Left Inferior Phrenic Artery Research Articles

Assessment of arterial supply to the stomach after bariatric surgery using multidetector CT arteriography.

To describe residual arterial supply to the stomach after bariatric surgery via a systematic arterial-phase CT assessment approach that can aid in diagnosis and treatment of postoperative complications and facilitate planning for future procedures. Arterial-phase CT of 46 patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) at 3 academic institutions were retrospectively reviewed to assess patency of left gastric artery (LGA), right gastric artery (RGA), gastroepiploic artery (GEA), and left inferior phrenic artery (LIPA) and presence of gastric perforators. In 25 RYGB and 21 SG patients, mean diameters were LGA 2.2 ± 0.4mm, RGA 1.6 ± 0.5mm, and GEA 1.7 ± 0.4mm. On RYGB scans, all LGAs, RGAs, and 24/25 (96%) of GEAs were identified. Excellent to good patency was seen in 20/25 (80%) LGAs, 21/25 (84%) RGAs, and 23/24 (96%) GEAs. On SG scans, all LGAs, 18/21 (86%) of RGAs, and 20/21 (95%) GEAs were identified. Excellent to good patency was seen in 17/21 (81%) LGAs, 15/18 (83%) RGAs, and 20/20 (100%) GEAs. In terms of gastric perforators, LGA supply was seen on 23/25 (92%) of RYGB and 17/17 (100%) of SG scans. RGA supply was seen on 13/21 (62%) RYGB and 9/18 (50%) SG scans. GEA supply was seen on 19/23 (83%) RYGB scans. No gastric supply via GEA was seen on SG scans. In this study, arterial supply to the stomach through the LGA was consistently identified in all RYGB and SG cases, indicating an uncomplicated surgical approach with regard to preserving the LGA. Dedicated CT angiography protocol or catheter-directed angiography is recommended for accurate and comprehensive assessment of the gastric blood supply, particularly before surgical re-intervention.

A morphological study of the inferior phrenic arteries on multidetector computed tomography and angiography

IntroductionThe inferior phrenic artery is a paired artery with a variable origin and course, primarily supplying the diaphragm, but also the suprarenal glands, inferior vena cava, stomach, and oesophagus. The aim of this study is to investigate the origin and course of the inferior phrenic arteries on multidetector computed tomography and angiography. Materials and methodsThe anatomy of the inferior phrenic artery was analysed on 2449 multidetector computed tomography scans. Three-dimensional reconstructions were made of the main variations. Additionally, the course and branching pattern of the inferior phrenic artery were descriptively analysed in a cohort of 28 angiograms. ResultsIn 565 (23.1%) cases the inferior phrenic arteries arose as a common trunk and in 1884 (76.9%) cases as individual vessels. The most common origins of a common trunk were the coeliac trunk (n=303; 53.6%) and abdominal aorta (n=255; 45.1%). The most common origins of the right inferior phrenic artery were the coeliac trunk (n=965; 51.2%), abdominal aorta (n=562; 29.8%) and renal arteries (n=214; 11.4%). The most common origins of the left inferior phrenic artery were the coeliac trunk (n=1293; 68.6%) and abdominal aorta (n=403; 21.4%). ConclusionThe inferior phrenic artery has a very variable anatomy. The most common origins of the inferior phrenic artery are the coeliac trunk and its branches, the abdominal aorta, and the renal arteries.

Variant Anatomy and Morphometric Characteristics of the Celiac Trunk and its Branches According to Multislice Computed Tomography

