Hepatic arterial anatomy and vascular optimization final

Justin McWilliams, MD
UCLA Interventional Radiology

1. Hepatic arterial anatomy
2. Anatomic variants
3. Extrahepatic collaterals
4. Vascular optimization

RHA LHA

PHA CHA

GDA

61%
Conventional hepatic artery anatomy; the CHA gives off the GDA and continues as the PHA, which splits into RHA and
LHA. In the surgical literature, 55-70% of the population has this configuration; in the largest DSA study, 61%.

Michels et al. Blood supply and antaomy of the upper abdominal organs with a descriptive atlas. Philadelphia, PA: Lippincott, 1955.
Hiatt et al. Surgical anatomy of the hepatic arteries in 1000 cases. Ann Surg 1994; 220: 50-52.
Covey et al. Variant hepatic arterial anatomy revisited: DSA performed in 600 patients. Radiology 2002; 224: 542-547.

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4
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Conventional hepatic artery anatomy (Couinaud segments)

Middle hepatic artery from RHA Middle hepatic artery from PHA (trifurcation)

A “middle hepatic artery” supplying segment 4 can arise from the right hepatic artery, or from the PHA as a
trifurcation.

Definition
Entire left hepatic artery originates
elsewhere other than the PHA

Origin
Left gastric artery

4% (lone anomaly)
+ 0.5% (with other accessory or replaced HA)
4.5% total incidence
Replaced left hepatic artery arising from left gastric artery. Left gastric
branches (arrowheads) can mimic segment 2 or 3 branches; true left
hepatic branches take off beyond the umbilical point (arrow).


Definition
Part (but not all) of the left hepatic artery has
an anomalous origin
“Accessory” is a misnomer; such arteries
usually supply a distinct territory of liver

Origin
Left gastric artery (almost always)
Right hepatic artery (very rare) CHA injection reveals segment 3 and 4 arteries, but no segment 2

11% (lone anomaly)
+ 4% (with other accessory or replaced HA)
15% total incidence
Injection of left gastric artery (arising directly from the aorta)
demonstrates segment 2 artery (arrows)


When an arterial structure is seen passing through the fissure of the ligamentum venosum, expect a replaced/accessory left hepatic artery (or less
likely, an accessory left gastric artery)

Definition
Entire right hepatic artery originates
elsewhere other than the PHA

Origin
SMA (almost always)
Right phrenic (rare)

9% (lone anomaly)
12% total incidence
Replaced right hepatic artery (arrow) arising from the SMA.


Definition
Part (but not all) of the right hepatic artery has
an anomalous origin
“Accessory” is a misnomer; such arteries
usually supply a distinct territory of liver

Origin
SMA (usually)
Also GDA, LGA, right phrenic

1.5% (lone visceral anomaly)
5.5% total incidence Accessory right hepatic artery (arrow) arising from GDA. The
remainder of the right hepatic artery was replaced to the SMA.


Celiac injection demonstrates absence of
RHA and LHA. Expected course of CHA
(arrow) terminates in GDA and RGA.

0.5%
Replaced LHA from LGA Replaced RHA from SMA


2%

Injection of celiac axis demonstrates splenic and left gastric Common hepatic artery arises from the superior mesenteric
arteries, but no common hepatic artery. artery.


Celiac injection demonstrates splenic artery supply but no evidence Slightly lower, the common hepatic artery arises directly from the
of common hepatic artery. aorta.

2%

Celiac injection demonstrates left hepatic artery (arrow) Different patient, oblique aortogram. The left hepatic
and right hepatic artery (arrowhead) both arising from the artery (arrow) and right hepatic artery (arrowhead) both
celiac trunk. The GDA arises from the RHA. arise from the celiac trunk. The GDA arises from the LHA.

4%
Images courtesy of David Liu, MD

 Only tumors with surface location

 17% overall likelihood of extrahepatic supply at initial
presentation
• 3% if <4 cm
• 63% if >6 cm

 Likelihood of extrahepatic supply increases with repeated transarterial
treatments

Chung et al. Transcatheter arterial chemoembolization of hepatocellular carcinoma: prevalence and causative factors of extrahepatic collateral arteries in 479
patients. Korean J Radiol 2006; 7(4): 257-266.

