Are the hepatic arteries "end arteries"?

Twenty-five autopsy livers were studied for intrahepatic arterial anastomoses. Under fluoroscopy, barium suspension at various concentrations, with or without latex, was injected into the hepatic artery. One-centimeter axial or coronal liver sections were radiographed with high-resolution mammographic technique. All films were reviewed. Seven interconnecting arterial pathways were demonstrated: subcapsular and peripheral arcades, proximal and intermediate connecting vessels, periportal arterial rete and ring, a fine parenchymal network, and connections with the gallbladder arterial system. In the six cases where a branch artery was occluded, arterial filling of the entire liver was demonstrated. The authors conclude that these interconnecting networks could account for the infrequency of hepatic infarcts, are the anatomic basis for the intrahepatic spread of malignant lesions, the "duplication" and "triplication" patterns on arteriography, and may account for the outer streaks of the arteriographic "thread and streak" sign in portal vein invaded by hepatocellular carcinoma.     

Interventional radiology in the management of hepatic injuries

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Does variant hepatic artery anatomy in a liver transplant recipient increase the risk of hepatic artery complications after transplantation?

OBJECTIVE: Our aim was to determine whether variant hepatic artery anatomy in a liver transplant recipient increases the risk of hepatic artery complications after liver transplantation. MATERIALS AND METHODS: The study group consisted of 84 patients who underwent gadolinium-enhanced 3D MR angiography before orthotopic liver transplantation in which a branch patch arterial anastomosis at the gastroduodenal takeoff was used. MR angiography studies were retrospectively reviewed and assessed for the presence and type of variant hepatic artery anatomy. The diameter of the distal common hepatic artery was measured. The incidence of posttransplantation hepatic artery stenosis or thrombosis was assessed. RESULTS: Seven (8.3%) of the 84 patients developed hepatic artery complications after transplantation. Of the 24 patients with variant hepatic artery anatomy, five (20.8%) had posttransplantation/ hepatic artery complications. In contrast, only two (3.3%) of the 60 patients with classic hepatic artery anatomy had complications. The higher complication rate in patients with variant hepatic artery anatomy was statistically significant (p < 0.05). The odds ratio was 7.6 (95% confidence interval, 1.4-42.6). The diameter of the distal common hepatic artery was smaller in patients with variant hepatic artery anatomy compared with those with classic hepatic artery anatomy (range, 4.3-7.1 mm [mean, 5.8 mm] vs 4.0-8.9 mm [mean 6.3 mm], p < 0.05), and it was also smaller in patients who had posttransplantation hepatic artery complications compared with those who had no complications (range, 4.2-6.3 mm [mean, 5.2 mm] vs 4.0-8.9 mm, [mean, 6.2 mm], p < 0.01). CONCLUSION: Variant hepatic artery anatomy in a liver transplant recipient increased the risk of hepatic artery complications after transplantation. The smaller caliber of the native common hepatic artery may contribute to the higher risk.     

Arteries of the falciform ligament on C-arm CT hepatic arteriography: The hepatic falciform artery and the Sappey’s superior artery

Background and aim

To investigate the prevalence, anatomy and distribution of the hepatic falciform artery (HFA) and Sappey’s superior artery (SSA) using C-arm CT hepatic arteriography (C-arm CTHA).

Materials and methods

From January 2011 to December 2012, 220 patients who underwent C-arm CTHA during initial transarterial treatment for hepatocellular carcinoma were included in this retrospective study. The HFAs and SSAs prevalence and origin were evaluated using axial images of C-arm CTHA. A 5-point scale for HFAs and a 4-point scale for SSAs were used to designate the radiologically conspicuous arteries.

Results

The prevalences of the total HFAs and SSAs were 95 % (n=209) and 22 % (n=49), while those of radiologically conspicuous HFAs and SSAs were 62 % (n=137) and 10 % (n=22), respectively. Thirty HFAs (22 % of radiologically conspicuous HFAs and 14 % of the total study population) were distributed in the subcutaneous layer of the anterior abdominal wall, while the majority of SSAs ran through the superior part of the falciform ligament in the left-anterior direction and anastomosed with left inferior phrenic artery.

