Hepatic arteriogram

Fig. 7.3a,b. Hepatic arteriogram in a 26-year-old man with a small inoperable neuroendocrine tumour in the head of his pancreas. The papilla of Vater could not be accessed at ERCP and he underwent a percutaneous stenting procedure at which two self-expanding stents were inserted (lower arrowheads) apparently side by side (a). 12 hours later repeat ERCP revealed a significant haemorrhage from the papilla. The angiogram revealed a segment 4 arterial pseudoaneurysm (upper arrowheads) which was embolized successfully with coils (b)... 

Fig. 2.5.8. Selective hepatic arteriogram shows a hypervas-cular hepatocellular carcinoma (HCC) in the right lobe with transtumoral arterioportal shunting. Before starting the chemoembolization, embolization of these shunts is necessary to prevent serious side-effects...

Fig. 7.6. a Hepatic arteriogram in a patient who developed bleeding several days after a Whipple operation. A pseudoaneurysm (arrow) is seen where the gastroduodenal artery was resected, b A balloon occlusion catheter (arrow) was inflated across the arterial defect to tamponade bleeding until a decision was made regarding deflnitive therapy, c A bare balloon expandable stent (arrows) was placed across the arterial defect with plans to pass microcoils through the stent however, this post-stent study showed that the arterial defect had been sealed by the uncovered stent alone... 

Fig. 7.8. a Arterial phase of a hepatic arteriogram in a patient with hemobilia 5 days after TIPS, b Later phase of the same study shows prominent opacification of the bile ducts, c Magnified super-selective arteriogram through a microcatheter shows rapid flow into the bile ducts from this arterial branch, d Post-embolization arteriogram shows no further Howto the arterio-biliary fistula... 

Selective left hepatic arteriogram-injection of 2 cc/ sec for 8 cc. In cases of normal anatomy, this allows for the assessment of flow to segments 2,3,4A, and 4B. Special attention should be paid to the falciform, phrenic, right or accessory gastric arteries. 

Selective right hepatic arteriogram-injection of 3 cc/sec for 12 cc. Normally, the right hepatic artery provides flow to segments 1 (caudate lobe may have other blood supply), 5,6,7, and 8. Particular attention should be paid to the supraduodenal, retro-duodenal, retroportal and cystic arteries. 

The arteriograms of the celiac trunk and superior mesenteric artery should completely map the gastroduodenal blood supply. Anatomical variants should be searched for (esophageal, phrenic, hepatic arteries branching from the aorta, direct origin of the left gastric from the aorta, etc.). If all territories are visualized and no bleeding source... 

---