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Incidence, Patterns, and Clinical Relevance of Variant Portal Vein Anatomy

¹ All authors: Department of Diagnostic Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY 10021.

View larger version (26K): [in a new window]   Fig. 1A. —Illustrations show classification scheme of portal vein anatomy used in this study. LPV = left portal vein, RPPV = right posterior portal vein, RAPV = right anterior portal vein. (Printed with permission from Memorial Sloan-Kettering Cancer Center) Drawings depict standard portal vein anatomy (type 1, A), trifurcation (type 2, B), right posterior portal vein as first branch of main portal vein (type 3, C), segment VII branch as separate branch of right portal vein (types 4, D), and segment VI branch as separate branch of right portal vein (type 5, E).

View larger version (26K): [in a new window]   Fig. 1B. —Illustrations show classification scheme of portal vein anatomy used in this study. LPV = left portal vein, RPPV = right posterior portal vein, RAPV = right anterior portal vein. (Printed with permission from Memorial Sloan-Kettering Cancer Center) Drawings depict standard portal vein anatomy (type 1, A), trifurcation (type 2, B), right posterior portal vein as first branch of main portal vein (type 3, C), segment VII branch as separate branch of right portal vein (types 4, D), and segment VI branch as separate branch of right portal vein (type 5, E).

View larger version (34K): [in a new window]   Fig. 1C. —Illustrations show classification scheme of portal vein anatomy used in this study. LPV = left portal vein, RPPV = right posterior portal vein, RAPV = right anterior portal vein. (Printed with permission from Memorial Sloan-Kettering Cancer Center) Drawings depict standard portal vein anatomy (type 1, A), trifurcation (type 2, B), right posterior portal vein as first branch of main portal vein (type 3, C), segment VII branch as separate branch of right portal vein (types 4, D), and segment VI branch as separate branch of right portal vein (type 5, E).

View larger version (31K): [in a new window]   Fig. 1D. —Illustrations show classification scheme of portal vein anatomy used in this study. LPV = left portal vein, RPPV = right posterior portal vein, RAPV = right anterior portal vein. (Printed with permission from Memorial Sloan-Kettering Cancer Center) Drawings depict standard portal vein anatomy (type 1, A), trifurcation (type 2, B), right posterior portal vein as first branch of main portal vein (type 3, C), segment VII branch as separate branch of right portal vein (types 4, D), and segment VI branch as separate branch of right portal vein (type 5, E).

View larger version (33K): [in a new window]   Fig. 1E. —Illustrations show classification scheme of portal vein anatomy used in this study. LPV = left portal vein, RPPV = right posterior portal vein, RAPV = right anterior portal vein. (Printed with permission from Memorial Sloan-Kettering Cancer Center) Drawings depict standard portal vein anatomy (type 1, A), trifurcation (type 2, B), right posterior portal vein as first branch of main portal vein (type 3, C), segment VII branch as separate branch of right portal vein (types 4, D), and segment VI branch as separate branch of right portal vein (type 5, E).

View larger version (114K): [in a new window]   Fig. 2A. —45-year-old man with metastatic colorectal cancer. CT portograms show standard portal vein anatomy. Main portal vein divides into left portal vein (arrow, A) and right portal vein, which subsequently divides into right anterior portal vein (arrow, C) to supply segments V and VIII, and right posterior portal vein (arrow, D) to supply segments VI and VII. It is uncommon for all major branches to be seen on a single image, and being able to scroll through images on workstation or PACS is invaluable in correctly identifying and classifying variant anatomy. Multiplanar reconstruction may also overcome this limitation of 2D imaging.

View larger version (117K): [in a new window]   Fig. 2B. —45-year-old man with metastatic colorectal cancer. CT portograms show standard portal vein anatomy. Main portal vein divides into left portal vein (arrow, A) and right portal vein, which subsequently divides into right anterior portal vein (arrow, C) to supply segments V and VIII, and right posterior portal vein (arrow, D) to supply segments VI and VII. It is uncommon for all major branches to be seen on a single image, and being able to scroll through images on workstation or PACS is invaluable in correctly identifying and classifying variant anatomy. Multiplanar reconstruction may also overcome this limitation of 2D imaging.

View larger version (112K): [in a new window]   Fig. 2C. —45-year-old man with metastatic colorectal cancer. CT portograms show standard portal vein anatomy. Main portal vein divides into left portal vein (arrow, A) and right portal vein, which subsequently divides into right anterior portal vein (arrow, C) to supply segments V and VIII, and right posterior portal vein (arrow, D) to supply segments VI and VII. It is uncommon for all major branches to be seen on a single image, and being able to scroll through images on workstation or PACS is invaluable in correctly identifying and classifying variant anatomy. Multiplanar reconstruction may also overcome this limitation of 2D imaging.

View larger version (116K): [in a new window]   Fig. 2D. —45-year-old man with metastatic colorectal cancer. CT portograms show standard portal vein anatomy. Main portal vein divides into left portal vein (arrow, A) and right portal vein, which subsequently divides into right anterior portal vein (arrow, C) to supply segments V and VIII, and right posterior portal vein (arrow, D) to supply segments VI and VII. It is uncommon for all major branches to be seen on a single image, and being able to scroll through images on workstation or PACS is invaluable in correctly identifying and classifying variant anatomy. Multiplanar reconstruction may also overcome this limitation of 2D imaging.