Conclusion

Our study using C-arm CTHA revealed that the prevalence of the HFA is higher than the existing knowledge and proved the existence of the SSA radiologically for the first time.

Key Points

? Prevalence of hepatic falciform artery is 95 %, higher than previously known. ? 22 % of conspicious hepatic falciform arteries distributed in subcutaneous tissue around umbilicus. ? The existence of Sappey’s superior artery was proved with a radiological method.

     

Are all urgent nephrostomies that urgent?

Purpose

To investigate if the presence of systemic inflammatory response syndrome (SIRS) in patients with urinary tract obstruction at time of presentation to the emergency department correlates with a subsequent positive urine culture and to determine if it could be used as a tool to predict the urgency of a percutaneous nephrostomy (PCN). The secondary aim of the study was to assess the incidence of in-hour and after-hour emergent PCNs performed in a tertiary center which has both interventional radiological and urological expertise.

Methods and materials

Emergent adult PCN cases referred from the emergency department between 2011 and 2016 were identified retrospectively. Urine culture results, clinical features of SIRS, timing of procedure, and radiological findings were analyzed.

Results

A total of 110 patients met the inclusion criteria. There were a total of 60 male and 50 female patients with a mean age of 62 (age range 18–99 years). Ninety-two (83%) PCN patients were referred and performed on after-hours with the remaining 18 patients performed in-hours. There were 53 (48%) patients that met the criteria for obstruction with SIRS and 57 (52%) patients with obstruction without SIRS. The number of after-hours PCN performed in both groups was equal at 46 patients each. The most common cause of obstruction in the SIRS group was stone related in 31 (58%) patients. Whereas, the most common cause of obstruction in the non-SIRS group was due to malignancy in 26 (45%) cases. An elevated temperature and heart rate were the most common features of SIRS at 96 and 83% respectively in the SIRS group. An organism was isolated in 35 (67%) out of the 52 urine culture results obtained for the SIRS group. No organism was isolated in 42 (95%) out of the 44 urine culture results obtained in the non-SIRS group. Statistical analysis using Fisher’s test revealed that the association between obstruction without SIRS and a negative urine culture result was statistically significant (p <?0.0001).

Conclusion

A large percentage (50%) of PCN cases performed after-hours could have been performed during daytime hours instead due to the absence of infection. This would be in line with the practices of some centers that consider an infected obstructed kidney as the only absolute indication for emergent decompression overnight. The study also demonstrates that the absence of a SIRS in a patient with urinary tract obstruction correlates well with a negative urine culture result from the nephrostomy specimen which has a high negative predictive value for excluding pyonephrosis.

     

Pattern approach to MR imaging in patients with end-stage hepatic failure: a proposal for a new disease entity “hepatic encephalopathy continuum”

INTRODUCTION: The purpose of this study was to evaluate the clinical features and the characteristics of MR images of patients with end-stage hepatic failure. METHODS: We reviewed the MR findings and clinical features of 31 consecutive patients (20 men, 11 women=31, mean age 58.7 years) who had been diagnosed with clinical hepatic encephalopathy. Associations between the lesion locations on each MR sequence were analyzed using a binominal test. The clinical and MR findings were compared in relation to the etiology and clinical status. RESULTS: The most frequently involved site, seen as high signal intensity on T2-W images, was the corpus callosum (20 patients), followed by the dentate nucleus (16 patients) and the globus pallidus (13 patients). Significant associations were seen between the pallidus and the crus cerebri, between the crus cerebri and the red nucleus, between the crus cerebri and the dentate nucleus, and between the red nucleus and the dentate nucleus on the T2-W and DW images (P < 0.004). The crus cerebri, red nucleus, and dentate nucleus were involved concurrently with the corpus callosum more frequently in hepatic encephalopathy grades 3 and 4. CONCLUSION: Concurrent involvement of the globus pallidus-crus cerebri-red nucleus-dentate nucleus axis was the main MR pattern in end-stage hepatic encephalopathy, which connected with various areas of the brain. We hypothesize that these overlapping MR features could be regarded as an entity denoted as the "hepatic encephalopathy continuum".     

