Aberrant Right Hepatic Artery Research Articles

Variations of the hepatic artery and bile duct in patients with pancreaticobiliary maljunction: Impact on postoperative outcomes.

Preoperative comprehension of the anatomical variations of the hepatic artery and bile duct is essential for safe laparoscopic surgery for pancreaticobiliary maljunction (PBM). This study aimed to investigate the impact of anatomical variations of the hepatic artery and bile duct on surgical technique and postoperative complications. We conducted a retrospective review of patients with PBM who underwent laparoscopic surgery at our institution between January 2014 and December 2022 to investigate anatomical variations in the hepatic artery and bile duct, surgical technique, and postoperative complications. We included 112 patients with PBM, with a median age of 4 years (interquartile range, 0-55). Overall, 29 of 112 patients had an aberrant right hepatic artery (ARHA) running ventral to the common hepatic duct (CHD), and they underwent hepaticojejunostomy on the ventral side of the ARHA. Additionally, eight of 112 patients had an aberrant posterior hepatic duct (APHD), which was joined to the CHD in all but one case. The presence of APHD was associated with postoperative bile leak occurrence. Performing hepaticojejunostomy ventral to the ARHA is important to prevent complications. Furthermore, APHD may be a risk factor for postoperative bile leak and requires careful bile duct plasty.

Laparoscopic Kasai Procedure of Treating Biliary Atresia with an Aberrant Right Hepatic Artery.

Background: An aberrant vascular anatomy might present a technical pitfall for biliary atresia (BA) surgery. The purpose of this study was to report the rare cases and discuss the significance and management strategy for BA with an aberrant right hepatic artery (ARHA) by laparoscopic Kasai procedure in children. Methods: The subjects for this study were 10 consecutive type III BA patients with an ARHA who had laparoscopic Kasai procedure at our institute between January 2012 and August 2021. The common bile duct was mobilized between the right hepatic artery and the right branch of portal vein, and then lifted to the liver hilum. The fibrous cord was transected and then the laparoscopic Kasai was carried out. Results: All patients survived the laparoscopic Kasai without any intraoperative complications. The mean operative time was 235 minutes for each laparoscopic Kasai. The mean follow-up time was 32.6 months. The total and direct bilirubin dropped to normal within 4 months of surgery in 7 patients. One patient died of repeated cholangitis and liver failure 1 year after surgery. In the additional 2 patients the bilirubin levels dropped significantly after the surgery but elevated again because of repeated cholangitis and requiring ongoing observation and intermittent treatment. Conclusions: With the perfect laparoscopic skills, the common bile duct could be safely mobilized between the right hepatic artery and right branch of portal vein for the infants with type III BA associated with an ARHA, and laparoscopic Kasai could be carried out safely and successfully.

Right hepatic artery: primum discere anatomia-first, learn anatomy

Laparoscopic cholecystectomy (LC) is the most commonly performed surgical procedure and considered as the gold standard treatment of gallstone disease. However, the overall rate of complications like injury to bile duct and hepatic artery in LC remains higher than that seen in open cholecystectomy. Hence complete knowledge of the anatomy and anatomical relationship of biliary tree and liver plays a key role in the laparoscopic hepatobiliary surgeries. Being an end artery, blood supply to the right lobe of the liver solely depends on the right hepatic artery. Identification of variations in hepatic arterial anatomy is important in the planning and performing of hepatobiliary surgeries varying from simple LC to pancreaticoduodenectomy. In the current study, the authors referenced laparoscopic dissection results to examine another rare case showing "anterior" relationship of aberrant right hepatic artery (ARHA) with the common hepatic duct having clinically important implications in LC. The objective of this study is to highlight the importance of learning anatomy as the first step for a successful surgery and with the help of this case contribute to existing knowledge of the right hepatic artery to improve surgical safety.

Resectability Status of Pancreatic Cancer Having Tumor Contact with an Aberrant Right Hepatic Artery: Is Upfront Surgery Justified?

