VARIAÇÕES ANATÔMICAS DA ARTÉRIA CÍSTICA DURANTE COLECISTECTOMIAS: É IMPORTANTE O CIRURGIÃO CONHECER?

SCHIEWE, João Alfredo; MIRANDA, Livia Hoyer Garcia; ROMANO, Renata Marino; ROMANO, Marco Aurelio

doi:10.1590/0102-67202025000011e1880

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Review Article • ABCD, arq. bras. cir. dig. 38 • 2025 • https://doi.org/10.1590/0102-67202025000011e1880 linkcopiar

VARIAÇÕES ANATÔMICAS DA ARTÉRIA CÍSTICA DURANTE COLECISTECTOMIAS: É IMPORTANTE O CIRURGIÃO CONHECER?

Autoria SCIMAGO INSTITUTIONS RANKINGS

RESUMO

RACIONAL: O conhecimento anatômico da artéria cística e de suas variações é essencial para a realização de colecistectomias seguras. A artéria cística possui origem na artéria hepática direita, passando posteriormente ao ducto hepático comum, anteriormente ao ducto cístico, ramificando-se em dois ramos no colo da vesícula biliar. Todavia, variações de posição, tamanho e relação com estruturas adjacentes são comuns.

OBJETIVOS: Este artigo apresenta uma revisão de literatura em relação às variações da artéria cística e sua frequência durante colecistectomias.

MÉTODOS: Os artigos selecionados desta revisão foram escolhidos a partir das bases de dados PubMed e SciELO. Utilizou-se os descritores padronizados: Anatomic variation e cholecystectomy. Estes, foram escolhidos usando o “Medical Subject Headings” e combinados com o operador booleano AND e o descritor não padronizado Cystic artery.

RESULTADOS: Verificou-se em 54,5% dos estudos que o padrão anatômico da artéria cística foi o tipo de maior ocorrência. Citou-se uma origem diferente do padrão em 63,6% dos artigos. Encontrou-se a irrigação dupla da vesícula biliar em 59,1%. Em 36,4% a artéria cística estava anteriormente ao ducto hepático comum ou ao ducto cístico. Encontrou-se artérias císticas fora do triângulo de Calot em 36,4%. Artérias císticas curtas foram encontradas em 13,6%. Relatou-se a ausência ou não identificação da artéria em 9,1%.

CONCLUSÕES: Variações da artéria cística são comuns, sendo frequentemente relatadas. Um aspecto de uma colecistectomia segura é o conhecimento anatômico e de possíveis variações. Assim, cirurgiões devem estar familiarizados com este ponto a fim de reduzir lesões vasculares e biliares.

DESCRITORES:
Anatomia; Colecistectomia; Variação Anatômica; Artéria Hepática

Database	Search terms
SciELO	cystic artery AND anatomic variation AND cholecystectomy
PubMed	cystic artery AND anatomic variation AND cholecystectomy

