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Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018



Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018



Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018



Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018



Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018



Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata



Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018



Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018



Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018



Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011



Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2022 | Month : February | Volume : 16 | Issue : 2 | Page : TC05 - TC10 Full Version

Origin and Prevalence of the Retroportal Course of Hepatic Artery- A Retrospective Study

Published: February 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/53317.15993

Priya Appanraj, M Venugopal

1. Assistant Professor, Department of Radiodiagnosis, Regional Cancer Centre, Trivandrum, Kerala, India. 2. Professor and Head, Department of Radiodiagnosis, Regional Cancer Centre, Trivandrum, Kerala, India.

Correspondence Address :
Dr. Priya Appanraj,
Assistant Professor, Department of Radiodiagnosis, Regional Cancer Centre, Trivandrum-695011, Kerala, India.
E-mail: primula.sharon16@gmail.com

Abstract

Introduction: Anatomical variations of celiac and hepatic arteries are relatively common and impact operative time and technique. Intraoperative identification of the entire course of these vessels can be a challenge due to limited surgical field and increases the chance of iatrogenic injury.

Aim: To evaluate and describe the origin and prevalence of retroportal course of hepatic arteries seen in Computed Tomography (CT) angiography in a large series of patients.

Materials and Methods: The present retrospective study was conducted in the Department of Radiology, affiliated to a tertiary cancer centre in Southern India. CT angiogram done between January 2020 to June 2021 were included. Total of 326 abdominal CT angiograms were studied for celiac axis variations, variations in the origin and branching pattern of hepatic arteries, trajectory of the hepatic artery and its relation to portal vein. The branching pattern of celiac axis was analysed with adherence to the modified definition of Common Hepatic Artery (CHA) and it was classified as normal/variant/ambiguous. Based on the origin and branching pattern, hepatic arteries were divided into standard/replaced/accessory and classic/variant divisions, respectively. Variant divisions include trifurcation, duplicate or double hepatic artery and late origin of Gastro Duodenal Artery (GDA). Retroportal hepatic arteries under each variation was identified separately and their prevalence calculated. Confidence interval was calculated using simple proportion-frequency analysis open Epi version 3 software.

Results: The age of the patients varies from 3-83 years (mean age 53.7 years). A 207 (63.49%) cases were male and 119 (36.5%) cases were female. A 262 (80.37%) cases had a normal celiac axis anatomy. Eight specific types of celiac axis variations were observed in 48 (14.72%) cases. In the remaining 16 (4.91%) cases, the celiac axis anatomy was ambiguous. CHA originated from the celiac axis, Superior Mesentric Artery (SMA) and aorta in 294 (90.18%), 10 (3.07%) and 6 (1.84%) cases respectively. Out of the 52 replaced Right Hepatic Artery (rRHA), 48 (14.72%), 3 (0.92%) and 1 (0.30%) cases had Right Hepatic Artery (RHA) replaced to the SMA, aorta and GDA, respectively. Except for the one rRHA from GDA, all of them had a retroportal course. Classic branching pattern of hepatic artery was seen in 154 (47.24%). Trifurcation, early branching of RHA and early branching of LHA were found in 49 (15.03%), 4 (1.22%) and 8 (2.45%) respectively. 63 (70%) cases of variations in hepatic artery origin, 15 (16.67%) cases of variations in hepatic artery branching and 12 (13.33%) cases of variations in celiac axis contributed to a total of 90 cases with retroportal hepatic artery. Prevalence of retroportal hepatic artery in the present study is 27.61% (confidence interval 22.82-32.8) and the most common cause was aberrant RHA origin.

Conclusion: Knowledge about the origin and prevalence of retroportal course of hepatic artery will help the surgeon to approach it systematically. Preoperative knowledge of the variations in origin and branching patterns and its influence on the trajectory will help in a better intraoperative identification of these variant vessels.