Two classifications are currently most commonly used to classify branching variations of the celiac trunk (CT): N. Michels (1955) and R. Uflacker (1997). Many researchers note the imperfection of classifications and make additions to each of them. The aim is to determine the anatomical variants of the branching of the CT, and to perform a morphometry of it’s main branches. Material and methods. A sample of 700 MSCT angiograms of the abdominal aorta was analyzed. The study examined angiograms of 602 men and 98 women. Visualization of the vessels of the CT and measurement of the diameter of the arteries was carried out using digital computer programs of the personal station of the radiologist «Syngo.via». Results. The most common type of CT (77,9% observations), according to the classification of N. Michels, was type I, when the common hepatic artery (CHA) originated from the CT. The frequency of other variants was 22,1%. According to R. Uflacker, the most common variant (90,3% cases) was type I, corresponding to the typical anatomy of the CT, with the origin of the splenic, common hepatic and left gastric arteries. In addition to the main variants of the arterial basin of the liver and types of branching of the CT, we noted additional arteries that were not included in both classifications. In 48 cases, such vessels as the left inferior phrenic artery (44 observations / 91,7%), two inferior phrenic arteries (2IPA) (3 observations / 6,3%), and the right hepatic artery (RHA) (1 observation / 2,1%) were identified as originated from the CT. Conclusion. In the course of our study, we detected variants of CT that were not included in any of the most commonly used classifications: the RHA and 2IPA which ramified from CT. Three morphometric parameters of the CT: its length, diameter, and diameter of common hepatic artery had a significant correlation with gender. We consider that the data obtained on the variant anatomy of the CT will make additions to the current classifications in order to detail and objectify variations of the celiac-mesenteric basin arteries.

Hepatocellular carcinoma vascularization: CT angiography variations identifying arteries feeding the tumour

BackgroundHepatic arterial anatomy is important in performing many surgical and endovascular procedures. Familiarity with variations in the hepatic arterial anatomy is essential to achieving adequate embolization. In some patients, in addition to anatomic variations of the hepatic arteries, different extrahepatic collateral arteries may provide partial or total vascular supply to hepatocellular carcinoma (HCC), which makes transcatheter arterial chemoembolization (TACE) technically challenging. We aim to evaluate the different feeding vessels of HCC using multi-detector computed tomography angiography (MDCTA) as a pre-procedural step before planning suitable management.ResultsOne hundred patients with 150 focal HCC lesions were involved in our study. The anatomy of the blood supply and the morphological characteristics of HCC, including the size, location, and history of previous hepatitis, were quantitatively assessed and statistically analysed. The number of patients who had classic hepatic arterial supply for the HCC lesions in our study was 54 (54%). The number of patients with additional extrahepatic supply is 26, while the number of patients with anatomical vascular variants is 20. Among these 26 patients with extrahepatic (parasitic) blood supply, six patients were supplied by the right inferior phrenic artery, four patients were supplied by the right internal mammary artery, and two patients were supplied by each other type of extrahepatic feeder, which are the left inferior phrenic artery, left internal mammary artery, left gastric artery, cystic artery, right lumbar artery, direct branch from the aorta, omental arteries, right renal artery, and LHA from the LGA. Twelve of the 20 patients with anatomical vascular variants had replaced RHA from the SMA; four patients had replaced LHA from the LGA; two patients had replaced RHA from the GDA; and two patients had replaced CHA from the SMA. Only 50 cases of CT findings were correlated with the data from the interventional procedures of these patients.ConclusionsBecause of the differences in HCC blood supply between typical, parasitic, and anatomical vascular variants, MDCTA has significant clinical significance prior to TACE and any interventional procedure.

Comprehensive evaluation of three-dimensional anatomy of perigastric vessels using enhanced multidetector-row computed tomography

BackgroundTo perform laparoscopic gastrectomy safely, we aimed to comprehensively re-evaluate perigastric vessel anatomies using a three-dimensional angiography reconstructed from enhanced multidetector-row computed tomography data.MethodsPerigastric vessel anatomy was preoperatively analyzed using a multidetector-row computed tomography-based three-dimensional angiography reconstructed in 127 patients undergoing gastric surgery.ResultsOf the 67 left gastric veins that ran along the dorsal side of the arteries, 59 (88.1%) ran along the dorsal side of the common hepatic artery and flowed into the portal vein. In 18 cases, a common trunk of one to three left gastric arteries and the replaced left hepatic artery was observed. The left inferior phrenic artery ramified from the left gastric artery in 5.5% of the cases. The right gastric artery was classified into distal (73.2%), caudal (18.1%), and proximal (8.7%) types. The infra-pyloric artery was also classified into distal (64.6%), caudal (26.0%), and proximal (9.4%) types. The posterior gastric artery branched as a common trunk with the superior polar artery in the proximal (37.9%) and distal (18.4%) regions of the splenic artery. The left gastroepiploic artery ramified from the splenic (18.1%) and inferior terminal arteries (81.9%). No, one, and two gastric branches of the left gastroepiploic artery, which ramified between the roots of the left gastroepiploic artery and its omental branch, were found in 36.5%, 49.2%, and 14.3% of the cases, respectively.ConclusionsPreoperative 3D angiography is useful for the precise evaluation of perigastric vessel anatomies, and may help us to perform laparoscopic gastrectomy and robotic surgery safely.

