Double closed loop small bowel obstruction due to right diaphragmatic hernia after transcatheter arterial chemoembolization and microwave ablation for hepatocellular carcinoma

64-Year-old male patient with hepatocellular carcinoma (HCC), liver cirrhosis, chronic hepatitis C infection, and glottic cancer presented with acute progressive abdominal pain and palpable mass in right upper quadrant of the abdomen. Despite treatment with hyoscine and tramadol, the symptoms persisted. He had received three sessions of Transcatheter arterial chemoembolization (TACE) and two sessions of microwave ablation (MWA) for HCC treatment, with the last session being TACE 11 months prior. Plain film abdomen showed bowel gas pattern in the right hemithorax compatible with bowel obstruction. CT imaging revealed a right diaphragmatic hernia containing closed loop small bowel obstruction. An emergency exploratory laparotomy was performed. The patient improved and was discharged. There was no recurrence of diaphragmatic hernia or abdominal mass or pain at the 6-month follow-up visit. We herein demonstrate a catastrophic complication of TACE by using an IPA and MWA which leads to right diaphragmatic hernia.

Diaphragmatic weakness after transcatheter arterial chemoembolization of the right inferior phrenic artery for treatment of hepatocellular carcinoma: a comparison of outcomes after N-butyl cyanoacrylate versus gelatin sponge embolization

BACKGROUND

The inferior phrenic artery (IPA) is the most common extrahepatic feeder for hepatocellular carcinoma (HCC) during transhepatic arterial chemoembolization (TACE).

PURPOSE

To compare the incidence of diaphragmatic weakness in patients with HCC after TACE of the right IPA conducted using either N-butyl cyanoacrylate (NBCA) or gelatin sponge particles.

MATERIAL AND METHODS

Medical records of 111 patients who underwent TACE of the right IPA using NBCA were retrospectively reviewed and compared with data from 135 patients with IPA embolization using gelatin sponge particles.

RESULTS

The incidence of diaphragmatic weakness after the initial TACE procedure did not significantly differ between the groups (NBCA group 16.2%; gelatin sponge group 20.7%; P = 0.458). Five patients in the NBCA group and 11 in the gelatin sponge group showed spontaneous resolution of diaphragmatic weakness after a mean period of 3.5 months. Diaphragmatic weakness developed after the initial follow-up visit in 17 patients from the gelatin sponge group due to repeated TACE of the right IPA (mean 2.4 sessions; range 2-4 sessions), while it spontaneously developed without additional TACE procedures in one patient from the NBCA group. Permanent diaphragmatic weakness was less common in the NBCA than in the gelatin sponge group (12.6% and 25.2%, respectively; P = 0.017). The complete response rate did not significantly differ between the groups (NBCA group 16.2%; gelatin sponge group 25.9%; P = 0.065).

CONCLUSION

Use of NBCA rather than gelatin sponge particles for TACE of the right IPA resulted in a lower incidence of permanent diaphragmatic weakness.

The inferior phrenic arteries: A systematic review and meta-analysis

INTRODUCTION

The inferior phrenic artery is a paired artery that supplies the diaphragm from its inferior aspect. It may arise as a common trunk, the common inferior phrenic artery (CIPA), or as two individual arteries, the right and left inferior phrenic arteries (RIPA and LIPA, respectively). The aim of this study was to perform a systematic review and meta-analysis to create pooled prevalence data on the various origins of the inferior phrenic arteries and to discuss their clinical importance.

METHODS

Major electronic medical databases were reviewed to identify articles with anatomical prevalence data on the origin of the inferior phrenic arteries. Data on the origin of the left, right and common inferior phrenic arteries were extracted and quantitatively synthesized.

