"Anatomical" versus "territorial" belonging of the middle hepatic vein: virtual imaging and clinical repercussions.
BACKGROUND
Venous drainage patterns are of vital importance in live donor liver transplantation. The purpose of this study was to delineate "anatomical-topographical" and "territorial-physiologic" patterns of the middle hepatic vein (MHV) in a 3-D liver model as determined by the Pringle line and its drainage volume of the right and left hemilivers.


METHODS
One hundred thirty-seven consecutive live donor candidates were evaluated by 3-D CT reconstructions and virtual hepatectomies. Based on right (R) and left (L), anatomical (A) and territorial (T) belonging patterns of the MHV, each individual was assigned to one of four possible types: type I:A(R)-T(R); type II:A(L)-T(L); type III:A(R)-T(L); type IV:A(L)-T(R). Couinaud's anatomical MHV variants A-C were subsequently included in our combined anatomical/territorial MHV belonging classification.


RESULTS
The MHV showed a significant predominance of right "anatomical" (59.1%) and left "territorial" belonging patterns (65.7%). The paradoxical combinations A(R)-T(L) (type III) and A(L)-T(R) (type IV) were encountered in 36.5% and 11.7% of cases, respectively. The constellations Couinaud's A-belonging type IV and Couinaud's C-belonging type IV were predictive of right hemiliver venous congestion.


CONCLUSIONS
(1) Almost half of all livers in our series had paradoxical "anatomical"/"territorial" MHV belonging patterns that placed them at risk for right and left hepatectomies. (2) The proposed combined "anatomical"/"territorial" MHV belonging types (I-IV) provide useful preoperative information. (3) Combined types III and IV as well as Couinaud's A-IV, and Couinaud's C-IV should be considered particularly risky for venous congestion in right hemiliver grafts and in extended left hepatectomies.
Radtke
Arnold
A
Department of General, Visceral, and Transplantation Surgery, University Hospital Essen, Essen, Germany. radtke@ach.klinik.uni-mainz.de
Sotiropoulos
Georgios C
GC
Sgourakis
George
G
Molmenti
Ernesto P
EP
Schroeder
Tobias
T
Saner
Fuat H
FH
Beckebaum
Susanne
S
Schenk
Andrea
A
Lang
Hauke
H
Broelsch
Christoph E
CE
Malagó
Massimo
M
D000328:Adult; D000718:Anatomy, Regional / Q000379:methods; D005260:Female; D006498:Hepatectomy / Q000379:methods*; D006503:Hepatic Veins / Q000033:anatomy & histology / Q000502:physiology / Q000601:surgery; D006801:Humans; D021621:Imaging, Three-Dimensional; D008099:Liver / Q000098:blood supply / Q000601:surgery; D008102:Liver Circulation / Q000502:physiology; D016031:Liver Transplantation / Q000379:methods*; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D010690:Phlebography; D014057:Tomography, X-Ray Computed