Educational Exhibit Authors: S. Aquilina, K. Cortis, R. Miraglia, L. Maruzzelli, A. Mizzi ; 1

Transcription

1 Variant Hepatic Arterial Anatomy and Extra-hepatic Arterial Supply in Hepatocellular Carcinoma (HCC) and Colorectal Metastases: Impact on Transarterial Chemoembolization (TACE) Planning and Technique Poster No.: C-1686 Congress: ECR 2016 Type: Educational Exhibit Authors: S. Aquilina, K. Cortis, R. Miraglia, L. Maruzzelli, A. Mizzi ; Msida/MT, Palermo/IT Keywords: Interventional vascular, Liver, Oncology, Catheter arteriography, CT-Angiography, MR, Chemoembolisation, Neoplasia DOI: /ecr2016/C-1686 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 34

2 Learning objectives This educational exhibit aims to: Illustrate the conventional hepatic arterial supply Describe commonly encountered anatomic variants in hepatic arterial supply and extra-hepatic collateral routes Describe possible complications from lack of recognition of variant or extrahepatic collateral supply Define optimised CT and MRI protocols enabling correct pre-procedural planning and catheter selection, with potential decreased radiation exposure during TACE Page 2 of 34

3 Background Over the last two decades Transarterial Chemoembolisation (TACE) has become a widely established procedure for the treatment of liver malignancies, especially hepatocellular carcinoma [1]. The rationale behind TACE is that the majority of these tumours are supplied by the hepatic artery, unlike normal liver parenchyma, regenerative and low grade dysplastic nodules, which are supplied mainly by the portal vein [2-4]. TACE targets hepatic malignancies through two inter-related mechanisms of action - the ischaemic effect induced by selective embolisation of the arterial supply, and the direct effect resulting from infusion of the chemotherapeutic agent. The first step in performing safe and effective TACE is a thorough assessment of appropriately protocoled pre-procedural scans, to establish the hepatic arterial anatomy [1]. The classification scheme of anatomic variation in the hepatic arterial supply was described in 1955 by Michel. Results were based on dissection of 200 cadavers and its results are summarised in Table 1. Page 3 of 34

4 Table 1: Hepatic arterial variants according to the Michel's classification References: Sureka B, et al. (2013) Variations of celiac axis, common hepatic artery and its branches in 600 patients. Indian J Radiol Imaging;23: Table 2 summarises the results of a study performed in 2001 by Gruttadauria et al, where hepatic arterial anatomy was reviewed in 701 patients. Variant hepatic arterial anatomy in this study was found to be present in approximately 42% of cases [6]. Page 4 of 34

5 Table 2: Common and rare types of hepatic arterial anomalies References: Gruttadauria S et al. (2001) The hepatic artery in liver transplantation and surgery: vascular anomalies in 701 cases. Clin Transplant; 15: In addition, extrahepatic collateral arterial supply to these malignant liver lesions may also be encountered, even when the hepatic artery is patent [8,9]. There are two mechanisms for the development of extrahepatic collateral routes [1]: Loss of native hepatic artery due to repeated TACE, dissection from catheterization, or occlusion by surgical ligation Parasitization of the extrahepatic arteries in the presence of a patent native hepatic artery, in cases where the malignant lesion is exophytic or located in the subcapsular region of the liver. The development of extrahepatic collateral arteries that supply HCC interferes with effective TACE [10]. Page 5 of 34

6 It is therefore of great importance for the interventional radiologist to be familiar with these anatomic variants and extra-hepatic collaterals, and with their characteristic appearances on cross-sectional imaging. It is also necessary to optimise CT and MR liver scanning protocols to enable recognition of vascular supply of the lesion(s) being treated at the planning stage of the procedure rather than during the procedure itself. This potentially reduces screening time and therefore radiation dose during angiography for the patient and operators alike. Page 6 of 34