 Where to look based on tumor location
• Bare area of liver (seg 7/8): R phrenic and R adrenal
• Superior-anterior liver (cardiophrenic area): R internal mammary
• Exophytic toward kidney: R renal and R adrenal
• Any peritoneal surface: Omental branches from R gastroepiploic
• Contacts chest wall: Lower intercostal
• Left lateral segment: L gastric
• Contacts colon: Colic branches of SMA
• Gallbladder fossa: Cystic Bare area = Posterior surface
of segment 7 and posterior
half of the diaphragmatic
surface of segment 8 .

Chung et al. Transcatheter arterial chemoembolization of hepatocellular carcinoma: prevalence and causative factors of extrahepatic collateral arteries in 479
patients. Korean J Radiol 2006; 7(4): 257-266.

Origin
Aorta 50%
50%
of collateral supply
Celiac trunk 40%
Right renal artery 5%
Left gastric artery 4%
Rarely other

Supplies
Right hemidiaphragm
HCC near diaphragmatic surface (bare area)

Effects of embolization
Usually well-tolerated
Shoulder pain
Pleural effusion
Basal atelectasis
R phrenic artery from aorta. Injection demonstrates dense
Diaphragmatic weakness (usually asymptomatic) tumor blush consistent with parasitic supply of HCC.

Basile A et al. MDCT anatomic assessment of right inferior phrenic artery origin related to potential supply to hepatocellular carcinoma and its embolization.
CVIR 2008.
Image courtesy of David Liu, MD

Origin
Right or left gastroepiploic artery

Supplies
Greater omentum (mobile!)
Can supply tumors on almost any surface of the liver


15%
After multiple TACEs, common hepatic injection demonstrates multiple
omental branches (arrows) from the R gastroepiploic artery supplying
right lobe HCC (arrowheads).

Kim HC et al. Recognizing extrahepatic collateral vessels that supply hepatocellular carcinoma to avoid complications of transcatheter arterial chemoembolization.
Radiographics 2005.

Origin
Usually first branch of right hepatic artery

Supplies
Gallbladder
HCC in gallbladder fossa

Recognized by
Proximal bifurcation
Curved shape outlining viscus

Cholecystitis/gallbladder infarction
Often asymptomatic
Cystic artery injection demonstrates parasitic

9%
supply to HCC (arrow)

Radiographics 2005.

Origin
Aorta
5%
Supplies
Right body wall and skin
Spinal artery (occasionally)
T10 > T9 > T11 for tumor supply

Skin necrosis
Dermatomal pain
Spinal artery infarction

Right T11 injection demonstrates tumor supply (left). To avoid complications, a
microcatheter was advanced beyond the diaphragm insertion site (right) prior to TACE.

Radiographics 2005.

Skin reaction related to intercostal embolization

Images courtesy of David Liu, MD

Right adrenal artery (6%)

Right or left gastric artery (3%)

Right internal mammary artery (3%)

Superior mesenteric artery (2%)

Right renal capsular artery (2%)

Left inferior phrenic artery (2%)

Radiographics 2005.

Infiltrative HCC of the right lobe Replaced RHA angiogram demonstrates tumor supply. DEB-TACE
was performed.

1 month post-TACE, tumor necrosis is seen, but persistent Right phrenic angiography demonstrates copious
enhancement is seen at the posterior diaphragmatic margin. tumor supply. DEB-TACE was performed.

One month post TACE #2, persistent enhancement is present at the posterior The right T10 intercostal artery demonstrates tumor supply.
margin of segment 6. DEB-TACE was performed from the vertical segment.

1 month post TACE
#3, the tumor is
almost completely
devascularized.

Protective coil embolization of extrahepatic branches arising from the hepatic
circulation prior to embolotherapy

1. Gastroduodenal artery

2. Right gastric artery

3. Accessory left gastric artery

4. Retroduodenal artery
Uncommon considerations:
5. Supraduodenal artery -Dorsal pancreatic artery
-Left phrenic artery
-Esophageal branches
6. Falciform artery

7. Cystic artery

Accessory left gastric
Right gastric
Falciform
Left phrenic

Cystic
Supraduodenal
Retroduodenal

Right gastric
Supraduodenal
Retroduodenal
Dorsal pancreatic

Origin
Common hepatic artery

Supplies
Pylorus of stomach
Proximal duodenum
Pancreatic head (via pancreaticoduodenals)
Greater curvature of stomach (via R gastroepiploic)

Anatomic Clues
Near constant origin from CHA
Characteristic branching pattern

The gastroduodenal artery arises from the CHA. It typically gives
off the posterior superior pancreaticoduodenal artery (curved
arrow), then bifurcates into the anterior superior
pancreaticoduodenal artery (arrow) and the right gastroepiploic
artery (arrowhead).