The NCCN guidelines define pancreatic cancer that has contact with an aberrant right hepatic artery (A-RHA) as a borderline-resectable tumor. However, the impact of tumor contact with an A-RHA on surgical and survival outcomes has not been well discussed. A total of 541 patients who underwent pancreatoduodenectomy for resectable and borderline-resectable pancreatic cancer between 2002 and 2019 were retrospectively analyzed. The presence of an A-RHA and tumor contact with an A-RHA were evaluated based on the preoperative computed tomography findings. Patients with resectable tumors and tumors with A-RHA-contact (having contact with an A-RHA without involvement of the major arteries) were generally treated by upfront surgery, whereas those with borderline-resectable tumors generally underwent neoadjuvant therapy and subsequent resection. Among the 541 patients, 116 (21.4%) had an A-RHA and 15 (2.8%) had tumor with A-RHA-contact. The A-RHA was resected in 12, and arterial reconstruction was performed in 8. The rates of morbidity and R1 resection in patients with an A-RHA (32.8 and 10.3%, respectively) were comparable to those without an A-RHA (27.3 and 11.3%, respectively). The overall survival in patients with A-RHA-contact was significantly worse than that in patients with borderline-resectable tumors (median survival time, 14.6 vs. 35.3 months, p = 0.048). Although upfront resection was safely performed and led to a high R0 resection rate in patients with A-RHA-contact, the survival outcome was dismal. A tumor with A-RHA-contact should be regarded as technically resectable but oncologically borderline-resectable. Upfront surgery may not be appropriate for patients with A-RHA-contact.

Origin and Prevalence of the Retroportal Course of Hepatic Artery- A Retrospective Study

Introduction: Anatomical variations of celiac and hepatic arteries are relatively common and impact operative time and technique. Intraoperative identification of the entire course of these vessels can be a challenge due to limited surgical field and increases the chance of iatrogenic injury. Aim: To evaluate and describe the origin and prevalence of retroportal course of hepatic arteries seen in Computed Tomography (CT) angiography in a large series of patients. Materials and Methods: The present retrospective study was conducted in the Department of Radiology, affiliated to a tertiary cancer centre in Southern India. CT angiogram done between January 2020 to June 2021 were included. Total of 326 abdominal CT angiograms were studied for celiac axis variations, variations in the origin and branching pattern of hepatic arteries, trajectory of the hepatic artery and its relation to portal vein. The branching pattern of celiac axis was analysed with adherence to the modified definition of Common Hepatic Artery (CHA) and it was classified as normal/variant/ambiguous. Based on the origin and branching pattern, hepatic arteries were divided into standard/replaced/accessory and classic/variant divisions, respectively. Variant divisions include trifurcation, duplicate or double hepatic artery and late origin of Gastro Duodenal Artery (GDA). Retroportal hepatic arteries under each variation was identified separately and their prevalence calculated. Confidence interval was calculated using simple proportionfrequency analysis open Epi version 3 software. Results: The age of the patients varies from 3 to 83 years (mean age 53.7 years). 207 (63.49%) cases were male and 119 (36.5%) cases were female. 262 (80.37%) cases had a normal celiac axis anatomy. Eight specific types of celiac axis variations were observed in 48 (14.72%) cases. In the remaining 16 (4.91%) cases, the celiac axis anatomy was ambiguous. CHA originated from the celiac axis, Superior Mesentric Artery (SMA) and aorta in 294 (90.18%), 10 (3.07%) and 6 (1.84%) cases respectively. Out of the 52 replaced Right Hepatic Artery (rRHA), 48 (14.72%), 3 (0.92%) and 1 (0.30%) cases had Right Hepatic Artery (RHA) replaced to the SMA, aorta and GDA, respectively. Except for the one rRHA from GDA, all of them had a retroportal course. Classic branching pattern of hepatic artery was seen in 154 (47.24%). Trifurcation, early branching of RHA and early branching of LHA were found in 49 (15.03%), 4 (1.22%) and 8 (2.45%) respectively. 63 (70%) cases of variations in hepatic artery origin, 15 (16.67%) cases of variations in hepatic artery branching and 12 (13.33%) cases of variations in celiac axis contributed to a total of 90 cases with retroportal hepatic artery. Prevalence of retroportal hepatic artery in the present study is 27.61% (confidence interval 22.82- 32.8) and the most common cause was aberrant RHA origin. Conclusion: Knowledge about the origin and prevalence of retroportal course of hepatic artery will help the surgeon to approach it systematically. Preoperative knowledge of the variations in origin and branching patterns and its influence on the trajectory will help in a better intraoperative identification of these variant vessels.

