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.

Rare left colic artery variation of the gut arterial system.

Most variations of the abdominal blood supply are related to branching of the coeliac trunk and superior mesenteric artery. This case details a remarkable variation in the branching pattern of the left colic artery (LCA) observed during routine cadaveric dissection of an 84-year-old male donor. An anomalous common trunk, originating from the common hepatic artery, gave rise to three branches: 1) an accessory posterior pancreaticoduodenal artery to the head of the pancreas and adjacent duodenum, 2) the dorsal pancreatic artery anastomosing with branches of the splenic artery, and 3) the LCA. The LCA descended between the splenic vein and superior mesenteric artery to supply the left colic flexure and form a collateral route with the middle colic artery by contributing to the marginal artery of Drummond. Knowledge of this variation is clinically relevant for surgical and radiological procedures in the abdomen.

A Case of High-Output Heart Failure.

CASE PRESENTATION: A 55-year-old woman with a medical history of hereditary hemorrhagic telangiectasia (HHT) complicated by recurrent nosebleeds, severe blood loss anemia, hepatic arterial-venous malformation (AVM), pulmonary hypertension, and severe tricuspid regurgitation presented to the HHT specialty clinic with acute hypoxic respiratory failure (new 3-L O2 requirement), weight gain, and volume overload. She was directly admitted to the pulmonary hypertension unit of our hospital. She had two recent admissions for similar symptoms thought to be due to worsening pulmonary arterial hypertension. In prior admissions, she had undergone right heart catheterization demonstrating mild pulmonary hypertension (pulmonary arterial pressure, 29 mm Hg, cardiac output by Fick 5.76, and cardiac index 3.22, mildly elevated pulmonary vascular resistance to 5.5 woods units). She would undergo diuresis with symptomatic improvement; however, after discharge she would rapidly develop recurrent heart failure symptoms. She reported compliance with guideline-directed medications, diuretics, and dietary restrictions and was still suffering severe symptoms. Notably she had previously elevated liver enzymes concerning for cirrhosis and had begun a workup to evaluate for causes of cirrhosis; she had a history of mild alcohol use, negative hepatitis viral serology, and no known history of liver disease.

Portal Annular Pancreas With Common Hepatic Artery Trajectory Abnormality: A Case Report and Review of the Literature.

ABSTRACT: Portal annular pancreas (PAP) is a rare congenital pancreatic anomaly, in which the uncinate process of the pancreas fuses to the body of pancreas behind the portal vein. Here, we report a case of PAP with common hepatic arterial anomaly, which was identified during surgery. A 57-year-old man who had branch type intraductal papillary mucinous neoplasm in the head of the pancreas developed a nodule in the cystic lesion. We planned pylorus preserving pancreaticoduodenectomy. The common hepatic artery from the celiac artery passing behind the portal vein was revealed in preoperative examinations. During surgery, we discovered that the uncinate process of the pancreas was fused with the body of the pancreas behind the portal vein. We divided the pancreas at the anterior and posterior of the portal vein. The main pancreatic duct was present in the anterior pancreatic stump. We performed pancreaticojejunostomy in the anterior stump and closed the posterior stump by interrupted suture. Forty-four surgical cases of PAP have been reported in the English medical literature. There are few previous reports of PAP which involved an arterial anomaly. Clinicians should consider PAP preoperatively to ensure that the surgeon can appropriately plan pancreatic resection to avoid postoperative complications.

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.

Two novel hepatic arterial variations in a living liver donor detected by multidetector computed tomography angiography.

PURPOSE: Considering that the knowledge of variations in the hepatic vascular structure is essential for hepatic surgery and liver transplantation, we aimed to present a rare case of the anatomic variation of arterial blood supply to the liver to help prevent complications and choose suitable donors. METHODS: We present a novel variant in this case report (living liver donor), an accessory right hepatic artery (supplying segment 6) originating from the dorsal pancreatic artery and a middle hepatic artery (supplying segment 4) arising from the pancreaticoduodenal artery (first branch of the gastroduodenal artery). Preoperative diagnosis was made using computed tomography angiography (CTA) with multiplanar reformate (MPR) images, curved planar reformate (CPR), maximum intensity projection (MIP) images and three-dimensional volume renderings (3D VR). RESULTS: To the best of our knowledge, this is the first case in the English literature describing this type of variation. A search for new donors began since the living liver donor was not suitable due to the very thin segment 4 artery, posing potential risks for the donor and the thin segment 6 artery being a complicating factor for anastomosis. CONCLUSIONS: The preoperative knowledge of liver blood supply has great importance in planning surgery and transplantation. CTA, reformate and reconstruction techniques allow for the evaluation of difficult and complex anatomic variations.

