Suitability of DNN-based vessel segmentation for SIRT planning.

PURPOSE: The segmentation of the hepatic arteries (HA) is essential for state-of-the-art pre-interventional planning of selective internal radiation therapy (SIRT), a treatment option for malignant tumors in the liver. In SIRT a catheter is placed through the aorta into the tumor-feeding hepatic arteries, injecting small beads filled with radiation emitting material for local radioembolization. In this study, we evaluate the suitability of a deep neural network (DNN) based vessel segmentation for SIRT planning. METHODS: We applied our DNN-based HA segmentation on 36 contrast-enhanced computed tomography (CT) scans from the arterial contrast agent phase and rated its segmentation quality as well as the overall image quality. Additionally, we applied a traditional machine learning algorithm for HA segmentation as comparison to our deep learning (DL) approach. Moreover, we assessed by expert ratings whether the produced HA segmentations can be used for SIRT planning. RESULTS: The DL approach outperformed the traditional machine learning algorithm. The DL segmentation can be used for SIRT planning in [Formula: see text] of the cases, while the reference segmentations, which were manually created by experienced radiographers, are sufficient in [Formula: see text]. Seven DL cases cannot be used for SIRT planning while the corresponding reference segmentations are sufficient. However, there are two DL segmentations usable for SIRT, where the reference segmentations for the same cases were rated as insufficient. CONCLUSIONS: HA segmentation is a difficult and time-consuming task. DL-based methods have the potential to support and accelerate the pre-interventional planning of SIRT therapy.

Evaluation of celiac artery and common hepatic artery variations by CT-angiography and new classification model.

PURPOSE: Knowledge of anatomical variations is important in all interventional procedures. This study aims to evaluate the variations and prevalence of celiac trunk (CeT) and its branches. METHODS: The computerized tomography-angiography (CT-A) findings of 941 adult patients were evaluated retrospectively. Variations of the CeT and common hepatic artery (CHA) were evaluated according to the number of branches and their origin. Findings were compared with classical classification methods. A new classification model has been defined. RESULTS: Normal (complete) trifurcation was detected in 856 (90.9%) of them, where left gastric artery (LGA), splenic artery (SpA) and CHA branches were derived from the CeT. Among 856 complete trifurcation cases, 773 (90.3%) had non-classical trifurcation patterns. The rate of classic trifurcation was 8.8%, while non-classic trifurcation was 82.1% in all cases. In one case (0.1%), LGA and left hepatic artery together and right hepatic artery and SpA together appeared as a double bifurcation. Complete celiacomesenteric trunk was observed only in 4 (0.42%) cases. In seven cases (0.7%), LGA, SpA and CHA were coming out of abdominal aorta (AAo) independently. CHA normal anatomy (Michels Type I) was detected in 618 (65.5%) patients. We found that 49 (5.2%) of our cases were ambiguous according to the Michels Classification. We have described five different variations of hepatic arteries directly arising from the AAo. CONCLUSION: Preoperative recognition of anatomical variations of CeT, superior mesenteric artery and CHA is of primary importance in both surgical and radiological procedures. With careful evaluation of CT-angiographies, it is possible to detect rare variations.

Doppler Ultrasound of Vascular Complications After Pediatric Liver Transplantation: Incidence, Time of Detection, and Positive Predictive Value.