Anatomic Variations of the Hepatic Artery in 5625 Patients.

To analyze the origin and anatomic course of the hepatic arteries by using digital subtraction angiography (DSA) and multidetector CT in a large study sample. This retrospective study included 5625 patients who underwent liver CT and chemoembolization between January 2005 and December 2018 (mean age, 60 years ± 11 [range, 11-99 years]; 4464 males). The CT and DSA images were reviewed to evaluate the visceral arterial anatomy for variations in the celiac axis and hepatic arteries. Aberrant right hepatic arteries (aRHAs) and aberrant left hepatic arteries (aLHAs) were defined on the basis of their origin and anatomic course. Statistical analyses were performed to evaluate the association between aRHAs and aLHAs and the association between variations in the hepatic artery and celiac axis. Right hepatic arteries were categorized as being aRHAs (if originating from the proximal to middle common hepatic artery, gastroduodenal artery, superior mesenteric artery [SMA], celiac axis, aorta, splenic artery, or left gastric artery [LGA]) or as being aLHAs (if arising from the LGA, celiac axis, aorta, or SMA). The prevalence of aRHAs (15.63%; 879 of 5625) and the prevalence aLHAs (16.32%; 918 of 5625) were similar. Patients with an aRHA were more likely to have an aLHA than those without an aRHA (29.01% vs 13.97%; P < .001), and patients with an aLHA were more likely to have an aRHA than those without an aLHA (27.78% vs 13.26%; P < .001). There was no association between the hepatic arterial variations and celiac axis variations. A hypothetical anatomic model summarizing the observed variations was created. A comprehensive list of hepatic arterial variations and a three-dimensional hypothetical model for the observed variations were described.Keywords: CT, Angiography, Liver, Anatomy, Arteries© RSNA, 2021 Supplemental material is available for this article. See also commentary by Sutphin and Kalva in this issue.

An aberrant right hepatic artery arising from the gastroduodenal artery: a pitfall encountered during pancreaticoduodenectomy.

Among the variations of the right hepatic artery (RHA), the identification of an aberrant RHA arising from the gastroduodenal artery (GDA) is vital for avoiding damage to the RHA during surgery, since ligation of the GDA is necessary during pancreaticoduodenectomy (PD). However, this variation is not frequently reported. The purpose of this study was to focus on an aberrant RHA arising from the GDA, which was not noted in the classifications reported by Michels and Hiatt. A total of 574 patients undergoing a PD between Jan 2001 and Dec 2015 at a tertiary care hospital in Switzerland (n = 366) and between Jan 2009 and May 2015 at a hospital in Japan (n = 208) were included in the analysis. Of these, preoperative CT angiography or/and MRI angiography findings were available for 532 patients. We retrospectively analyzed the hepatic artery variations, patient demographics, and surgical outcomes. Among the 532 patients who received a PD, an RHA originating from the GDA was observed in 19 cases (3.5%). Eleven patients (2.1%) had both an aberrant RHA and an aberrant left hepatic artery (LHA) (Hiatt Type 4). Six patients (1.2%) had a replaced CHA arising from the SMA (Hiatt Type 5). We could, therefore, correctly identify the aberration in all cases. We observed rarely reported but important aberrant RHA variations arising from the GDA. To prevent injury during PD in patients with this type of aberrant RHA, intensive preparations using CT and/or MRI imaging before surgery and intraoperative liver Doppler ultrasonography are considered to be essential.