Efficacy and safety of endovascular therapy for delayed hepatic artery post-pancreatectomy hemorrhage: development of extrahepatic collateral circulation and complications of post endovascular therapy

BackgroundEndovascular therapy (ET) for delayed hepatic artery post-pancreatectomy hemorrhage (HA-PPH) may require complete hepatic artery occlusion (HAO). Nonetheless, the development of extrahepatic collateral circulation (EHC) and the relationship between radiological factors (EHC, portal vein stenosis, and HAO) and adverse hepatic events after ET remain unclear. This study aimed to evaluate the efficacy and safety of ET for delayed PPH and examine the development of EHC.MethodsA total of 19 ET cases for delayed HA-PPH were reviewed. Hepatic adverse events, portal vein stenosis, HAO, and mortality rate after ET were evaluated. Moreover, EHC from the left gastric artery (LGA), right inferior phrenic artery (RIPA), left inferior phrenic artery (LIPA), right internal thoracic artery (RITA), left internal thoracic artery (LITA), renal artery (RA), omental artery (OA), intercostal artery (IA), and branch of superior mesenteric artery (BSMA) was assessed using angiogram and computed tomography angiography (CTA).ResultsAll cases were successfully treated using transcatheter arterial embolization (n = 17) and stent-graft placement (n = 2) without mortality. EHC from the LGA (8/19), RIPA (10/19), LIPA (4/19), and RITA (3/19) was observed on post-ET CTA. The incidence of hepatic adverse events was significant in the group with both HAO and portal vein stenosis (p < 0.001) and absence of EHC from LIPA and RITA (p < 0.05).ConclusionET for delayed HA-PPH might be effective and safe. While avoiding both HAO and portal vein stenosis is important, the development of EHCs from LIPA and RITA may prevent hepatic adverse events after ET.

A rare hepatic artery variant reporting and a new classification.

Variations of the hepatic artery are very common, but they greatly increase the difficulty of surgery and the risk of complications in perihepatic surgeries such as liver transplantation, liver segmentectomy, and gastroduodenal surgery. Thus, it is important to precisely define the type of hepatic artery variant before surgery. However, there are often rare variants that cannot be defined with existing classifications. For example, the type of hepatic artery variant in the current case could not be classified with conventional classifications, and no such variation has been reported to date, involving two accessory left hepatic arteries from the common hepatic and left inferior phrenic arteries, respectively. Based on the existing 3DCT technology and the CRL classification method, which is applicable to the most common hepatic artery variants, we reviewed many rare variant types and proposed a new classification method (ex-CRL classification) for hepatic artery variations that do not fit the classic scope. The ex-CRL classification can accurately classify the vast majority of rare cases in the literature, greatly compensates for the limitations of current hepatic artery classifications, improves the generalization and understanding of rare cases, and reduces surgical complications.

Computed tomography assessment of postoperative gastric vascular supply and staple-line leak development after sleeve gastrectomy.

