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All right, so let's talk a little bit about liver transplant anatomy.

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I'm not going to focus a ton on the surgical details, but understanding some of the

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anatomy is critical. So I'm going to show a few examples of what some of those

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surgical anatomy might look like.

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So one of the things that you are going to have to anastomose with a donor liver is

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going to be the hepatic veins and the IVC.

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So there are a couple of different options.

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You can have what's called a modified classical, where they intermingle the donor

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IVC with their recipient's IVC and the superior vena cava.

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Then you have what we would call the piggyback and the modified piggyback, where

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you have a common trunk of the hepatic veins that they reshape.

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Sometimes, depending on which of those systems that they're using, it's either the

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three hepatic veins or the left and the middle.

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And then you have portions of the recipient, either SCC or IVC, where they

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essentially take a small area and anastomose those two things together.

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For the hepatic arteries, this is a more straightforward anastomosis.

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You can have a typical just end-to-end anastomosis.

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Sometimes you can have what's called a Carol patch, where they take an oval segment

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of the aorta where all the native vessels are going into and then bring that over

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to anastomose into the recipient's vessels.

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And then you have a process of what we call as jump graft.

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So if you have an hepatic artery from the donor that is too short to anastomose,

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then you need to bring some other type of graft up into place to stretch that

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length and make sure that you're covering as much territory as you need to.

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Similar process is seen with the portal vein.

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It is typically just an end-to-end or jump graft system.

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These are going to be venous jump grafts that you see, although some jump grafts in

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the hepatic artery can be arterial in nature.

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And then finally, there is the biliary reconstruction.

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So in a perfect world, we will do a duct to duct reconstruction, so it's as close

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to native anatomy as possible. But if you have duct disease or significant size

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mismatch between the donor and the recipient, or if there's been a concern for a

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biliary ischemia system, then you would do a slightly different system where you

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would do a Roux-en-Y hepaticojujunostomy that you're creating that bowel

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anastomosis to be able to allow for biliary drainage.

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So really briefly, just to talk about what we see sometimes in the early

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postoperative setting for liver transplant, we sometimes see transient elevations

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in resistive index, and that can be considered within normal limits for a couple of

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weeks. And we can also see elevations in the hepatic artery peak systolic velocity.

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So it's not unexpected for us to see potentially even in the 200s at that point,

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at least early on in the process. And so the key is trying to recognize what's

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expected during that early post-op setting and what suggests a thrombosis or

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stenosis. When we see these elevations, we shouldn't see any kind of downstream

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issue where we would see a Tartus Parvus waveform within the liver.

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We should see just isolated, elevated velocities.

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That is what tells us it's more of a post-op edema or collection setting rather

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than true pathology.