Purpose Doppler ultrasound (DUS) is widely used to detect vascular complications after pediatric liver transplantation (LT). This study aimed to assess the moment of first detection of vascular complications with DUS, and to determine the positive predictive value (PPV) of DUS. Materials and Methods Patients aged 0-18 years who underwent LT between 2015 and 2019 were retrospectively included. 92 LTs in 83 patients were included (median age: 3.9 years, interquartile range: 0.7-10.5). Patients underwent perioperative (intra-operative and immediately postoperative) and daily DUS surveillance during the first postoperative week, and at 1, 3, and 12 months. Vascular complications were categorized for the hepatic artery, portal vein, and hepatic veins. DUS findings were compared to surgical or radiological findings during the 1-year follow-up. Results 52 vascular complications were diagnosed by DUS in 35/92 LTs (38%). 15 out of 52 (28.8%) were diagnosed perioperatively, 29/52 (55.8%) were diagnosed on postoperative days 1-7, and 8/52 (15.4%) after day 7. The PPV for all vascular complications diagnosed with DUS was 92.3%. During the 1-year follow-up, 18/19 (94.7%) hepatic artery complications, 19/26 (73.1%) portal vein complications, and 7/7 (100%) hepatic vein complications were diagnosed perioperatively or during the first week. Conclusion The majority of vascular complications during the first year after pediatric LT were diagnosed by DUS perioperatively or during the first week, with a high PPV. Our findings provide important information regarding when to expect different types of vascular complications on DUS, which might improve DUS post-LT surveillance protocols.

[Distal pancreatectomy with resection of the celiac trunk, right or left hepatic artery without arterial reconstruction (extended DP-CAR)]. / Distal'naya rezektsiya podzheludochnoi zhelezy s rezektsiei chrevnogo stvola vmeste s pravoi ili levoi pechenochnoi arteriei bez arterial'noi rekonstruktsii (rasshirennaya DP-CAR).

OBJECTIVE: To evaluate safety and postoperative outcomes of DP-CAR with resection of one of the lobar hepatic arteries without arterial reconstruction (extended DP-CAR). MATERIAL AND METHODS: Perioperative data and survival after 7 extended DP-CARs R0 were retrospectively analyzed. Arterial blood flow in the liver was assessed using intraoperative ultrasound and postoperative CT angiography. RESULTS: Among 40 DP-CARs, resection of left or right hepatic artery was performed in 7 cases of aberrant anatomy including 1 case of portal vein resection. Mortality and ischemic complications were not observed. The main source of blood supply to the «devascularized¼ liver lobe was interlobar communicating artery or the arcade of the lesser curvature of the stomach. Incidence of pancreatic fistula was 44%, mean blood loss - 230 (100-650) ml, surgery time - 259 (195-310) min, mean hospital-stay - 14 (9-26) days. Median survival of patients with pancreatic ductal adenocarcinoma was 25 months after combined treatment. Three patients died after 26, 28 and 77 months. Other patients are alive without progression for 109, 24, 23 and 12 months after therapy onset. CONCLUSION: Extended DP-CAR is advisable and safe procedure if reliable intraoperative control of liver and stomach blood supply is ensured.

Right hepatic arterial girdle around the common hepatic duct in liver donors: technical considerations for successful living donor liver transplantation.

PURPOSE: Variations in hepatic arterial anatomy can result in multiple arterial trunks in the graft liver. We describe our experience in dealing with five right lobe liver donors where in the right hepatic artery (RHA) branches were passing anterior and posterior to the common hepatic duct (CHD) forming an arterial girdle around it. METHODS: Five of 771 right lobe living donor liver transplants (January 2012 and March 2020) demonstrated the RHA girdle around the CHD. Three patients had the typical girdle resulting in two graft arteries which were reconstructed using arterial Y grafts. Arterial girdle was formed by the right anterior hepatic artery branches in one patient resulting in 3 graft arteries of which two were reconstructed using a Y graft. One donor had the arterial girdle and an accessory artery from SMA giving rise to 3 graft arteries. Two of them were ligated (brisk back bleed), and one was reconstructed. RESULTS: All donors (median follow-up 17 months, range 6-60 months) had an uneventful postoperative recovery. No vascular or biliary complications were encountered in the recipients. One recipient died due to sepsis and multiorgan failure, while the other 4 recipients recovered uneventfully and continue to have stable graft function. CONCLUSION: Adhering to safe surgical principles during RHA mobilization, ligation of minor arterial branches, and precise reconstruction of multiple major branches can ensure successful outcomes in the donor and recipient in this scenario.

