Hepatic Arterial Velocity Research Articles

Hepatic arterial hemodynamics and model for end-stage liver disease (MELD) scores in chronic liver disease: insights from Doppler ultrasonography

BackgroundDoppler ultrasonography is essential to provide insights into hemodynamic alterations and liver function changes in pre-cirrhotic and cirrhotic patients. Utilizing Doppler examinations, this study aims to explore the correlation between hepatic arterial hemodynamics and Model for end-stage liver disease (MELD) scores in chronic liver disease patients.MethodsA study of 50 chronic liver disease patients included sonographic assessments, measuring liver, portal vein size, and flow. Hepatic artery velocity, resistive index (RI), pulsatility index (PI), and acceleration time (AT) were evaluated. Biochemical parameters (serum bilirubin, creatinine, INR) were used to calculate MELD scores, compared with different Doppler sonographic parameters.ResultsThe study found a mean peak systolic velocity (PSV) of 107.42 ± 48.10, with end-diastolic velocity (EDV) of 26.40 ± 14.68, RI of 0.74 ± 0.06, and PI of 1.47 ± 0.24. The mean MELD score was 19.28 ± 6.09. Correlations between MELD scores and PSV, EDV, RI, PI, and AT did not yield statistically significant correlations. 80% of subjects displayed high RI (> 0.7) values in the hepatic artery, and a significant correlation was found between portal vein thrombosis and hepatic artery PSV and RI (p < 0.05).ConclusionsHepatic artery RI and PSV show a significant correlation with portal vein thrombosis. Doppler ultrasonography, while not directly tied to MELD scores, is valuable for non-invasive liver disease monitoring when invasive methods are impractical. Further research is needed to unravel the relationships between hemodynamic changes, MELD scores, and clinical outcomes in a broader patient population.

Pediatric hepatic hemangiomas: spectrum and prognostic significance of initial ultrasound findings.

Hepatic hemangiomas may be associated with serious complications; however, it is unknown whether ultrasound (US) features can predict complications. To analyze initial US features of hepatic hemangiomas predictive of complications. This is a single-center retrospective cohort study of clinical, biological, and imaging data of infants with hepatic hemangioma between 2000 and 2018. Patients were categorized as having or not having any complication(s). Associations between initial US features and complications were analyzed through logistic regression. Receiver operating characteristic (ROC) curve analyses were performed to determine optimal cutoff values for continuous variables. Stepwise forward logistic regression was used to construct risk prediction models with training and validation sets. Model calibration and discrimination were evaluated using Hosmer-Lemeshow tests, area under the ROC curve, and overall accuracy. Of 112 infants with hepatic hemangioma, 67 (60%) had focal, 32 (28%) had multifocal, and 13 (12%) had diffuse lesions, with complication rates of 51%, 34%, and 92%, respectively, mostly cardiac (54/57, 95%). The US characteristics of the hemangiomas were diverse. Risk factors for complications included diffuse subtype; large tumor volume (focal forms); elevated peak systolic hepatic arterial velocity (PSV); and hepatic vein dilation. For focal forms, initial tumor volume >40ml and PSV >100cm/s had >70% sensitivity and specificity, respectively, to predict complications; a model including these variables had 75% overall accuracy in the validation set. For multifocal/diffuse forms, a PSV >115cm/s had sensitivity and specificity to predict complications of >70%; a model including this variable had 78% overall accuracy in the validation set. Diffuse subtype, large tumor volume, elevated hepatic arterial PSV, and hepatic vein dilation are risk factors for complications of hepatic hemangiomas.

Splenic Artery Steal Syndrome in Patients with Liver Cirrhosis: A Retrospective Clinical Study.