Author	Study sample	Main results
Ding et al.⁹	600 patients (232 men and 368 women)	In 440 patients (73.3%), the cystic artery passed through Calot’s triangle, originated from the right hepatic artery, and was single. In 73 patients (12.2%), the artery passed through Calot’s triangle, originated from the right hepatic artery, and was double, with an anterior and a posterior branch. In 45 patients (7.5%), the artery did not pass through Calot’s triangle and originated from the gastroduodenal artery. In 18 patients (3.0%), the artery did not pass through Calot’s triangle and originated from variants of the right hepatic artery. In 15 patients (2.5%), the artery did not pass through Calot’s triangle and originated directly from the liver parenchyma. In nine patients (1.5%), there was more than one artery supplying the gallbladder: 5 (0.8%) had a normal cystic artery within Calot’s triangle with an additional artery posteriorly crossing the cystic duct and some small arteries extending directly from the liver parenchyma to the gallbladder; 3 (0.5%) had an additional cystic artery (besides the normal one passing through Calot’s triangle) superficial to the cystic duct; and 1 (0.2%) had multiple cystic arteries, one double artery passing through the triangle, one crossing the common bile duct anteriorly, and another situated on the right side of the gallbladder’s body and fundus edge.
Fateh et al.¹¹	1,850 patients (1658 women and 192 men)	In 1,752 patients (94.7%), the cystic artery was superomedial to the cystic duct. In 10 patients (0.5%), the cystic artery was posteromedial to the cystic duct. In 5 patients (0.3%), the cystic artery was anterior to the cystic duct. Three patients (0.2%) did not have a cystic artery.
Kim et al.¹⁶	Single (1 male patient)	Double cystic artery, one originating from the right hepatic artery and the other from the hepatic artery of liver segment IV.
Talpur et al.²⁸	300 patients (255 women and 45 men)	Among the 300 patients, 32 (10.7%) had abnormalities of the cystic artery, as follows: 8 (2.7%) cystic arteries anterior to the cystic duct; 7 (2.3%) with origins different from the right hepatic artery; 5 (1.7%) short cystic arteries; 4 (1.3%) cystic arteries posterior to the cystic duct; 3 (1%) cystic arteries arising above Calot’s triangle; 3 (1%) double cystic arteries; and 2 (0.7%) cystic arteries to the right of the cystic duct.
Kim and Yoon¹⁵	Single (1 male patient)	Cystic artery originating from the middle hepatic artery.
Suzuki et al.²⁷	244 patients (unspecified sex)	In 187 patients (76.7%), a single cystic artery passing through Calot’s triangle was found. In 27 patients (11.1%), no artery was present in Calot’s triangle. In 13 patients (5.3%), there was a double blood supply to the gallbladder, with a single cystic artery passing through Calot’s triangle and an accessory artery located inferolateral to the cystic duct. In 6 patients (2.5%), the cystic artery was single, passed through Calot’s triangle, and during its course, “hooked” around the cystic duct posteriorly, reappearing on the peritoneal surface near the gallbladder neck. In 6 patients (2.5%), a double cystic artery passing through Calot’s triangle was found. In 3 patients (1.2%), there was a double blood supply to the gallbladder, with a single cystic artery passing through Calot’s triangle and the accessory artery perforating the gallbladder bed. In 1 patient (0.4%), there was a double blood supply to the gallbladder, with a single cystic artery passing through Calot’s triangle and the accessory artery running along with the cystic duct. In 1 patient (0.4%), there was a double blood supply to the gallbladder, with a single cystic artery passing through Calot’s triangle and the accessory artery located just below Hartmann’s pouch.
Martín Pérez et al.¹⁸	Single (1 female patient)	Short and single cystic artery originating from the “Moynihan’s hump” (an abnormal variation of the right hepatic artery).
Nguyen et al.²¹	Single (1 female patient)	Cystic artery passing anterior to the common bile duct from right to left toward the gallbladder on the left side without situs viscerum inversus.
Pavlidis et al.²³	Single (1 female patient)	Presence of additional branches of the cystic artery, such as a posterior branch coursing toward the undersurface of the gallbladder in a patient with previously unknown total situs inversus.
Yamazaki et al.³⁰	Single (1 male patient)	Cystic artery was found on the left side of the gallbladder, originating from an aberrant artery that passed anteriorly to the fundus of the gallbladder and coursed toward hepatic segment V. The aberrant artery arose from the left hepatic artery.