Intrahepatic cholangiocarcinoma with aberrant hepatic artery presenting as hepatic abscess: a case report

Intrahepatic cholangiocarcinoma (ICC) is a primary hepatic malignancy that originates from epithelial cells of bile duct. Lack of diagnostic measures and therapies leads to an increasing number of deaths from ICC worldwide. Here we described a case of 61-year-old Chinese female, who initially presented with right upper quadrant pain, combined with the results that a low density mass accompanied by multiple nodules occupied the right liver lobe by CT-scan, which also showed an aberrant right hepatic artery that participated in the right liver lobe and origining from the superior mesenteric artery, this patient was clinically considered as hepatic abscess (HA). The patient’s right upper quadrant pain was alleviated after been treated with the infusion chemotherapy of the aberrant right hepatic artery (ARHA) via percutaneous femoral arterial catheterization by Seldinger technique (Meropenem 7 days) following the failure of the liver-puncture drainage. However, the right upper quadrant pain occurred again 6 days later, serum CA19-9&gt;1000.0 U/ml, which indicated the possibility of hepatic malignancy, so we performed laparotomy. The histopathological result of intraoperative frozen section demonstrated cholangiocarcinoma, unfortunately, it was unresectable. Finally, right lower lung pneumonia and pleural empyema happened to her and she succumbed to respiratory failure 22 days following surgery. In this report, we will discuss the case with reference to the literature.

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.

Anatomic variation and introperative disposal of right hepatic artery in pancreaticoduodenectomy

Anatomic variation of right hepatic artery (RHA) is not rare in clinical. we retrospective reviewed the clinical data of 179 patients underwent pancreaticoduodenectomy (PD) between January 2012 and June 2017 in Department of Hepatobiliary Surgery, Hospital of Binzhou Medical University, Shandong Province, China. 28 patients from them presented variant RHA including replaced RHA (rRHA) and accessory RHA (aRHA), and the incidence of aberrant RHA was about 15.64%. The variation was confirmed with preoperative imaging in 25 cases by contrast-enhanced computed tomographic (CT) and the preoperative diagnostic accuracy was up to 89.29% in our study. The duration of operation in variant group was prolonged than normal and there was a statistical difference between two groups, no difference was demonstrated in estimated amount of blood loss and postoperative complications including biliary fistula, pancreatic fistula, chylous fistula, intraperitoneal haemorrhage between two groups. It is essential for surgeons to be vigilant for rRHA or aRHA to avoid potentially disastrous complications and the best introperative disposal, only if transection and reconstruction is unavoidable, is to dissect and preserve despite it may cost much more time.

Anastomotic loop between common hepatic artery and gastroduodenal artery in coexistence with an aberrant right hepatic artery.

Anatomical variations of the hepatic arteries are not uncommon. The anomalous hepatic arterial supply is of paramount importance in hepatobiliary, pancreatic or liver transplantation and in laparoscopic surgery. We describe an unusual case of a 66-year-old Greek male cadaver, where a rare anastomosis (in the form of an enlarged arterial loop, 4.84 mm in diameter) between the common hepatic artery (6.42 mm) and the gastroduodenal artery (GDA) (4.82 mm) coexisted with an aberrant right hepatic artery (ARHA) (6.38 mm) originating from the superior mesenteric artery. The proper hepatic artery was absent. The ARHA followed a route posterior to the portal vein and the common hepatic duct, entering the liver and supplying the right hepatic segment. A hypoplastic right gastric artery emanated from the GDA. Our case report highlights the combined variations of hepatic arteries and possible anastomoses emphasizing that a thorough knowledge of the classic and variable hepatic arterial anatomy are mandatory for surgeons and radiologists performing hepatic surgery and arteriography to avoid potential iatrogenic injuries in hepatobiliary and pancreas area and further medico-legal implications.