BACKGROUND Splenic artery steal syndrome (SASS) can aggravate liver damage in patients with cirrhosis. This study explored whether SASS could be an effective therapeutic target for improving hepatic artery perfusion and liver function in patients with decompensated cirrhosis. MATERIAL AND METHODS Based on inclusion and exclusion criteria, 87 patients with hepatitis B cirrhosis and portal hypertension hypersplenism admitted to our General Surgery Department for splenectomy and pericardial devascularization surgery were selected. A total of 35 cases met the diagnostic criteria of SASS and were assigned to the SASS group; the remaining 52 cases were assigned to the control group. The indicators before, during, and after surgery were compared between the 2 groups. RESULTS There were no significant differences in preoperative and intraoperative indicators between SASS group and control group (P>0.05). The MELD score 7 days after surgery and the hepatic artery diameter and hepatic artery velocity 14 days after surgery in both groups were significantly better than before surgery. The MELD score 7 days after surgery in the SASS group was significantly better than that in the control group, and the hepatic artery diameter and hepatic artery velocity 14 days after surgery in the SASS group were significantly better than those in the control group (P<0.05). CONCLUSIONS Splenectomy and pericardial devascularization surgery was an effective treatment to redirect blood flow to the hepatic artery for cirrhotic patients diagnosed with SASS. The introduction of cirrhotic SASS into clinical practice may benefit more patients with cirrhotic portal hypertension and hypersplenism.

Diagnostic Value of Color Doppler Ultrasound and Contrast-Enhanced Ultrasound in the Artery Steal Syndrome After Orthotopic Liver Transplantation.

This study aimed to investigate the application of color Doppler ultrasound (CDU) and contrast-enhanced ultrasound (CEU) in the early diagnosis of arterial steal syndrome (ASS) after orthotopic liver transplantation (OLT). A total of 1827 patients received OLT in our department between January 2007 and December 2021, and CDU and CEU were performed after surgery. Ultrasonographic data were collected and further analyzed. ASS was confirmed by digital subtraction angiography (DSA), and the use of splenic artery embolization was dependent on the DSA findings and clinical conditions. The ultrasonographic data were collected before and after embolization. ASS was found in 23 patients (23/1827; 1.26%). CDU: the portal vein velocity was higher than normal in 17 patients (52.83±21.74 cm/s); the hepatic artery flow signals disappeared in 7 patients; the hepatic artery velocity was 13.57±5.85 cm/s in 16 patients. In 23 patients, the spleen artery velocity was 170.12±32.04 cm/s. CEU: the hepatic artery was observed in 7 patients without hepatic artery flow signals on CDU; in 23 patients, the contrast agent reached the portal vein at the presence of contrast in the hepatic artery or earlier (difference: 2.21±1.09 s). Splenic artery embolization was done in 17 of 23 patients with ASS. The hepatic artery flow velocity, hepatic artery resistance index, splenic artery velocity and time to the presence of contrast were significantly improved after embolization (P<0.05). CDU and CEU are the preferred, effective tools in the diagnosis of ASS. Reduced peak hepatic artery velocity, increased spleen artery velocity and reduced time difference in the contrast reaching the portal vein and hepatic artery are indicative of ASS.

Effect of meal intake for evaluating hepatic artery by Doppler ultrasonography in liver transplants: Does fasting matter for screening hepatic artery due to hemodynamic changes in splanchnic circulation?

The aim of this study is to assess the utility of fasting on Doppler ultrasonography findings of hepatic artery in liver transplants. Liver transplant patients without vascular abnormalities were prospectively evaluated between December 2017 and January 2020. Doppler sonography was used to describe hemodynamic changes in response to a standard meal. The diameter, peak systolic velocity, blood flow, resistive index (RI) of the main hepatic artery and portal vein peak velocity were measured. The mean hepatic arterial diameter of 44 patients was higher in the fasting group (4.5mm) than in the postprandial group (3.3mm) (p<.05). The mean hepatic arterial blood flow decreased (from .276 to .127 L/min) and hepatic arterial RI increased (from .66 to .71) following meal ingestion (p<.05). Hepatic arterial velocity was significantly lower and portal venous velocity was higher after oral intake. Meal ingestion has an important effect on hepatic artery Doppler features in liver transplants. Therefore, Doppler ultrasound evaluation should be considered after appropriate fasting due to postprandial responses of liver transplant.

