Illustrated Encyclopedia of Human Anatomic Variation: Opus II: Cardiovascular System: Arteries: Abdomen: Variations in Branches of Celiac Trunk
Ronald A. Bergman, PhD
Adel K. Afifi, MD, MS
Ryosuke Miyauchi, MD
Peer Review Status: Internally Peer Reviewed
The common hepatic artery usually arises from the celiac trunk (85% of cases), but may also arise directly from the aorta or from the left gastric, superior mesenteric (3% of cases), gastroduodenal, right renal or splenic artery. The occurrence of these alternate sources for the common hepatic can be accounted for developmentally.
(NOTE: Aberrant (variant) Hepatic Arteries: Quite often the hepatic artery has an incomplete set of branches because one or the other of its usual branches arises from a source other than the proper hepatic artery from the celiac trunk. Such a vessel is from an outside source is spoken of as aberrant (a variation). Aberrant hepatic arteries are of two types, replacing and accessory. An aberrant replacing hepatic artery is a substitute for the normal (usual) hepatic artery which is absent. An aberrant (a variable) accessory hepatic appears in addition to one that is normally (usually) present. Some sort of aberrant (variable) hepatic artery, either replacing or accessory, occurs in approximately 42% of individuals.)
Together with the usual artery, an accessory hepatic may arise from one of the above-named or neighboring branches. An accessory left hepatic artery may give rise to an esophageal artery. The common hepatic artery may be doubled, tripled, or missing (12% of cases), in which case one or more accessory arteries derived from one of the above sources may take its place. In one case of three hepatic arteries, a right and left arose independently from the celiac trunk, and one branch arose from the superior mesenteric which supplied the gallbladder (Poynter). Four hepatic arteries have also been recorded by several authors (Poynter, 1922).
The common hepatic is almost always located between the bile duct and the portal vein.
The course of the right hepatic artery observed in 165 specimens was as follows: anterior to the bile duct, 64%; anterior to the portal vein, 0.1%; and posterior to the portal vein, 9%. The right hepatic artery arose from the superior mesenteric in 12%. The cystic artery arises from the right hepatic in about 89% of cases.
Although the cystic normally arises from the hepatic arterial system, it may also arise from the gastroduodenal artery.
The left hepatic artery arises from the common hepatic in 89% of cases; in 11% of cases the vessel is unusual and may arise from the left gastric. Supernumerary or "accessory" vessels to the left lobe of the liver occur in 23% of cases. In one study of 257 cadavers, 21% had one accessory hepatic artery, 9.3% had two, 7% had three, and 3.1% had four. "Accessory hepatic arteries and ducts" must not be considered simply as accessory or extra, but always as an essential, tissue-sustaining blood supply and as mandatory biliary drainage ducts (Michels).
The gallbladder may be supplied by one (79% of cases), two (19.9%), or three cystic arteries (1.8%).
The hepatic pedicle is of surgical importance, hence the following description of the variations of the right hepatic, cystic, and gastroduodenal arteries in relation to the biliary system. The relations of the right hepatic artery to the hepatic duct have already been described. In 70% of individuals, the right hepatic artery is behind the hepatic bile duct, and the cystic artery arises from the right hepatic artery at a point between this artery and the cystic duct. In 12%, the hepatic artery passes across the front of the hepatic duct before entering the right lobe of the liver. The cystic artery arises in 70% of cases as described above. In 10%, the right hepatic artery runs parallel, and in close proximity, to the cystic duct and neck of the gallbladder throughout its course. At the level of the neck of the bladder, it enters the right lobe of the liver. In 8% of individuals, the right hepatic artery passes across the right edge of the hepatic duct and enters the liver or loops around the hepatic duct to pass behind it. Before entering the liver, the hepatic artery gives rise to the cystic artery. The right hepatic artery is an end-artery; any damage to this artery will result in necrosis of the right lobe of the liver.
The variations of the gastroduodenal artery in relation to the common bile duct may be described as follows. In 42% of individuals, a branch of the gastroduodenal artery (posterior superior pancreatoduodenal artery) crosses the part of the common bile duct that lies behind the duodenum. In 38%, the gastroduodenal projects over the left edge of the common bile duct in its retroduodenal segment. In 20%, the gastroduodenal artery crosses the anterior aspect of the retroduodenal part of the common bile duct. The right hepatic artery may pass in front or behind the common bile duct. The gastroduodenal artery may give rise to the cystic artery.
