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

99m Tc-Macroaggregated Albumin Liver Lung Shunt Study With Uptake Indicative of Patent Falciform Artery

ABSTRACT

Intra-arterial injection of radioactive isotope 90-yttrium 90 Y has been used for elective internal radiation therapy for the treatment of localized hepatocellular carcinoma deemed surgically unresectable. It has also been used to treat intrahepatic cholangiocarcinoma and colorectal cancer that has metastasized to the liver. To prepare for 90 Y treatment, preprocedural mapping via hepatic angiography and 99m Tc-macroaggregated albumin liver lung shunt study followed by postprocedural 90 Y SPECT/CT is essential to ensure a targeted therapy. Therapy is contraindicated if lung shunt fraction is greater than 20% for SIR-Spheres. Anatomic variation in hepatic angiography may be present that can lead to complications if unaccounted for.

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.

Abdominal Skin Rash After TACE Due to Non-Target Embolization of Hepatic Falciform Artery

Transcatheter arterial chemoembolization (TACE) is a well-recognized procedure for management of hepatocellular carcinoma. We present a 54-year-old man who presented with a periumbilical maculopapular skin rash that developed after an otherwise uneventful TACE procedure. A retrospective review of imaging was consistent with non-target embolization of the hepatic falciform artery (HFA). He was treated with oral non-steroidal antiinflammatory medication for 3 weeks with improvement, but had slight skin induration and an excoriated papule at 6-month follow-up. Non-target embolization of HFA is very rare, but clinicians and interventionalists should be aware of this complication, especially in patients predisposed to enlargement of HFA.

Uncommon CT imaging of the hepatic falciform artery in patients presenting with very unusual variants of gastrointestinal arteries: report of two cases

The hepatic falciform artery (HFA) may be found in 68% of subjects in post-mortem dissections. It is well known by interventional radiologists who perform selective hepatic angiography. The reason essentially results from the potential supraumbilical skin complications which may produce by the distribution of chemotherapeutic agents through the HFA after transcatheter chemoinfusion or chemoembolization for liver tumors. Nevertheless, the spontaneous visualization of the HFA remains very unusual in current abdominal CT practice. We hereby report the demonstration of a patent HFA during conventional abdominal CT in two patients presenting without liver disease but in which very unusual variants of the gastrointestinal arteries were simultaneously found. The first patient had a common celiomesenteric trunk and the second had a severe compression of both the celiac trunk and superior mesenteric artery by the median arcuate ligament of the diaphragm. We shortly review the literature about these rare variants. We hypothesize that the HFA was spontaneously visible in our patients because of hypertrophy due supplying collateralization.

Prophylactic topically applied ice to prevent cutaneous complications of nontarget chemoembolization and radioembolization

Cutaneous complications can result from nontarget deposition during transcatheter arterial chemoembolization or radioembolization. Liver tumors may receive blood supply from parasitized extrahepatic arteries (EHAs) that also perfuse skin or from hepatic arteries located near the origin of the falciform artery (FA), which perfuses the anterior abdominal wall. To vasoconstrict cutaneous vasculature and prevent nontarget deposition, ice packs were topically applied to at-risk skin in nine chemoembolization treatments performed via 14 parasitized EHAs, seven chemoembolization treatments near the FA origin, and five radioembolization treatments in cases in which the FA could not be prophylactically coil-embolized. No postprocedural cutaneous complications were encountered.

Effectiveness of repeat angiographic assessment in patients designated for radioembolization using yttrium-90 microspheres with initial extrahepatic accumulation of technitium-99m macroaggregated albumin: a single center's experience

PURPOSE

To evaluate the efficacy of a workflow consisting of repeat assessment in patients planned for yttrium-90 ((90)Y) radioembolization in case of nontarget visceral technetium-99m ((99m)Tc)-macroaggregated albumin (MAA) accumulation despite initial prophylactic coil embolization of nonhepatic arteries.

MATERIALS AND METHODS

In 341 patients with primary and secondary liver cancer, pretreatment hepatic angiograms, as well as single-photon emission computed tomography coregistered with magnetic resonance imaging scans, were obtained. Extrahepatic tracer deposition was identified in 33 patients (9.7%) necessitating repeat assessment. Images were reviewed to correlate the site of MAA accumulation with causative gastrointestinal vessels, and repeat angiograms served as reference standard.

