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Recognizing Extrahepatic Collateral Vessels That Supply Hepatocellular Carcinoma to Avoid Complications of Transcatheter Arterial Chemoembolization¹

¹ From the Department of Radiology, Seoul National University College of Medicine, and the Institute of Radiation Medicine, Seoul National University Medical Research Center, and Clinical Research Institute, Seoul National University Hospital, 28 Yongon-dong, Chongno-gu, Seoul 110-744, Korea. Recipient of a Cum Laude award for an education exhibit at the 2004 RSNA Annual Meeting. Received February 8, 2005; accepted March 23. All authors have no financial relationships to disclose.

View larger version (47K): [in a new window]   Figure 1.  Diagram illustrates the potential extrahepatic collateral arteries that supply HCCs according to anatomic location. 1 = internal mammary artery, 2 = pericardiophrenic artery, 3 = musculophrenic artery, 4 = inferior phrenic artery, 5 = superior adrenal artery, 6 = inferior adrenal artery, 7 = superior renal capsular artery, 8 = omental branch, 9 = colic branch, 10 = intercostal artery, 11 = left gastric artery, 12 = gastroepiploic artery.

 

View larger version (110K): [in a new window]   Figure 2a.  HCC supplied by the left inferior phrenic artery in a 60-year-old woman. (a) Transverse CT scan shows an exophytic mass (arrowheads) in the left hepatic lobe. (b) Left inferior phrenic arteriogram shows a hypervascular tumor (arrow). There was no tumor staining on the hepatic arteriogram (not shown).

 

View larger version (110K): [in a new window]   Figure 2b.  HCC supplied by the left inferior phrenic artery in a 60-year-old woman. (a) Transverse CT scan shows an exophytic mass (arrowheads) in the left hepatic lobe. (b) Left inferior phrenic arteriogram shows a hypervascular tumor (arrow). There was no tumor staining on the hepatic arteriogram (not shown).

 

View larger version (131K): [in a new window]   Figure 3a.  HCC supplied by the right inferior phrenic artery in a 56-year-old man. (a) Transverse CT scan shows a huge mass (M) at the dome of the right hepatic lobe. Note the hypertrophied right inferior phrenic artery (arrow). (b) Celiac arteriogram from the first session of TACE shows a huge hypervascular mass. Note faint tumor staining in the superolateral portion (arrowheads) of the tumor. (c) Right inferior phrenic arteriogram shows hypervascular tumor staining that corresponds to the faint staining seen on the celiac arteriogram.

 

View larger version (129K): [in a new window]   Figure 3b.  HCC supplied by the right inferior phrenic artery in a 56-year-old man. (a) Transverse CT scan shows a huge mass (M) at the dome of the right hepatic lobe. Note the hypertrophied right inferior phrenic artery (arrow). (b) Celiac arteriogram from the first session of TACE shows a huge hypervascular mass. Note faint tumor staining in the superolateral portion (arrowheads) of the tumor. (c) Right inferior phrenic arteriogram shows hypervascular tumor staining that corresponds to the faint staining seen on the celiac arteriogram.

 

View larger version (108K): [in a new window]   Figure 3c.  HCC supplied by the right inferior phrenic artery in a 56-year-old man. (a) Transverse CT scan shows a huge mass (M) at the dome of the right hepatic lobe. Note the hypertrophied right inferior phrenic artery (arrow). (b) Celiac arteriogram from the first session of TACE shows a huge hypervascular mass. Note faint tumor staining in the superolateral portion (arrowheads) of the tumor. (c) Right inferior phrenic arteriogram shows hypervascular tumor staining that corresponds to the faint staining seen on the celiac arteriogram.

 

View larger version (128K): [in a new window]   Figure 4a.  HCC supplied by the right inferior phrenic artery in a 49-year-old man. (a) Transverse CT scan obtained after two sessions of TACE shows a defect in iodized oil retention and enhancement of the defect portion, findings that indicate viable tumor (arrowhead). (b) Right inferior phrenic arteriogram shows hypervascular staining (straight arrow) within the tumor retaining iodized oil. Note normal adrenal gland staining (arrowhead) and the superior adrenal artery (curved arrow).

 

View larger version (127K): [in a new window]   Figure 4b.  HCC supplied by the right inferior phrenic artery in a 49-year-old man. (a) Transverse CT scan obtained after two sessions of TACE shows a defect in iodized oil retention and enhancement of the defect portion, findings that indicate viable tumor (arrowhead). (b) Right inferior phrenic arteriogram shows hypervascular staining (straight arrow) within the tumor retaining iodized oil. Note normal adrenal gland staining (arrowhead) and the superior adrenal artery (curved arrow).

