Liver Arterial Anatomy, Variants and Extrahepatic Feeders Friday, 6

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.