Aberrant Hepatic Arterial Anatomy Research Articles

Strategic Approach to Aberrant Hepatic Arterial Anatomy during Laparoscopic Pancreaticoduodenectomy: Technique with Video

It is critical for every pancreatic surgeon to determine how to protect the aberrant hepatic artery intraoperatively in order to safely implement laparoscopic pancreatoduodenectomy (LPD). "Artery-first" approaches to LPD are ideal procedures in selected patients with pancreatic head tumors. Here, we described our surgical procedure and experience of aberrant hepatic arterial anatomy-LPD (AHAA-LPD) in a retrospective case series. In this study, we also sought to confirm the implications of the combined SMA-first approach on the perioperative and oncologic outcomes of AHAA-LPD. From January 2021 to April 2022, the authors completed a total of 106 LPDs, of which 24 patients underwent AHAA-LPD. We evaluated the courses of the hepatic artery via preoperative multi-detector computed tomography (MDCT) and classified several meaningful AHAAs. The clinical data of 106 patients who underwent AHAA-LPD and standard LPD were retrospectively analyzed. We compared the technical and oncological outcomes of the combined SMA-first approach, AHAA-LPD, and the concurrent standard LPD. All the operations were successful. The combined SMA-first approaches were used by the authors to manage 24 resectable AHAA-LPD patients. The mean age of the patients was 58.1 ± 12.1 years; the mean operation time was 362 ± 60.43 min (325-510 min); blood loss was 256 ± 55.72 mL (210-350 mL); the postoperation ALT and AST were 235 ± 25.65 IU/L (184-276 IU/L) and 180 ± 34.43 IU/L (133-245 IU/L); the median postoperative length of stay was 17 days (13.0-26.0 days); the R0 resection rate was 100%. There were no cases of open conversion. The pathology showed free surgical margins. The mean number of dissected lymph nodes was 18 ± 3.5 (14-25); the number of tumor-free margins was 3.43 ± 0.78 mm (2.7-4.3 mm). There were no Clavien-Dindo III-IV classifications or C-grade pancreatic fistulas. The number of lymph node resections was greater in the AHAA-LPD group (18 vs. 15, p < 0.001). Surgical variables (OT) or postoperative complications (POPF, DGE, BL, and PH) showed no significant statistical differences in both groups. In performing AHAA-LPD, the combined SMA-first approach for the periadventitial dissection of the distinct aberrant hepatic artery to avoid hepatic artery injury is feasible and safe when performed by a team experienced in minimally invasive pancreatic surgery. The safety and efficacy of this technique need to be confirmed in large-scale-sized, multicenter, prospective randomized controlled studies in the future.

Ex Situ Arterial Reconstruction During Normothermic Perfusion of the Liver.

Background.Aberrant hepatic arterial anatomy may be seen in up to 30% of liver grafts, and reconstruction prolongs the cold ischemic time or the arterialization times. If normothermic machine preservation (NMP) is used to preserve liver grafts, the presence of aberrant arterial anatomy poses a challenge. Dual arterial cannulation is a temporary solution to enable effective perfusion, until optimal circumstances are met for arterial reconstruction, without compromising ischemia time. To date the technical and logistical feasibility of arterial reconstruction ex situ and during NMP has not been reported.Methods.Series of 5 cases from the Consortium for Organ Preservation in Europe randomized controlled trial in which grafts with arterial anatomic variations were reconstructed while organs were perfused on NMP.Results.One donor after cardiac death and 4 donor after brain death livers with arterial anatomical variations reconstructed while on NMP were included. All patients survived transplantation, spending 1–7 d in intensive care unit and discharged home after 5–15 d. None of the cases developed early allograft dysfunction or any early technical complications. At follow-up, there were no late hepatic artery thrombosis, stenosis, or any other vascular–related complication. Four of 5 patients underwent magnetic resonance cholangiopancreatography at 6 mo with no evidence of ischemic cholangiopathy.Conclusions.The case series described above suggests that ex vivo arterial reconstruction surgery on liver grafts while on board the NMP device is feasible, safe, and effective.

Does aberrant hepatic arterial anatomy impact the complication rate or survival following resection of pancreatic adenocarcinoma?

