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Angiographic identification of extrahepatic perfusion after hepatic arterial pump placement: implications for surgical prevention.

BACKGROUND
Hepatic arterial infusion (HAI) chemotherapy is an effective treatment for patients with liver malignancy. Extrahepatic perfusion (EHP) after HAI pump placement requires correction prior to starting chemotherapy. The aim of this study was to define the origin of arterial branches causing EHP in order to determine if alterations in surgical technique during pump placement might prevent EHP.


METHODS
A prospectively maintained, single-centre HAI database was reviewed for all patients (2008-2011) with EHP. The origin of arterial branches causing EHP was classified anatomically and patient outcomes were analysed.


RESULTS
Of the 327 patients with pumps implanted, 24 evidenced EHP. The arterial branch responsible for EHP perfused the duodenum, pancreas and/or stomach. The branch responsible for EHP arose from the proper hepatic artery (PHA), 1(st) , 2(nd) , or 3(rd) order hepatic artery branches in 7, 10, 5 and 2 patients, respectively. The majority of branches beyond the PHA causing EHP (13/17) originated from the right hepatic artery. In 18 patients, aberrant branches were successfully treated with embolization.


CONCLUSION
These findings provide the anatomic basis for prevention of up to one-third of the cases of EHP intra-operatively, decreasing the number of patients who will require additional procedures for correction of EHP post-operatively.