Novel embryological classifications of hepatic arteries based on the relationship between aberrant right hepatic arteries and the middle hepatic artery: A retrospective study of contrast-enhanced computed tomography images.

BACKGROUND: Variations in hepatic arteries are frequently encountered during pancreatoduodenecomy. Identifying anomalies, especially the problematic aberrant right hepatic artery (aRHA), is crucial to preventing vascular-related complications. In cases where the middle hepatic artery (MHA) branches from aRHAs, their injury may lead to severe liver ischemia. Nevertheless, there has been little information on whether MHA branches from aRHAs. This study aimed to investigate the relationship between aRHAs and the MHA based on the embryological development of visceral arteries. METHODS: This retrospective study analyzed contrast-enhanced computed tomography images of 759 patients who underwent hepatobiliary-pancreatic surgery between January 2011 and August 2022. The origin of RHAs and MHA courses were determined using three-dimensional reconstruction. All cases of aRHAs were categorized into those with or without replacement of the left hepatic artery (LHA). RESULTS: Among the 759 patients, 163 (21.4%) had aRHAs. Five aRHAs patterns were identified: (Type 1) RHA from the gastroduodenal artery (2.7%), (Type 2) RHA from the superior mesenteric artery (SMA) (12.7%), (Type 3) RHA from the celiac axis (2.1%), (Type 4) common hepatic artery (CHA) from the SMA (3.5%), and (Type 5) separate branching of RHA and LHA from the CHA (0.26%). The MHA did not originate from aRHAs in Types 1-3, whereas in Type 4, it branched from either the RHA or LHA. CONCLUSIONS: Based on the developmental process of hepatic and visceral arteries, branching of the MHA from aRHAs is considered rare. However, preoperative recognition and intraoperative anatomical assessment of aRHAs is essential to avoid injury.

Bilateral pulmonary sequestrations: Distinct types sharing a common celiac artery origin, presented with pneumonia and associated findings in a pediatric case.

A 14-year-old boy presented with shortness of breath, cough, and mild chest pain, with a history of intermittent milder symptoms. Physical examination and initial tests showed mild iron deficiency anemia, elevated C-reactive protein, and normal vital signs. Chest radiograph revealed abnormalities in the left lower zone, leading to contrast-enhanced chest CT. The CT scan revealed bilateral intrapulmonary sequestrations, both deriving blood supply from a common trunk originating from the celiac artery. The patient's symptoms initially attributed to a pulmonary infection improved with antibiotic therapy. Pulmonary sequestration is a congenital anomaly characterized by aberrant lung tissue lacking connections to bronchial tree or pulmonary arteries. It can lead to recurrent pulmonary infections and postinfectious sequelae. This case presented a unique bilateral sequestration, both originating from the celiac artery. Radiologists should be aware of sequestration types and associated anomalies, even in atypical locations. Blood supply can originate from various arteries, not just the aorta.

A rare case of unconnection between the celiac trunk and the abdominal aorta and a large anastomosis with the inferior mesenteric artery with a literature review.

PURPOSE: Direct connection between the celiac trunk (CT) and inferior mesenteric artery (IMA) is very rare, knowledge of this anomaly is of great importance to surgeons and anatomists. INTRODUCTION: Splanchnic arteries arise from the abdominal aorta (AA). Unusual development of these arteries can lead to considerable variations. Historically there were a lot of classification of the variation in the CT and IMA, none of the classifications describes a direct connection from IMA to CT. MATERIALS AND METHODS: We report a rare case in which the connection between the CT and AA was lost and replaced by a direct anastomosis with IMA. RESULTS: 60 year old male presented to the hospital to undergo a computed tomography scan. Which showed that there was no CT arising from the AA, but there was a large anastomosis arises from the IMA and ended with a short axis and Left gastric artery (LGA), Splenic artery (SA), Common hepatic artery (CHA) arise from this axis, these arteries continued to the stomach and spleen and liver normally. The anastomosis provides the total supply to the CT. The CT branches are normal. CONCLUSION: Knowledge of the arterial anomalies provides an important help in clinical surgical implications especially in organs transplant.

Nutcracker Phenomenon as a Result of Celiomesenteric Trunk Aneurysm.

A common origin of the celiac trunk and superior mesenteric artery is exceedingly rare, and aneurysms of this common trunk are even rarer. According to our literature search, there are no reported cases of nutcracker syndrome or phenomenon involving this rare aneurysmal anomaly. Repair of such anomalies is standardly via open surgical approach with few reported cases of endovascular repair. We describe a patient with an aneurysm of the celiomesenteric trunk resulting in nutcracker phenomenon of the left renal vein. The celiomesenteric trunk aneurysm was repaired endovascularly, resulting in decreased surrounding inflammation and improvement of the left renal vein compression.