RESULTS

The CIPA was present in 24.2% of cases and most commonly originated from the aorta, with a pooled prevalence 57.2% (95% CI 52.4-62.0%), and the coeliac trunk, with a pooled prevalence of 41.3% (95% CI 36.8-45.9%). Other origins were much less common (1.00% (95% CI 0.28-1.71%)). Independent origin of the RIPA and LIPA were present in 75.8%. The RIPA arose from the aorta (49.6%, 95% CI 43.2%-55.9%), coeliac trunk (35.7%, 95% CI 28.7-42.6%), right renal artery (10.3%, 95% CI 7.27-13.3%) and left gastric artery (2.07%, 95% CI 0.97-3.16%). Other less common origins had a pooled prevalence of 2.07% (95% CI 0.97-3.16%). The LIPA arose from the aorta (46.8%, 95% CI 39.1-54.6%), coeliac trunk (46.1%, 95 CI 38.6-53.5%), left renal artery (1.47%, 95% CI 0.78-2.15%) and left gastric artery (1.07%, 95% CI 0.25-1.89%). Other less common origins had a pooled prevalence of 1.29% (95% CI 0.44-2.14%).

CONCLUSION

The inferior phrenic arteries express a wide range of variations in origin. Knowledge of their origins are important in interventional radiology, gastroenterology, surgery and traumatology.

The march of extrahepatic collaterals: analysis of blood supply to hepatocellular carcinoma located in the bare area of the liver after chemoembolization

The purpose of this study was to evaluate changes in vascular supply to hepatocellular carcinoma (HCC) located in the bare area of the liver in patients who were mainly treated with chemoembolization. Twenty-six patients with HCC showing a mean diameter of 3.1 +/- 1.4 cm (mean +/- standard deviation) were mainly treated with chemoembolization. All patients underwent 2.7 +/- 2.3 chemoembolization sessions over 40.1 +/- 25.2 months. Tumor feeding branches demonstrated in each chemoembolization session were retrospectively evaluated. Initially, 18 tumors (59.2%) were supplied by the hepatic artery (H) and 8 (30.8%) by both the hepatic and the extrahepatic arteries (H + C). Fourteen tumors (53.8%) recurred at the posterior aspect of the tumor and were supplied by H (n = 4), H + C (n = 5), and extrahepatic collaterals (C) (n = 5). Several tumors recurred despite repeated chemoembolization, and these were supplied by H (n = 1), H + C (n = 7), and C (n = 2) at the second recurrence, by H (n = 1), H + C (n = 2), and C (n = 3) at the third, by H + C (n = 2) and C (n = 2) at the fourth, by H + C (n = 2) and C (n = 2) at the fifth, and by H (n = 1) and C (n = 1) at the sixth. One tumor was supplied by H at the seventh and by H + C at the eighth recurrence. As the number of local recurrences increased, the feeding vessel shifted from H to C. Especially, the right inferior phrenic artery (IPA) and renal capsular artery (RCA) supplied the tumor early, while the small right RCAs, adrenal arteries, and intercostal and lumbar artery supplied late recurrences in turns. In conclusion, HCCs located in the bare area are frequently supplied by extrahepatic vessels initially, while recurrence after chemoembolization is mainly due to extrahepatic blood supply. The right IPA and RCA are common feeding vessels demonstrated early, while other extrahepatic collateral supply from the retroperitoneal circulation occurs in turns during the later course.

The right inferior phrenic artery: origin and proximal anatomy on digital subtraction angiography and thin-section helical computed tomography

PURPOSE

To investigate the origin sites of the right inferior phrenic artery (RIPA) and its proximal anatomy with use of digital subtraction angiography (DSA) and thin-section computed tomography (CT).

MATERIALS AND METHODS

Among 2,593 patients, selective RIPA arteriography was attempted in 591 (507 men; mean age, 54 years) who underwent chemoembolization and thin-section liver CT. CT and DSA images were reviewed.

