R E V I E W

A R T I C L E

The Role of Color Doppler Ultrasound in

Living Donor Liver Transplantation
Tung-Liang Huang*

Color Doppler ultrasound (CDUS) is performed to ensure perfect vascular reconstruction

after hepatic reperfusion. For the immediate assessment of general condition and early
detection of vascular complications, CDUS is becoming essential and is the modality of
choice to evaluate hepatic hemodynamics. Thus, CDUS is an important modality, which
is widely used in all types of liver transplantation, and is performed in the preoperative,
intraoperative and postoperative periods for routine evaluation of vasculature. Timely recog-
nition of any threat of vascular complications improves the success of living donor liver
transplantation. This article will review the current applications of CDUS in living donor
liver transplantation.

KEY WORDS color Doppler ultrasound, living donor liver transplantation

J Med Ultrasound 2008;16(3):177187

Introduction are involved in the diagnosis and management of

Liver transplantation (LT) is now a well accepted
therapy for end-stage liver disease. Due to a short-
age of cadaveric donors, advances in modern hep-
atectomy techniques have resulted in the success
of living donor liver transplantation (LDLT) as a
routine procedure for end-stage liver disease. LDLT
has also become the major source of livers for
transplantation, especially in Asia. However, the
threat of vascular complications is still a problem
and the major cause of graft failure. If a liver graft
fails, it is almost impossible for a patient to receive
a second graft in Taiwan; thus, it is necessary to
eliminate the possibility of graft failure. Many im-
aging modalities and interventional procedures
these problems.
Color Doppler ultrasound (CDUS) is performed
to ensure perfect vascular reconstruction after he-
patic reperfusion. For the immediate assessment of
general condition and early detection of vascular
complications, CDUS is becoming essential and is
the modality of choice to evaluate hepatic hemo-
dynamics. Thus, CDUS is an important modality
which is widely used in all types of LT and is per-
formed in the preoperative, intraoperative and
postoperative periods for routine evaluation of vas-
culature. Timely recognition of any threat of vascular
complications improves the success of LDLT [14].
This article will review the current applications of
CDUS in LDLT.

Received: August 2, 2008 Accepted: August 25, 2008

Department of Diagnostic Radiology and Liver Transplant Program, Chang Gung University and Memorial
Hospital, Kaohsiung Medical Center, Taiwan.
*Address correspondence to: Dr. Tung-Liang Huang, Department of Diagnostic Radiology and Liver Transplant
Program, Chang Gung University and Memorial Hospital, Kaohsiung Medical Center, 123 Ta-Pei Road,
Niao-Sung Hsiang, Kaohsiung Hsien 833, Taiwan. E-mail: tlhuang@adm.cgmh.org.tw