Fatal hepatic haemorrhage in a child—peliosis hepatis versus maltreatment

A 2.5-year-old boy with known myotubular myopathy (Spiro-Shy-Gonatas syndrome) and gonadorelin intake 9 months ante-mortem was found dead in his bed at home. At autopsy a ruptured subcapsular haematoma of the liver with resulting haemoperitoneum (600 ml) was found. Both lobes of the liver showed numerous circular blood foci <1 mm–2 cm in diameter. Signs of mechanical trauma such as bruising of the abdominal wall were absent. Histologically, the blood cysts were commonly connected to the sinusoids but did not have an endothelial lining and the reticular fibres showed ruptures. These pathomorphological findings are characteristic for peliosis hepatis and the cause of death was therefore determined to be exsanguination due to hepatic haemorrhage from peliosis hepatis instead of from mechanical trauma. To our knowledge this is the youngest casualty from peliosis reported so far.     

Pneumobilia: where to look for on hepatic MR imaging?

The presence of pneumobilia is a particular problem in magnetic resonance cholangiopancreatography (MRPC) and may create an appearance that can be mistaken for intraductal stones. Compared with biliary stones, however, pneumobilia causes a susceptibility artifact on hepatic MR imaging and appears as a signal void on a dual echo gradient MR sequence, such as the T1-weighted in-phase and opposed-phase gradient echo sequence. This susceptibility artifact is more pronounced on the gradient echo image with the longer echo time due to the continued decay of the transverse magnetization. Besides identification of hepatic steatosis, the double echo approach is particularly helpful in identification of pneumobilia.     

Can imaging patterns of neuroendocrine hepatic metastases predict response yttruim-90 radioembolotherapy?

AIM:To evaluate the response to treatment in patients with neuroendocrine tumor liver metastases following yttrium-90 ( 90 Y) radioembolotherapy, as a function of image patterns at presentation for 90 Y radioembolotherapy. METHODS: The study cohort consisted of patients with hepatic metastatic neuroendocrine tumors treated with 90 Y at our institution during a two-year time period. Hepatic metastases were evaluated on a pretherapy study assessing relative arterial enhancement compared to liver, lesion size, necrosis of the lesion, and associated tumor burden in the liver. We used six response criteria: Response Evaluation Criteria in Solid Tumors (RECIST) size, World Health Organization (WHO) size, European Association for the Study of the Liver (EASL) necrosis guidelines, Choi size, Choi necrosis and combination of Choi size and necrosis. RESULTS: About 65 lesions in 17 patients met study criteria and formed the cohort. Statistically significant response was found for lesions < 5 cm vs those ≥5 cm with RECIST (P = 0.04), WHO (P = 0.002) and combined Choi criteria (P = 0.02). Hyperenhancing lesions demonstrated greater response only with the Choi size criteria (P = 0.04). Lesions with ≤ 50% necrosis on the pre-scan had statistically significant greater response with the Choi necrosis criteria (P = 0.01). There was no statistical significance for response comparing lesions < 2 cm vs ≥ 2 cm or in comparing the degrees of tumor burden. CONCLUSION: Based on our findings in this study, it is suggested that initial imaging findings, as listed above, are not a good predictor of response to 90 Y radioembolization.     

Nanoradiopharmaceuticals: is that the future for nuclear medicine?

