Hepatic falciform artery. Angiographic findings in 25 patients

Purpose: To determine the frequency of hepatic falciform artery (HFA) occurrence on celiac or hepatic angiograms and elucidate the anatomy and clinical importance.Material and Methods: Among 1,250 patients who underwent celiac or hepatic arteriography, we encountered 25 patients (2%) with a HFA. Prospectively, CT hepatic falciform arteriography (CTHA) was performed in 4 patients. Indigocarmine dye was injected into the HFA in 6 patients to evaluate whether the abdominal skin was stained. Embolization of the HFA before chemoembolization for hepatocellular carcinoma was performed in 4 patients to prevent abdominal wall injury.Results: Among 25 patients, the HFA arose as a terminal branch of the middle hepatic artery in 14 patients (56%) and of the left hepatic artery in 11 patients (44%). The vessel was single in 18 patients (72%) and double in 7 patients (28%). Two vessels ran side by side along the hepatic falciform ligament. On CTHA, the HFA ran within the hepatic falciform ligament and the branches were connected with the liver around the hepatic falciform ligament. After indigocarmine dye injection, the stain of abdominal skin was recognized in all 6 patients. No abdominal wall injury occurred in any of the 4 patients who were subjected to hepatic chemoembolization.Conclusion: HFA is an extrahepatic pathway which runs to the abdominal wall. Before chemoembolization of the middle or left hepatic artery for hepatic malignancy, the HFA should be recognized.     

Chemoembolization for Hepatocellular Carcinoma Supplied Exclusively by the Hepatic Falciform Artery

Purpose

The purpose of this study was to describe imaging appearances of hepatocellular carcinoma (HCC) supplied exclusively by the hepatic falciform artery (HFA) and safety of chemoembolization via the HFA.

Methods

During the past 6?years, we have performed chemoembolization for the treatment of 12 patients with HCCs supplied exclusively by the HFA. Computed tomography (CT) scans, digital subtraction angiograms, and medical records were retrospectively reviewed by consensus.

Results

Tumors were located in Couinaud segments IV (n?=?7) and III (n?=?5) and in subcapsular areas around the falciform ligaments. Tumor size ranged from 1.0 to 1.8?cm (mean, 1.3?cm; median, 1.3?cm). HFAs originated from A4 (n?=?7), A3 (n?=?4), and the left hepatic artery near the umbilical point (n?=?1). All tumors were supplied exclusively by the HFA. Prophylactic embolization of the distal HFA before chemoembolization was performed using gelatin sponge particles in only one patient, and selective chemoembolization via the HFA was achieved in all patients. One patient suffered from a skin rash after chemoembolization and recovered after conservative management. Individual responses of tumors supplied exclusively by the HFA were complete response (n?=?8), partial response (n?=?1), and stable disease (n?=?2) at the first follow-up enhanced CT scan.

Conclusions

The HFA can supply HCC located in subcapsular areas around the falciform ligament, and the tumors can be safely chemoembolized without significant complications.     

Extrahepatic Blood Supply to Hepatocellular Carcinoma: Angiographic Demonstration and Transcatheter Arterial Chemoembolization

Purpose To evaluate the incidence of each extrahepatic collateral pathway to hepatocellular carcinoma (HCC) and to assess technical success rates and complications of transcatheter arterial chemoembolization (TACE) through each collateral. Methods We retrospective evaluated extrahepatic collateral pathways to HCC on angiography in 386 procedures on 181 consecutive patients. One hundred and seventy patients had previously undergone TACE. TACE through extrahepatic collaterals using iodized oil and gelatin sponge particles was performed when a catheter was advanced into the tumor-feeding branch to avoid nontarget embolization. Results A single collateral was revealed in 275 TACE procedures, two were revealed in 74, and three or more were revealed in 34. Incidences of collateral source to HCC were 83% from the right inferior phrenic artery (IPA), 24% from the cystic artery, 13% from the omental artery, 12% from the right renal capsular artery (RCA) and left IPA, 8% from the right internal mammary artery (IMA) and right intercostal artery (ICA), and 7% from the right inferior adrenal artery (IAA). Technical success rates of TACE were 53% in the right ICA, 70% in the cystic artery, 74% in the omental artery, 93% in the left IPA, 96% in the right IPA, and 100% in the right RCA, right IMA, and right IAA. Complications included skin necrosis after TACE through the right IMA (n = 1), cholecystitis after TACE through the cystic artery (n = 1), and ulcer formation after TACE through the right gastric artery (n = 1), in addition to pleural effusion and basal atelectasis after TACE through the IPA and IMA. Conclusion Our study suggests that TACE through extrahepatic collaterals is possible with high success rates, and is also relatively safe.     