Considerations for optimization:

Should be coil embolized in almost all cases

High flow, need lots of coils to occlude (usually 5-7
mm coils)

Coil all the way back to origin to avoid hypertrophy
of small proximal vessels

Look for accessory hepatic arteries and parasitized
tumor supply

GDA flow reversed?
If due to low hepatic artery resistance, best to coil GDA with reversed flow. Depending on the etiology, this
may or may not require coil embolization.
If due to celiac stenosis, probably OK not to coil

Origin
Proper hepatic artery (55%)
Left hepatic artery (20%)
Common hepatic artery (5%)
Gastroduodenal artery (5%)
Right or middle hepatic artery (rare)

Supplies Right gastric artery (arrow) arising from the origin of the gastro-
duodenal artery. Note anastomoses with the left gastric artery.
Gastric antrum and pylorus
Proximal duodenal bulb

Anatomic Clues
Leftward course along lesser curvature of stomach
Anastomoses with left gastric artery

Right gastric artery (arrow) arising from the left hepatic artery.

VanDamme JP, Bonte J. Vascular anatomy in abdominal surgery. New York: Thieme, 1990.

Considerations for optimization

Should be coil embolized in almost all patients
-Unnecessary if RGA origin is very proximal (CHA)

May have acute angle, difficult to catheterize

Options for difficult cannulation
-Shaped microcatheter
-Ultra-floppy wire (Synchro)
-Retrograde access via left gastric artery
-“Jail” right gastric by coiling left hepatic artery
-If all else fails, can deliver particles distal to origin

Right gastric artery accessed retrograde from the left gastric
artery, followed by coil embolization
Yamagami et al. Embolization of the right gastric artery before hepatic arterial infusion chemotherapy to prevent gastric mucosal lesions: approach through the
hepatic artery versus the left gastric artery. AJR Am J Roentgenol 2002; 179:1605-1610.

Prevalence 3-21% (low in Caucasian, high in
Asian populations)

Origin
Left hepatic artery in proximal portion – 60%
Left hepatic artery in distal portion – 40%

Destination
Gastric cardia and fundus

Anatomic Clues
Runs in the fissure of the ligamentum venosum (same
place as a replaced left hepatic artery) on CT
Proximal-type accessory left gastric artery (arrow) arises from
the LHA prior to the umbilical point and courses to the gastric
fundus (arrowheads).

Ishigami K, Yoshimitsu K, Irie H, et al. Accessory left gastric artery from left hepatic artery shown on MDCT and conventional angiography: correlation with CT
hepatic arteriography. Am J Roentgenol 2006;187:1002-1009.


Should be coil embolized if present

Often difficult to identify on angio

Tips for identification
-Gastric mucosal enhancement
-Delayed-phase coronary vein filling Left hepatic injection reveals abnormal vascularity in the left upper
-Use cone beam CT quadrant, overlapping the left lobe of the liver

Superselective injection demonstrates accessory left gastric
artery (distal type).

Also known as the posterior superior
pancreaticoduodenal artery
Origin
Gastroduodenal artery – 78%
Hepatic artery (proper or right) – 15%
Superior mesenteric artery – 5%

Destination
Head of pancreas
Uncinate process
Duodenal bulb

Anatomic Clues
Runs along common hepatic duct
Parallels 2nd segment of duodenum
The retroduodenal artery (arrows) typically arises as the first branch of
the gastroduodenal artery.

VanDamme JP, Van der Schueren G, Bonte J. Vascularisation du pancreas: proposition de nomenclature PNA et angioarchitecture des ilots. C R Assoc Anat 1968;
139:1184 –1192.


