Justin McWilliams, MDUCLA Interventional Radiology
1.        Hepatic arterial anatomy            2.  Anatomic variants     3.    Extrahepatic collaterals        4.   Vascula...
RHA                         LHA                                                                         PHA              C...
8                                     7                                                              2                    ...
The umbilical point (arrows)
Middle hepatic artery from RHA                            Middle hepatic artery from PHA (trifurcation)A “middle hepatic a...
Definition            Entire left hepatic artery originates            elsewhere other than the PHA     Origin            ...
Definition            Part (but not all) of the left hepatic artery has            an anomalous origin            “Accesso...
When an arterial structure is seen passing through the fissure of the ligamentum venosum, expect a replaced/accessory left...
Definition            Entire right hepatic artery originates            elsewhere other than the PHA     Origin           ...
Definition            Part (but not all) of the right hepatic artery has            an anomalous origin            “Access...
Celiac injection demonstrates absence of                                                           RHA and LHA. Expected c...
2%      Injection of celiac axis demonstrates splenic and left gastric                Common hepatic artery arises from th...
Celiac injection demonstrates splenic artery supply but no evidence             Slightly lower, the common hepatic artery ...
Celiac injection demonstrates left hepatic artery (arrow)                           Different patient, oblique aortogram. ...
     Only tumors with surface location         17% overall likelihood of extrahepatic supply at initial          present...
     Where to look based on tumor location            • Bare area of liver (seg 7/8): R phrenic and R adrenal            ...
Origin         Aorta 50%                                                                                                  ...
Origin           Right or left gastroepiploic artery     Supplies           Greater omentum (mobile!)           Can supply...
Origin           Usually first branch of right hepatic artery     Supplies           Gallbladder           HCC in gallblad...
Origin           Aorta                                                                                                    ...
Skin reaction related to intercostal embolizationImages courtesy of David Liu, MD
Right adrenal artery (6%)     Right or left gastric artery (3%)     Right internal mammary artery (3%)     Superior mesent...
Infiltrative HCC of the right lobe                           Replaced RHA angiogram demonstrates tumor supply. DEB-TACE   ...
One month post TACE #2, persistent enhancement is present at the posterior   The right T10 intercostal artery demonstrates...
Protective coil embolization of extrahepatic branches arising from the hepatic   circulation prior to embolotherapy   1. G...
Accessory left gastric                Right gastric                Falciform                Left phrenicCysticSupraduodena...
Origin   Common hepatic arterySupplies   Pylorus of stomach   Proximal duodenum   Pancreatic head (via pancreaticoduodenal...
Considerations for optimization:   Should be coil embolized in almost all cases   High flow, need lots of coils to occlude...
Origin         Proper hepatic artery (55%)         Left hepatic artery (20%)         Common hepatic artery (5%)         Ga...
Considerations for optimization       Should be coil embolized in almost all patients       -Unnecessary if RGA origin is ...
Prevalence 3-21% (low in Caucasian, high in     Asian populations)  Origin        Left hepatic artery in proximal portion ...
Considerations for optimization   Should be coil embolized if present   Often difficult to identify on angio   Tips for id...
Also known as the posterior superior     pancreaticoduodenal artery  Origin       Gastroduodenal artery – 78%       Hepati...
Considerations for optimization   No need to coil embolize in most cases   -Usually arises from GDA   Coil embolize if ori...
Origin        Gastroduodenal artery – 26%        Common or proper hepatic artery – 20%        Left hepatic artery – 20%   ...
Considerations for optimization      Often not visualized      Be suspicious if branch from hepatic artery passes      inf...
Origin      Middle hepatic artery – 56%      Left hepatic artery – 44% Destination      Anterior abdominal wall, umbilical...
Considerations for optimization      Usually not seen      Coil embolize if present (2%)      Lack of protection can resul...
Origin      Right hepatic artery – 90%      Left hepatic artery – 7%      Common hepatic artery – 3%      Gastroduodenal a...
