Power Doppler ultrasonography for the assessment of vascular invasion by pancreatic cancer

Aim: To investigate the diagnostic accuracy of power Doppler ultrasonography (US) in assessing the vascular invasion by pancreatic cancer. Methods: A prospective study of 40 consecutive patients with pancreatic cancer (head 35, body 5) was performed. All patients underwent surgery. The relationships between tumor and each vessel were classified into four types according to the closest circumferential contact of the tumor with the vessel. A type 0 indicated no contact; type 1 indicated less than one third contact; type 2 indicated one third to 99% contact, and type 3 indicated encasement. Vascular invasion was diagnosed in types 2 and 3. The diagnostic accuracy was evaluated in the portal vein and in the splanchnic arteries (celiac artery, common hepatic artery, and superior mesenteric artery). The power Doppler US findings were confirmed by the operative findings. The results of power Doppler US were compared with those of CT scan and angiography. Results: Portal vein invasion was confirmed in resected specimens in 23 cases and by operative findings in 5 cases. For the diagnosis of portal vein invasion, sensitivity, specificity, and overall accuracy of power Doppler US were, respectively, 79.3, 90.9, and 82.5%. The respective values were 79.3, 100, and 85% for CT and 72.4, 81.8, and 75% for angiography. For the diagnosis of arterial invasion, sensitivity, specificity, and overall accuracy of power Doppler US were 80, 92, and 90%, respectively. The corresponding values were 47, 88, and 73% for CT and 47, 100, and 80% for angiography. Conclusion: Power Doppler US proved to be useful for the diagnosis of vascular invasion by pancreatic cancer.     

Multidetector CT Evaluation of the Course of Nonresectable Pancreatic Carcinomas with Neoadjuvant Therapy

Objective: A prospective study to determine the value of multidetector CT (MD-CT) in assessing the course of nonresectable pancreatic carcinoma during therapy. Material and Methods: 26 patients with nonresectable pancreatic carcinoma underwent MD-CT before and after therapy. The examinations were evaluated with regard to tumor size and vascular invasion using an invasion score (IS) by 2 radiologists independently (κ analysis). Diagnosis was confirmed surgically, by biopsy or clinical course. Results: Sensitivity for the assessment of irresectability was 100%. Following therapy, 54% of all the tumors were smaller (14/26), 42% had increased in volume (11/26), and one tumor remained stable (1/26). The IS (veins) during follow-up changed in 26 patients (portal vein: 5 higher (mean score 10.4/16.2), 4 lower (mean score 17.5/11.5); superior mesenteric vein: 12 higher (11/14.4), 5 lower (16.2/14.6); p = 0.026). The IS (arteries) changed in 13 patients (celiac trunk: 3 higher (3.3/10); hepatic artery: 4 higher (5.7/10.2), 3 lower (11.6/10.3); superior mesenteric artery: 2 higher (4.5/9.5), 1 lower (12/11)). The k values were calculated between 0.56 and 0.87. Conclusion: MD-CT is suitable for evaluating tumor spread during therapy for nonresectable pancreatic carcinoma. The IS is useful for assessing the degree of change in vessel invasion.     

Visualization of coronary artery anomalies by contrast-enhanced multi-detector row spiral computed tomography

BACKGROUND: We investigated the potential of 16-slice multi-detector row spiral CT (MDCT) with retrospective ECG-gating for evaluation of coronary artery anomalies. METHODS: A total of 35 patients (23 men, 12 women, 19-81 years) in whom anomalous coronary arteries had been detected by invasive coronary angiography underwent MDCT (Sensation 16, Siemens, Germany). During one breathhold, a contrast-enhanced (90 ml, 5 ml/s) volume data set of the heart was acquired (16x0.75mm collimation, gantry rotation 375 ms). Images were reconstructed with a slice thickness of 1.0 mm in 0.5-mm intervals using retrospective ECG-gated reconstruction. The 35 data sets and 80 data sets of patients with angiographically normal coronary anatomy were analysed in random order concerning the origin and course of the coronary arteries. The results were compared to invasive coronary angiography. RESULTS: All patients with coronary artery anomalies and all controls with normal coronary anatomy were identified by MDCT. In addition, the origins and course concerning their anatomical relationship to adjacent cardiac structures were visualized in all patients, including right-sided origin of the left main (n=10), left anterior descending coronary artery (n=4) or left circumflex coronary artery (n=10); left-sided origin of the right coronary artery (n=6); four coronary fistula to the pulmonary artery (two from the left anterior descending, one from the right coronary artery, one from the left main), and one fistula from the circumflex coronary artery to the left atrium CONCLUSIONS: The study demonstrates that MDCT is a reliable noninvasive technique to identify and define anomalous coronary arteries and their course.     

