Multiple Variation in the Upper Abdominal Aorta: A Unique Cadaveric Case Report and Clinical Implications

Received: 01-Apr-2024, Manuscript No. ijav-24-7014; Editor assigned: 04-Apr-2024, Pre QC No. ijav-24-7014 (PQ); Reviewed: 22-Apr-2024 QC No. ijav-24-7014; Revised: 26-Apr-2024, Manuscript No. ijav-24-7014 (R); Published: 30-Apr-2024, DOI: 10.37532/1308-4038.17(4).380

Citation: Mak YS. Multiple Variation in the Upper Abdominal Aorta A Unique Cadaveric Case Report and Clinical Implications. Int J Anat Var. 2024;17(4): 524-527.

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Abstract

The arterial vasculature supplying upper abdominal organs demonstrates a high degree of variation. Such variations pose considerable challenges to hepatic surgical procedures like transarterial chemoembolization (TACE), treating inoperable hepatocellular carcinoma (HCC) or trauma handling complicated. We, therefore, report a rare Chinese cadaveric case of coexistence of 4 anatomical variations branching in the foregut of the abdominal aorta, including (1) separate origins of inferior phrenic arteries from the celiac trunk (2) trifurcation of the common hepatic artery, (3) an aberrant right gastric artery origin, and (4) accessory right hepatic artery originating from the celiac trunk from a Chinese female donor body during the human dissection enhancement workshop carried out in CUHK. With such a special case discovered in a Chinese cadaver, this paper explores the related clinical significance and helps educate medical practitioners to minimize complications related to arterial variation.

Keywords

Celiac trunk; Anatomic variations; Panagouli classification; Right gastric artery; Common hepatic artery

INTRODUCTION

The upper abdominal aorta typically branches into the celiac trunk and superior mesenteric artery at the lesser omentum to supply the stomach, spleen, liver, and small intestine. The arterial vasculature supplying upper abdominal organs demonstrates a high degree of variation reported in various publications [1], thereby increasing the complexity and difficulty of diagnostic imaging and therapeutic procedures. The celiac axis, celiac artery or celiac trunk CT, the first abdominal branch of the aorta at the level of T12/L1 vertebrae passing below the median arcuate ligament of the aortic hiatus, serves as the primary arterial blood supply of the foregut. In 87.6% majority, the common hepatic artery (CHA), left gastric artery (LGA) and splenic artery (SA) share a common origin from the celiac trunk [2,3]. The inferior phrenic arteries (IPA) can arise from a common IPA trunk or independently from either the aorta or celiac trunk [4]. The CHA after giving branch to the gastroduodenal artery (GDA) continues as the hepatic artery proper (HAP). HAP gives rise to the right gastric artery (RGA) and bifurcates into left and right hepatic arteries [5]. The right accessory hepatic artery (aRHA) is an arterial branch of the right liver run in the portacaval space, which commonly derives from superior mesenteric artery (SMA) [6].

A major classification of CT branching variation was proposed by Panagouli et al (2013), upon a systematic review of 12,196 cases [1]. Trifurcation of the CT into LGA, CHA, and SA (Panagouli type I), bifurcation of the CT (Panagouli type II), and additional branches existing in the CT (Panagouli type III) have been recorded with a prevalence of 89.42%, 7.40%, and 1.06% respectively.

Concerning the blood supplies of the CT to the stomach, spleen, liver, gallbladder, and pancreas, the vascular variation of the celiac trunk and its branches are essential in planning surgical interventions. Medical educational trainings, radiologists and clinicians should be aware of the presence of any variations of abdominal aorta, particularly during liver transplantation, chemotherapy for hepatocellular carcinoma (HCC) and other abdominal surgeries, which minimize the treatments to lower risks and avoid complications [6,7]. We have investigated and aimed to report the rare from the CT co-existence of the four variant branches from the celiac trunk and its branches in a single body donor from a Chinese population as none of researchers have documented such variation patterns from the literature review present their importance.