Reexamination of hepatic falciform artery: angiographic study]

Supraumbilical skin complication during hepatic artery infusion chemotherapy or transcatheter arterial chemoembolization (TACE) for liver tumor has been reported by some authors. This complication is thought to be caused by the flow of chemotherapeutic, agent and embolus into the hepatic falciform artery (HFA). It is important for angiographers to be aware of the presence of HFA to prevent possible supraumbilical skin complication. The rate of visualization of the HFA on angiography has been considered to be only about 2%. In a retrospective study of celiac angiograms performed in 200 patients, we found an incidence of 32/200 (16%). The proximal side of this artery may be tortuous. In all cases, the flow of the HFA is slower than that of the hepatic artery. The paraumbilical vein was visualized with the HFA in 18 cases. Chemotherapy or transcatheter arterial chemoembolization was performed in 10 patients, and there was no postprocedure supraumbilical skin complication.     

Reactivation of tuberculosis in hepatocellular carcinoma treated with transcatheter arterial chemoembolization: A report of 3 cases

Pulmonary tuberculosis is an opportunistic infection that can be reactivated in immunocompromised conditions, for example, in malignancy or after liver transplantation. Hepatocellular carcinoma (HCC) has a high mortality rate because it is frequently diagnosed at an advanced stage. Although surgical resection is the established curative measure for HCC, it is only feasible for earlystage HCC. Transcatheter arterial chemoembolization (TACE) is the most common treatment modality for patients with unresectable HCC. However, repeated TACE sessions and, occasionally, the tumor itself can further impair the reserve hepatic function and immunity. We report 3 recent cases of HCC with reactivation of pulmonary tuberculosis after TACE.     

Transcatheter hepatic segmental arterial embolization using lipiodol mixed with an anticancer drug and gelfoam particles for hepatocellular carcinoma

Transcatheter hepatic segmental arterial chemoembolization using Lipiodol mixed with an anticancer drug followed by the injection of Gelfoam particles, introduced into the tumor-bearing hepatic segment as the target area (segemental Lipiodol-TAE), was carried out in 54 patients with hepatocellular carcinoma (HCC), 7 of whom were later resected. In 5 of the resected 7 cases, complete necrosis was histologically verified. No death due to HCC was encountered in 47 nonoperated cases, and better therapeutic results were obtained with segmental Lipiodol-TAE. It was concluded that this technique does not adversely affect normal tissues, and it does reinforece the effect of TAE.     

原发性肝癌TACE前后血清VEGF与CT灌注参数间相关性的研究

目的 探讨原发性肝癌(HCC)患者TACE前后血清血管内皮生长因子(VEGF)水平和CT灌注参数之间的关系. 资料与方法 对17例HCC患者于TACE术前1天及术后7～10天测量血清VEGF水平,同时行CT灌注扫描,计算肝血流量(HBF)、肝动脉灌注分数(HAF),肝动脉灌注量(HAP)、门静脉灌注量(PVP). 结果 原发性肝癌TACE前后HBF、HAP差异有统计学意义,血清VEGF与HBF、HAF、HAP呈正相关. 结论 血清VEGF水平及CT灌注可帮助评价肝癌TACE疗效.     

微导管在肝癌介入治疗上的应用

目的探讨微导管在肝癌化疗性栓塞中的作用。方法将4F～5FYashiro、Kouno亲水超滑导管、5F牧羊钩导管作为导引导管插入肝总或肝固有动脉及肠系膜上动脉,3F微导管经导引导管置入肝段或肿瘤滋养动脉施行肝癌化疗性栓塞术。结果本组35例共行化疗性栓塞50例次,其中16例小肝癌行肝段栓塞,19例非小肝癌但癌灶尚局限者行左/右叶或右叶前、后叶栓塞。随访1～2年生存期分别为100％、87.5％及52.6％、42.1％。术后肝功能损害轻微,无并发症。结论在小肝癌、非小肝癌但癌灶尚局限者或伴有肝动脉异常迂曲、损伤后狭窄、发育变异的情况下,使用微导管提高栓塞精度对改善疗效和避免并发症具有十分重要的临床应用价值。     

Variations in feeding arteries of hepatocellular carcinoma located in the left hepatic lobe

