows: in type I, the IRHV was absent; in type II, the IRHV was smaller than the right hepatic vein (RHV); and in type III, the IRHV was greater than or equal to the RHV in size. The drainage volume of the middle hepatic vein (MHV) and especially its tributaries in the right lobe increased with the size of the IRHV (P < 0.001). In type III hepatic veins with a large IRHV (17% of the donors), the MHV tributaries had the largest drainage volume in the right lobe (41.2% 6 11.8%). Furthermore, type III hepatic veins typically exhibited biliary variations in 75% of the donors. No correlation was observed between variations in the hepatic artery and portal vein. In conclusion, a right lobe graft with a large IRHV is accompanied by a large drainage volume via the MHV and by bile duct variations in 17% of livers. Therefore, anatomical and volumetric analysis is important for preoperative evaluations. Living donor liver transplantation (LDLT) is an alternative to deceased donor liver transplantation for the treatment of patients with end-stage liver disease. 1 However, its application in adult recipients has been complicated by the problems associated with anatomical variations of hepatic vasculatures 2 and insufficient graft volume caused by venous outflow disturbances. 3 This is particularly true when the right lobe is selected for transplantation.To successfully perform right lobe LDLT, the drainage volume of the middle hepatic vein (MHV) tributaries and the inferior right hepatic vein (IRHV) must be Abbreviations: 3D, 3-dimensional; A1, normal branching of the hepatic artery; A2, replacement of the left hepatic artery from the left gastric artery; A3, replacement of the right hepatic artery from the superior mesenteric artery; A4, middle hepatic artery arising from the left hepatic artery; A5, middle hepatic artery arising from the right hepatic artery; B1, normal branching of the biliary duct; B2, trifurcation of the biliary duct; B3, posterior branching from the left hepatic duct; B4, independent posterior branching from the common hepatic duct; B5, segment 3 or 4 bile duct from the right hepatic duct; CT, computed tomography; IRHV, inferior right hepatic vein; LDLT, living donor liver transplantation; LGA, left gastric artery; LHV, left hepatic vei...

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