 

View larger version (126K): [in a new window]   Figure 5a.  HCC supplied by the right inferior phrenic artery after repeated TACE via the hepatic artery in a 62-year-old man. (a) Transverse CT scan obtained after seven sessions of TACE shows a recurrent tumor (arrow) in the right hepatic lobe. (b) Celiac arteriogram from the eighth session of TACE shows an attenuated right hepatic artery (arrow) and no tumor staining. (c) Inferior phrenic arteriogram shows a hypervascular mass (arrow). Note the inferior phrenic artery originating from the right renal artery and normal parenchymal staining of the upper pole of the right kidney (arrowhead).

 

View larger version (128K): [in a new window]   Figure 5b.  HCC supplied by the right inferior phrenic artery after repeated TACE via the hepatic artery in a 62-year-old man. (a) Transverse CT scan obtained after seven sessions of TACE shows a recurrent tumor (arrow) in the right hepatic lobe. (b) Celiac arteriogram from the eighth session of TACE shows an attenuated right hepatic artery (arrow) and no tumor staining. (c) Inferior phrenic arteriogram shows a hypervascular mass (arrow). Note the inferior phrenic artery originating from the right renal artery and normal parenchymal staining of the upper pole of the right kidney (arrowhead).

 

View larger version (125K): [in a new window]   Figure 5c.  HCC supplied by the right inferior phrenic artery after repeated TACE via the hepatic artery in a 62-year-old man. (a) Transverse CT scan obtained after seven sessions of TACE shows a recurrent tumor (arrow) in the right hepatic lobe. (b) Celiac arteriogram from the eighth session of TACE shows an attenuated right hepatic artery (arrow) and no tumor staining. (c) Inferior phrenic arteriogram shows a hypervascular mass (arrow). Note the inferior phrenic artery originating from the right renal artery and normal parenchymal staining of the upper pole of the right kidney (arrowhead).

 

View larger version (93K): [in a new window]   Figure 6a.  HCC supplied by the right internal mammary artery in a 55-year-old man who had undergone S2 segmentectomy. (a) Transverse CT scan obtained after the 11th session of postoperative TACE shows a recurrent tumor of the ventral aspect of segment S4 (arrows). (b) Oblique right internal mammary arteriogram shows tumor staining, mainly supplied by the pericardiophrenic artery (arrow). The musculophrenic artery (arrowhead) is also seen.

 

View larger version (156K): [in a new window]   Figure 6b.  HCC supplied by the right internal mammary artery in a 55-year-old man who had undergone S2 segmentectomy. (a) Transverse CT scan obtained after the 11th session of postoperative TACE shows a recurrent tumor of the ventral aspect of segment S4 (arrows). (b) Oblique right internal mammary arteriogram shows tumor staining, mainly supplied by the pericardiophrenic artery (arrow). The musculophrenic artery (arrowhead) is also seen.

 

View larger version (84K): [in a new window]   Figure 7a.  HCC supplied by the left internal mammary artery in a 63-year-old man. (a) Transverse CT scan obtained after three sessions of TACE shows a large tumor (arrows) directly adjacent to the ventral part of the diaphragm. (b) Left internal mammary arteriogram shows tumor staining supplied by the branch of the internal mammary artery (straight arrow). Note the superior epigastric artery (arrowhead) and musculophrenic artery (curved arrow).

 

View larger version (128K): [in a new window]   Figure 7b.  HCC supplied by the left internal mammary artery in a 63-year-old man. (a) Transverse CT scan obtained after three sessions of TACE shows a large tumor (arrows) directly adjacent to the ventral part of the diaphragm. (b) Left internal mammary arteriogram shows tumor staining supplied by the branch of the internal mammary artery (straight arrow). Note the superior epigastric artery (arrowhead) and musculophrenic artery (curved arrow).

 

View larger version (125K): [in a new window]   Figure 8a.  HCC supplied by the intercostal artery in a 46-year-old man. (a) Transverse CT scan obtained after the first session of TACE shows disseminated tumor in the liver, particularly in the right hepatic lobe. Note the focal obscured margin (arrowhead) between the liver and chest wall. (b) Celiac arteriogram from the second session of TACE shows a diffuse hypervascular tumor of the liver and a focal defect (arrowheads) in tumor staining. (c) Intercostal arteriogram shows the 10th intercostal artery, which supplies the defect portion of the tumor. Note the sharp upward turn (arrow) of the vessels feeding the tumor.