The left hepatic lobe is divided into three subsegments according to anatomical landmarks; however, there are several variations in the vascular territories of the left hepatic arterial branches. Hepatocellular carcinoma (HCC) located near the umbilical fissure or at the left side of the umbilical portion of the left portal vein has frequent crossover blood supply. HCC located in the caudal aspect of the lateral segment has a variety of feeding arteries, and is infrequently supplied by the caudate artery or the medial subsegmental artery (A4), and by the lateral left hepatic arteries. HCC located in the posterior aspect of segment 4 is frequently supplied by the caudate artery or a small A4 branch arising from the caudate artery. In addition, the left inferior phrenic, right and left internal mammary, right and left gastric, cystic, and omental arteries are well known extrahepatic collateral pathways supplying HCC in the left hepatic lobe, especially when the hepatic artery is attenuated by previous transcatheter arterial chemoembolization (TACE). Interventional radiologists should have sufficient knowledge of vascular territories in the left hepatic arterial branches and extrahepatic collaterals to perform effective TACE for HCC located in the left hepatic lobe.     

原发性肝癌的肝外动脉供血来源类型和形成因素

目的分析手术不能切除的肝细胞肝癌(HCC),化疗栓塞前后形成肝外侧支动脉(ECAs)的来源类型和形成因素。方法回顾性分析35例患者,手术不能切除的肝癌,形成39支肝外侧支动脉供血,接受化疗栓塞术前后的病史、肝脏的电子机算机断层扫描片(CT)和肝脏血管数字减影片(DSA),研究HCC的ECAs来源类型与肝癌在肝内的部位、肝癌的大小和接受化疗栓塞的次数之间的关系。结果ECAs来源类型分别源于胸廓内动脉(5.1％)、右肋间动脉(7．7％)、胃左动脉(12．8％)、右膈下动脉(38．5％)、大网膜动脉(2．6％)、右肾上腺或肾包膜动脉(10．3％)。形成ECAs的影响因素较多,包括化疗栓塞的次数、肿瘤在肝内的部位、肿瘤的直径和化疗栓塞方式。绝大多数ECAs形成于多次化疗性栓塞后：化疗栓塞3～4次后,容易出现肝外动脉供血(17．9％);5～6次后,出现的概率显著增加(56.4％)。肿瘤位于肝脏表浅部位容易形成ECAs(71．8%),常为肝脏相邻部位：前、后及右腹壁、右膈顶和右肾。肿瘤的直径在5～10cm时(76．9％)。结论ECAs来源类型与肝癌的肝内部位有密切关系。ECAs的形成与肿瘤的多次化疗栓塞、肿瘤的大小和肿瘤在肝内的部位有显著关系。     

Hepatocellular carcinoma in the caudate lobe of the liver: variations of its feeding branches on arteriography

There are usually multiple caudate arteries arising from the right, left, and middle hepatic arteries, and they are frequently connected to each other. Therefore, hepatocellular carcinoma (HCC) in the caudate lobe is frequently fed by multiple branches arising from different origins. HCC located in the Spiegel lobe is usually fed by the caudate arteries derived from the right and/or left hepatic artery. HCC in the paracaval portion is mainly fed by the caudate artery derived from the right hepatic artery; with low frequency, it is fed by the caudate artery derived from the left hepatic artery. HCC in the caudate process is usually fed by the caudate artery derived from the right hepatic artery. Because of the complexity and overlap of vascular territories, the tumor-feeding branch of a recurrent HCC lesion in the caudate lobe frequently changes on follow-up arteriograms. In addition, several extrahepatic collateral vessels supply the recurrent tumor. To perform effective transcatheter arterial chemoembolization (TACE) for HCC in the caudate lobe, radiologists should have sufficient knowledge of vascular anatomy supplying HCC in the caudate lobe.     

MRI与SCT在原发性肝癌经TACE治疗后随访的对比研究

目的 对比分析MRI与螺旋CT(SCT)在原发性肝癌经肝动脉栓塞化疗(TACE)后随访中的应用价值. 资料与方法 经TACE治疗的原发性肝癌患者31例,分别于治疗前1周及治疗后3个月行MRI及SCT检查,MRI包括平扫和动态增强扫描;SCT检查包括平扫和增强后三期扫描.并于MRI与SCT检查后1周内行DSA.以DSA结果 为金标准,比较MRI和SCT对于TACE后肿瘤的残留与复发显示情况. 结果 DSA检查发现30例39个瘤灶残留,7例新发病灶,其中2例单发,5例多发,共13个新发病灶.残留灶与新发灶均表现为局部异常肿瘤血管和肿瘤染色.MRI共显示29例36个残留灶,6例共12个新发病灶;敏感性为92%,特异性为100%.SCT显示共有23例28个残留病灶,显示6例共12个新发病灶;敏感性为72%,特异性为100%.MRI对于肿瘤残留灶的检出率、敏感性高于SCT(P＜0.05),对于新发病灶两者差异无统计学意义(P＞0.05). 结论 与SCT比较,MRI能排除碘油沉积的影响,更加敏感地检测出肿瘤的残留、复发及新发病灶,而且更能反映肿瘤TACE治疗后的病理改变.     

