Replaced Right Hepatic Artery Research Articles

An Aberrant Origin of the Right Hepatic Artery: A Rare Anatomic Variation. And Its Clinical Application

The right hepatic artery is an important arterial supply to right lobe of the liver. And the knowledge of the normal anatomy and anatomical variations of the right hepatic artery is essential to perfume, and will minimize morbidity, and also help to decrease the number of complications of hepatobiliary surgery. This study was conducted on eleven human cadavers, which were obtained from the routine autopsies at the dissection room of the Anatomy Department. During dissection of the eleven cadaveric livers, we found a case with an ex-ceptional anatomic variation; a replaced right hepatic artery (RRHA) coming off the superior mesenteric artery (SMA), directly to the hepatic right lobe passing through the Calot’s triangle, crossing behind the common hepatic duct (CHD). Our objective is to draw much attention to this particularly anatomic variation of the origin of the RRHA as well as its clinical importance in order to ensure that no damage will be made during gastrointestinal and hepatobiliary surgery.

Common hepatic artery arises from superior mesenteric artery: bipode celiac trunk.

Classic Common Hepatic Artery (CHA) from the celiac artery and the proper hepatic artery into right and left is seen in 55-60% of the population. A classification method was described by Michel et al. in 1955: I: standard anatomy ~60% (range 55-61%), II: replaced Left Hepatic Artery (LHA) ~7.5% (range 3-10%) III: replaced Right Hepatic Artery (RHA) ~10% (range 8-11 %) IV: replaced RHA and LHA ~1%,V: accessory LHA from Left Gastric Artery(LGA) ~10% (range 8-11%),VI: accessory RHA from Superior Mesenteric Artery (SMA) ~5% (range 1.5-7%),VII: accessory RHA and LHA ~1%,VIII: accessory RHA and LHA and replaced LHA or RHA ~2.5%, IX: CHA replaced to SMA ~3% (range 2-4.5%), X: CHA replaced to LGA ~0.5%. We present a case report of an 82 years old Caucasian man who suffered from left colic tumor with a CHA, LHA, RHA arising from SMA: IX Michel Classification. Angio-CT Abdominal Scan demonstrated absence of complete celiac trunk. Bipode and CHA, LHA, RHA arising from SMA. 3D image: SMA+CHA, celiak bipode.

Anomalous Celiac Trunk Variation Encountered in Y-90 Radioembolization

Background: 
 Yttrium-90 microsphere embolization is a selective internal radiation therapy (SIRT) used in the treatment of hepatocellular carcinoma and liver metastases. Current literature recommends lobar, or more selective, infusion of SIRT to allow for precise radiation administration and to mitigate risk of non-target embolization. Lobar infusion requires knowledge of anatomical variations of hepatic arterial supply. The trifurcation of the celiac trunk into the left gastric artery, splenic artery, and common hepatic artery is the most common presentation representing 51% to 89% of patient anatomy. A replaced right hepatic artery (RHA) arising from the superior mesenteric artery (SMA) is one of the most common variants of hepatic arterial supply with a prevalence of 10.6% to 15%. Common variations such as these are well described and easily mapped using catheter angiography, but rarer variations are not as well described and more challenging to map. 
 
 Project Methods: 
 Mapping catheter angiogram of the celiac trunk and SMA was obtained. Additional aortogram and CT angiogram were obtained to further elucidate patient’s anatomy. 
 
 Results: 
 Initial mapping angiogram was only partially successful because the RHA could not be selected. Abdominal aortogram and CT angiogram of the abdomen and pelvis revealed a replaced RHA arising directly from the distal celiac trunk. Additionally, the patient had a replaced cystic artery arising from the left hepatic artery and an arc of Buhler connecting the proximal SMA to the proximal aspect of the right hepatic artery. 
 
 Conclusion: 
 Radiologists need to be aware of rare variations in hepatic arterial supply for the safe and effective treatment of hepatic neoplasms, whether primary or metastatic. Description of arterial variation and informed selection of arterial branches will remain a critical aspect of improving efficiency and reducing risks of hepatic embolization procedures.