Elsevier & CTSUM. All rights reserved. J Med Ultrasound 2008 Vol 16 No 3 177
 T.L. Huang
The Principles and Methods for
Instrumental Hepatic Vascular
Measurements
The CDUS instruments used are Acuson Aspen and
Sequoia scanners (Acuson, Mountain View, CA,
USA; the machines used in most transplant centers
and published papers), which have a phased array
of 3.5, 4.0, 5.0 or 7.0 MHz scanners in the imaging
and Doppler mode, respectively. Measurements of
blood flow by Doppler ultrasound include qualita-
tive evaluations such as determination of the pres-
ence of flow, direction of color signal flow, and any
abnormal flow indicating vascular insufficiency or
stenosis. The quantitative evaluations performed
include the measurement of flow velocity, flow vol-
ume and calculation of flow index. The width of
the sample volume for pulsed Doppler flowmetry,
which ranges from 1 to 5 mm, is dependent on the
diameter of the detected vessels. The pulse repeti-
tion frequency which ranges from 3.0 to 9.0 kHz
and is selected to obtain adequate Doppler spec-
tral waveforms of the targeted blood vessels with-
out aliasing. CDUS examinations are performed for
hemodynamic evaluation of the portal vein (PV),
hepatic vein (HV) and hepatic artery (HA) in the
Fig. 1. Standard model of scanning by color Doppler ultra-
sound showed hepatic artery flow and measurement of param-
eters with angle correction and scale without aliasing. For this
case, the formula and calculations were as follows: PSV =
124 cm/s; PI = (PSV EDV)/Vm = (124 39)/71 = 1.21; RI =
PSV EDV/PSV. PI = pulsatility index; RI = resistance index;
EDV = end-diastolic velocity; Vm = mean of flow velocity.
178 J Med Ultrasound 2008 Vol 16 No 3
pretransplantation, intraoperative and postoperative
periods, respectively.
Pretransplantation study
In the pretransplantation study of the native liver of
the recipient, the measurement of PV flow is ob-
tained at the extrahepatic portion of the main PV
near the bifurcation. The size and flow direction of
the PV are recorded. Any abnormal intraluminal
portal thrombus or flow occlusion should be ruled
out. The flow of the HA is recorded along with wave-
form, peak systolic velocity (PSV), resistance index
(RI [RI = PSV EDV/PSV, where EDV = end-diastolic
velocity]) and pulsatility index (PI [PI = PSV EDV/
Vm, where Vm = mean velocity]), obtained at the
hepatic hilum for quantitative evaluation. The ab-
sence of HA flow in the liver may be related to
arterial occlusion (Fig. 1).
Intraoperative study
In the intraoperative study of the liver graft, the
measurements of HV, PV and HA are performed both
just after graft reperfusion and abdomen closure.
All the PV measurements are obtained at the intra-
hepatic and extrahepatic portion over and along
the anastomosis. The size, flow direction and veloc-
ity of the PV are recorded. The angle-corrected
flow velocity and cross-sectional area of the PV at
the same site should also be recorded. The sample
volume size for the Doppler ultrasound mode is set
at 35 mm, about half the diameter of the meas-
ured PV. The PV mean velocity should be corrected
by the angle between the long axis of the PV and
the Doppler beam of less than 60. The portal flow
volume per body weight is also calculated by the
PV sectional area and mean velocity using the
formula: portal vein flow volume (PVFV) = A Vm,
where A = sectional area (Fig. 2). The measure-
ments of the HA flow including waveform, PSV, RI
and PI are performed at the intrahepatic portion of
the liver graft. The PSV of the HA is detected with
suitable gate and angle correction along the long
axis of the color-coded HA. The angle between the
long axis of the color-coded HA and the Doppler
beam should be less than 60. The Doppler sample
 CDUS in LDLT

B
Fig. 2. Standard model of scanning by color Doppler ultra-
sound showed portal vein flow and measurement of parame-
ters with angle correction and scale without aliasing. For this
case, the formula and calculations were as follows: portal vein
flow volume (PVFV) = mean of flow velocity (Vm) cross-
section area (A) = 39 60 (0.78/2)2 = 1,118 mL/min;
further calculation of PVFV in per 100 g graft weight is
172 mL/min/100 g.

volume is set at 12 mm and the waveforms are

made on the lowest possible frequency shift range
without aliasing. The flow measurements of the
HVs are performed at each anastomotic vein at the C
intrahepatic portion about 12 cm from the infe-
rior vena cava. The detected velocities are taken at
peak waveform and angle correction is done under
less than 60. The waveform patterns of the HVs
are classified as monophasic, biphasic or triphasic,
reflecting the cardiac oscillation from the pressure
change of the right atrium (Fig. 3).

Postoperative study
In the postoperative study, CDUS examinations are
performed once a day during the first week after
surgery. The protocol for both qualitative and
quantitative hemodynamic evaluations follow the
previous general principles for PV, HV and HA,
respectively. The first postoperative CDUS examina-
tion is best performed within 12 hours after surgery.
After 7 postoperative days, the schedule for CDUS
is once per week before discharge or based on
need according to clinical condition.
Fig. 3. Standard model of scanning by color Doppler ultra-
sound showed hepatic vein flow and measurement of parame-
ters with angle correction and scale without aliasing. For these
cases, the waveform analysis and calculations were as follows:
there are normal triphasic waveform and biphasic waveform
in the case of (A) and (B), the peak of flow velocity (Vp)
are 59 and 61 cm/s, respectively; otherwise, there is an abnor-
mal monophasic waveform in the case of (C) and relatively
low Vp.