775 Background: Patients with aberrant hepatic arterial anatomy (AHAA) are susceptible to tumor invasion and/or ligation during resection of the pancreatic head. The purpose of this study is to determine if AHAA negatively impacts perioperative outcomes or survival. Methods: All patients who underwent either pancreaticoduodenectomy or total pancreatectomy for pancreatic ductal adenocarcinoma (PDAC) between 2005 and 2014 at our center were retrospectively reviewed. Univariate logistic regression was used to compare outcomes between patients with conventional hepatic arterial anatomy to those with AHAA. Survival analysis was performed by Kaplan-Meier method with log rank test. Results: During the study period, 330 patients underwent resection for PDAC, 69 (20.9%) with aberrant hepatic arterial anatomy. The presence of AHAA does not significantly increase operative time (p= 0.110) or length of stay (p=0.518). The overall frequency of complications (49.3% vs 37.9%, p=0.088) was higher in the AHAA group, but not significantly so. Certain postoperative complications are more common in the AHAA group, namely superficial surgical site infection (18.8% vs. 8.8%, p=0.018) and pancreatic fistula (18.8% vs. 10.0%, p=0.042). However, deep SSI, need for blood transfusion, respiratory failure, DGE, bleed from GDA/pseudoaneurysm, biliary fistula, chyle leak, PV thrombus, fascial dehiscence, and reoperation are not statistically different between the two groups. There is a trend for reduced overall survival in the AHAA group that is not statistically significant (p=0.11). Conclusions: Aberrant hepatic arterial anatomy is encountered in greater than 20% of pancreatic surgery patients, and its presence may increase the rate of certain postoperative complications such as superficial surgical site infection and pancreatic fistula.

Hepatic arterial system anomalies encountered during pancreaticoduodenectomy - our experience.

We present our experience of incidence and management of aberrant hepatic arterial anatomy encountered during pancreaticoduodenectomy (PD). Patients undergoing PD between December 2014 and November 2016 at the Shaukat Khanum Memorial Cancer Hospital, Lahore were included in this short report. Preoperative imaging and operative findings of these patients were reviewed to evaluate the hepatic arterial anatomy and classified according to Hiatt classification. Sixty-four PD were performed with aberrant arterial anatomy identified in 24 (37.5%) of the cases. Most common anomaly was replaced right hepatic artery (rRHA) arising from the superior mesenteric artery seen in seven (11%) of the patients. Aberrant vessels were recognised and preserved in 23 cases. In one patient, the rRHA was coursing through the pancreatic parenchyma needing resection and reconstruction with uneventful postoperative recovery. Hepatic arterial anomalies are common and it is possible to preserve these vessels with careful surgical dissection using artery first technique.

Aberrant Right Hepatic Artery Leading to Duodenal Obstruction

A 60-year-old male presented with 1 day of epigastric abdominal pain and vomiting. His medical history included type II diabetes and hypertension. He underwent a weight loss of approximately 45 pounds in five months to better control his diabetes. General physical examination revealed diffuse tenderness and distention of the abdomen without peritoneal signs. Complete blood count and basic metabolic panel results were normal. An abdominal radiograph showed marked gastric distention with air-fluid levels in the stomach and proximal duodenum (Fig. 1). Computed tomography angiogram of the abdomen showed an aberrant right hepatic artery (ARHA) causing proximal duodenal obstruction (Fig. 2). The patient's clinical condition improved with nasogastric drainage and he was subsequently discharged the day after admission. He consulted with a vascular surgeon one week after discharge. The vascular supply to the liver consists of the hepatic portal vein and hepatic artery. Within 77% of the population the hepatic artery branches from the celiac artery to supply the liver; however, aberrant hepatic arterial anatomy is quite common. Studies have shown greater than 41% of the population posses anomalies of which 13-26% have anomalies in the origin of their right hepatic artery. Despite its frequency ARHAs are generally encountered during pancreaticoduodenectomy and have not been associated with intestinal obstruction. The condition is also encountered in liver transplant (15% of donor livers). ARHA can arise from the superior mesenteric artery in 11.6% of patients. This case presents an ARHA originating from the superior mesenteric artery that encircled the second portion of the duodenum and led to compression after a rapid weight loss by the patient. The main importance is recognition by the radiologist and surgical consultation to prevent ligation of the aberrant artery or biliary duct which can lead to ischemia. The patient opted for conservative management as an outpatient but was offered vascular input versus a surgical Biliroth II procedure.2584_A Figure 1. Moderate gastric distention with multiple air-fluid levels seen in the stomach and proximal duodenum on abdominal radiograph.2584_B Figure 2. An aberrant right hepatic artery causing obstruction of the proximal duodenum on computed tomography angiogram of the abdomen.