Replaced Right Hepatic Artery Originating from the Common Hepatic Artery: A Case Report

The presence of an aberrant right hepatic artery is the most frequently encountered vascular anomaly during pancreaticoduodenectomy, and its recognition and preservation are of paramount importance to prevent ischemia of the bile duct and consequently the bilioenteric anastomosis, which can lead to anastomotic leak or dehiscence and fistula. In this case report, we describe proximal branching of the common hepatic artery (CHA) to give rise to a replaced right hepatic artery (RHA), which courses posterior to the portal vein (PV) and common bile duct (CBD) to the right lobe of the liver. The location of this replaced RHA in the hepatoduodenal ligament is consistent with the location of a replaced RHA described by the Michels classification, although with the important distinction that origin was the CHA instead of the superior mesenteric artery (SMA). From our review of the current literature, this is the first published description of such an anatomic course of the RHA.

Y90-radioembolization via variant hepatic arteries: Is there a relevant risk for non-target embolization?

BACKGROUNDThe hepatic arterial anatomy is highly variable, with the two most common variants being a replaced right hepatic artery (RHA) originating from the superior mesenteric artery (SMA) and a left hepatic artery (LHA) originating from the left gastric artery (LGA). These anatomical variants could potentially increase the risk for non-target embolization during Y90-Radioembolization due to the close proximity between hepatic and enteric vessel branches.AIMTo evaluate the safety of Yttrium-90 radioembolization (90Y-RE) with resin microspheres in patients with a variant hepatic arterial anatomy.METHODSIn this retrospective single-center observational study, 11 patients who underwent RE with 90Y-resin microspheres via a LHA originating from the LGA, and 13 patients via a RHA originating from the SMA were included. Patient and treatment data were reviewed regarding clinical and imaging evidence of non-target embolization of 90Y-resin microspheres to the GI tract. Positioning of the tip of the microcatheter in relationship to the last hepatoenteric side branch was retrospectively analyzed using angiographic images, cone-beam CT and pre-interventional CT-angiograms.RESULTSNone of the 24 patients developed clinical symptoms indicating a potential non-target embolization to the GI tract within the first month after 90Y-RE. On the postinterventional 90Y-bremsstrahlung images and/or 90Y-positron emission tomographies, no evidence of extrahepatic 90Y-activity in the GI tract was noted in any of the patients. The mean distance between the tip of the microcatheter and the last enteric side branch during delivery of the 90Y microspheres was 3.2 cm (range: 1.9-5 cm) in patients with an aberrant LHA originating from a LGA. This was substantially shorter than the mean distance of 5.2 cm (range: 2.9-7.7 cm) in patients with an aberrant right hepatic originating from the SMA.CONCLUSION90Y-RE via aberrant hepatic arteries appears to be safe; at least with positioning of the microcatheter tip no less than 1.9 cm distal to the last hepatoenteric side branch vessel.

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

Pancreaticoduodenectomy with resection and reconstruction of replaced right hepatic artery (RRHA)

Pancreaticoduodenectomy with resection and reconstruction of replaced right hepatic artery (RRHA)

Aberrant Vasculature During Minimally Invasive Transhiatal Esophagogastrectomy

Fig 3. Aadenocarcinoma of the gastroesophageal junction. He underwent neoadjuvant chemotherapy and radiation therapy followed by a minimally invasive transhiatal esophagogastrectomy. Duringmobilization of the stomach, a suspected aberrant left hepatic artery (LHA) was identified within the gastrohepatic ligament (Fig 1). Given the extent of residual celiac nodal disease, a complete celiac dissection and lymphadenectomy was performed, including skeletonization of the left gastric artery (LGA) and aberrant LHA (Fig 2; IVC, inferior vena cava). Careful attention was then paid to ligating the LGA distal to the aberrant LHA takeoff to preserve hepatic arterial supply. Three-dimensional reconstructions of the preoperative imaging were able to elucidate the aberrant anatomy, revealing a replaced LHA. Further, the patient also had a replaced right hepatic artery (RHA) branching from the superior mesenteric artery (Fig 3). A critical pitfall of an esophagogastrectomy is recognizing and preserving aberrant hepatic vasculature to prevent subsequent hepatic ischemia. A replaced LHA originating from the LGA is an anomaly found in up to 10% of people [1]. It is important to work with radiology colleagues to perform time contrast studies to allow for clear delineation of aberrant anatomy, as well as to view in detail axial and coronal projections. Finally, awareness

