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Validation of clinical scoring systems ART and ABCR after transarterial chemoembolization of hepatocellular carcinoma
S86
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Monday
Scientific Session
MONDAY: Scientific Sessions
Results: During the follow-up period (mean 5.6 months), 19 (41.3%) tumors recurred (mean time to recurrence¼3.6 months). In a multivariate model, low baseline Lipiodol uptake and higher washout rate were significant predictors of tumor recurrence (P ¼ 0.001 and o0.0001, respectively). The baseline Lipiodol uptake with selective (subsegmental/ segmental) TACE (401.6 ± 32.4 HU) was significantly higher than that with lobar TACE (190.9 ± 26.4 HU) (P o 0.0001). Also, the baseline Lipiodol uptake of lesions without subsequent washout (480.4 ± 35.8) was significantly higher than that of lesions demonstrating subsequent washout (239.1 ± 26.5) (P o 0.0001). On ROC analysis, a threshold Lipiodol uptake of 270.2 HU was significantly associated with tumor response (95% sensitivity, 93% specificity). Conclusions: Baseline Lipiodol uptake and washout rate on follow-up were independent predictors of tumor response. A threshold value of baseline Lipiodol uptake 4270.2 HU was highly sensitive and specific for tumor response. These findings may prove useful in subsequent treatment strategy for tumors with low baseline Lipiodol uptake values.
3:54 PM
Abstract No. 184
Utility of dual-phase cone-beam CT: Can it predict tumor response after super-selective TACE for HCC? K. Mueller1, S. Datta2, S. Gehrisch3, T. Moore2, M. Ahmad1, J. Louie4, D. Wang4, G. Hwang4, D. Sze4, N. Kothary4; 1Stanford University, Stanford, CA; 2 Siemens Medical Solutions Inc., Malvern, PA; 3Siemens Healthcare GmbH, Forchheim, CA; 4Stanford University Medical Center, Stanford, CA. Purpose: The addition of delayed phase imaging to cone-beam CT (dual phase, dpCBCT) has been advocated to improve ability to predict tumor response in patients undergoing transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). We investigated the prognostic value of dpCBCT applied to patients undergoing super-selective TACE. Materials: From November 2014-February 2015, 26 patients with 34 HCCs underwent super-selective (subsegmental) TACE with dpCBCT imaging. Mean tumor diameter was 2.1 ± 1.0 cm. Pre-TACE dpCBCT images were obtained 4s (arterial) and 36s (delayed) after injection of contrast medium into the common hepatic artery. After TACE, a completion unenhanced CBCT was obtained to confirm complete tumor treatment. 3-dimensional voxel-based tumor enhancement intensity in both, arterial and delayed phase, washout between phases ([arterial enhancement – delayed enhancement]/arterial enhancement x 100%) and 3dimensional capsule thickness were measured. Tumor response was assessed using mRECIST criteria on follow-up imaging obtained 8-12 weeks following TACE. Results: 19 of 34 tumors (55%) showed complete response (CR). Partial response was seen in 7 (21%), stable disease in 3 (9%), and progressive disease in 5 (15%). dpCBCT enhancement intensities did not correlate with response on either phase individually (arterial r2¼0.01, p¼0.51; delayed r2¼0.02; p¼0.41). Similarly, the degree of washout also varied widely and bore no statistical correlation to response (r2¼.001; p¼0.86). Finally, capsule thickness and regularity were not predictive of response
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JVIR
(p¼0.93). dpCBCT led to an additional dose area product (DAP) of 52.3 ± 11.3 Gycm2 compared to standard singlephase CBCT, required a longer and more complex breathhold with more unpredictability of image quality, and laborious registration of the two volume datasets. Conclusions: Single phase arterial CBCT typically provides clinically useful information, but the addition of a second delayed phase (dpCBCT) did not provide supplementary prognostic power and resulted in higher radiation dose to the patient.
