Anatomic

Variants
of Mesenteric
Veins: Depiction
with Helical CT
Venography
Oswald Graf1
GilesW. Boland1
John A. Kaufman1
Andrew L Warshaw2
Carlos Fernandez del Castillo2
Peter A. Mueller1

OBJECTIVE.
on axial

The purpose of this study was to describe

the variable
anatomy
of mesenteric
CT images
and on volume-rendered
CT venograms
that use maximum
intensity

veins

and shaded-surface

projection

SUBJECTS
were included
were

patients

display.

AND
METHODS.
Fifty-seven
patients undergoing
helical CT ofthe pancreas
in the study. The mesenteric
venous
system was analyzed
in 54 patients.
Three
excluded

RESULTS.

because

On helical

the superior
mesenteric
In seven other patients.

the helical

CT with

CT data

maximum

were

unsatisfactory.

intensity

projection

and shaded-surface

display,

vein (SMV)
was seen as a single trunk of variable
length in 4() patients.
two mesenteric
trunks merged
separately
with the splenic
vein. In the

remaining
seven patients.
the SMV was occluded
by tumor. The inferior mesenteric
vein drained
into the splenic vein in 28 patients
(56%). into the SMV in 14 patients
(26%). and into the splenomesenteric
angle
CONCLUSION.

in nine patients (18%).

Both axial and volume-rendered

able mesenteric
venous
surgical
planning.

anatomy.

onventional

and

CT venograms

helical

imaging
methods
to evaluate
the pancreas

peripancreatic

region.

most

of the essential

when

determining

accurate
and

depiction
of vascular
anatomic
depiction
of the disease
process

its relationship

to splanchnic

method

tDepartment of Radiolo9y-WHT 220, Massachusetts

General Hospital, 32 Fruit St, P.0. Box 9657, Boston,
MA 02114. Address correspondence to G. W. Boland.
2Oepartment of Surgery, Massachusetts General Hospital,

with

AJR:168, May 1997

which

give

helical

become
the vascular

diagnostic

and

its tributaries.

rendering

which

structures,

represent

especially

criti-

in pancreatic

have not been evaluated with volumetechniques.

The purpose
of this study

and

few

applications
studies
have

in the venous
evaluated
the

intrahepatic

segmental

7J. The
has concen-

in various
reports

regions

describe

its

system.
Previous
portal vein and its

branches

we analyzed

and anatomic

using maximum
shaded-surface

intensity

display

correlated
the anatomy
grams with the anatomy
angiography

Subjects

cost

[6.

technique

system

anatomy

variants

nor and
inferior
mesenteric
images and on volume-rendered

tional

imaging

at a lower

angiography

new

system. For this pur)se.

vein

on

axial

CT venograms

projection

(SSD).

the nor-

of the supe-

(MIP)

Furthermore.

and

we

shown
on CT venoseen during conven-

or surgery.

increasingly
systeni. This

vascular

morbidity

CT

reconstruction

has

[8. 91. and

on

information

image

on the arterial

of the body

views.
spatial

contrast-enhanced

permits

less patient

vasculature

13-5 1-

three-dimensional

than conventional
application
of this
trated

to

(1 images

(CT angiography)
important
to evaluate

October 21, 1996.

lateral

quality

recently.

More

209

and

pictorial

do axial

with

American Roentgen Ray Society

in pre-

mal

than

0361-803X/97/1685-1

(SMV)
disease,

of

the vari-

dimensional
helical
CT rendering
techniques
I 10. 1 1]. However.
the superior
mesenteric
vein
cal anatomic

especially
resectability

reveal

angiography

include

a more

AJR1997;i68:1209-1213

provide

information.

the potential

anterior-posterior

Boston, MA 02114.

images

accurately

conventional

was to show the ability of helical CT venography to accurately

depict the mesenteric
venous

and

June 11, 1996; accepted afterrevision

of choice
and
the

replace

pancreatic
neopla.sms
[1 , 2]. To date. however.
many surgeons
still request
preoperative
conventional
angiography.
Their
stated
reasons
variants

Received

Axial

are the

CT

current

CT venograms
may

with

three-

and Methods

Fifty-seven
consecutive
patients (37 men, 20
women: 3()-X3 years old: mean age. 64 years old)
with known r suspected
disease
of the pancreas
were referred for CT and were included
in the
stud. Forty-one patients had neoplastic disease of
the pancreas
(36 adenocarcinomas,
two islet cell
tumors.
two ampullary
carcinomas,
one metastatic
disease ). Eight patients
had chronic pancreatitis.
Another eight patients were scanned for suspected