Aberrant gastroduodenal and proper hepatic arteries.

PURPOSE: Anatomic variants of the celiac trunk and superior mesenteric artery are common, thus knowledge of these variants is important for preoperative planning of abdominal surgery and interventional procedures. METHODS: We report a rare anatomic variant of replaced proper hepatic and gastroduodenal arteries discovered upon CT angiography and diagnostic angiogram. RESULTS: Emergent angiogram performed on a 61-year-old male who presented with signs and symptoms of upper gastrointestinal hemorrhage revealed a rare variant of an absent common hepatic artery and its branches with aberrant origins. The replaced proper hepatic artery originated from the superior mesenteric artery and the replaced gastroduodenal artery originated from a gastrosplenic trunk. CONCLUSION: This case emphasizes the importance of evaluating preoperative imaging to identify vascular variants prior to undergoing abdominal surgery or interventional procedures.

Absence of the celiac trunk and anomalous very low origin of the common hepatic artery arising independently from the abdominal aorta just above aortic bifurcation in patient undergoing radical pancreaticoduodenectomy.

PURPOSE: Knowledge of anomalies of the celiac trunk is very important during various surgical procedures (such as pancreatic and gastric resections including Appleby operation, liver resections and liver transplantations) and as well as radiologic procedures (such as chemoembolization of pancreatic and hepatic tumors). METHODS: A 77-years-old woman was admitted to our department for surgical treatment of ampullary adenocarcinoma G2 confirmed in endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy and ampullary biopsy. In the contrast-enhanced computed tomography, the ampullary tumor was not visible, but the main pancreatic duct within pancreatic head and isthmus was dilated (indirect radiological tumor signs). An absence of the celiac trunk (CT) was established via computed tomography. Therefore, computed tomography-based angiography (angio-CT) of the abdominal aorta (AA) was performed before operation. RESULTS: Angio-CT confirmed an extremely rare vascular anomaly: an absence of CT. The left gastric (LGA), splenic (SA), and common hepatic (CHA) arteries connected above origin of the superior mesenteric artery (SMA) from the AA. Pylorus-preserving pancreaticoduodenectomy (PD) was performed. This anomaly was also confirmed intraoperatively. The postoperative course was uneventful and the patient was discharged on postoperative day 10. There were no signs of recurrence of the tumor during the 6 months follow-up. CONCLUSION: The proper preoperative identification of anomalies within major abdominal vessels and its relationship to the tumor is very important to avoid intraoperative vascular injury and major postoperative complications.

Quadrifurcation Variants of the Celiac Trunk.

BACKGROUND: 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. METHODS: The CT quadrifurcations were documented on 112 computed tomography angiograms. RESULTS: 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. CONCLUSIONS: 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.

Pentafurcated Celiac Trunk.

BACKGROUND: Commonly, but not exclusively, the celiac trunk (CT) trifurcates into the left gastric (LGA), common hepatic (CHA) and splenic (SA) arteries. Additional branches of the CT are scarcely reported in the literature. Less than ten reports were found presenting patterns of pentafurcation of the CT (pCT), all being resulted after anatomic dissections. METHOD: We hereby report such a rare pCT, which was found on the computed tomography angiograms of a 71-year-old female patient. RESULTS: From that pCT were branching off three collateral branches, two ascending and one descending, and two terminal branches. The ascending ones were the left inferior phrenic artery and a secondary hepatogastric trunk, further divided into a replaced left hepatic artery and the left gastric artery. The dorsal pancreatic artery was the descending collateral branch of the pCT. The pCT ended by dividing into the CHA and SA. The CHA reached the anterior side of the portal vein to divide into the gastroduodenal and right hepatic arteries. An accessory right hepatic artery left the superior mesenteric artery (SMA) and ascended posterior to the portal vein. CONCLUSIONS: To the authors' knowledge, the combination of a pCT and a hepatic branch from the SMA, which raises to three the main arteries of the liver, was not reported previously. Additional branches of the CT should be carefully documented by computed tomography prior to surgical or interventional approaches of the aorta in the celiac region.

Hepatic arterial system anomalies encountered during pancreaticoduodenectomy - our experience.