7 Images for this section: Table 1: Hepatic arterial variants according to the Michel's classification Sureka B, et al. (2013) Variations of celiac axis, common hepatic artery and its branches in 600 patients. Indian J Radiol Imaging;23: Page 7 of 34

8 Table 2: Common and rare types of hepatic arterial anomalies Gruttadauria S et al. (2001) The hepatic artery in liver transplantation and surgery: vascular anomalies in 701 cases. Clin Transplant; 15: Page 8 of 34

9 Findings and procedure details Conventional hepatic arterial anatomy In conventional hepatic arterial anatomy, the coeliac trunk trifurcates into the splenic artery, the left gastric artery (LGA) and the common hepatic artery (CHA). The CHA in turn divides into the gastroduodenal artery (GDA) and proper hepatic artery. The latter divides into the right and left hepatic arteries (RHA and LHA), which give off segmental branches [7]. This conventional anatomy is depicted in Figure 1. Page 9 of 34

10 Fig. 1: 58 year old male with liver cirrhosis and focal HCC in right lobe. Top image: Coronal MIP image demonstrating conventional anatomy of the hepatic arterial supply. Image also shows the known HCC in the right lobe (arrow). Bottom image: Digital subtraction angiographic (DSA) image in the same patient. (1)Coeliac axis (2)CHA (3)LGA (4)Splenic artery (5)GDA (6)LHA (7)RHA (8)SMA References: - Msida/MT Anatomic Variants The most commonly encountered anatomic variants include: Page 10 of 34

11 Replaced or Accessory RHA from the superior mesenteric artery (SMA). On cross-sectional imaging this variant is readily identified on the axial sequences by a portocaval course of this artery. In conventional anatomy the portocaval space does not contain any vascular structures [1]. This is the most frequently encountered variant, in 15% of the population [6]. Figure 2 demonstrates a replaced RHA from the SMA. Fig. 2: Middle-aged patient with established liver cirrhosis and multifocal HCC Top left image: Coronal T1+C FatSat MT image demonstrating a vessel coursing below the portal vein (arrowhead). Multiple arterialised lesions are noted in the liver, in keeping with multifocal HCC. Top right image: DSA image with catheter in coeliac trunk (6) the splenic (1), left gastric (LGA) (2) and common hepatic artery (CHA) (3) are seen. Branches of the CHA seen are the Gastroduodenal (GDA) (4) and the left hepatic artery (LHA) (5). Bottom left image: DSA image with catheter in superior mesenteric artery (SMA) (8). The first branch is the replaced right hepatic artery (7). Bottom right image: DSA image with catheter advanced into the replaced RHA Page 11 of 34

12 References: - Msida/MT Replaced or Accessory LHA arising from the LGA. This is also readily identified at axial sequences as it courses along the fissure for the ligamentum venosum [1]. It is the second commonest variant, encountered in 12% of cases [6]. Figure 3 demonstrates a replaced LHA. Figure 4 demonstrates an accessory LHA arising from the CHA. Fig. 3: 52 year old lady with three colorectal metastases, being treated by irinotecaneluted beads. These appear as highly metabolically active lesions seen on the PETCT. Top left image: MIP-Coronal CT image in the arterial phase demonstrating a replaced LHA (arrow) originating from the LGA (arrowhead) and supplying the left liver Page 12 of 34

13 lobe. Right top and bottom images: DEB-TACE for the left lobe performed through this route, with the microcatheter parked distal to the gastric branches. References: - Msida/MT Fig. 4: 45 year old gentleman with multiple liver metastasis from a well-differentiated retroperitoneal neuroendocrine tumour (NET). Top image: Coronal T1+C FatSat MR image demonstrating a branch (5 - arrow) originating from the CHA (4), proximal to the origin of the GDA (6). This is in keeping with an accessory LHA. Multiple lipiodol laden lesions are noted in both liver lobes, compatible with previously treated NET metastases. Bottom image: DSA image with catheter in coeliac trunk, again demonstrating the accessory LHA originating from the coeliac trunk. (1) Coeliac axis, Page 13 of 34