J Med Ultrasound 2008 Vol 16 No 3 179

 T.L. Huang

The CDUS Study for Pretransplant overcome using venous grafts, and successful
Recipients on the Waiting List LDLT has been achieved in recent years by some
centers. PV thrombosis is not a contraindication to
Since the initiation of LDLT in Kaohsiung in 1994, LDLT, but the limit of thrombosis must not be
we have evaluated many infants and young children
with biliary atresia awaiting LT, and have found a A
high incidence of vascular anomalies in these pa-
tients. The incidence of associated vascular anom-
alies was found to be up to 42% (16/38 cases).
These vascular anomalies included: absence or hy-
poplasia of the inferior vena cava (n = 3), congeni-
tal absence or hypoplasia of the PV (n = 8), and
anomalous origin of the HA (n = 6) [2,3,5].
In the preoperative study, we also found a group
of pediatric recipients with high HA RI (some with
an RI > 1.0) and frequent admissions because of
fever and sepsis. According to the survival analysis
B
for all relevant risk factors, high HA RI (> 1.0) and
low portal flow velocity (< 10 cm/s) had definite
significance for mortality [6] (Fig. 4). These cases
could no longer wait and required transplantation
for life-saving reasons. For the preoperative evalua-
tion of PV quality, a smooth portal wall and patent
flow are essential. In our research report of a group
with portal insults, portal occlusion or absence is a
contraindication to LDLT, and low portal flow less
than 7 cm/s and small portal size less than 4 mm
are risk factors for intraoperative portal thrombosis C
[7]. With advances in surgical techniques, some
cases of intraportal partial thrombosis have been

Fig. 5. These cases were evaluated in a pretransplant study

Fig. 4. For this case of a young child on the waiting list for liver
transplantation, the HA impedance was detected with an
resistance index of 1.20 (exceeding 1.0). This case has a high
risk of mortality, and an early transplantation is a priority to
save this patients life.
and showed abnormal portal flow by color Doppler ultrasound:
(A) the first case had portal vein (PV) occlusion with obscured
PV tract and no portal flow signal; (B) the second had a small
PV tract and slow low inflow (3 cm/s); (C) the third had
reverse hepatofugal portal flow and pulsatile waveform due to
an arterioportal shunt. These abnormal portal flows are signif-
icant and may be a contraindication to living donor liver trans-
plantation or are a risk for post-transplant portal thrombosis.

180 J Med Ultrasound 2008 Vol 16 No 3

 CDUS in LDLT

beyond the main PV [8] (Fig. 5). All these predis-
posing vascular anomalies may be significant in
the decision to transplant and are well detected by
CDUS. Therefore, in deciding on the priority of pa-
tients waiting for early transplantation, CDUS plays
a really important role in pretransplant assessment.
The Major Vascular Complications
Detected by Intraoperative CDUS
HA thrombosis and insufficiency
HA thrombosis (HAT) is the most serious vascular
complication in LT and results in hepatic necrosis,
dysfunction and failure. The incidence of HAT in LT
varies from 7.413% and is higher in adult LDLT [9].
The advancement of HA anastomosis using micro-
surgical techniques has improved the success rate
of HA reconstruction. The diagnosis of HAT by
CDUS just after reperfusion of the graft is reliable.
The diagnostic criterion of HAT is the absence of
Doppler signals, and in this situation, redo of HA
anastomosis or thrombectomy for resuscitation must
be undertaken immediately. If an abnormal flow
pattern with dampened systolic peak and slow peak
velocity (< 30 cm/s) occurs, HA angulation, stran-
gulation or spasm is usually the cause of HA insuf-
ficiency [4]. Rapid thrombosis formation in these
cases is possible. CDUS can help to assess and con-
firm the optimal flow change after the problem is
resolved. The peak systolic Doppler velocity (PSV)
and waveform distal to the HA stenosis are also
dampened, the PI and RI of the HA also fall owing
to poststenotic reactive vasodilatation and distal im-
pedance [10,11]. Under this condition, a low HA
PSV due to a proportional increase in end-diastolic
flow velocity is observed (Fig. 6). If the parameters
of HA flow detected are distal to the anastomosis,

A B

C D

Fig. 6. This case was evaluated during intraoperative color Doppler ultrasound (CDUS) after vascular reperfusion. (A) A damp-
ened hepatic artery (HA) peak wave, such as tardus-parvus waveform due to partial thrombosis, was found. (B) Reopen for
thrombectomy was done with a slight improvement in flow, but optimal flow was not noted. (C, D) Thus, redo of HA anastomosis
was done and normal HA flow was regained as noted on CDUS check-up.