S2707 A Case of Fatal Immune Checkpoint Inhibitor Mediated Hepatitis

Introduction: Immune checkpoint inhibitors (ICPI) have become mainstays of therapy for advanced malignancies including melanoma, lung cancer, and renal cell carcinoma. Although they have shown promising mortality benefit, their risk of serious immune-related toxicities, including hepatitis, is increasingly documented in the literature. Case Description/Methods: A 27-year-old man with stage IV renal cell carcinoma on nivolumab/ipilimumab was transferred from state prison for acute transaminitis and hyperbilirubinemia. Prison records showed AST 3267, ALT 2236, and total bilirubin 5.9, increased from AST 113 and ALT 156 two weeks prior. On presentation the patient endorsed generalized abdominal pain and fatigue. Sclera were icteric and the abdomen was diffusely tender to palpation without organomegaly. Abdominal ultrasound revealed mild hepatomegaly, elevated hepatic artery velocity, and numerous gallstones. Broad work up to exclude other etiologies of liver failure was negative. Treatment included high-dose solumedrol, mycophenolate mofetil, n-acetylcysteine, and ursodiol. Transaminases improved but bilirubin worsened to >34. Repeat abdominal ultrasounds showed no biliary obstruction. An MRCP was non-diagnostic due to procedural intolerance. Hospital course was complicated by encephalopathy, septic shock from bacteremia, renal failure and disseminated intravascular coagulation. The patient was not a transplant candidate due to metastatic malignancy. He transitioned to comfort-oriented measures and expired within 24 hours. Discussion: ICPI mediated hepatitis is typically asymptomatic and occurs 6-14 weeks following treatment initiation, as was the case in our patient. Treatment is guided by the severity of hepatic injury as represented by transaminase and bilirubin levels (Grades 1-4) and typically involves medication discontinuation and steroid administration. Severe disease is also treated with mycophenolate mofetil. Acute hepatitis occurs in less than 5-10% of patients receiving a single ICPI, with 1-2% experiencing grade 3-4 hepatitis. However, grade 3-4 hepatitis has been observed in approximately 20% of patients receiving ipilimumab + nivolumab, consistent with previous findings that combination CTLA-4 and PD-1 blockade is associated with more frequent and more severe immune-related toxicities. This case illustrates a rare but important complication of dual ICPI therapy that, if not promptly diagnosed and treated, can be fatal.Figure 1.: Mechanisms of Action of Ipilimumab and Nivolumab.

Assessment of hemodynamic parameters of hepatic and visceral blood flow in decompensated liver cirrhosis

The aim. To assess the hemodynamic parameters of the hepatic and visceral blood flow in patients with compensated and decompensated liver cirrhosis. Materials and methods. 290 patients with liver cirrhosis were examined: 206 had gastrointestinal bleeding, 84 had diuretic-resistant ascites. Ultrasonic scanning, Doppler sonography, esophagogastroduodenoscopy, angiography, radioisotope scintigraphy were performed to assess blood flow in the portal, splenic and superior mesenteric veins and in the hepatic, splenic and superior mesenteric arteries. Results. Change in the hepatic microcirculatory blood flow in the natural course of liver cirrhosis was characterized by decreased portal and increased arterial blood flow, “arterialization” of hepatic blood flow based on scintigraphy. Decompensation of the disease was associated with progressive reduction in both portal and arterial hepatic blood flow, which were correlated with the severity of functional liver disorders regardless of the complication nature. The portal blood flow in the natural course of liver cirrhosis was characterized by 3.5–4.5 times increased volume of visceral blood. Decompensation of the disease was accompanied by a decrease in blood flow in the portal vein as compared to the splenic and superior mesenteric veins by 1.8–2.2 and 1.5–2.7 times, respectively. Arterial blood flow in the natural course of liver cirrhosis was characterized by a relatively increased hepatic arterial flow. The ultrasound criterion of hepatic blood flow “arterialization” was an increase in hepatic-splenic arterial index, which can be used as a sign to differentiate between different forms of portal hypertension. Decompensation of the disease was characterized by an average of 8.2 % decreased arterial blood flow in the hepatic artery compared to the splenic artery in dynamics. Prognostically unfavorable signs were the progression of splenomegaly degree, the increase in the portal vein diameter with the decreased velocity characterizing the increase in congestive index by 2.4–2.6 times, the decrease in the hepatic artery diameter and velocity in it over time.Conclusions. The hepatic and visceral blood flow characteristics should be considered when choosing method of conservative, surgical or minimally invasive treatment of liver cirrhosis complications. Based on the hepatic hemodynamic characteristics, the mismatch between portal perfusion (reduced) and visceral blood flow (increased) is the essence of portal hypertension in liver cirrhosis. Accordingly, the criterion of treatment effectiveness in decompensated liver cirrhosis should be improved portal liver perfusion and (or) reduced volume of visceral blood flow.