Considerations for optimization   Players choice   Advance catheter beyond cystic origin if possible   Coil embolization c...
Variations in hepatic arterial anatomy are extremely common, and often affect   treatmentConsider parasitic supply, especi...
jumcwilliams@mednet.ucla.edu
Problem      Hepatosplanchnic artery cannot be catheterized                   or      Catheter position unsafe for Y90 adm...
jumcwilliams@mednet.ucla.edu
Hepatic arterial anatomy and vascular optimization final
Hepatic arterial anatomy and vascular optimization final
Hepatic arterial anatomy and vascular optimization final
Hepatic arterial anatomy and vascular optimization final
Hepatic arterial anatomy and vascular optimization final
Hepatic arterial anatomy and vascular optimization final
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  • Potential HA mimicker
  • Hepatic arterial anatomy and vascular optimization final

    1. 1. Justin McWilliams, MDUCLA Interventional Radiology
    2. 2. 1. Hepatic arterial anatomy 2. Anatomic variants 3. Extrahepatic collaterals 4. Vascular optimization
    3. 3. RHA LHA PHA CHA GDA 61% Conventional hepatic artery anatomy; the CHA gives off the GDA and continues as the PHA, which splits into RHA and LHA. In the surgical literature, 55-70% of the population has this configuration; in the largest DSA study, 61%.Michels et al. Blood supply and antaomy of the upper abdominal organs with a descriptive atlas. Philadelphia, PA: Lippincott, 1955.Hiatt et al. Surgical anatomy of the hepatic arteries in 1000 cases. Ann Surg 1994; 220: 50-52.Covey et al. Variant hepatic arterial anatomy revisited: DSA performed in 600 patients. Radiology 2002; 224: 542-547.
    4. 4. 8 7 2 4 3 5 6Conventional hepatic artery anatomy (Couinaud segments)
    5. 5. The umbilical point (arrows)
    6. 6. Middle hepatic artery from RHA Middle hepatic artery from PHA (trifurcation)A “middle hepatic artery” supplying segment 4 can arise from the right hepatic artery, or from the PHA as atrifurcation.
    7. 7. Definition Entire left hepatic artery originates elsewhere other than the PHA Origin Left gastric artery 4% (lone anomaly) + 0.5% (with other accessory or replaced HA) 4.5% total incidence Replaced left hepatic artery arising from left gastric artery. Left gastric branches (arrowheads) can mimic segment 2 or 3 branches; true left hepatic branches take off beyond the umbilical point (arrow).Covey et al. Variant hepatic arterial anatomy revisited: DSA performed in 600 patients. Radiology 2002; 224: 542-547.
    8. 8. Definition Part (but not all) of the left hepatic artery has an anomalous origin “Accessory” is a misnomer; such arteries usually supply a distinct territory of liver Origin Left gastric artery (almost always) Right hepatic artery (very rare) CHA injection reveals segment 3 and 4 arteries, but no segment 2 11% (lone anomaly) + 4% (with other accessory or replaced HA) 15% total incidence Injection of left gastric artery (arising directly from the aorta) demonstrates segment 2 artery (arrows)Covey et al. Variant hepatic arterial anatomy revisited: DSA performed in 600 patients. Radiology 2002; 224: 542-547.
    9. 9. When an arterial structure is seen passing through the fissure of the ligamentum venosum, expect a replaced/accessory left hepatic artery (or lesslikely, an accessory left gastric artery)
    10. 10. Definition Entire right hepatic artery originates elsewhere other than the PHA Origin SMA (almost always) Right phrenic (rare) 9% (lone anomaly) + 3% (with other accessory or replaced HA) 12% total incidence Replaced right hepatic artery (arrow) arising from the SMA.Covey et al. Variant hepatic arterial anatomy revisited: DSA performed in 600 patients. Radiology 2002; 224: 542-547.
