IVR 会誌 Jpn J Intervent Radiol Vol.18 No.3 2003

State of the Art
Interventional Radiology and Clinical Anatomy

1. Anatomy of the Caudate Lobe of the Liver
Department of Anatomy, Sapporo Medical University School of Medicine
Toshio J. Sato, Gen Murakami

The caudate lobe is defined as a dorsal liver parenchymal area that is supplied by the portal vein branches originating directly from the left and right portal vein trunks, including the hilar bifurcation(HB) area. The HB branch is observed in approximately half of the specimens(24 of 48 livers). The caudate lobe consists of three subsegments : (1) Spiegel’s lobe, (2) caudate process, and (3) paracaval portion. The paracaval portion, lying ventral to and on the right side of the inferior vena cava, occupies a large area in the lobe. The caudate lobe has three free surfaces and two intraparenchymal border planes : (1) left surface, (2) dorsal surface, (3) hilar surface, (4) ventral border plane, and (5) right border plane. The ligament venosum is located along the angle between the left surface and ventral border plane. Couinaud postulated the concept of“dorsal liver,”which is defined by its location in the liver. This concept is different from portal segmentation, and causes great logical confusion for surgeons.
Key words
● Caudate lobe
● Portal vein
● Hepatic vein

2. Topographic Anatomy of the Venous System of the Cardioesophageal Region
Functional Anatomy, Tokyo Medical and Dental University1)
Division for the Visually Impaired, Tsukuba College of Technology 2)
Tatsuo Sato1), Hirokazu Sakamoto1, 2)

For a better understanding of the porto-caval venous communications in portal hypertension, two cadaveric dissections are demonstrated.
1) Comprehension of the cardioesophageal venous plexus is critical for the understanding of porto-caval venous communications because it is situated at the crossroad of venous communications. This plexus has the potential for development of various venous communications via mediating veins of the two different systems.
2) In Specimen 1(Figs. 1-5), several ascending pathways from the cardioesophageal venous plexus were dissected. Connections of this plexus with the thoracic part of the inferior vena cava and those with the azygos and hemiazygos veins were confirmed.
3) In Specimen 2(Figs. 8-11), an atypical enlarged transverse communicating vein is found in front of the cardioesophageal area. This transverse vein continues to the left gastric vein to enter the portal vein, while it also continues to the left inferior phrenic vein to drain into the left renal vein. It should be stressed that the retrocardial area of the stomach, without the covering of the peritoneum, is a critical area for vascular communication between the peritoneal and the retroperitoneal organs.
Key words
● Paraportal circulation
● Cardioesophageal venous plexus
● Left vein inferior phrenic

3. Morphology of the Left Portal Vein
Department of Anatomy, Tokyo Medical University
Takayoshi Miyaki

The right and left gastric veins drain the venous blood of the stomach. The left gastric vein joins either the splenic vein or the portal vein. The vein running in the hepatogastric ligament was found in four specimens of human liver. The author adopted the name of“left portal vein”for this vein. The left portal vein has already been described as“V. portae sinistra”in the bird. In two of the four specimens, the left portal vein sends the venous blood from the stomach to the liver. The left portal vein joins the branch of the intrahepatic portal vein. In another specimen, the left portal and the left gastric veins coexist. The left gastric vein joins the splenic vein, and the left portal vein arises from the left gastric vein. Moreover, in the remaining one, the left hepatic artery arising the left gastric artery runs with the left portal vein in the hepatogastric ligament. The left portal vein arises from the left gastric vein at the cardiac portion of the stomach. The left gastric vein joins the usual portal vein. Besides the left portal vein, the artery has been found in the hepatogastric ligament at a frequency of 30%.
Key words
● Left portal vein
● Hepatogastric ligament
● Left gastric vein

4. Arterial Supply and the Collateral Circulation of the Diaphragm
Department of Anatomy, Graduate School of Medical Sciences, Kumamoto University
Masahiro Koizumi

The distribution of the inferior phrenic arteries and the collateral pathways for the arterial supply to the diaphragm were observed in an 88-year-old female cadaver. Right and left inferior phrenic arteries arose from the aorta by a common stem. The right inferior phrenic artery ran forward along the right of the opening of the inferior vena cava giving rise to some muscular branches laterally. Near the origin of the sternal part it sent a small branch into the falciform ligament to supply the liver. The left inferior phrenic artery(Lipa), after passing behind the esophagus, had superior suprarenal and cardio-esophageal branches. At the posterior margin of the left leaf of the central tendon, Lipa showed a medial branch, which supplied the liver through the coronary ligament. Lipa traversed the antero-lateral muscular portion to anastomose with the pericardiacophrenic artery on the upper surface of the diaphragm and terminated to anastomose with the musculophrenic artery at the sternal margin. In the cardio-esophageal region the branches from both left gastric artery and Lipa were distributed. The anastomoses among these branches can contribute to the formation of the phrenic branches originating from the left gastric artery in a second case observed in this study.
Key words
● Inferior phrenic artery
● Diaphragm
● Collateral circulation