1209

Graf

disease

of

tOtlfld

the

flot

ihe

pancreas

have

tO

in detail

prt(cl

subsequently

using

in both

fx)stprocessing

were

disease.

tions.

and the Piril)itcreatic

pancreas

exaniined

and

pancreatic

region

a dual-phase

the arterial

and

were

helical

the portal

CT

algorithnis

filter

structures

floaters.

considered

dat:t

the mesentenc

set.

CT

Advantage
tenis.

scans

were

scatiner

(General

s1ilv,aukee.

\Vl

ampere-second
performed

from

i1argin

of the

the

scan

helical

was

This

positioning

of the

chosen

-(-

( Niedrad.

sequence
phase

were
cephalad

was chosen
trunk.

to

scan

nonionic

range

rate of 4 ml/ec
needle)

Pittsburgh.

PA

of

One

NY)

I I

the infection.

Helical

The

scanning

first

paraiaeters

teric arteri

the origin

for venous

cal S stems

5,eiR)tis anatomy
rendenng

were

transferred

\Vorkstation:

General

I for

variants

techniques.

splanclinic

vessels

Generation

of SSD

Hounsfield

units

axial

images

at

images

by regions
the

and

using

the

branches

of the SMV.

and distal

intiior

splenoportal

vein

all

posterior

details

of the

Anatomic

venograms

were

correlated

with

in

patients.

angiography
were

aid

15

surgery.

axial

additionally

correlated

by

four

at

In

19

and CT

by two sur-

reviewed

with findings

radiolo-

images

placed

junction.

at surgery.

The

time

to generate

MIP

images

was

shown

axial

on

patients

who

the

source
also

CT

venograms

anatomy

venograms.

In

the

In the

on

the

15

22 (47%).

mination

of the gastrocolic

(5-50

division
and
main

on

into

mm)
two

trunk

a main

was

observed

intestinal

trunk

into

right

images

images

who

before

a division
and

left

venous

(Fig.

6).

of

is a tributary

invasion.

trunk

The

in 25 (53%) and
of the SMV in

distance

from

trunk

branch

Of

drained

the

ter-

into the SMV

to the splenoportal

anteroposterior

MIP

SSD

and

3B

superior

tributaries

a threshold
ing

the

6B).

On

anteroposterior

to the gastrocolic

trunk
vein,

pancreaticoduodenal

vein,

superimposed
the

The

and

tributaries

right

colic

vein)

were

by the SMV.

On SSD

frequently

erased by

were

effect.
jejunal

first

duodenojejunal

branch

of the SMV
flexure

and

drainthe

first

jejunal
vessel

loop was observed

in 41 patients.
This
drained either into the main trunk of the

SMV

(22

patients)

or into

the left

intestinal

(19 patients).

of variable

branches

2). In 12 of 54 patients

the

(Figs.

MIP

branch

In 28 of 54 patients

which

of the

and

pathways

trunk,

the other

frequently

also underwent
surgical
exploration,
surgical
findings
confirmed
the anatomic
pattern seen
with CT venography.

length

trunk

tumor

by collateral

right gastroepiploic

SMV

in the

into

was revealed
in 47 of 54 patients;
in
seven patients
the gastrocolic
trunk

(anterior

con-

19 patients

the main
by

into the main trunk ofthe SMV

into the right intestinal
branch

images

correlated

shown

and two

directly

images.
anatomic
details were best visualized
on the axial source images
and on axial MIP

conventional

underwent

the
venous

images.

drained

not be seen because oftumor

47 patients the gastrocolic

ble

approximately
10 mm, and generation
of SSD
images
required
approximately
15-20
mm.
The anatomy
shown on volume-rendered
CT
venograiTis
corresponded
to the
anatomy

on the

Advanced

could
these

of 54 patients

4 and 5). In the remain-

occluded

the SMV,
the other

scan-

confluence
ranged from I I to 39 mm (mean, 24
mm). Although
the gastrocolic
trunk was visi-

Results

of

junction.
in distal
and in the proximal

(IMV).

of 54 patients

the

splenoportal

was absent

branches

The gastrocolic

findings

SMV

ing seven

was

the

3). In seven

ofthe

vein (Figs.