Celiac Trunk and Hepatic Arteries: Anatomical Variations of Liver Arterial Supply as Detected with Multidetector Computed Tomography in 1,520 Patients and its Clinical Importance.

Hepatic arterial variations are relatively common, but usually overlooked by radiologists, leading to iatrogenic complications or prolonging interventional or surgical procedures. Michels in 1966 classified hepatic arterial variations in 10 categories, based on a cadaveric study. Establishment of multidetector computed tomography (MDCT) provides useful anatomical information. The purpose of our study is to highlight these variations and to propose of a user-friendly algorithm when studying a CT examination. We studied 1,520 contrast-enhanced CTs (16-row MDCT system) during arterial phase and searched for hepatic arteries and celiac trunk (CTr) variations. CT images were postproccessed using multiplanar reconstruction, maximum intensity projection and volume rendering techniques in axial, sagittal, and coronal planes. Our results were organized according to Michels' classification. Normal anatomy was found in 72.89% of the cases and variations classified in Types II-X in 22.24%. However, 4.87% of the cases could not be classified in Michels' types. A single arterial variation was found in 22.89% of the cases and multiple arterial variations were found in 4.21% of the cases. We examined first the aorta for supernumerary branches and then checked the fissure between right and left liver lobe, following porta hepatis, and finally the CTr and superior mesenteric artery. Hepatic arteries and CTr variations are relatively common (27.11%) and should be identified by the radiologists when studying CTs as their recognition provides better surgical planning, preventing iatrogenic complications. Imaging in coronal plane was helpful for end branches, while sagittal plane was better for aortic branches. Clin. Anat., 33:1091-1101, 2020. © 2019 Wiley Periodicals, Inc.

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

BACKGROUND: The 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. AIM: To evaluate the safety of Yttrium-90 radioembolization (90Y-RE) with resin microspheres in patients with a variant hepatic arterial anatomy. METHODS: In 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. RESULTS: None 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. CONCLUSION: 90Y-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.

Variant hepatic arterial anatomy encountered during pancreatoduodenectomy does not influence postoperative outcomes or resection margin status: A matched pair analysis of 105 patients.

BACKGROUND/AIM: Anatomic vascular abnormalities of the hepatic arteries are frequent. The aim of the study was to analyze the influence of hepatic arterial variations on postoperative morbidity and resection margin status after pancreatoduodenectomy (PD). MATERIALS/METHODS: Patients who underwent PD over a 7-year period (2010-2017) were included in the study. Patients with variant hepatic arterial anatomy were matched 1:2 for age, sex, ASA score, and histology. RESULTS: A total of 232 patients underwent PD. Variant hepatic arterial anatomy was found in 35 (15.1% of the total patient population). The most common variation was an accessory right hepatic artery (8.19%) and a replaced right hepatic artery (5.60%) arising from the superior mesenteric artery. These 35 patients were compared with 70 patients with no hepatic artery variations. Postoperative surgical complications occurred in 12.1% and 26.5% (P = 0.08) and in-hospital mortality was 6% and 5.4% ( P = 0.99) between patients with and without variant hepatic arteries. There was no difference in positive resection margins (R1) (18.2% vs 20.5%, P = 0.99) between the two groups. CONCLUSIONS: An aberrant hepatic artery does not increase morbidity or R1 resection in patients undergoing PD.

The segmental branching of the hepatic arteries in the liver: a cadaveric study.

The purpose of this work was to evaluate the sectorial and segmental arterial branching (second- and third-order branching) in the right and left hemilivers, as knowledge of this branching should lead to improved vascular mapping for various endovascular procedures in the liver. The study was conducted on 100 formalin-fixed adult cadaveric livers. The arterial anatomy of the liver was dissected from the origin of the hepatic arteries to their segmental branches. Conventional segmental branching of both the right and the left hepatic arteries was seen in only 25% of the livers. In the remaining livers, the segmental branching of one or both of the hepatic arteries was different from that given in anatomy texts. The branching of the right and left hepatic arteries was anatomically classified into seven and six patterns, respectively, mainly on the basis of their sectorial and segmental anatomy. The present study details the highly diverse segmental arterial anatomy of the liver. The information provided here has important implications for procedures that involve selective catheterization of segmental arteries.

