Hepatofugal flow in the portal venous system: pathophysiology, imaging findings, and diagnostic pitfalls

Hepatofugal flow (ie, flow directed away from the liver) is abnormal in any segment of the portal venous system and is more common than previously believed. Hepatofugal flow can be demonstrated at angiography, Doppler ultrasonography (US), magnetic resonance imaging, and computed tomography (CT). The current understanding of hepatofugal flow recognizes the role of the hepatic artery and the complementary phenomena of arterioportal and portosystemic venovenous shunting. Detection of hepatofugal flow is clinically important for diagnosis of portal hypertension, for determination of portosystemic shunt patency and overall prognosis in patients with cirrhosis, as a potential pitfall at invasive arteriography performed to evaluate the patency of the portal vein, and as a contraindication to specialized imaging procedures (ie, transarterial hepatic chemoembolization and CT during arterial portography). Hepatofugal flow is generally diagnosed at Doppler US without much difficulty, but radiologists should beware of pitfalls that can impede correct determination of flow direction in the portal venous system.