Three-Dimensional Quantitative Color-Coding Analysis of Hepatic Arterial Flow Change during Chemoembolization of Hepatocellular Carcinoma

Purpose

To evaluate feasibility of using three-dimensional (3D) quantitative color-coding analysis (QCA) to quantify substasis endpoints after transcatheter arterial chemoembolization of hepatocellular carcinoma (HCC).

肝动脉化疗栓塞的临床应用与进展

肝动脉化疗栓塞（TACE）是医学史上第一次通过破坏滋养血管以治疗恶性肿瘤的技术,在肝癌治疗中发挥举足轻重的作用,也是介入科的重要工作。40年来,TACE逐渐标准化、精细化、规范化,本文就TACE的临床应用和最新进展进行综述。     

Solitary hepatocellular carcinoma fed by the cystic artery: Limitation of transcatheter arterial embolization

Purpose: To clarify the limitations of transcatheter treatment for hepatocellular carcinoma (HCC) with parasitic feeders from the cystic artery. Methods: Three male patients had a solitary HCC (average diameter 3 cm) fed by the cystic artery among 221 patients with HCC from 1994 to 1997. One tumor was nourished entirely from the cystic artery arising from the medial branch of the left hepatic artery, and two tumors were fed partially by the cystic arteries arising from the anterior inferior branch of the right hepatic artery. We analyzed the indications for transcatheter treatment for these three patients. Results: We chose not to embolize the cystic artery for fear of necrosis of the gallbladder. Although embolization of the anterior branch of the right hepatic artery was performed in one patient with a tumor fed partially by the cystic artery, only half the tumor was embolized. Two patients underwent hepatic resection, and one received percutaneous ethanol injection therapy. At follow-up of 28–40 months (average 33 months) all patients are alive. Conclusion: Feeding by the cystic artery represents a limitation of TAE for HCC.     

320排 CT 及血管成像在肝癌诊断及介入治疗中的优势

目的：探讨320排 CT 在肝癌(HCC)诊断中应用价值及血管成像对介入治疗的指导价值。方法回顾性选取41例行肝动脉栓塞化疗(TACE)HCC 患者,治疗前均行320排 CT 三期扫描及血管重建,观察腹主动脉及其主要分支的起源、走行,肿瘤供血动脉、门静脉癌栓与数字减影血管造影(DSA)图像进行对比分析。结果320排 CT 对于发现直径<3 cm 的小肝癌具有优势,对于肝动脉变异、肿瘤供血动脉、门静脉癌栓的显示与 DSA 一致。结论320排 CT 及血管成像可以准确诊断、评价 HCC 并供血动脉、门静脉癌栓,对介入治疗具有重要的指导意义。     

Transcatheter arterial chemoembolization in patients with hepatocellular carcinoma and coexisting hepatic cavernous hemangioma

We investigated the consequence of repeated transcatheter arterial chemoembolization (TACE) for coexisting small hepatic hemangioma in the treatment of patients with hepatocellular carcinomas and describe the imaging features of embolized hemangioma on the follow-up Lipiodol CT and MR. Six of 431 patients with biopsy-confirmed hepatocellular carcinomas, who underwent TACE, also had seven small hepatic cavernous hemangiomas (0.8∼2.3 cm) in the same area of embolization. All six patients underwent repeated TACE All lesions were evaluated with CT and/or MR for the post-treatment follow-up. The outcomes and imaging features of these embolized hemangiomas were reviewed for the change of tumor size, Lipiodol deposition, enhancing pattern as well as embolization complications. Six of the seven hemangiomas did not depict changes in the size or enhancement pattern without being ablated. One hemangioma showed a decrease in size, but still persisted after TACE. All of the hemangiomas showed Lipiodol deposition for 2∼15 months, in which five hemangiomas depicted irregular rim patterns. There is no complication caused by the procedures. The differentiation of small hepatic hemangiomas from viable HCC is important in the post-TACE follow-up to avoid unnecessary repeated embolization.     

Safety of Chemotherapeutic Infusion or Chemoembolization for Hepatocellular Carcinoma Supplied Exclusively by the Cystic Artery

Purpose

This study was designed to evaluate the safety of chemotherapeutic infusion or chemoembolization by way of the cystic artery in patients with hepatocellular carcinoma (HCC) supplied exclusively by the cystic artery.