Pancreaticoduodenectomy with vascular reconstruction for adenocarcinoma of the pancreas with borderline resectability

AIM: To analyze whether pancreaticoduodenectomy with simultaneous resection of tumor-involved vessels is a safe approach with acceptable patient survival.METHODS: Between January 2001 and March 2012, 136 patients received pancreaticoduodenectomy for adenocarcinoma at our hospital. Seventy-eight patients diagnosed with pancreatic head carcinoma were included in this study. Among them, 46 patients received standard pancreaticoduodenectomy (group 1) and 32 patients received pancreaticoduodenectomy with simultaneous resection of the portal vein or the superior mesenteric vein or artery (group 2) followed by reconstruction. The immediate surgical outcomes and survivals were compared between the groups. Fifty-five patients with unresectable adenocarcinoma of the pancreas without liver metastasis who received only bypass operations (group 3) were selected for additional survival comparison.RESULTS: The median ages of patients were 67 years (range: 37-82 years) in group 1, and 63 years (range: 35-86 years) in group 2. All group 2 patients had resection of the portal vein or the superior mesenteric vein and three patients had resection of the superior mesenteric artery. The pancreatic fistula formation rate was 21.7% (10/46) in group 1 and 15.6% (5/32) in group 2 (P = 0.662). Two hospital deaths (4.3%) occurred in group 1 and one hospital death (3.1%) occurred in group 2 (P = 0.641). The one-year, three-year and five-year overall survival rates in group 1 were 71.1%, 23.6% and 13.5%, respectively. The corresponding rates in group 2 were 70.6%, 33.3% and 22.2% (P = 0.815). The one-year survival rate in group 3 was 13.8%. Pancreaticoduodenectomy with simultaneous vascular resection was safe for pancreatic head adenocarcinoma.CONCLUSION: The short-term and survival outcomes with simultaneous resection were not compromised when compared with that of standard pancreaticoduodenectomy.     

Pancreaticoduodenectomy preserving aberrant gastroduodenal artery utilized in a previous coronary artery bypass grafting: A case report and review of literature

Rationale:Pancreaticoduodenectomy (PD) is a technically demanding procedure with high rates of morbidity and mortality. Therefore, preoperative evaluation of anatomy is indispensable. Multi-detector row computed tomography (CT) enables us to precisely understand arterial anatomy. It is a well-known fact that anatomical variants are often present in the hepatic artery (HA) but rarely in the gastroduodenal artery (GDA). We present the case of a patient with ampullary cancer with a rare anatomical anomaly, “replaced GDA (rGDA) ” arising from the superior mesenteric artery, along with a history of coronary artery bypass grafting (CABG) using right gastroepiploic artery (RGEA).Patient concerns:A 69-year-old male patient was referred to our department for further investigation of elevated hepatobiliary enzymes. He presented with no symptoms besides intermittent fever of 38°C. He had an operative history of CABG using the RGEA.Diagnosis:Abdominal CT and esophagogastroduodenoscopy showed an ampullary tumor and biopsy specimen from the lesion revealed adenocarcinoma. CT angiography revealed the rGDA instead of a normal common HA.Intervention:We performed a safe PD, preserving the rGDA and the RGEA to maintain hepatic and cardiac perfusion.Outcomes:Owing to the presence of a refractory pancreatic fistula, the length-of-hospital stay was extended, and he was discharged on postoperative day 72 without vascular complications. At present, the patient is in good physical condition and does not present with cardiovascular complications as well as tumor recurrence at 6 months after surgery.Lessons:This is possibly the first case of a patient who underwent PD and has a proper HA following a GDA arising from a superior mesenteric artery (rGDA) and has a previous operative history of CABG using the gastroepiploic artery. The coexistence of the history of cardiovascular surgery made PD for this patient considerably more challenging.In the case of a rare anatomical anomaly, a coronary artery bypass via the RGEA should not be considered as an obstacle when R0 resection is achievable.     

