I. Kanetsuki

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.

LOCALIZATION OF INSULINOMAS: Comparison of conventional arterial stimulation with venous sampling (ASVS) and superselective ASVS

Purpose: To examine the value of superselective arterial stimulation venous sampling (ASVS) to localize insulinomas. Material and Methods: Superselective ASVS (SS-ASVS) was performed in 9 patients with insulinoma. Injection of secretagogue (calcium gluconate: 0.01 mEq Ca++/kg) was performed into the gastroduodenal, splenic (proximal and distal), and superior mesenteric arteries in 9 patients and additionally into the dorsal pancreatic artery in 6 patients. Sampling from the hepatic vein was performed to measure serum insulin concentrations at 30, 60 and 120 s after each injection of secretagogue into these arteries. SS-ASVS results were correlated with surgical findings, compared to those of conventional ASVS. Results: Insulinomas were correctly localized to the head, body or tail of the pancreas by SS-ASVS in 8 patients (89%). Conventional ASVS detected insulinomas in 7 patients (78%), although it could not distinguish whether the insulinoma was located in the pancreatic body or tail in 4 of the 7 patients. There were eight-fold or more increases in serum insulin levels in hepatic venous samples related to the artery supplying the tumor in 8 patients. Localization of the insulinomas was verified at surgery in all patients. Conclusion: SS-ASVS is a useful method for detailed evaluation of overproduction of insulin from pancreatic insulinomas and their localization. When the pancreatic insulinoma is situated in the pancreatic body or tail, the localization is more accurately made by SS-ASVS than by conventional ASVS.

Altered flow dynamics of intravascular contrast material to the liver in superior vena cava syndrome: CT findings

AbstractBackground: To evaluate the findings of altered flow dynamics in the livers of patients with obstruction of superior vena cava (SVC) on helical computed tomography (CT). Methods: In six patients (age range = 28–80 years) with SVC obstruction, CT findings were retrospectively reviewed to identify the abnormal enhancement patterns of the liver and the relation with the extrahepatic collateral vessels and hepatic vessels. Results: Abnormal hepatic enhancement was observed in the following four (A–D) portions: (A) anterior portion of segment IV (n = 5), (B) subdiaphragmatic portion of the liver (n = 4), (C) posterior portion of the right lobe (bare area; n = 1), and (D) lateral segment of the left lobe (n = 2). Two major collateral pathways to the liver were demonstrated as follows: A and D → from the umbilical vein to the left portal vein, and B and C → from the subcapsular vein to the bare area of the liver or to the hepatic veins. On helical CT, these collateral pathways were also clearly visualized. Conclusion: When these abnormal enhancements of the liver on CT are recognized within the liver, these findings indicate diversion of contrast material into collateral pathways to the liver with SVC obstruction.

Small hepatocellular carcinoma supplied by the right renal capsular artery. A case report.

We present a case of hepatocellular carcinoma (HCC), which was fed only by the right renal capsular artery. Ten years earlier, this patient underwent surgery for a solitary HCC in segment IV. However, the hepatic artery was patent and did not participate in feeding the HCC. We consider the renal capsular artery as an essential extrahepatic parasitic feeding artery to HCC.

Retrograde visualization of the portal venous system using CO2 intraarterial digital subtraction angiography

Carbon dioxide (CO2) intraarterial digital subtraction angiography (IADSA) provides retrograde visualization of the portal vein via a peripheral segmental hepatic artery. IADSA was performed in 12 patients with known hepatic diseases by injecting a peripheral hepatic artery with both CO2 gas and an iodinated contrast medium. The portal vein was constantly visualized only with CO2 IADSA in all patients. The injected CO2 may flow back into the portal vein through an anastomotic system known as the peribiliary or periportal plexus. This new method is safe and useful to image the portal venous system in patients with hepatic malignancy.

Treatment of Hepatocellular Carcinoma by Intraarterial Injection of Adriamycin/Mitomycin C Oil Suspension (ADMOS) Alone or Combined with CIS-Diaminodichloroplatinum (CDDP)

We evaluated the effects of intraarterial injection of Adriamycin/Mitomycin C oil (Lipiodol) suspension (ADMOS) alone and ADMOS + cis-diaminodichloroplatinum (CDDP) in 135 patients with hepatocellular carcinoma (HCC). A total of 59 patients received ADMOS alone and 76 patients received ADMOS + CDDP (ADMOS/CDDP). Tumor size was reduced by over 25% in 13 (34%) of the evaluable 38 patients in the ADMOS-alone group and in 39 (51%) of the 76 evaluable patients in the ADMOS/CDDP group. Serum alpha-fetoprotein (AFP) levels decreased by more than 50% in 10 (59%) of 17 ADMOS-alone patients and in 23 (70%) of 33 ADMOS/CDDP patients whose pretreatment AFP levels were above 0.2 mg/l. The overall one- and 2-year survival rates were 68% and 41%, respectively. No severe complications and no significant changes in laboratory values were observed, except for one patient in the ADMOS/CDDP group who developed a liver abscess. Although the tumor response was significantly better in patients treated by ADMOS/CDDP than in those treated by ADMOS-alone (p < 0.05), there was no significant difference in the survival rates between the 2 groups. The intraarterial injection of ADMOS and CDDP was concluded to be effective in treating HCC judging by tumor response.