Doppler ultrasound in liver cirrhosis: correlation of hepatic artery and portal vein measurements with model for end-stage liver disease score in Egypt

BackgroundLiver cirrhosis is a multi-etiological entity that alters the hepatic functions and vascularity by varying grades. Hereby, a cross-sectional study enrolling 100 cirrhotic patients (51 males and 49 females), who were diagnosed clinically and assessed by model for end-stage liver disease (MELD) score, then correlated to the hepatic Doppler parameters and ultrasound (US) findings of hepatic decompensation like ascites and splenomegaly.ResultsBy Doppler and US, splenomegaly was evident in 49% of patients, while ascites was present in 44% of them. Increased hepatic artery velocity (HAV) was found in70% of cases, while 59% showed reduced portal vein velocity (PVV).There was a statistically significant correlation between HAV and MELD score (ρ = 0.000), but no significant correlation with either hepatic artery resistivity index (HARI) (ρ = 0.675) or PVV (ρ =0.266).Moreover, HAV had been correlated to splenomegaly (ρ = 0.000), whereas HARI (ρ = 0.137) and PVV (ρ = 0.241) did not significantly correlate.Also, ascites had correlated significantly to MELD score and HAV (ρ = 0.000), but neither HARI (ρ = 0.607) nor PVV (ρ = 0.143) was significantly correlated.Our results showed that HAV > 145 cm/s could confidently predict a high MELD score with 62.50% and 97.62 % sensitivity and specificity.ConclusionDoppler parameters of hepatic vessels (specifically HAV) in addition to the US findings of hepatic decompensation proved to be a non-invasive and cost-effective imaging tool for severity assessment in cirrhotic patients (scored by MELD); they could be used as additional prognostic parameters for improving the available treatment options and outcomes.

S1103 Predicting Hepatic Artery Complications Post-Liver Transplantation

INTRODUCTION: Hepatic artery complications after liver transplantation can impact overall morbidity and mortality and may be challenging to identify and treat. We describe our experience evaluating hepatic artery complications after liver transplantation (LT) in a single transplant center. METHODS: This is a retrospective analysis of 358 patients who underwent LT at a single liver transplant center between 2013 and 2018. Hepatic artery complications, both stenosis (HAS) and thrombosis (HAT), were followed for overall occurrence post-LT. Laboratory abnormalities, doppler ultrasound (US) velocities, infections, rate of hepatic abscess, restenosis rates, mortality and post-transplant inpatient parameters were collected. Wilcoxon Rank sum was used to compare continuous variables, and Fisher’s Exact Test to compare categorical variables. Logistic regression was also utilized for analyses of lab abnormalities, and hepatic artery velocities adjusting for age, gender, and race. P-value of < 0.05 was considered statistically significant. RESULTS: Demographic features of those with and without HAS and HAT are shown (Table 1). HAS post-LT was associated with an increased rate of graft failure (16.7%, P = 0.02), restenosis (11.5%, P < 0.001), and overall mortality (23.1%, P = 0.02). HAT was associated with an increase in ICU length of stay (6 days, P = 0.002), hospital LOS (13 days, P = 0.005), surgical re-exploration (34.6%, P = 0.001), graft failure (26.9%, P = 0.007), restenosis (15.4%, P = 0.005), and death (34.6%, P = 0.007). On doppler US, no specific hepatic artery velocity cutoff was identified that predicted HAS, HAT, infection or hepatic abscess. However, serial evaluation of biliary markers revealed that elevation in alkaline phosphatase (ALP) day 3 post-transplant (Table 2) when compared to day 0 (day of transplant) was found to be associated with HAS (23% rise on day 3 compared to day of transplant, P = 0.03). In contrast, ALP changes were not associated with the development of HAT. Changes in bilirubin and ALP did not predict biliary complications including biliary leak post-LT. CONCLUSION: HAS and HAT resulted in increased rate of graft failure, restenosis, and overall death. Doppler US features did not predict hepatic artery complications but changes in ALP post-LT day 3 were predictive of HAS but not HAT. Laboratory features did not predict the severity of biliary complications. Further research is necessary to identify predictors of HAS and HAT and associated biliary complications post-LT.Table 1.: Demographics and clinical characteristicsTable 2.: Laboratory abnormalities post-transplant predicting hepatic artery and biliary complications (any occurrence post-LT)

Markedly elevated hepatic arterial velocity-HAV greater than 200 cm/s-is not specific to hepatobiliary disease.

