A comprehensive study of right and left inferior phrenic artery variations in 1000 patients with multidetector computed tomography angiography: an important study for HCC

PURPOSE

To investigate the anatomic variations in the origins of the right and left inferior phrenic arteries (IPAs) using multidetector computed tomography and to classify their combined variations.

METHODS

This retrospective study included patients undergoing abdominal aorta angiography between January 2015 and October 2019. The RIPA and LIPA origins were evaluated both separately and combined on three-dimensional images. The variant patterns of the IPAs were determined and classified. The numerical evaluation of the data was performed with SPSS 21.

RESULTS

In total, 1000 patients (478 women, 522 men) were evaluated. The IPAs originated from a common trunk or a common root in 360 (36.00%) patients, while the IPAs originated independently without a common trunk in 609 (60.90%) patients. The most common combined variant detected in the present study was IPAs originating as a common trunk from the coeliac trunk in 197 (19.70%) patients; 14 (1.40%) patients had no inferior phrenic artery (IPA), and 17 (1.70%) patients had only one IPA.

CONCLUSION

Fifty-two different types of variations in the combined origin of the inferior phrenic arteries were described in this study for the first time in the literature. Awareness of the anatomic variations in the IPAs, which is critical for hepatocellular carcinoma origins, may benefit various clinical procedures, such as transcatheter arterial chemoembolization, organ transplantations, laparoscopic surgical procedures, and radiological procedures.

Blood supply to the caudate lobe of the liver from the right inferior phrenic artery: observation by cone-beam computed tomography during arteriography

PURPOSE

To retrospectively evaluate blood supply to the caudate lobe of the liver from the right inferior phrenic artery (RIPA) using cone-beam computed tomography during arteriography (CBCTA-RIPA).

METHODS

CBCTA-RIPA examinations during transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) were collected from 2448 procedures in 787 patients. The exclusion criteria were (1) major artifacts, (2) TACE of hepatic arterial branches before performing CBCTA-RIPA, and (3) repeated CBCTA-RIPA studies in the same patient. Blood supply to three subsegments, the Spiegel lobe (SP), paracaval, and caudate process, was evaluated on CBCTA-RIPA images. The origins and routes of branches supplying the caudate lobe were also evaluated by three-dimensional vessel-tracking software.

RESULTS

Forty-seven CBCTA-RIPA examinations in 47 patients (38 with a history of TACE [repeated TACE group] and nine without it [initial TACE group]) were eligible, including five who had previously undergone hepatectomy. Seven had caudate lobe HCCs. Blood supply to the caudate lobe was demonstrated in 21 (44.7%) patients: in 50% (19/38) and 22.2% (2/9) of the repeated and initial TACE groups, respectively. The caudate arteries had previously been embolized in eight patients, the RIPA branch in three, and both in one. Forty-one proximal branches mainly supplied the dorsal part of the SP. All branches but five reached there through the inferior vena cava (IVC) ligament. The RIPA supplied eight of nine caudate lobe HCCs, totally (n = 7) or partially (n = 1).

CONCLUSION

The proximal RIPA branches mainly supply the dorsal SP through the IVC ligament, especially in the repeated TACE group.

Right inferior phrenic artery pseudoaneurysm after a laparoscopic gastrectomy: a case report

Background

Ruptured pseudoaneurysms are a rare complication of gastrectomy, but when they do develop, they are often fatal. We presented herein the first report of a case of pseudoaneurysm arising from the right inferior phrenic artery (RIPA) after a laparoscopic gastrectomy.

Case presentation

A 61-year-old male patient underwent a laparoscopic distal gastrectomy and D1+ lymph node dissection with Roux-en-Y reconstruction for early gastric cancer. He was discharged on postoperative day (POD) 9 without any complications, such as anastomotic or pancreatic leakage. On POD 19, he was referred to the emergency room for upper abdominal pain. Enhanced abdominal computed tomography revealed a 60 × 70 mm hematoma, indicating intra-abdominal bleeding and a 10-mm pseudoaneurysm in the RIPA. Selective digital subtraction angiography confirmed the presence of a pseudoaneurysm in the RIPA, which was embolized using multiple microcoils. Thereafter, no clinical signs were observed, and the patient was discharged from the hospital 15 days after angiography without any recurrence of bleeding. We hypothesized that the cause of the pseudoaneurysm was mechanical vascular injury due to the thermal spread of the ultrasonically activated devices (USADs) during lymphatic node dissection.

Conclusion

Given the thermal spread of USADs, safe and appropriate lymph node dissection based on precise anatomical knowledge is crucial to preventing postoperative pseudoaneurysms.

Vascular anomalies of the celiac trunk and implications in treatment of HCC with TACE. Description of a case and review of the literature

Knowledge of the vascular anatomy of the upper abdomen is important in the daily practice of surgeons specialized in the hepatobiliary and pancreatic area, and for general surgeons and radiologists, mainly those involved in interventional radiology. Since anatomical variants of the celiac axis and hepatic arteries are common, an accurate description of vascularization is required before procedures to avoid iatrogenic vascular changes.

We reported a case of a young male patient with HBV related cirrhosis, who came to our institution for the treatment of 2 HCC nodules. The preprocedural contrast-enhanced CT examination showed combined variations of celiac trunk, hepatic arteries, gastroduodenal artery, and right inferior phrenic artery. The careful pre- and intraprocedural evaluation of vascularization allowed us to perform transarterial chemoembolization of the 2 nodules without complications.

The incidence and developmental and clinical significance of this variation is discussed with a detailed review of the literature. Knowledge of such a case has important clinical significance in abdominal operations or invasive arterial procedures.

Combined transarterial chemoembolization of the right inferior phrenic artery and radiofrequency ablation for small hepatocellular carcinoma near the diaphragm: its efficacy and safety

PURPOSE

The purpose of the study is to report the efficacy and safety of combined transarterial chemoembolization (TACE) of the right inferior phrenic artery (IPA) and radiofrequency ablation (RFA) for small hepatocellular carcinoma (HCC) near the diaphragm supplied by the right IPA.

METHODS

From July 2009 through April 2015, 11 patients with small (≤ 3 cm) HCC near the diaphragm, which was infeasible for ultrasound-guided RFA and supplied by the right IPA, received TACE of the right IPA and subsequent RFA in one session. The safety and therapeutic efficacy, including technique effectiveness and local tumor progression (LTP), were evaluated.

RESULTS

Technique effectiveness was achieved in all the 11 patients (100%). During average follow-up period of 39.2 months (range 13-89 months), LTP occurred in none of the 11 patients. There were twelve minor complications in eight patients, including right shoulder pain (n = 4), right pleural effusion (n = 2), diaphragmatic thickening (n = 2), transient lung change (n = 2), subsegmental intrahepatic bile duct stricture (n = 1), and subsegmental hepatic infarction (n = 1). No major complications were encountered CONCLUSION: Combined TACE of the right IPA and RFA can be a safe and effective treatment for small HCC near the diaphragm that is supplied by the right IPA.