| Hepatoma, a widespread disease covering major population. Since the 90th of twentieth century, it has become the No.2 fatal disease in China. Surgery is the most preferred and most effective treatment solution.Due to the complexity and variation of hepatic duct systems, the difficulty and risk of surgical operation and intervention increased. The success of liver cancer surgery requires the surgeon to have a comprehensive understanding on the structure and variation of intrahepatic vessels, which can reduce the time of operation, improve the achievement ratio of surgery, decrease the operation complications, also can be helpful to choosing the operative program and elevating the curative effect of intervention.MSCT Angiography (MSCTA) is a technique that contrast medium is administrated through body surface vein in a breathhold condition and three-dimensional image is reconstructed by computer to display the target vessel structures. The technique has many advantages, such as easy performance, economy ,utility and atraumatic. With the appearance of 64-detector row helical CT, CTA could display the anatomy and variation of the target vessel more accurately, especially the relationship between the target vessel and tumor from multiple point of view, which was of great clinical value.Objective1.To study the feature of 64-detector row helical CT angiography of hepatoma.2.To study the normal anatomy and anatomical variation of hepatic artery and the clinic applications of the variations by 64-detector row helical CT angiography.3.To study the manifestation of the blood-supply for hepatoma by the use of 64-detector row helical CT angiography.4.To discuss clinical applications and value of 64-detector row helical CT angiography on hepatoma surgery.Materials and Methods1.Patient data: (1) 106 patients who had clinically been definited hepatoma underwent CTA examination with 64- detector row helical CT. They included 85 men and 21 women, and the average age was 47.4 years. The final diagnoses of the patients were hepatocellular carcinoma (n=83), metastatic hepatic tumors(n=23).(2) 68 HCC patients (exclude 2 patients with Transplantation of liver) were performed with surgical treatment who included 60 men and 8 women, and the average age was 49.0 years.2.Examination methods: (1)plain scan: All patients took 500～1000 ml pure water orally before examination and lay supinely on the scan table, with the scan direction from the top of liver to the inferior pole of kidney and the length of 220-270mm. By using a section thickness of 5mm, interval of 5mm, a pitch of 0.984, the voltage of 120 kV, the electric current of 250mA, per rotation of 0.5 second and a FOV of 330mm. (2) CTA scan: The nonionic iodinated contrast agent was intravenously administered 20 ml in a rate of the 5ml/s with a double tube power injector of tube A through a plastic 20-gauge intravenous catheter that was inserted into the cubital vein. The starting scan of time delay was determined by using the test bolus of contrast agent followed by a series of single level CT scans at low dose. The scan location was 20 cm below the dome of the liver, and the monitoring scans were acquired every 1 seconds from 0 to 30 seconds. A mask put over the abdominal aorta at this level, and the time to peak aortic enhancement was used to determine the starting scan of time for the first arterial phase images of hepatic artery of CTA. Subsequently, 20 ml saline was injected from tube B after a bolus injection of 70-120 mL of contrast agent (with the dosage of 1.5ml/kg) from tube A with the same rate (5ml/s), and the starting scan time of arterial phase was the time to peak aortic enhancement(21-25S). Based on the time to peak aortic enhancement, the starting scan time of portal venous phase(include venous phase) was 50-55s. The time of every phase continue 6-8S.3.Image processing and analysis: All the images derived from CTA were reconstructed with the minimum slice of 0.67mm and the interval of 0.33mm and transmitted into the Mxview workstation. Image postprocessing were introduced with maximum intensity projection (MIP), volume rendering (VR) and multiple planar reformation(MPR). CT original images and 3D images of CTA were analyzed by two senior image doctors, which clearly showed the origin of hepatic artery, the shape of tumor supplying arteries, tumor vessels, tumor stain, the signs of portal vein invaded and the relationship between tumor and hepatic vessels. The average time of postprocessing was 30 minutes.4.Statistical analyses: the experiment was mainly description of morphology which wasn't involved in statistic inference.Results1.The appearance of hepatoma in CTA: In 83 patients with HCC CTA showed tumor stain in 52 cases, tumor vessels in 48 cases, tumor supplying arteries in 44 cases. The tumor supplying arteries manifested thickening, expanding in 35 cases and shifting in 32 cases. The tumors were supplied by two hepatic arteries in 7 cases. Compared to DSA of 23 cases, the accurate rate of 64-detector row helical CT angiography was 96.2% in detecting tumor supplying arteries. 