The aim of the study was to review the different etiologies and outcomes of patients with hepatic artery velocities greater than 200 cm/s. This retrospective study included 88 hospitalized patients in whom angle-corrected proper hepatic artery flow velocities greater than 200 cm/s were obtained during an abdominal ultrasonographic examination. Peak systolic hepatic artery flow velocities, hepatic artery resistance index, and portal vein flow velocities were evaluated. The patients were then allocated to one of four groups based on their primary underlying diagnosis: structural liver disease, nonstructural liver disease, generalized infection, or miscellaneous. The median hepatic artery velocity was similar for all groups, ranging from 226 to 238 cm/s. The maximum portal venous velocities were not significantly different between groups. No lab values were statistically different between the groups, except total bilirubin that was greater in the nonstructural liver disease group (8 mg/dL). Overall, 9/88 (10.2%) of patients with elevated hepatic artery velocity died within 30 days of their ultrasonographic examination. Elevated hepatic artery velocity greater than 200 cm/s in hospitalized patients is not specific to primary hepatobiliary disease but may indicate acute hepatic dysfunction from other causes such as infection or sepsis.

Historical and Contemporary Management of Infantile Hepatic Hemangioma: A 30-year Single-center Experience.

To describe outcome of infants with hemangioma(s) of the liver. Infantile hepatic hemangiomas exhibit a diverse phenotype. We report our 30-year experience and describe optimal management based on precise radiological classification. Retrospective review of 124 infants (66 female) 1986-2016. Categorical analysis with Chi2 and nonparametric comparison. Data expressed as median (range) and P < 0.05 considered significant. Lesions classified as focal (n = 70, 56%); multifocal (n = 47, 38%) or diffuse (n = 7, 6%) and of these 80(65%) were symptomatic (eg, cardiac failure n = 39, 31%; thrombocytopenia n = 12, 10%).Increased hepatic artery velocity was seen in 63 (56%). Median hepatic artery velocity was greatest in diffuse lesions [245 (175-376) cm/s vs focal 120 (34-242) cm/s vs multifocal 93 (36-313) cm/s; P = 0.0001]. Expectant management alone was followed in 55 (44%). Medical therapy was utilised in 57(46%) and sufficient for symptom control in 29/57 (51%). Propranolol therapy (from 2008) was sufficient for symptom control in 22/28 (79%). Surgery (hepatic artery ligation n = 26; resection n = 13; embolization n = 1) was required in 40 (32%). Median maximal lesion diameter was 3 (0.5-17.1) cm and greater in those requiring surgery (7 cm vs 4.9 cm; P = 0.04). The proportion requiring surgery decreased markedly in the propranolol era [pre-propranolol 25/48 (52%) vs post-propranolol 16/76 (21%) (P = 0.0003)]. Systematic follow-up with ultrasound to a median of 2.6 (0.02-16) years. A proportion of infantile hepatic hemangiomas remain asymptomatic permitting observation until resolution but the majority require complex multi-modal therapy. First-line pharmacotherapy with propranolol has reduced but not abolished the need for surgery.

Ultrasound in Hepatic Veno-occlusive Disease (HVOD) after Pediatric Hematopoietic Stem Cell Transplantation (HSCT): Comparison of Diagnostic Criteria Including the Pediatric Criteria of European Society for Blood and Marrow Transplantation (EBMT)

The European Society for Blood and Marrow Transplantation (EBMT) has recently announced new diagnostic criteria for pediatric hepatic veno-occlusive disease (HVOD) after hematopoietic stem cell transplantation (HSCT). We retrospectively inspected 97 ultrasound exams of 60 pediatric HSCT patients, and compared its diagnostic value using the Baltimore, Seattle and pediatric EBMT criteria. Nine of the ten patients who were diagnosed as HVOD only in the EBMT criteria had severe or very severe HVOD. In the Seattle and EBMT criteria, portal vein velocity, peak systolic velocity and resistance index of hepatic artery, gallbladder wall thickening and ascites were statistically significant. No ultrasound variable showed significant association in the Baltimore criteria. All patients with portal vein velocity below 10 cm/s were in higher EBMT grade. A scoring system was developed, to evaluate the overall relationship of the ultrasound findings with the diagnosis of HVOD, showing fair (0.768 and 0.733) AUC in the ROC curve of EBMT and Seattle criteria.