14 (2) Splenic Artery, (3) LGA, (4) CHA, (5) Accessory LHA, (6) GDA, (7) LHA, (8) RHA, (9)SMA References: - Msida/MT These variants can also co-exist with each other and other variants as shown in Figures 5 and 6. Fig. 5: 53 year old gentleman known case of liver cirrhosis with focal HCC in the left liver lobe. Top left image: Axial MIP CT image demonstrating an artery coursing posterior to the unopacified portal vein (P) - this is a replaced RHA (1). Top middle image: Axial MIP CT image demonstrating an artery in the fissure of the ligamentum venosus, originating from the left gastric artery - this is a replaced LHA (2). Top right image: Sagittal Oblique MIP CT image again demonstrating aberrant anatomy: (1)Replaced RHA (2)Replaced LHA (3)SMA (4)Coeliac axis. Bottom left image: DSA with catheter in SMA (3) confirming the presence of the replaced RHA (1). Bottom right image: DSA with catheter in the coeliac axis (4), confirming a replaced LHA (2) originating from the LGA (5). References: - Msida/MT Page 14 of 34

15 Fig. 6: 63 year old gentleman with liver cirrhosis and focal HCC (not shown). Right image: Coronal MIP image demonstrating a replaced LHA from LGA and a replaced RHA arising directly from the coeliac axis. Left image: DSA image with catheter in coeliac axis again demonstrating replaced LHA and RHA. (1)Replaced LHA (2)LGA (3)CHA (4)Coeliac axis (5)Replace RHA from coeliac axis (6)GDA (7)Splenic artery References: - Msida/MT Fig. 7: Axial and Sagittal MIP CT images demonstrating the common hepatic trunk arising directly from the aorta (Red and white arrows). A common trunk arises adjacent Page 15 of 34

16 to this (red arrowhead), dividing into LGA and splenic artery. An accessory LHA is arising from the LGA (white arrowhead) is seen. References: - Msida/MT Fig. 8: Middle-aged gentleman with diffuse HCC of the right liver lobe with coeliac axis occlusion. Left image: Sagittal MIP image showing occlusion of the coeliac trunk. Right top and bottom images: DSA images showing the hepatic/splenic arteries are being supplied by retrograde flow through the GDA through collateralisation from the pancreatico-duodenal arcade. TACE was performed by lodging a SOS2 catheter in the SMA, and by passing a 2.4 Fr microcatheter through the inferior pancreaticoduodenal artery, into the GDA, and in the proper hepatic artery. References: Diagnostic and Therapeutic Services Department Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IsMeTT), Palermo, Italy. Arterial variants may also consist of the substitution of a single branch, such as the RHA or LHA, for two or more branches. Such a variant is more common and usually more complex in the LHA than in the RHA [11]. An accessory artery is one which is co-existing alongside the conventional branch whereas a replaced artery is one where there is no conventional anatomic communication for the mentioned branch. This difference is depicted in Figures 3 and 4. Page 16 of 34

17 Extrahepatic collateral supply In a study published in 2005 by Kim et al [10], 860 out of a total of 3179 patients undergoing TACE for HCC demonstrated extrahepatic collateral arterial communication. The establishment of such arterial supply was most commonly noted in patients whose tumours were noted to be exophytic or subcapsular, or demonstrated direct contact or invasion with surrounding organs on pre-procedural CT scan. Another important cause for formation of collateral vascular supply, especially in recurrent tumours, is repeated TACE procedures. The resultant chronic ischaemic effect of TACE seems to promote neoangiogenesis [10]. This is shown in a recent study by Yilin et al [15] in which 698 from a total of 942 HCC cases where shown to be supplied by extrahepatic arteries. This study also shows a positive association between the number of extrahepatic arterial supply to HCC and tumour size and location. Multiple possible extrahepatic collateral arteries have been described in the literature. these include: inferior phrenic artery, internal mammary artery, intercostal and lumbar arteries, omental branches, adrenal artery, renal arteries, superior mesenteric artery, gastric artery, and the cystic artery. If a tumour observed at cross-sectional imaging is not demonstrated on hepatic angiography, then possible collateral supply should be investigated by selective angiography, accordingly. Figures 9-11 demonstrate examples of extrahepatic collateral supply. Fig. 9: Left image: Axial contrast enhanced CT image demonstrating an arterialized lesion in segment V, in the gallbladder fossa. Right image: DSA image demonstrating catheterization of the cystic artery (arrowhead) and tumour blush (arrow). Page 17 of 34

