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344 J. E. Silberzweig
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FIGURE 28-8. Standing wave phenomenon. Uniform wavelike changes in arterial contour of superior mesenteric (SMA)
branches are seen in this normal vessel. These changes may
be seen after one injection and may not be present on subsequent injection of the same vessel. This phenomenon is not
associated with any known pathologic process within the ves-
18
sel.
Middle colic artery
This vessel arises from the proximal SMA at the level of
the first jejunal artery. The middle colic artery divides
into left and right branches: The left branch anastomoses
with the ascending branch of the left colic artery, and the
right branch of the middle colic artery anastomoses with
the ascending branch of the right colic artery. The middle colic artery supply occasionally originates from the
celiac artery or one of its branches (0.5%).
3
The left
branch of the middle colic artery may have an accessory
branch that arises from the dorsal pancreatic artery
3
(3%).
Right colic artery
The right colic artery may arise from the SMA, middle
colic artery, or ileocolic artery. The right colic artery
typically is described to originate from the SMA but is
found in only 13% of cases.
6
The right colic artery divides
into an ascending branch, which anastomoses with the
right branch of the middle colic artery, and a descending
branch, which anastomoses with the ascending branch of
FIGURE 28-9. Common origin of celiac artery and superior
mesenteric artery (SMA).
the ileocolic artery. The right colic artery supplies the
ascending colon and hepatic flexure.
Ileocolic artery
The last major branch of the SMA, the ileocolic artery is
the only constant branch of the SMA and it has a characteristic course downward and to the right, is the only
constant branch of SMA, and therefore serves as an important angiographic landmark. It distributes branches
to the terminal ileum, cecum, appendix, and the lower
third of the ascending colon.
10
Inferior mesenteric artery
The inferior mesenteric artery (Fig. 28-10) arises at the
level of the left pedicle of L3, descends to the left, and
divides into the left colic artery, sigmoid arteries, and
superior hemorrhoidal artery. The inferior mesenteric
artery supplies the distal half of the transverse colon, the
descending colon, sigmoid colon, and rectum.
Left colic artery
The ascending branch of the left colic artery anastomoses
with the left branch of the middle colic artery to form the
Anatomy of GI Tract, Liver, and Biliary System
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Lc
S
345
A
FIGURE 28-10. A: Inferior mesenteric artery. B: Inferior mesenteric arteriogram, Lc, left colic
artery; S, sigmoid branches; Sr, superior rectal artery.
marginal artery (of Drummond). This vessel divides into
ascending and descending branches. The ascending
branch anastomoses with the left branch of the middle
colic artery, and the descending branch anastomoses with
branches of the sigmoid arteries.
Sigmoid arteries
Usually two to three of these arteries are present.
Superior hemorrhoidal artery
The branches of the superior hemorrhoidal artery anastomose with the middle and inferior hemorrhoidal arteries, which are branches from the anterior division of the
internal iliac artery. This anastomosis can act as a collateral pathway to the lower extremity in cases of common
iliac artery occlusion. An internal iliac artery angiogram
should be considered in cases of lower GI bleeding in
which the SMA and IMA injections demonstrate no abnormality.
Sr
■ Anastomotic Arteries
Arc of Riolan
This inconstant anastomotic artery joins the proximal
portion of the middle colic artery and the ascending
branch of the left colic artery. It is located near the root
of the colonic mesentery.
6,10
Arc of Buehler
This represents a persistent congenital anastomosis between the celiac artery and the SMA (Fig. 28-11).
Arc of Barkow (greater omental arcade)
The omental arteries act as potential collaterals between
hepatic, splenic, and superior mesenteric arteries. The
arc of Barkow receives anterior epiploic arteries from the
right and left gastroepiploic arteries and posterior epi-
B
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FIGURE 28-11. Arc of Buehler. Superior mesenteric artery
(SMA) injection shows congenital connection between the
SMA and celiac artery (
arrow
).