Unusual branching pattern of celiac trunk associated with supernumerary hepatic arteries and abnormal adrenal venous drainage - case study and review of the literature.

Celiac artery (trunk) is one of the three major arteries which arise from abdominal aorta. It's variations not seem to be very uncommon. A routine dissection of a male cadaver at Department of Anatomy Jagiellonian University revealed unusual branching pattern of the celiac trunk with numerous supernumerary hepatic arteries. Additionally unusual venous drainage of the adrenal glands was found. A review of current literature has shown that a changed branching pattern may be important from clinical point of view, with special respect to endovascular procedures, laparoscopic surgery or radiology.

Pressure-Directed Embolization of Hepatic Arteries in a Porcine Model Using a Temporary Occlusion Balloon Microcatheter: Proof of Concept.

PURPOSE: The purpose of this project was to test the hypothesis that temporary hepatic artery balloon occlusion would favorably alter the distribution of particle emboli within the targeted and nontargeted downstream vascular compartments. MATERIALS AND METHODS: Five Yorkshire pigs underwent transfemoral placement of balloon microcatheters into selected segmental hepatic arteries. A collection catheter was surgically introduced into a downstream hepatic artery branch. Blood pressures at the femoral artery sheath and the collection catheter were obtained with the microcatheter balloon deflated and inflated. Identical quantities of calibrated 250- and 400-µm microspheres were injected via the balloon microcatheter when inflated, then deflated. Each animal underwent up to four paired microsphere embolizations. Microspheres collected from the intrahepatic collection catheter were counted manually by light microscopy. RESULTS: Inflation of the balloon microcatheter in the segmental hepatic artery resulted in a consistent and significant decrease in blood pressure (mean: 30 mmHg; range 23-43 mmHg; p < 0.05) in the downstream vascular compartment. The number of microspheres selectively delivered to the targeted intrahepatic collection catheter was significantly greater when the balloon microcatheter was inflated rather than deflated in all 20 paired embolic deliveries (by 2.4-fold, mean; p = 0.0002), despite delivery of the same total number of microspheres. CONCLUSION: Balloon occlusion significantly reduces blood pressure in the downstream vascular compartment, resulting in increased delivery of emboli to a targeted intrahepatic arterial collection catheter relative to other portions of the embolized vascular compartment, likely due to blood flowing into this compartment from neighboring hepatic and extrahepatic arteries.

Triple arterial blood supply to the liver and double cystic arteries.

A rare combination of variations in the arterial supply of the liver and gallbladder was encountered in a male cadaver. The simultaneous occurrence of an accessory left hepatic artery and an accessory right hepatic artery from which double cystic arteries arose (one of which was low-lying). This combination has not yet been reported. The accessory left hepatic artery originated from the left gastric artery. The accessory right hepatic artery originated from the superior mesenteric artery. Such arterial variations are caused by differences in embryological development. This, however, may lead to complications related to diagnostic and therapeutic procedures in the upper abdomen.

Extrahepatic Arteries Originating from Hepatic Arteries: Analysis Using CT During Hepatic Arteriography and Visualization on Digital Subtraction Angiography.