5. Vessels in the Hepatic Falciform Ligament
Department of Radiology, Mitsui Memorial Hospital
Kenji Ibukuro
Unit of Clinical Anatomy, Graduate School, Tokyo Medical and Dental University
Keiichi Akita

There are two distinct groups of vessels in the hepatic falciform ligament, known as the superior and inferior groups of Sappey. The superior group is located at the upper aspect of the hepatic falciform ligament and derives from the anastomosis between the internal thoracic and the inferior phrenic vessels. The inferior group is located at the lower part of the hepatic falciform ligament, where the hepatic falciform ligament artery and paraumbilical veins are demonstrated. Those vessels also anastomose with the peripheral branches of the internal thoracic vessels in the properitoneal fat pad.
Hepatic falciform ligament is the important structure where the parietal vessels such as the internal thoracic vessels and inferior phrenic vessels anastomose with the organic vessels such as the hepatic falciform ligament artery(branch of left hepatic artery) and the paraumbilical veins(branch of portal vein).
Key words
● Hepatic falciform ligament
● Paraumbilical vein
● Veins of Sappey
● Xiphoid process

6. Anatomical Variations of the Internal Iliac Artery and its Branches
Unit of Clinical Anatomy, Graduate School, Tokyo Medical and Dental University
Keiichi Akita

The internal iliac artery is an artery which has various intrapelvic and extrapelvic branches. This artery is embryologically conosisted of the two main trunk: the medial umbilical ligament (the superior vesical artery) and the inferior gluteal artery. Most of branches are originated from two trunks and the junction between them. The intrapelvic branches run anterocaudalward. The branches make various connections around the lower part of the urinary bladder region and the prostate region(in male) or the lower part of the vagina(in female). In addition, it is sometimes observed that the accessory pudendal artery which runs through the prevesical space and communicate with the dorsal artery of the penis. In the present study, various patterns of the branches of the internal iliac artery are shown.
Key words
● Superior vesical artery
● Inferior gluteal artery
● Accessory pudendal artery
● Internal iliac artery

7. Anatomy of the Bronchial Arteries
Division of Gross Anatomy and Morphogenesis,
Department of Regenerative and Transplant Medicine,
Niigata University Graduate School of Medical and Dental Sciences
Shoji Chiba

The origins of the bronchial arteries are found in five areas : 1) right subclavian artery and its branches, 2) left subclavian artery and its branches, 3) right aortic intercostal arteries, 4) aortic arch proximal to the left recurrent laryngeal nerve and 5) thoracic aorta distal to the above-mentioned nerve. The origin appears in 29%, 4%, 85%, 29% and 97% of 100 bodies, respectively. The arteries from the origins 1) and 3) continue as the right superior bronchial arteries, the arteries from 2) and 4) continue as both the right inferior and the left superior bronchial, and the arteries from 5) continue as the left superior, left inferior and right inferior bronchial arteries and frequently form a common trunk for the lungs. The most common pattern, 2 right and 2 left bronchial arteries, is found in 31% of 100 bodies. Along the vagus and recurrent laryngeal nerves on each side, the bronchial arteries form a longitudinal communication. The bronchial arteries as well as the communications give off many branches to the surrounding organs such as the trachea, bronchi, esophagus, lymph nodes, aorta and vagus nerves. Above the bifurcation of the trachea, both sides of the esophagus are supplied by the right and left superior bronchial arteries in halves. Below the bifurcation, the anterior and posterior surfaces are supplied by the esophageal branches of the left inferior bronchial and the right superior or inferior bronchial artery, descending with the vagus nerves. The bronchial arteries often communicate with the esophageal arteries from the thoracic aorta on both surfaces of the esophagus.
Key words
● Bronchial artery
● Esophageal artery
● Vagus nerve
● Segmental bronchus
● Macroscopic anatomy

Original Article
Topography of the Accessory Left Gastric Artery (ALGA) Analyzed by CT Angiography from the Left Hepatic Artery
Department of Radiology, The Central Hospital and Cancer Center of Ibaraki
Yasukazu Shioyama, Isao Takasaka, Hiroaki Onaya, Toshiyuki Okumura
Department of Radiology, Wakayama Medical College
Nozomu Takeuchi, Takami Hagihira, Mitsunori Masuda
Koushi Horihata, Masashi Kimura, Morio Sato

 Purpose : To avoid gastric complications when we perform transcatheter treatment via left hepatic artery, we analyzed the topography of ALGA(accessory left gastric artery) by left hepatic arteriography and CT angiography from left hepatic artery.
Materials and Methods : Six hundred seventy eight cases of CT angiography were performed between 1995 and 2000. Among them, selective left hepatic arteriography was done in 85 cases. We analyzed the frequency and the course of ALGA on the hepatic angiogram and CT angiogram.
Results : ALGA were identified in eighteen(21.2%) of the 85 cases. We classified them into eleven cases of the proximal type and six cases of the distal type. When ALGA bifurcated from the left hepatic artery very close to the bifurcation of A2(dorsolateral branch) and A3(ventro-
lateral branch), we classified them as the distal type on hepatic angiogram. On the other hand, when ALGA bifurcated from the left hepatic artery apart from the bifurcation of A2 and A3 they were classified as the proximal type. In one rare case ALGA originated from the dorsolateral branch of the left hepatic artery.
Conclusion : ALGA were classified as the distal and proximal types. Distal type of ALGA often overlapped dorsolateral branch of the left hepatic artery, and it was sometimes difficult to notice the existence of them. We should check the existence of ALGA on the arterial phase of dynamic CT before we plan to make a transcatheter treatment from the left hepatic artery. Then we can avoid gastric complications caused by a transcatheter treatment from the left hepatic artery.
Key words
●Accessory left gastric artery
●CT angiography
●Transcatheter arterial embolization