Does Aberrant Hepatic Arterial Anatomy Affect Resection Margin Status In Pancreaticoduodenectomy For Pancreatic Adenocarcinoma?

Resection margin status impacts on survival after resection of pancreatic adenocarcinoma. This study aims to assess the incidence and association between aberrant hepatic arterial anatomy and resection margin status.

ARTERY FIRST TECHNIQUE FOR MANAGEMENT OF ABERRANT HEPATIC ARTERIAL ANATOMY DURING PANCREATICODUODENECTOMY-EXPERIENCE FROM A SPECIALIZED HEPATO-PANCREATO-BILIARY UNIT

Purpose: Aberrant hepatic arterial anatomy poses a challenge for surgeon during pancreaticoduodenectomy (PD). These anomalies are best picked up on pre-operative imaging to avoid inadvertent injury to the aberrant vasculature resulting in liver ischaemia or biliary-enteric anastomotic failure. We present our experience of dealing with aberrant hepatic vessels during PD. Methods: Patients with aberrant hepatic vasculature who underwent PD between September 2014 and August 2015 were included in the study. We used artery rst technique for dissection in cases identified on pre operative imaging. Aberrations were classed according to Hiatt classi cation. Results: A total of 23 PD were performed with aberrant arterial anatomy in 10 (43%) cases. These vessels were recognised and preserved in nine cases. In one patient, the replaced right hepatic artery (RRHA) arising from superior mesenteric artery (SMA) was coursing through pancreatic parenchyma needing resection and reconstruction with uneventful post-operative recovery. We also identified one RRHA arising from SMA coursing lateral to common bile duct and entering liver parenchyma in gallbladder fossa. Conclusion: Aberrant hepatic arterial anomalies are common and should ideally be picked up by pre-operative imaging. It is possible to preserve these vessels in most cases with careful surgical dissection using artery first technique. Surgeons performing PD should be well versed with the aberrant vascular anatomy to minimise any inadvertent damage. Key words: Aberrant hepatic artery, artery first technique, pancreaticoduodenectomy

Article Commentary: Aberrant Hepatic Arterial Anatomy and the Whipple Procedure: Lessons Learned

Appreciation and study of hepatic arterial anatomical variability is essential to the performance of a pancreaticoduodenectomy to avoid surgical complications such as bleeding, hepatic ischemia/failure, and anastomotic leak/stricture. Awareness of this variability permits the surgeon to adapt the surgical technique to deal with anomalies identified preoperatively or intraoperatively thereby preventing unnecessary surgical morbidity and mortality. The objective of our study is to provide a comprehensive review of the anatomic arterial anomalies and discuss surgical strategies that will equip the surgeon to deal with all anomalies that may be encountered a priori or en passant during the course of a Whipple procedure.

Correlation Between Graft Arterial Anatomy and Biliary Complications After Liver Transplantation

Knowledge of the arterial vascular anatomy of the liver is important for orthotopic liver transplantation (OLT) because the lack of an adequate arterial blood supply results in biliary and parenchymal complications or graft loss. A number of reports have shown a relationship between aberrations of graft arteries and an increased incidence of early or late complications. Recent studies suggest no differences unless multiple anastomoses are required. The aim of this study was to report the incidence of aberrant hepatic arterial anatomy and its impact on vascular and biliary complications. We retrospectively reviewed data of 90 OLT performed on 82 patients, including 4 who underwent retransplantation from March 2003 to March 2006. The means recipient age was 52.47 years and 49 were men. The main caval vein reconstruction technique was piggyback (n = 55; 61.2%). The biliary reconstruction was performed by an end-to-end choledocho-choledocho anastomosis in 83 cases (92.3%) with choledocho-jejunal anastomosis (Roux-in-Y) in 7 cases (7.7%). Aberrant arterial anatomy was noted in 20 liver grafts (22.2%), namely, accessory right hepatic artery (n = 6; 6.6%), accessory left (n = 10; 11%), both accessory right and left (n = 3; 3.3%), and hepatic common artery from mesenteric artery (n = 1; 1.1%). Among the transplantations of grafts with aberrant arterial anatomy, 2 cases (10%) developed hepatic artery thrombosis (HAT) and 4 (20%) biliary complications. The rate of HAT and biliary complications among grafts with normal arterial anatomy was 3 and 8 cases (4.2% and 11.42%), respectively. Despite a greater number of complications among OLT with aberrant arterial anatomy, the Fisher test showed no significant relationship between HAT or biliary complications and aberrant arterial anatomy.

