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 bleeing 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 arteries circulation to well defined segments of the liver. Unfortunate injury may result in severe ischemic truama of the liver. Preoperative vicseral arteriography is essential prior to any contemplated portosystemic shunt procedure. The unusual anatomic relationship of such an anomalous right to hepatic artery to the portal vein may contraindicate standard portacaval, interposition portacaval or portarnal shunt procedures; graft angulation and anastomotic distortion may jeopardize shunt patancy and result in recurrent variceal hemmorrhage. 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.