3:36 PM Abstract No. 302 Effect of bridging locoregional therapy on hepatic arterial complications following liver transplant: 3-year, multicenter, retrospective analysis of 608 patients

Recent studies have suggested a relationship between intra-arterial therapy and the development of HAS following orthotopic liver transplant (OLT). This study evaluates the role of pretransplant locoregional therapies on post-OLT HAS. An IRB-approved, multicenter, retrospective analysis was performed on all patients who underwent liver transplant from January 2, 2016, to December 30, 2018 (n = 608). Patients undergoing locoregional therapy were identified, which was determined based on consensus review of a multidisciplinary liver conference for patients with hepatocellular carcinoma (HCC) and included DEB-TACE (100-300μ LC Beads mixed with doxorubicin), Yttrium radioembolization segmentectomy (TheraSphere), and thermal ablation. Additional treatments were performed as deemed necessary, based on incomplete response, with the majority of patients (n = 96) receiving 1-2 treatments. Patients were surveyed with doppler ultrasound at 1 day, 1 week, 1 month, and 3 months following orthotopic liver transplant (OLT). HAS was suspected based on findings of elevated hepatic artery velocity with downstream intrahepatic artery tardus parvus waveforms and low resistive indices and confirmed angiographically in all patients. Of the 608 patients who were transplanted during the 3-year cohort, 145 patients had HCC, and intra-arterial bridging therapy was performed on 126 patients (115 TACE, 5 Y90, and 6 TACE and Y90). Following OLT, 78 patients (13%) developed HAS. Fewer rates of HAS were noted in patients with HCC (12/145 [8.3%] vs. 66/463 [14.3%], P = 0.05). Similarly, fewer rates of HAS were encountered in patients bridged with intra-arterial therapy (10/126 [8%] vs. 68/482 [14.1%], P = 0.06). Additionally, patients who were treated with thermal ablation prior to liver transplant also had lower rates of HAS (1/24 [4%] vs. 77/584 [13%], P = 0.03). However, MELD scores at the time of liver transplant were associated with the development of HAS (P = 0.001). Intra-arterial therapy is not associated with the development of HAS following OLT; however, underlying liver disease appears to be associated with the development of HAS.

The postoperative hepatic artery resistance index after living donor liver transplantation can predict early allograft dysfunction.

To investigate whether postoperative hepatic hemodynamics have an impact on graft function.Using a retrospective cohort with 262 adult living donor liver transplantation (LDLT) recipients, we discussed the relationship between postoperative hepatic hemodynamics and patient outcomes.According to the definition of early allograft dysfunction (EAD), the patients were classified into the EAD group (43 patients) and the non-EAD group (219 patients). In terms of postoperative hemodynamic parameters, there was no significant differences between these 2 groups regarding hepatic artery flow (HAF), hepatic artery velocity (HAV), portal vein flow (PVF), and portal vein velocity (PVV), except for the hepatic artery resistance index (HARI) which was somewhat higher in the EAD group on postoperative day 3 (POD3) (0.70 vs 0.61, P < .05). According to these results, we used a ROC curve and found that a HARI of 0.68 was the cutoff point (with 73.8% sensitivity and 58.3% specificity) for predicting EAD after LDLT. In addition, multivariate analysis showed that fulminant hepatic failure, pretransplant hepatorenal syndrome, and HARI ≥ 0.68 on POD3 were independent risk factors for postoperative EAD.Our results showed that postoperative hemodynamics might influence graft function by altering hepatic artery flow.