MATERIALS AND METHODS

During a dissection enhancement workshop held between early June to early August 2023 in the Faculty of Medicine, The Chinese University of Hong Kong (CUHK), Hong Kong, we found a few variations in vascular pattern in the upper abdominal region on an 86-year-old Chinese female body donor, who was one of ‘silent teachers’ from the CUHK body donation program and signed up the consent form to express their voluntary commitment to contribute to anatomy education.

CASE REPORT

From the investigation of the dissection, the multiple variation branches were identified, and unseen of the arterial blood supply of the foregut as shown in schematic diagram (Figure 1). A false tripod was displayed in which the celiac trunk gave rise to the LGA before bifurcating into the CHA and the SA.

Figure 1) Schematic diagram showing arterial variation discovered in the study cadaver. A Type IV False tripod of celiac trunk, with aRHA, RIPA and LIPA originating separately from the CT. B Type I Normal anatomy of the CT and its branches. C Trifurcation of CHA with aberrant origin of RGA from RHA. D. Normal anatomy of the CHA and its branches.

IPAs originated individually from the celiac trunk without a common trunk, demonstrating the variant pattern of Panagouli type III (Figures 2 and Figure 3). Trifurcation of the CHA was observed when it divided into the GDA, LHA and RHA, resulting in the absence of the hepatic artery proper. The RGA originates from the RHA instead of the hepatic artery proper (Figure 3 and Figure 4. The accessory right hepatic artery found incidentally branches from the celiac trunk (Figure 2 and Figure 3).

Figure 2) Overview of RIPA and LIPA originate separately from the CT. (CT: celiac trunk, LGA: left gastric artery; CHA: common hepatic artery; SA: splenic artery; LIPA: left inferior phrenic artery; RIPA: right inferior phrenic artery; aRHA: accessory right hepatic artery; AA: abdominal aorta).

Figure 3) Overview of arterial vascular pattern with the category of Panagouli Type III with additional branches. CT gives rise to LGA first, and then bifurcates into CHA and SA with separated IPAs as additional branches. (CT: celiac trunk, LGA: left gastric artery; CHA: common hepatic artery; SA: splenic artery; LIPA: left inferior phrenic artery; RIPA: right inferior phrenic artery; LHA: left hepatic artery; MHA: middle hepatic artery; RHA: right hepatic artery; aRHA: accessory right hepatic artery; GDA: gastroduodenal artery; RGA: right gastric artery; AA: abdominal aorta; LLL: left lobe of liver; DP: diaphragm; PAN: pancreas).

Figure 4) Overview of trifurcation of CHA into LHA, RHA and GDA with RGA arising from RHA. (CHA: common hepatic artery; LHA: left hepatic artery; MHA: middle hepatic artery; RHA: right hepatic artery; GDA: gastroduodenal artery; RGA: right gastric artery; LHD: left hepatic duct; RHD: right hepatic duct; CA: cystic artery; CD: cystic duct; GB: gallbladder; AA: abdominal aorta; LLL: left lobe of liver; PAN: pancreas).

DISCUSSION

In Figure 1 of the case, additional branches arise from the CT. Therefore, it is classified as Panagouli type III, with the LIPA and RIPA arising independently from the CT, and the aRHA originates from the CT distal to the RIPA as additional branches; and the CT displays a false tripod with the LGA branching off proximal to the bifurcation of the CT into SA and CHA. It is crucial for surgeons and radiologists to take note of the variations of the celiac trunk branching pattern during procedures such as transplant surgeries, hepatobiliary and pancreatic laparoscopic surgeries, selective embolization treating pseudoaneurysm, and radiological procedures [8,9]. The complexity of the procedures and associated risk of inadvertent vascular injury could be high given the multiple variations presented in our case [10]. There is an increased amount of blood loss, operation time, and postoperative drainage for patients with celiac trunk variation [11].