Keywords

Celiac axis variations, Computed tomography angiography, Hepatic artery variations

Introduction
Anatomical variations of celiac and hepatic arteries are relatively common. These variations have substantial impact on operative time and technique in hepatobiliary surgeries and interventional radiological procedures. Preoperative knowledge of the origin and course of these vessels are essential to avoid intraoperative injury and to have a good postoperative outcome (1),(2). Intraoperative identification of these vessels can be a challenge in obese patients, inflammation surrounding the biliary stent in preoperatively stented patients, mass at the porta displacing the vessels and also in patients with previous history of supramesocolic surgery. According to a 2002 study, the accuracy, sensitivity and specificity of CT Angiogram (CTA) to know the branching pattern and course of the celiac artery branches and Superior Mesenteric Artery (SMA) were 97%, 94% and 100% (3). Few other studies done earlier also showed similar results (4),(5),(6).

With the present technical advances in the CT machine, the sensitivity can reach upto 100%. CTA also has an advantage over the conventional angiogram in demonstrating the course of these vessels, essential information for the surgeon.

Existing knowledge is that a normal hepatic artery originating from the celiac axis takes a preportal course and a replaced Hepatic Artery (rHA) takes a retroportal course. However, there are few exceptions to this as there are numerous celiac axis variations. The trajectory of the replaced hepatic vessels can be understood based on the embryological perspective. The primitive arteries that provide blood to the foetal liver are the left hepatic branch, medial hepatic branch, and right hepatic branch. Embryonic right hepatic branch arises from the omphalomesenteric artery, and takes a retroportal course. Omphalomesenteric artery will later become the SMA. At a later time, the left and right embryonic arteries involute, with persistence of medial hepatic branch which develops into Proper Hepatic Artery (PHA) (7). Persistence of these embryonic arteries gives rise to accessory or replaced hepatic arteries.

Though there are many literatures available on the incidence of celiaco mesenteric axis variations (8),(9),(10),(11),(12), there are only few articles on the trajectory of these variant hepatic arteries and its relation to the portal vein (13),(14),(15),(16),(17). The hypothesis is that the abnormalities of origin, branching pattern of celiac and hepatic arteries will overlap with the trajectory of the hepatic artery and its relation to portal vein. The primary objective of the study was to analyse the prevalence of retroportal hepatic artery and futher study the influence of variations in origin and branching pattern, over the trajectory of the hepatic artery and its relation to the portal vein.
Material and Methods
The retrospective study was conducted in the Department of Radiology, affiliated to a tertiary cancer centre in Southern India. CT scans done between January 2020 and June 2021 were retrieved from Picture Archiving and Communication System (PACS) and searched for abdominal CTA. Institutional review board approval was obtained for this study. Data collection and analysis was done over a period of one month after obtaining IRB clearance.

Inclusion criteria: All abdominal CTA, done between January 2020 and June 2021 were included in the study.

Exclusion criteria: Technically poor scans, large mass in the porta and patients with history of major supracolic compartment surgeries were excluded.

Study Procedure

Total of 326 CTA were studied. As a routine practice, all the CTA for the hepatic vasculature were done by bolus tracking method with ROI kept in aorta (18). The arterial phase was acquired after a delay of 9 seconds once the threshold in the aorta reached 100 HU. The raw imaging data of the arterial phase, the multiplanar and 3D reconstructed images were analysed for the celiac axis, SMA, Left Gastric Artery (LGA), Common Hepatic Artery (CHA) and splenic artery origins. Volume Rendered (VR) 3D images were used in evaluating the arteries with tortuous course and the sagittal Multiplanar Images (MPR) in easy identification of the LGA origin.