18 References: Diagnostic and Therapeutic Services Department Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IsMeTT), Palermo, Italy. Fig. 10: Top image: Axial MRI image demonstrating an exophytic lesion in segment VII (arrow) Bottom left image: DSA image after catheterization of the coeliac axis. No tumour blush is demonstrated in the expected site. Bottom right image: Right phrenic artery catheterised (arrowhead) with tumour blush (arrow). References: Diagnostic and Therapeutic Services Department Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IsMeTT), Palermo, Italy. Page 18 of 34

19 Fig. 11: 76 year old non-cirrhotic lady presenting with an alpha-fetoprotein (AFP) level in excess of 40,000IU. On imaging by CT scan (top left and middle images) a large liver lesion replacing most of the right liver lobe. Incorrect CT protocol failed to show all of the vessels supplying the tumour, which was being supplied by the RHA (bottom left image), LGA (bottom middle), inferior pancreaticoduodenal branch of the SMA (top right) and by the right adrenal artery (bottom right). References: - Msida/MT Possible complications Non-target embolisation during TACE from collateral vessels is a serious complication with significant consequences [1,10]. It may occur from [12]: Lack of recognition of arterial supply to non-hepatic structures, or Reflux of chemoembolic agents back along the catheter during delivery. Gastrointestinal erosions, ulceration and perforation may be caused by gastric, omental or colic branch artery embolisation. Paraplegia may result from embolisation of spinal branches arising from intercostal or lumbar collateral vessels. Embolisation of the cystic artery may result in ischaemic cholecystitis with or without perforation. A rare variant is the presence of a hepatic falciform artery, a terminal branch of the left hepatic artery [13,14]. Anatomically this runs in the falciform ligament. Chemoembolisation results in abdominal pain and a supraumbilical skin rash with tender Page 19 of 34

20 induration. On CT/MR, this is identified as infiltration of the subcutaneous fat. Figure 12 demonstrates images from a case report described in 2004 [13]. Fig. 12: 63 year old lady with with cirrhosis secondary to chronic Hepatitis C. A small HCC was identified at screening in segment IV (blush on left image). Left image: DSA image demonstrating the presence of a hepatic falciform artery (black arrow). Right top image: Photograph demonstrating the typical erythema and induration in the supra umbilical region when inadvertent chemoembolisation of the hepatic falciform artery occurs. Right bottom image: Contrast-enhanced axial CT image demonstrating thickening of the supraumbilical skin and increased density in the underlying subcutaneous tissue. Right top image: typical location of cutaneous erythema following chemoembolisation of the hepatic falciform artery. References: Chao-Chun Lin et al. (2004) Supraumbilical skin rash and fat necrosis after transarterial chemoembolisation: A Case Report. Kaohsiung J Med Sci 20:36-40 There are several methods to avoid these complications [10]: Page 20 of 34