Prevalence of coronary artery anomalies in 12,457 adult patients who underwent coronary angiography

Background

Coronary artery anomalies are found in 0.2% to 1.3% of patients undergoing coronary angiography and 0.3% of an autopsy series. We aimed to estimate the frequency of coronary artery anomalies in our patient population.

Methods

The data were collected retrospectively by analyzing the angiographic data of 12 457 consecutive adult patients undergoing coronary angiography between September 2002 and October 2007.

Results

Coronary artery anomalies were found in 112 patients (0.9% incidence), 100 patients (89.3%) had origin and distribution anomalies, and 12 patients (10.7%) had coronary artery fistulae. Their mean age was 52 ± 8 years (range, 22–79 y). Separate origins of left anterior descending and left circumflex coronary artery from the left sinus of Valsalva was the most common anomaly (63.4%). The right coronary artery rising from the left coronary sinus of Valsalva was found in 10 (8.9%) patients. Anomalous origin of the left circumflex coronary artery from the right sinus of Valsalva was seen in 10 (8.9%) patients. The left main coronary artery from the right coronary sinus of Valsalva was found in 1 (0.89%) patient while an isolated single coronary artery was seen in 2 (1.78%) patients.

Conclusion

The incidence and the pattern of coronary artery anomalies in our patient population were almost identical with previous studies. Cardiologists should be aware of the coronary anomalies which may be associated with potentially serious cardiac events, because recognition of these coronary anomalies is mandatory in order to prescribe appropriate therapy.     

Pancreaticoduodenectomy for advanced duodenal and ampullary adenomatosis in familial adenomatous polyposis

Background

Patients with familial adenomatous polyposis (FAP) develop duodenal and ampullary polyps that may progress to malignancy via the adenoma–carcinoma sequence.

Objective

The aim of this study was to review a large series of FAP patients undergoing pancreaticoduodenectomy for advanced duodenal and ampullary polyposis.

Methods

A retrospective case notes review of all FAP patients undergoing pancreaticoduodenectomy for advanced duodenal and ampullary adenomatosis was performed.

Results

Between October 1993 and January 2010, 38 FAP patients underwent pancreaticoduodenectomy for advanced duodenal and ampullary polyps. Complications occurred in 29 patients and perioperative mortality in two. Postoperative histology revealed five patients to have preoperatively undetected cancer (R = 0.518, P < 0.001).

Conclusions

Pancreaticoduodenectomy in FAP is associated with significant morbidity, but low mortality. All patients under consideration for operative intervention require careful preoperative counselling and optimization.     

Congenital coronary anomalies in adults: comparison of anatomic course visualization by catheter angiography and electron beam CT.

The objective of this study was to compare the anatomic course of anomalous coronary arteries by axial and three-dimensional volume-rendered electron beam computed tomography (EBCT) angiography and X-ray catheter angiography (CAG). We performed a blinded study where patients who previously underwent CAG with (n = 14) and without (n = 14; age- and gender-matched controls) anomalous coronary anatomy were studied with EBCT coronary angiography. Forty to 50 EKG-triggered 3 mm overlapping axial slices were acquired with 2 mm table movement within one breath hold during the i.v. injection of 140 cc of nonionic iodinated contrast (4 ml/sec). The axial source images and volume-rendered three-dimensional reconstructions were evaluated for the presence, type, and course of coronary anomalies and the results were compared to those of CAG. All normal and anomalous coronary arteries were identified by both modalities in all subjects. Identified anomalies include single coronary artery (n = 3), left-sided right coronary artery (n = 3), right-sided left main coronary artery (n = 3), anterior descending coronary artery (n = 2), circumflex coronary artery (n = 2), and separate left-sided ostia for left anterior descending and circumflex coronary arteries (n = 1). In five cases, there was discrepancy in the course of the anomalous vessels between the two modalities. Consensus reading among cardiologist and radiologists favored the interpretation of EBCT over catheter angiography. Noninvasive EBCT coronary angiography compares well with CAG in identifying anomalous coronary arteries and may provide confirmatory evaluation of their precise anatomic relationships to the heart and great vessels.     