28 cases were detected with tumor thrombi in portal vein, 4 cases with tumor thrombi in inferior vena cave, 8 cases with arterio-venous fistula. In 23 patients with MHT CTA showed multiple focus of similar quality in liver. The blood vessels didn't manifest thickening in 18 cases. 5 cases were found with thickening of blood vessels which were also stiffness.2.The normal anatomy and variation of hepatic artery: normal hepatic artery anatomy was found in 80 of 106 cases(75.5%), and variation presented in 26 cases (24.5%). Seven types of variation (total 21 cases ) belonged to Michels type which included 7 cases with MichelsⅡtype, 4 cases withⅢtype, 1 cases withⅣtype, 3 cases withⅤV type, 2 cases withⅥtype, 1 cases withⅧtype, 3 cases withⅨtype. In addition, 5 cases showed the variation types which weren't included in Michels type.3.The classification of hepatoma supplying arteries: tumor was regular supplied by hepatic artery in 86 cases(81.1%), variable blood-supply in 18 cases(17.0%) which were divided into four hypotypes on the basis of the origin of hepatic artery. 2 cases(1.9%) showed parasitic blood-supply to hepatoma both of which diaphragmatic arteries were the blood-supply arteries.4.The surgical treatment analyses of 68 patients with HCC: The results of three-dimensional reconstruction based on 64-detector row helical CTA could definitely demonstrate the tumor limit, especially the relationship between tumor and blood vessels. Tumor was located on right liver in 42 cases, left liver in 18 cases, both right and left liver in 6 cases, caudate lobe in 2 cases. Tumor's diameter exceeded 10cm in 8 cases(11.8 %), between 5cm and 10cm in 50 cases (73.5 %), not exceeded 5cm in 10 cases(14. 7 %). 29 cases were performed with interventional therapy. CTA showed tumor blood-supply was from SMA in 2 cases, from LGA in 1 case, from right diaphragmatic arteries combined with RHA in 1 case. Other 39 cases were performed with operation. The three-dimensional reconstruction results demonstrated that tissues and blood vessels were not invaded in 23 cases, while portal vein and(or) hepatic vein were invaded by the tumor in 9 cases, and 2 patient was found with arterio-venous fistula, and 5 cases were detected with tumor thrombi in portal vein. 38 of other 39 cases were consistent with the intraoperative exploration findings, and the accurate rate was 97.4%. Radical excision was performed in 16 patients, right hepatectomy in 10 patients, left external lobe resection in 7 patients, left hepatectomy in 2 patients, hepatoma resection and removal of tumor thrombi in 1 patients, left trilobectomy in 1 patients, right trilobectomy in 1 patients, caudate lobe resection in 1 patients.Conclusions1.64-detector row helical CT angiography is an examination method on blood vessels which is rapid, precise, untraumatic. Based on it, the 3D structure between tumor and target vessel were satisfactorily established. It could accurately manifest the feature of tumor blood vessels which was helpful to diagnosis and differential diagnosis on hepatoma.2.64-detector row helical CT could accurately visualized the type of anatomical variation of hepatic artery and could display clearly the artery for feed-tumor or the abnormality branch blood-supply for tumor.3.64-detector row helical CT angiography could definitely demonstrate the tumor limit and position, especially could manifest the relationship between tumor and blood vessels. So it played an important role in estimating availability of the operation, choosing the modus operandi, providing information for liver transplantation.4.64-detector row helical CT angiography was helpful to reducing the incidence rate of blood vessel complications and soundly blocking the blood-supply for tumor when intervention, which could elevate the curative effect.
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