Contrast-enhanced MR angiography (CEMRA) is an accepted reference standard for the pre-transplant evaluation of the hepatic vasculature (1-3). Given the prevalence of renal insufficiency in this patient cohort, a non-contrast alternative is needed to evaluate vascular anatomy, patency and detect significant extrahepatic portosystemic shunts. Doppler sonography has demonstrated utility in assessing portal flow directionality; however, this modality is limited in the assessment of variceal flow. As liver transplant recipients with extrahepatic portosystemic shunts greater than 1 cm in size have increased graft complications, robust diagnostic tests to identify these shunts pre-transplantation is vital (4). In addition, portal vein thrombosis is a relative contraindication to liver transplantation; accurate assessment of the residual portal vein lumen and identification of patent intrahepatic portal branches enables portal thrombectomy pre-transplant. We hypothesize that a NCMRA protocol comprised of techniques optimized for arterial and venous evaluation will delineate the liver vascular anatomy and identify significant extrahepatic portosystemic shunts (>1cm) when compared to CEMRA in patients with cirrhosis.33 patients (13 women, avg age 51.2 ± 11.3 yrs) with liver cirrhosis and portal hypertension were prospectively recruited under an IRB-approved protocol. All subjects underwent MR imaging at 3.0T (Magnetom Skyra, Siemens Medical Systems, Erlangen, Germany). Hepatic arterial anatomy was evaluated primarily using 2D QISS MRA applied with and without a venous saturation pulse as well as native TrueFISP with respiratory bellows, a single axial saturation slab positioned over the porta hepatis, and a patient-specific inversion time between 1600 and 2000 msec. Hepatic venous anatomy was evaluated primarily using native TrueFISP with respiratory bellows, an axial saturation band positioned over the liver parenchyma, and an inversion time of 1300 msec as well as coronal 3D STIR imaging with a pencil beam respiratory navigator. Portal and mesenteric venous anatomy and patency were primarily evaluated on the coronal 3D STIR sequence as well as axial and doubly obliquued (orthogonal to the portal vein) 2D QISS MRA without a flow sensitive suppression pulse. All subjects underwent multiphase first pass contrast-enhanced MRA (CEMRA) with breath-holding, using 0.03 mmol/kg of gadofoveset trisodium (Ablavar, Lantheus Medical Imaging, Minneapolis, Minnesota) administered as a bolus at 2mL/sec. A single reviewer independently evaluated NCMRA and CEMRA datasets for hepatic arterial and venous anatomy, as well as portal and mesenteric venous patency. The presence of portal thrombus was recorded. Spontaneous portosystemic shunts were noted and categorized by size as < or ³10mm. Each NCMRA sequence was scored as evaluable or non-evaluable. The reviewer noted when none of the NCMRA sequences were evaluable for a region of the vascular anatomy (hepatic artery, hepatic vein, or portal venous system) and considered this a non-diagnostic NCMRA exam. CEMRA was considered the reference standard for evaluating the NCMRA protocol; when individual NCMRA sequences differed in vascular assessment, the result of the technique demonstrating the least amount of disease was taken as the outcome of the NCMRA protocol. All subjects successfully completed the study protocol. The NCMRA protocol was diagnostic in 31 patients (94%); in two subjects moderate to large ascites coupled with an irregular breathing pattern precluded hepatic arterial and limited hepatic venous assessment, while portal venous assessment was diagnostic. In the remaining 31 subjects, hepatic arterial anatomy, hepatic venous patency, and portal venous patency as assessed using the NCMRA protocol demonstrated perfect agreement with CEMRA (Figure 1, Table 1). Among diagnostic NCMRA studies, 14 of 14 and 19 of 20 portosystemic shunts ³ 1cm and < 1 cm in size were correctly characterized, respectively. Nine subjects (27%) demonstrated variant hepatic arterial anatomy, which was clearly identified with the NCMRA protocol. One subject (3%) demonstrated non-occlusive mural thrombus at the portal confluence.The NCMRA vascular protocol demonstrated excellent performance, delineating the vascular anatomy in 94% of subjects. No single NCMRA technique was able to characterize all of the liver vasculature; rather the protocol applied complementary techniques to enable comprehensive vascular assessment. Interestingly, the NCMRA protocol performed well for portal vein assessment alone; however, evaluation of the hepatic arteries and hepatic veins proved more challenging, and was limited in two subjects.Our results suggest that a NCMRA liver vascular protocol utilizing multiple complementary non-contrast imaging techniques demonstrates promise for the comprehensive pre-transplant hepatic vascular evaluation in patients with cirrhosis and portal hypertension. Patient recruitment is on-going to validate these preliminary results in a larger patient cohort, determine performance detecting complete and partial portal thrombosis, and improve accuracy in subjects with large volume ascites or irregular breathing patterns.