Pancreaticoduodenal arcades
The superior and inferior pancreaticoduodenal arteries
(Fig. 28-12) supply the pancreatic head and proximal
portion of the duodenum. The anterior and posterior
branches of the superior pancreaticoduodenal artery
form anastomoses with the anterior and posterior
branches of the inferior pancreaticoduodenal artery, a
branch of the proximal SMA. The pancreaticoduodenal
arcades can act as an important collateral pathway in
cases of celiac artery or SMA origin occlusion. The presence of this dual arterial supply to the duodenum can
make bleeding duodenal ulcers difficult to treat by transarterial embolization.
Marginal artery (of Drummond)
The marginal artery is a vessel formed by the vascular
arcades of the right, middle, and left colic arteries. It runs
within the mesentery parallel to the mesenteric border of
the colon and gives off the vasa recta to the colon. The
marginal artery can act as a collateral pathway in cases of
occlusion of the SMA or IMA. The marginal artery is
usually not complete because the vasa recta of the transverse colon often will arise directly from the middle colic
10
artery.
ploic arteries from the transverse pancreatic artery as well
as branches from the middle colic artery.
C
SMA
FIGURE 28-12. Pancreaticoduodenal arcades. Superior mes-
enteric artery (SMA) injection shows prominent pancreaticoduodenal arcades acting as a collateral pathway in this case
of celiac artery origin stenosis. C, celiac trunk.
10
Griffith’s point
Located at the splenic flexure, Griffith’s point is a watershed area between the SMA and IMA circulations. It is
vulnerable to ischemia because the marginal arter y is
often incomplete at the splenic flexure and has no anastomotic arcades linking the left branch of the middle
colic artery with the ascending branch of the left colic
10
artery.
Central anastomotic artery
The central anastomotic artery represents a direct anastomosis of the middle colic and left colic arteries. It is
located within the colonic mesentery between the marginal artery and the arc of Riolan.
10
Meandering artery
This arter y (Fig. 28-13) may be identified angiographically when either the superior or the inferior mesenteric
artery is occluded. The meandering artery is a dilated
central anastomotic artery or a dilated arc of Riolan. The
direction of the blood flow in the meandering artery is
from the patent to the occluded main artery. The medical literature contains great variety concerning the definitions and the angiographic appearance of the central
anastomotic artery and the meandering artery.
10,11
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Splenic
Vein
Portal
Vein
Superior
Mesenteric
Vein
FIGURE 28-13. Meandering mesenteric artery. A large collat-
eral vessel arising from the inferior mesenteric artery (IMA)
with flow toward the middle colic artery (
superior mesenteric artery (SMA) origin occlusion.
arrows
) in this case of
■ Venous Anatomy
Portal venous system
The portal venous system drains blood from the small intestine, stomach, spleen, pancreas, gallbladder, and colon
(except the lower part of the rectum). The superior mesenteric vein (SMV) and the splenic vein join to form the
portal vein posterior to the head of pancreas (Fig. 28-14).
The splenic vein arises at the splenic hilus and receives
the pancreatic veins; the short gastric veins, which drain
the fundus and the left part of the greater curvature of
the stomach; the left gastroepiploic veins; and the inferior mesenteric vein (IMV) (Fig. 28-15). The IMV is
formed by the left colic vein, sigmoid veins, and superior
hemorrhoidal vein and usually drains into the splenic
FIGURE 28-14. Portal venous anatomy. Venous phase of simultaneous injection of celiac artery and superior mesenteric
artery (SMA).
FIGURE 28-15. Inferior mesenteric vein (IMV) opacification
following inferior mesenteric artery injection.
348 J. E. Silberzweig
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vein proximal to the confluence of the splenic vein and
the SMV. In 10% of cases, the portal vein is formed by the
confluence of the SMV, IMV, and splenic vein.
3
The right
gastric and left gastric (coronary) veins drain into the
splenic vein or directly into the portal vein. The SMV
receives the jejunal, ileal, ileocolic, right colic, and middle colic veins as well as the right gastroepiploic and the
pancreaticoduodenal veins.
The portal vein enters the liver and divides into right
and left portal vein branches. The portal vein branches
divide into smaller branches that run with the hepatic
artery branches and biliary ducts, terminating in the
sinusoids. The sinusoids represent the point of origin of
the hepatic venules, which eventually drain into the inferior vena cava by the hepatic veins.
