Radiology in Transplantation

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Radiology in Transplantation

• Liver, Kidney, Pancreas

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Role of diagnostic imaging

• Evaluation of indications and contraindications
  before transplantation
• Follow up of the transplanted organ/patient
• Function, vascularisation
• Neoplasm, Infections
• Basic methods
• Color Doppler and B-mode Ultrasound
• X-ray plain films and Fluoroscopy
• CT, MR, Scintigraphy
• Biopsy, Aspiration, FNAB

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Basic imaging follow up

• Chest X-ray, and US with CDUS assessment of the
  transplanted organ regularly and in cases of
  clinical signs
• Evaluation for PTLD and other neoplastic
  disorders with X-ray and US yearly
• Special examinations (CT, MR etc) in patients
  with known risk factors (HCC, PTLD, heavy
  smokers...), or clinical signs

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Interventional Radiology

• Special patients, organs in strange locations
  and with multiple anastomosis
• Vascular complications
• Arteries
• Veins
• Non-vascular complications
• Biliary (LX)
• Ureter/bladder/prostate
• Fluid collections

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Preoperative imaging

• Indications/contraindications
• Comorbidities/infections
• Evaluation of risks
• Malignant tumors (staging)
• Patient selection
• Anatomical variations, vascular status
• Living donation
• Liver (CTA, MRA, MRCP, Volumetry)
• Kidney (CTA, MRA, Scintigraphy)

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Acut liver failure/elevated intracranial
pressure/brain edema/ ONS US (Fundamentals of
transorbital sonographic evaluation of optic
nerve sheath expansion under intracranial
hypertension II. Patient study. Helmke K, Hansen
HC. Pediatr Radiol. 1996 Oct26(10)706-10. Echogr
aphic correlation of optic nerve sheath size and
cerebrospinal fluid pressure. Galetta S, Byrne
SF, Smith JL.J Clin Neuroophthalmol. 1989
Jun9(2)79-82 Detection and monitoring of
intracranial pressure dysregulation in liver
failure by ultrasound. Helmke K, Burdelski M,
Hansen HC. Transplantation. 200070(2)392-5.) Non
invasive, bedside, easy, quick, reliable. Mobile
US, B-mode, more than 7,5Mhz linear transducer.
5,7mm cutoff value!
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Volumetric Calculations

• TLV total liver volume
• TFLV total functional liver volume TLV tumor
  volume
• FRLV future remaining liver volume
• FLVR functional liver volume ratio
• FRLV/TFLV (gt30)
• GRWR graft-to-recipient weight ratio
• lt1 SmfS,1-3 MS,3-5 LS, gt5 XLS

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Vascular complications after LX/RX

• Arteria (hepatic/renal) - v.portae
• Stenosis, thrombosis, bleeding, steal sy.
• Surgery
• PTA (stent),???
• Embolisation
• V.cava inf. Hepatic vein/renal vein
• Stenosis, thrombosis PTA/stent, thrombolysis

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Arterial complications CDUS

• Lack of intrahepatic/intrarenal arterial flow
• HAT/RAT
• Low velocity (lt20cm/sec, in a central hepatic
  artery), low RI flow (lt0,50), parvus-tardus
  pattern, elongated acceleration time, lack of ESP
• HAT, HAS, RAS

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Arterial complications, CTA, MRA, DSA

• Direct visualisation of a stenosis
• HAS/RAS
• Direct visualisation of a kinking
• HAS/RAS
• Lack of filling of the whole, or segment of the
  hepatic (renal) artery/vascular graft, with or
  without intrahepatic (renal) refilling from
  collaterals
• HAT/RAT

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Poststenotic intrahepatic arterial flow low RI,
elongated systolic acceleration time, ESP
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CDUS control after stenting
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Venous complications

• Portal vein (clinical signs )
• CDUS
• No flow - thrombosis, occlusion
• Revers flow large portosystemic shunts
• Low flow intrahepatically and/or high velocity
  extrahepatically (anastomisis), /- high flow
  collaterals - stricture/torsion
• CTA/MRA
• Direct visualisation of stenosis (in 3D)
• Increased filling of collaterals, shunts

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Venous complications

• V.cava inferior, Hepatic veins (Clinical signs )
• CDUS
• High flow at the site of the stricture/torsion
• Dilated vein low velocity, monophasic
  prestenotic flow
• Visualisation of a thrombus/stricture/torsion
• CTA, MRA, DSA
• Visualisation of stenosis/thrombus
• Pressure gradient measurement during DSA
• Thrombosis of renal vein
• CDUS upside-down M sign, High RI, no venous
  outflow

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Bleeding

• Iatrogenic
• Early p.op. surgery
• Biopsy AVF, pseudoaneurysm, bleeding
• Rare in the liver
• After minimally invasive therapies
• ERCP, Endourology, Uroradiological interventions
• From hepatic/splenic artery aneurysm
• Diagnostic imaging
• Localize the bleeding site, source and the
  hematoma
• US, CT, (MR), DSA

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Non-vascular complications

• Liver
• Biliary
• Biloma
• Leakage
• Extrahepatic/anastomotic stricture
• Intrahepatic stricture
• Sludge/stone
• Other fluid collections
• Hematoma
• Seroma
• Lymphocele

• Kidney
• Ureter
• Urinoma
• Leakage
• Anastomotic stricture
• PU stricture
• VUR/infections
• Stone/debris
• Other fluid collections
• Hematoma
• Seroma
• Lymphocele

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Biliary complications Dg.Im.

• US/CT
• Dilatation (sometime mild), sludge, stone
• Visualisation of the stricture
• MR
• MRCP 3D visualisation of the bile ducts and
  other fluid collections. Assessment of filling
  defects
• NU HIDA/BrIDA
• Signs of cholestasis
• PTC/PTD/ERCP
• DgTherapy (dilatation, stent, drainage)

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Pyelo-ureteral complications

• US/CT/CTU
• Dilatation (sometime mild), debris, stone
• Visualisation of the stricture (rare with US)
• MR
• MRU 3D visualisation of the dilated collecting
  system and other fluid collections without
  contrast media. Assessment of filling defects
• NU Signs of retention
• PNS/Retrograde pyelography
• DgTherapy (dilatation, stent, drainage)

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Perirenal fluid collection

• Aspiration, for culture and chemical examinations
• Lymphocele 15
• Between 4-16 weeks
• Urinoma
• Painful, higher temperature, early post op., can
  be seen on scintigraphy.
• Hematoma, seroma, abscess

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PAK, IAK, SPK

• SPK
• Same diagnostic methods
• Evaluation of pancreas morfology an dvascularity
• Assessment of complication, vascular thrombosis
• Fluid collections, pancreatitis
• Biopsy
• Islet after kidney transhepatic portal vein
  canulation, slow infusion of islets

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Others (post TX)

• Infections
• Lung, GI, Neuro, Joints and bones, abscesses
• Post Tx tumors
• PTLD
• HCC
• Others

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Summary

• Diagnostic imaging/Radiology
• Key role in patient selection and follow up
• Interventional Radiology
• Minimally invsive alternative treatment options
• More tolerable than surgery, with good results
• Special interventions (IAK, Hepatocyta TX...)
• Team work
• Surgeons, hepatologists, nephrologists,
  infectologists, anesthesiologists, immunologists,
  gastroenterologists, radiologists
  (intervention), etc.