    11. 11. Definition Part (but not all) of the right hepatic artery has an anomalous origin “Accessory” is a misnomer; such arteries usually supply a distinct territory of liver Origin SMA (usually) Also GDA, LGA, right phrenic 1.5% (lone visceral anomaly) + 4% (with other accessory or replaced HA) 5.5% total incidence Accessory right hepatic artery (arrow) arising from GDA. The remainder of the right hepatic artery was replaced to the SMA.Covey et al. Variant hepatic arterial anatomy revisited: DSA performed in 600 patients. Radiology 2002; 224: 542-547.
    12. 12. Celiac injection demonstrates absence of RHA and LHA. Expected course of CHA (arrow) terminates in GDA and RGA. 0.5% Replaced LHA from LGA Replaced RHA from SMACovey et al. Variant hepatic arterial anatomy revisited: DSA performed in 600 patients. Radiology 2002; 224: 542-547.
    13. 13. 2% Injection of celiac axis demonstrates splenic and left gastric Common hepatic artery arises from the superior mesenteric arteries, but no common hepatic artery. artery.Covey et al. Variant hepatic arterial anatomy revisited: DSA performed in 600 patients. Radiology 2002; 224: 542-547.
    14. 14. Celiac injection demonstrates splenic artery supply but no evidence Slightly lower, the common hepatic artery arises directly from the of common hepatic artery. aorta. 2%Covey et al. Variant hepatic arterial anatomy revisited: DSA performed in 600 patients. Radiology 2002; 224: 542-547.
    15. 15. Celiac injection demonstrates left hepatic artery (arrow) Different patient, oblique aortogram. The left hepatic and right hepatic artery (arrowhead) both arising from the artery (arrow) and right hepatic artery (arrowhead) both celiac trunk. The GDA arises from the RHA. arise from the celiac trunk. The GDA arises from the LHA. 4%Covey et al. Variant hepatic arterial anatomy revisited: DSA performed in 600 patients. Radiology 2002; 224: 542-547.Images courtesy of David Liu, MD
    16. 16.  Only tumors with surface location  17% overall likelihood of extrahepatic supply at initial presentation • 3% if <4 cm • 63% if >6 cm  Likelihood of extrahepatic supply increases with repeated transarterial treatmentsChung et al. Transcatheter arterial chemoembolization of hepatocellular carcinoma: prevalence and causative factors of extrahepatic collateral arteries in 479patients. Korean J Radiol 2006; 7(4): 257-266.
    17. 17.  Where to look based on tumor location • Bare area of liver (seg 7/8): R phrenic and R adrenal • Superior-anterior liver (cardiophrenic area): R internal mammary • Exophytic toward kidney: R renal and R adrenal • Any peritoneal surface: Omental branches from R gastroepiploic • Contacts chest wall: Lower intercostal • Left lateral segment: L gastric • Contacts colon: Colic branches of SMA • Gallbladder fossa: Cystic Bare area = Posterior surface of segment 7 and posterior half of the diaphragmatic surface of segment 8 .Chung et al. Transcatheter arterial chemoembolization of hepatocellular carcinoma: prevalence and causative factors of extrahepatic collateral arteries in 479patients. Korean J Radiol 2006; 7(4): 257-266.
    18. 18. Origin Aorta 50% 50% of collateral supply Celiac trunk 40% Right renal artery 5% Left gastric artery 4% Rarely other Supplies Right hemidiaphragm HCC near diaphragmatic surface (bare area) Effects of embolization Usually well-tolerated Shoulder pain Pleural effusion Basal atelectasis R phrenic artery from aorta. Injection demonstrates dense Diaphragmatic weakness (usually asymptomatic) tumor blush consistent with parasitic supply of HCC.Basile A et al. MDCT anatomic assessment of right inferior phrenic artery origin related to potential supply to hepatocellular carcinoma and its embolization.CVIR 2008.Image courtesy of David Liu, MD
    19. 19. Origin Right or left gastroepiploic artery Supplies Greater omentum (mobile!) Can supply tumors on almost any surface of the liver Effects of embolization Usually well-tolerated 15% of collateral supply After multiple TACEs, common hepatic injection demonstrates multiple omental branches (arrows) from the R gastroepiploic artery supplying right lobe HCC (arrowheads).Kim HC et al. Recognizing extrahepatic collateral vessels that supply hepatocellular carcinoma to avoid complications of transcatheter arterial chemoembolization.Radiographics 2005.