21 Selective catheterisation of the feeding vessel should be achieved by placing the catheter as close as possible to the specific branches supplying the tumour. Rate of infusion of the chemoembolic agent should be very slow to avoid refluxing into a non-targeted branch. In selective cases, coils may be used to occlude the variant vessel proximally, and protect the territory of normal distal branches before chemoembolisation. To reduce referred shoulder pain on phrenic artery chemoembolisation, a small amount of 1% Lignocaine can be injected intra-arterially during the procedure The role of cross sectional imaging in planning TACE Selective angiography is time consuming and exposes the patient and operator(s) to radiation. It is therefore essential to carefully protocol and examine the planning CT or MRI scan for evidence of variant arterial or extrahepatic collateral supply. Choice of catheters to be used during the procedure can also be planned in advance. In our centre, contrast liver imaging with both CT and MRI includes an early arterial phase using bolus tracking, a late arterial phase which is performed 18 seconds after the bolus peak and portal venous phase 40 seconds after. Page 21 of 34

22 Images for this section: Fig. 1: 58 year old male with liver cirrhosis and focal HCC in right lobe. Top image: Coronal MIP image demonstrating conventional anatomy of the hepatic arterial supply. Image also shows the known HCC in the right lobe (arrow). Bottom image: Digital subtraction angiographic (DSA) image in the same patient. (1)Coeliac axis (2)CHA (3)LGA (4)Splenic artery (5)GDA (6)LHA (7)RHA (8)SMA - Msida/MT Page 22 of 34

23 Fig. 2: Middle-aged patient with established liver cirrhosis and multifocal HCC Top left image: Coronal T1+C FatSat MT image demonstrating a vessel coursing below the portal vein (arrowhead). Multiple arterialised lesions are noted in the liver, in keeping with multifocal HCC. Top right image: DSA image with catheter in coeliac trunk (6) - the splenic (1), left gastric (LGA) (2) and common hepatic artery (CHA) (3) are seen. Branches of the CHA seen are the Gastroduodenal (GDA) (4) and the left hepatic artery (LHA) (5). Bottom left image: DSA image with catheter in superior mesenteric artery (SMA) (8). The first branch is the replaced right hepatic artery (7). Bottom right image: DSA image with catheter advanced into the replaced RHA - Msida/MT Page 23 of 34

24 Fig. 3: 52 year old lady with three colorectal metastases, being treated by irinotecaneluted beads. These appear as highly metabolically active lesions seen on the PET-CT. Top left image: MIP-Coronal CT image in the arterial phase demonstrating a replaced LHA (arrow) originating from the LGA (arrowhead) and supplying the left liver lobe. Right top and bottom images: DEB-TACE for the left lobe performed through this route, with the microcatheter parked distal to the gastric branches. - Msida/MT Page 24 of 34

25 Fig. 4: 45 year old gentleman with multiple liver metastasis from a well-differentiated retroperitoneal neuroendocrine tumour (NET). Top image: Coronal T1+C FatSat MR image demonstrating a branch (5 - arrow) originating from the CHA (4), proximal to the origin of the GDA (6). This is in keeping with an accessory LHA. Multiple lipiodol laden lesions are noted in both liver lobes, compatible with previously treated NET metastases. Bottom image: DSA image with catheter in coeliac trunk, again demonstrating the accessory LHA originating from the coeliac trunk. (1) Coeliac axis, (2) Splenic Artery, (3) LGA, (4) CHA, (5) Accessory LHA, (6) GDA, (7) LHA, (8) RHA, (9)SMA - Msida/MT Page 25 of 34

26 Fig. 5: 53 year old gentleman known case of liver cirrhosis with focal HCC in the left liver lobe. Top left image: Axial MIP CT image demonstrating an artery coursing posterior to the unopacified portal vein (P) - this is a replaced RHA (1). Top middle image: Axial MIP CT image demonstrating an artery in the fissure of the ligamentum venosus, originating from the left gastric artery - this is a replaced LHA (2). Top right image: Sagittal Oblique MIP CT image again demonstrating aberrant anatomy: (1)Replaced RHA (2)Replaced LHA (3)SMA (4)Coeliac axis. Bottom left image: DSA with catheter in SMA (3) confirming the presence of the replaced RHA (1). Bottom right image: DSA with catheter in the coeliac axis (4), confirming a replaced LHA (2) originating from the LGA (5). - Msida/MT Fig. 6: 63 year old gentleman with liver cirrhosis and focal HCC (not shown). Right image: Coronal MIP image demonstrating a replaced LHA from LGA and a replaced RHA arising Page 26 of 34