4:03 PM
Abstract No. 185
Validation of clinical scoring systems ART and ABCR after transarterial chemoembolization of hepatocellular carcinoma R. Kloeckner, M. Pitton, C. Dueber, M. Wörns, P. Galle, A. Weinmann; Johannes Gutenberg University, Mainz, Germany. Purpose: Transarterial chemoembolization (TACE) is the standard of care for intermediate hepatocellular carcinoma (HCC). Deciding to what extent treatment should be repeated remains challenging. Several scoring systems have been introduced during the last years. Nonetheless, none of these systems have managed to enter clinical practice yet. Therefore, the purpose of this study is to perform an external validation of the recently published ART score and the ABCR score as well as to compare both against each other in terms of their capacity to predict survival. Materials: 871 HCC patients underwent TACE at our institution from 2000 to 2015. All variables needed to calculate each score (at baseline: BCLC-stage and AFP-level 200 ng/ml; prior second TACE: increase in Child-Pugh by 1 or 2 points, increase in AST by 425%, and radiologic tumor response) were determined. Overall survival was calculated. A multivariate analysis of all variables used in both scores was performed in order to identify independent predictors of survival. Furthermore, ART and ABCR score were validated and compared by using Harrel´s C index. Results: 176 patients could finally be included; 55 receiving drug eluting bead TACE and 121 receiving lipiodol-based conventional TACE. Both scores were able to differentiate between two patient groups with considerably different prognosis (ART: 21.1 versus 16.2 months; ABCR: 20.5 versus 9.9 months). The Harrel´s C index was 0.625 for the ART and 0.641 for the ABCR score. Independent predictors of survival in both scores were an increase in Child Pugh 2 and radiological response. In the ABCR score additionally the BCLC stage proved significant (all po0.05). The AFP-level at baseline and the increase in AST were not significantly associated with survival. Conclusions: The ART and the ABCR score are both able to identify patients with a dismal prognosis who may not benefit from further TACE sessions. In our study the ABCR score was of slightly higher predictive value. Overall, we recommend the use of either scoring system in daily clinical practice to support decision making. References 1. Sieghart W, Hucke F, Pinter M, Graziadei I, Vogel W, Mu¨ller C, Heinzl H, Trauner M, Peck-Radosavljevic M. The ART of decision making: retreatment with transarterial chemoembolization in patients with hepatocellular
JVIR
’
Scientific Session
Monday
carcinoma. Hepatology. 2013 Jun;57(6):2261-2273. http://dx.doi.org/10.1002/ hep.26256. 2. Adhoute X, Penaranda G, Naude S, Raoul JL, Perrier H, Bayle O, Monnet O, Beaurain P, Bazin C, Pol B, Folgoc GL, Castellani P, Bronowicki JP, Bourlie`re M. Retreatment with TACE: the ABCR SCORE, an aid to the decision-making process. J Hepatol. 2015 Apr;62(4):855-862. http://dx.doi.org/10.1016/j.jhep.2014. 11.014.
4:12 PM
Abstract No. 186
Arteries of the falciform ligament on C-arm CT hepatic angiography: hepatic falciform artery and Sappey’s superior artery S. Hur1, H. Jae1, M. Kim2, J. Choi3, J. Lee1, J. Park4; 1 Seoul National University Hospital, Seoul, Republic of Korea; 2Seoul National University Hopsital, Seoul, Republic of Korea; 3Seoul National University Hospital, Seoul, Republic of Korea; 4Myongji Hospital, Seoul, Republic of Korea.
References 1. Bruix J, Sherman M. Management of hepatocellular carcinoma: an update. Hepatology. 2011;53(3):1020-1022.
S87
2. Salem R, Lewandowski RJ, Mulcahy MF, Riaz A, Ryu RK, Ibrahim S, et al. Radioembolization for hepatocellular carcinoma using Yttrium-90 microspheres: a comprehensive report of long-term outcomes. Gastroenterology. 2010;138(1): 52-64. 3. Chung JW, Park JH, Han JK, Choi BI, Han MC, Lee H-S, et al. Hepatic tumors: predisposing factors for complications of transcatheter oily chemoembolization. Radiology. 1996;198(1):33-40. 4. Kim H-C, Chung JW, Lee W, Jae HJ, Park JH. Recognizing Extrahepatic Collateral Vessels That Supply Hepatocellular Carcinoma to Avoid Complications of Transcatheter Arterial Chemoembolization 1. Radiographics. 2005;25(suppl_1): S25-S39. 5. Kim H-C, Chung JW, Choi SH, Jae HJ, Lee W, Park JH. Internal Mammary Arteries Supplying Hepatocellular Carcinoma: Vascular Anatomy at Digital Subtraction Angiography in 97 Patients 1. Radiology. 2007;242(3):925-932.