View larger version (110K): [in a new window]   Fig. 3A. —CT portograms in 54-year-old woman with portal vein trifurcation (type 2 anatomy) and metastatic colorectal cancer. In 9% of patients, main portal vein trifurcates into left portal vein (straight thin arrow), right anterior portal vein (straight thick arrow), and right posterior portal vein (curved arrow), as depicted in single 2D image in this patient.

View larger version (116K): [in a new window]   Fig. 3B. —CT portograms in 54-year-old woman with portal vein trifurcation (type 2 anatomy) and metastatic colorectal cancer. More typically, trifurcation is less apparent and requires scrolling through images with attention to portal vein to accurately determine anatomy. In C, straight arrow indicates right anterior portal vein, curved arrow indicates right posterior branch.

View larger version (119K): [in a new window]   Fig. 3C. —CT portograms in 54-year-old woman with portal vein trifurcation (type 2 anatomy) and metastatic colorectal cancer. More typically, trifurcation is less apparent and requires scrolling through images with attention to portal vein to accurately determine anatomy. In C, straight arrow indicates right anterior portal vein, curved arrow indicates right posterior branch.

View larger version (104K): [in a new window]   Fig. 4A. —CT portograms in 47-year-old man with metastatic colorectal cancer shows Z type of portal vein variant (type 3 anatomy). In this patient, right posterior portal vein (arrow, A) is first branch of main portal vein. Common trunk of variable length gives rise to left portal vein (arrow, B) and right anterior portal vein (arrow, C).

View larger version (108K): [in a new window]   Fig. 4B. —CT portograms in 47-year-old man with metastatic colorectal cancer shows Z type of portal vein variant (type 3 anatomy). In this patient, right posterior portal vein (arrow, A) is first branch of main portal vein. Common trunk of variable length gives rise to left portal vein (arrow, B) and right anterior portal vein (arrow, C).

View larger version (117K): [in a new window]   Fig. 4C. —CT portograms in 47-year-old man with metastatic colorectal cancer shows Z type of portal vein variant (type 3 anatomy). In this patient, right posterior portal vein (arrow, A) is first branch of main portal vein. Common trunk of variable length gives rise to left portal vein (arrow, B) and right anterior portal vein (arrow, C).

View larger version (119K): [in a new window]   Fig. 4D. —CT portograms in 47-year-old man with metastatic colorectal cancer shows Z type of portal vein variant (type 3 anatomy). In this patient, right posterior portal vein (arrow, A) is first branch of main portal vein. Common trunk of variable length gives rise to left portal vein (arrow, B) and right anterior portal vein (arrow, C).

View larger version (107K): [in a new window]   Fig. 5A. —CT portograms in 58-year-old man with metastatic colorectal cancer. CT portograms show liver segment VI portal branch (star, A) arising as first branch of main portal vein. Segment VII branch (arrow, B) arises from right anterior portal vein (arrow, C).

View larger version (103K): [in a new window]   Fig. 5B. —CT portograms in 58-year-old man with metastatic colorectal cancer. CT portograms show liver segment VI portal branch (star, A) arising as first branch of main portal vein. Segment VII branch (arrow, B) arises from right anterior portal vein (arrow, C).

View larger version (111K): [in a new window]   Fig. 5C. —CT portograms in 58-year-old man with metastatic colorectal cancer. CT portograms show liver segment VI portal branch (star, A) arising as first branch of main portal vein. Segment VII branch (arrow, B) arises from right anterior portal vein (arrow, C).

View larger version (114K): [in a new window]   Fig. 5D. —CT portograms in 58-year-old man with metastatic colorectal cancer. CT portograms show liver segment VI portal branch (star, A) arising as first branch of main portal vein. Segment VII branch (arrow, B) arises from right anterior portal vein (arrow, C).

View larger version (111K): [in a new window]   Fig. 5E. —CT portograms in 58-year-old man with metastatic colorectal cancer. CT portograms show liver segment VI portal branch (star, A) arising as first branch of main portal vein. Segment VII branch (arrow, B) arises from right anterior portal vein (arrow, C).

View larger version (111K): [in a new window]   Fig. 5F. —CT portograms in 58-year-old man with metastatic colorectal cancer. CT portograms show liver segment VI portal branch (star, A) arising as first branch of main portal vein. Segment VII branch (arrow, B) arises from right anterior portal vein (arrow, C).

View larger version (111K): [in a new window]   Fig. 5G. —CT portograms in 58-year-old man with metastatic colorectal cancer. Transhepatic portal venogram (obtained on another date) confirms interpretation of variant portal anatomy. Arrow represents left portal vein, star indicates segment VI branch.