 

View larger version (129K): [in a new window]   Figure 8b.  HCC supplied by the intercostal artery in a 46-year-old man. (a) Transverse CT scan obtained after the first session of TACE shows disseminated tumor in the liver, particularly in the right hepatic lobe. Note the focal obscured margin (arrowhead) between the liver and chest wall. (b) Celiac arteriogram from the second session of TACE shows a diffuse hypervascular tumor of the liver and a focal defect (arrowheads) in tumor staining. (c) Intercostal arteriogram shows the 10th intercostal artery, which supplies the defect portion of the tumor. Note the sharp upward turn (arrow) of the vessels feeding the tumor.

 

View larger version (115K): [in a new window]   Figure 8c.  HCC supplied by the intercostal artery in a 46-year-old man. (a) Transverse CT scan obtained after the first session of TACE shows disseminated tumor in the liver, particularly in the right hepatic lobe. Note the focal obscured margin (arrowhead) between the liver and chest wall. (b) Celiac arteriogram from the second session of TACE shows a diffuse hypervascular tumor of the liver and a focal defect (arrowheads) in tumor staining. (c) Intercostal arteriogram shows the 10th intercostal artery, which supplies the defect portion of the tumor. Note the sharp upward turn (arrow) of the vessels feeding the tumor.

 

View larger version (149K): [in a new window]   Figure 9a.  HCC supplied by the lumbar artery in a 55-year-old man. (a) Transverse CT scan shows a huge exophytic mass with partial uptake of iodized oil. Note the tumor invasion of the right abdominal wall (arrowheads) and omental infiltration around the tumor. (b) Gastroduodenal arteriogram shows a large area of tumor staining (arrowheads) supplied by the omental branch. (c) Abdominal aortogram shows the engorged lumbar artery (arrow) supplying the tumor stain.

 

View larger version (133K): [in a new window]   Figure 9b.  HCC supplied by the lumbar artery in a 55-year-old man. (a) Transverse CT scan shows a huge exophytic mass with partial uptake of iodized oil. Note the tumor invasion of the right abdominal wall (arrowheads) and omental infiltration around the tumor. (b) Gastroduodenal arteriogram shows a large area of tumor staining (arrowheads) supplied by the omental branch. (c) Abdominal aortogram shows the engorged lumbar artery (arrow) supplying the tumor stain.

 

View larger version (123K): [in a new window]   Figure 9c.  HCC supplied by the lumbar artery in a 55-year-old man. (a) Transverse CT scan shows a huge exophytic mass with partial uptake of iodized oil. Note the tumor invasion of the right abdominal wall (arrowheads) and omental infiltration around the tumor. (b) Gastroduodenal arteriogram shows a large area of tumor staining (arrowheads) supplied by the omental branch. (c) Abdominal aortogram shows the engorged lumbar artery (arrow) supplying the tumor stain.

 

View larger version (116K): [in a new window]   Figure 10a.  HCC supplied by the omental branch in a 42-year-old man who had undergone right lobectomy of the liver. (a) Transverse CT scan shows multiple small enhancing nodules in the liver. (b) Celiac arteriogram shows multiple hypervascular nodules in the liver. Note the prominent omental branch (arrow).

 

View larger version (137K): [in a new window]   Figure 10b.  HCC supplied by the omental branch in a 42-year-old man who had undergone right lobectomy of the liver. (a) Transverse CT scan shows multiple small enhancing nodules in the liver. (b) Celiac arteriogram shows multiple hypervascular nodules in the liver. Note the prominent omental branch (arrow).

 

View larger version (111K): [in a new window]   Figure 11a.  HCC supplied by the omental branches in a 57-year-old man. (a) Transverse CT scan obtained after 14 sessions of TACE shows multiple enhancing masses in the liver. Note prominent omental vessels (arrowhead) around the liver. The spleen (S) is also seen. (b) Gastroduodenal arteriogram obtained at the 15th session of TACE shows two prominent omental branches (arrowheads) supplying a hypervascular mass. (c) Radiograph obtained at TACE shows a microcatheter (arrowheads) inserted in the omental branch passed over the gastroduodenal and right gastroepiploic arteries. Arrow = microcatheter tip.

 

View larger version (136K): [in a new window]   Figure 11b.  HCC supplied by the omental branches in a 57-year-old man. (a) Transverse CT scan obtained after 14 sessions of TACE shows multiple enhancing masses in the liver. Note prominent omental vessels (arrowhead) around the liver. The spleen (S) is also seen. (b) Gastroduodenal arteriogram obtained at the 15th session of TACE shows two prominent omental branches (arrowheads) supplying a hypervascular mass. (c) Radiograph obtained at TACE shows a microcatheter (arrowheads) inserted in the omental branch passed over the gastroduodenal and right gastroepiploic arteries. Arrow = microcatheter tip.

