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Variant Hepatic Arterial Anatomy Revisited: Digital Subtraction Angiography Performed in 600 Patients¹

¹ From the Department of Diagnostic Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021 (A.M.C., L.A.B., G.I.G., K.T.B.); and Department of Surgery, New York Presbyterian Hospital, New York, NY (M.A.M.). Received July 26, 2001; revision requested September 4; revision received October 23; accepted December 11. Address correspondence to A.M.C. (e-mail: coveya@mskcc.org).

View larger version (200K): [in a new window]   Figure 1. Anteroposterior angiogram of standard hepatic arterial anatomy. The celiac axis gives rise to the LGA (small short arrow), splenic artery (open arrow), and CHA (long straight arrow). After the origin of the GDA (arrowhead), the CHA becomes the PHA (curved arrow). The PHA bifurcates into the RHA (large short arrow) and LHA (thin arrow).

View larger version (183K): [in a new window]   Figure 2a. Anteroposterior angiograms show RHA replaced to SMA. (a) Angiogram of the celiac axis shows CHA (straight arrow) bifurcating into the GDA (arrowhead) and the LHA (curved arrow). No RHA is depicted. (b) After injection of contrast material into the SMA (open arrow), the angiogram shows a replaced RHA (solid arrow).

View larger version (189K): [in a new window]   Figure 2b. Anteroposterior angiograms show RHA replaced to SMA. (a) Angiogram of the celiac axis shows CHA (straight arrow) bifurcating into the GDA (arrowhead) and the LHA (curved arrow). No RHA is depicted. (b) After injection of contrast material into the SMA (open arrow), the angiogram shows a replaced RHA (solid arrow).

View larger version (183K): [in a new window]   Figure 3. Anteroposterior angiogram shows LHA replaced to LGA. Angiogram of the celiac axis (not shown) demonstrated the RHA arising from the CHA. No LHA was visualized. After injection of contrast material into the gastrolienal artery, this angiogram shows the LHA (curved arrow) originating from the LGA (straight solid arrow). The splenic artery is identified by the open arrow.

View larger version (144K): [in a new window]   Figure 4a. Anteroposterior angiograms show accessory RHAs. Angiograms of the (a) celiac axis and (b) SMA show the RHA (curved arrow in a) at the normal site and an accessory RHA (curved arrow in b) arising from the SMA (straight arrow in b), the most common site for accessory RHAs. The LHA (small arrow in a) and CHA (large straight arrow in a) are normal. (c) Angiogram shows the uncommon case of an accessory RHA (curved white arrow) arising from the GDA (arrowhead). The RHA at the normal site is identified by the curved black arrow. (d) Angiogram of the celiac axis shows the CHA (straight arrow), RHA (curved black arrow), and LHA (white arrow). (e) Angiogram obtained in the same patient as in d shows the single case of an accessory RHA (curved black arrow) arising from the LGA (straight arrow). The accessory RHA also gives rise to an accessory LHA (white arrow).

View larger version (182K): [in a new window]   Figure 4b. Anteroposterior angiograms show accessory RHAs. Angiograms of the (a) celiac axis and (b) SMA show the RHA (curved arrow in a) at the normal site and an accessory RHA (curved arrow in b) arising from the SMA (straight arrow in b), the most common site for accessory RHAs. The LHA (small arrow in a) and CHA (large straight arrow in a) are normal. (c) Angiogram shows the uncommon case of an accessory RHA (curved white arrow) arising from the GDA (arrowhead). The RHA at the normal site is identified by the curved black arrow. (d) Angiogram of the celiac axis shows the CHA (straight arrow), RHA (curved black arrow), and LHA (white arrow). (e) Angiogram obtained in the same patient as in d shows the single case of an accessory RHA (curved black arrow) arising from the LGA (straight arrow). The accessory RHA also gives rise to an accessory LHA (white arrow).

View larger version (157K): [in a new window]   Figure 4c. Anteroposterior angiograms show accessory RHAs. Angiograms of the (a) celiac axis and (b) SMA show the RHA (curved arrow in a) at the normal site and an accessory RHA (curved arrow in b) arising from the SMA (straight arrow in b), the most common site for accessory RHAs. The LHA (small arrow in a) and CHA (large straight arrow in a) are normal. (c) Angiogram shows the uncommon case of an accessory RHA (curved white arrow) arising from the GDA (arrowhead). The RHA at the normal site is identified by the curved black arrow. (d) Angiogram of the celiac axis shows the CHA (straight arrow), RHA (curved black arrow), and LHA (white arrow). (e) Angiogram obtained in the same patient as in d shows the single case of an accessory RHA (curved black arrow) arising from the LGA (straight arrow). The accessory RHA also gives rise to an accessory LHA (white arrow).

View larger version (201K): [in a new window]   Figure 4d. Anteroposterior angiograms show accessory RHAs. Angiograms of the (a) celiac axis and (b) SMA show the RHA (curved arrow in a) at the normal site and an accessory RHA (curved arrow in b) arising from the SMA (straight arrow in b), the most common site for accessory RHAs. The LHA (small arrow in a) and CHA (large straight arrow in a) are normal. (c) Angiogram shows the uncommon case of an accessory RHA (curved white arrow) arising from the GDA (arrowhead). The RHA at the normal site is identified by the curved black arrow. (d) Angiogram of the celiac axis shows the CHA (straight arrow), RHA (curved black arrow), and LHA (white arrow). (e) Angiogram obtained in the same patient as in d shows the single case of an accessory RHA (curved black arrow) arising from the LGA (straight arrow). The accessory RHA also gives rise to an accessory LHA (white arrow).

