Unusual development of the celiac trunk and its clinical significance / Desenvolvimento incomum do tronco celíaco e sua importância clínica

Abstract We describe a case of unusual development of the celiac trunk observed in the cadaver of 1-year old male child. The celiac trunk branched into five vessels: the splenic, common hepatic and left gastric arteries, the left inferior diaphragmatic artery, and a short trunk that branched into the right inferior diaphragmatic artery and right accessory hepatic artery. Additionally, the manner of branching of the vessel was unusual: it was possible to distinguish two branching points that corresponded to its s-shaped trajectory. There were also other variations of vascular supply, such as the presence of a left accessory hepatic artery, an additional superior pancreatoduodenal artery, and others. It should be noted that multiple developmental variations can be common in clinical practice and clinicians should be aware of them during diagnostic and interventional procedures.

Resumo Apresentamos um relato de caso de desenvolvimento incomum do tronco celíaco em um cadáver do sexo masculino de 1 ano de idade. O tronco celíaco ramificou-se para cinco vasos: as artérias esplênica, hepática comum e gástrica esquerda, a artéria diafragmática inferior esquerda e um tronco pequeno que se ramificou para a artéria diafragmática inferior direita e para a artéria hepática direita acessória. Além disso, a forma como o vaso se ramificou foi incomum: é possível distinguir dois pontos de ramificação que correspondem à trajetória em formato de S. Também houve outras variações do suprimento vascular, como a presença da artéria hepática esquerda acessória, da artéria pancreaticoduodenal superior acessória e outras. Cabe observar que a variação de desenvolvimento múltipla pode ser comum na prática clínica, e os médicos devem estar cientes dela durante os procedimentos de diagnóstico e intervenção.

Angiotomografía de las variantes anatómicas de la arteria cística: estudio en el preoperatorio de colelitiasis / Angiotomography of the anatomical variants of the cystic artery: pre-operative study of cholelithiasis

La colecistectomía laparoscópica es el tratamiento indicado en la colelitiasis, sin embargo el procedimiento no está exento de complicaciones o morbilidad concomitante. Es posible que, debido a lesiones ductales colaterales, ocurra sangrado con posibilidad de conversión de la cirugía e indeseables resultados. Para un correcto abordaje de la región se hace fundamental la identificación del trígono cistohepático (TCH) y sus componentes, a su vez de la ligadura y sección de la arteria cística (AC). Conociendo la elevada variabilidad de la AC, el objetivo de este trabajo consistió en identificar el número, origen, trayecto y relación de la AC con el TCH y sus variaciones, utilizando angiotomografía por medio de un tomógrafo detector de 64 cortes, en el preoperatorio de 30 pacientes de sexo femenino, entre 24 y 54 años de edad, con colelitiasis diagnosticadas clínicamente y por ecosonografía. La AC en el 76,67 % era única y se encontraba dentro del TCH, en el 16,67 % era única y se observó fuera del TCH. En el 6,67 % se observaron dos AC, una dentro y otra fuera del TCH. En el 66,67 % de los casos la AC se originaba de manera normal de la arteria hepática derecha. La trazabilidad de la AC fue en el 53,3 % medianamente visible y en el 46,7 % de trazabilidad excelente. En conclusión, la identificación de la AC y sus variaciones anatómicas se puede determinar en el preoperatorio y puede ser útil para mejorar el plan quirúrgico en pacientes con colelitiasis, brindando información al procedimiento, optimizarlo y disminuir los riesgos de eventuales complicaciones relacionados con sangrado.