was

within

below

the splenic

drainage

on MIP and SSD proimages

who underwent

geons

with

to

techniques.

measurement

of interest

intestinal

patients).

cooperation

trunk

mesenteric

SMV

generation

txine

required

splenoportal

mesenteric

performed

cutting

SMV. 3 cm below

or poor

source

conventional

ventional

Mcd-

the nonnal

MIP

al of the aorta

patient)

(two

angiography,

with three-diitiensional

maneuvers.

remos

Electric

A radiologist

volume-rendering
the

niesen-

to a worksta-

to show

pstprocessing

ind

of

CT data (axial

of all axial
CT

with

data

tiOfl (Advantage

required

of the superior

svis used.

Reconstnicted

for evaluation

Helical

large

cm

(Fig.

the main

were

not observed
(6.5

or the right intestinal

CT

included l4() kVp. 2(X)-22() mAs, 3i,ilifl

collinlatI(in.
i pitch of
I .3. and I -naii overlapping reconstri.iction.
Patients held their breath for
approximately
27-30 sec. A narrow field ofview
(20
over

quality

system.

was

volume

confluence)

injector

helical

phase scanning

cia ) centered

(one

venograms

I l sec aller the initiation of the

the secoiid helical
scan for venous
was started
fit) sec after initiation of

inlaging

spinal
opaci-

and CT venograms

SMV and IMV were analyzed

started

and

habitus

patients

was

(e.g..
aorta.

into an ainecubital
by a power

I ()-

riiediuni

York.

body

gists.

hundred

contrast
New

to 20-gauge

process.

ning

and three-dimensional
reconstructions)
were unsatisfactory in three of 57 examinations
because of either

jections

caudal

(e.g..

branches

mesentery).

scans

venous

functo erase

of interest

to be of sufficient

breath-holding

2 cm

The

in the 57 patients.
of

was

injection.

Iosv-milli-

the uncinate

3(X): Nycomed.
at a llO\

(I

volume

Sys-

images

to [.3. The

celiac

equated

ailliliters

(Omnipaque
\,eiil

Iocaliting

2 cm below

cut in the z-directioii

Medical

axial

the diaphragm

origin

slice

injected

Initial

).

on a 1-liSpeed

Electric

precontrast

abt)\e

sixty

performed

axial

remove
applied

structures

parenchyma.

In 54 patients

Phases.
Fur the purpose
of this study.
mesenteric
veins were aiialvzed
from the portal venous
phase

and

were

the regions

or overlapping

lied pancreatic

venous

(cut

erosion)

outside

coluiiin)

et al.

its

(Figs.
of the
intestinal

!MV

The IMV could be seen in 51 of 54 patients

on axial and MIP images. On SSD images the
proximal

segment

was occasionally

erased

by

Fig. 1.-Normal

mesenteric veins in 56-year-old man examined because of abdominal pain with no evidence of
pancreatic disease.

A, Restricted anterior maximum intensity projection of

venous

phase

of contrast-enhanced

helical

CT scan

shows superior mesenteric vein (smv)formed by right(R)

and left(L) intestinal branches. Splenic vein Isv) and portal vein (pv) are clearly seen. Inferior mesenteric vein
(open arrow) joins smv just below confluence
with
splenic

vein. Left colic vein (curvedarrow)

drains into intrunk (large solid
arrow) drains into right intestinal branch. Superior mesenteric artery (smailsolid
arrow) is also seen.

ferior mesenteric vein. Gastrocolic

B, Anterior shaded-surface display of edited data from A

shows portal vein (pv), splenic vein Isv), superior mesenteric artery (smv), inferior mesenteric vein (open arrow),
right (RI and left (LI branches of smv, and gastrocolic
trunk (solid arrow).

1210

AJR:168,

May

1997

Fig. 2.-55-year
old man with pancreatic
carcinoma
invading superior mesenteric vein (confirmed at surgery).
A. Source axial image from contrast-enhanced helical
CT scan at level 2 cm below splenoportal confluence
shows right intestinal branch (straightsolid
arrow) of supenor mesenteric vein (SMV) adjacent to tumor. Larger
left intestinal branch of SMV (open arrow) and superior
mesentenc artery (SMA) (cuivedarrow)
are normal.