Variations in origin of a single cystic artery have been reported as follows. There is only one cystic artery in 88% of individuals. Of these individuals, the cystic artery arises from the the right hepatic artery in 82%; from the proper hepatic artery in 3%; from the left hepatic artery, distal to the origin of the right hepatic artery, in 2%; and from the gastroduodenal in 1%, crossing the common bile duct to reach the neck of the gallbladder.
The relations of the single cystic artery to the hepatic bile duct have been described as follows. The cystic artery arises close to the right edge of the hepatic duct in 71% of individuals; arises on the left side of the hepatic duct or common bile duct in 27%, crossing one or more of these structures to reach the neck of the gallbladder; and arises behind the hepatic bile duct in 2%.
In cases of two cystic arteries, their origins have been reported as follows. Two cystic arteries occur in 12% of individuals according to one author and in 18% by another author; we can assume here a frequency of about 15%. Of these individuals, both cystic arteries arise from the the right hepatic artery in 9%; one cystic artery arises from the right hepatic and the second from the gastroduodenal artery in about 3%; one artery arises from the right hepatic and the second from the proper hepatic artery in 1.5%; and both cystic arteries arise from the left hepatic artery in 1.5%.
Thompson provided the following listing of probable or estimated frequencies of what he described as the most important anatomic arrangements in the hepatic pedicle:
Hepatic artery absent,
Left hepatic from celiac trunk,
Right hepatic artery from superior mesenteric,
Right hepatic artery dorsal to portal vein,
Two cystic arteries from right hepatic,
Common hepatic duct formed within liver.
Left hepatic artery from left gastric,
Accesssory right hepatic arteries,
Right hepatic artery ventral to common hepatic duct,
Right hepatic artery dorsal to cystic duct,
Two cystic arteries,
Cystic artery ventral to common hepatic duct,
Common hepatic duct entirely to right of portal vein,
Cystic duct presenting dorsal arterial relations.
Right hepatic artery presenting peculiar relationships to biliary ducts,
Cystic duct presenting ventral arterial relations.
Unusual (aberrant) arteries to the liver,
Right hepatic artery close to left or upper aspect of cystic duct,
"High opening" of cystic and common hepatic ducts,
Common hepatic duct presenting ventral arterial relations.
Cystic artery closely related to cystic duct,
Either common hepatic or common bile duct (suprarenal portion) presenting large ventral arterial relations,
Right hepatic artery close to cystic duct [frequency not satisfactorily established, (Thompson)].
"Low opening" of cystic and common hepatic ducts.
Right hepatic artery dorsal to common hepatic duct,
Cystic artery crossing neither common bile nor common hepatic duct,
Angular junction of cystic and common bile ducts,
Common hepatic duct ventral to portal vein.
Right hepatic artery from hepatic artery,
Right hepatic artery dorsal to common bile duct,
Single cystic artery,
Supraduodenal portion of common bile duct entirely to right of portal vein.
Hepatic artery from celiac trunk,
Hepatic artery entirely to the left of the common bile and common hepatic ducts,
Hepatic artery ventral to portal vein,
Gastroduodenal artery from hepatic,
Gastroduodenal artery entirely to left of supraduodenal portion of common bile duct,
Left hepatic artery from hepatic artery,
Left hepatic artery entirely to left of common bile and common hepatic bile ducts,
Right hepatic artery ventral to portal vein,
Cystic artery from right hepatic,
Definite right and left hepatic ducts outside liver,
Cystic duct ventral to portal vein.
In the most common or textbook description, the cystic artery arises from the right hepatic artery. Scott-Conner and Hall (1992) reported the site of origin of the cystic artery is Calot's triangle in about 80% of patients and a careful dissection of Calot's triangle is crucial for safe cholecystectomy. The cystic artery is solitary in approximately 75% of individuals and is termed an "anterior cystic artery" in this, its usual location. After crossing Calot's triangle, the cystic artery typically divides into a superficial and a deep branch. The superficial branch of the cystic artery runs along the peritoneal surface of the left side of the gallbladder. It can be identified as a cord-like structure lifting the peritoneum of Calot's triangle* and Hartmann's pouch** when upward traction is placed on the gallbladder. It supplies the free peritoneal surface of the gallbladder.The deep branch of the cystic artery supplies the attached surface of the gallbladder and frequently anastomoses with small vessels in the gallbladder fossa, "low-lying or posterior cystic artery."
*Calot's triangle is defined as the "triangle" formed by the cystic artery superiorly, the cystic duct inferiorly, and the hepatic duct medially.