RESULTS

At repeat angiography, the source of extrahepatic flow was identified and eliminated in 31 of 33 patients (93.9%). In 20 patients (60.6%), successful embolization of nontarget vessels was achieved, in 13 patients (39.4%), MAA was administered more distally. Afterward, extrahepatic MAA deposition was eliminated in 30 patients (90.9%).

CONCLUSION

The algorithm of repeat assessment in case of extrahepatic MAA accumulation has proven highly effective to eliminate extrahepatic shunting, thus decreasing the risk of postradioembolization complications due to inadvertent visceral microsphere deposition.

[Extrahepatic vessels depending on the hepatic artery. Identification and management]

Patients with malignant liver tumors, whether primary tumors or metastases, that are not candidates for surgical treatment can benefit from different endovascular treatments with proven efficacy in local control of the disease. Correct treatment requires a careful angiographic technique and precise knowledge about the vascular anatomy afferent to the lesion. Occasionally, lesions considered relapse are actually areas that were untreated because the afferent pedicle was not adequately detected. On the other hand, some of the complications of endovascular treatments are related with material passing into non-hepatic vessels. Knowing the hepatic vascular anatomy and correctly identifying all the extrahepatic vessels will make it possible to perform safer, more efficacious treatments. In this article, we present different representative examples of extrahepatic vessels that originate in the hepatic artery.

A case of hepatocellular carcinoma with skin injury of the upper abdominal wall after transcatheter arterial chemoembolization: a case report

INTRODUCTION

Transcatheter arterial chemoembolization has been widely used to treat advanced hepatocellular carcinoma that cannot be treated by local ablation therapies or surgical resection. The effectiveness of transcatheter arterial chemoembolization in prolonging survival has been well established, and approximately one third of newly discovered hepatocellular carcinoma patients were repeatedly treated by transcatheter arterial chemoembolization in Japan. Various kinds of complications have been reported, and many of which are general complications such as hepatic coma, jaundice, fever-up, ascites, and bile duct injury. The hepatic falciform artery is found frequently during postmortem anatomic dissection and the incidence of hepatic falciform artery is reported to be over 60%. Hepatic falciform artery is known to be the responsible artery for supraumbilical skin rash development after arterial chemo infusion therapy; however, skin complications after transcatheter arterial chemoembolization are rare.

CASE PRESENTATION

A 70-year-old female with chronic hepatitis C infection was diagnosed as having hepatocellular carcinoma (S4, 20 mm in diameter). Transcatheter arterial chemoembolization was performed via the left hepatic artery, which was a feeding artery of the hepatocellular carcinoma. Two days after that, supraumbilical skin rash with local tenderness and redness appeared. Retrospective analysis revealed that occlusion of the hepatic falciform artery branching from the left hepatic artery with micromaterials caused the skin lesion.

CONCLUSION

We should keep in mind that anticancer drugs or embolic materials can flow into the HFA and may cause abdominal wall injury after transcatheter arterial chemoembolization.

Anterior abdominal wall uptake in intrahepatic arterial brachytherapy with yttrium-90 sir spheres for hepatic malignancy

Patients with primary or secondary liver cancer who are not suitable for surgical resection may be treated with selective internal radiation therapy with yttrium-90. This may cause down staging of the tumor to a resectable size in some patients, and in these and other patients may prolong survival. It delivers a high dose of radiation therapy directly to the tumor, thus minimizing exposure to liver sensitive to radiation. Prior scanning with Tc-99m macroaggregated albumin is performed to assess lung shunting and potential extrahepatic deposition, which can cause significant clinical sequelae. Two patients with hepatic malignancy are presented who demonstrated extrahepatic deposition of Tc-99m macroaggregated albumin in the anterior abdominal wall. This is thought to be related to a patent hepatic falciform ligament artery.

Angiographic considerations in patients undergoing liver-directed therapy

The rapid evolution and increasing complexity of liver-directed therapies has forced the medical community to further advance its understanding of hepatic arterial anatomy. The anatomy of the mesenteric system, and particularly the hepatic arterial bed, has been demonstrated to have a high degree of variation. This is important when considering presurgical planning, catheterization, and transarterial hepatic therapies. Although anatomic variants have been well described, the characterization and understanding of regional hepatic perfusion is also required to optimize endovascular therapy and intervention. Although this is true for patients undergoing bland embolization or chemoembolization, drug delivery, and hepatic infusional pump therapy, it is particularly true for intraarterial brachytherapy. The purpose of this review is to provide historical perspective in angiographic aspects of liver-directed therapy, as well as a discussion of normal vascular anatomy, commonly encountered variants, and factors involved in changes to regional perfusion in the presence of liver tumors. Methods of optimizing the safety and efficacy of liver-directed therapies with use of percutaneous techniques will be discussed. This review is based on the experience gained in treating more than 500 patients with transarterial liver-directed therapies. Although the principles described in this article apply to all liver-directed therapies such as chemoembolization and administration of drug-coated microspheres, they apply particularly to intraarterial brachytherapy.

