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Two-Way Gastroduodenal Artery

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Two-Way Gastroduodenal Artery Diagnostic and Interventional Imaging (2013) 94, 330—332 View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector LETTER / Gastrointestinal imaging Two-way gastroduodenal artery ∗ C. Cassinotto , B. Lapuyade, M. Montaudon Department of Diagnostic and Interventional Radiology, Haut-Lévêque Hospital, Groupe hospitalier Sud, CHU de Bordeaux, 1, avenue de Magellan, 33604 Pessac cedex, France Clinical case KEYWORDS Radio-embolisation; Following a multidisciplinary consultative meeting, radio-embolisation treatment with Gastroduodenal Yttrium-90 had been proposed to a 74-year-old male patient for palliative treatment of artery; non-resectable hepatic metastases of a colorectal cancer. The hepatic angiogram produced Coil embolisation; during the preparatory phase (Fig. 1) showed that the anatomy was normal as regards to Toxicity the main vascular routes. The coeliac trunk trifurcated into a splenic artery, a left gastric artery and a common hepatic artery. The hepatic artery proper is relatively short, bifur- cating into a left and a right branch. The right gastric artery (or pyloric artery) was clearly seen, arising from the first segment of the left branch of the hepatic artery. A few special features and anatomical variants from the normal were nevertheless seen: • the dorsal pancreatic artery arose from the first third of the common hepatic artery (and not from the splenic artery); • the cystic artery arose from an arterial branch to segment IV and arose from the right hepatic branch; • the gastroduodenal artery (GDA) was very short, with early bifurcation into an anterior—superior pancreaticoduodenal trunk and a posterior—superior pancreaticoduo- denal trunk. The image produced after microcatheterisation of the common hepatic artery (Fig. 2) showed intermittent opacification of the anterior pancreaticoduodenal arcade, unlike the posterior arcade which remained correctly opacified. A retrograde flow only present in the anterior pancreaticoduodenal arcade was later confirmed on the angiographic image of the superior mesenteric artery. Under these conditions, preventive embolisation was undertaken only of the posterior pancreaticoduodenal arcade (Fig. 3). The injection of Yttrium-90 microspheres was possible later under normal conditions by positioning the microcatheter after catheterization of the coeliac trunk in the hepatic artery proper. There were no complications, particularly duodenal or pancreatic, in the mid to long term, related to the procedure. ∗ Corresponding author. E-mail address: [email protected] (C. Cassinotto). 2211-5684/$ — see front matter © 2012 Éditions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.diii.2012.11.004 Two-way gastroduodenal artery 331 Figure 1. Coeliac artery angiogram. The coeliac trunk trifurcates Figure 3. Superior mesenteric angiogram (SMA) produced after into a left gastric artery, a splenic artery and a common hepatic embolisation of the right gastric artery (black arrows), the cystic artery (CHA). The dorsal pancreatic artery (black arrowhead) arises artery (white arrow) and the anterior pancreaticoduodenal arcade from the first third of the common hepatic artery. After the origin (white arrowheads). The posterior pancreaticoduodenal arcade is of the gastroduodenal artery, a short hepatic artery proper (HAP) not embolised, participating in provision of the hepatic circulation. divides into left and right hepatic branches. The right gastric (or pyloric) artery is clearly visible (black arrows) arising from the first hepatic artery [1,2]. Other, sometimes very old, studies have segment of the left branch of the hepatic artery (on the angiog- concentrated on anatomical variants affecting the smaller raphic image crossing the hepatic artery and the gastroduodenal caliber arterial axes of the hepatic hilum, such as the cys- artery (GDA)); the cystic artery (white arrow), also clearly visible, tic, right gastric, retroduodenal, supraduodenal or falciform arises from a branch of segment IV. The gastroduodenal artery is arteries [3,4]. short, bifurcating early on into the pancreaticoduodenal arteries. The increase in recent years of new complex hepatic endovascular treatments, such as radio-embolisation or Discussion fitting implantable hepatic arterial ports, requires the inter- ventional oncology radiologist to be familiar with the many Splanchnic vascular anatomy can present many variations. anatomical variants of the hepatic arterial bed. In the case Michels’ classification, published in 1953 and extended by of Yttrium-90 radio-embolisation treatment, not recogniz- Hiatt in 1994 from surgical data from 1000 patients who ing an arterial variation or a collateral vessel may result had undergone a liver transplant, is internationally recog- in serious complications such as ulceration or gastroduode- nized for describing the variants of the coeliac trunk and nal perforation, acute pancreatitis, acute cholecystitis or Figure 2. Hepatic artery angiogram showing intermittent opacification of the anterior—superior pancreaticoduodenal artery (black arrows) due to retrograde flow in the anterior pancreaticoduodenal arcade issuing from the superior mesenteric artery. Gastroduodenal artery (GDA) (white arrowhead). Posterior—superior pancreaticoduodenal artery (white arrow). 332 C. Cassinotto et al. necrosis of the skin. To prevent the risk of complications, Disclosure of interest radio-embolisation treatment is preceded by a first angiog- raphy session, the purpose of which is to occlude digestive The authors declare that they have no conflicts of interest arteries arising from the hepatic artery (GDA, right gastric concerning this article. artery etc.) and to ensure that any parasitic vessels which are participating in supplying the tumor (the right diaphrag- References matic artery, right adrenal artery, right internal thoracic artery etc.) are embolised. The embolisation performed is [1] Michels NA. Collateral arterial pathways to the liver after liga- definitive, generally using coils or vascular occlusion plugs, tion of the hepatic artery and removing of the celiac axis. Cancer particularly for the gastroduodenal artery [5]. When angiog- 1953;6:708—24. raphy shows a GDA with reversed flow, either because of [2] Hiatt JR, Gabbay J, Busuttil RW. Surgical anatomy of the hepatic stenosis of the coeliac trunk or due to increased superior arteries in 1000 cases. Ann Surg 1994;220:50—2. mesenteric artery flow, its occlusion may be avoided as long [3] Michels NA. The hepatic, cystic and retroduodenal arteries and as the necessary precautions are taken during the thera- their relations to the biliary ducts with samples of the entire peutic injection (monitoring vascular stasis and injection celiacal blood supply. Ann Surg 1951;133(4):503—24. [4] Bianchi HF, Albanese AF. The supraduodenal artery. Surg Radiol downstream of the origin of the GDA) [6]. The example of Anat 1989;11(1):37—40. our patient illustrates the therapeutic traps that vascular [5] Pech M, Kraetsch A, Wieners G. Embolization of the gas- anatomical variants can represent. Because of their resolu- troduodenal artery before selective internal radiotherapy: a tion, hepatic CT angiography and MRA provide a reliable map prospectively randomized trial comparing platinum fibered of the main splanchnic arterial axes. However, they cannot microcoils with the Amplatzer Vascular Plug II. Cardiovasc Inter- be substituted for digital angiography, which not only pro- vent Radiol 2009;32:455—61. vides much more precise information concerning the small [6] Daghir AA, Gungor H, Haydar AA, Wasan HS, Tait NP. Embolisation and medium caliber arterial network, but also the functional of the gastroduodenal artery is not necessary in the presence of information necessary, by allowing flow characteristics to be reversed flow before Yttrium-90 radioembolisation. Cardiovasc assessed. Intervent Radiol 2011;35(4):839—44..
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