Features of right lobe liver transplantation from living related donor

Aim. To determine the peculiarities of liver transplantation using right lobe graft from living related donor with and without the middle hepatic vein inclusion.Materials and methods. The study has analyzed preoperative, intraoperative and postoperative data of 76 recipients who underwent right lobe living donor liver transplantation with different types of hepatic vein reconstruction: group 1 – patients who received a right lobe liver graft with a middle hepatic vein, and group 2 – recipients of right lobe liver graft without the middle hepatic vein. For comparative analysis, we used biochemical and regional hemodynamic parameters in both groups during the first week and on days 10, 14, 21 and 30 after transplantation.Results. In group 1, the higher values of Qpv – 649 ± 220 ml/min, 1222 ± 491 ml/min; 1264 ± 372 ml/min; 1166 ± 284 ml/min; 1016 ± 211 ml/min; 1095 ± 301 ml/min were observed compared to group 2 – 643 ± 230 ml/min; 1127 ± 385 ml/min; 1132 ± 372 ml/min; 1030 ± 263 ml/min; 980 ± 254 ml/min; 922 ± 293 ml/min on days 0, 1, 3, 5, 7 and 30 after transplantation, respectively, (P &lt; 0.05). Peak systolic velocity (PSV) and resistance index of hepatic artery (RIha) were increased to higher values in group 2 (from 0.54 m/s to 0.69 m/s and from 0.63 to 0.69, respectively, P &lt; 0.05) compared to group 1 (from 0.58 m/s up to0.62 m / s and from 0.62 to 0.69, respectively, P &lt; 0.05). In the postoperative period, the level of total bilirubin in group 1 (grafts with middle hepatic vein) was significantly lower and the level of transaminases was higher than in group2. In the group of recipients, who had a graft with middle hepatic vein, the frequency of small-for-size syndrome (SFSS) was lower compared with group 2 (17.94 % vs 27.00 %, P &lt; 0.05).Conclusions. When performing the right lobe liver transplantation, the middle hepatic vein presence in the graft is correlated with a decrease in the frequency of postoperative complications and small for size syndrome development. Adequate venous outflow with sufficient volume of right lobe liver graft determines the functional graft mass.

Portal hypertension evolving from sickled hepatopathy: Could hepatic venous Doppler ultrasound be beneficial in its evaluation?

PurposeSickle cell intrahepatic cholestasis involves sickling within hepatic sinusoids leading to vascular stasis and localized hypoxia resulting in ballooning of the hepatocytes causing a direct back pressure effect with resultant intracanalicular cholestasis. Vascular stasis may ultimately lead to portal hypertension. We proposed to document findings suggestive of portal hypertension evolving from hepatopathy in steady-state sickle cell disease (SCD) patients using hepatic venous Doppler ultrasound. MethodsThis is a prospective case series of 6 SCD subjects in steady-state (median age, 30 years; range, 19–43), comprising of 3 males and 3 females, who underwent a routine Doppler ultrasound evaluation of their hepatic veins and were discovered to have an abnormal biphasic waveform pattern. Venous blood was obtained from all subjects to evaluate for P-selectin, homocysteine, foetal haemoglobin, haematocrit levels, white cell and platelet counts. Doppler ultrasound was also carried out on all subjects to evaluate for the hepatic waveform, right renal artery RI and PI along with the hepatic artery velocities. ResultsAll the 6 subjects had reduced haematocrit (median value of 21.5%; range, 18–25%) and some degree of renal dysfunction (plasma cystatin-C ranged from 1.6 to 12.2 mg/L). Elevated white cell count, hyperhomocysteinemia, reduced SpO2(<94.0%) and reduced estimated GFR (eGFR < 90 ml/min) was also noted in 4 subjects (66.7%). Similarly, 4 subjects (66.7%) had elevated RI in the right kidneys while 3 subjects (50.0%) had elevated PI in the right kidney. ConclusionDoppler ultrasound Hepatic vein waveform analysis may be a useful examination in the evaluation of patients with SCD as it may elicit feature of portal hypertension. Further studies are suggested to confirm this in a larger population of SCD patients using the gold standard.

Does measurement of the hepatic artery velocity improve the sonographic diagnosis of cholangitis?

To determine the frequency of elevated peak systolic proper hepatic artery velocity (HAV) in patients with acute cholangitis and to determine the diagnostic performance of this metric relative to existing criteria. Between 9/2016 and 11/2017, 107 patients clinically suspected to have cholangitis were referred for an abdominal ultrasound. Of these, 56 patients had HAV measurements and were included in the final analysis. Clinical and imaging features, including HAV, HAV resistive index (RI), portal vein velocity (PVV), biliary dilation, and presence of an obstructive etiology were extracted. The diagnostic performance of HAV was compared to the existing available clinical criteria (Charcot's triad and 2018 Tokyo Guidelines). Elevated HAV was defined as HAV > 100cm/s. Presence of cholangitis was determined by the discharge summary following medical workup and admission or observation. 32% had cholangitis while 68% did not. Average HAV for patients with cholangitis was 152 ± 54cm/s versus 91 ± 44cm/s for those without (p < 0.0001; t test). The HAV was elevated in 83% of patients with cholangitis. When considered in isolation, an elevated HAV had a high negative predictive value (90%), was more accurate (77%; 95% confidence interval 64-87%) than Charcot's triad (73%; 60-83%), and had similar accuracy compared to 2018 Tokyo Guidelines (79%; 66-88%). Substitution of conventional imaging criteria with elevated HAV in the 2018 Tokyo Guidelines yielded the highest overall accuracy of 84% (72-92%). HAV is elevated in the majority of patients with cholangitis. Substitution of an elevated HAV for conventional sonographic criteria is more accurate than existing clinical criteria in identifying patients with cholangitis.

