Technical dilemmas in portacaval shunt operations as a consequence of replaced right hepatic artery

Surgical procedures designed to decompress the portal venous system in patients with cirrhosis and bleeding esophageal varices may be complicated by anatomic variations in the extrahepatic arterial circulation. Anomalous right hepatic arteries which arise from the superior mesenteric artery may be encountered in 18 to 20 per cent of the normal population. Replaced arteries are not accessory vessels but rather provide the sole arterial circulation to well defined segments of the liver. Unfortunate injury may result in severe ischemic trauma of the liver. Preoperative visceral arteriography is essential prior to any contemplated portosystemic shunt procedure. The unusual anatomic relationship of such an anomalous right hepatic artery to the portal vein may contraindicate standard portacaval, interposition portacaval or portarenal shunt procedures; graft angulation and anastomotic distortion may jeopardize shunt patency and result in recurrent variceal hemorrhage. A technique for portal vein-hepatic artery transposition and end-to-side portacaval shunt is presented as a feasible alternative if anomalies of the hepatic artery preclude standard shunt procedures.