Conventional hepatic arterial anatomy? Novel findings and insights of a multi-disciplinary hepatic arterial infusion pump program.

INTRODUCTION: Variant hepatic arterial anatomy (vHAA) is thought to occur in 20-30% of patients. Hepatic arterial infusion (HAI) pump placement for liver cancers requires thorough hepatic artery dissection; we sought to compare vHAA identified during pump placement with established dogma. METHODS: Between 2016 and 2020, n = 30 patients received a HAI pump. Intra-operatively identified vHAA was characterized and compared with published data. RESULTS: vHAA was identified in 60% (n = 18) of patients, significantly higher than 19% (3671 of 19013) in the largest published series (P < 0.001). The most common variations were accessory left (n = 12; 40%) and replaced right (n = 6; 20%) hepatic arteries; six (20%) had ≥2 variants. Pre-operative imaging correctly identified 67% of variant hepatic arteries. DISCUSSION: Meticulous operative dissection of the hepatic arterial tree reveals vHAA not captured by imaging or cadaveric dissection. vHAA likely has a higher prevalence than previously reported and should be addressed to optimize therapeutic efficacy of HAI pump therapy.

An aberrant right hepatic artery arising from the gastroduodenal artery: a pitfall encountered during pancreaticoduodenectomy.

PURPOSE: Among the variations of the right hepatic artery (RHA), the identification of an aberrant RHA arising from the gastroduodenal artery (GDA) is vital for avoiding damage to the RHA during surgery, since ligation of the GDA is necessary during pancreaticoduodenectomy (PD). However, this variation is not frequently reported. The purpose of this study was to focus on an aberrant RHA arising from the GDA, which was not noted in the classifications reported by Michels and Hiatt. METHODS: A total of 574 patients undergoing a PD between Jan 2001 and Dec 2015 at a tertiary care hospital in Switzerland (n = 366) and between Jan 2009 and May 2015 at a hospital in Japan (n = 208) were included in the analysis. Of these, preoperative CT angiography or/and MRI angiography findings were available for 532 patients. We retrospectively analyzed the hepatic artery variations, patient demographics, and surgical outcomes. RESULTS: Among the 532 patients who received a PD, an RHA originating from the GDA was observed in 19 cases (3.5%). Eleven patients (2.1%) had both an aberrant RHA and an aberrant left hepatic artery (LHA) (Hiatt Type 4). Six patients (1.2%) had a replaced CHA arising from the SMA (Hiatt Type 5). We could, therefore, correctly identify the aberration in all cases. CONCLUSIONS: We observed rarely reported but important aberrant RHA variations arising from the GDA. To prevent injury during PD in patients with this type of aberrant RHA, intensive preparations using CT and/or MRI imaging before surgery and intraoperative liver Doppler ultrasonography are considered to be essential.

Common hepatic artery originating from superior mesenteric artery with replaced right hepatic artery.

We found a variational case relating to the arteries distributed to the liver and pancreas during the routine cadaver dissection course. The common hepatic artery originated from the superior mesenteric artery as the first branch. The common hepatic artery was soon divided into the left and right hepatic arteries and distributed to the left and right lobe of the liver. The superior pancreaticoduodenal artery arose from the gastroduodenal artery, a branch of the left hepatic artery. The inferior pancreaticoduodenal artery originated from the superior mesenteric artery. Besides, two posterior branches of the right hepatic artery supplied the duodenum and the head of the pancreas. The arterial arcades were formed behind the head of the pancreas among the superior pancreaticoduodenal artery and these two posterior branches of the right hepatic artery. In conclusion, this case can be considered a rare case in which the replaced common hepatic artery and replaced right hepatic artery occurred simultaneously. The coexisting of these two replaced arteries suggests that the developmental processes to form these variations are independent.