    20. 20. Origin Usually first branch of right hepatic artery Supplies Gallbladder HCC in gallbladder fossa Recognized by Proximal bifurcation Curved shape outlining viscus Effects of embolization Cholecystitis/gallbladder infarction Often asymptomatic Cystic artery injection demonstrates parasitic 9% of collateral supply supply to HCC (arrow)Kim HC et al. Recognizing extrahepatic collateral vessels that supply hepatocellular carcinoma to avoid complications of transcatheter arterial chemoembolization.Radiographics 2005.
    21. 21. Origin Aorta 5% of collateral supply Supplies Right body wall and skin Spinal artery (occasionally) T10 > T9 > T11 for tumor supply Effects of embolization Usually well-tolerated Skin necrosis Dermatomal pain Spinal artery infarction Right T11 injection demonstrates tumor supply (left). To avoid complications, a microcatheter was advanced beyond the diaphragm insertion site (right) prior to TACE.Kim HC et al. Recognizing extrahepatic collateral vessels that supply hepatocellular carcinoma to avoid complications of transcatheter arterial chemoembolization.Radiographics 2005.
    22. 22. Skin reaction related to intercostal embolizationImages courtesy of David Liu, MD
    23. 23. Right adrenal artery (6%) Right or left gastric artery (3%) Right internal mammary artery (3%) Superior mesenteric artery (2%) Right renal capsular artery (2%) Left inferior phrenic artery (2%)Kim HC et al. Recognizing extrahepatic collateral vessels that supply hepatocellular carcinoma to avoid complications of transcatheter arterial chemoembolization.Radiographics 2005.
    24. 24. Infiltrative HCC of the right lobe Replaced RHA angiogram demonstrates tumor supply. DEB-TACE was performed.1 month post-TACE, tumor necrosis is seen, but persistent Right phrenic angiography demonstrates copiousenhancement is seen at the posterior diaphragmatic margin. tumor supply. DEB-TACE was performed.
    25. 25. One month post TACE #2, persistent enhancement is present at the posterior The right T10 intercostal artery demonstrates tumor supply.margin of segment 6. DEB-TACE was performed from the vertical segment. 1 month post TACE #3, the tumor is almost completely devascularized.
    26. 26. Protective coil embolization of extrahepatic branches arising from the hepatic circulation prior to embolotherapy 1. Gastroduodenal artery 2. Right gastric artery 3. Accessory left gastric artery 4. Retroduodenal artery Uncommon considerations: 5. Supraduodenal artery -Dorsal pancreatic artery -Left phrenic artery -Esophageal branches 6. Falciform artery 7. Cystic artery
    27. 27. Accessory left gastric Right gastric Falciform Left phrenicCysticSupraduodenalRetroduodenal Right gastric Supraduodenal Retroduodenal Dorsal pancreatic
    28. 28. Origin Common hepatic arterySupplies Pylorus of stomach Proximal duodenum Pancreatic head (via pancreaticoduodenals) Greater curvature of stomach (via R gastroepiploic)Anatomic Clues Near constant origin from CHA Characteristic branching pattern The gastroduodenal artery arises from the CHA. It typically gives off the posterior superior pancreaticoduodenal artery (curved arrow), then bifurcates into the anterior superior pancreaticoduodenal artery (arrow) and the right gastroepiploic artery (arrowhead).