J Med Ultrasound 2008 Vol 16 No 3 181

 T.L. Huang
A B
Fig. 7. (A, B) Intraoperative color Doppler ultrasound detection of portal vein thrombosis in two cases with no signal flow and
a marked decrease in hepatic artery resistance index (< 0.5) due to buffer mechanism.
any dampened flow waveform and velocity will in-
dicate the presence of anastomotic stenotic change
in the proximal HA [12]. Intraoperative CDUS is
easy to perform and provides the opportunity for
immediate treatment of such inadequate arterial
reconstructions. CDUS also plays an important role
in reducing the incidence of HAT following LDLT
[13,14].
PV thrombosis, insufficiency and
hyperperfusion
If there are no Doppler flow signals in the recon-
structed PV, thrombosis of the PV is highly sus-
pected. However, poor PV flow signals with CDUS
can be caused by acute angulation of the sound
scanning beam to the axis of the portal tract (> 60)
or the obliteration of extrahepatic PV with interven-
ing adipose tissue or bowel gas after surgery [10,11].
Thus, we should carefully exclude PV thrombosis
by CDUS. Immediate thrombectomy is the gold
standard for treatment of PV thrombosis. Inadequate
low PV inflow (mean velocity < 12 cm/s) as PV insuf-
ficiency is usually detected in pediatric recipients
owing to persistent large portosystemic collaterals
such as the coronary vein, splenorenal shunt and
gastrorenal shunt, sometimes owing to HV outflow
obstruction or low cardiac output (Fig. 7). An
increase in PV inflow can be achieved by ligation
of portosystemic collaterals, relief of HV outflow
obstruction or redo of PV anastomosis [13,15].
182 J Med Ultrasound 2008 Vol 16 No 3
On the contrary, PV hyperperfusion may occur with
extremely high PVFV above 250 mL/min/100 g in
adult LDLT recipients. These patients will develop
post-transplant hepatic dysfunction such as small-
for-size syndrome, which is often found among
those with a relatively small-for-size graft (graft-to-
recipient weight ratio < 0.8) (Fig. 8). Portal hyper-
perfusion in small-for-size graft is thought to be
the main cause of small-for-size syndrome by portal
hypertension and damage to sinusoids and hepa-
tocytes [16,17]. To overcome this problem, several
therapeutic options have also been reported, such
as surgical modulation of splenic arterial ligation or
splenectomy to release portal hyperperfusion and
liver tissue congestion [1820] (Fig. 8). For detec-
tion of this disorder, CDUS is the most important
modality for monitoring portal hemodynamics.
HV outflow obstruction, HV thrombosis,
HV stenosis
Normal flow velocity and waveforms of HV should
be more than 12 cm/s at the peak of biphasic or
triphasic waveforms, which reflect the patency of
hepatic outflow. Hepatic outflow obstruction after
reperfusion will result in a hard consistency and dark
discoloration of the graft noted by the surgeon
during the operation. CDUS examination is used
immediately for evaluation. The characteristic CDUS
findings are: (1) mild dilatation of the HVs; (2) flat
or monophasic HV flow waveform; (3) slow HV
 CDUS in LDLT

A B

Fig. 8. (A) This case of low graft-to-recipient weight ratio of 0.8 such as small-for-size graft, and extremely high portal vein flow
volume (PVFV) up to 682 mL/min/100 g was detected by color Doppler ultrasound just after hepatic flow reperfusion. A high
possibility of post-transplant dysfunction or graft failure exists in this case. (B) Immediate ligation of the splenic artery was carried
out for modulation of portal hyperperfusion, and the PVFV was dramatically reduced to 233 mL/min/100 g, which was within
normal limits. The postoperative course of this patient was uneventful.

A B

Fig. 9. Case of a young child with right rotation of the graft in the
wide abdomen during operation. (A) Hepatic vein (HV) outflow was
impeded with a flat waveform and low peak velocity detected by intra-
operative color Doppler ultrasound (CDUS). (B, C) For improvement
of HV outflow obstruction, left-side fixation for a stable graft position
and posthepatic balloon interposition to correct HV angulation were
carried out until optimal HV flow was regained under CDUS guidance.

peak velocity (< 10 cm/s); and (4) extremely low PV
flow velocity (< 14 cm/s) [9,21]. Intrahepatic venous
thrombus is usually observed in HV thrombosis and
immediate thrombectomy is needed. During trans-
plant surgery, torsion of the graft was described by
Broelsch et al [22]. In our experience, right rotation
of the graft in the wide abdominal space may result
in outflow stenosis and a flat HV flow waveform
(Fig. 9). We can prevent such outflow obstruction
by fixing and stabilizing the graft in the optimal