Laparoscopic cholecystectomy is the treatment indicated for cholelithiasis, however the procedure is not free of complications or concomitant morbidity. It is possible that, due to collateral ductal lesions, bleeding occurs with the possibility of surgery conversion and undesirable results. For a correct approach to the region it is essential to identify the cystohepatic trigone (CHT) and its components, as well as the ligation and section of the cystic artery (AC). Knowing the high variability of CA, the aim of this work was to identify the number, origin, path and relationship of CA with the CHT and its variations using angiotomography by means of a 64-slice detector tomograph in the preoperative period of 30 female patients, between 24 and 54 years old, with clinically diagnosed cholelithiasis and by echo sonography. The AC in 76.67 % was unique and was within the CHT, in 16.67 % it was unique and was observed outside the CHT. In 6.67 %, two ACs were observed, one inside and one outside the TCH. In 66.67 % of cases, CA originated normally from the right hepatic artery. The traceability of AC was 53.3 % moderately visible and 46.7 % excellent traceability. In conclusion, the identification of AC and its anatomical variations can be determined in the preoperative period and can be useful to improve the surgical plan in patients with cholelithiasis, providing information on the procedure, optimizing it and reducing the risks of possible bleeding related complications.

Prevalence of hepatic arterial variations with implications in pancreatoduodenectomy / Prevalência de variações arteriais hepáticas com implicações em pancreatoduodenectomia

ABSTRACT Background: Pancreaticoduodenectomy is the usual surgical option for curative treatment of periampullary cancer and carries a significant mortality. Arterial anomalies of the celiac axis are not uncommon and might lead to iatrogenic lesions or requiring arterial resection/reconstruction in a pancreatoduodenectomy. Aim: Determine the prevalence of arterial variations having implications in pancreatoduodenectomy. Methods: Celiac trunk and hepatic arterial system anatomy was retrospectively evaluated in 200 abdominal enhanced computed tomography studies. Results: Normal anatomy of hepatic arterial system was found in 87% of cases. An anomalous right hepatic artery was identified in 13% of cases. In 12 cases there was a substitute right hepatic artery arising from superior mesenteric artery and in two cases an accessory right hepatic artery with similar origin. A hepatomesenteric trunk was identified in seven cases and in five there was a right hepatic artery directly from the celiac trunk. All cases of anomalous right hepatic artery had a route was behind the pancreatic head and then, posteriorly and laterally, to the main portal vein before reaching the liver. Conclusions: Hepatic artery variations, such as anomalous right hepatic artery crossing posterior to the portal vein, are frequently seen (13%). These patients, when undergoing pancreatoduodenectomy, may require a change in the surgical approach to achieve an adequate resection. Preoperative imaging can clearly identify such variations and help to achieve a safer pancreatic head dissection with proper surgical planning.

RESUMO Racional: Pancreatoduodenectomia consiste no procedimento cirúrgico usual para tratamento curativo de neoplasias periampulares e apresenta mortalidade significativa. Variações arteriais do tronco celíaco não são incomuns e podem favorecer lesões iatrogênicas ou exigirem realização de ressecção/reconstrução arterial durante pancreatoduodenectomia. Objetivo: Determinar a prevalência de variações arteriais que apresentam implicações durante pancreatoduodenectomia. Métodos: A anatomia do tronco celíaco e sistema arterial hepático foi investigada retrospectivamente em 200 exames tomográficos contrastados do abdome. Resultados: Anatomia normal do sistema arterial hepático foi observada em 87% dos casos. Presença de uma artéria hepática direita anômala foi identificada em 13%. Em 12 casos houve uma artéria hepática direita substituta originária da artéria mesentérica superior, em dois uma artéria hepática direita acessória com origem similar. Tronco hepaticomesentérico foi identificado em sete casos e em cinco houve uma artéria hepática direita originária diretamente do tronco celíaco. Em todos casos de artéria hepática direita anômala seu curso foi por trás da cabeça do pâncreas e com trajeto passando posteriormente ao tronco da veia porta e após percorrendo sua face lateral direita antes de alcançar o fígado. Conclusões: Variações arteriais hepáticas, como artéria hepática direita anômala com trajeto posterior à veia porta, são frequentes (13%). Nestes pacientes, quando submetidos à pancreatoduodenectomia, pode ser necessária alteração na abordagem cirúrgica para ressecção adequada. Exames de imagem pré-operatórios podem claramente identificar estas variações e auxiliar na realização de dissecção segura da cabeça do pâncreas com adequado planejamento cirúrgico.