 

View larger version (130K): [in a new window]   Figure 11c.  HCC supplied by the omental branches in a 57-year-old man. (a) Transverse CT scan obtained after 14 sessions of TACE shows multiple enhancing masses in the liver. Note prominent omental vessels (arrowhead) around the liver. The spleen (S) is also seen. (b) Gastroduodenal arteriogram obtained at the 15th session of TACE shows two prominent omental branches (arrowheads) supplying a hypervascular mass. (c) Radiograph obtained at TACE shows a microcatheter (arrowheads) inserted in the omental branch passed over the gastroduodenal and right gastroepiploic arteries. Arrow = microcatheter tip.

 

View larger version (126K): [in a new window]   Figure 12a.  HCC supplied by the superior adrenal artery in a 56-year-old man. (a) Transverse CT scan obtained after 19 sessions of TACE shows a viable tumor (arrow) in the inferomedial portion of the right hepatic lobe. (b) Inferior phrenic arteriogram obtained at the 20th session of TACE shows the hypervascular mass supplied by the superior adrenal artery (arrow).

 

View larger version (116K): [in a new window]   Figure 12b.  HCC supplied by the superior adrenal artery in a 56-year-old man. (a) Transverse CT scan obtained after 19 sessions of TACE shows a viable tumor (arrow) in the inferomedial portion of the right hepatic lobe. (b) Inferior phrenic arteriogram obtained at the 20th session of TACE shows the hypervascular mass supplied by the superior adrenal artery (arrow).

 

View larger version (127K): [in a new window]   Figure 13a.  HCC supplied by the adrenal artery in a 62-year-old man. (a) Transverse CT scan shows a large tumor (M) abutting the inferior vena cava. (b) Celiac arteriogram shows a hypervascular tumor (arrows). (c) On an unenhanced transverse CT scan obtained after the first TACE session, iodized oil was not retained in the medial portion of the tumor (arrow). (d) Adrenal arteriogram obtained at the second session of TACE shows the hypervascular tumor (arrow). Unenhanced CT scan obtained after the second session of TACE (not shown) demonstrated additional retention of iodized oil in the medial portion of the tumor.

 

View larger version (129K): [in a new window]   Figure 13b.  HCC supplied by the adrenal artery in a 62-year-old man. (a) Transverse CT scan shows a large tumor (M) abutting the inferior vena cava. (b) Celiac arteriogram shows a hypervascular tumor (arrows). (c) On an unenhanced transverse CT scan obtained after the first TACE session, iodized oil was not retained in the medial portion of the tumor (arrow). (d) Adrenal arteriogram obtained at the second session of TACE shows the hypervascular tumor (arrow). Unenhanced CT scan obtained after the second session of TACE (not shown) demonstrated additional retention of iodized oil in the medial portion of the tumor.

 

View larger version (113K): [in a new window]   Figure 13c.  HCC supplied by the adrenal artery in a 62-year-old man. (a) Transverse CT scan shows a large tumor (M) abutting the inferior vena cava. (b) Celiac arteriogram shows a hypervascular tumor (arrows). (c) On an unenhanced transverse CT scan obtained after the first TACE session, iodized oil was not retained in the medial portion of the tumor (arrow). (d) Adrenal arteriogram obtained at the second session of TACE shows the hypervascular tumor (arrow). Unenhanced CT scan obtained after the second session of TACE (not shown) demonstrated additional retention of iodized oil in the medial portion of the tumor.

 

View larger version (130K): [in a new window]   Figure 13d.  HCC supplied by the adrenal artery in a 62-year-old man. (a) Transverse CT scan shows a large tumor (M) abutting the inferior vena cava. (b) Celiac arteriogram shows a hypervascular tumor (arrows). (c) On an unenhanced transverse CT scan obtained after the first TACE session, iodized oil was not retained in the medial portion of the tumor (arrow). (d) Adrenal arteriogram obtained at the second session of TACE shows the hypervascular tumor (arrow). Unenhanced CT scan obtained after the second session of TACE (not shown) demonstrated additional retention of iodized oil in the medial portion of the tumor.

 

View larger version (121K): [in a new window]   Figure 14a.  HCC supplied by the renal arteries in a 51-year-old man. (a) Transverse CT scan obtained after the third session of TACE shows an exophytic mass (M) in the tip of the right hepatic lobe, compressing the right kidney. (b) Right renal arteriogram shows tumor staining (arrowhead) supplied by renal arteries and a prominent superior renal capsular artery (arrow).