Case Report
Intrahepatic Extravasation during Hepatic Arterial Infusion Chemotherapy through the Implanted Side-slit Catheter : Report of Two Cases
Department of Radiology, Iwate Medical University
Miyuki Sone, Kenichi Kato, Shigeru Ehara
Department of Radiology, Iwate Prefectural Kitakami Hospital
Toya Obara

 We report two cases of intrahepatic extravasation from an implanted catheter for hepatic arterial infusion chemotherapy of liver metastases. Tapered catheters with shape-memory alloy in the tip wall were used in these cases. A side-slit was created to apply distal fixation technique using this catheter. Catheters having side holes and no side slits appear to be needed to prevent this complication.
Key words
●Hepatic arterial infusion chemotherapy
●Side-hole catheter

Case Report
A Case of Stage IVb Advanced Pancreatic Carcinoma with Liver Metastases Treated Successfully by Arterial Continuous Infusion Chemotherapy Combined with Systemic Administration of Gemcitabine
Department of Radiology, Kumamoto University School of Medicine
Kouichi Kudoh, Tsuyoshi Yasuda, Tadahito Urakado, Yuri Yoshida, Kouichi Kawanaka
Ichirou Ikushima, Osamu Ikeda, Akihiko Arakawa, Yasuyuki Yamashita

 We report a case of stage IVb advanced pancreatic cancer with liver metastases treated successfully by arterial continuous infusion chemotherapy of 5-fluorouracil and cisplatin through a total transcutaneous implanted catheter system by angiographic procedure, combined with systemic administration of gemcitabine. Both inferior pancreaticoduodenal artery and pancreaticoduodenal arterial arcade were embolized by platinum coils in order to redistribute pancreatic blood supply only through the celiac artery. Gastroduodenal artery, and left and right gastric artery were also embolized to prevent blood flow to upper gastrointestinal tract. Two side holes were made on the catheter at the celiac trunk so that drugs were delivered into both common hepatic artery and splenic artery. Two months after this treatment, tumor marker levels markedly decreased, and CT showed decrease in tumor size. The patient survived for about 1 year. This treatment may be effective for stage IVb advanced pancreatic cancer with liver metastases, when appropriate drug distribution and arterial infusion can be continued for a long period.
Key words
●Pancreatic cancer
●Arterial infusion chemotherapy
●Anticancer agent
(5-fluorouracil, cisplatin, gemcitabine)

Case Report
A Case of Fibroid Calcification after Uterine Artery Embolization
Division of Radiology, Haibara General Hospital
Hajime Kato, Masatoki Ozaki

 We report a case of fibroid calcification after uterine artery embolization(UAE). A 41-year-old woman with multiple intramuscular uterine fibroids received UAE with gelatin sponge particles alone. Plain and contrast-enhanced computed tomography(CT) was performed 1 year after UAE for non-uterine abdominal pain. CT revealed ring-like peripheral calcification in the fibroids. It is reported that fibroids cause peripheral calcification on ultrasonography 6 months or later after UAE with polyvinyl alcohol. Our case shows that uterine fibroids may cause ring-like peripheral calcification after UAE with gelatin sponge particles alone.
Key words
●Uterine Artery Embolization(UAE)

Technical Note
Implantation of the Intra-Arterial Port-Catheter System
Using W Spiral Catheter in the Peripheral Hepatic Arteries without Fixation for Treatment of Malignant Liver Tumors : Clinical Experience
Department of Radiology, Internal Medicine, Division of Digestive Disease1) and Surgery2)
Nara Prefectural Nara Hospital
Tetsuya Yoshioka, Noriko Horikawa, Katsutoshi Takayama, Toshiya Nakatani1)
Kazuhiro Masui1), Eiryou Kikuchi1), Teruyuki Sakaguchi2), Akihiko Watanabe2)

 Purpose : To describe our experience of the intra-arterial port-catheter system using a W spiral catheter for treatment of malignant liver tumors.
Materials nad Methods : Twenty-one W spiral catheters in 20 patients were implanted to treat malignant liver tumors. Catheter tip was placed in the peripheral hepatic arteries without fixation via the femoral artery in 16 patients and left subclavian artery in 4 patients.
Results : All catheters were successfully placed. Dislodgement of the side hole of a catheter occurred in one patient without migration of the catheter tip. Drug distribution was good at follow up except in one patient. There was one severe complication of pseudoaneurysm.
Conclusions : This method seemed to be feasible for implantable reservoir therapy of patients with malignant liver tumors.
Key words
●Port-catheter system
●Liver cancer
●Intra-arterial chemotherapy