Variação anatômica do tronco celíaco e do sistema arterial hepático: uma análise por exames de imagem / Anatomical variations of the celiac trunk and the hepatic arterial system: an imaging analysis

Introdução: As variações anatômicas das artérias hepáticas e do tronco celíaco são de grande importância para cirurgias laparoscópicas, transplantes hepáticos, intervenções radiológicas e tratamento de lesões abdominais. O grande aumento de intervenções minimamente invasivas deixou os atos cirúrgicos com menos espaço para o reconhecimento de estruturas anatômicas. Métodos: Foi realizado um estudo retrospectivo do banco de dados do Hospital São Vicente de Paulo durante o ano de 2016, analisando imagens abdominais de tomografia computadorizada com contraste e angiotomografias que envolvem a aorta abdominal e seus ramos ­ um total de 461 imagens foram analisadas. Resultados: Dos 461 pacientes analisados, 86,9% apresentaram a conformação usual do tronco celíaco ­ cuja anatômica é a origem tríplice com as artérias gástrica esquerda, esplênica e hepática comum e artéria mesentérica superior se originando sozinha da aorta abdominal. Dentre as anatomias anômalas (13%), o padrão mais comum desses ramos foi a presença em 4,5% de um tronco hepatomesentérico e um tronco gastroesplênico. No sistema arterial hepático a conformação mais prevalente foram as artérias hepáticas direita e esquerda sendo ramos da hepática próprias em 66,3%. Das alterações anatômicas (33,2%), as mais comuns foram a presença de uma artéria hepática esquerda acessória ramo da artéria gástrica esquerda (7,8%). Conclusão: Variações anatômicas do sistema arterial hepático e do tronco celíaco são prevalentes, podendo apresentar diversos arranjos organizacionais. (AU)

Introduction: Anatomical variations in the hepatic arteries and the celiac trunk are of great importance for laparoscopic surgeries, liver transplants, radiological interventions and treatment of abdominal injuries. A large increase in the number of minimally invasive interventions hampered the recognition of anatomical structures in surgical procedures. Methods: A retrospective study was performed using the 2016 São Vicente de Paulo Hospital database of contrast-enhanced abdominal computed tomography images and computed tomography angiographies showing the abdominal aorta and its branches. In total, 461 images were analyzed. Results: Of the 461 patients analyzed, 86.9% had usual conformation of the celiac trunk, which trifurcates into the left gastric artery, the common hepatic artery and the splenic artery, while the superior mesenteric artery originates alone from the abdominal aorta. Among the cases of anomalous anatomy (13%), the most common pattern in these branches was the presence of a hepatomesenteric trunk and a gastrosplenic trunk in 4.5%. In the hepatic arterial system, the most prevalent conformation was the right and left hepatic arteries being branches of the hepatic artery proper in 66.3%. Of all anatomical variations (33.2%), the most common were the presence of a left accessory hepatic artery of the left gastric artery (7.8%). Conclusion: Anatomical variations in the hepatic arterial system and the celiac trunk are common, having different structural arrangements. (AU)

Tronco hepato-espleno-mesentérico: descripción de una disposición anómala del tronco celíaco / Hepato-splenic-mesenteric trunk: description of an abnormal disposition of the celiac trunk

El estudio de los patrones arteriales de distribución vascular requiere un conocimiento preciso de las variaciones anatómicas, tanto de origen y distribución de las arterias, como de sus correspondientes ramas arteriales. En este trabajo se describe la presencia de un tronco hepato-espleno-mesentérico, disposición arterial altamente infrecuente. El conocimiento de las distintas posibilidades de disposición de las arterias correspondientes al tronco celíaco y sus ramas será de importancia para la interpretación adecuada de estudios imagenológicos, como así también para la planificación precisa de actos quirúrgicos e intervencionistas en la región abdominal.