The Histopathological Features and CT/MRI Imaging Performances in Hepatic Angiomyolipoma Patients

AimTo evaluate the diagnostic value of dynamic contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) in the differential diagnosis of hepatic angiomyolipoma (HAML) and hepatocellular carcinoma (HCC) and to clarify the relationship between histopathological features and CT or MRI imaging performances in HAML.Material and methodsSix HAML and 33 non-cirrhotic HCC patients confirmed by histopathology were retrospectively analyzed. The serum biomarkers, CT and MRI examinations were conventionally performed before the confirmatory histological diagnosis. The clinical data from their medical records was also analyzed.ResultsSix HAML patients were annotated as two types according to CT and MRI imaging characteristics, including hypovascular type (n = 1) and hypervascular type (n = 5). The imaging performances of the 33 HCC patients were hypervas-cular type. Moreover, all the 5 hypervascular type HAML patients were misdiagnosed as HCC by CT or MRI. We also found that the hypervascular type of HAML patients contained more vessels and less fatty tissues in histopathology than hypovascular type of HAML patients. However, the clinical features included HCC high risk factors (hepatitis B or C), non-specific symptoms, male and increased serum alpha fetoprotein (AFP) were more common in HCC patients than HAML patients (P < 0.05, respectively).ConclusionsThe CT or MRI imaging performances of HAML patients containing more vessels and less fatty tissues in histopathology resemble the imaging performance of HCC patients. These clinical features may be of great help in the differential diagnosis in the current clinical practices.     

Left-sided gallbladder： Its clinical significance and imaging presentations

AIM： To assess the importance of preoperative diagnosis and presentation of left-sided gallbladder using ultrasound （US）, CT and angiography.
METHODS： Retrospective review of 1482 patients who underwent enhanced CT scanning was performed. Left-sided gallbladder was diagnosed if a right-sided ligamentum teres was present. The image presentations on US, CT and angiography were also reviewed.
RESULTS： Left-sided gallbladder was diagnosed in nine patients. The associated abnormalities on CT imaging included portal vein anomalies, absence of umbilical portion of the portal vein in the left lobe of the liver, club-shaped portal vein in the right lobe of the liver, and difficulty in identifying segment Ⅳ. Angiography in six of nine patients demonstrated abnormal portal venous system （trifurcation type in four of six patients）. The main hepatic arteries followed the portal veins in all six patients. The segment Ⅳ artery was identified in four of six patients using angiography, although segment Ⅳ was difficult to define on CT imaging. Hepatectomy was performed in three patients with concomitant liver tumor and the diagnosis of left-sided gallbladder was confirmed intraoperatively.
CONCLUSION： Left-sided gallbladder is an important clinical entity in hepatectomy due to its associated portal venous and biliary anomalies. It should be considered in US, CT and angiography images that demonstrate no definite segment Ⅳ ,absence of umbilical portion of the portal vein in the left lobe, and club-shaped right anterior portal vein.     

A patient undergoing pancreaticoduodenectomy in whom involved common hepatic artery anomalously arising from the superior mesenteric artery was removed and reconstructed

Identifying anatomical variations of the celio-mesenteric arterial branches is important when performing pancreaticoduodenectomy. A relatively rare variation is the common hepatic artery entirely originated as a branch of the superior mesenteric artery. This type of variation is termed hepatomesenteric trunk type common hepatic artery, in which an accessory left hepatic artery arising from the celiac trunk is absent. Preservation of hepatomesenteric trunk type common hepatic artery is indispensable during pancreaticoduodenectomy because fatal hepatic injury or leak of hepaticojejunostomy can occur. The present case report shows a patient with pancreatic head tumor in whom hepatomesenteric trunk type common hepatic artery was involved by the tumor. The patient underwent pancreaticoduodenectomy during which the involved hepatomesenteric type common hepatic artery was removed and reconstructed using saphenous venous grafts. Histopathological examination showed double cancers which were composed of an advanced ductal adenocarcinoma of the pancreas and early bile duct adenocarcinoma. The patient is alive 18 months after the surgery without recurrence.     