New advances in nanotechnology has been responsible for the development of a new science called nanomedicine. In the recent years many discoveries as nanotubes and nanoparticles, especially for pharmaceuticals use, has increasing the application of nanotechnology for medical purposes. In this direction the development of nanoradiopharmaceuticals are also promising as novel radiopharmaceuticals. In this study we made an extensive overview of the most recent advantages in this field of nanotechnology and a fully application to radiopharmaceuticals. Despite, we gaive some nanoradiopharmaceuticals already developed and under investigation for clinical use. The results described that is possible to make nanoradiopharmaceuticals of two ways. The first one directly: nanoencapsulating an already radioactive radiopharmaceuticals. And the second way is nanoencapsulating a non-radioactive ligand for posterior labeling with a radioisotope alikes 99mTc. In both cases the nanoradiopharmaceuticals are acquired. We ended that nanoradiopharmaceuticals are feasible and may represent the future of the nuclear medicine.     

Hepatic falciform artery: is prophylactic embolization needed before short-term hepatic arterial chemoinfusion?

OBJECTIVE: The purpose of this study was to assess the need for prophylactic embolization of the hepatic falciform artery (HFA) to prevent supraumbilical skin rash before short-term hepatic arterial chemoinfusion with or without subsequent embolization. MATERIALS AND METHODS: Transcatheter arterial chemoinfusions or chemoembolizations were performed on 127 consecutive patients with hepatocellular carcinoma between August 1997 and September 1997. Hepatic angiography findings regarding the anatomic variations of the hepatic artery and the presence and origin of the HFA were analyzed. The patients were followed up for 35-143 days (mean, 78 days). The incidence of supraumbilical skin rash was assessed for two groups of patients, those with an HFA and those without. We also evaluated other factors that seemed closely related to the presence of an HFA. RESULTS: An HFA was identified in 16 (13%) of 127 patients. Each HFA originated either in the left hepatic artery (n = 14) or the middle hepatic artery (n = 2). In the 16 patients with an HFA, serum bilirubin levels were significantly higher than in patients without one (p < .05), whereas serum albumin levels and prothrombin times were significantly lower (p < .05) and more prolonged (p = .02) than in patients without one. Portal venous collateral vessels were more frequently seen in patients with an HFA (50%) than in those without one (31%), but the frequency was not significant (p = .157). However, supraumbilical skin rash was not seen in any patient. CONCLUSION: We found no need for prophylactic embolization of the HFA to prevent supraumbilical skin rash before short-term hepatic arterial chemoinfusion with or without subsequent embolization.     

Endovascular treatment for hepatic vein-type Budd–Chiari syndrome: effectiveness and long-term outcome

Purpose

To determine the clinical effectiveness and long-term outcomes of endovascular treatment for hepatic vein (HV)-type Budd–Chiari syndrome (BCS).

Materials and methods

From June 2011 to August 2016, 68 consecutive patients with symptomatic HV-type BCS underwent endovascular treatment in our center. Data on the baseline characteristics, technical success, clinical success, and long-term outcomes were collected and analyzed retrospectively.

Results

The technical success rate of endovascular treatment was 100%. Fifty patients underwent HV recanalization, and 18 underwent accessory HV (AHV) recanalization. The clinical success rate was 95.6% (65/68). During a mean follow-up period of 29.4?±?13.6 months, 19 patients experienced re-obstruction of either the HV (n?=?18) or the AHV (n?=?1). The cumulative 1-, 2-, and 5-year primary patency rates were 80.0, 72.8, and 67.9%, respectively. The cumulative 1-, 2-, and 5-year secondary patency rates were 93.8, 90.3, and 82.9%, respectively. Univariate and multivariate analyses revealed that the independent predictor of a prolonged primary patency duration was recanalization of the AHV. Five patients died 1–28 months (median, 15 months) after treatment. The cumulative 1-, 2-, and 5-year survival rates were 96.9, 93.4, and 91.2%, respectively. There was no significant difference in survival between the HV and AHV recanalization groups.

Conclusion

Endovascular treatment is effective for patients with HV-type BCS. It can result in excellent long-term patency and survival rates. If it is applicable, AHV recanalization should be considered prior to treatment in order to achieve a longer patency.