The study of arterial patterns of vascular distribution requires a precise knowledge of the anatomical variations of both origin and distribution of the corresponding arteries and arterial branches. In this work, the presence of a hepatosplenic-mesenteric trunk is described, a highly infrequent arterial disposition. The knowledge of the different possibilities of disposition of the arteries corresponding to the celiac trunk and its branches will be of importance for the adequate interpretation of imaging studies, as well as for the precise planning of surgical and interventional acts in the abdominal region.

Variaciones vasculares en cavidad abdominal y de vías urinarias: presentación de caso / Vascular variations in urinary tract and abdominal cavity: case report

Se presenta un raro caso de múltiples variaciones en la cavidad abdominal de un espécimen cadavérico de 50 años de género masculino, del laboratorio de anatomía de la Universidad Industrial de Santander (Bucaramanga-Colombia). Se observó variaciones arteriales (arteria renal adicional derecha y origen de la rama hepática derecha desde la arteria mesentérica superior), venosa (vena renal derecha adicional) y de vía urinaria (doble uréter en el lado derecho). Estas diversas variantes anatómicas además de suscitar interés académico, deben ser consideradas y descritas correctamente por los clínicos durante la realización de procedimientos quirúrgicos, radiológicos y de imágenes diagnósticas en la cavidad abdominal.

Here we present a rare case of multiple abdominal cavity variations in a 50-year-old male cadaveric specimen of the anatomy laboratory of the Universidad Industrial de Santander (Bucaramanga, Colombia). The anatomical dissection revealed arterial variations (right additional renal artery and origin of the right hepatic branch from the superior mesenteric artery), venous (right additional renal vein) and urinary tract (duplicated ureter on the right side). These multiple anatomic variations in addition to raising academic interest, should be considered and described correctly by clinicians while performing surgical, radiological and imaging procedures in the abdominal cavity.

Arteria hepática izquierda de arteria gastroduodenal: Un desafío técnico durante cirugía de Whipple. Caso clínico / Left hepatic artery (LHA) emerging from the gastroduodenal artery: Report of one case

Anatomic variations of the hepatic artery, which occur in 30 to 50% of patients, are a very important factor to be considered for Whipple procedure. The most common variations are those coming from the superior mesenteric artery, left gastric artery and the aorta. We report a 58-year-old woman with a story of one month of epigastric pain, jaundice and progressive itching. Magnetic resonance imaging showed a mass in the head of the pancreas. During pancreatoduodenectomy a left hepatic artery (LHA) emerging from the gastroduodenal artery and an accessory LHA emerging from the left gastric artery, were observed. The rest of the surgery was performed with no incidents. The patient had an uneventful postoperative evolution.

Accessory hepatic artery arising from celiac trunk: an incidence in a Thai cadaver / Arteria hepática accesoria derivada del tronco celiaco: hallazgo en un cadaver tailandés

An exhaustive knowledge of the liver vascular patterns as well as possible anatomical variations is significant in the planning and performance of all liver surgical procedures in order for the vascularity not to be disturbed or not causing necrosis of the liver parenchyma postoperatively. The celiac trunk usually provides three branches; left gastric, splenic and common hepatic arteries. The left and right hepatic arteries generally derive from proper hepatic artery which is a branch of common hepatic artery. To study the incidence of celiac trunk ramification, the branching patterns of the celiac trunk of 23 Thai cadavers (17 males, 6 females) were documented during routine dissection by medical students at the Department of Anatomy, Faculty of Medical Science, Naresuan University, Thailand. The clinically important variations of the celiac trunk were noted. The results showed that all celiac trunks arose from each aortas at the T12 vertebra (17.39%, 4 cases), intervertebral disc between T12 and L1 vertebra (78.26%, 18 cases) and upper 1/3rd of L1 vertebra (4.35%, 1 case). We found 95.65% (22 cases) normal celiac trunk trifurcation; whereas, 4.35% (1 case) was abnormal quadrifurcation of the trunk. The accessory hepatic artery (aHA) was presented as an additional branch of celiac trunk because the conventional pattern of the left and right hepatic arteries was presented. This finding is one of the rare anatomical variations which is reported in available literatures. The awareness of celiac trunk and its stems aberrant is important in procedures such as liver transplant for appropriate vascular ligation and anastomosis.