Residual arterial supply of the gastric tube after sleeve gastrectomy (SG) can be damaged by surgery, which can reduce gastric tube perfusion and could promote postoperative leakage. To compare the postoperative vascularization of the gastric tube using early computed tomography (CT) scanning after SG in patients with or without postoperative staple-line leak. University hospital. A retrospective analysis of a prospective database was performed in consecutive patients undergoing SG. Patients who presented with a staple-line leak were matched (1:3) with a control group of patients who underwent surgery without postoperative morbidity during the same period. Gastric tube vascularization was studied on a postoperative day 2 CT scan in both groups of patients. During the study period, 1826 patients underwent SG, including 42 patients (2.3%) who presented with a staple-line leak. Those 42 patients were successfully matched to 126 control patients. Global identification of residual gastric arterial supply in early postoperative CT scans was similar in patients with or without staple-line leak after SG. However, residual vascular supply of the gastroesophageal junction (i.e., terminal and anterior cardiotuberosity branches of the left gastric artery or left inferior phrenic artery) was more frequently interrupted by the staple line in the group of patients who developed a gastric leak. This study suggests a correlation between interruption of the main arteries supplying the gastroesophageal junction by the staple line on early postoperative CT scans and the development of gastric leak after SG. These results support the vascular theory as one of the causes of leak after SG.

Association between Vascular Calcification and Esophagojejunal Anastomotic Complications after Total Gastrectomy for Gastric Cancer: A Propensity-Matched Study.

Esophagojejunal anastomosis (EJA) complications after total gastrectomy are related to significant morbidity and mortality. The aim of this study was to evaluate the association between arterial calcifications and EJA complications such as leak and stricture for gastric cancer. Between January 2014 and October 2019, 30 patients with EJA complications after total gastrectomy were enrolled and matched to 30 patients without complications through retrospective data review. Arterial calcification grade on preoperative computed tomography (CT) was reported in the abdominal aorta and superior mesenteric artery (SMA) as “absent”, “minor”, or “major”, and in the jejunal vascular arcade (JVA) and left inferior phrenic artery (LIPA) as “absent” or “present”. A Chi-square test was used to compare the variables between the two groups. p-Value < 0.050 was considered statistically significant. Among 30 patients, the numbers of patients with leak and stricture were 23 and seven, respectively. Aortic calcifications were not associated with EJA complications regardless of their grade (p = 0.440). Only major SMA calcifications were associated with EJA complications, as they were present in five patients (16.7%) in the complication group and absent in the non-complication group (p = 0.020). Major SMA calcifications were more related to anastomotic stricture than leak. Three (13.0%) out of 23 patients with leak and two (28.6%) out of seven with stricture had major SMA calcifications (p = 0.028). No calcifications were detected in the JVA or LIPA in any of the 60 patients. Major SMA calcifications were found to be associated with EJA complications, especially in stricture.

Trans-arterial Embolization in a Patient with Unilateral Absence of Pulmonary Artery: Treatment Success and the Four-year Prognosis.

Unilateral absence of the pulmonary artery (UAPA) with or without other anomalies in the heart is a rare congenital malformation. A 55-year-old Filipino woman without a remarkable medical history was admitted to our hospital for hemoptysis. Contrast-enhanced chest computed tomography revealed the absence of the left pulmonary artery. Echocardiography and right heart catheterization showed no cardiac malformations or pulmonary hypertension. We diagnosed her with isolated left-sided UAPA and performed transarterial embolization of the left inferior phrenic artery. This resolved the hemoptysis, and there was no recurrence during the four-year follow-up period.

Safety of performing distal pancreatosplenectomy in patients who underwent distal gastrectomy previously: a multicenter cohort analysis with systematic literature review.

PurposeIn patients who have previously undergone subtotal gastrectomy (STG), the remnant stomach is supplied with arterial blood through the splenic artery. It is currently unclear whether the remnant stomach can be safely preserved when performing distal pancreatosplenectomy (DPS) in these patients. Thus, this study aimed to evaluate the safety and feasibility of performing DPS in patients who had undergone a previous STG.MethodsA multicenter cohort study was performed to identify patients who underwent DPS. Electronic medical data of Clinical Data Warehouse from 7 representative high-volume centers in 5 cities were retrospectively reviewed. A propensity score-matched analysis was performed to match patients who had no history of upper abdominal surgery with patients who had undergone a previous STG.ResultsFourteen DPS patients who had a history of STG (STG group) were studied and matched to 70 patients who underwent DPS without any history of upper abdominal surgery (non-STG group). All patients in the STG group had the remnant stomach preserved. In most patients, the blood vessel supplying blood to the remnant stomach was the left inferior phrenic artery. There was no significant difference in the incidence of stomach-related complications or length of hospital stay between the 2 groups.ConclusionOur study results suggest that the remnant stomach could be safely preserved when performing DPS in patients with a prior STG. However, it is necessary to carefully evaluate the vascular structure of the remnant stomach through preoperative imaging study and closely observe changes to the blue stomach during the operation.