**Hartmann's pouch is defined as the pelvis of the gallbladder, fossa provesicalis, a spheroid or conical pouch at the junction of the neck of the gallbladder and the cystic duct.
Daseler, et al. (1947) provide the following summaries:
The origin of the common hepatic artery: 500 cases; celiac trunk, 416; superior mesenteric, 22; aorta, 1; absent, 61.
Location of hepatic artery: 439 cases: left of common bile duct, 431; posterior to same, 7; anterior to same, 1.
Origin of right hepatic artery (right ramus of hepatic proper): 500 cases; common hepatic, 415; superior mesenteric, 56; replacing common hepatic, 23; celiac, 4; aorta, 1. (According to Anson (1956), a right hepatic artery from the celiac trunk is found in 85% of individuals.
Origin of accessory right hepatic artery: 36 cases; superior mesenteric, 15; left hepatic, 13; gastroduodenal, 5; celiac, 2; aorta, 1.
Location of right hepatic artery: 500 cases; posterior to common hepatic duct, 325; anterior to common hepatic duct, 58; posterior to common bile duct, 58; right of duct system, 22; posterior to right and left hepatic ducts, 18; left of duct system, 8; anterior to common bile duct, 7; anterior to right and left hepatic ducts, 4.
Origin of left hepatic artery: 500 cases; common hepatic, 410; celiac, 57; replacing common hepatic, 23; left gastric, 9; gastroduodenal, 1.
Origin of accessory left hepatic artery: 175 cases; right hepatic, 99; left gastric, 54; common hepatic, 11; gastroduodenal, 6; celiac, 5.
Origin of gastroduodenal artery: 500 cases; common hepatic, 377; replacing left hepatic, 52; right hepatic, 35; replacing common hepatic, 19; accessory left hepatic, 2; celiac, 1; absent, 14.
Origin of right gastric artery: 250 cases; common hepatic, 125; left hepatic, 81; gastroduodenal, 33; right hepatic, 10; celiac, 1.
Origin of cystic artery: 580 cases; right division of hepatic artery, 416; right hepatic from superior mesenteric, 90; left hepatic, 36; common hepatic, 16; gastroduodenal, 15; replacing or accessory right hepatic, 3; celiac, 2; superior mesenteric, 1; superior pancreaticoduodenal, 1.
Origin of accessory cystic artery: 65 cases; right hepatic, 50; gastroduodenal, 6; common hepatic, 4; left hepatic, 3; accessory right hepatic from superior mesenteric, 2.
Origin of single replacing cystic artery: 120 cases; replacing right hepatic from superior mesenteric, 36; left hepatic, 27; right hepatic from replacing common hepatic, 21; accessory right hepatic from superior mesenteric, 12; common hepatic, 11; gastroduodenal, 6; accessory right hepatic from celiac, 3; celiac, 2; superior mesenteric, 1; superior pancreaticoduodenal, 1.
Origin of dual replacing cystic arteries: 15 cases; both from right hepatic branch of superior mesenteric, 7; replacing right hepatic and left hepatic, 3; both from left hepatic, 1; gastroduodenal and accessory right hepatic, 1; gastroduodenal and right hepatic branch from celiac, 1; gastroduodenal and left hepatic, 1; gastroduodenal and right hepatic branch of superior mesenteric, 1.
Location of cystic artery: 580 vessels; *Calot's triangle, 405; anterior to common hepatic duct, 123; anterior to common bile duct, 17; posterior to common bile duct, 12; between hepatic ducts, 6; anterior to cystic duct and right hepatic duct, 6; right duct system, 5; posterior to common bile duct, 3; left of duct system, 2; posterior to cystic duct and right hepatic duct, 1. *Calot's triangle is formed by the common hepatic duct, cystic duct and the undersurface of the liver.
Image 18, Image 101, Image 254A, Image 255A, Image 255B, Image 255C, Image 255D, Image 255E, Image 255F, Image 335, Image 336, Image 343, Image 344A, Image 344B, Image 346A, Image 346B, Image 346CImage 502Image 519
See Image 18, Image 54
See Image 18, Image 101,Image 343, See Image 336
Image 442, Image 443,Image 444, Image 445, Image 446,Image 447, Image 448, Image 449, Image 450
See Image 18, Image 96
Image 19, See Image 54, Image 101, See Image 335, Image 343
Image 17, See Image 101, Image 108, Image 337
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