RESULTS

The origin sites of the RIPA and its proximal segment were analyzed on DSA and CT in 580 patients after 11 were excluded because of a completely occluded or unidentifiable RIPA. The RIPA originated directly from the aorta in 336 patients (57.9%) and from the major visceral aortic branches in 244 (42.1%). In RIPAs of aortic origin, the most common level was the supraceliac aorta (n = 119; 35.4%), and the mean angular orientation slightly deviated to the left side of the aorta (12.1 degrees ). As the level of origin became lower (from "juxtaceliac" to suprarenal), there were two groups in whom the RIPAs arose around an oblique path from the supraceliac aorta to the right renal artery (n = 199; 59.2%) or left renal artery (n = 18; 5.4%). When the RIPA origin was draped by the diaphragm (n = 197; 58.6%), its proximal segment showed a downward and/or leftward impression or an acute rightward turn depending on its level of origin and angular orientation. Unusually, three RIPAs under the right hemidiaphragm exhibited a transdiaphragmatic course.

CONCLUSIONS

RIPAs had diverse proximal anatomy relative to their origin level and overhanging diaphragmatic crus, which could be evaluated with thin-section helical CT.

The origin of the inferior phrenic artery: a study in 32 South Indian cadavers with a review of the literature

BACKGROUND: Considering the paucity of information presently available concerning inferior phrenic arteries, a more definitive study seemed appropriate and necessary, both for its potential clinical applications and to provide additional data to contemporary anatomical literature. OBJECTIVE: Most anatomical textbooks of gross anatomy offer very little information concerning the anatomy and distribution of the inferior phrenic artery (IPA). For that reason, the origin of the IPA has been studied and the available literature has been reviewed. METHODS: Thirty-two human adult cadavers preserved in formalin obtained from the departments of Anatomy, Kasturba Medical College, Manipal and Mangalore were dissected and the origin of the IPA was studied. RESULTS: The IPA had its usual origin from the abdominal aorta in 28 cases but in the remaining four cases, two were arising from the celiac trunk, one from the left gastric artery and one from the right renal artery. CONCLUSION: The IPA usually originates from the aorta or celiac artery, and less frequently from the renal, hepatic or left gastric arteries. The IPA is a major source of collateral or parasitized arterial supply to hepatocellular carcinoma, second only to the hepatic artery. Literature on the IPA origin and clinical implications of variation in its origin have been reviewed in this article.

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.

An anatomical classification of the variations of the inferior phrenic vein

The majority of anatomical textbooks of gross anatomy offer very little information concerning the anatomy and distribution of the inferior phrenic vein (IPV). However, in the last decade, an increasing number of reports have arisen, with reference to the endoscopic embolization of esophageal and paraesophageal varices, as well as venous drainage of hepatocellular carcinomas (HCC). The IPV is one of the major sources of collateral venous drainage in portal hypertension and HCC. The aim of this study was to identify the origin and distribution of the IPVs (right and left), both in normal and (selective) pathological cases. We have examined 300 formalin-fixed adult cadavers, without any visible gastrointestinal disease, and 30 cadavers derived from patients with HCC. The right IPV drained into the following: the inferior vena cava (IVC) inferior to the diaphragm in 90%, the right hepatic vein in 8%, and the IVC superior to the diaphragm in 2%. The left IPV drained into the following: the IVC inferior to the diaphragm in 37%, the left suprarenal vein in 25%, the left renal vein in 15%, the left hepatic vein in 14%, and both the IVC and the left adrenal vein in 1% of the specimens. The IPVs possessed four notable tributaries: anterior, esophageal, lateral and medial. The right IPV served as one of the major extrahepatic draining veins for all 30 cases of HCC. These findings could have potential clinical implications in the transcatheter embolization of esophageal and paraesophageal varices, as well as in mobilizing the supradiaphragmatic segment of IVC.