Newly proposed classification of celiac artery variations based on embryology and correlation with computed tomography angiography.

We studied the prevalence of celiac trunk and its anatomical variations on diagnostic computed tomography angiography (CTA) studies and have proposed a new classification to define the celiac artery (CA) variations based on embryology. We retrospectively assessed the celiac trunk variations in 1113 patients who came to our department for diagnostic CTA for liver and renal donor workup. The patient data were acquired from the Picture Archiving and Communication System of our institutions. We analysed the celiac trunk's origin and branching pattern, including the superior mesenteric artery (SMA) and inferior phrenic artery (IPA). We evaluated the CTA studies of 1050 patients. A normal trifurcation pattern, the most common type, was observed in 39% of cases. Variation with CA + left IPA was the most common subtype. Other variations noted in the study and their incidences are listed in the table below. We attempted to propose a new classification based on embryo-logy, which comprises 6 main types and their subtypes. We also analysed previous studies from the literature, including cadaveric, post-mortem, CTA, and digital subtraction angiography studies and compared them with the present study. Because variations of CA classifications reported to date do not encompass all CA branching pattern variants, we have proposed a new classification that incorporates most of the variants. We reiterate the clinical importance of anatomical variants of CA, IPA, and SMA in surgical and interventional radiology procedures.

Unraveling Variations in Celiac Trunk and Hepatic Artery by CT Angiography to Aid in Surgeries of Upper Abdominal Region.

Understanding of variations in the course and source of abdominal arteries is crucial for any surgical intervention in the peritoneal space. Intricate surgeries of the upper abdominal region, such as hepato-biliary, pancreatic, gastric and splenic surgeries, require precise knowledge of regular anatomy and different variations related to celiac trunk and hepatic artery. In addition, information about the origin of inferior phrenic artery is important in conditions such as hepatocellular carcinoma and gastroesophageal bleeding management. The present study gives an account of anatomical variations in origin and branching pattern of celiac trunk and hepatic artery by the use of CT (computed tomographic) angiography. The study was performed on 110 (66 females and 44 males) patients in a north Indian population. Results unraveled the most common celiac trunk variation as hepatosplenic trunk with left gastric artery, which was observed in 60% of cases, more common in females than in males. Gastrosplenic and hepato-gastric trunk could be seen in 4.55% and 1.82% cases respectively. Gastrosplenic trunk was more commonly found in females, whereas hepato-gastric trunk was more common in males. A gastrosplenic trunk, along with the hepato-mesenteric trunk, was observed in 1.82% cases and was more common in males. A celiacomesenteric trunk, in which the celiac trunk and superior mesenteric artery originated as a common trunk from the aorta, was seen only in 0.91% of cases, and exhibited an origin of right and left inferior phrenic artery from the left gastric artery. The most common variation of hepatic artery, in which the right hepatic artery was replaced and originated from the superior mesenteric artery, was observed in 3.64%, cases with a more common occurrence in males. In 1.82% cases, the left hepatic artery was replaced and originated from the left gastric artery, which was observed only in females. Common hepatic artery originated from the superior mesenteric artery, as observed in 1.82% cases, with slightly higher occurrence in males. These findings not only add to the existing knowledge apart from giving an overview of variations in north Indian population, but also give an account of their correlation with gender. The present study will prove to be important for various surgeries of the upper abdominal region.

Types of inferior phrenic arteries: a new point of view based on a cadaveric study.