Methods

Between Jan 2002 and Dec 2011, we performed chemotherapeutic infusion or chemoembolization using iodized oil for the treatment of 27 patients with HCC supplied exclusively by the cystic artery. Computed tomography (CT) scans, digital subtraction angiograms, and medical records were retrospectively reviewed by consensus.

Results

The cystic artery originated from the main right hepatic artery in 24 (89 %) patients, from the right anterior hepatic artery in 2 (7 %) patients, and from the left hepatic artery in 1 (4 %) patient. Selective catheterization of the cystic artery was achieved in all patients. Superselection of tumor-feeding vessels from the cystic artery was achieved in 7 patients (26 %). Chemotherapeutic infusion was performed in 18 patients (67 %), and chemoembolization was performed in 9 patients (33 %). There were no major complications and only 2 minor complications, including vasovagal syncope and nausea with vomiting. Individual tumor response supplied exclusively by the cystic artery at the follow-up enhanced CT scan were complete response (n = 16), partial response (n = 3), and stable disease (n = 8).

Conclusion

HCC supplied exclusively by the cystic artery can be safely treated without severe complications by chemotherapeutic infusion or chemoembolization using iodized oil through the cystic artery.     

肝动脉化疗栓塞术后胆囊炎

目的：探讨肝动脉化疗栓塞（TACE）术后并发胆囊炎的影像特点、临床表现及病因。资料与方法：回顾性分析TACE术后并发胆囊炎患者的临床及影像资料，其中原发性和继发性肝癌138例，肝血管瘤4例，观察其胆囊动脉及胆囊血管造影表现；胆囊炎症状和体征；白细胞计数及分类；B超和／或CT胆囊形态变化。对于确诊为胆囊炎的患者，分析其所应用的化疗方案。结果：17例患者（肝癌14例，血管瘤3例）TACE后并发胆囊炎（12％），其中术后即刻血管造影示胆囊动脉和／或其分支闭塞，胆囊染色11例，发热17例，右季肋部疼痛17例，10例伴右肩部放射，Murphy征阳性17例。17例白细胞总数及中性粒细胞百分比均有明显增加。术后腹部B超（12例）、CT（5例）示胆囊壁增厚、水肿，胆囊窝渗出。14例TACE后并发胆囊炎的肝癌患者化疗方案为：BLM5例，DDP（或CP）4例，BLM＋DDP或CP2例，EADM3例；3例肝血管瘤患者仅用BLM。结论：TACE后胆囊炎的发生与胆囊动脉的解剖、导管尖端的位置、栓塞剂、化疗药等多种因素有关，应综合临床、影像、实验室检查等资料作出诊断，及时治疗，避免胆囊穿孔等严重并发症的发生。     

Usefulness of Cone-Beam Computed Tomography During Ultraselective Transcatheter Arterial Chemoembolization for Small Hepatocellular Carcinomas that Cannot be Demonstrated on Angiography

This study evaluated the usefulness of cone-beam computed tomography (CBCT) during ultraselective transcatheter arterial chemoembolization (TACE) for hepatocellular carcinomas (HCC) that could not be demonstrated on angiography. Twenty-eight patients with 33 angiographically occult tumors (mean diameter 1.3 ± 0.3 cm) were enrolled in the study. The ability of CBCT during arterial portography (CBCTAP), during hepatic arteriography (CBCTHA), and after iodized oil injection (LipCBCT) to detect HCC lesions was retrospectively analyzed. The technical success of TACE was divided into three grades: complete (the embolized area included the entire tumor with at least a 5-mm wide margin), adequate (the embolized area included the entire tumor but without a 5-mm wide margin in parts), and incomplete (the embolized area did not include the entire tumor) according to computed axial tomographic (CAT) images obtained 1 week after TACE. Local tumor progression was also evaluated. CBCTAP, CBCTHA, and LipCBCT detected HCC lesions in 93.9% (31 of 33), 96.7% (29 of 30), and 100% (29 of 29) of patients, respectively. A single branch was embolized in 28 tumors, and 2 branches were embolized in five tumors. Twenty-seven tumors (81.8%) were classed as complete, and 6 (18.2%) were classed as adequate. None of the tumors were classed as incomplete. Twenty-five tumors (75.8%) had not recurred during 12.0 ± 6.2 months. Eight tumors (24.2%), 5 (18.5%) of 27 complete success and 3 (50%) of 6 adequate success, recurred during 10.1 ± 6.2 months. CBCT during TACE is useful in detecting and treating small HCC lesions that cannot not be demonstrated on angiography.