View larger version (190K): [in a new window]   Figure 4e. Anteroposterior angiograms show accessory RHAs. Angiograms of the (a) celiac axis and (b) SMA show the RHA (curved arrow in a) at the normal site and an accessory RHA (curved arrow in b) arising from the SMA (straight arrow in b), the most common site for accessory RHAs. The LHA (small arrow in a) and CHA (large straight arrow in a) are normal. (c) Angiogram shows the uncommon case of an accessory RHA (curved white arrow) arising from the GDA (arrowhead). The RHA at the normal site is identified by the curved black arrow. (d) Angiogram of the celiac axis shows the CHA (straight arrow), RHA (curved black arrow), and LHA (white arrow). (e) Angiogram obtained in the same patient as in d shows the single case of an accessory RHA (curved black arrow) arising from the LGA (straight arrow). The accessory RHA also gives rise to an accessory LHA (white arrow).

View larger version (163K): [in a new window]   Figure 5. Anteroposterior angiogram of celiac axis shows an accessory LHA. Accessory LHAs (curved white arrow) almost exclusively originate from the LGA (straight arrow), as shown here. The other LHA is indicated by the curved black arrow.

View larger version (197K): [in a new window]   Figure 6. Anteroposterior angiogram shows CHA replaced to the SMA. Four percent of the patients in this series had an anomalous origin of the CHA. In half of these patients, the CHA (straight solid arrow) was replaced to the SMA (open arrow), as in this case. The RHA (arrowhead) and LHA (curved arrow) are normal.

View larger version (191K): [in a new window]   Figure 7a. Separate origin CHA and gastrolienal trunk. In 50% of cases in which there is a variant origin of the CHA, the CHA arises as a separate branch of the aorta. (a) Anteroposterior angiogram of the CHA arising directly from the aorta (arrow). (b) Anteroposterior angiogram of a gastrolienal artery (arrow) that arises as a separate branch of the aorta.

View larger version (156K): [in a new window]   Figure 7b. Separate origin CHA and gastrolienal trunk. In 50% of cases in which there is a variant origin of the CHA, the CHA arises as a separate branch of the aorta. (a) Anteroposterior angiogram of the CHA arising directly from the aorta (arrow). (b) Anteroposterior angiogram of a gastrolienal artery (arrow) that arises as a separate branch of the aorta.

View larger version (157K): [in a new window]   Figure 8a. Anteroposterior angiograms show PHA replaced to the SMA. (a) Angiogram of celiac axis shows the LGA (solid arrow), splenic artery (open arrow), and GDA (arrowhead). No hepatic artery is depicted. (b) Angiogram of SMA region shows a replaced PHA (straight solid arrow) as the first branch of the SMA (open arrow). The PHA gives rise to the LHA (curved arrow) and the RHA (arrowhead).

View larger version (168K): [in a new window]   Figure 8b. Anteroposterior angiograms show PHA replaced to the SMA. (a) Angiogram of celiac axis shows the LGA (solid arrow), splenic artery (open arrow), and GDA (arrowhead). No hepatic artery is depicted. (b) Angiogram of SMA region shows a replaced PHA (straight solid arrow) as the first branch of the SMA (open arrow). The PHA gives rise to the LHA (curved arrow) and the RHA (arrowhead).

View larger version (158K): [in a new window]   Figure 9. Anteroposterior angiogram shows late origin of the GDA. In 25 of 600 patients in the current study, the GDA arose distal to the origin of one hepatic artery. In the case shown, the GDA (arrowhead) arises just distal to the LHA (curved arrow), which is the first branch of the CHA (straight arrow).

View larger version (130K): [in a new window]   Figure 10. Anteroposterior angiogram shows a double hepatic artery. In the so-called double hepatic artery, there is no CHA and the GDA may originate from either hepatic artery. In the case shown, the RHA (straight solid arrow) and LHA (curved arrow) arise separately from the celiac axis. The GDA (arrowhead) originates from the LHA. The splenic artery is indicated by the open arrow.

View larger version (186K): [in a new window]   Figure 11a. Anteroposterior angiograms show variant origins of the GDA. (a) Trifurcation of the CHA into the LHA (curved arrow), RHA (open arrow), and GDA (arrowhead). (b) Quadrifurcation of the CHA (large straight solid arrow) into the LHA (curved arrow), RHA (open arrow), middle hepatic artery (small straight solid arrow), and GDA (arrowhead). These anomalies often are not included in the classic anatomy literature, but they have important implications in interventional and surgical procedures.

View larger version (139K): [in a new window]   Figure 11b. Anteroposterior angiograms show variant origins of the GDA. (a) Trifurcation of the CHA into the LHA (curved arrow), RHA (open arrow), and GDA (arrowhead). (b) Quadrifurcation of the CHA (large straight solid arrow) into the LHA (curved arrow), RHA (open arrow), middle hepatic artery (small straight solid arrow), and GDA (arrowhead). These anomalies often are not included in the classic anatomy literature, but they have important implications in interventional and surgical procedures.