The paraumbilical veins are small vessels that establish
an anastomosis between the anterior abdominal wall, the
portal vein, and internal iliac veins. The paraumbilical
veins extend along the ligamentum teres.
5
In cases of
portal hypertension, the paraumbilical veins can become
enlarged, especially in the event of portal vein thrombosis. The umbilical vein (Fig. 28-16) originates at the umbilicus and courses dorsally and upward, between the
layers of the falciform ligament along the surface or
within the ligamentum teres, and ends in the left branch
of the portal vein. The umbilical vein can act as a major
collateral vessel to the abdominal wall or internal iliac
veins in the presence of portal hypertension (Cruveilhier-
Baumgarten syndrome).
Hepatic veins
The hepatic veins (Figs. 28-17 and 28-18) provide venous
return from the liver to the systemic circulation. The
right, middle, and left hepatic veins converge at the posterior surface of the liver and drain into the inferior vena
cava near its termination at the right atrium. The middle
and left hepatic veins often have a common trunk, and
the right hepatic vein joins the inferior vena cava sepa-
3
rately.
into the inferior vena cava. The caudate lobe of the liver
has a separate venous drainage directly into the inferior
vena cava.
of the right hepatic vein makes it the vein most commonly used for creation of a transjugular portosystemic
shunt (TIPS).
Often a right inferior hepatic vein drains directly
6
The location, angulation, and large diameter
Pressure measurements obtained from a catheter
FIGURE 28-16. Umbilical vein. Portal vein injection during
transjugular portosystemic shunt (TIPS) procedure. Hepatofugal flow is demonstrated in a patent umbilical vein.
FIGURE 28-17. Hepatic veins. Reflux of contrast into the hepatic veins is demonstrated during inferior vena cava (IVC)
contrast injection. Reflux into the hepatic veins during IVC
injection is often seen in patients with an elevated right heart
pressure or during Valsalva maneuver. The middle hepatic vein
is superimposed over the inferior vena cava.
Anatomy of GI Tract, Liver, and Biliary System 349
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wedged ina hepatic venule can act as a reflection of portal
venous pressure. A wedged hepatic venogram opacifies
the portal venous system by reflux of contrast through the
hepatic sinusoids into the portal vein (Fig. 28-19) and
most often is performed for localization of the portal vein
during a TIPS procedure.
Portosystemic anastomoses
Multiple communications exist between the portal and
systemic venous systems and serve as collateral pathways
to decompress the portal venous system in patients with
portal hypertension. These collaterals may be identified
at portography as enlarged and tortuous vessels with hepatofugal flow. The most common collateral pathways
encountered at portography include the following:
1. Esophageal (coronary) → azygous vein
2. Gastric/splenic → azygous and/or left renal vein
3. Mesenteric → left renal, gonadal, or retroperitoneal
veins
4. Intrahepatic portal veins → paraumbilical veins or
umbilical vein
5. Inferior mesenteric vein → hemorrhoidal veins
12
FIGURE 28-18. Right hepatic vein. Selective right hepatic
venogram shows normal intrahepatic branching pattern and
parenchymal stain.
■ Liver Anatomy
The liver has a dual blood supply. The hepatic blood
supply comprises 75% by the portal vein and 25% by the
hepatic artery. The right and left lobes of the liver are
divided by the middle hepatic vein. The right lobe is
divided into an anterior and posterior segment by the
right hepatic vein, and the left lobe is divided into medial
and lateral segment by the left hepatic vein. The caudate
lobe has an independent venous drainage directly into
the IVC. The Couinaud and Bismuth numbering systems
of segmental anatomy divides the liver into eight segments based on the distribution of the three hepatic veins
and the right and left main portal trunks (Fig. 28-20).
The segmental numbering system provides a means for
detailed description of the location, extent, and relation
to the venous structures of a liver lesion. This functional
division of the liver is used to determine the surgical
approach for liver tumor resection and for reduced-size
orthotopic liver transplantation.
14
■ Biliary System Anatomy
13
FIGURE 28-19. Wedged hepatic venogram. Injection of contrast into the right hepatic vein with the catheter wedged into a
venule results in reflux of contrast into portal vein branches. This
injection was performed during a transjugular portosystemic
shunt (TIPS) procedure.