The diaphragm is supplied by the superior and inferior phrenic arteries. This present study focusses on the latter. The inferior phrenic arteries (IPA) usually originate from the abdominal aorta. The two arteries have different origins, and knowledge of these is important when performing related surgical interventions and interventional radiological procedures. The aim of this study was to identify variations in the origin of the IPA and conduct relevant morphometric analyses. The anatomical variations in the origins of the left inferior phrenic artery (LIPA) and the right inferior phrenic artery (RIPA) were examined in 48 cadavers fixed in 10% formalin solution. A dissection of the abdominal region of the cadavers was performed according to a pre-established protocol using traditional techniques. Morphometric measurements were then taken twice by two of the researchers. In the cadavers, six types of origin were observed. In type 1, the most common type, the RIPA and LIPA originate from the abdominal aorta (AA) (14 = 29.12%). In type 2, the RIPA and the LIPA originate from the coeliac trunk (CT) (12 = 24.96%). In type 3, the RIPA and the LIPA originate from the left gastric artery, with no CT observed (3 = 6.24%). Type 4 has two subtypes: 4A, in which the LIPA originates from the AA and the RIPA originates from the CT (9 = 18.72%) and 4B, in which the RIPA originates from the AA and the LIPA originates from the CT (6 = 12.48%). In type 5, the LIPA originates from the AA and the RIPA originates from the AA (1 = 2.08%). Type 6 is characterised by the RIPA and LIPA forming a common trunk originating from the CT (3 = 6.24%). Our findings suggest the presence of six different types of LIPA and RIPA origin. The most common form is type 1, characterised by an IPA originating from the abdominal aorta, while the second most common is type 2, in which the IPA originates from the AA by a common trunk. The diversity of other types of origin is associated with the occurrence of coeliac trunk variation (type 3). No significant differences in RIPA diameter could be found, whereas LIPA diameter could vary significantly. No significant differences in RIPA and the LIPA diameter could be found according to sex.

A comprehensive study of right and left inferior phrenic artery variations in 1000 patients with multidetector computed tomography angiography: an important study for HCC.

To investigate the anatomic variations in the origins of the right and left inferior phrenic arteries (IPAs) using multidetector computed tomography and to classify their combined variations. This retrospective study included patients undergoing abdominal aorta angiography between January 2015 and October 2019. The RIPA and LIPA origins were evaluated both separately and combined on three-dimensional images. The variant patterns of the IPAs were determined and classified. The numerical evaluation of the data was performed with SPSS 21. In total, 1000 patients (478 women, 522 men) were evaluated. The IPAs originated from a common trunk or a common root in 360 (36.00%) patients, while the IPAs originated independently without a common trunk in 609 (60.90%) patients. The most common combined variant detected in the present study was IPAs originating as a common trunk from the coeliac trunk in 197 (19.70%) patients; 14 (1.40%) patients had no inferior phrenic artery (IPA), and 17 (1.70%) patients had only one IPA. Fifty-two different types of variations in the combined origin of the inferior phrenic arteries were described in this study for the first time in the literature. Awareness of the anatomic variations in the IPAs, which is critical for hepatocellular carcinoma origins, may benefit various clinical procedures, such as transcatheter arterial chemoembolization, organ transplantations, laparoscopic surgical procedures, and radiological procedures.

The inferior phrenic arteries: A systematic review and meta-analysis

IntroductionThe inferior phrenic artery is a paired artery that supplies the diaphragm from its inferior aspect. It may arise as a common trunk, the common inferior phrenic artery (CIPA), or as two individual arteries, the right and left inferior phrenic arteries (RIPA and LIPA, respectively). The aim of this study was to perform a systematic review and meta-analysis to create pooled prevalence data on the various origins of the inferior phrenic arteries and to discuss their clinical importance. MethodsMajor electronic medical databases were reviewed to identify articles with anatomical prevalence data on the origin of the inferior phrenic arteries. Data on the origin of the left, right and common inferior phrenic arteries were extracted and quantitatively synthesized. ResultsThe CIPA was present in 24.2% of cases and most commonly originated from the aorta, with a pooled prevalence 57.2% (95% CI 52.4–62.0%), and the coeliac trunk, with a pooled prevalence of 41.3% (95% CI 36.8–45.9%). Other origins were much less common (1.00% (95% CI 0.28–1.71%)). Independent origin of the RIPA and LIPA were present in 75.8%. The RIPA arose from the aorta (49.6%, 95% CI 43.2%–55.9%), coeliac trunk (35.7%, 95% CI 28.7–42.6%), right renal artery (10.3%, 95% CI 7.27–13.3%) and left gastric artery (2.07%, 95% CI 0.97–3.16%). Other less common origins had a pooled prevalence of 2.07% (95% CI 0.97–3.16%). The LIPA arose from the aorta (46.8%, 95% CI 39.1–54.6%), coeliac trunk (46.1%, 95 CI 38.6–53.5%), left renal artery (1.47%, 95% CI 0.78–2.15%) and left gastric artery (1.07%, 95% CI 0.25–1.89%). Other less common origins had a pooled prevalence of 1.29% (95% CI 0.44–2.14%). ConclusionThe inferior phrenic arteries express a wide range of variations in origin. Knowledge of their origins are important in interventional radiology, gastroenterology, surgery and traumatology.