Key Definitions

• Normal celiac axis (Table/Fig 1): Common arterial trunk that branches off CHA, LGA, and splenic arteries (Sp A)
• Ambiguous celiac axis (Table/Fig 2) (8): Congenital absence of CHA or persistent embryonic anastomotic channel connecting the celiac axis and SMA or CHA to the celiac axis and the SMA
• Hepatomesenteric Trunk (HMT)(Table/Fig 3): CHA completely replaced to SMA
• Celiacomesenteric Trunk (CMT) (Table/Fig 4): Celiac axis completely replaced to SMA
• CHA (8): Arterial trunk giving rise to Gastroduodenal Artery (GDA) and Right Hepatic Artery (RHA) or Left Hepatic Artery (LHA), irrespective of the origin and anatomic course
• Standard hepatic artery: Arterial blood supply to the liver from celiac axis is only through CHA
• Replaced Hepatic Artery (rHA): Only hepatic arterial branch supplying to that portion of liver but with aberrant origin
• Accessory Hepatic Artery (aHA): Hepatic artery branch with aberrant origin, in addition to the hepatic artery with normal origin
• Classical division: CHA divides into GDA and PHA, and PHA further divides into RHA and LHA
• Trifurcation: No PHA. CHA trifurcates into GDA, RHA and LHA
• Late origin of GDA: No PHA. Early branching of RHA/LHA before GDA
• Double or duplicate hepatic artery (Table/Fig 5): No CHA and PHA. RHA and LHA arises directly from the celiac axis or aorta and GDA originates from either of the hepatic arteries.

Normal celiac trunk, also known as hepatosplenogastric trunk, refers to a common arterial trunk that branch off CHA, Left Gastric Artery (LGA) and Splenic arteries, while SMA originates separately from the aorta (Table/Fig 1). The pattern of the aortic origin of these four major arteries were analysed with adherence to the modified definition of CHA proposed by Song SY et al., (8). They further described the ambiguous celiac axis anatomy as: (i) absent CHA due to presence of persistent anastomotic channels; and (ii) absent CHA due to separate origins of the hepatic arteries and the GDA (Table/Fig 2). Based on these definitions, celiac axis anatomy was classified as, variant or ambiguous (Table/Fig 6). Relation of hepatic artery to portal vein was studied in each variant. Two types of persistent anastomotic channels are possible: (i) through a pancreaticoduodenal arcade (Table/Fig 2); and (ii) through a vertical anastomosis like Arc of Buhler.

After classifying celiac axis anatomy, CHA anatomy was analysed for its origin, trajectory, its relationship to portal vein/SMV and pancreas, and its branching patterns (Table/Fig 6). Normal CHA arises from the celiac axis and courses along the upper border of the pancreatic head and anterior to the portal vein. Possible variant site of origin for CHA includes: (i) direct origin from aorta (Table/Fig 7); (ii) origin from SMA (Table/Fig 3); and (iii) LGA. Trajectory and portal vein relation of the CHA with variant origin was evaluated for the 5 possible anatomic courses (8). They are supra/trans/infrapancreatic with relation to the pancreatic head, and pre/retroportal with relation to the portal vein/SMV.

Based on the origin, hepatic arteries were divided into standard, replaced or accessory (Table/Fig 8). Replaced and accessory hepatic arteries can take origin from: (i) SMA; (ii) aorta; (iii) LGA; or (iv) GDA.

The standard hepatic arteries were further subclassified based on their branching pattern to identify the influence of the branching pattern of CHA over the trajectory of the hepatic artery and its relation to the portal vein. Different branching patterns of standard hepatic artery includes classic, trifurcation, duplicate or double hepatic artery and late origin of GDA based on the presence or absence of CHA and PHA (Table/Fig 9) (13). Late origin of GDA was further divided into early branching of RHA and early branching of LHA. The presence or absence of a middle hepatic artery was considered normal. In “late origin of the GDA”, CHA is present, and RHA/LHA takes origin before GDA, and GDA may originate from either of the hepatic arteries. CHA in this variant is usually short and further divided based on the artery which originates first as: (i) early branching RHA; or (ii) early branching LHA. Whereas in the “double or duplicated hepatic artery”, CHA is absent, the right and LHA branches take separate origin directly from the coeliac trunk and the GDA may originate from either of the hepatic arteries (Table/Fig 5). Retroportal hepatic arteries under each variation were identified separately and their prevalence calculated (Table/Fig 10).

Statistical Analysis

Confidence interval calculated using simple proportion-frequency analysis open epi version 3 software (19).
Results
Origin and Branching Pattern of Celiac Axis (Table/Fig 6)

Fifteen types of celiac axis anatomy with an aortic origin of the major four arteries, including normal celiac axis, are theoretically possible (8). Of the 15 celiac axis anatomy types, nine including normal celiac axis were identified in our study (Table/Fig 6).