4:21 PM
Abstract No. 187
The use of transcatheter selective arterial chemoembolization in pediatric patients with unresectable hepatocellular carcinoma K. Weiss1, M. Lungren2, A. Rangaswami3, W. Concepcion4, D. Sze5; 1Stanford University Medical Center, Atherton, CA; 2N/A, Stanford, CA; 3Stanford University Medical Center, Palo Alto, CA; 4Stanford University Medical Center, Palo Alto, CA; 5Stanford University Medical Center, Stanford, CA. Purpose: To retrospectively assess the toxicity and efficacy of transcatheter selective arterial chemoembolization (TACE) in children with unresectable hepatocellular carcinoma (HCC) in a large pediatric tertiary care center. Materials: Retrospective analysis was performed of eight patients aged 4 – 17 years (4 male and 4 female, mean age 12.5 years) who underwent TACE for unresectable HCC between August 2005 and February 2013 at a single institution. A total of 21 TACE procedures were performed with an average of 11 weeks between TACE treatments. Chemoembolization suspensions used consisted of cisplatin, doxorubicin, and ethiodol in five patients, with the addition of mitomycin C in two patients and adriamycin in one patient. PRETEXT imaging staging was used for all patients. Results: 100% technical success was achieved in all procedures; there were no procedural complications. TACE was well-tolerated by all eight patients with minimal toxicity. Post-TACE response was monitored with follow-up imaging, AFP levels, and clinical evaluation. Follow-up ranged from 1.5 to 10 years (average of 6.1 years). Tumor shrinkage for the eight patients ranged from -17% to 87%, with an average of 41%. Percent change in AFP ranged from -100% to þ89.3%, with an average of -49.6%. Two patients did not undergo resection and died of progressive disease. Six patients underwent technically successful orthotopic liver transplant with mean TACE-totransplant interval of 141 days (range 11 – 514). Following transplant, five of these six patients were alive at the end of the follow up period with one having died of progressive disease. Conclusions: Children with unresectable HCC have a dismal prognosis and few approved treatment options. TACE is a minimally invasive treatment option for HCC but experience in children is limited. Based on our initial experience, we believe that conventional TACE for children with unresectable HCC may be a safe and effective method for managing hepatic tumor burden and as an adjunct to definitive cure with liver transplantation.
MONDAY: Scientific Sessions
Purpose: To investigate incidence, anatomy and distribution of hepatic falciform artery (HFA) and Sappey’s superior artery (SSA), an arterial counterpart of Sappey’s superior vein, using C-arm CT hepatic angiography (C-arm CTHA). Materials: We defined SSA as an artery traversing cranial portion of the falciform ligament and connecting the intrahepatic artery around the falciform ligament attaching area with the artery of the diaphragm or the body wall. From January 2011 to December 2012, 220 consecutive patients underwent Carm CTHA during an initial transarterial treatment for hepatocellular carcinoma after exclusion of any condition which might affect the detection of HFA or SSA. The incidence, origin, diameter, course, destination, and anastomosis with other arteries of HFA and SSA were evaluated using axial images of C-arm CTHA retrospectively. 5-scale grading system (0: not present, 1: hairy, 2: thin, 3: intermediate, 4: prominent) for HFA and 4-scale one (0: not present, 1: suspicious, 2: intermediate, 3: prominent) for SSA were used to designate the radiologically conspicuous arteries (grade 2 or higher). Results: Incidences of all HFA and SSA were 95% (n¼209) and 22% (n¼49), while those of radiologically conspicuous HFA and SSA were 63% (n¼138) and 9.5% (n¼21), respectively. 30 HFAs (22% of radiologically conspicuous HFA and 14% of all study population) distributed to the subcutaneous layer of the anterior abdominal wall. 90% (n¼20) of radiologically conspicuous SSA ran through the superior part of the falciform ligament in left anterior direction and anastomosed with left inferior phrenic artery. Conclusions: The incidences of both all and radiologically conspicuous HFA were higher in our study than in previous radiological studies and significant portion of them (14%) distributed to the subcutaneous layer of the anterior abdominal wall. The presence of SSA was proved radiologically for the first time to our knowledge. These new concept on the anatomy of hepatic falciform ligament and its related arteries enabled easy interpretation of complex arterial communication among hepatic artery, inferior phrenic artery and internal mammary artery.