Influential factors and formation of extrahepatic collateral artery in unresectable hepatocellular carcinoma

AIM: To analyze the influence factors and formation of extrahepatic collateral arteries (ECAs) in unresectable hepatocellular carcinoma (HCC) with or without chemoe-mbolization.

METHODS: Detailed histories of 35 patients with 39 ECAs of HCC and images including computerized tomography scan, digital subtraction angiography were reviewed carefully to identify ECAs of HCC, ECAs arising from, and anatomic location of tumors in liver. Tumor sizes were measured, and relations of ECAs with times of chemoemb-olization, tumor size, and the anatomic tumor location were analyzed. Complications were observed after chemoemb-olization through ECAs of HCC with different techniques.

RESULTS: Influence factors of formation of ECAs of HCC included the times of repeated chemoembolization, the location of tumors in liver, the tumor size and the types of chemoembolization. ECAs in HCC appeared after 3-4 times of chemoembolization (17.9%), but a higher frequency of ECAs occurred after 5-6 times of chemoem-bolization (56.4%). ECAs presented easily in peripheral areas (71.8%) of liver abutting to the anterior, posterior abdominal walls, the top right of diaphragm and right kidney. ECAs also occurred easily after complete obstruction of the trunk arteries supplying HCCs or the branches of proper hepatic arteries. Extrahepatic collaterals of HCC originated from right internal thoracic (mammary) artery (RITA, 5.1%), right intercostal artery (RICA, 7.7%), left gastric artery (LGA, 12.8%), right inferior phrenic artery (RIPA, 38.5%), omental artery (OTA, 2.6%), superior mesenteric artery (SMA, 23.1%), and right adrenal and renal capsule artery (RARCA, 10.3%), respectively. The complications after chemoembolization attributed to no super selective cathet-erization.

CONCLUSION: The formation of ECAs in unresectable HCC is obviously correlated with multiple chemoembolization, tumor size, types of chemoembolization, anatomic location of tumors. Extrahepatic collaterals in HCC are corresponding to the tumor locations in liver.

Supraumbilical Skin Rash and Fat Necrosis after Transcatheter Arterial Chemoembolization: A Case Report

We report the case of a 63-year-old female who had chronic hepatitis C and who was diagnosed with hepatocellular carcinoma. Hepatic angiography showed one visible and tortuous falciform artery arising as the terminal branch of the left hepatic artery. Transcatheter arterial chemoembolization (TACE) was performed via the left hepatic artery. The patient developed supraumbilical skin rash with local tenderness on the following day. After supportive treatment by a dermatologist, the skin rash subsided gradually with sequelae of irregular skin surface and one small subcutaneous nodule. Skin biopsy of the lesion 1 year later showed fat necrosis with foreign body reaction and fibrosis. We discuss this rare complication of TACE and review the literature.

Transcatheter arterial chemoembolization for hepatocellular carcinoma: anatomic and hemodynamic considerations in the hepatic artery and portal vein

Hepatocellular carcinoma (HCC) is the most common malignant tumor of the liver. Although several therapeutic options have been advocated, transcatheter arterial chemoembolization (TACE) in particular has been widely performed in the treatment of HCC. Still, hepatic arteriography and portography are mandatory for evaluation of (a) the resectability and multiplicity of HCCs and (b) the hemodynamic status of the portal vein. Thereafter, TACE can be considered as the initial therapeutic modality. The possibility of nontarget organ complications during TACE (eg, ischemic cholecystitis, splenic infarction, gastrointestinal mucosal lesions, pulmonary embolism and infarction, spinal cord injury, ischemic skin lesions) should be taken seriously. A thorough understanding of the anatomic variants and hemodynamic features of the hepatic artery and portal vein is the first step in performing effective and safe TACE for HCC.