Out of 326 abdominal CTA studied, 262 (80.37%) cases had a normal celiac axis anatomy. Eight specific types of celiac axis variations were observed in 48 (14.72%) cases. In the remaining 16 (4.91%) cases, the celiac axis anatomy was termed as ambiguous because the CHA was absent or persistent anastomotic channels were present. The most common celiac axis variation was a Hepatosplenic trunk (HSp trunk) with separately originating LGA and SMA, found in 26 (7.97%) cases (Table/Fig 11). Incidence of less than 1% was found in 5 types of celiac axis variants. Sixteen cases had ambiguous celiac axis anatomy. The causes were absent celiac axis with persistent anastomotic channels, quadrification of celiac axis and hepatic arteries without a GDA component as found in one, one and fourteen cases respectively.

When the celiac axis was absent, as found in one case, its branches were filled retrogradely from SMA, through GDA by longitudinal and transverse pancreaticoduodenal arcades (Table/Fig 2). In the remaining 15 cases, CHA was absent. Absent CHA were due to quadrification of the celiac axis into RHA, GDA, LGA and Splenic arteries in one case and hepatic arteries without a GDA component in the remaining 14 cases. Among the 14 hepatic arteries without a GDA component, 12 (3.68%) had separate branching of the replaced right and left hepatic arteries from SMA and LGA, respectively while two cases (0.06%) had PHA totally replaced to SMA (Table/Fig 6).

To know the influence of variations in the celiac axis over the trajectory of CHA, the course of hepatic artery among the variant and ambiguous celiac axis were studied. Out of the 48 cases with variant celiac axis and 16 cases with ambiguous celiac axis, 12 cases were identified of retroportal hepatic arteries, primarily due to variations in celiac axis anatomy. Ten cases were due to CHA origin being replaced to the SMA, and two cases were due to branching variations in the celiac axis.

(i) Replaced CHA origin with retroportal hepatic artery: Replaced CHA (rCHA) origin can be from SMA or aorta. From SMA. rCHA was found to be the most common variant origin of CHA, found in 10 cases (Table/Fig 3). In all these 10 cases, CHA had a retroportal course. Nine out of these 10 cases had suprapancreatic origin of CHA, running a short vertical course posteromedial to the superior mesenteric vein and main portal vein (retroportal). The remaining one case with infrapancreatic type origin had dual pathway with respect to the pancreas and SMV. The RHA arose as the first branch from the infrapancreatic HMT and had retro- SMV course, ascending posterior to the portal vein and supplying the right lobe of liver. Whereas the downstream hepatic artery took a lateral C-shaped loop in the pancreatoduodenal groove anterior to the pancreatic head, simulating the position of the GDA in the groove and ascended as LHA.
Six cases of CHA with a direct aortic origin were found, and all six of them had normal suprapancreatic preportal course, with its site of aortic origin close to the origin of the celiac axis equivalent.
(ii) Branching variations of celiac axis with retroportal hepatic artery: In two cases, hepatic arteries with celiac axis origin had retroportal course. In both these cases, the celiac axis had branching variations. One was a bifurcation of the celiac axis with Hepatogastric trunk (HG trunk) while splenic artery having a common origin with SMA forming Spleno Mesenteric trunk (SM trunk). The other was a quadrification of the celiac axis into RHA, GDA, LGA and Splenic arteries with retroportal RHA.

Thus celiac axis variations contributed to a total of 12 cases with retroportal hepatic artery. (Table/Fig 10).

Origin and branching pattern of hepatic artery (Table/Fig 8).