 

View larger version (125K): [in a new window]   Figure 14b.  HCC supplied by the renal arteries in a 51-year-old man. (a) Transverse CT scan obtained after the third session of TACE shows an exophytic mass (M) in the tip of the right hepatic lobe, compressing the right kidney. (b) Right renal arteriogram shows tumor staining (arrowhead) supplied by renal arteries and a prominent superior renal capsular artery (arrow).

 

View larger version (126K): [in a new window]   Figure 15a.  HCC supplied by the colic branch of the superior mesenteric artery in a 55-year-old man. (a) Transverse CT scan obtained after the third session of TACE shows an exophytic mass (arrow) with partial iodized oil retention in the right hepatic lobe. (b) Celiac arteriogram shows some tumor staining supplied by the hepatic artery and omental branch from the gastroduodenal artery. Note the large defect of tumor staining (*). (c) Selective angiogram of the colic branch shows vessels supplying the tumor (arrowhead) and tumor staining (arrow) corresponding to the tumor staining defect in seen b.

 

View larger version (128K): [in a new window]   Figure 15b.  HCC supplied by the colic branch of the superior mesenteric artery in a 55-year-old man. (a) Transverse CT scan obtained after the third session of TACE shows an exophytic mass (arrow) with partial iodized oil retention in the right hepatic lobe. (b) Celiac arteriogram shows some tumor staining supplied by the hepatic artery and omental branch from the gastroduodenal artery. Note the large defect of tumor staining (*). (c) Selective angiogram of the colic branch shows vessels supplying the tumor (arrowhead) and tumor staining (arrow) corresponding to the tumor staining defect in seen b.

 

View larger version (152K): [in a new window]   Figure 15c.  HCC supplied by the colic branch of the superior mesenteric artery in a 55-year-old man. (a) Transverse CT scan obtained after the third session of TACE shows an exophytic mass (arrow) with partial iodized oil retention in the right hepatic lobe. (b) Celiac arteriogram shows some tumor staining supplied by the hepatic artery and omental branch from the gastroduodenal artery. Note the large defect of tumor staining (*). (c) Selective angiogram of the colic branch shows vessels supplying the tumor (arrowhead) and tumor staining (arrow) corresponding to the tumor staining defect in seen b.

 

View larger version (140K): [in a new window]   Figure 16a.  HCC supplied by the left gastric artery in a 62-year-old woman. (a) Transverse CT scan obtained after the 18th session of TACE shows a viable tumor (arrow) with partial retention of iodized oil that abuts the stomach in the left hepatic lobe. (b) Left gastric arteriogram shows multiple tumor staining (arrows) and normal stomach staining (arrowheads).

 

View larger version (137K): [in a new window]   Figure 16b.  HCC supplied by the left gastric artery in a 62-year-old woman. (a) Transverse CT scan obtained after the 18th session of TACE shows a viable tumor (arrow) with partial retention of iodized oil that abuts the stomach in the left hepatic lobe. (b) Left gastric arteriogram shows multiple tumor staining (arrows) and normal stomach staining (arrowheads).

 

View larger version (134K): [in a new window]   Figure 17a.  HCC supplied by the cystic artery in a 49-year-old man. (a) Transverse CT scan shows a tumor in the gallbladder fossa (arrowheads). Arrow = gallbladder. (b) As seen on the cystic arteriogram, part of the tumor (arrow) in the gallbladder fossa was supplied by the cystic artery. (c) Radiograph obtained at TACE shows retention of iodized oil. Note the microcatheter (arrowheads) inserted in the tumor-feeding branch.

 

View larger version (121K): [in a new window]   Figure 17b.  HCC supplied by the cystic artery in a 49-year-old man. (a) Transverse CT scan shows a tumor in the gallbladder fossa (arrowheads). Arrow = gallbladder. (b) As seen on the cystic arteriogram, part of the tumor (arrow) in the gallbladder fossa was supplied by the cystic artery. (c) Radiograph obtained at TACE shows retention of iodized oil. Note the microcatheter (arrowheads) inserted in the tumor-feeding branch.

 

View larger version (116K): [in a new window]   Figure 17c.  HCC supplied by the cystic artery in a 49-year-old man. (a) Transverse CT scan shows a tumor in the gallbladder fossa (arrowheads). Arrow = gallbladder. (b) As seen on the cystic arteriogram, part of the tumor (arrow) in the gallbladder fossa was supplied by the cystic artery. (c) Radiograph obtained at TACE shows retention of iodized oil. Note the microcatheter (arrowheads) inserted in the tumor-feeding branch.

 

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