Posterior Approach for Laparoscopic Pancreaticoduodenectomy to Prevent Replaced Hepatic Artery Injury

Laparoscopic pancreaticoduodenectomy (PD) has become more popular despite its complexity and tendency for higher morbidity.1 Replaced right hepatic artery (RRHA) and replaced common hepatic artery (RCHA), both originating from the superior mesenteric artery (SMA), are the most significant and relatively common vascular anomalies in patients undergoing PD, occurring in 8.6-21 and 0.4-4.5% of cases, respectively.2,3 An inadvertent injury to theses arteries may result in an intra- or postoperative bleeding, hepatic or bile duct ischemia, and consequent leakage or delayed stricture in the bilioenteric anastomosis.2-4 Therefore, preservation of these aberrant hepatic arteries is essential unless their resection is oncologically indicated.2 We describe a posterior approach that can be advantageous in laparoscopic PD for patients with a RRHA or RCHA. The posterior approach was used in 81 laparoscopic PDs at the Institute Mutualiste Montsouris between 1994 and 2012.5 In brief, retropancreatic dissection is performed to complete kocherization and expose the posterolateral aspect of the SMA. The origin of the RRHA or RCHA can then be identified and dissected. After division of the pancreatic neck, the portal vein and RRHA or RCHA are separated off the pancreatic neck. In case of the RCHA, the gastroduodenal artery originating from the RCHA is divided during this dissection. The video shows a secure procedure to preserve a RCHA in laparoscopic PD by early identification and dissection of the aberrant artery via the posterior approach. The posterior approach can help to prevent inadvertent RRHA or RCHA injury in laparoscopic PD.

Preoperative embolization of replaced right hepatic artery prior to pancreaticoduodenectomy

Aberrancy of the hepatic arterial anatomy is common. Because of its course directly adjacent to the head of the pancreas, a replaced right hepatic artery (RHA) is vulnerable to invasion by peri-pancreatic malignancies. Division of the RHA at the time of pancreaticoduodenectomy, however, may result in hepatic infarction and/or bilioenteric anastomotic complications. We report two cases of patients undergoing preoperative embolization of tumor encased replaced RHAs to allow for sufficient collateralization prior to pancreaticoduodenectomy.

Assessment of Hepatic Arterial Anatomy in Keeping with Preservation of the Vasculature While Performing Pancreatoduodenectomy: An Opinion

Pancreatic surgeons often must make decisions regarding hepatic artery (HA) resection while performing a pancreatoduodenectomy (PD). The purpose of this report was to review and summarize HA resection experience with a focus on vascular preservation during PD and to develop a useful guideline for pancreatic surgeons in dealing with these needs. We reviewed 1324 cases that had available computed tomographic and angiographic findings and summarized the problematic HA variations encountered in PD. In reviewing our PD series (n = 254), we have created a set of guidelines that enable a pragmatic approach to the unique variations in HA and the risks of cancer invasion. Challenging HA variations during PD were found in 20.1% of the cases and included the common HA arising from the superior mesenteric artery (SMA) (2.34%), a replaced right HA (RHA) from the SMA (9.82%), an RHA or left HA from the gastroduodenal artery (0.97%), and the right anterior or right posterior HA from the SMA (1.06%), among others. In our PD series, the problematic HAs (15.8%) were preserved, except for a single case (0.4%) in which PD involved en bloc resection of the RHA from the SMA due to a cancerous invasion and without right hemihepatectomy. Surgeons should have knowledge of the anatomically variable vasculature of the HA when planning for PD. Preoperative imaging studies can aid and should be performed in anticipation of the potential HA variations during PD.