27 directly from the coeliac axis. Left image: DSA image with catheter in coeliac axis again demonstrating replaced LHA and RHA. (1)Replaced LHA (2)LGA (3)CHA (4)Coeliac axis (5)Replace RHA from coeliac axis (6)GDA (7)Splenic artery - Msida/MT Fig. 7: Axial and Sagittal MIP CT images demonstrating the common hepatic trunk arising directly from the aorta (Red and white arrows). A common trunk arises adjacent to this (red arrowhead), dividing into LGA and splenic artery. An accessory LHA is arising from the LGA (white arrowhead) is seen. - Msida/MT Page 27 of 34

28 Fig. 8: Middle-aged gentleman with diffuse HCC of the right liver lobe with coeliac axis occlusion. Left image: Sagittal MIP image showing occlusion of the coeliac trunk. Right top and bottom images: DSA images showing the hepatic/splenic arteries are being supplied by retrograde flow through the GDA through collateralisation from the pancreatico-duodenal arcade. TACE was performed by lodging a SOS2 catheter in the SMA, and by passing a 2.4 Fr microcatheter through the inferior pancreaticoduodenal artery, into the GDA, and in the proper hepatic artery. Diagnostic and Therapeutic Services Department Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IsMeTT), Palermo, Italy. Page 28 of 34

29 Fig. 9: Left image: Axial contrast enhanced CT image demonstrating an arterialized lesion in segment V, in the gallbladder fossa. Right image: DSA image demonstrating catheterization of the cystic artery (arrowhead) and tumour blush (arrow). Diagnostic and Therapeutic Services Department Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IsMeTT), Palermo, Italy. Fig. 10: Top image: Axial MRI image demonstrating an exophytic lesion in segment VII (arrow) Bottom left image: DSA image after catheterization of the coeliac axis. No tumour blush is demonstrated in the expected site. Bottom right image: Right phrenic artery catheterised (arrowhead) with tumour blush (arrow). Diagnostic and Therapeutic Services Department Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IsMeTT), Palermo, Italy. Page 29 of 34

30 Fig. 11: 76 year old non-cirrhotic lady presenting with an alpha-fetoprotein (AFP) level in excess of 40,000IU. On imaging by CT scan (top left and middle images) a large liver lesion replacing most of the right liver lobe. Incorrect CT protocol failed to show all of the vessels supplying the tumour, which was being supplied by the RHA (bottom left image), LGA (bottom middle), inferior pancreaticoduodenal branch of the SMA (top right) and by the right adrenal artery (bottom right). - Msida/MT Page 30 of 34

31 Fig. 12: 63 year old lady with with cirrhosis secondary to chronic Hepatitis C. A small HCC was identified at screening in segment IV (blush on left image). Left image: DSA image demonstrating the presence of a hepatic falciform artery (black arrow). Right top image: Photograph demonstrating the typical erythema and induration in the supra umbilical region when inadvertent chemoembolisation of the hepatic falciform artery occurs. Right bottom image: Contrast-enhanced axial CT image demonstrating thickening of the supraumbilical skin and increased density in the underlying subcutaneous tissue. Right top image: typical location of cutaneous erythema following chemoembolisation of the hepatic falciform artery. Chao-Chun Lin et al. (2004) Supraumbilical skin rash and fat necrosis after transarterial chemoembolisation: A Case Report. Kaohsiung J Med Sci 20:36-40 Page 31 of 34