No need to coil embolize in most cases
-Usually arises from GDA

Coil embolize if originating from the hepatic artery (15%)

Aberrant origin of the retroduodenal artery (arrows) from the
proper hepatic artery. The origin of the GDA is seen more
proximally (arrowhead).

Origin
Common or proper hepatic artery – 20%
Left hepatic artery – 20%
Right hepatic artery – 13%
Cystic artery – 10%
Right gastric artery – 8%

Destination
Proximal duodenum

Anatomic Clues
Extremely variable origin
Small branch
Distribution to duodenal bulb area
Supraduodenal artery (arrows) arises from the proper hepatic
artery and passes toward the proximal duodenum.

Bianchi et al. The supraduodenal artery, Surg Radiol Anat 11 ( 1989), pp. 37-40.
Image courtesy of David Liu, MD

Often not visualized

Be suspicious if branch from hepatic artery passes
inferomedially toward duodenum

Coil embolize if originating from hepatic
circulation (about 50%) CHA injection demonstrates small artery passing inferomedially from
the right hepatic artery (arrows).

Superselective injection confirms supply to proximal duodenum. Coil embolization performed for duodenal protection (arrow).
Images courtesy of David Liu, MD.

Origin
Middle hepatic artery – 56%

Destination
Anterior abdominal wall, umbilical region
Falciform artery (arrow) arising from the left hepatic
Anatomic Clues artery, early phase.

Rarely seen (2%)

Courses anteriorly and diagonally toward the
midline (paralleling the falciform ligament)

Anterior course can be confirmed by
angiography in RPO projection

Late phase confirms typical course of falciform artery

Williams et al. Hepatic falciform artery: anatomy, angiographic appearance, and clinical significance. Radiology 1985. 156: 339-340.

Usually not seen

Coil embolize if present (2%)

Lack of protection can result in abdominal wall injury, pain, and/or rash

Typical appearance of falciform artery Coil embolization of falciform artery

Williams et al. Hepatic falciform artery: anatomy, angiographic appearance, and clinical significance. Radiology 1985. 156: 339-340.
Image courtesy of David Liu, MD.

Origin
Right hepatic artery – 90%
Common hepatic artery – 3%

Destination
Gallbladder

Anatomic Clues
Typically the first branch of right hepatic artery

Bifurcation into superficial and deep branches

Network of vessels outlining viscus
Cystic artery (arrow) arising from the anterior division branch of the right
hepatic artery

Daseler EH, Anson BA, Hambley WC, Reimann AF. The cystic artery and constituents of the hepatic pedicle. A study of 500 specimens. Surg Gynecol
Obstet 1947: 85: 47–63

Players choice

Advance catheter beyond cystic origin if possible

Coil embolization can rarely lead to ischemic
cholecystitis

Lack of coil embolization can rarely lead to chemical Coil embolization of cystic artery
or radiation cholecystitis

Can protect with gelfoam embolization at the time of
treatment

Gelfoam embolization of cystic artery

Variations in hepatic arterial anatomy are extremely common, and often affect
treatment

Consider parasitic supply, especially in large surface tumors
Tumor location predicts source of parasitic supply

Multiple splanchnic branches arise from the hepatic circulation
Will only be seen if you look for them!
Optimization with coil embolization is safe and protective

Consider CT angiogram of the liver prior to mesenteric mapping

Problem
Hepatosplanchnic artery cannot be catheterized

or

Catheter position unsafe for Y90 administration

Solution Gastrohepatic trunk injection demonstrates no safe
catheter position for Y90 delivery to left hepatic lobe
Occlude entire offending hepatic artery proximally

Cross-perfusion between lobes (artery to artery
collaterals) will allow Y90 delivery to the parenchyma
downstream from the obstruction

Karunanithy N, et al. Embolization of hepatic arterial branches to simplify hepatic
blood flow before yttrium 90 radioembolization: a useful technique in the
Left hepatic artery coil-occluded; Y90 administered from R
presence of challenging anatomy. CVIR 2010 Aug 11 (Epub ahead of print) hepatic artery, relying on cross-perfusion to reach L lobe
Images courtesy of David Liu, MD tumors.

Hepatic arterial anatomy and vascular optimization final

Hepatic arterial anatomy and vascular optimization final

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Hepatic arterial anatomy and vascular optimization final

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