The hepatic ducts have a lobar and a segmental distribution (Fig. 28-21). The right hepatic duct is formed by the
anterior and posterior segmental ducts. The left hepatic
duct is formed by the medial and lateral segmental ducts.
350 J. E. Silberzweig
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FIGURE 28-20. Segmental anatomy of the
liver.
Bile ducts from the caudate lobe drain into either the left
or the right hepatic ducts. The main left duct is usually
longer than the main right duct.
The common hepatic duct (CHD) forms at the porta
hepatis by the junction of the left and right hepatic
ducts. The distal 1 to 2 cm of the right and left hepatic
ducts lies outside the liver parenchyma. The CHD is
Left
Hepatic
Right
Hepatic
Duct
Common
Bile Duct
Duodenum
FIGURE 28-21. T-tube cholangiogram.
Duct
Pancreatic
Duct
closely related to the hepatic artery and portal vein. The
hepatic artery lies to the left of the CHD, and the portal
vein runs posterior and to the left of the CHD. Insertion
of the cystic duct into the CHD defines the origin of
the common bile duct (CBD), which is joined by the
pancreatic duct at the ampulla. The ampulla drains into
the second portion of the duodenum at the papilla of
15
Vater.
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M.J. Hallisey and S. G. MeranzeGastrointestinalStrictures
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29
■■■
Interventional Management of
Gastrointestinal Strictures
MICHAEL J. HALLISEY AND STEVEN G. MERANZE
Strictures of the gastrointestinal (GI) tract have many
causes, including malignant, congenital, benign, and
postsurgical lesions. Although these strictures can be difficult to manage, surgery has been the standard method
of treatment; however, endoscopic and interventional radiologic treatments are rapidly proving to be effective
methods in caring for these patients. In the upper GI
tract, esophageal stenoses are the most common lesions,
followed by gastric and duodenal lesions; newer techniques now allow interventional management of colonic
strictures. All these lesions are amenable to stricture dilation.
■ Esophageal Strictures
Strictures of the esophagus may be secondary to primary
congenital anomaly, caustic ingestion, malignant disorders, esophageal surgery, or esophagitis. Malignant strictures arise directly from a primary esophageal carcinoma
or from an adjacent lung or mediastinal malignancy invading the esophagus. In the midesophagus, 90% of the
primary esophageal malignancies are due to squamous
cell carcinoma. In the distal third of the esophagus, the
most common malignancy is gastric adenocarcinoma.
Treatment of these malignant disorders has included surgical bypass, stent placement, or primary repair. Although
50% of esophageal tumors are deemed resectable, the
5-year survival rate of these patients is only 10%, regardless of the treatment.
benign etiology for strictures in adults is reflux
esophagitis. Other causes include achalasia, caustic ingestion, postradiation changes, and iatrogenic trauma. Tra-
1,2
The most commonly encountered
ditional treatment of these benign strictures is repetitive
dilation with mercury bougies.
Transluminal dilation with angioplasty balloons has
added yet another effective tool to the treatment armamentarium of these stenotic lesions. When used with
fluoroscopic and standard guidewire techniques, these
balloons have proved safe and effective. The recent availability of expandable metallic stents has added to the
interventional radiologists ability to assist in the treatment of these patients, particularly those with malignant
disease.
Surgical and endoscopic treatments
Traditional surgical methods for the treatment of esophageal strictures include patching the esophagus in the
region of the stricture or bypassing the stricture with
colon or jejunum. Although the former method may
result in excellent relief of dysphagia and reflux symptoms, about one half of patients undergoing patching
may require dilation at a later date. Intestinal interposition operations are effective but also are associated with
significant morbidity and mortality and constitute a major surgical procedure. For malignant disease, radiation
therapy and chemotherapy have short-lived effects, and
although laser treatment is used for exophytic tumors, it
must be repeated frequently.
Bougienage has been performed for centuries and involves the use of an instrument with a straight or rounded
olive-shaped tip inserted through the stricture, progressively stretching the narrowed segment to achieve the
desired lumen. In the past, these instruments could be
passed repeatedly by the patient using bougies (such as
353
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