Abdominal Intervention for Liver Transplant Candidates

The interventional radiologist plays a critical role in the multi-disciplinary approach to the liver transplant patient. Pretransplant, the
interventionalist uses diagnostic angiographic procedures to define the anatomy for the surgeon. Increasingly, successful interventional radiologic procedures such as transjugular intrahepatic portosystemic shunt (TIPS) and biliary stricture dilation allow transplantation to be delayed. In the posttransplant patient, interventional radiologic manipulation is more effective than surgery in the management of many postoperative complications.

Interventional radiology as a subspecialty of radiology that arose following the introduction of diagnostic catheter angiography in the 1950s, as
initially described by Seldinger. Technical advances in angiography led to so-called interventional applications. One of the earliest was the use of diagnostic catheters for the treatment of gastrointestinal hemorrhage by infusion of vasoconstrictive drugs. The development of the modern balloon dilatation catheter for transluminal angioplasty by Gruntzig et al in the mid-1970s was an important step in converting this predominantly diagnostic modality into a therapeutic one. More recent innovations include a variety of percutaneous drainage procedures and the use of vascular and biliary stents.

Pretransplantation

Diagnostic Arteriography

The pretransplant evaluation is usually performed without angiography. Noninvasive modalities such as ultrasound, computed tomography, and
magnetic resonance imaging have largely replaced angiography for diagnostic evaluation in the liver transplant population. However, on occasion angiography is necessary. Arteriography can easily define the arterial anatomy of the native liver if a significant abnormality or variation is suspected on noninvasive imaging. If the celiac trunk is narrowed by atherosclerosis or compression by the median arcuate ligament, then aortography not only confirms this prior to transplantation, but also gives precise anatomic detail.

Occasionally, a patient is referred for transplant with known or suspected thrombosis of the portal vein. The surgeon, before contemplating transplant, must be able to find a superior mesenteric vein or vein branch large enough to support the anastomosis to the donor portal vein. Cut-film superior mesenteric arteriography with tolazoline hydrochloride enhancement and prolonged venous filming can delineate this anatomy.

Percutaneous Transhepatic Cholangiography, Biliary Drainage, and Stricture Dilation

Chronic biliary obstruction with subsequent hepatic failure is a common indication for liver transplantation. Primary sclerosing cholangitis,
congenital obstructions, and surgical bile duct injuries account for many such candidates. In the course of evaluating these patients for transplantation, it is not unusual to find central ductal strictures that have not been completely treated. If so, liver function can be stabilized or even improved by repair of the underlying abnormality, and transplantation can be deferred. In some instances, this delay is critical in allowing other medical conditions to stabilize.