应用CTA技术和超声评估肝移植术患者术前肝脏血供状态研究*

目的 研究计算机断层扫描血管成像(CTA)和超声检测评估肝移植术患者术前肝脏血管解剖变异和管腔通畅性。方法 2014年5月～2020年5月我院收治的接受肝移植手术患者138例,术前均行腹部三期CT增强扫描、CTA后处理[包括容积再现(VR)和最大密度投影(MIP)等重建和超声检查。分析肝动脉、门静脉、肝静脉和下腔静脉及其侧支循环情况。结果 138例患者中,CTA显示107例(77.5%)肝动脉解剖起源和走行正常(Michels aⅠ型),31例(22.5%)存在肝动脉解剖变异,肝动脉管腔未出现狭窄和异常扩张情况,1例(0.7%)合并脾动脉瘤;136例患者术中肝动脉解剖与术前CTA评估一致;CTA诊断血栓和瘤栓的灵敏度和准确度分别为83.3%和68.6%,而超声检查诊断为58.3%(P<0.05)和60.0%;超声和CTA诊断肝静脉和下腔静脉通畅性的准确率均为99.3%。结论 相对于超声检查,CTA检查可准确评估肝移植术前肝动脉解剖变异情况,对门静脉栓子定性诊断的准确性也较高,且可清晰显示门静脉侧支循环开放情况。     

Severe exercise-induced ischemia does not identify high risk patients with normal left ventricular function and one- or two-vessel coronary artery disease

Objectives. This study was conducted to determine whether severe exercise-induced ischemia identifies high risk patients with a normal left ventricular ejection fraction and one- or two-vessel coronary artery disease.Background. Severe ischemia during exercise radionuclide angiography has been shown to identify high risk patients among certain other patient subsets.Methods. Four hundred twenty patients with left ventricular ejection fraction ≥50% and one- or two-vessel disease underwent exercise radionuclide angiography within 3 months of coronary angiography. Patients were treated initially with revascularization (n = 140) or medical therapy (n = 280) at the discretion of their physicians. Patients treated with revascularization were more likely to have angina by history, a positive exercise electrocardiogram, a lower exercise ejection fraction, two-vessel disease and proximal left anterior descending coronary artery disease. Two hundred sixty-four of the 280 patients given medical therapy who had complete follow-up data formed the study group. Outcome was compared between patients with (n = 56) and without (n = 208) severe exercise-induced ischemia, defined by previously published criteria (work load ≤600 kg-m/min, ST segment depression ≥1 mm and decrease in ejection fraction with exercise).Results. During follow-up, there were 30 initial cardiac events (12 cardiac deaths and 18 nonfatal myocardial infarctions). There was no difference in the 5-year event-free survival rate: 91% in patients with and 87% in patients without severe ischemia (p = 0.89). There was no association between event-free survival and severe ischemia (χ²= 1.41, p = 0.24). The study had approximately 80% power at α = 0.05 to detect a 25% decrease in event-free survival in the group with severe ischemia. In addition, there was no association between severe ischemia and outcome if late revascularization was included as an event or if the total mortality rate (overall survival) was analyzed.Conclusions. Severe exercise-induced ischemia fails to identify a high risk subgroup among patients with normal left ventricular function and one- or two-vessel disease who are treated initially with medical therapy.     