Graft positioning at liver transplantation in situs inversus

Situs inversus (SI) totalis is a rare congenital anomaly. In the past it was considered an absolute contraindication to liver transplantation (LT) because of associated malformations, and difficulty achieving accurate graft positioning. We describe successful outcome following LT in a 41-year-old with alcoholrelated chronic liver disease and complete SI using a novel technique (Fig. 1). Recipient hepatectomy was uncomplicated. A donor whole liver was implanted using a piggyback technique. Reduced space in the right upper quadrant from the stomach and spleen resulted in 40% clockwise graft rotation. To attenuate this effect, the left diaphragm was plicated and a Sengstaken-Blakemore tube was inserted percutaneously into the left upper quadrant (LUQ). The gastric balloon was inflated with 400 ml of normal saline to support the left lobe (Fig. 2). The donor remnant falciform ligament was fixed to the recipient diaphragmatic surface to effect long-term optimal positioning. Abdominal CT scan on day 7 demonstrated the gastric balloon elevating and supporting the graft (Figure 3). On day 12, 200 ml of normal saline was aspirated with gradual balloon deflation over the next 3 days, and removal of the Sengstaken-Blakemore tube on day 15. Serial Doppler ultrasonography demonstrated normal hepatic venous flow. An abdominal CT scan at 3 months demonstrated no change in graft position (Figure 4A). The hepatic veins, portal vein and hepatic artery appeared patent (Figure 4B). The patient remains well 17 months following LT with normal graft function. Abdominal SI is described in association with the polysplenia syndrome with inferior vena caval absence, preduodenal portal vein, midgut malrotation, aberrant hepatic arterial anatomy, and portal vein hypoplasia. Anatomic anomalies result in a more complex recipient hepatectomy. Consideration has to be given to correct donor graft positioning, and additional vascular reconstruction. However, LT has been performed successfully using modified surgical techniques. Most cases are in the paediatric population in whom graft displacement and hepatic venous pedicle torsion are less due to a smaller abdominal cavity when even split and reduced grafts are typically large-for-size, and greater use of caval replacement techniques. Cadaveric segmental and living related left lateral segment grafts have been successfully placed with suitable orientation for hilar vessel anastomoses. However, in adults following recipient hepatectomy, a large empty space exists in the LUQ predisposing to lateral displacement with supero-lateral graft rotation and torsion of the hepatic venous pedicle particularly with a piggyback technique. Split, reduced, and right lobe living related LT have been performed successfully. Technical modifications with an intact recipient cava include piggyback implantation over the right suprahepatic vein with orthotopic graft position, and graft rotation by 90°. In our patient, only partial volume reduction of the left hepatic fossa was achieved by diaphragmatic plication. Due to its large size, filling the defect with omentum and mobilized hepatic flexure would have been inadequate. The use of a Sengstaken-Blakemore tube represents an innovative and simple technique to provide effective graft support, and reduce the risk of outflow obstruction. Subsequent peri-hepatic adhesion formation and migration of bowel loops into the LUQ would be expected to provide longterm graft fixation.

Effect of aberrant hepatic arterial anatomy on tumour response to hepatic artery infusion of floxuridine for colorectal liver metastases.