Clinical anatomy of the inferior phrenic artery

The majority of anatomical textbooks of gross anatomy offer very little information concerning the anatomy and distribution of the inferior phrenic artery (IPA). In the last decade, however, increased numbers of reports have appeared with reference to the arterial supply of hepatocellular carcinoma (HCC). The IPA is a major source of collateral or parasitized arterial supply to this type of carcinoma, second only to the hepatic artery. The aim of this study was to identify the origin and distribution of the IPA (right and left), in normal and pathological cases, and to apply such findings to the clinical scenario of treating hepatic cancer. We have examined 300 formalin-fixed adult cadavers lacking abdominal pathology, and 30 cadavers derived from patients with HCC. Dissections in normal cadavers showed that the right IPA originated from the: a) celiac trunk in 40% of the specimens; b) aorta in 38%; c) renal in 17%; d) left gastric in 3%; and e) hepatic artery proper in 2% of the specimens. The left IPA originated from the: a) celiac trunk in 47%; b) aorta in 45%; c) renal in 5%; d) left gastric in 2%; and e) hepatic artery proper in 1% of the specimens. The IPA gave rise to eight notable branches: ascending, descending, inferior vena cava, superior suprarenal, middle suprarenal, esophageal, diaphragmatic hiatal, and accessory splenic. The right IPA was always associated with HCC and served as the major collateral artery adjunct to the hepatic artery. These findings could have major implications in the transcatheter embolization of HCC patients.

Combined Use of an Occlusion Balloon Catheter and a Microcatheter for Embolization of the Unselectable Right Inferior Phrenic Artery Supplying Hepatocellular Carcinoma

We report the combined use of an occlusion balloon catheter and a microcatheter for transcatheter arterial embolization (TAE) of hepatocellular carcinoma (HCC) fed by the unselectable right inferior phrenic artery (IPA). In one case, HCC was fed by the reconstructed right IPA via a small branch arising from the proximate portion of the celiac artery. In another, the tumor was fed by the right IPA that had been previously embolized with coils. TAE was successfully performed through a microcatheter placed in the celiac artery immediately proximal to the occluding balloon catheter of the celiac trunk and coil embolization of the left gastric artery.

Inferior phrenic arteries: depiction with thin-section three-dimensional contrast-enhanced dynamic MR imaging with fat suppression

The purpose of this study was to evaluate visibility of the inferior phrenic arteries in normal subjects at thin-section, multiphasic, three-dimensional (3D) contrast-enhanced dynamic magnetic resonance (MR) imaging with fat suppression, and to compare the appearances and frequencies of MR visualization of these vessels between normal and cirrhotic patients. This study included 95 patients (44 normal and 51 cirrhotic patients) who underwent 3D contrast-enhanced dynamic imaging on a high-performance gradient (25 mT/m) system as a part of abdominal MR examinations. The right and left inferior phrenic arteries were visible in 84% and 73% of the normal subjects, respectively. The averaged rating for visibility in the right inferior phrenic artery was significantly greater in the cirrhotic patients than in the normal subjects (2.1 +/- 0.1 vs. 1.7 +/- 0.2; P = 0.040). Mean diameters of the right inferior phrenic artery in the cirrhotic patients (1.7 +/- 0.1 mm) were significantly larger (P = 0.002) than those in the normal subjects (1.3 +/- 0.1 mm). No significant difference was noted in the mean diameters and the visibility of the left inferior phrenic artery between the two groups. The inferior phrenic arteries can frequently be identified on thin-section, 3D contrast-enhanced arterial-phase dynamic MR images with fat-suppression techniques. Dilatation of the right inferior phrenic artery depicted by this technique may be a nonspecific but an additional secondary finding suggestive of cirrhosis.

Internal mammary artery embolization for hepatic tumors

PURPOSE

To prospectively identify patients with collateral internal mammary artery (IMA) supply to hepatic tumors, and to embolize the IMA as part of palliative hepatic artery embolization (HAE).

METHODS

Over a 4-year period, 222 patients were enrolled in an HAE protocol for inoperable liver tumors. All underwent abdominal computed tomography (CT) prior to preembolization diagnostic hepatic arteriography. When anterior subcapsular hepatic tumor was seen on the CT scan, patients underwent IMA arteriography as well. All arteries supplying tumor were embolized.

RESULTS

Six patients had anterior subcapsular lesions identified on CT. IMA catheterization revealed that these lesions drew blood supply directly or indirectly from one or both IMAs in all six patients. All IMAs were embolized.

CONCLUSION

When an hepatic tumor is identified in an anterior subcapsular location prior to HAE, the IMA should be examined and, if significant tumor supply is demonstrated, these branches should be embolized.