View larger version (104K): [in a new window]   Fig. 6A. —51-year-old man with metastatic colorectal cancer. CT portograms show right portal vein trifurcates into right anterior portal vein (arrow, B) and segment VI (curved arrow, C) and segment VII (straight arrow, C) branches. Left portal vein is denoted by arrow in A. This anatomy is surgically relevant to left trisegmentectomy, in which damage to either right posterior segment branch would leave patient with single-segment remnant liver.

View larger version (105K): [in a new window]   Fig. 6B. —51-year-old man with metastatic colorectal cancer. CT portograms show right portal vein trifurcates into right anterior portal vein (arrow, B) and segment VI (curved arrow, C) and segment VII (straight arrow, C) branches. Left portal vein is denoted by arrow in A. This anatomy is surgically relevant to left trisegmentectomy, in which damage to either right posterior segment branch would leave patient with single-segment remnant liver.

View larger version (101K): [in a new window]   Fig. 6C. —51-year-old man with metastatic colorectal cancer. CT portograms show right portal vein trifurcates into right anterior portal vein (arrow, B) and segment VI (curved arrow, C) and segment VII (straight arrow, C) branches. Left portal vein is denoted by arrow in A. This anatomy is surgically relevant to left trisegmentectomy, in which damage to either right posterior segment branch would leave patient with single-segment remnant liver.

View larger version (100K): [in a new window]   Fig. 6D. —51-year-old man with metastatic colorectal cancer. CT portograms show right portal vein trifurcates into right anterior portal vein (arrow, B) and segment VI (curved arrow, C) and segment VII (straight arrow, C) branches. Left portal vein is denoted by arrow in A. This anatomy is surgically relevant to left trisegmentectomy, in which damage to either right posterior segment branch would leave patient with single-segment remnant liver.

View larger version (126K): [in a new window]   Fig. 7A. —59-year-old man with metastatic colorectal cancer. CT portograms show single patient in our series in whom portal vein variant branch pattern involved left portal vein. In this patient, segment IV portal vein (arrow, F) arose from right portal vein (straight arrow, E) and not from left portal vein, which supplied only lateral segment. Curved arrow (E) indicates segment VI portal vein branch. If it is not recognized before procedure in a patient undergoing portal vein embolization, segment IV branch could be inadvertently embolized during right portal vein embolization or inadvertently not embolized during left portal vein embolization.

View larger version (127K): [in a new window]   Fig. 7B. —59-year-old man with metastatic colorectal cancer. CT portograms show single patient in our series in whom portal vein variant branch pattern involved left portal vein. In this patient, segment IV portal vein (arrow, F) arose from right portal vein (straight arrow, E) and not from left portal vein, which supplied only lateral segment. Curved arrow (E) indicates segment VI portal vein branch. If it is not recognized before procedure in a patient undergoing portal vein embolization, segment IV branch could be inadvertently embolized during right portal vein embolization or inadvertently not embolized during left portal vein embolization.

View larger version (125K): [in a new window]   Fig. 7C. —59-year-old man with metastatic colorectal cancer. CT portograms show single patient in our series in whom portal vein variant branch pattern involved left portal vein. In this patient, segment IV portal vein (arrow, F) arose from right portal vein (straight arrow, E) and not from left portal vein, which supplied only lateral segment. Curved arrow (E) indicates segment VI portal vein branch. If it is not recognized before procedure in a patient undergoing portal vein embolization, segment IV branch could be inadvertently embolized during right portal vein embolization or inadvertently not embolized during left portal vein embolization.

View larger version (126K): [in a new window]   Fig. 7D. —59-year-old man with metastatic colorectal cancer. CT portograms show single patient in our series in whom portal vein variant branch pattern involved left portal vein. In this patient, segment IV portal vein (arrow, F) arose from right portal vein (straight arrow, E) and not from left portal vein, which supplied only lateral segment. Curved arrow (E) indicates segment VI portal vein branch. If it is not recognized before procedure in a patient undergoing portal vein embolization, segment IV branch could be inadvertently embolized during right portal vein embolization or inadvertently not embolized during left portal vein embolization.

View larger version (132K): [in a new window]   Fig. 7E. —59-year-old man with metastatic colorectal cancer. CT portograms show single patient in our series in whom portal vein variant branch pattern involved left portal vein. In this patient, segment IV portal vein (arrow, F) arose from right portal vein (straight arrow, E) and not from left portal vein, which supplied only lateral segment. Curved arrow (E) indicates segment VI portal vein branch. If it is not recognized before procedure in a patient undergoing portal vein embolization, segment IV branch could be inadvertently embolized during right portal vein embolization or inadvertently not embolized during left portal vein embolization.

View larger version (131K): [in a new window]   Fig. 7F. —59-year-old man with metastatic colorectal cancer. CT portograms show single patient in our series in whom portal vein variant branch pattern involved left portal vein. In this patient, segment IV portal vein (arrow, F) arose from right portal vein (straight arrow, E) and not from left portal vein, which supplied only lateral segment. Curved arrow (E) indicates segment VI portal vein branch. If it is not recognized before procedure in a patient undergoing portal vein embolization, segment IV branch could be inadvertently embolized during right portal vein embolization or inadvertently not embolized during left portal vein embolization.

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