B, Restricted anterior maximum intensity projection of

venous phase of contrast-enhanced helical CT scan
shows narrowing of right branch of SMV (small solid
straight arrow) and main trunk of SMV (large solid
straight arrow) because of tumor invasion. Left branch
of SMV (open straight arrow) is normal. Short segment
of SMA (solid cuived arrow) is seen, as well as inferior
mesenteric vein (IMV) (open curved arrow).
C,Anterior

shaded-surface

displayofedited

data from B

shows narrowing of right branch of SMV (small solid

straight arrow) and main trunk of SMV (large solid
straight arrow) because of tumor invasion. Also seen
are left branch of SMV (open straight arrow) and IMV
(open curved arrow).
D, Portal phase from conventional cut-film SMA angiogram (left posterior oblique) shows invasion of lateral
wall of SMV (arrow) by tumor.

Fig. 3.-Normal mesenteric veins in 68-year-old woman

with colon cancer metastatic to liver but no evidence of
pancreatic

disease.

A, Restricted anterior maximum intensity projection

(MIP) of venous phase of contrast-enhanced helical CT
scan shows single large superior mesentenc vein (SMV)
(large straight arrow), gastrocolic trunk (small straight
arrow), and jejunal vein (caned arrow).
B, Restricted axial MIP from same study shows jejunal
vein (solid caned arrow) and gastrocolic trunk (small
solid straight arrow) joining SMV (large solid straight
arrow). Right colic vein (open straightarrow) drains into
gastrocolic

trunk.

Portion

of middle

colic

vein (open

caned arrow) is seen anterior to SMV.

Fig. 4.-Variant

normal superior mesenanatomy in 64-year-old woman with

pancreatic carcinoma.
A, Restricted anterior maximum intensity projection of
venous phase of contrast-enhanced
helical CT scan
shows right (RI and left (L) intestinal branches of SMV
merging directly with splenic vein. Inferior mesenteric
vein (IMV) (open arrow) drains into splenic vein. Portion
of superior mesenteric artery (SMA)(solid arrow) is seen
between branches of SMV.
B, Anterior shaded-surface display of edited data from A
shows right (RI and left (LI intestinal branches of SMV,
IMV (open arrow), and SMA (solid arrow).
teric

vein (SMV)

but otherwise

Graf

et al.

Fig. 5.-Variant but otherwise normal superior mesenteric vein (SMV) anatomy in53-year-old man with pancreatic carcinoma.
A, Restricted anterior maximum intensity projection of venous phase of contrast-enhanced
helical CT scan shows two large intestinal branches of SMV forming single confluence
with splenic vein.Inferiormesenteric vein (straight arrow) joins leftbranch of SMV. Artifacts from plastic biliary stent (curved arrow) are present
B, Anterior shaded-surface
display of edited data from A.
C, Portalphase from conventional cut-film angiogram (rightposterioroblique)of superior mesenteric artery shows inflow of unopacifled blood from splenic vein (arrow) at level of
confluence

with

SMV branches.

tem, including
This

study

the celiac

establishes

trunk

the

the SMA.

and

of CT

ability

venog-

raphy to show the mesenteric venous system.

Helical

CT

angiography

requires

the helical scan to maximal

to obtain

optimal

reveal

three-dimensional

the mesenteric

60

dose

sec

not

the helical
study

vessel

postprocessing
into the splenic

of SMV (black arrow).

nine
which

patients

(Fig.

is a tributary

1). The

(Fig.

of the IMV

region of the left colic flexure,

in 45 patients (Fig. 1).

5), and

confluence

left

colic
draining

in

vein,
the

was visualized

find it essential

surgeons

uate the disease

surrounding

1212

data

radiologists
interpreting

depend
on axial
CT scans, many

to

for

structions

in various

many

regions

thoracic,

surgeons

still

for obtaining

the vasculature
processes.

image

three-dimensional

l3J. In vascular,

ease

most
when

and its relationship

demand

about
Although

process

eval-

manner.

gery,

Discussion

to preoperatively

structures
in a three-dimensional
This
need has led to an increasing

angiography

source

mI/sec

patients.