先天性单侧肺动脉缺如25例影像学诊断

目的:评价先天性一侧肺动脉缺如(UAPA)多排螺旋CTA的影像学诊断价值。方法:回顾分析25例我院明确诊断为先天性一侧肺动脉缺如的胸X线片、经胸超声心动图检查、胸部多排螺旋CTA及心血管造影表现。结果:15(15/25)例为右肺动脉缺如,10(10/25)例为左肺动脉缺如。单发UAPA 4例,均为右肺动脉缺如。UAPA合并其他心血管畸形21例,其中合并简单心血管畸形9例,合并复杂畸形12例,简单畸形中包括动脉导管未闭、房间隔缺损、室间隔缺损等,复杂畸形中包括肺动脉闭锁、法洛四联症各4例,肺动脉狭窄3例,另有大动脉转位等。9例经外科手术证实,12例经心血管造影证实。结论:对于一侧肺动脉缺如的诊断,多排螺旋CTA检查作为一种无创的检查方法与心血管造影同样具有明确诊断价值,CTA所显示的客观的解剖结构,为治疗方案的选择提供依据。     

Prevalence and spectrum of coronary artery anomalies in 8021 patients: A single center study in South India

ObjectiveTo identify the prevalence of coronary artery anomalies (CAAs) and their subtypes based on Angelini et al. classification in symptomatic yet stable population of South India using 64- slice dual source multi detector CT coronary angiography (MDCT-CA).MethodsWe retrospectively reviewed reports of 8021 symptomatic patients predominantly South Indians who were referred for CT coronary angiography (CT-CA) to our tertiary cardiac care center in Hyderabad, India from January 2011 to March 2017.ResultsWe identified a total of 838 coronary artery anomalies in 812 patients with a prevalence of 10.09%. 96.9% of patients were older than 30 years of age with a M:F ratio of 1.39:1. Coronary artery disease (CAD) was seen in 61.5% of these patients. Among these anomalies, myocardial bridging (MB) was the most common anomaly followed by anomalous location of coronary ostium at improper sinus (ACOIS).ConclusionThere is no significant difference in prevalence of CAAs (including and excluding MB) in Indian and World population. CAAs were more common in males than females and most of these patients remain asymptomatic during first three decades of their life. Myocardial bridging is the most common anomaly detected by MDCT-CA followed by ACOIS. Right coronary artery (RCA) arising from left coronary sinus (LCS) is the most commonly encountered ACOIS.     

CT血管成像诊断颅内动脉成窗变异与血管异常

目的探讨CT血管成像(CTA)诊断颅内动脉成窗变异及合并其他血管异常。方法回顾性分析2013年1月—2014年1月中山大学附属中山医院653例经头部CTA检查,并诊断为颅内动脉成窗的39例患者的影像资料,分析颅内动脉成窗的发生率、部位、形态及其他血管异常。结果 (1)653例患者共检出39例(5.97%)41个成窗动脉,其中基底动脉成窗检出率3.37%(22个),椎动脉成窗检出率0.31%(2个),大脑前动脉成窗检出率1.22%(8个),前交通动脉成窗检出率0.61%(4个),大脑中动脉成窗检出率0.76%(5个)。后循环成窗以凸透镜型为主(66.67%,16/24),前循环成窗以裂隙型为主(76.47%,13/17),差异有统计学意义(χ2=7.411,P0.05)。(2)39例中22例成窗患者合并其他血管异常,以单侧或双侧胚胎型大脑后动脉最多(10例),其次为颅内动脉瘤(5例)。5例动脉瘤部位均远离成窗部位,位于颈内动脉交通段3例、基底动脉顶端1例、双侧大脑中动脉M2段1例。结论 CTA可以直观、清晰地显示颅内动脉成窗及合并其他血管异常,但血管成窗与血管异常之间无显著相关性。     

Contrast enhanced electron beam computed tomography to analyse the coronary arteries in patients after acute myocardial infarction

