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334 M. Rosenblatt and K. W. Dickey
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BA
C
tions for treatment that other wise would not be available
to a select number of infertile patients who have intractable cervical stenosis or false passage.
144
■ Conclusion
Treatment of the infertile couple can be complex, and
many widely varying therapies are advocated. Catheterdirected therapy offers a nonsurgical alternative for the
treatment of infertility. In women, advancements in
catheter-directed techniques have offered noninvasive
solutions for mechanical obstruction of the reproductive
tract. In men, these techniques permit nonsurgical occlusion of varicoceles. Catheter-directed techniques are
effective and safe and have exceptionally low complication rates. Recovery is rapid, and most patients usually
can return to normal activities within 24 hr of treatment.
FIGURE 27-14. The technique of cervical dilation in a patient
who has previously had multiple unsuccessful attempts at hysterosalpingogram (HSG) and endometrial biopsy. A: HSG via
a balloon catheter in the lower cervix reveals the uterus to be
markedly anteverted. Note also that there is nonfilling of the
right fallopian tube. B: An 8-mm ⫻ 2-cm angioplasty balloon is
inflated over a wire within the true cervical canal in the region
of cervical stenosis and false passage. C: HSG after cervical
dilation shows the cervical canal to be patent (
false passages do not fill.
arrows
), and the
These techniques have distinct advantages over surgical
alternatives. The use of radiographic imaging often can
identify pathology that would be unrecognized at surgery. Examples include the inability to identify complex
venous collaterals during surgical ligation, thus resulting
in varicocele recurrence, and the creation of false passages in the cervix when treating women with cervical
stenoses. In addition to the imaging advantage, catheterdirected therapy is often more cost effective than the
myriad of surgical alternatives.
145–147
Thus, we recommend that these treatment methods be considered instead of surgical methods in most cases.
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J.E. SilberzweigAnatomy ofGI Tract, Liver, and Biliary System
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28
■■■
Anatomy of the Gastrointestinal Tract,
Liver, and Biliary System
JAMES E. SILBERZWEIG
Familiarity with the normal and variant anatomy of the
gastrointestinal (GI) tract, liver, and biliary system is
essential for the interventional radiologist. Pathologic
conditions may distort normal anatomy and make therapeutic interventions difficult or impossible. An understanding of variant vascular and ductal anatomy, as well as
of the presence and location of collateral pathways is
essential to both diagnosis and therapy.
■ Arterial Anatomy
The arterial supply to the GI tract is by the three main
ventral branches of the abdominal aorta (Fig. 28-1): the
celiac arter y, the superior mesenteric artery (SMA), and
the inferior mesenteric artery (IMA). There is considerable variation in the branching pattern from these three
main vessels. Furthermore, there are copious collateral
pathways between the vascular territories.
Celiac artery
The celiac artery arises from the aorta at the level of the
T12 vertebral body.
der, stomach, proximal duodenum, pancreas, and spleen.
The three major branches of the celiac artery are the left
gastric artery (LGA), splenic artery, and common hepatic
artery (Figs. 28-2 through 28-4).
Left gastric artery
The LGA is a branch of the celiac artery in 90% of all
persons. It arises from the superior margin of the proximal celiac artery and courses vertically toward the lesser
1
Its branches supply the liver, gallblad-
curvature of the stomach. The origin and orientation of
the LGA sometimes make selective catheterization of the
LGA difficult. Accessor y LGA branches may arise from
the left hepatic artery. The LGA arises directly from the
aorta in 1 to 5% of all persons
esophagus, cardia, fundus, and body of the stomach.
Splenic artery
The splenic artery is the largest branch of the celiac
artery and is tortuous in adults. It courses superior and
anterior to the splenic vein and may arise directly from
the aorta in 2% of persons.
the spleen, the pancreas, and the stomach.
Branches of the splenic artery include the posterior
gastric artery, short gastric arteries, left gastroepiploic
artery, and the superior and inferior terminal branches
supplying the spleen. The splenic artery gives rise to
three pancreatic branches: the dorsal pancreatic artery
supplies the neck and body of the pancreas; the great
pancreatic artery (arteria pancreatica magna) supplies
the body of the pancreas; and the caudal pancreatic artery supplies the tail of the pancreas. The transverse
pancreatic artery runs within the pancreas and originates
from the left branch of the dorsal pancreatic artery. The
transverse pancreatic artery anastomoses with the other
pancreatic branches from the splenic artery.
Common hepatic artery
The main branch of the common hepatic artery is the
gastroduodenal artery (GDA). The superior pancreaticoduodenal artery arises from the GDA, which continues
as the right gastroepiploic artery along the greater curvature of the stomach. The right gastroepiploic artery then
2–4
and supplies the lower
3
The splenic artery supplies
5
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C
SMA
A
FIGURE 28-1. Abdominal aortogram. Frontal (A) and lateral (B) projections. C, celiac artery;
SMA, superior mesenteric artery; IMA, inferior mesenteric artery; Sp, splenic artery; Ch, common
hepatic artery; GDA, gastroduodenal artery; Ph, proper hepatic artery; Rr, right renal artery; Lr, left
renal artery; Lg, left gastric artery.
forms an anastomosis with the left gastroepiploic artery.
The leftgastroepiploic artery arises from the distal splenic
artery.