    29. 29. Considerations for optimization: Should be coil embolized in almost all cases High flow, need lots of coils to occlude (usually 5-7 mm coils) Coil all the way back to origin to avoid hypertrophy of small proximal vessels Look for accessory hepatic arteries and parasitized tumor supply GDA flow reversed? If due to low hepatic artery resistance, best to coil GDA with reversed flow. Depending on the etiology, this may or may not require coil embolization. If due to celiac stenosis, probably OK not to coil
    30. 30. Origin Proper hepatic artery (55%) Left hepatic artery (20%) Common hepatic artery (5%) Gastroduodenal artery (5%) Right or middle hepatic artery (rare) Supplies Right gastric artery (arrow) arising from the origin of the gastro- duodenal artery. Note anastomoses with the left gastric artery. Gastric antrum and pylorus Proximal duodenal bulb Anatomic Clues Leftward course along lesser curvature of stomach Anastomoses with left gastric artery Right gastric artery (arrow) arising from the left hepatic artery.VanDamme JP, Bonte J. Vascular anatomy in abdominal surgery. New York: Thieme, 1990.
    31. 31. Considerations for optimization Should be coil embolized in almost all patients -Unnecessary if RGA origin is very proximal (CHA) May have acute angle, difficult to catheterize Options for difficult cannulation -Shaped microcatheter -Ultra-floppy wire (Synchro) -Retrograde access via left gastric artery -“Jail” right gastric by coiling left hepatic artery -If all else fails, can deliver particles distal to origin Right gastric artery accessed retrograde from the left gastric artery, followed by coil embolizationYamagami et al. Embolization of the right gastric artery before he- patic arterial infusion chemotherapy to prevent gastric mucosal lesions: approach through thehepatic artery versus the left gastric artery. AJR Am J Roentgenol 2002; 179:1605-1610.
    32. 32. Prevalence 3-21% (low in Caucasian, high in Asian populations) Origin Left hepatic artery in proximal portion – 60% Left hepatic artery in distal portion – 40% Destination Gastric cardia and fundus Anatomic Clues Runs in the fissure of the ligamentum venosum (same place as a replaced left hepatic artery) on CT Proximal-type accessory left gastric artery (arrow) arises from the LHA prior to the umbilical point and courses to the gastric fundus (arrowheads).Ishigami K, Yoshimitsu K, Irie H, et al. Accessory left gastric artery from left hepatic artery shown on MDCT and conventional angiography: correlation with CThepatic arteriography. Am J Roentgenol 2006;187:1002-1009.
    33. 33. Considerations for optimization Should be coil embolized if present Often difficult to identify on angio Tips for identification -Gastric mucosal enhancement -Delayed-phase coronary vein filling Left hepatic injection reveals abnormal vascularity in the left upper -Use cone beam CT quadrant, overlapping the left lobe of the liver Superselective injection demonstrates accessory left gastric artery (distal type).
    34. 34. Also known as the posterior superior pancreaticoduodenal artery Origin Gastroduodenal artery – 78% Hepatic artery (proper or right) – 15% Superior mesenteric artery – 5% Destination Head of pancreas Uncinate process Duodenal bulb Anatomic Clues Runs along common hepatic duct Parallels 2nd segment of duodenum The retroduodenal artery (arrows) typically arises as the first branch of the gastroduodenal artery.VanDamme JP, Van der Schueren G, Bonte J. Vascularisation du pancreas: proposition de nomenclature PNA et angioarchitecture des ilots. C R Assoc Anat 1968;139:1184 –1192.
    35. 35. Considerations for optimization No need to coil embolize in most cases -Usually arises from GDA Coil embolize if originating from the hepatic artery (15%) Aberrant origin of the retroduodenal artery (arrows) from the proper hepatic artery. The origin of the GDA is seen more proximally (arrowhead).
