Hepatic arterial variations detected at multidetector computer tomography angiography in the Romanian population.

BACKGROUND: Our purpose was to determine the prevalence of normal hepatic vascularization and variations of the hepatic arteries using multidetector computed tomography (MDCT) angiography. These variants should be known before any surgery of the upper abdomen, the downside being that there aren't many studies on large groups of patients using high-specialized imaging. MATERIALS AND METHODS: This study was carried out on 4192 patients. We performed MDCT angiography on each one of the patients and had a specialized team observe the images. RESULTS: Using Michels' classification, the normal anatomy (type I) was present in 3392 (80.91%) cases, while abnormal hepatic arteries were observed in 800 (19.08%) cases. The variations were distributed as follows: type II in 40 (0.95%) cases, type III in 442 (10.54%) cases, type IV in 13 (0.31%) cases, type V in 285 (6.79%) cases, type VI in 12 (0.28%) cases, type VII in 3 (0.07%) cases, type VIII in 108 (2.57%) cases, type IX in 6 (0.14%) cases and type X in one case (0.02%). 170 (4.05%) unclassified cases were observed. Using Hiatt's classification, the variations were: type II in 325 (7.75%) cases, type III in 454 (10.83%) cases, type IV in 124 (2.95%) cases, type V in 6 cases (0.14%) and type VI in 69 (1.64%) cases. 102 (2.43%) unclassified cases were observed. CONCLUSIONS: We observed well-known variations of the hepatic arterial pattern and also found a large number of rare, unclassified cases.

Clinical Consideration of Anatomical Variations in the Common Hepatic Arteries: An Analysis Using MDCT Angiography.

PURPOSE: The purpose of this study was to determine the prevalence of normal hepatic vascularization and variations in the common hepatic arteries using multidetector computer tomography angiography. These variants should be acknowledged before any surgery of the upper abdomen. The aim of our work was to analyze the variations in the hepatic arteries and their possible clinical and surgical implications. MATERIALS AND METHODS: This study was carried out on 4192 patients who underwent 64-slice MDCT angiography, from August 2015 to December 2021. We used surface and volume-rendering techniques in order to post-process images of the vascular components in the desired area. RESULTS: We highlighted 76 cases with replaced common hepatic arteries, which are characterized by the origin of the common hepatic artery trunk located outside the classical composition of the celiac trunk. We identified three levels of origin: the abdominal aorta, the superior mesenteric artery and the left gastric artery. We observed six different aspects of the morphological variability of the celiac trunk and the superior mesenteric artery. The trajectory of the artery trunk, between the aortic origin and the hepatic pedicle portion of the hepatic portal vein, is variable and we analyzed the pancreatic trajectory accordingly. CONCLUSIONS: The prevalence of hepatic arterial variants found during this study was similar to that in other specialized studies. We came across variants that have not been described in the well-known classification of Michels and even described extremely rare variations. The study of abnormal hepatic vascularization plays an important role in the surgical planning of hepatic transplantation, liver and pancreatic resection and extrahepatic upper abdominal surgeries.

A Rare Variant of the Great Cardiac Vein Draining Directly into the Superior Vena Cava.

OBJECTIVE: A routine dissection of the cadaver of a 67-year-old man revealed a very rare morphological variant of the great cardiac vein (GCV). PRESENTATION: The vein originated in the upper third of the anterior interventricular sulcus, crossed the anterior interventricular artery superficially, ran beneath the circumflex artery, crossed the transverse pericardial sinus, and drained directly into the superior vena cava. CONCLUSION: This variant of the GCV is interesting due to its rarity. It is important to know about it for procedures that require venous access such as coronary surgery requiring retrograde cardioplegia, surgical ablation of aberrant conducting pathways, pacemaker insertion, and valve surgery.

Rare variant of renal vascularization with bilateral multiple pedicles and incomplete rotation - case report.