Un conocimiento exhaustivo de los patrones vasculares del hígado, así como sus posibles variaciones anatómicas son importantes en la planificación y realización de todos los procedimientos quirúrgicos hepáticos para evitar comprometer la vascularización y posible necrosis del parénquima después de la cirugía. El tronco celíaco, por lo general, proporciona tres ramas: gástrica izquierda, esplénica y arteria hepática común. Las arterias hepáticas izquierda y derecha en general derivan de la arteria hepática propia, que es una rama de la arteria hepática común. El objetivo de este trabajo fue estudiar la incidencia de distribución del tronco celíaco mediante la documentación de patrones de ramificación en 23 cadáveres de Tailandia (17 hombres y 6 mujeres). El estudio se efectuó durante la disección de rutina realizada por los estudiantes de medicina en el Departamento de Anatomía de la Facultad de Ciencias Médicas, Universidad de Naresuan, Tailandia. Se observaron las variaciones clínicamente importantes del tronco celíaco. Los resultados mostraron que todos los troncos celíacos surgieron desde la aorta a nivel de la vértebra T12 (17,39%, 4 casos), a nivel del disco intervertebral entre T12 y L1 vértebra (78,26%, 18 casos) y a nivel del tercio superior de la vértebra L1 (4,35%, 1 caso). Encontramos un 95,65% (22 casos) de troncos celíacos normales, es decir, con trifurcación; mientras que un 4,35% (1 caso) era anormal, con 4 ramos terminales. La arteria hepática accesoria (AHA) se presentó como una rama accesoria del tronco celíaco, ya que existía un patrón convencional de las arterias hepáticas izquierda y derecha. Este hallazgo representa una de las raras variaciones anatómicas informada en la literatura. El conocimiento del tronco celíaco y sus ramas aberrantes son importantes en procedimientos como el trasplante hepático, la anastomosis y una ligadura vascular adecuada.

Estenosis crítica de conducto hepático común por anillo vascular: reporte de un caso / Common bile duct stricture caused by vascular ring: A case report

Introduction: The most common congenital malformations of the bile duct are biliary atresia and choledochal cyst. In addition, the most common liver anatomical variation is the right hepatic artery aberration. The goal of this study is to characterize a patient with this disease and propose the hepatoduodenal anastomosis as surgical treatment. Case report: One-month-old patient with suspected congenital biliary atresia due to progressive jaundice and acholia since birth. Liver tests consistent with a cholestatic pattern and brain MRI scan consistent with biliary atresia. Periods of decreased bilirubin and sporadic slight pigmentation of depositions were described. The surgical finding was a bile duct stricture due to a vascular ring caused by aberrant right hepatic artery. Resection of bile duct and hepatic-duodenal bypass were performed. The patient evolved satisfactorily from this condition. Conclusion: There are few reports of biliary obstruction due to vascular malformations. It is important to keep in mind that not all neonatal jaundice episodes are caused by biliary atresia or choledo-chal cyst. The clinical course, laboratory tests and imaging should be considered and in the case of suspicion, further exploration should take place.

Introducción: Las malformaciones congénitas de la vía biliar más frecuentes son la atresia de vías biliares y quiste de colédoco. Por otro lado, la variante anatómica hepática más común es la aberración de la arteria hepática derecha. El objetivo es caracterizar un paciente portador de esta patología y plantear la hepato-duodeno anastomosis como tratamiento quirúrgico. Caso clínico: Paciente de 1 mes de edad, con sospecha de Atresia de Vía Biliar congénita por ictericia progresiva y acolia desde recién nacido. Pruebas hepáticas concordantes con un patrón colestásico y resonancia magnética compatible con atresia de vías biliares. Evolucionó con períodos de descenso de bilirrubina y leve pigmentación, esporádica, de deposiciones. El hallazgo quirúrgico fue una estenosis crítica de vía biliar a nivel del conducto hepático común debido a un anillo vascular por una arteria hepática derecha aberrante. Se realizó una sección de vía biliar y una derivación hepato-duodenal. Evolucionó con una resolución completa de su patología. Conclusión: Existen pocos reportes de obstrucción de vía biliar por malformaciones vasculares. Es importante tener presente que no todas las ictericias neonatales son por atresia de vías biliares o quiste de colédoco. Se debe considerar la evolución clínica, laboratorio e imágenes, y si existen sospechas, explorar.