The common hepatic artery courses to the right and
becomes the proper hepatic artery after giving rise to the
GDA. The right and left hepatic arteries arise from the
proper hepatic artery,and the middle hepatic artery arises
from either the leftor righthepatic artery and supplies the
medial segment of the left lobe of the liver.
6
Cystic artery
The cystic artery is usually a branch of the right hepatic
artery, but it may arise from the left or common hepatic
artery (Fig. 28-5).
3
This artery is inconsistently visualized
on arteriography.
Right gastric artery
This small vessel arises from the proper hepatic or left
hepatic artery in 80% of persons. In the remaining 20%,
the right gastric artery arises from the GDA or from the
right or middle hepatic artery.
3
The right gastric artery
forms an anastomosis with the left gastric artery along the
lesser curvature of the stomach. This vessel usually is not
visualized on arteriography.
Hepatic Arterial Variants
There is considerable anatomic variation in the arterial
3,6
supply to the liver.
The most common variations in-
clude the following:
1. The left hepatic artery arises from the LGA (10–30%)
and also may be referred to as the aberrant left hepatic
branch.
2. The accessory left hepatic artery arises from the LGA
(8%).
3. The replaced right hepatic artery arises from the SMA
(14–20%) and also may be referred to as the aber-
rant right hepatic branch. It runs behind the pancreas
and the portal vein.
4. The accessory right hepatic artery (partial replacement) arises from the SMA (6%).
5. The replaced common hepatic artery (Fig. 28-6), arises
from the SMA with no hepatic artery branches originating from the celiac artery (2.5%).
7
B
Anatomy of GI Tract, Liver, and Biliary System 341
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FIGURE 28-2. Branches of the celiac artery.
The presence of a replaced hepatic artery branch is an
important variant that may affect arterial anastomoses
during liver transplant surgery, dissection during liver
resection, portocaval shunt surgery, or pancreaticoduodenectomy (Whipple procedure). Variant anatomy, such as
an LGA branch arising from the left hepatic artery or a
replaced hepatic arter y branch, must be recognized in
cases of percutaneous transarterial tumor chemoembolization. Failure to recognize these variants may result in
inadequate embolization or unintentional embolization
of the vessels supplying the bowel. During papaverine
infusion into the SMA in a patient with a replaced hepatic
FIGURE 28-3. Celiac axis compression. Lateral abdominal
aortogram shows a smooth narrowing of the superior aspect of
the celiac artery that resulted from crural fibers of the diaphragm (median arcuate ligament).
and should not be considered a pathologic condition in asymptomatic persons. It remains unresolved whether compression
of the celiac axis by the median arcuate ligament, as an isolated
finding, can result in clinically significant mesenteric ischemia.
16
This finding is common
17
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Ip
C
Sp
Lg
Gda
Ch
Ge
FIGURE 28-4. Celiac arteriogram. C, celiac trunk; Sp, splenic
artery; Lg, left gastric artery; Ch, common hepatic. Gda, gastroduodenal artery; Ge, gastroepiploic artery; Ip, inferior
phrenic artery.
Rh
C
FIGURE 28-5. The cystic artery, (C) typically arises from the
right hepatic (RH) artery.
FIGURE 28-6. Replaced common hepatic artery. Superior mesenteric artery (SMA) injection
shows the common hepatic artery origin from the proximal SMA. Ch, common hepatic artery.
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343
artery branch, the catheter tip must be positioned distal
to the replaced hepatic artery branch for an effective
infusion.
Inferior phrenic artery
The inferior phrenic artery can arise from the celiac
artery in 35% to 65% of persons or directly from the
aorta. The right and left inferior phrenic arteries may
have a common or separate origins. Before entering the
diaphragm, the left inferior phrenic artery may give off a
small gastroesophageal branch. The inferior phrenic arteries may not be well opacified on celiac arteriography,
because they arise from the most proximal aspect of this
8,9
vessel.
Superior mesenteric artery
The SMA arises from the aorta approximately 1 to 2 cm
inferior to the origin of the celiac artery at the level of L1
vertebral body
and the SMA from the aorta (celiacomesenteric trunk)
have a common origin in 0.4% of persons (Fig. 28-9).
Branches of the SMA include the inferior pancreatico-
1
(Figs. 28-7 and 28-8). The celiac artery
duodenal artery, the jejunal and ileal arteries, the middle
colic artery, right colic artery, and ileocolic artery.
Branches of the SMA supply the head of the pancreas,
duodenum, jejunum, ileum, cecum, ascending colon,
and proximal half of the transverse colon.
Inferior pancreaticoduodenal artery (IPDA)
The first branch of the SMA, the IPDA occasionally may
have a common origin with a jejunal artery. It divides into
anterior and posterior branches, which anastomose with
the corresponding branches of the superior pancreaticoduodenal arteries from the GDA to form the pancreaticoduodenal arcades. The IPDA may arise as a single
artery or as one anterior branch and one posterior
branch with separate origins.
3,6
Jejunal and ileal arteries
Ten to 14 of these arteries arise from the left lateral
border of the SMA. The ileal arteries are the branches that
arise from the SMA beyond the origin of the ileocolic
artery. Multiple arcade-like anastomoses exist between
3
these branches. The arcades closest to the small intestine
(marginal artery of Dwight) give off the vasa recta.
10
A
FIGURE 28-7. A: The superior mesenteric artery. B: Superior mesenteric arteriogram. Jej, jejunal branches; Il, ileal branches;
Mc, middle colic artery; Rc, right colic artery; Ic, ileocolic artery.
B
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