Renal blood vessels present great morphological variability. The routine dissection of a 68-year-old male cadaver revealed multiple bilateral vascular variations associated with the incomplete rotation of both kidneys. The left kidney was supplied by three renal arteries: one superior artery and one middle artery with hilum penetration, and one inferior artery with inferior polar penetration. All three arteries arose from the aorta: two from the anterior side at levels L1 and L3, and one - the inferior artery - from the posterior side of the aorta, as a common trunk with the middle sacral artery. The right kidney had two arteries, both arising from the aorta. The superior renal artery, arising at level L1, entered the renal parenchyma at the hilum; the inferior artery, arising at the point where the abdominal aorta branches in the two common iliac arteries, entered the parenchyma at the inferior pole. Each of the five arteries was accompanied by a vein. The (bilateral) superior renal veins and the middle left vein drained into the inferior vena cava. The two inferior renal veins joined to form a common trunk that drained into the left common iliac vein. Both kidneys presented incomplete rotation, each renal pelvis being situated anterior to the renal vessels, and the ureters descending on the anterior sides of the kidneys. The presence of several vascular pedicles may represent a contraindication in laparoscopic nephrectomy or cause severe bleeding if the pedicles are injured during endopyelotomy.

Rare variant of celiac trunk branching pattern associated with modifications of hepatic arterial vascularization.

The routine dissection of a male body revealed multiple anatomical variations of the celiac trunk and hepatic artery vascularization. The origin of the celiac trunk was on the left side of the abdominal aorta, next to the T12-L1 intervertebral disk. The celiac trunk gave off five branches: the left inferior phrenic artery, the left gastric artery, the accessory right hepatic artery, the common hepatic artery and the splenic artery (the last two arteries had a common origin in a hepatosplenic trunk). A right branch detached off the left gastric artery and anastomosed with the hepatic artery proper. The proper hepatic artery also anastomosed with the accessory right hepatic artery at the same level. Consequently, the entire hepatic arterial supply was from the celiac trunk - through two arteries directly and a third via the left gastric artery. The anatomical variant described in this case can be considered very rare. Thorough knowledge of such variants is important both for upper abdominal surgery and for imagistic and interventional radiology.

Morphological variability of arterial sources of the renal polar parenchyma and its clinical importance.

A sample of 250 kidneys (200 corrosion casts and 50 dissection pieces) provided the basis for the analysis of the number, source, origin point and parenchymal penetration of the arterial branches supplying the two renal poles. Of the studied pieces, 76.80% had a single renal artery, while 23.20% had multiple renal arteries. The superior pole had only one arterial source in 95.20% of cases, and the inferior pole had only one arterial source in 97.20% of cases. The arteries supplying the superior pole originated from one of the renal artery's branches in 59.60% of cases and from its' main trunk in 17.20% of cases. They were also found to originate from branches of the multiple renal arteries in 18% of cases and from the abdominal aorta (5.20% of cases - inferior polar arteries). The arteries supplying the inferior pole arose in similar fashion - from the single renal artery's trunk in 9.20% of cases; from its division branches in 66.40% of cases; from the abdominal aorta in 9.60% of cases and from branches of multiple renal arteries in 14.80% of cases. Familiarity with the renal arteries' morphological variability is becoming increasingly important, as new urologic surgical and radiological techniques develop.

Morphological variability of the renal artery branching pattern: a brief review and an anatomical study.

The segmental branches of the renal artery vary in number and origin. The 1998, Terminologia Anatomica homologates two branches of the renal artery (anterior, posterior) and five segmental arteries: four from the anterior branch and one from the posterior one. The purpose of this study is to evaluate the renal artery branching pattern, the number and origin of the segmental arteries, as well as to review data from similar studies. The study material consisted of 60 formalin-fixed adult kidneys. Dissections and microdissections were performed on the renal arteries and their branches. The branching of the renal artery was prehilar in 81.67% of cases, hilar in 10% and intra-sinusal in 8.33%. The number branches varied as follows: two branches in 42 cases (70%), three branches in 14 cases (23.33%) and four branches in four cases (6.67%). We subsequently analyzed the origin of the segmental arteries and found that in 53% of the cases the segmental arteries arose independently from the renal artery's branches, while in 47% of the cases they derived from common trunks of type I (85%) or II (15%). Type I trunks are those that originate directly from the main renal artery. They divide either into 2-3 segmental branches, or into just 1-2 branches and a smaller trunk (type II). The type II trunks further divide into 2-3 other segmental branches. These common trunks must be taken into account to avoid confusion with the segmental arteries. Knowledge of these variations is useful not only morphologically, but also clinically.