Improved severe hepatopulmonary syndrome after liver transplantation in an adolescent with end-stage liver disease secondary to biliary atresia

Hepatopulmonary syndrome (HPS) is a serious complication of end-stage liver disease, which is characterized by hypoxia, intrapulmonary vascular dilatation, and liver cirrhosis. Liver transplantation (LT) is the only curative treatment modality for patients with HPS. However, morbidity and mortality after LT, especially in cases of severe HPS, remain high. This case report describes a patient with typical findings of an extracardiac pulmonary arteriovenous shunt on contrast-enhanced transesophageal echocardiography (TEE), and clubbing fingers, who had complete correction of HPS by deceased donor LT. The patient was a 16-year-old female who was born with biliary atresia and underwent porto-enterostomy on the 55th day after birth. She had been suffered from progressive liver failure with dyspnea, clubbing fingers, and cyanosis. Preoperative arterial blood gas analysis revealed severe hypoxia (arterial O2 tension of 54.5 mmHg and O2 saturation of 84.2%). Contrast-enhanced TEE revealed an extracardiac right-to-left shunt, which suggested an intrapulmonary arteriovenous shunt. The patient recovered successfully after LT, not only with respect to physical parameters but also for pychosocial activity, including school performance, during the 30-month follow-up period.

Sonography of hepatic hemangioma accompanied by arterioportal shunt

No abstract available.

N-Butyl Cyanoacrylate Embolization with Blood Flow Control of an Arterioportal Shunt That Developed after Radiofrequency Ablation of Hepatocellular Carcinoma

We present a case of a patient with rapid deterioration of esophageal varices caused by portal hypertension accompanied by a large arterioportal shunt that developed after radiofrequency ablation of hepatocellular carcinoma. We used n-butyl cyanoacrylate (NBCA) as an embolic material to achieve pinpoint embolization of the shunt, because the microcatheter tip was 2 cm away from the shunt site. Under hepatic arterial flow control using a balloon catheter, the arterioportal shunt was successfully embolized with NBCA, which caused an improvement in the esophageal varices.

RE: Aberrant Vascular Structures and Its Effect on the Adjacent Organs: How Can We Evaluate Efficiently and Safely?

No abstract available.

Compression of the Main Pancreatic Duct by the Intrapancreatic-Replaced Common Hepatic Artery

We describe a unique case of a patient who presented with a linear, transverse, and incidentally-detected main pancreatic duct dilatation that was caused by the intrapancreatic-replaced common hepatic artery, detected on the MDCT, MRCP and endoscopic retrograde cholangiopancreatography. We believe this case to be the first of its kind reported in the literature.

Haga su diagnóstico / Make your diagnosis

El diagnóstico es Fístula arterioportal congénita

Pseudoaneurisma de la arteria hepática propia: reporte de un caso / Traumatic pseudoaneurysm of hepatic artery: case report

