Spectrum of the Portal Vein on
Color and Spectral Doppler,
and Contrast Enhanced
Ultrasound in both Native and
Transplanted Livers
NicholasLesleinMD;BiancaCarpen4erMD;Priyanka
Jha,MD;JudyYeeMD;StefanieWeinsteinMD
University of California, San Francisco
TheAuthorsHaveNoFinancialDisclosures
LearningObjec-ves
■ 
■ 
■ 
ReviewrangeofnormalDopplerfindingsintheportalvein
Reviewpathologicappearanceoftheportalvein(PV)in
na4veandtransplantedliverswithuseofcolorDoppler,
spectralDoppler,andcontrastenhancedultrasound
Topicstobediscussedinclude:
■ 
■ 
■ 
Monophasicityvs.increasedpulsa4lity
Flowdirec4on:antegrade/bidirec4onal/reversed/helical
Increasedintraluminalechoes
■ 
■ 
■ 
PVOcclusions:Par4al/Complete/Obliterated
Air/Rouleaux(slow)flow
Slowvs.highflowstates(cardiac,pregnancy,shun4ng)
NormalPortalVein
■ Normalvelocity
range20-40cm/s
■ Monophasic
waveformwith
gentleundula4ons
■ Antegradeflow
IncreasedPulsa-lity
■  Pulsa4lityisthevariabilityofbloodvelocityinavessel
■ Increasedpulsa4lityisusuallyseenintheseZngofelevated
rightatrialpressure:
■ Rightheartfailure
■ Tricuspidregurgita4on
ImagesoftheMPVdemonstrateincreased
pulsa7lityinthese9ngofrightheartfailure
Alsonoteincreasedpulsa7lityinthemiddle
hepa7cveinanddilata7onofthehepa7cveins
IncreasedPulsa-lity
■  Donotmistakearterializedflowforincreasedvenouspulsa4lity
TeachingPoint:arterializedflowinportalveinistumorthrombus,
mostcommonlyhepatocellularcarcinoma,un4lprovenotherwise
Note the arterialized waveforms in the region of the portal vein in both images
Varia-oninFlowDirec-on
Retrograde(hepatofugal)-Bidirec-onal
MainCauses:Cirrhosis,PortalHypertension,CardiacDisease
Twoexamplesofspectralwaveformoftheportal
veinwithflowseenbothaboveandbelowthe
baselineinthesepa7entswithliverdisease
Teachingpoint:Evensmallpressurechanges
relatedtoinspira7onandexpira7oncan
causereversalofflowdirec7on
Retrograde–Bidirec-onalFlow
S7llimagefromCINEloopdemonstra7ng
bidirec7onal(alterna7ngredandblue
color)flowinthemainportalvein–
HyperlinkforCINEhostedonweb
Teachingpoint:Thiscanbe
misinterpretedasunidirec7onal
flowons7llimagesonly
Varia-onsinFlowDirec-on
Helicalflow
■  Disrup4oninthenormallaminar
flowsecondaryto:
■  Vesselgeometry
■  Irregularityofthevesselwall
■  Changesinflowdirec4onand
speed
■  Dopplerdemonstrates
alterna4ngredandbluebandsin
aspiral
■  Canbeseena\erliver
transplantorTIPSpa4entsasa
normalfinding
■  Abnormalifpersistent
Varia-onsinFlowDirec-on
Helicalflow
■  Transplant
■ SecondarytochangeinPV
diameterbetweendonor
andna4vevessel,most
prominentwhen
discrepancyis>50%
■ Localturbulence
■  TIPS
■ ChangesinPVvelocity,flow
direc4on,andpulsa4lity
■ Reportedlyashighas28%
ofTIPS1
IntraluminalEchoes
PortalVeinAir
S7llimagefromCINEloop(hyperlink)
demonstra7ngrapidlymoving
intraluminalechogenicfociinthe
portalsystem
SpectralDopplerdemonstra7ng
characteris7c“spike”likeaberra7oninthe
portalveinwaveform
Teachingpoint:bewareofpiballs
■  Rouleauxfromslowflow
■  Truethrombus
■  Misdiagnosisofpneumobilia
IntraluminalEchoes
AnotherexampleofPortalVeinAir
Still image from CINE loop (hyperlink) demonstrating numerous
swirling internal reflectors within the main portal vein
PortalVeinAir
■  CTmaybeconfirmatory
■  Unlikepneumobilia,
generallyconsidereda
moreominousfinding
■  Poten4alCauses
■  BowelIschemia/infarc4on
■  Bowelobstruc4on