The diagnostic value of EMA expression in the renal parenchyma tumors.

Renal parenchyma tumors are a heterogeneous group of malignancies that are difficult to diagnose and classify. Immunohistochemistry begun to be routinely used for the diagnosis of these tumors. Panels of antibodies are developed for the diagnostic assessment of these tumors, which include cytokeratins, epithelial membrane antigen and vimentin. Epithelial membrane antigen (EMA) is expressed by most of the tumor cell types. Forty-seven specimens of renal parenchyma tumors were studied immunohistochemically for the expression of EMA. In the majority of the cases, clear cells carcinoma was positive for EMA (25/33, 75.70%). All of the papillary carcinomas were positive, with different staining patterns between the two subtypes. The two cases of chromophobe cells carcinomas were intensely positive with a granular cytoplasmic staining pattern. The mixed epithelial-stromal tumor was negative for EMA in both of the components. Out of the three cases of sarcomatoid carcinomas, one was negative, one was weakly positive (+1) and the last was positive (+2). Intensely positive normal tubes were caught by the tumor proliferation in the negative case and in the negative stained areas of the weakly positive case.

Anatomical variations of the hepatic portal vein associated with incomplete celiac trunk.

An association of two anatomical variations was revealed in a 65-year-old male cadaver: the first variation concerns the forming of the trunk of the hepatic portal vein, while the second concerns the branches of the celiac trunk. In this case, the inferior and superior mesenteric veins form a common trunk that is further united with the splenic vein and gives rise to the hepatic portal vein. At the same time, the existence of an incomplete (branched) celiac trunk was revealed, the hepatosplenic trunk from which the common hepatic artery and the splenic artery arise; the left gastric artery arises separately at 0.5 cm superolaterally from the origin of the celiac trunk. Familiarity with this anatomical variation provides useful information for abdominal surgery procedures.

Ectopic kidney with malrotation and bilateral multiple arteries diagnosed using CT angiography.

Right renal ectopia with malrotation was seen on a CT angiography in a 64-year-old male patient. Bilateral triple renal arteries were also revealed: one main (superior) renal artery and two accessory arteries (middle and inferior), all originating in the abdominal aorta. The renal arteries are disposed symmetrically. The main arteries and the accessory ones are of equal caliber. Simple renal ectopia is a congenital malformation with an incidence of 1-2 cases in 1000 births; of these, only one of 10 cases is diagnosed. Like our case, many such cases are diagnosed by accident, during investigations of causes that have no connection with renal ectopia. Variations in kidney position and renal vascular variants are very important clinically, for both the complications they may generate and the technical difficulties of certain surgical interventions. CT angiography is a minimally invasive method that allows the identification of malformations or anatomic variations, providing accurate information on position, size and anatomic ratios, which are very useful in diagnosing and treating various affections.

Clinical significance of Her2/neu overexpression in urothelial carcinomas.

HER2/neu is a defective transmembrane tyrosine kinase receptor, homologue to the epidermal growth factor receptor, showing overexpression in a large variety of tumor cells. There are no studies published so far regarding HER2/neu overexpression and sensitivity of the urothelial tumors of the urinary bladder to anti-HER2/neu therapy. There are a relatively high number of articles in the literature referring to HER2/neu expression in urothelial tumors of the urinary bladder, but only two of them had investigated HER2/neu expression in patients with urothelial tumors of the upper urinary tract. We have studied HER2/neu overexpression in 59 patients with urothelial carcinomas of the urinary tract by immunohistochemistry. Normal urothelium and the elements of the neighboring renal parenchyma were negative. Out of the 59 cases of urothelial carcinomas, 38 were negative (0 and +1) and 21 were positive: eight were moderately and 13 were intensely positive (+2 and +3). The percentage of positive cases was 35.59%. The negative cases were mostly well-differentiated, G1 tumors, no matter the T-tumor stage. Most of the cases were diagnosed as papillary or, rarely, infiltrative. There is no correlation between HER2/neu overexpression and the tumor stage. The same was true for the lymph node status. The expression intensity, however, was significantly correlated with the differentiation grade. Overexpression was most likely present in tumors with high differentiation grade (p<0.05).