Variations in the Origin and Course of Right Hepatic Artery and its Surgical Significance.

Variations in the Right Hepatic Artery (RHA) are exceedingly common and these variations are of great importance to surgeons and interventional radiologists. A thorough knowledge of the right hepatic arterial anatomy is mandatory while performing hepatic surgery and hepatic arteriography. To find out the variations in the origin and course of the RHA and its surgical significance. This study was conducted in 60 embalmed adult cadavers of both sexes of age group between 50 to 80 years. Abdomen was opened by a linear midline incision extending from the xiphoid process to the pubic symphysis. The origin of RHA from the proper hepatic artery was traced. The presence of aberrant right hepatic arteries -replaced and accessory were noted. The source of origin of accessory or replaced RHA arising from the superior mesenteric artery (SMA), right renal artery and inferior mesenteric artery was traced. The course of normal and aberrant RHA from its origin to the entrance into the right lobe of the liver was followed and structures related to it were noted. The RHA mostly originated from the main trunk of the proper hepatic artery in 52 specimens (86.6%). Presence of aberrant RHA was found in 8 specimens (13.3%). Among 8 specimens of aberrant RHA, replaced RHA arising from SMA was found in 5 specimens (8.3%) and accessory RHA arising from SMA was observed in 3 specimens (5%). In 86.6% of specimens, the RHA coursed dorsal to the duct system to enter the Calot's triangle. In 8.3% of specimens, the RHA coursed ventral to duct system to reach the Calot's triangle. The caterpillar like loop of the RHA was found in two specimens (3%). The replaced and accessory RHA (13.3%) arising from the SMA had a course dorsal to duct system to reach the Calot's triangle. Right hepatic artery is subject to anatomical variation in its origin and course. Our study identified the variations in the origin and course of right hepatic artery. Adequate knowledge of these variations would be of incredible help to the hepatobiliary surgeon and interventional radiologist.

Does an aberrant right hepatic artery really influence the short- and long-term results of a pancreaticoduodenectomy for malignant disease? A matched case-controlled study

BackgroundAn aberrant right hepatic artery (ARHA) is a common anatomic variation. The risk associated with ARHA during pancreaticoduodenectomy (PD) continues to be debated. The aim of this study was to compare the clinical outcomes and survival after PD with ARHA against a matched cohort of patients without ARHA. MethodsPD with an ARHA performed between January 2000 and September 2009 were retrospectively analyzed. Patients with an ARHA (group 1) were matched (1:2) to patients without an ARHA (group 2) according to gender, age, body mass index, type of tumor, and lymph node status. Peri- and postoperative outcomes were compared between the two groups. Overall survival and disease-free survival were estimated by Kaplan-Meier method and compared with log-rank test. ResultsA total of 29 patients (group 1) and 55 patients (group 2) were compared. In group 1, an ARHA entered the tumor in six cases (20.7%), was sacrificed in four cases, and repaired in two cases. There was no difference regarding the rate of intraoperative and postoperative variables between the two groups. The oncological clearance (P = 0.731) and survival (overall survival, P = 0.843; disease-free survival, P = 0.832) were also similar. ConclusionsOur study showed that the presence of an ARHA during PD was not associated with worse postoperative outcomes or survival.