A Study of Anatomical Pattern of Inferior Phrenic Artery using Multidetector CT

Introduction: Inferior Phrenic Artery (IPA), though a small artery, is important from several points of view. Apart from being arterial supply to normal structures, it is also involved in many pathological conditions such as tumours, haemoptysis, gastroesophageal bleeding and traumatic conditions where interventional radiology or surgery play an important role in management. A preprocedure idea about variations in its anatomical pattern may help better treatment planning and minimise morbidity. Aim: To study variations in anatomical pattern of IPA in terms of vessel of origin, vertebral level of origin and diameter of IPA using Multidetector Computed Tomography (MDCT). Materials and Methods: The present study was a cross-sectional study conducted in Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. A retrospective analysis of CT angiography or Triple phase CT abdomen studies of 200 adult patients (M:F 119:81) performed during December 2020 to April 2021 was done to look for anatomical pattern variations in IPA. Vessel of origin and level of origin were recorded. Diameters of IPAs were also recorded and statistical analysis was done. Results: Common Inferior Phrenic Artery (CIPA) was seen in 23% cases, with independent Right and Left Inferior Phrenic artery (RIPA and LIPA) in remaining 77%. Vessels of origin for CIPA were aorta (n=27; 58.7%), celiac trunk (n=16; 34.8%) and right Main Renal Artery (right MRA) (n=3; 6.5%); for RIPA, celiac trunk (n=69; 44.8%), aorta (n=57; 37.01%), right MRA (n=23;14.94%), Left Gastric Artery (LGA) (n=5; 3.25%), and for LIPA, celiac trunk (n=97; 63%), aorta (n=53; 34.4%), left MRA (n=2; 1.3%) and LGA (n=2; 1.3%), respectively. Level of origin from aorta for RIPA was L1&gt;T12&gt;T12/L1 disc&gt;others; LIPA, T12&gt;T12/L1&gt;L1&gt;others; celiac trunk, T12&gt;L1&gt;T12/L1 disc&gt;others. Mean diameters of apparently normal RIPA and LIPA were 1.75 mm and 1.76 mm, respectively. Conclusion: The most common vessels of origin for CIPA, RIPA and LIPA were abdominal aorta (58.7%), celiac trunk (44.8%) and celiac trunk (63%), respectively. The predominant vertebral levels of origin for CIPA, RIPA and LIPA arising from aorta were T12, L1, and T12 respectively, and for celiac trunk T12. The mean diameter of IPA was found to be greatest in cirrhotic group followed by chronic pancreatitis and apparently normal IPA group, but not statistically significant. These can be efficiently and readily demonstrated by CT angiography or arterial phase of multiphasic CT study.

