Complications after Liver Transplant Related to Preexisting Conditions: Diagnosis, Treatment, and Prevention.

Diagnostic imaging after orthotopic liver transplant focuses primarily on depicting complications related to surgical hepatic vascular and biliary anastomoses. Less common preexisting vascular conditions include congenital anatomic variants, atherosclerosis, chronic portal venous thrombosis, splenic artery and variceal steal phenomena, and transarterial embolization (TAE) for hepatocellular carcinoma (HCC). If unappreciated or left untreated preoperatively, these conditions negatively impact the transplant by impairing hepatic arterial or portal vascular inflow. Many of the complications related to preexisting vascular conditions can be prevented or mitigated by proper performance and careful evaluation of preoperative imaging studies. The authors describe the diagnosis and treatment of complications arising from narrowing of the celiac axis by atherosclerosis and the median arcuate ligament, variant anatomy of the hepatic artery, insufficiency of the portal vein requiring surgical conduits, and large varices or an enlarged splenic artery and spleen that may steal blood and compromise hepatic arterial or venous inflow. While preoperative evaluation primarily involves CT and MRI, postoperative diagnosis involves screening with sonography and confirmation with other modalities. We propose the use of a preoperative checklist of vascular status and measurements in patients undergoing liver transplant. Reports of imaging studies in recipients after transplant should include details of surgical vascular anastomoses and conduits, any history of HCC and preoperative TAE, details of the preoperative α-fetoprotein levels, and any unusual procedures or pathologic findings in the explanted liver that may affect postoperative surveillance. The authors review the pretransplant imaging evaluation of vascular and HCC issues that may affect surgical outcomes and methods to help recognize complications after transplant that can arise from these conditions.©RSNA, 2020.