Los aneurismas de la arteria hepática son relativamente poco frecuentes y representan del 16 al 20 % de los aneurismas de las arterias viscerales. Las manifestaciones clínicas no son específicas y pueden incluir dolor abdominal, hemorragia digestiva alta o ictericia obstructiva, como el caso que se presenta. Caso clínico: presenta el caso de un hombre de 17 años remitido por ictericia obstructiva; se determinó que la patología causante era un pseudoaneurisma de más de 30 mm. de diámetro en la arteria hepática propia, de origen traumático. La evolución fue tórpida por las lesiones asociadas, pese a la colaboración intensiva de distintas especialidades y al tratamiento electivo. Conclusiones: este tipo de aneurisma ocurre con muy poca frecuencia y tiene un pronóstico muy incierto. El tratamiento debe ser necesariamente individual para cada caso. La ictericia constituyó el signo de debut e indicó la gravedad del pseudoaneurisma de la arteria hepática, cuyo pronóstico es incierto, precisando tratamiento individualizado. Debe seleccionarse cuidadosamente el abordaje que requiere cada paciente, y aunque la vía endovascular es una opción, a veces es imposible recurrir a ella por la complejidad de la localización de la lesión, de ahí la necesidad de que el cirujano posea experiencia en el eje hepatobiliar y su vascularización.

Haemobilia: a rare cause of gastrointestinal bleeding

Iatrogenic injury to hepatic duct leading to pseudoaneurysm and haemobilia can occur following laparoscopic cholecystectomy. We report a case of a 60 years old man presenting with haematemesis found to have pseudoaneurysm of accessory hepatic artery 4 months after laparoscopic cholecystectomy. Diagnosis was made by computed tomography [CT] scan followed by celiac and mesenteric artery angiogram. The bleeding was successfully treated with coil embolization

Síndrome de Rendu-Osler-Weber en paciente adulto: reporte de un caso y revisión de la literatura / Rendu-Osler-Weber syndrome in adult patient: a case report and literature review

El síndrome de Rendu-Osler-Weber es un trastorno hereditario de los vasos sanguíneos, con gran variedad de manifestaciones clínicas que predisponen a fenómenos hemorrágicos (epistaxis, hemorragia digestiva) asociados a telangiectasias en piel y mucosas, acompañados generalmente de anemia ferropriva secundaria. Dichas manifestaciones generalmente subestiman la presencia de otras malformaciones arteriovenosas en órganos como pulmón y cerebro, cuyas complicaciones pueden determinar un riesgo vital para el paciente. La sospecha dada por alguno de los eventos descritos, sumado a la presencia de antecedentes familiares con la misma patología, obligan a realizar la búsqueda activa de malformaciones arteriovenosas en órganos potencialmente afectados para evaluar la posibilidad de un eventual tratamiento, el cual ante cualquier tipo de manifestación, y según avala la literatura, sigue siendo sintomático.

Osler-Weber-Rendu syndrome is an inherited disorder of the vessels, with a great variety of clinical manifestations that predispose to hemorrhage (epistaxis, gastrointestinal bleeding) associated to telangiectasis in skin and mucoses, usually with secondary ferropenic anemia. Those manifestations generally underestimate the presence of other arteriovenous malformations in organs like lungs and brain, where complications are of vital risk for the patient. The suspect given by any of the events described previously, added to the presence of family medical history for the same disorder, make necessary an active search of arteriovenous malformations in potentially affected organs to evaluate the possibility of an eventual treatment, which is for any type of manifestation and according to the literature, still symptomatic.

[ rare variation in branches of abdominal aorta]

Although there are many reports about variation of the branches of abdominal aorta, the present report is a very rare case that it has not been reported so far. The coeliac trunk is a wide ventral branch of abdominal aorta with 2.25cm long. The coeliac trunk divided into three branches: left gastric, common hepatic and splenic branch. Normally, the trunk has not any branches for small intestine after duodenum. In cudavr of a man with 65 years old who was dissected with grants method, the following variations were observed: a common trunk which is raised from common hepatic artery and divided to following branches: branches for pancreas near the neck and body of pancreas, a branch for head of pancreas, branches for duodenum, a huge branch for jejunum and ileum from right side, a huge branch for large intestine from left side, a communication branch between right gasteroepiploic and coeliac, arise cystic artery from common hepatic artery. Since the current report is a rare case, which has not been reported in any anatomical and clinical literatures so far, it may be an interesting and important case