ANATOMY FOR TACE/TARE Robert J Lewandowski MD FSIR DISCLOSURES • Advisory Board: BTG, BSC • Consultant: Cook, ABK JVIR 2005 CVIR 2007 TVIR 2007 CELIAC AXIS 3-4 mL/s for 12-15 mL • Classic branches: • splenic, common hepatic, left gastric, dorsal pancreatic • Variants: • Replaced left hepatic (gastrohepatic trunk) • Right and left inferior phrenic arteries • ‘‘Double hepatic’’ artery • Early takeoff of the right hepatic artery GASTROHEPATIC TRUNK • Most Challenging Variant • Look in fissure • Ligamentum venosum • Often perfuses segments II/III • Beware horizontal segment of replaced left hepatic artery Inferior Phrenic Arteries Double Hepatic Artery Variant COMMON HEPATIC ARTERY 3 mL/s for 12 mL • Classic branching pattern • GDA, right gastric, supraduodenal, dorsal pancreatic • Variants: • Trifurcation into a GDA, right, and left hepatic arteries • LHA origin prior to GDA • Separate segment 4 artery Left Hepatic Artery Originates prior to GDA Separate Segment 4 Artery LEFT HEPATIC ARTERY 2-3 mL/s for 8-10 mL • Right gastric artery • Falciform artery • Left inferior phrenic artery • Accessory left gastric artery • Inferior esophageal artery • 68% variants off left hepatic • 78% right gastric artery • 52% falciform artery • 2% left inferior phrenic Song et al JVIR 2006 RIGHT GASTRIC ARTERY • Often off proximal left hepatic artery • Characteristic course • When in doubt -- Selective catheterization with venous phase imaging ACCESSORY LEFT GASTRIC ARTERY • Review imaging • Fissure - ligamentum venosum • Size of left hepatic lobe • Look for vessel out of proportion to others • Abnormal flow pattern LEFT INFERIOR PHRENIC ARTERY • Courses along the left diaphragm 2% • Outside the confines of the liver FALCIFORM ARTERY • Extra-hepatic course • May form a “complex” BOTTOM LINE: • BEWARE the left hepatic artery • Look for these vessels of interest: • Right gastric artery • Accessory left gastric artery • Left inferior phrenic artery • Falciform artery • Be aware of size of left hepatic lobe • Interrogate any vessels in question RIGHT HEPATIC ARTERY 2-4 mL/s for 10-12 mL • Retro-portal artery • Cystic Artery Retroportal Artery • 46 patients • 35 gelfoam pledgets/11 coil embolization • 7% RUQ pain • 2% (n=1) required cholecystectomy • Proximal cystic artery embolization with gelfoam pledgets is safe and feasible CVIR 2011 • 327 patients, 569 Y90 infusions • Imaging findings post Y90: 10% of pts • Biliary stricture 2.4% • Biliary necrosis 3.9% • Biloma 1% • Cholecystitis 1.8% • 0.6% requiring surgery • Unplanned intervention: 1.8% of pts TIP #1 All vessels should have same flow dynamics TIP #2 Know expected course of hepatic arteries TIP #3 Be cautious of branches off LHA prior to termination* * Excluding segment 1 and 4 arteries C-Arm CT CONE-BEAM CT: CONFIRMING TUMOR TARGETING Arterial-Phase MRI Venous-Phase MRI Axial Cone Beam CT Coronal Cone Beam CT CONE-BEAM CT: CONFIRMING TUMOR TARGETING Thank you .