Quantitative 4D-Digital Subtraction Angiography to Assess Changes in Hepatic Arterial Flow during Transarterial Embolization: A Feasibility Study in a Swine Model

PurposeTo determine the feasibility of using time-resolved 3D-digital subtraction angiography (4D-DSA) for quantifying changes in hepatic arterial blood flow and velocity during transarterial embolization. Materials and MethodsHepatic arteriography and selective transarterial embolization were performed in 4 female domestic swine (mean weight, 54 kg) using 100–300-μm microspheres. Conventional 2D and 4D-DSA were performed before, during, and after each embolization. From the 4D-DSA reconstructions, blood flow and velocity values were calculated for hepatic arterial branches using a pulsatility-based algorithm. 4D-DSA velocity values were compared to those measured using an intravascular Doppler wire with a linear regression analysis. Paired t-tests were used to compare data before and after embolization. ResultsThere was a weak-to-moderate but statistically significant correlation of flow velocities measured with 4D-DSA and the Doppler wire (r = 0.35, n = 39, P = .012). For vessels with high pulsatility, the correlation was higher (r = 0.64, n = 11, P = .034), and the relationship between 4D-DSA and the Doppler wire fit a linear model with a positive bias toward the Doppler wire (failed to reject at 95% confidence level, P = .208). 4D-DSA performed after partial embolization showed a reduction in velocity in the embolized hepatic arteries compared to pre-embolization (mean, 3.96 ± 0.74 vs 11.8 2± 2.15 cm/s, P = .006). ConclusionQuantitative 4D-DSA can depict changes in hepatic arterial blood velocity during transarterial embolization in a swine model. Further work is needed to optimize 4D-DSA acquisitions and to investigate its applicability in humans.

Median arcuate ligament syndrome, a rare case of chronic abdominal pain

The median arcuate ligament syndrome (MALS) is a rare disease characterized by abdominal pain caused by the external compression of the celiac artery by the median arcuate ligament. Surgical treatment is indicated, but given the non-specific symptoms, these patients are often hospitalized in the Departments of Internal Medicine where the diagnosis may be unknown. We present a case of MALS admitted to our Internal Medicine Division. An abdominal ultrasound in a woman with longstanding abdominal pain showed elevated celiac artery velocities during forced expiration. Computed tomography angiography (CTA) of the abdomen showed stenosis of the origin of the celiac artery and confirmed the diagnosis of MALS. MALS is a syndrome that has to be considered, especially in young women with abdominal pain of unclear etiology; evaluated by color Doppler ultrasound, in the presence of elevated hepatic artery velocities during forced expiration, the confirmatory test is CTA.

Performance of Hepatic Artery Velocity in Evaluation of Causes of Markedly Elevated Liver Tests

The purpose of this study was to assess the utility of peak systolic proper hepatic artery velocity (HAV) in differentiating causes of severely elevated liver function tests. HAV, hepatic artery resistive index and portal vein velocity of 41 patients with severely elevated liver function tests were evaluated. In 19 patients (46%), the causes were structural (e.g., cholecystitis, cholangitis), whereas in 22 patients (54%) the causes were non-structural (e.g., rhabdomyolysis, drug-induced liver injury). The average HAV for structural causes was 138 ± 68cm/s, and for non-structural causes, 65 ± 29cm/s (p < 0.0001). An HAV >100cm/s was correlated with structural causes (p = 0.0001). With respect to diagnostic performance, this threshold was 79% sensitive and 86% specific, with a high positive likelihood ratio (5.8) and low negative likelihood ratio (0.24). The resistive index and portal vein velocity were not statistically different. In patients with severely elevated liver function tests, an HAV >100cm/s can help distinguish structural from non-structural causes, which may guide management while awaiting definitive laboratory tests.