Regional hepatic artery infusion of colorectal liver metastases produces the highest reported treatment response. The effect of variation in hepatic artery anatomy on tumour response to regional floxuridine (FUdR) was studied. Aberrant hepatic arterial anatomy occurred in 13 of 74 patients (18 per cent) who underwent cannulation of the hepatic artery and infusion of FUdR for colorectal liver metastases. The non-dominant hepatic artery was ligated and the dominant artery cannulated in those with aberrant anatomy. Despite evidence of a collateral circulation to the non-dominant area of the liver in these patients, there was no significant reduction in median tumour volume with treatment (before treatment 214 ml, after treatment 339 ml). By contrast, there was a significant (P < 0.001) decrease in median tumour volume (before treatment 329 ml, after treatment 148 ml) in those with normal anatomy. Delivery of FUdR to metastases via an intrahepatic collateral circulation was not as effective as through a main hepatic artery.

Multidetector CT arteriography with volumetric three-dimensional rendering to evaluate patients with metastatic colorectal disease for placement of a floxuridine infusion pump.

We sought to evaluate the usefulness of multidetector CT (MDCT) arteriography with volumetric three-dimensional (3D) rendering to depict the hepatic vascular anatomy. Our study population was patients who had undergone arterial mapping in preparation for placement of a hepatic arterial floxuridine infusion pump for treatment of metastatic hepatic colorectal carcinoma. We retrospectively reviewed the medical records of 26 patients with hepatic colorectal metastases who had been scheduled for implantation of a hepatic artery pump. Before surgery, all patients underwent MDCT arteriography with volumetric 3D rendering of the hepatic vessels. The axial and 3D arteriograms were evaluated for their usefulness in depicting hepatic arterial anatomy. Subsequently, three patients also underwent catheter angiography. Twenty-two of the 26 patients imaged had a hepatic artery floxuridine infusion pump implanted. Results of the CT arteriography were correlated with findings at surgery or on catheter angiography if surgery was not performed. MDCT arteriography correctly revealed hepatic arterial anatomy in all 25 patients with angiographic or surgical confirmation. One patient with aberrant hepatic arterial anatomy did not have angiographic or surgical confirmation. Classic hepatic arterial anatomy was identified in 16 (64%) of 25 patients. The following hepatic arterial variants were found in one patient each: the common hepatic artery arising directly from the aorta; a replaced left hepatic artery; an accessory right hepatic artery; a replaced left hepatic artery and accessory right hepatic artery; a replaced right hepatic artery; a right hepatic arterial branch arising early (before the origin of the gastroduodenal artery); and replaced right and left hepatic arteries. Three patients were not suitable candidates for placement of a hepatic artery floxuridine pump. The patient who had no angiographic or surgical confirmation was also not considered a good surgical candidate because of replaced right and left hepatic arteries. Two patients (8%) had an accessory left hepatic artery. MDCT arteriography with volumetric 3D rendering is an accurate, noninvasive method of depicting hepatic arterial anatomy and, therefore, of selecting patients with colorectal metastatic disease who could benefit from hepatic artery pump implantation. Catheter angiography provides no additional information, and we have eliminated it as a routine preoperative imaging examination.

Development of extrahepatic arterial blood supply to the liver during hepatic arterial infusion chemotherapy

The aim of this study was to evaluate the correlation of development of the collateral circulation to the liver during hepatic arterial infusion chemotherapy (HAIC) with the presence of hepatic tumours adjacent to the hepatic surface, and with pretreatment occlusion of aberrant hepatic arteries. In 102 patients with unresectable malignant hepatic tumours treated with HAIC using an implantable port system, development of collaterals to the liver was assessed with CT arteriography using the implantable port and pre- and postoperative angiography. Aberrant hepatic arteries, if present, were occluded prior to treatment for hepatic arterial redistribution. Collaterals to the liver were seen in 29 patients, who had 35 areas with collateral perfusion: 22 areas were in the right posterosuperior area, 6 in the left peripheral area and 7 in the right or left lobar area. Collaterals were revealed more frequently in patients with hepatic tumours adjacent to the hepatic surface than in those without hepatic tumours in peripheral areas in the liver (p < 0.0001). In addition, collaterals developed more frequently in patients with an aberrant hepatic arterial anatomy compared with those with conventional anatomy (p = 0.0007). Our results indicated that patients with hepatic tumours adjacent to the hepatic surface and with pretreatment occlusion of aberrant hepatic arteries had the potential to develop collaterals to the liver during HAIC.