Balija et al.⁴	200 patients (unspecified sex)	In 189 patients (94.5%), the cystic artery passed through the hepatobiliary triangle, as follows: 147 (73.5%) normal cystic arteries; 31 (15.5%) double cystic arteries, with one anterior and one posterior branch; and 11 (5.5%) cystic arteries originating from an aberrant right hepatic artery. In 11 patients (5.5%), the cystic artery did not pass through the hepatobiliary triangle, as follows: 9 (4.5%) cystic arteries originating from the gastroduodenal artery and 2 (1%) originating from the left hepatic artery.
Singh et al.²⁶	740 patients (280 men and 460 women)	In 340 patients (45.9%), there was a single cystic artery. In 240 patients (32.4%), there were two cystic arteries, one superficial and one deep. In 28 patients (3.8%), there was a single short cystic artery originating from the right hepatic artery within Calot’s triangle. In 17 patients (2.3%), there was a single short cystic artery not originating from the right hepatic artery, crossing the common hepatic duct anteriorly. In 23 patients (3.1%), neovascularization was noted, with the presence of small vessels in the areolar and adipose tissues. In 27 patients (3.6%), there was a double or accessory cystic artery. In 15 patients (2%), there were vessels originating directly from the liver. In 47 patients (6.4%), there was a vessel posterolateral to the margin of the gallbladder. In 22 patients (3%), the cystic arteries were observed more anteriorly than posteriorly in relation to the lymph node. In 18 patients (2.4%), the cystic artery initially crossed the cystic duct laterally and terminated medially to the cystic duct.
Nagendram et al.¹⁹	Single (1 female patient)	Cystic artery crossing anteriorly to the cystic duct from right to left in a patient with a left-sided gallbladder without total situs inversus.
Katagiri et al.¹⁴	Single (1 male patient)	The anterior cystic artery adhered to the cystic duct outside Calot’s triangle, originating from an aberrant right hepatic artery arising directly from the celiac trunk.
Pereira-Graterol et al.²⁴	Single (1 female patient)	The cystic artery located along the posterior wall of the body of the gallbladder, not identified during the initial dissection of Calot’s triangle in a patient with total situs inversus.
Torres et al.²⁹	84 patients (16 men and 64 women)	In 60.7% of patients, the cystic artery originated from the right hepatic artery. In 7.2% of patients, the cystic artery originated from the common hepatic artery, its bifurcation, or the left hepatic artery. In 6% of patients, the cystic artery originated from the gastroduodenal artery. In 26.2% of patients, the cystic artery reached the gallbladder at the fundus or the distal part of the body as a recurrent artery.
Zubair et al.³¹	220 patients (unspecified sex)	In 192 patients (87.3%), the cystic artery was observed within Calot’s triangle, of which 166 (75.5%) were single, 26 (11.8%) were double, 4 (1.8%) had the cystic artery syndrome, and 2 (0.9%) originated from an aberrant right hepatic artery. In 12 patients (5.5%), more than one blood vessel was observed, with one inside Calot’s triangle and the other outside, of which 4 (1.8%) had the vessel outside the triangle passing caudally and parallel to the cystic duct, and 8 (3.6%) had the vessel outside the triangle passing between the gallbladder and the hepatic parenchyma along the right lateral border of the gallbladder, giving off multiple small branches to this organ. Additionally, in 16 patients (7.3%), cystic arteries were observed only outside Calot’s triangle, of which 14 (6.4%) had a single artery and 2 (0.9%) had multiple vessels.
Eken et al.¹⁰	Single (1 female patient)	Double cystic artery originating from the gastroduodenal artery.
Singh et al.²⁵	600 patients (unspecified sex)	In 426 patients (71%), single cystic arteries were found within Calot’s triangle. In 88 patients (14.7%), double cystic arteries were found within Calot’s triangle. In 42 patients (7%), cystic arteries were found outside Calot’s triangle, originating from the gastroduodenal artery. In 28 patients (4.7%), cystic arteries were found outside Calot’s triangle, originating from a variant of the right hepatic artery running parallel to the cystic duct. In 10 patients (1.7%), cystic arteries were found outside Calot’s triangle, originating from the hepatic parenchyma. In 6 patients (1%), there was blood supply to the gallbladder both outside and inside Calot’s triangle.
Larobina et al.¹⁷	186 patients (unspecified sex)	In 164 patients (88.2%), the cystic artery was considered normal. In 16 patients (8.6%), the cystic artery was anterior to the cystic duct. In 4 patients (2.2%), the cystic artery was located directly on top of the cystic duct. In 2 patients (1.1%), the cystic artery was not identified. In 6 patients (3.2%), there was a double cystic artery, among which, in 3 (1.6%), there were anterior and posterior branches, and in 3 (1.6%), both arteries were posterior to the cystic duct.