The implications of the presence of an aberrant right hepatic artery in patients undergoing a pancreaticoduodenectomy

An aberrant right hepatic artery (ARHA) is a common anomaly and its implications for patients undergoing a pancreaticoduodenectomy (PD) have not yet been previously reported. We compared the outcomes following PD in patients with and without an ARHA. A novel classification of the anatomical course of ARHA, and surgical techniques for its identification and preservation are described herein. All patients undergoing PD between June 1, 2002, and May 31, 2007, were divided into two groups, one with ARHA and the other without. These groups were compared to identify differences in the intraoperative variables, the oncological clearance, the postoperative complications, and the survival. A total of 135 patients underwent PD of which 28 (20.8%) patients were found to have either accessory or replaced right hepatic arteries (ARHA group). There were no significant differences in the intraoperative variables (blood loss and operative time) and the incidence of postoperative complications (pancreatic leak and delayed gastric emptying). Oncological clearance (nodal yield and resection margins) and survival were also similar in the two groups. The surgical and oncological outcomes of PD remain unaffected by the presence of ARHA provided that the anatomy is recognized and appropriately managed. Aberrant right hepatic artery can be classified into three types according to their anatomical relationship with the head of the pancreas.

Clinical Implications of an Aberrant Right Hepatic Artery in Patients Undergoing Pancreaticoduodenectomy

Sometimes, it seems to be difficult to preserve the aberrant hepatic artery (HA) during pancreaticoduodenectomy (PD), with respect to en bloc lymph node dissection, especially in the case of aberrant right hepatic artery (RHA). Therefore, we evaluated the influence of incomplete en bloc lymph node (LN) dissection when aberrant RHA arises. We reviewed 103 patients with mid-to-distal common bile duct (CBD) cancers who underwent PD by one surgeon at Asan Medical Center from December 1994 to November 2005 (73 men, 30 women; mean age, 61.1 +/- 9.4 (range: 40-84) years). The mean follow-up period was 32.7 months. We compared the normal RHA group with the aberrant RHA group. Eighty-eight cases showed normal RHA anatomy, including nine cases (8.7%) of aberrant left hepatic artery (LHA) with normal RHA cases (normal HA group). RHA anomalies were observed in 15 cases (14.6%, aberrant HA group). In all cases, there was no direct invasion of cancer to aberrant HA. Among two groups, 43 cases (41.7%) showed recurrence and there was no significant difference in recurrence between two groups (p = 0.202). Three-year and 5-year overall survivals were 33.3% and 28.5% in the normal HA group, whereas 47.1% and 28.3% in the aberrant RHA group, respectively. There also was no statistically significant difference in survival (p = 0.763). When performing PD for CBD cancer, aberrant RHA should be preserved if there was no cancerous invasion and it does not seem to affect the recurrence of disease and overall survival of patients.

Zebra Pattern in CT during Arterial Portography: Analysis of Associated Factors

Purpose :To analyze the factors associated with the zebra pattern in CT during arterial portography(CTAP).Materials and Methods : In 275 CTAP procedures, the factors associated with the zebra pattern, such as laminar flow in the portal vein, the presence of liver cirrhosis, the artery selected for CTAP, location of the catheter tip in the superior mesenteric artery(SMA), splenic volume, and the existence of an aberrant right hepatic artery(RHA) emerging from the SMA were analyzed.Results : In 106 of 275 procedures (38.5%), a zebra pattern was apparent. Portal venous laminal flow was seen in 92% of procedures in the group with this pattern and in 63% in the group without it. Eighty-three of 235 procedures (35.3 %) in which the SMA was injected and 23 of 40(57.5 %) involving splenic artery injectionshowed the zebra pattern. In 22 of 35(62.8%) in which the catheter tip was located in the distal SMA and 61 of 200(30.5%) in which this was at a proximal site, the zebra pattern was evident. Mean splenic volume was less in the group with the zebra pattern. The effect on the zebra pattern of liver cirrhosis and an aberrant RHA emerging from the SMA was not statistically significant.Conclusion : In CTAP, the incidence of the zebra pattern was 38.6%, and was related to laminal flow in the portal vein. The pattern is frequently seen in CTAP involving contrast injection via the splenic artery, distal location of a catheter tip in the SMA, and small splenic volume.