(i) Variation origin of hepatic arteries and retroportal course- To know the overlap between the hepatic artery origin and its trajectory, the origin of 324 hepatic arteries were identified and divided into: (i) standard hepatic artery origin from celiac axis; and (ii) replaced origin. The 2 cases excluded include absent celiac axis and quadrification of the celiac axis. Standard hepatic arterial anatomy was found in 224 cases (69.13%) and while the rest 100 (30.86%) cases had replaced origin of one or both hepatic arteries. Out of the 52 rRHA, 48 (14.72%), 3 (0.92%) and 1 (0.30%) cases had RHA replaced to the SMA, aorta and GDA, respectively. Except for the one rRHA from GDA, all of them had a retroportal course. Fifty five cases had rLHA and they did not affect the relation of hepatic artery with portal vein.
Accessory hepatic arteries (aRHA), if found, were evaluated separately for its origin, since they also contributed to the total number of retroportal hepatic arteries. 10 cases had aRHA originated from SMA and GDA, and all had a retroportal course (Table/Fig 8).
(ii) Branching variations of hepatic artery and retroportal course: Standard hepatic arterial anatomy was found in 224 cases (68.71%). Standard hepatic arteries were further divided into classic, trifurcation, duplicate or double hepatic artery and late origin of GDA. Classic branching pattern of hepatic artery was seen in 154 (47.24%) cases. Trifurcation, early branching of RHA and early branching of LHA were found in 49 (15.03%), 4 (1.22%) and 8 (2.45%), respectively. One case with a classic branching pattern had early branching GDA at a distance of 6.5 mm from the CHA origin and had a preportal course, while PHA had a retroportal course (Table/Fig 12). Out of the 49 cases with trifurcation pattern, only one had retroportal hepatic artery. In 3 out of 4 cases with early branching of RHA before GDA, RHA had a retroportal course. When LHA branched off early before GDA, the downstream RHA had normal preportal course. In all nine cases of double hepatic artery variant from celiac axis, the GDA arose from LHA and had a preportal course, while RHA had a retroportal course. Apart from these patterns, 1 case had both variations in origin and branching while LHA origin was replaced RHA branched off early from CHA before portal vein crossing and had a retroportal course.

Distribution of the Retroportal Hepatic Artery

A total of 63 (70%) cases of variations in hepatic artery origin, 15 (16.67%) cases of variations in hepatic artery branching and 12 (13.33%) cases of variations in celiac axis contributed to a total of 90 cases with retroportal hepatic artery (Table/Fig 10). Prevalence of retroportal hepatic artery in the present study is 27.61% (Confidence interval 22.82-32.8) and the most common cause was aberrant RHA origin.
Discussion
Song SY et al., has published the largest series of celiac and hepatic artery variations using CT scan and digital subtraction angiography and classified the celiac artery origin into normal, variant and ambiguous anatomy (8). In the present study findings in 326 cases were compared to prior work by Song SY et al., and Sureka B et al., who used the same classification strategy in 5002 and 600 cases respectively (8),(12).

Normal, variant and ambiguous celiac axis anatomy was seen in 80.37%, 14.72% and 4.91% in the present study. The incidence of these three patterns was 89.1%, 9.64% and 1.26% in Song SY et al., 91%, 5.5% and 3.5% in Sureka B et al., study (8),(12).

The HSp trunk with separate origin of LGA and SMA from aorta (7.97%) was the most common celiac axis variant in the present study (Table/Fig 6). This was the most common variant in the previous two studies (8),(12) also found in 4.42% and 2.83% cases, respectively. However, compared to the other two studies, our group exhibited a higher incidence of this pattern. The next common anatomic variation in present study was HMT and gastrosplenic trunk (2.45%) which was also found in Song Y et al., study (2.64%). Incidence of direct aortic origin of CHA, a rare variation, had an incidence of 1.84% in our study, whereas the other two studies had an incidence of 0.4% and 0.33%, respectively.

One case of congenitally absent celiac axis was found with reformation of its branches by retrograde filling through GDA from SMA by pancreaticoduodenal arcades (Table/Fig 2). This rare anatomic variant has greater importance in surgical procedures like pancreatoduodenectomy that require GDA ligation. Tumour involvement of these communicating vessels makes the lesion unresectable or demands a major vascular reconstruction using grafts from aorta.