Recently,

phy,
a noninvasive
promise
in its ability

of

and
require
spatial

the body
abdominal

pitch,
view

CT

quality
structed

technique,
has
shown
to reveal the arterial sys-

we

an injection

accomplished

limited

the

in all

duration

of the

and

to

field of
optimize

images
into
this technique,

of axial
images. With

three-

high-

axial images
and reconwere obtained
for most

patients. Poor image quality in one patient

likely due to low photon statistics
because
The technique

weight.

excessive

denced
The

angiogra-

we did
rates,

Furthermore,

was readily

venous-phase
CT venograms

sur-

to dis-

Although
injection

overlapping
reconstructions,
were chosen
specifically

be successful

information

Cl scan.

helical scan and the breath-hold

to 30 sec. Helical scanning
parameters
including
collimation,

[12,

conventional

and its relationship

helical

recon-

we chose a scan delay

of a relatively
highcontrast
injection
before

contrast

We

reconstruction
dimensional

maneuvers.
The IMV drained
vein in 28 patients (Figs. 2 and

4), into the SMV in 14 patients

into the angle of the splenoportal

lower

opacification.

rate of4

shows tumor invasion

using

that a high rate is necessary to optimize

believe

Fig. 6.-Occlusion
of superior mesenteric vein (SMV) by pancreatic carcinoma in 73-year-old woman.
A, Restricted anterior maximum intensity projection (MIP) of venous phase of contrast-enhanced
helical CT scan
shows occlusion of SMV by tumor (black arrow) and dilatation of gastrocolic trunk (white arrow).
B, Restricted axial MIP at level of gastrocolic trunk (straight white arrow) and middle colic vein (cuived white arrow)

To

system

initiation

high-flow

and

starting

our

alter

images.

venous

helical CT venography,
of

matching

vessel opacification

in uncooperative

by two

patients

axial

images

ing techniques,

MIP

the

anatomic

Additionally,
accurately

mesentenc

variants

in this
and
and

both

SSD,

vessels

and

their

of

is unlikely
patients,

to

as evi-

study.

volume-renderclearly

revealed

of the mesenteric

the reconstructed
depicted
the spatial

was

veins.

venograms
anatomy
of the
CT

relationship

AJR:168, May

to

1997

Helical CT of Mesenteric
surrounding

structures,

correlated
or

surgery.

the CT venograms

and

with findings

well
This

study

suggested

phy

as

these

technique
Further

whether

are

CT

needed

venograms

Postmortem

formed

mesenteric

in most

CF

the SMV
tnrnk of
tributaries,

patients,

trunk

was

but in seven

of 54

(13%) the main tnmk ofthe SMV was

not present and a large right and left mesenteric
merged

images
the

separately

with the splenic

vein

to form

in most

IMV

studies.

prior

Misregistration

CT studies

IMV

patients

of a wide

collimation,

and

IV contrast

lower

likely

angle,

and

drained

a longer
flow

In

in the

remaining

mation

with

injection

of

to poorer opacification
left mesenteric
branch,

that

tage

reconstructions

the splenic vein, may have been interpreted

in previous reports as being the IMV
[2, 13].
The IMV

itself,

which

has a relatively
been identified

normal

under

small
at all.

diameter,

Previous CT reports
have
the gastrocolic
trunk uniformly
right

anterior

the SMV
eral

wall

only

half

trunk

the

into

SMV.

Similarly,

study

and

the right

the main

trunk
the

of the

drained

into the left intestinal

the

of

course
space.

visualized
phy after

only
Its

major

unite

to form

AJR:168, May 1997

half

of the

other

half

branch.
method
in the

its course

tributaries

a common

to
left

can be

angiogramesenare

the sigmoid
former two

organs

scan.

A limitation

is that
and

only

structures

such as when

large

15.

volume

is obtained

outside

parts ofthe

this

16.

CT study or other imaging

techniques.
However,
the intention
of this specific
examination
is the trade-offof
noninvasive
CT angiography
conventional

performed
patients

in

angiography,

many

which

institutions

who will undergo

in

the
vein,
veins

ascending

Pancreatic

staging

WM,

18.

RK.

pancreas

those

BE.

Preoperative

staging

and assessment

LW.
21.

N EnglJMed

22.

BD, ed.

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Berman

AiR

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Baggenstoss

AH.

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Surg

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WH.

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W, Cameron

CM,

Mori

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The

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the

R. Anatomy

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Glazer

GM, Williams
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new observations.
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FR Malone

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Crabo LG. Conley

DM. Graney
DO. Freeny PC.
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head: normal

Reuter SR. Redman

Radiologs

Shapir

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AiR

HC, Cho KJ. Gastrointestinal

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877-880

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