’
’
Monday
Scientific Session
MONDAY: Scientific Sessions
Results: During the follow-up period (mean 5.6 months), 19 (41.3%) tumors recurred (mean time to recurrence¼3.6 months). In a multivariate model, low baseline Lipiodol uptake and higher washout rate were significant predictors of tumor recurrence (P ¼ 0.001 and o0.0001, respectively). The baseline Lipiodol uptake with selective (subsegmental/ segmental) TACE (401.6 ± 32.4 HU) was significantly higher than that with lobar TACE (190.9 ± 26.4 HU) (P o 0.0001). Also, the baseline Lipiodol uptake of lesions without subsequent washout (480.4 ± 35.8) was significantly higher than that of lesions demonstrating subsequent washout (239.1 ± 26.5) (P o 0.0001). On ROC analysis, a threshold Lipiodol uptake of 270.2 HU was significantly associated with tumor response (95% sensitivity, 93% specificity). Conclusions: Baseline Lipiodol uptake and washout rate on follow-up were independent predictors of tumor response. A threshold value of baseline Lipiodol uptake 4270.2 HU was highly sensitive and specific for tumor response. These findings may prove useful in subsequent treatment strategy for tumors with low baseline Lipiodol uptake values.
3:54 PM
Abstract No. 184
Utility of dual-phase cone-beam CT: Can it predict tumor response after super-selective TACE for HCC? K. Mueller1, S. Datta2, S. Gehrisch3, T. Moore2, M. Ahmad1, J. Louie4, D. Wang4, G. Hwang4, D. Sze4, N. Kothary4; 1Stanford University, Stanford, CA; 2 Siemens Medical Solutions Inc., Malvern, PA; 3Siemens Healthcare GmbH, Forchheim, CA; 4Stanford University Medical Center, Stanford, CA. Purpose: The addition of delayed phase imaging to cone-beam CT (dual phase, dpCBCT) has been advocated to improve ability to predict tumor response in patients undergoing transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). We investigated the prognostic value of dpCBCT applied to patients undergoing super-selective TACE. Materials: From November 2014-February 2015, 26 patients with 34 HCCs underwent super-selective (subsegmental) TACE with dpCBCT imaging. Mean tumor diameter was 2.1 ± 1.0 cm. Pre-TACE dpCBCT images were obtained 4s (arterial) and 36s (delayed) after injection of contrast medium into the common hepatic artery. After TACE, a completion unenhanced CBCT was obtained to confirm complete tumor treatment. 3-dimensional voxel-based tumor enhancement intensity in both, arterial and delayed phase, washout between phases ([arterial enhancement – delayed enhancement]/arterial enhancement x 100%) and 3dimensional capsule thickness were measured. Tumor response was assessed using mRECIST criteria on follow-up imaging obtained 8-12 weeks following TACE. Results: 19 of 34 tumors (55%) showed complete response (CR). Partial response was seen in 7 (21%), stable disease in 3 (9%), and progressive disease in 5 (15%). dpCBCT enhancement intensities did not correlate with response on either phase individually (arterial r2¼0.01, p¼0.51; delayed r2¼0.02; p¼0.41). Similarly, the degree of washout also varied widely and bore no statistical correlation to response (r2¼.001; p¼0.86). Finally, capsule thickness and regularity were not predictive of response
’
JVIR
(p¼0.93). dpCBCT led to an additional dose area product (DAP) of 52.3 ± 11.3 Gycm2 compared to standard singlephase CBCT, required a longer and more complex breathhold with more unpredictability of image quality, and laborious registration of the two volume datasets. Conclusions: Single phase arterial CBCT typically provides clinically useful information, but the addition of a second delayed phase (dpCBCT) did not provide supplementary prognostic power and resulted in higher radiation dose to the patient.