Arterial supply of the liver normally depends on the right and left hepatic artery from hepatic artery proper. Different variations occur in approximately 20% of the population [7]. Reviewing studies based on observations on multidetector computed tomography (MDCT) angiography, the trifurcation of CHA into GDA, RHA, LHA are found in 1.8% to 8% of the cases [12- 15]. The presence of aRHA from the celiac trunk can be classified as superior accessory hepatic artery with prevalence of up to only 2% [8]. It provides an alternative arterial supply to the liver when major hepatic arteries are injured [9]. In liver transplantation, aRHA is either sacrificed or preserved and revascularized if it is large and replaces normal hepatic artery [10]. Such knowledge of variations in the origins of aRHA is essential to prevent intraoperative bleeding and complications during hepatobiliary surgeries [9]

According to a systemic review and meta-analysis of the origins of the RGA in 1,971 cases, the pooled prevalence of RGA originating from RHA is only 3.43% [16-19]. The variation of hepatic and gastric arteries is particularly important for gastrectomy. MDCT is highly suggested in revealing vascular anomalies in the preoperative stage [20].

Most HCC patients (>70%) are diagnosed with advanced unrespectable HCC [21]. Treatment options include systemic therapy, radiation therapy, transarterial chemoembolization (TACE), and hepatic arterial infusion chemotherapy (HAIC) [22]. TACE administers embolic and anti-cancer agents to HCCs via the hepatic artery. Understanding the variation in vascular patterns and pretreatment imaging such as MRI and CTA to identify arterial supply to HCC are imperative in preventing accidental embolization of the non-target artery [23]. In this case study, trifurcation of the common hepatic artery increases the risk of GDA injury when it is unintentionally embolized. Acute pancreatitis may occur when chemo-drugs flow through pancreaticoduodenal branches of GDA causing chemotherapyinduced ulceration [24]. RGA originating from RHA is also susceptible to damage if the catheter is positioned proximal to the opening of the RGA. Superselective TACE using microcatheter embolizes more distal hepatic artery. It can be used to prevent accidental delivery of chemodrugs into extrahepatic arteries such as GDA and RGA in our case [25,26]. HAIC continuously delivers high-concentration anticancer drugs to HCCs also depending on the vasculature distribution. Recent papers support that HAIC provides better survival [27], and tumour response rate [28]. It also lowers intrahepatic metastasis over TACE [29,30].

Patients with portal vein tumour thrombus (PVTT) are usually a contraindication to TACE since the process of treatment in TACE further reduces hepatic perfusion and worsens liver dysfunction [31]. According to a study documented by Chen et al in An Nan Hospital, China Medical University in Taiwan, the GDA, and RGA are embolized to prevent reflux of cytotoxic drugs into the stomach and the duodenum [27], which is particularly crucial attention to the treatment as the GDA and RGA can originate with aanatomical variants in our case findings.

Whitley et al documented in a systematic review and meta-analysis on 4,208 patients from 18 studies, that independent origins of RIPA and LIPA and the presence of CIPA have been observed in 75.8% and 24.2% of the patients respectively. The RIPA and LIPA arising from the CT have a prevalence of 35.7% and 46.1% respectively among all cases [32]. It should be noted that HCC occasionally receives parasitic blood supply from extrahepatic vessels, with RIPA(70-83%) and LIPA(12%) being the most common collateral arterial source [33]. Hence, although the branching pattern of RIPA and LIPA in our case (RIPA and LIPA arising from the CT separately) is relatively common, understanding the variations of the origins of RIPA and LIPA is important in the embolization of the IPAs during TACE. The knowledge could also be applied in handling IPAs injuries which can be caused by chest aspiration blunt trauma or cardiopulmonary resuscitation [34-34].

CONCLUSION

We report on anatomical multiple variants of the ventral roots branching from the upper abdominal aorta. The rare variants of (1) separating origins of inferior phrenic arteries from the celiac trunk, (2) trifurcation of the common hepatic artery, (3) an aberrant right gastric artery origin, and (4) accessory right hepatic artery originating from the celiac trunk in the donor body. Comprehending and understanding the numerous variations in the upper abdominal of the foregut is crucial for managing liver disease. The findings empower medical professionals to judge the critical arrangement and make decisions regarding treatment procedures, minimizing medication errors. Failure to recognize the patterns of vascular variations could lead to complications like misdiagnosis, intraoperative bleeding, and inadvertent damage to structures in the vicinity.

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