One case of rCHA from SMA had an infrapancreatic origin and its distal branches had dual relation with the SMV. While the RHA branches off first and maintains a posterior relation to superior mesenteric vein, the hepatic artery distal to it traversed through the anterior pancreaticoduodenal groove, where GDA is commonly found. A potential chance for mistaking the later branch for GDA and ligating it would result in compromised blood supply to the liver and biliary tract. Its origin from SMA near the neck of pancreas would also put them at risk of damage during neck transection or uncinate process dissection. An aberrant arterial course like this may demand a change in technique like infracolic SMA first approach during pancreatoduodenectomy, rather than a usual approach wherein SMA dissection is done as the latter part of the surgery (20).

All replaced and accessory right hepatic arteries originating from SMA and aorta had retroportal course. One replaced and one accessory RHA each, having origin from GDA had inconsistent relation to portal vein. While the former had a preportal course, the latter had a retroportal course. A rare variant of rRHA from SMA dividing into 2 branches and had dual relation to portal vein was found. This was not described before.

Variations in the branching pattern of hepatic artery include trifurcation, duplicate or double hepatic artery and late origin of GDA with an incidence of 15.03%, 2.76% and 3.68% respectively. Vandamme JP et al., reported their incidence to be 2%, 4% and 12%, respectively (17). Late origin of GDA was further divided into early branching of RHA and early branching of LHA. Early branching LHA was more common than the early branching RHA in our study found in 2.45% and 1.22% of cases, respectively. They accounted for 10% and 2% of branching variants, respectively, in the Vandamme JP et al., study. One case with a classic branching pattern had a short CHA, with preportal course of GDA, while PHA had a retroportal course (Table/Fig 12). This rare variation is not described by Vandamme JP et al (17). We observed 75% of the cases with early branching RHA before GDA took a retroportal course, whereas 100% of the cases with early branching LHA had normal preportal course of both hepatic arteries.

Double hepatic artery was found in 9 (2.76%) cases. Though not mentioned in Michels classification, this variant was observed in many studies with an overall frequency ranging between 1 and 5% (9),(14). Importance of this variation includes the possibility of one hepatic branch being overlooked, when the catheter is advanced very far in selective angiographic study of the celiac trunk in various endovascular procedures of the liver. This variant is also helpful in living related liver transplants, where a long LHA pedicle allows retrieval of the left hemi liver without jeopardising the right hemi liver of the donor.

One case had variations in both branching and origin, where LHA origin is aberrant and RHA branched off early and had a retroportal course while GDA had a preportal course.

Aberrant RHA origin was found to be the single most common cause for retroportal coursing hepatic artery and contributed 70% of cases, while hepatic artery branching variations and celiac axis branching variations contributed 16.67% and 13.33% of cases, respectively.

Limitation(s)

The present study had some limitations, since it was based on only the analysis of CT images, description of fine arterial networks beyond the capability of CT examination could potentially be missed. However, in the current scenario, CT has largely replaced the conventional angiogram for diagnostic purposes, and presurgical planning in transplant and hepatobiliary surgery is entirely dependent only on CT. As a new nomenclature system for CHA was followed there was no comparison done between the present study and the other studies which used traditional classification.
Conclusion
The CT angiography in preoperative evaluation of patients having liver transplant, hepatobiliary surgeries and interventional radiological procedures cannot be overlooked in today’s scenario. Preoperative knowledge of the variations in origin and branching patterns and its influence on the trajectory will help in a better intraoperative identification of these variant vessels. To the best of the knowledge available, this is the first study of its sort to compare the overlap of the hepatic artery’s retroportal path with the origin and branching variations of celiac and hepatic artery.
Acknowledgement
We thank Dr. Prashanth Kumar MPH for the technical assistance and expertise in analysing the data.
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DOI and Others
DOI: 10.7860/JCDR/2022/53317.15993

Date of Submission: Nov 15, 2021
Date of Peer Review: Dec 04, 2021
Date of Acceptance: Jan 13, 2022
Date of Publishing: Feb 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? No
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. No

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Nov 17, 2021
• Manual Googling: Oct 08, 2021
• iThenticate Software: Jan 11, 2022 (23%)

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