Quadrifurcation Variants of the Celiac Trunk

The celiac trunk (CT) commonly trifurcates into the left gastric artery, common hepatic artery (CHA), and splenic artery (SA). The CHA then sends off the proper hepatic artery and gastroduodenal artery (GDA). The arcades of the head of the pancreas are celiacomesenteric anastomoses between branches of the GDA and the superior mesenteric artery. A quadrifurcation of the CT commonly occurs when a different branch is added to the 3 normal ones. An uncommon quadrifurcation of the CT occurs when only one or 2 of the normal branches of the CT participate. The CT quadrifurcations were documented on 112 computed tomography angiograms. Five different types of CT quadrifurcation-3 uncommon (types 1-3) and 2 common (types 4-5)-were found in 15/112 cases (13.39%). A marginal significant association was found between the presence of quadrifurcations and male gender (P=0.05; Fisher's exact test). Type 1 showed a hepatogastric trunk+SA+right hepatic artery+GDA pattern, type 2 had an HGT+right inferior phrenic artery+CHA+SA pattern, type 3 had a gastrophrenic trunk+left inferior phrenic artery+CHA+SA pattern, type 4 showed an left gastric artery+CHA+SA+left inferior phrenic artery combination, and type 5 had an additional common inferior phrenic trunk. One of the type 4 cases showed a buildup of a mesentericomesenteric anastomotic pancreatic arcade between the inferior pancreaticoduodenal arteries, rather than a celiacomesenteric one. Anatomic variation of the celiacomesenteric axis is important during hepatobiliary and duodenopancreatic approaches. Therefore, preoperative evaluation is essential because theoretical anatomic possibilities could be real arterial variants.

Hypertrophied Right Inferior Phrenic Artery in Cirrhotic Patients without Hepatocellular Carcinoma: An Interesting Observation on 256 Slice Multidetector Computed Tomography

Abstract Aim To evaluate whether right inferior phrenic artery (RIPA) is a source of extrahepatic arterial supply to the liver in cirrhotic patients without hepatocellular carcinoma (HCC) using 256 slice computed tomography (CT). Materials and Methods Institutional review board approval was obtained for this retrospective study. A total of 262 consecutive cirrhotic patients (male:female–172:90; mean age 56.45 ± 12.96 years) without HCC and hepatic vascular invasion, and who underwent technically successful multiphase CT, were included in the study. Additionally, 280 noncirrhotic patients (male:female–169:111; mean age 54.56 ± 14.21 years) who underwent abdominal multiphase CT scans for indications other than liver disease and did not have focal liver lesions or hepatic vascular disease were included as a control group. The RIPA and left inferior phrenic artery (LIPA) diameters were measured at the level of the ascending segment of IPA located anterior to the diaphragmatic crus. The relationship between RIPA diameters and Child–Pugh score was assessed. Results The cirrhotic patient group and control group were matched for age (p = 0.11) and gender (p = 0.20). The mean diameter of RIPA in the cirrhotic group (1.93 ± 0.4 mm) was significantly higher than in the control group (1.50 ± 0.5 mm), p &lt; 0.001. The mean diameter of LIPA in the cirrhotic group (1.34 ± 0.5 mm) was not significantly higher than in the control group (1.30 ± 0.5 mm), p = 0.32. We found a statistically linear and moderate degree relationship between RIPA diameter values and Child–Pugh scores (p = 0.002, r = 0.593). Conclusion RIPA is hypertrophied in patients with cirrhosis without HCC. It may be an important contributor to the blood flow to the liver in cirrhotic patients even without HCC, especially with portal hypertension.

Variations in the Origins of Inferior Phrenic Arteries—An Evaluation with 256 Slice Multidetector Computed Tomography

Abstract Aim To evaluate the frequency and pattern of variations in the origins of right inferior phrenic artery (RIPA) and left inferior phrenic artery (LIPA) on 256 slice multidetector computed tomography (MDCT). Materials and Methods MDCT abdominal images of 600 patients (male: 344, female: 256; mean age 56.45 ± 12.96 years) who underwent technically successful multiphase computed tomography were assessed for IPA variations with emphasis on their origins and results analyzed. Results Both IPA origins were documented in all patients. Both RIPA and LIPA originated from the common trunk in 128 (21.3%) patients. IPAs with common trunk most commonly originated from the aorta (68, 11.3%). Without common trunk RIPA most commonly originated from the aorta (225, 37.5%) and LIPA from the celiac artery (278, 46.3%). The least frequently detected IPA variations were RIPA originating from the common hepatic artery (1, 0.2%), superior mesenteric artery (1, 0.2%), and common truncus originating from left renal artery (1, 0.2%). Conclusion MDCT demonstrates the IPA origins very well, enabling planning of interventional procedures related to IPA. Without common trunk RIPA most commonly originates from aorta and LIPA from the celiac artery. IPAs with common trunk most commonly originate from aorta.