    36. 36. Origin Gastroduodenal artery – 26% Common or proper hepatic artery – 20% Left hepatic artery – 20% Right hepatic artery – 13% Cystic artery – 10% Right gastric artery – 8% Destination Proximal duodenum Anatomic Clues Extremely variable origin Small branch Distribution to duodenal bulb area Supraduodenal artery (arrows) arises from the proper hepatic artery and passes toward the proximal duodenum.Bianchi et al. The supraduodenal artery, Surg Radiol Anat 11 ( 1989), pp. 37-40.Image courtesy of David Liu, MD
    37. 37. Considerations for optimization Often not visualized Be suspicious if branch from hepatic artery passes inferomedially toward duodenum Coil embolize if originating from hepatic circulation (about 50%) CHA injection demonstrates small artery passing inferomedially from the right hepatic artery (arrows).Superselective injection confirms supply to proximal duodenum. Coil embolization performed for duodenal protection (arrow).Images courtesy of David Liu, MD.
    38. 38. Origin Middle hepatic artery – 56% Left hepatic artery – 44% Destination Anterior abdominal wall, umbilical region Falciform artery (arrow) arising from the left hepatic Anatomic Clues artery, early phase. Rarely seen (2%) Courses anteriorly and diagonally toward the midline (paralleling the falciform ligament) Anterior course can be confirmed by angiography in RPO projection Late phase confirms typical course of falciform arteryWilliams et al. Hepatic falciform artery: anatomy, angiographic appearance, and clinical significance. Radiology 1985. 156: 339-340.
    39. 39. Considerations for optimization Usually not seen Coil embolize if present (2%) Lack of protection can result in abdominal wall injury, pain, and/or rash Typical appearance of falciform artery Coil embolization of falciform arteryWilliams et al. Hepatic falciform artery: anatomy, angiographic appearance, and clinical significance. Radiology 1985. 156: 339-340.Image courtesy of David Liu, MD.
    40. 40. Origin Right hepatic artery – 90% Left hepatic artery – 7% Common hepatic artery – 3% Gastroduodenal artery – 1% Destination Gallbladder Anatomic Clues Typically the first branch of right hepatic artery Bifurcation into superficial and deep branches Network of vessels outlining viscus Cystic artery (arrow) arising from the anterior division branch of the right hepatic arteryDaseler EH, Anson BA, Hambley WC, Reimann AF. The cystic artery and constituents of the hepatic pedicle. A study of 500 specimens. Surg GynecolObstet 1947: 85: 47–63
    41. 41. Considerations for optimization Players choice Advance catheter beyond cystic origin if possible Coil embolization can rarely lead to ischemic cholecystitis Lack of coil embolization can rarely lead to chemical Coil embolization of cystic artery or radiation cholecystitis Can protect with gelfoam embolization at the time of treatment Gelfoam embolization of cystic artery
    42. 42. Variations in hepatic arterial anatomy are extremely common, and often affect treatmentConsider parasitic supply, especially in large surface tumors Tumor location predicts source of parasitic supplyMultiple splanchnic branches arise from the hepatic circulation Will only be seen if you look for them! Optimization with coil embolization is safe and protectiveConsider CT angiogram of the liver prior to mesenteric mapping
    43. 43. jumcwilliams@mednet.ucla.edu
    44. 44. Problem Hepatosplanchnic artery cannot be catheterized or Catheter position unsafe for Y90 administration Solution Gastrohepatic trunk injection demonstrates no safe catheter position for Y90 delivery to left hepatic lobe Occlude entire offending hepatic artery proximally Cross-perfusion between lobes (artery to artery collaterals) will allow Y90 delivery to the parenchyma downstream from the obstructionKarunanithy N, et al. Embolization of hepatic arterial branches to simplify hepaticblood flow before yttrium 90 radioembolization: a useful technique in the Left hepatic artery coil-occluded; Y90 administered from Rpresence of challenging anatomy. CVIR 2010 Aug 11 (Epub ahead of print) hepatic artery, relying on cross-perfusion to reach L lobeImages courtesy of David Liu, MD tumors.
    45. 45. jumcwilliams@mednet.ucla.edu

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