32 Conclusion Variant hepatic arterial anatomy and extrahepatic collateral vessels commonly supply malignant hepatic tumours. Familiarity with these cross-sectional features of these variations of tumour arterial supply is of paramount importance for the interventional radiologist to detect these vessels at an early stage. This results in super-selective and effective TACE of such lesions, decreasing complications encountered. Page 32 of 34

33 References [1] Kwang-Hun Lee, Kyu-Bo Sung, Do-Yun Lee, Sang Joon Park, Ki Whang Kim, and Jeong-Sik Yu. Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma: Anatomic and Hemodynamic Considerations in the Hepatic Artery and Portal Vein. RadioGraphics :5, [2]Matsui O, Kobayashi S, Sanada J et al. Hepatocelluar nodules in liver cirrhosis: hemodynamic evaluation (angiography-assisted CT) with special reference to multi- step hepatocarcinogenesis. Abdom Imaging 2011; 36: [3] Yamaguchi R, Yano H, Iemura A, Ogasawara S, Haramaki M, Kojiro M. Expression of vascular endothelial growth factor in human hepatocellular carcinoma. Hepatology 1998; 28: [4] Choi BI. The current status of imaging diagnosis of hepatocellular carcinoma. Liver Transpl 2004; 10: S20-5. [5] Michel NA. Observatons on the blood supply of the liver and gallbladder (200 dissections). Blood supply and anatomy of the upper abdominal organs, with a descriptive atlas. Philadelphia, Pa: Lippincott;1955. p [6] Gruttadauria S, Scotti Foglieni C, Doria C, Luca A, Lauro A, Marino IR. The hepatic artery in liver transplantation and surgery: vascular anomalies in 701 cases. Clin Transplant 2001; 15: [7] Sureka B, Mittal MK, Mittal A, Sinha M, Bhambri NK, Thukral BB. Variations of celiac axis, common hepatic artery and its branches in 600 patients. Indian J Radiol Imaging 2013;23: [8] KimJH, Chung JW, Han JK, Park JH, Choi BI, Han MC. Transcatheter arterial embolization of the internal mammary artery in hepatocellular carcinoma. J Vasc Interv Radiol 1995;6: [9] ChungJW, Park JH, Han JK, Choi BI, Kim TK, Han MC. Transcatheter oily chemoembolization of the inferior phrenic artery in hepatocellular carcinoma: the safety and potential therapeutic role. J Vasc Interv Radiol 1 998;9: Page 33 of 34

34 [10] Hyo-Cheol Kim, Jin Wook Chung, Whal Lee, Hwan Jun Jae, and Jae Hyung Park. Recognizing Extrahepatic Collateral Vessels That Supply Hepatocellular Carcinoma to Avoid Complications of Transcatheter Arterial Chemoembolization. RadioGraphics :suppl_1, S25-S39. [11] Ana Alonso-Torres, Jaime Fernández-Cuadrado, Inmaculada Pinilla, Manuel Parrón, Emilio de Vicente, and Manuel López-Santamaría. Multidetector CT in the Evaluation of Potential Living Donors for Liver Transplantation. RadioGraphics :4, [12] TimothyW.I Clark. Complications of Hepatic Chemoembolisation. Semin. Interventional Radiology 2006 Jun; 23(2): [13] Chao-Chun Lin, Ding-Kwo Wu, Paul Ming-Chen Shih, Gin-Chung Liu, Wan-Long Chuang. Supraumbilical skin rash and fat necrosis after transarterial chemoembolisation: A Case Report. Kaohsiung J Med Sci 2004;20:36-40 [14] Williams DM, Cho KJ, Ensminger WD, et al. Hepatic falciform artery: anatomy, angiographic appearance, and clinical significance. Radiology 1985;156: [15] Yilin Zhao, Zhuting Fang, Jianjun Luo, Qingxin Liu, Gang Xu, Heng Pan, Wei Wei, Zhiping Yan. Evaluation of extrahepatic collateral arteries in hepatocellular carcinoma in three independent groups in a single center. Exp Ther Med Dec; 10(6): Page 34 of 34