J Med Ultrasound 2008 Vol 16 No 3 183

 T.L. Huang

A B

C D

Fig. 10. Case of post-transplant pleural effusion and ascites was diagnosed as portal vein stenosis by color Doppler ultrasound.
(A, B) Local segmental stenosis and high-flow velocity were noted at the anastomotic site. (C, D) Normal mean of flow velocity
was regained after percutaneous transhepatic angioplasty with balloon dilatation.

position under the guidance of intraoperative CDUS,
until a normal biphasic HV waveform is obtained
[1,11].
The Postoperative Vascular
Complications Detected by CDUS
Postoperative HAT
Postoperative HAT usually occurs in the first post-
operative day but can occur up to 1 week after
surgery. We perform routine CDUS examinations
on the first postoperative day, especially within
12 hours of surgery and in patients with high risk
factors or with poor arterial quality. HAT is present
in Doppler findings when absent arterial signals are
found in the whole graft scan or when only damp-
ened slow HA flow is noted. Further imaging with
CT angiography is suggested for confirmation. HAT
is usually successfully treated by thrombectomy or
redo of anastomosis or jump graft following early
diagnosis [2325].
Postoperative PV thrombosis or PV stenosis
Postoperative PV thrombosis may also occur in the
early postoperative period. CDUS shows slow or
absent portal flow or direct visualization of throm-
bus. Sometimes, hepatofugal PV flow is noted and

184 J Med Ultrasound 2008 Vol 16 No 3

 CDUS in LDLT

A B

C D

Fig. 11. A case of persistent intractable massive ascites (> 2,000 mL/day) at postoperative color Doppler ultrasound examination.
(A) Low hepatic vein (HV) peak velocity (Vp) with a flat waveform favored hepatic vein stenosis. (B, C) After percutaneous trans-
luminal venoplasty with balloon dilatation and insertion of a Wallstent, (D) the HV waveform improved to a normal multiphasic
pattern and Vp increased to 72 cm/s. Following this treatment, the ascites dramatically subsided.

may be associated with HV outflow obstruction Postoperative HV thrombosis or

[10,12,26]. Surgical thrombectomy, redo of anas-
tomosis or infusion of a thrombolytic agent is used
in the management of this disorder. Postoperative
PV stenosis may develop and cause hepatic dys-
function with intractable ascites. CDUS examination
shows marked turbulent flow or slow flow and ex-
tremely high-flow velocity (may be up to 200 cm/s)
detected at the narrowed anastomosis. Further
management with percutaneous transhepatic por-
tal angioplasty with balloon dilatation or Wallstent
interposition is suggested [15,27] (Fig. 10).
HV stenosis
HV outflow obstruction may also develop after
transplantation, the obstruction usually occurs at the
anastomotic site and is mainly caused by chronic
fibrosis at the stenotic site and hypertrophy of the
graft [28,29]. CDUS detection shows a flat flow
waveform and slow HV flow velocity (< 10 cm/s);
hepatofugal PV flow may occur in severe obstruc-
tion. Therapeutic procedures of angioplasty with
balloon dilatation or Wallstent interposition are sug-
gested for this disorder [30] (Fig. 11). CDUS is used

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 T.L. Huang
before and after angioplasty or stenting for effec-
tive treatment with successful regain of normal HV
outflow [31,32].
Conclusion
CDUS has wide use in LT and is the modality of
choice in the evaluation of hepatic graft hemody-
namics and the diagnosis of vascular complications.
This modality has a very important role in preoper-
ative, intraoperative and postoperative evaluations
for the immediate assessment of general condition
and early detection of complications. Timely re-
cognition of any complications could improve the
success of LT.
Chang Gung Memorial Hospital was the first
center to perform LT in Taiwan and carried out a
successful case of orthotopic liver transplantation
in 1984, and was the first to start a program of LT.
Due to the scarcity of source- and size-matched graft
donors for infants and young children, we were
the first to initiate cadaveric split-liver transplanta-
tion and LDLT, respectively. CDUS is now performed
routinely for the evaluation of hepatic hemodynam-
ics. Although high rates of vascular complications
resulting in graft failure are still reported by many
centers worldwide, our center has had good results.
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