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.

Preserving a Replaced Left Hepatic Artery Arising from the Left Gastric Artery During Laparoscopic Distal Gastrectomy for Gastric Cancer.

BACKGROUND: A replaced left hepatic artery (RLHA) arising from the left gastric artery (LGA) is occasionally encountered during laparoscopic gastrectomy. Although the RLHA is usually divided at the root level as RLHA preservation might result in inadequate lymph node dissection, blood flow disruption by RLHA division may lead to hepatic ischemia. To date, there is no consensus on RLHA preservation. Thus, we aimed to evaluate the efficacy of RLHA preservation by investigating the short-term outcomes of patients with RLHA who underwent laparoscopic distal gastrectomy (LDG). METHODS: A total of 106 patients with an aberrant LHA from the LGA were identified as having gastric cancer and underwent LDG from 2012 to 2018. Finally, 55 patients were retrospectively diagnosed with RLHA by preoperative computed tomography and included in this study. Patients were classified into the divided (n = 18) or preserved (n = 37) group. Clinicopathological factors and surgical outcomes were compared between the two groups. RESULTS: The RLHA preservation rate in patients who had been preoperatively diagnosed with RLHA was 88%. No significant difference was found in the number of harvested lymph nodes between the groups. The incidence of hepatic infarction was significantly higher in the divided group (16.7% vs. 0%, p = 0.031). Moreover, RLHA division caused postoperative transaminase elevation and was an independent risk factor for postoperative transaminase elevation (odds ratio: 55.8, p < 0.001). CONCLUSIONS: Surgical procedures of RLHA preservation reduced postoperative transaminase elevation and hepatic infarction in patients who underwent LDG. Surgeons should confirm the RLHA preoperatively and preserve it to prevent hepatic damage.

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.

Unusual development of the celiac trunk and its clinical significance / Desenvolvimento incomum do tronco celíaco e sua importância clínica

Abstract We describe a case of unusual development of the celiac trunk observed in the cadaver of 1-year old male child. The celiac trunk branched into five vessels: the splenic, common hepatic and left gastric arteries, the left inferior diaphragmatic artery, and a short trunk that branched into the right inferior diaphragmatic artery and right accessory hepatic artery. Additionally, the manner of branching of the vessel was unusual: it was possible to distinguish two branching points that corresponded to its s-shaped trajectory. There were also other variations of vascular supply, such as the presence of a left accessory hepatic artery, an additional superior pancreatoduodenal artery, and others. It should be noted that multiple developmental variations can be common in clinical practice and clinicians should be aware of them during diagnostic and interventional procedures.

Resumo Apresentamos um relato de caso de desenvolvimento incomum do tronco celíaco em um cadáver do sexo masculino de 1 ano de idade. O tronco celíaco ramificou-se para cinco vasos: as artérias esplênica, hepática comum e gástrica esquerda, a artéria diafragmática inferior esquerda e um tronco pequeno que se ramificou para a artéria diafragmática inferior direita e para a artéria hepática direita acessória. Além disso, a forma como o vaso se ramificou foi incomum: é possível distinguir dois pontos de ramificação que correspondem à trajetória em formato de S. Também houve outras variações do suprimento vascular, como a presença da artéria hepática esquerda acessória, da artéria pancreaticoduodenal superior acessória e outras. Cabe observar que a variação de desenvolvimento múltipla pode ser comum na prática clínica, e os médicos devem estar cientes dela durante os procedimentos de diagnóstico e intervenção.

Congenital Hepatic Arteriovenous Malformation Presenting as Isolated Massive Hepatomegaly in an Otherwise Healthy Neonate: A Case Report.

Congenital hepatic arteriovenous malformations (HAVMs), though rare, carry high morbidity and mortality rates if left undiagnosed. The usual clinical presentation is in infancy with congestive heart failure, anaemia and hepatomegaly. There are reports of presentation as persistent pulmonary hypertension in newborns and reports of their spontaneous regression as well. We describe a healthy full-term neonate with HAVM who was presented with isolated massive hepatomegaly and underwent surgical ligation.

A single-center clinical study of hepatic artery variations in laparoscopic pancreaticoduodenectomy: A retrospective analysis of data from 218 cases.