PURPOSE: To investigate the prevalence and site of origin of extrahepatic arteries originating from hepatic arteries on early phase CT during hepatic arteriography (CTHA) was accessed. Visualization of these elements on digital subtraction hepatic angiography (DSHA) was assessed using CTHA images as a gold standard. MATERIALS AND METHODS: A total of 943 patients (mean age 66.9 ± 10.3 years; male/female, 619/324) underwent CTHA and DSHA. The prevalence and site of origin of extrahepatic arteries were accessed using CTHA and visualized using DSHA. RESULTS: In 924 (98.0%) patients, a total of 1555 extrahepatic branches, representing eight types, were found to originate from hepatic arteries on CTHA. CTHA indicated the following extrahepatic branch prevalence rates: right gastric artery, 890 (94.4%); falciform artery, 386 (40.9%); accessory left gastric artery, 161 (17.1%); left inferior phrenic artery (IPA), 43 (4.6%); posterior superior pancreaticoduodenal artery, 33 (3.5%); dorsal pancreatic artery, 26 (2.8%); duodenal artery, 12 (1.3%); and right IPA, 4 (0.4%). In addition, 383 patients (40.6%) had at least one undetectable branch on DSHA. The sensitivity, specificity, and accuracy of visualization on DSHA were as follows: RGA, 80.0, 86.8, and 80.4%; falciform artery, 53.9, 97.7, and 80.0%; accessory LGA, 64.6, 98.6, and 92.3%; left IPA, 76.7, 99.8, and 98.7%; PSPDA, 100, 99.7, and 99.9%; dorsal pancreatic artery, 57.7, 100, and 98.8%; duodenal artery, 8.3, 99.9, and 98.7%; and right IPA, 0, 100, and 99.6%, respectively. CONCLUSION: Extrahepatic arteries originating from hepatic arteries were frequently identified on CTHA images. These arteries were frequently overlooked on DSHA.

Surgical anatomy of the right hepatic artery in Rouviere's sulcus evaluated by preoperative multidetector-row CT images.

BACKGROUND: Lymph node dissection in Rouviere's sulcus (RS) is essential during left-sided hepatectomy and caudate lobectomy for hilar cholangiocarcinoma. However, the small segmental or subsegmental arteries (SA/SSA) are often encountered in RS and must be preserved to prevent critical complications, such as liver infarction or liver failure. The aim of this study is to elucidate the anatomy of SA/SSA around RS, which should be understood preoperatively. METHODS: Between January 2008 and April 2013 from a total of 124 consecutive patients with hilar cholangiocarcinoma, preoperative multidetector-row computed tomography (MDCT) images were obtained at our institution and evaluated. The bifurcation patterns of the SA/SSA, the courses of the posterior SA/SSA and the bifurcation site of the SA/SSA were investigated using MDCT images. RESULTS: The typical form, in which right hepatic artery (RHA) bifurcated into the anterior (Aant) and posterior (Apost) hepatic artery and thereafter, Aant/Apost bifurcated into the SA and SSA, was observed in 75 patients (60.5 %). On the other hand, the atypical forms, in which the SA/SSA were independently branched off from RHA before the main bifurcation of the Aant and Apost, were observed in 43 patients (34.7 %). The prior branched arteries supplied the whole or ventral area of segment VI (A6 or A6a) in 11 patients (8.9 %), which was most commonly observed in the atypical form. 15 patients (34.9 %) of the 43 patients with atypical form had partially supraportal posterior branches, that showed early-bifurcated posterior SA/SAA following supraportal course, while the other posterior SA/SSA followed infraportal course. The SA/SSA were extrahepatically bifurcated in 82 patients (66.1 %), comprised of all 43 atypical form and 39 of typical form, while the SA/SSA were intrahepatically bifurcated in remaining 36 patients of typical forms (29.0 %). CONCLUSION: The extrahepatic bifurcation of the SA/SSA from RHA was relatively common. The early-bifurcated SA/SSA was often observed (34.7 % of total cohort) and, in 34.8 % of those atypical forms, posterior SA/SSA from RHA followed a supraportal course. The detailed preoperative knowledge of the anatomy, including SA/SSA, is crucial for left-sided hepatectomy for hilar cholangiocarcinoma.

Hepatic Artery Pseudoaneurysm: A Life-Threatening Complication of Liver Transplantation.

