liver arterial anatomy, variants and extrahepatic feeders friday, 6
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GEST 2016Liver Arterial Anatomy, Variants and Extrahepatic Feeders
-Microanatomy and functions of terminal hepatic arterioles important for TACE-
Matsui ODepartment of Imaging Diagnosis and Interventional Radiology
Kanazawa University Graduate School of Medical Science. Kanazawa, Japan
Miyayama S Department of Radiology, Fukui-saikai Hospital , Fukui, Japan
Osamu Matsui, M.D.
• No relevant financial relationship reported
Terminal hepatic arterioles: peribiliary vascular plexus (PBP)
Peribiliary vascular plexus (PBP)
( Ekatasin W. Hepatology 2000;31:269-279)
PBP: peribiliaryvascular plexus
SEM of vascular cast in a rat liver
HA: hepatic artery
PV: portal vein
(Demachi H, Matsui O. CVIR 1991;14:158)
Scanning Electron Microscopy of Vascular Cast in Rat Liver(Demachi H, Matsui O. CVIR 1991;14:158)
PBP
HA
PV
HA
PBP
PV
HA
PBP
Sinusoids
Hepatic artery PBP
Drainage from PBP to portal venules and hepatic sinusoids.
There are abundant communications between hepatic artery and portal vein and hepatic sinusoids through PBP.
Importance of peribiliary vascular plexus (PBP) in TACE
Bile duct
Arterial collateral pathway following intrahepatic hepatic artery obstruction
Feeding artery of bile duct
Route of arterial compensation following portal vein obstruction
Lipiodol (iodized oil) injected into hepatic artery flows into portal vein via PBP
PBPs are dilated in cirrhotic liver
Intrahepatic arterial collaterals through PBP following repeated DEB- TACEs
Pre-TACE Post-TACE hepatic arteriography
Dilated PBP
Dilated PBP
Rare in TACE with gelatin sponge particle (temporal embolus) More frequent in TACE with microsphere (permanent embolus) Without PBP, safe TACE is impossible.
Biloma caused by severe damages on PBP following Lipiodol-TACE
Biloma following TACE
Bile duct necrosis Disappearance of PBP
Factor VIII immunohistochemical staining
(Kobayashi S, Matsui O et al. Am J Gastroenterol. 1993;88:1410-5)
Bile duct
Peribiliary Vascular Plexus (PBP) is markedly dilated and increased in cirrhotic livers
Normal liver Cirrhotic liver
Factor VIII immunohistochemical staining
inner layer outer layer
(Kobayashi S, Matsui O. et al. Hum Pathol. 1994;9:45)
PBPs including perinodular vascular plexus are markedly dilated in cirrhotic livers (arterialized liver).
Bile duct
Bile duct
Dilated PBP in cirrhotic liver
(Kobayashi S, Matsui O, et al. Am J Gastroenterol 1993;88:1410) (Kobayashi S, Nakanuma Y, Matsui O. Hum Pathol. 1994;25:940)
Larger amount of Lipiodolinjected into hepatic artery flows into portal vein through PBP in cirrhotic livers (enhances ischemic effects in superselective Lipiodol-TACE)
Damages on bile ducts by TACE are less in cirrhotic livers than in normal livers.
HCC
Peribiliary vascular plexus (PBP)
( Ekatasin W. Hepatology 2000;31:269-279)
Capsular arterial plexus
Isolated artery (not accompanied by PV, bile ducts)
Capsular arterial plexus
Arterial vascular cast in a human liver with yellow latex
Terminal hepatic arterioles: isolated arteries
(Terayama N, Matsui O, et al. CVIR 2004;27:278-81.)
Capsular arterial plexus
Isolated artery
Isolated artery
Capsular arterial plexus
Isolated artery
Extrahepatic arteries distribute bare area and ligaments of the liver and communicate with capsular arterial plexus
(Courtesy from Dr. Kenji Ibukuro, Mitsui Memorial Hospital, Tokyo.)