We present our experience of incidence and management of aberrant hepatic arterial anatomy encountered during pancreaticoduodenectomy (PD). Patients undergoing PD between December 2014 and November 2016 at the Shaukat Khanum Memorial Cancer Hospital, Lahore were included in this short report. Preoperative imaging and operative findings of these patients were reviewed to evaluate the hepatic arterial anatomy and classified according to Hiatt classification. Sixty-four PD were performed with aberrant arterial anatomy identified in 24 (37.5%) of the cases. Most common anomaly was replaced right hepatic artery (rRHA) arising from the superior mesenteric artery seen in seven (11%) of the patients. Aberrant vessels were recognised and preserved in 23 cases. In one patient, the rRHA was coursing through the pancreatic parenchyma needing resection and reconstruction with uneventful postoperative recovery. Hepatic arterial anomalies are common and it is possible to preserve these vessels with careful surgical dissection using artery first technique.

Tronco celíaco-mesentérico: una variante vascular poco frecuente / Celiacomesenteric trunk: A rare vascular variant

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Persisting bleeding from the duodenal ulcer in patients with occlusion of the celiac trunk: a case report.

INTRODUCTION: Endoscopic measures have continued to be the primary procedures in the management of ulcer bleeding. Nevertheless, in cases of failed endoscopic hemostasis and re-bleedings, endovascular techniques have gradually gained increased acceptance as an alternative to surgery, allowing to avoid surgical intervention in some cases. <br/> Case report: A case of a 42-year-old patient presenting to the authors' institution with massive bleeding from the duodenal ulcer, sprang from a pathologically enlarged gastroduodenal artery is reported. This vascular anomaly was a consequence of occlusion of the coeliac trunk (Dunbar syndrome), which was shown on an angio-CT scan. In spite of several endoscopic and endovascular measures, as well as three operations, the bleeding persistently recurred (a total of 6 episodes) and the patient eventually died. The article presents details of operative and endovascular treatments. Contemporary trends in management in cases of failed endoscopic interventions and re-bleedings form peptic ulcers are shown in the discussion.

Unusual anatomical variation: tetrafurcation of the celiac trunk.

The celiac trunk is one of the main sources of vascularization of the supracolic abdominal compartment. It arises from the abdominal aorta, at the level of T12-L1 vertebrae and classically branches into the splenic artery, common hepatic artery, and left gastric artery. We report here an atypical branching pattern of the celiac trunk, found during the dissection of a 60-year-old female's formalin-fixed cadaver. The atypically celiac trunk gave rise to four branches: a common trunk for left and right inferior phrenic arteries, an accessory left gastric artery, the common hepatic artery, and a splenogastric trunk. Knowledge in detail about normal anatomy and variation in the branching pattern of the celiac trunk is important in surgical, oncological, and radiological interventional procedures and must be taken into account to avoid possible complications.

Splenic artery arising from hepatic artery proper in a patient with celiacomesenteric trunk: a rare anatomical variant.

We report an extremely rare case of splenic artery arising from hepatic artery proper in a patient with celiacomesenteric trunk variant. This anatomical variation was detected angiographically during hepatic mapping prior to transarterial radioembolization (TARE) for hepatocellular carcinoma in an 84-year-old man. TARE of hepatic tumors is one of the frequent procedures done by interventional radiologists. The identification of such rare vascular aberrations is of great importance not only in current interventional radiology procedures such as radioembolization but also in surgery and diagnostic radiology. To the best of our knowledge, this vascular variant is a novel discovery.

Arc of Bühler: the surgical significance of a rare anatomical variation.

PURPOSE: The arc of Bühler, an anastomotic vessel between celiac artery and superior mesenteric artery, is a rare anatomic variation. Various radiologic and surgical procedures can be affected by its existence. We aim to review all available information and identify possible clinical implications. METHODS: A systematic review was conducted in accordance to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines. The following terms were utilized in various combinations: "Bühler", "arc of Bühler", "visceral aneurysm", "pancreaticoduodenal arcades". RESULTS: Only 53 cases have been described until today in the literature. The arc of Bühler enhances collateral circulation between celiac artery and superior mesenteric artery alongside with pancreaticoduodenal arcades and dorsal pancreatic artery. Computerized tomography and angiography are the main studies used for its detection and evaluation. Aneurysms of Bühler's arc have been rarely described and seem to share common pathophysiological mechanisms with aneurysms of the pancreaticoduodenal arcades. CONCLUSIONS: Various radiologic and surgical procedures such as embolization or pancreaticoduodenectomy are potentially affected by its existence.