Hepatic artery pseudoaneurysm is a rare but serious complication following liver transplantation. A 50-year-old male patient with ulcerative colitis, sclerosing cholangitis, and end-stage liver disease underwent right lobe transplantation from a living donor. The patient was hospitalized because of impairment in liver function tests and massive pretibial edema three months after surgery. In color Doppler ultrasound and multidetector computed tomography, a pseudoaneurysm with peripheral large thrombus was detected at the anastomosis site extending anterior to the hepatic artery. The patient died as a result of unstable hemodynamic conditions.

Stent graft in the treatment of pseudoaneurysms of the hepatic arteries.

OBJECTIVE: The purpose of our study was to evaluate the technical feasibility, procedural complications, clinical follow-up, and computed tomography (CT) scan outcomes of hepatic artery pseudoaneurysms (HAPs) treated with stent graft. METHODS: Between October 2004 and October 2009, we treated 8 patients with HAPs with stent graft. RESULTS: Stent graft deployment was technically successful in all the patients. Complete exclusion of the pseudoaneurysm preserving patency of the hepatic artery was achieved in 6 patients. Total occlusion of the common hepatic artery was observed in 1 patient, and vasospasm of proper hepatic artery and endoleak from distal stent margin were observed in another patient. The 2 patient were controlled through occlusion parent artery with coils. After these procedures, symptoms of bleeding and abdominal pain disappeared. Follow-up enhanced CT scan was performed at an average of 14 months (range, 6-26 months), which showed complete disappearance of the HAP and patency of the stent without intrastent stenosis in 6 patients who had successful deployment of the stent. CONCLUSIONS: Endovascular treatment of HAPs using stent graft can maintain the hepatic artery blood flow and could be considered as an alternative to embolization.

Dysfunction of a port-catheter system percutaneously implanted for hepatic arterial infusion chemotherapy due to a fibrin sheath.

Catheter-related difficulties occurred with a port-catheter system percutaneously implanted by the fixed catheter tip technique for repeated hepatic arterial infusion chemotherapy (HAIC) for unresectable metastatic liver cancer. A side hole in the indwelling catheter opened into the common hepatic artery. Four years and 3 months later, an occluded hepatic artery was diagnosed by arteriography with contrast medium infused via the port. Conversely, celiac arteriography performed from a catheter newly inserted from the femoral artery showed no such occlusion. A new port-catheter system replaced the original one to continue HAIC. Examination revealed a fibrin sheath covering the withdrawn catheter.

Polyvinyl Alcohol Embolization Adjuvant to Oily Chemoembolization in Advanced Hepatocellular Carcinoma with Arterioportal Shunts

OBJECTIVE: To assess the feasibility and safety of polyvinyl alcohol (PVA) embolization adjuvant to transarterial oily chemoembolization (P-TACE) in advanced hepatocellular carcinoma (HCC) with arterioportal shunts (APS). MATERIALS AND METHODS: Nineteen patients who underwent PVA embolization for APS before a routine chemoembolization (TACE) procedure were retrospectively reviewed. 10 of these 19 patients underwent follow-up TACE or P-TACE after P-TACE (Group A), but nine patients underwent only initial P-TACE because of progression of HCC and/or underlying liver cirrhosis (Group B). Hepatic function tests, APS grades, and portal flow directions were evaluated before and after P-TACE sessions. Complications after procedures and survival days were also evaluated. RESULTS: In group A, APS grade was improved in eight patients and five of six patients with hepatofugal flow showed restored hepatopetal flow postoperatively. No immediate complication was developed in either group. Transient hepatic insufficiency developed in eight (42.1%) of 19 patients after P-TACE, and seven (87.5%) of these eight recovered within two weeks under conservative care. The mean and median survival time all study subjects was 280 days and 162 days. CONCLUSION: P-TACE is feasible and safe in advanced HCC patients with APS.