4:03 PM
Abstract No. 185
Validation of clinical scoring systems ART and ABCR after transarterial chemoembolization of hepatocellular carcinoma R. Kloeckner, M. Pitton, C. Dueber, M. Wörns, P. Galle, A. Weinmann; Johannes Gutenberg University, Mainz, Germany. Purpose: Transarterial chemoembolization (TACE) is the standard of care for intermediate hepatocellular carcinoma (HCC). Deciding to what extent treatment should be repeated remains challenging. Several scoring systems have been introduced during the last years. Nonetheless, none of these systems have managed to enter clinical practice yet. Therefore, the purpose of this study is to perform an external validation of the recently published ART score and the ABCR score as well as to compare both against each other in terms of their capacity to predict survival. Materials: 871 HCC patients underwent TACE at our institution from 2000 to 2015. All variables needed to calculate each score (at baseline: BCLC-stage and AFP-level 200 ng/ml; prior second TACE: increase in Child-Pugh by 1 or 2 points, increase in AST by 425%, and radiologic tumor response) were determined. Overall survival was calculated. A multivariate analysis of all variables used in both scores was performed in order to identify independent predictors of survival. Furthermore, ART and ABCR score were validated and compared by using Harrel´s C index. Results: 176 patients could finally be included; 55 receiving drug eluting bead TACE and 121 receiving lipiodol-based conventional TACE. Both scores were able to differentiate between two patient groups with considerably different prognosis (ART: 21.1 versus 16.2 months; ABCR: 20.5 versus 9.9 months). The Harrel´s C index was 0.625 for the ART and 0.641 for the ABCR score. Independent predictors of survival in both scores were an increase in Child Pugh 2 and radiological response. In the ABCR score additionally the BCLC stage proved significant (all po0.05). The AFP-level at baseline and the increase in AST were not significantly associated with survival. Conclusions: The ART and the ABCR score are both able to identify patients with a dismal prognosis who may not benefit from further TACE sessions. In our study the ABCR score was of slightly higher predictive value. Overall, we recommend the use of either scoring system in daily clinical practice to support decision making. References 1. Sieghart W, Hucke F, Pinter M, Graziadei I, Vogel W, Mu¨ller C, Heinzl H, Trauner M, Peck-Radosavljevic M. The ART of decision making: retreatment with transarterial chemoembolization in patients with hepatocellular
JVIR
’
Scientific Session
Monday
carcinoma. Hepatology. 2013 Jun;57(6):2261-2273. http://dx.doi.org/10.1002/ hep.26256. 2. Adhoute X, Penaranda G, Naude S, Raoul JL, Perrier H, Bayle O, Monnet O, Beaurain P, Bazin C, Pol B, Folgoc GL, Castellani P, Bronowicki JP, Bourlie`re M. Retreatment with TACE: the ABCR SCORE, an aid to the decision-making process. J Hepatol. 2015 Apr;62(4):855-862. http://dx.doi.org/10.1016/j.jhep.2014. 11.014.
4:12 PM
Abstract No. 186
Arteries of the falciform ligament on C-arm CT hepatic angiography: hepatic falciform artery and Sappey’s superior artery S. Hur1, H. Jae1, M. Kim2, J. Choi3, J. Lee1, J. Park4; 1 Seoul National University Hospital, Seoul, Republic of Korea; 2Seoul National University Hopsital, Seoul, Republic of Korea; 3Seoul National University Hospital, Seoul, Republic of Korea; 4Myongji Hospital, Seoul, Republic of Korea.
References 1. Bruix J, Sherman M. Management of hepatocellular carcinoma: an update. Hepatology. 2011;53(3):1020-1022.
S87
2. Salem R, Lewandowski RJ, Mulcahy MF, Riaz A, Ryu RK, Ibrahim S, et al. Radioembolization for hepatocellular carcinoma using Yttrium-90 microspheres: a comprehensive report of long-term outcomes. Gastroenterology. 2010;138(1): 52-64. 3. Chung JW, Park JH, Han JK, Choi BI, Han MC, Lee H-S, et al. Hepatic tumors: predisposing factors for complications of transcatheter oily chemoembolization. Radiology. 1996;198(1):33-40. 4. Kim H-C, Chung JW, Lee W, Jae HJ, Park JH. Recognizing Extrahepatic Collateral Vessels That Supply Hepatocellular Carcinoma to Avoid Complications of Transcatheter Arterial Chemoembolization 1. Radiographics. 2005;25(suppl_1): S25-S39. 5. Kim H-C, Chung JW, Choi SH, Jae HJ, Lee W, Park JH. Internal Mammary Arteries Supplying Hepatocellular Carcinoma: Vascular Anatomy at Digital Subtraction Angiography in 97 Patients 1. Radiology. 2007;242(3):925-932.