OBJECTIVE—To evaluate the accuracy of contrast enhanced electron beam computed tomography (EBCT) after acute myocardial infarction in determining patency of the infarct related artery and detecting high grade stenoses and occlusions in the coronary vessels.
DESIGN—Case study using blinded comparison with invasive coronary angiography.
PATIENTS—36 patients (mean age 53 years) 4-70 days after acute myocardial infarction.
INTERVENTIONS—The patients were studied by EBCT and invasive coronary angiography. For EBCT, 50 axial images of the heart (3 mm slice thickness) were acquired. They were triggered by the ECG during breath holding, after intravenous injection of contrast agent. The original images, surface reconstructions, and maximum intensity projections were evaluated for the presence of high grade stenoses and occlusions of the coronary arteries.
MAIN OUTCOME MEASURES—EBCT results were compared with invasive coronary angiography.
RESULTS—Of a total of 144 coronary arteries (left main, left anterior descending, left circumflex, and right coronary artery in 36 patients), 29 (20%) were unevaluable by EBCT. In the remaining arteries, 33 of 36 high grade lesions were correctly detected (92% sensitivity). Specificity was also 92% (73/79). Patency of the infarct related artery was correctly detected in 15 of 16 cases (94%). Five of the 14 occluded infarct related arteries (35%) were mistaken as stenotic but patent, and six could not be assessed.
CONCLUSIONS—EBCT is very accurate in detecting significant coronary artery lesions in patients after acute myocardial infarction, but differentiation between occluded and patent infarct related arteries is currently unreliable.


Keywords: electron beam CT; coronary angiography; myocardial infarction; computed tomography     

Gastroduodenal artery used for arterial reconstruction during the Whipple operation

The right hepatic artery and the common hepatic artery originate from the superior mesenteric artery in approximately 10-15% of the population. Reconstruction of the hepatic artery using the gastroduodenal artery has previously been described to repair hepatic artery injury during the performance of biliary and pancreatic resections. We report the utilization of this technique in patients undergoing pancreaticoduodenectomy for a periampullary neoplasm involving a replaced right hepatic artery.     

A liver donor with double hepatic artery aneurysm: a saved graft

The shortage of organs and the increasing median age of deceased donors for orthotopic liver transplantation stimulate transplant centres to accept grafts that otherwise would have been discarded due to severe vascular abnormalities. We encountered a donor with two arterial aneurysms and a left accessory hepatic artery: an arterial aneurysm of the common hepatic artery and a left accessory hepatic artery arising from a second aneurysm of the left gastric artery(Michels type V). A complex reconstruction was created to transplant the liver. Multiple arterial anastomosis was made and the hepatic inflow of the transplanted liver restored. Although the procedure increased the risk of hepatic artery thrombosis, one more organ supposed to be discarded was saved.     

Study on hepatocellular carcinoma-associated hepatic arteriovenous shunt using multidetector CT

AIM: To investigate multidetector CT (MDCT) findings of hepatocelluar carcinoma (HCC)- associated hepatic arteriovenous shunt (HAVS) and to evaluate their clinical significance. METHODS: Thin-slice and dynamic enhancement MDCT of HAVS was performed on 56 patients with HCC. MDCT findings, including those of portal veins, hepatic veins, superior mesenteric veins, splenic veins, HCC foci, liver parenchyma without HCC foci, spleens, and thromboses in portal veins and hepatic veins, were all confirmed by digital subtract angiography and analyzed. RESULTS: MDCT demonstrated earlier enhancement of main portal trunks and/or the first order branches than that of superior mesenteric veins or splenic veins (n=31). One patient had strong early enhancement of left hepatic vein with thromboses in left hepatic vein and upper part of inferior vena cava and 1 patient had transient patchy enhancement peripheral to HCC foci in late hepatic arterial phase among them. It demonstrated stronger opacification of main portal trunks and/or the first order branches than that of superior mesenteric veins or splenic veins (n=18), and earlier enhancement of the second order and smaller branches of portal veins than that of main portal trunks (n=4), stronger opacification of the second order and smaller branches of portal veins than that of main portal trunks (n=3), with transient patchy enhancement (n=3) or wedge-shaped enhancement (n=4) peripheral to HCC foci in late hepatic arterial phase. Enhancement degree of HCC foci was all decreased. As for 49 patients with severe or moderate shunts, enhancement degree of liver parenchyma without HCC foci was increased with heterogeneous density, but enhancement degree of spleens was decreased. There were thromboses in main portal trunks and/or the first order branches in 32 patients. CONCLUSION: The main MDCT findings of HCC-associated HAVS are earlier enhancement and stronger opacification of portal veins and/or hepatic veins. Understanding of these findings will contribute to the diagnosis and prognosis of the disease and improve therapy for the patients.