Hepatic artery variations increase the difficulty of laparoscopic pancreaticoduodenectomy (LPD). The safety and efficacy of LPD in the presence of aberrant hepatic arteries (AHA) must be further verified.Patients with normal and variant hepatic arteries who underwent LPD and preoperative arterial angiography were retrospectively analyzed. Variation type, intraoperative management, and clinical treatment outcomes were compared.There were 54 cases (24.8%) of AHA. The most common hepatic artery variation was accessory right hepatic artery (RHA) from the superior mesenteric artery (SMA, n = 12, 5.5%), followed by replaced RHA from the SMA (n = 10, 4.6%), accessory left hepatic artery from the SMA (n = 10, 4.6%), and replaced common hepatic artery from the SMA (n = 6, 2.8%). Each type of arterial variation was successfully preserved in all cases, and there were no significant effects on the evaluated surgical indices, conversion rate, incidence of postoperative complications, or follow-up results.Our findings indicated that preservation of AHAs during total LPD is feasible. There were no significant effects on surgical indices, incidence of postoperative complications, or follow-up outcomes.The influence of AHA on the safety and efficacy of LPD must be further verified. Patients with normal and variant hepatic arteries who underwent LPD and preoperative arterial angiography were retrospectively analyzed. There were 54 cases (24.8%) of AHA. There were no significant effects of AHAs on surgical indices, incidence of postoperative complications, or follow-up outcomes.

Frequency of Anatomic Variations on Hepatic Arteries and Types of Reconstruction Employed: Study on Livers Prepared for Transplantation.

BACKGROUND: Recognition of anatomic variations in the hepatic artery is important at the time of organ uptake and at the back table for transplantation. PURPOSE: To know the frequency of these variations, in a 5-year series of liver transplantation and the various types of arterial reconstruction used in back table surgery. METHODS: We analyzed 340 donor files and calculated the frequencies of the various anatomic variations of the hepatic artery, according to Hiatt, and the types of vascular reconstruction employed. RESULTS: In total, 225 cases (66.17%) had a single hepatic artery, considered unchanged (type I), originating from the celiac trunk. Forty-six (13.52%) and 44 (12.94%) were, respectively, type II and III. Eight cases (2.35%) had a type II and III association (type IV), and another 8 (2.35%) were type V. There were no type VI cases. Nine cases were not described in the Hiatt classification. The most common reconstruction was right hepatic and splenic artery anastomosis, performed in 53 cases (91.37%). In 4 cases, this reconstruction was performed with the gastroduodenal (6.89%). In 1 case of 3 arteries with independent origins, in the aorta, reconstruction was performed using the iliac artery graft (common and its bifurcation), taken from the organ donor (1.72%). CONCLUSIONS: The most common variations were the presence of a left or right hepatic artery alone, each with a frequency of 13%, and the most commonly used reconstruction was the right hepatic with splenic arteries anastomosis.

Safety of Ligation of Aberrant Left Hepatic Artery Originating from Left Gastric Artery in Laparoscopic Gastrectomy for Gastric Cancer.

There are still lot of controversies whether aberrant left hepatic artery (ALHA) originating from left gastric artery should be ligated or preserved during gastric cancer (GC) surgery. We aimed to investigate this issue. We reviewed ALHA cases who had laparoscopic gastrectomy for gastric cancer at Seoul National University Hospital (SNUH) from 2012 to 2016. Type of ALHA variants using Michel's classification of hepatic arterial anatomy and diameter of each vessel were evaluated by 2 radiologists. Postoperative hepatic function and surgical outcome were collected until 6 months after surgery. Results showed that if the diameter of ALHA was larger than 1.5 mm, a transient elevation of SGOT and SGPT on postoperative day 2 was observed in the ligated cases. No differences were observed in operation time, amount of blood loss, overall complication rate, hospital stay, and number of lymph nodes retrieved between the ligated and preserved replaced left hepatic artery (RLHA) and accessory left hepatic artery (acLHA) group. In this study, we conclude that ligation of ALHA seems to be safe as none of the patients suffered adverse outcome. A transient rise in postoperative SGOT and SGPT levels were seen after ligating ALHA >1.5 mm in diameter regardless of subtype.