4:21 PM
Abstract No. 187
The use of transcatheter selective arterial chemoembolization in pediatric patients with unresectable hepatocellular carcinoma K. Weiss1, M. Lungren2, A. Rangaswami3, W. Concepcion4, D. Sze5; 1Stanford University Medical Center, Atherton, CA; 2N/A, Stanford, CA; 3Stanford University Medical Center, Palo Alto, CA; 4Stanford University Medical Center, Palo Alto, CA; 5Stanford University Medical Center, Stanford, CA. Purpose: To retrospectively assess the toxicity and efficacy of transcatheter selective arterial chemoembolization (TACE) in children with unresectable hepatocellular carcinoma (HCC) in a large pediatric tertiary care center. Materials: Retrospective analysis was performed of eight patients aged 4 – 17 years (4 male and 4 female, mean age 12.5 years) who underwent TACE for unresectable HCC between August 2005 and February 2013 at a single institution. A total of 21 TACE procedures were performed with an average of 11 weeks between TACE treatments. Chemoembolization suspensions used consisted of cisplatin, doxorubicin, and ethiodol in five patients, with the addition of mitomycin C in two patients and adriamycin in one patient. PRETEXT imaging staging was used for all patients. Results: 100% technical success was achieved in all procedures; there were no procedural complications. TACE was well-tolerated by all eight patients with minimal toxicity. Post-TACE response was monitored with follow-up imaging, AFP levels, and clinical evaluation. Follow-up ranged from 1.5 to 10 years (average of 6.1 years). Tumor shrinkage for the eight patients ranged from -17% to 87%, with an average of 41%. Percent change in AFP ranged from -100% to þ89.3%, with an average of -49.6%. Two patients did not undergo resection and died of progressive disease. Six patients underwent technically successful orthotopic liver transplant with mean TACE-totransplant interval of 141 days (range 11 – 514). Following transplant, five of these six patients were alive at the end of the follow up period with one having died of progressive disease. Conclusions: Children with unresectable HCC have a dismal prognosis and few approved treatment options. TACE is a minimally invasive treatment option for HCC but experience in children is limited. Based on our initial experience, we believe that conventional TACE for children with unresectable HCC may be a safe and effective method for managing hepatic tumor burden and as an adjunct to definitive cure with liver transplantation.
MONDAY: Scientific Sessions
Purpose: To investigate incidence, anatomy and distribution of hepatic falciform artery (HFA) and Sappey’s superior artery (SSA), an arterial counterpart of Sappey’s superior vein, using C-arm CT hepatic angiography (C-arm CTHA). Materials: We defined SSA as an artery traversing cranial portion of the falciform ligament and connecting the intrahepatic artery around the falciform ligament attaching area with the artery of the diaphragm or the body wall. From January 2011 to December 2012, 220 consecutive patients underwent Carm CTHA during an initial transarterial treatment for hepatocellular carcinoma after exclusion of any condition which might affect the detection of HFA or SSA. The incidence, origin, diameter, course, destination, and anastomosis with other arteries of HFA and SSA were evaluated using axial images of C-arm CTHA retrospectively. 5-scale grading system (0: not present, 1: hairy, 2: thin, 3: intermediate, 4: prominent) for HFA and 4-scale one (0: not present, 1: suspicious, 2: intermediate, 3: prominent) for SSA were used to designate the radiologically conspicuous arteries (grade 2 or higher). Results: Incidences of all HFA and SSA were 95% (n¼209) and 22% (n¼49), while those of radiologically conspicuous HFA and SSA were 63% (n¼138) and 9.5% (n¼21), respectively. 30 HFAs (22% of radiologically conspicuous HFA and 14% of all study population) distributed to the subcutaneous layer of the anterior abdominal wall. 90% (n¼20) of radiologically conspicuous SSA ran through the superior part of the falciform ligament in left anterior direction and anastomosed with left inferior phrenic artery. Conclusions: The incidences of both all and radiologically conspicuous HFA were higher in our study than in previous radiological studies and significant portion of them (14%) distributed to the subcutaneous layer of the anterior abdominal wall. The presence of SSA was proved radiologically for the first time to our knowledge. These new concept on the anatomy of hepatic falciform ligament and its related arteries enabled easy interpretation of complex arterial communication among hepatic artery, inferior phrenic artery and internal mammary artery.
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