Akay and Leblebici²	360 patients (76 men and 284 women)	In 11 patients (3.1%), double cystic arteries were found, comprising 2 men and 9 women.
Noguera et al.²²	2,000 patients (unspecified sex)	In 1,831 patients (91.6%), a single cystic artery was found within Calot’s triangle, with an apparent origin from the right hepatic artery. In 96 patients (4.8%), a double cystic artery was observed, with one inside Calot’s triangle and the other outside it (accessory cystic artery). In 44 patients (2.2%), the cystic artery was located outside the triangle, originating from the common hepatic artery. In 22 patients (1.1%), the cystic artery was within the triangle, crossing the anterior surface of the common bile duct to run transversely above the cystic duct, with a possible origin from the common hepatic artery. In 6 patients (0.3%), a double cystic artery was observed, with one at the upper border of Calot’s triangle attached to the hepatic margin and the other external to the cystic duct, coursing downward and inward, crossing the common bile duct below the liver, with a possible origin from the gastroduodenal artery.
Zubair et al.³¹	220 patients (unspecified sex)	In 192 patients (87.3%), the cystic artery was observed within Calot’s triangle, of which 166 (75.5%) were single, 26 (11.8%) were double, 4 (1.8%) had the cystic artery syndrome, and 2 (0.9%) originated from an aberrant right hepatic artery. In 12 patients (5.5%), more than one blood vessel was observed, with one inside Calot’s triangle and the other outside, of which 4 (1.8%) had the vessel outside the triangle passing caudally and parallel to the cystic duct, and 8 (3.6%) had the vessel outside the triangle passing between the gallbladder and the hepatic parenchyma along the right lateral border of the gallbladder, giving off multiple small branches to this organ. Additionally, in 16 patients (7.3%), cystic arteries were observed only outside Calot’s triangle, of which 14 (6.4%) had a single artery and 2 (0.9%) had multiple vessels.
Eken et al.¹⁰	Single (1 female patient)	Double cystic artery originating from the gastroduodenal artery.
Singh et al.²⁵	600 patients (unspecified sex)	In 426 patients (71%), single cystic arteries were found within Calot’s triangle. In 88 patients (14.7%), double cystic arteries were found within Calot’s triangle. In 42 patients (7%), cystic arteries were found outside Calot’s triangle, originating from the gastroduodenal artery. In 28 patients (4.7%), cystic arteries were found outside Calot’s triangle, originating from a variant of the right hepatic artery running parallel to the cystic duct. In 10 patients (1.7%), cystic arteries were found outside Calot’s triangle, originating from the hepatic parenchyma. In 6 patients (1%), there was blood supply to the gallbladder both outside and inside Calot’s triangle.
Larobina et al.¹⁷	186 patients (unspecified sex)	In 164 patients (88.2%), the cystic artery was considered normal. In 16 patients (8.6%), the cystic artery was anterior to the cystic duct. In 4 patients (2.2%), the cystic artery was located directly on top of the cystic duct. In 2 patients (1.1%), the cystic artery was not identified. In 6 patients (3.2%), there was a double cystic artery, among which, in 3 (1.6%), there were anterior and posterior branches, and in 3 (1.6%), both arteries were posterior to the cystic duct.
Akay and Leblebici²	360 patients (76 men and 284 women)	In 11 patients (3.1%), double cystic arteries were found, comprising 2 men and 9 women.
Noguera et al.²²	2,000 patients (unspecified sex)	In 1,831 patients (91.6%), a single cystic artery was found within Calot’s triangle, with an apparent origin from the right hepatic artery. In 96 patients (4.8%), a double cystic artery was observed, with one inside Calot’s triangle and the other outside it (accessory cystic artery). In 44 patients (2.2%), the cystic artery was located outside the triangle, originating from the common hepatic artery. In 22 patients (1.1%), the cystic artery was within the triangle, crossing the anterior surface of the common bile duct to run transversely above the cystic duct, with a possible origin from the common hepatic artery. In 6 patients (0.3%), a double cystic artery was observed, with one at the upper border of Calot’s triangle attached to the hepatic margin and the other external to the cystic duct, coursing downward and inward, crossing the common bile duct below the liver, with a possible origin from the gastroduodenal artery.

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