Variação anatômica do tronco celíaco e do sistema arterial hepático: uma análise por exames de imagem / Anatomical variations of the celiac trunk and the hepatic arterial system: an imaging analysis

Introdução: As variações anatômicas das artérias hepáticas e do tronco celíaco são de grande importância para cirurgias laparoscópicas, transplantes hepáticos, intervenções radiológicas e tratamento de lesões abdominais. O grande aumento de intervenções minimamente invasivas deixou os atos cirúrgicos com menos espaço para o reconhecimento de estruturas anatômicas. Métodos: Foi realizado um estudo retrospectivo do banco de dados do Hospital São Vicente de Paulo durante o ano de 2016, analisando imagens abdominais de tomografia computadorizada com contraste e angiotomografias que envolvem a aorta abdominal e seus ramos ­ um total de 461 imagens foram analisadas. Resultados: Dos 461 pacientes analisados, 86,9% apresentaram a conformação usual do tronco celíaco ­ cuja anatômica é a origem tríplice com as artérias gástrica esquerda, esplênica e hepática comum e artéria mesentérica superior se originando sozinha da aorta abdominal. Dentre as anatomias anômalas (13%), o padrão mais comum desses ramos foi a presença em 4,5% de um tronco hepatomesentérico e um tronco gastroesplênico. No sistema arterial hepático a conformação mais prevalente foram as artérias hepáticas direita e esquerda sendo ramos da hepática próprias em 66,3%. Das alterações anatômicas (33,2%), as mais comuns foram a presença de uma artéria hepática esquerda acessória ramo da artéria gástrica esquerda (7,8%). Conclusão: Variações anatômicas do sistema arterial hepático e do tronco celíaco são prevalentes, podendo apresentar diversos arranjos organizacionais. (AU)

Introduction: Anatomical variations in the hepatic arteries and the celiac trunk are of great importance for laparoscopic surgeries, liver transplants, radiological interventions and treatment of abdominal injuries. A large increase in the number of minimally invasive interventions hampered the recognition of anatomical structures in surgical procedures. Methods: A retrospective study was performed using the 2016 São Vicente de Paulo Hospital database of contrast-enhanced abdominal computed tomography images and computed tomography angiographies showing the abdominal aorta and its branches. In total, 461 images were analyzed. Results: Of the 461 patients analyzed, 86.9% had usual conformation of the celiac trunk, which trifurcates into the left gastric artery, the common hepatic artery and the splenic artery, while the superior mesenteric artery originates alone from the abdominal aorta. Among the cases of anomalous anatomy (13%), the most common pattern in these branches was the presence of a hepatomesenteric trunk and a gastrosplenic trunk in 4.5%. In the hepatic arterial system, the most prevalent conformation was the right and left hepatic arteries being branches of the hepatic artery proper in 66.3%. Of all anatomical variations (33.2%), the most common were the presence of a left accessory hepatic artery of the left gastric artery (7.8%). Conclusion: Anatomical variations in the hepatic arterial system and the celiac trunk are common, having different structural arrangements. (AU)

Tronco hepato-espleno-mesentérico: descripción de una disposición anómala del tronco celíaco / Hepato-splenic-mesenteric trunk: description of an abnormal disposition of the celiac trunk

El estudio de los patrones arteriales de distribución vascular requiere un conocimiento preciso de las variaciones anatómicas, tanto de origen y distribución de las arterias, como de sus correspondientes ramas arteriales. En este trabajo se describe la presencia de un tronco hepato-espleno-mesentérico, disposición arterial altamente infrecuente. El conocimiento de las distintas posibilidades de disposición de las arterias correspondientes al tronco celíaco y sus ramas será de importancia para la interpretación adecuada de estudios imagenológicos, como así también para la planificación precisa de actos quirúrgicos e intervencionistas en la región abdominal.

The study of arterial patterns of vascular distribution requires a precise knowledge of the anatomical variations of both origin and distribution of the corresponding arteries and arterial branches. In this work, the presence of a hepatosplenic-mesenteric trunk is described, a highly infrequent arterial disposition. The knowledge of the different possibilities of disposition of the arteries corresponding to the celiac trunk and its branches will be of importance for the adequate interpretation of imaging studies, as well as for the precise planning of surgical and interventional acts in the abdominal region.

Aberrant gastroduodenal artery with splenic origin.

PURPOSE: Knowledge of the wide variability in celiac trunk branches is of paramount importance when planning an abdominal surgery. METHODS: We, hereby, report a previously undescribed origin of the gastroduodenal artery discovered on an abdominal angio-CT. RESULTS: CT-angiogram performed on a 33-year-old female randomly revealed a new variant of gastroduodenal artery arising directly from the splenic artery along with other vascular aberrations. The latter were previously described in medical literature. CONCLUSION: High-quality preoperative imaging is crucial for identification of visceral artery variations, as those can technically modify the surgical or interventional procedure.