Bare area
Coronary ligament
Capsuslararterial plexus
Inferior phrenic artery
Abundant communications between intra and extra-hepatic arteries through capsular arterial plexus and isolated arteries
Arterial cast of the cadaver liver injected from the proper hepatic artery
Visualization of “Inferior phrenic artery”
Injection from “Proper hepatic artery”
(From “Hales MR et al. Amer. J Pathology 1959;5;909-941”)
Capsular arterial plexus
Anterior view Posterior view
Falciform ligament Internal thoracic a.
Left triangular ligament Left inf. Phrenic a.
Bare area
Coronary ligament Inferior phrenic a. Internal thoracic a. Intercostal a. Adrenal a.
Extra-hepatic arteries communicate with capsular arterial plexus through ligaments of the liver
Right triangular a. Intercostal a. Adrenal a.
Various extrahepatic arteries can have communication with capsular arterial plexus through the bare area and ligaments of the liver.
Importance of the communications among isolated arteries, capsular arterial plexus and extra-hepatic
arteries in TACE
Main collateral routes from extra to intrahepatic arteries
Main collateral routes between segmental arteries of intrahepatic artery
Multiple bleeding points in subcapsularhemorrhage
Main collateral routes from extra to intrahepatic arteries
Diffuse and abundant communications exist between extra and intrahepatic arteries through isolated arteries, capsular arterial plexus and hepatic ligaments surrounding bare area.
X
XX
Capsular arterial plexus
Collateral supply from left inferior phrenic artery through left triangular ligament, capsular arterial plexus and isolated arteries
Celiac arteriography
Inferior phrenic arteriography
Complete obstruction of the common hepatic artery
Inferior phrenic artery
Collateral supply from inferior phrenic artery though left triangular ligament, capsular arterial plexus and isolated arteries
MDCT during inferior phrenic arteriography
Inferior phrenic artery
A branch of IPA through left triangular ligament
Dilated capsular artery
Dilated isolated arteries
Dilated capsular artery
Dilated isolated arteries
45y.o. M multiple HCCs
Pre-TACE
Post two times of DEB-TACE
Common hepatic arteriography
Common hepatic arteriography
CT during hepatic arteriography (CTHA)
Right inferior phrenic arteriography
Collateral supply from right inferior phrenic artery through coronary ligament, capsular arterial plexus and isolated arteries
RT. inferior phrenic arteryIsolated arteries
Retrograde visualization of hepatic arteries
Rt. inferior phrenic arteryRt. inferior phrenic artery
Capsular artery
Direct feeding from rt. Inferior phrenic arterythrough bare area
Capsular artery
Retrograde visualization of hepatic arteries through isolated arteries
Dilated capsular arterial plexus
Capsular artery from rt. Inferior phrenic artery
CT during rt. inferior phrenic arteriography (3D MIP)
Dilated capsular arterial plexus+ isolated arteries+hepatic arteries
Rt. inferior phrenic artery
Collateral supply from right inferior phrenic artery through coronary ligament, capsular arterial plexus and isolated arteries
Main collateral routes between segmental arteries of intrahepatic artery
XCapsular arterial plexus
Intersegmental collateral supply through capsular arterial plexus and isolated arteries
67y.o M
Right hepatic arteriographyCeliac arteriography
A4
A4
Capsular arterial plexusCapsular arterial plexus
Dynamic CT
HCC
HCC
microcommunications through isolated arteries and capsular arterial plexus
( :Capsular artery)
( :Isolated artery)
Right hepatic arteriography CT during right hepatic arteriography (3D MIP)
Intersegmental collateral supply through capsular arterial plexus and isolated arteries
Multi-focal extravasation (hemorrhage) due to multiple disruptions of the connections between isolated artery and capsular arterial plexus
Equilibrium phase of dynamic CT (arrows indicate extravasation)
Superior mesenteric arteriography Inferior phrenic arteriography(arrows indicate extravasation)
Extravasation can be seen from both isolated arteries and capsular arteries, but more extensively from the former.
Bleeding points
Summary of the presentation
PBP is a feeding artery of bile ducts and main collateral pathway between intrahepatic arteries, and there are abundant communications between hepatic arteries and portal veins through PBP.
Micro-communications among Isolated arteries, capsular arterial plexus and extra-hepatic arteries is the main collateral pathway between intra and extra-hepatic arteries, and can be a collateral pathway between segmental arteries.
To understand these micro-communications is important for the precise performance of TACE.