■  Pancrea44s
■  Diver4culi4s/Appendici4s
IntraluminalEchoes
PortalVein
Thrombosis
CompletePVThrombus
Teachingpoint:
Needtoop4mizeDopplertechniquewhen
evalua4ngforthrombus
■  Usetheappropriatedepth
■  Usetheappropriatescale
■ Highscalemaymisslowerveloci4esthat
arebelowthresholdvalue
Par7alThrombus
CavernousTransforma-on
■  Sequelaeoflongstanding
portalveinthrombosis
■  Thrombosedmainportal
veinmaynolongerbe
present
■  Secondarysignsofchronic
thrombosis
■ Periportalcollaterals
withmanyflow
direc4ons
■ Smallcaliberorabsent
mainPV
CavernousTransforma7on
IntraluminalEchoes
TumorThrombus
Grayscaleimagedemonstrates
expandedmainportalvein
filledwithintraluminalechoes
ColorandspectralDopplerimages
demonstrateirregularvesselswith
arterializedwaveformsinPV
TumorThrombus
S7llimagefromCINEclip(hyperlink)
demonstra7ngtumorthrombusinMPV
RoleofCEUS
BlandversusTumorThrombus
■  Contrast-enhancedultrasoundaddsvaluein
differen4a4ngblandthrombusfromtumorthrombus
■  CEUSimprovessensi4vityanddiagnos4caccuracy4,7
(TopLe()Grayscaleimages
showsintraluminalfilling
defect
(Bo=om)CEUSdualscreen
CINEimages(hyperlink):
noteenhancementinarea
offillingdefectinle(portal
vein
Slowflow
■  NormalMPVpeaksystolic
velocity(PSV)measures
between20-40cm/s
■ PSVof<16cm/sand
increasedcaliberofMPVare
diagnos4cfeaturesofportal
hypertension
(Topright)Imagesdemonstrateslow,low
amplitudebidirec7onalflowintheRPV
(BoTomright)PowerDoppler
demonstra7nglowamplitudeflowinLPV
Slowflow
“Rouleaux”flow
a.
■  Imagesdemonstra4ngmobilelow
levelechoesintheMPV(a.)and
middlehepa4cveinandIVC(b.)bejer
appreciatedonCINE
■  “Rouleaux”flowisduetoredbloodcell
a.
b.
aggrega4onfromsluggishflow
a.)Hyperlink
b.)Hyperlink
Highflow
■  Highveloci4es
■  Causes
■ Stenosis
■ Mostcommonlyseeninpost-
transplant
■ Pregnancy
■ Pseudoaneurysm
■ ArteriovenousFistula/AVM
■ Congenital(OslerWeberRendu)
■ Acquired(postbiopsy/trauma)
Images from a liver transplant showing
turbulent high flow (>50 cm/s) related
to a hepatic artery-portal vein fistula
PVinLiverTransplant
■ Stenosis
■ Typicallywithendto
endanastomosis
■ 3-4xincreaseinpeak
systolicvelocity(PSV)
■ Associatedfindings
■ Aliasing
■ ElevatedPSV
■ Spectralbroadening
Notealiasingandelevatedveloci7esatsiteofPVanastamosis
Teachingpoint:bewareofpiballs
■ 
Pseudostenosis–canbeanormalfindingsecondarytodifferenceinvesselcaliber
betweenna4veanddonor.Usuallyresolvesinimmediatepostopera4veperiod
Conclusion
■ 
Abdominalradiologistsshouldbefamiliarwith
thespectrumofnormalvariantsand
pathologyintheportalveinreflec4ng
underlyingpathologicstates,includingbutnot
limitedto,cardiacdysfunc4on,portal
hypertension,stenosis,andthrombosis
References
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Contact
■  NicholasLeslein,[email protected]
■  BiancaCarpen4er,[email protected]
■  PriyankaJha,[email protected]
■  JudyYee,[email protected]
■  StefanieWeinstein,[email protected]
CINE Loops Hosted on Web
■  Slide8–Bidirec4onalFlow–hjps://vimeo.com/199039295
■  Slide11–PortalVeinAir-hjps://vimeo.com/199039639
■  Slide12–PortalVeinAir–hjps://vimeo.com/199039889
■  Slide17–TumorThrombus-hjps://vimeo.com/198946303
■  Slide18–CEUSTumorThrombus-hjps://vimeo.com/199041745
■  Slide20–RouleauxFlowinMPV-hjps://vimeo.com/198947317
■  Slide20–RouleauxFlowinHepa4cVeinsandIVC-
hjps://vimeo.com/198947045