Surg Radiol Anat (2016) 38:529–539
DOI 10.1007/s00276-015-1600-y
REVIEW
The clinical anatomy of cystic artery variations: a review
of over 9800 cases
R. G. Andall1 • P. Matusz2 • M. du Plessis1 • R. Ward3 • R. S. Tubbs1,4
M. Loukas1
Received: 27 April 2015 / Accepted: 30 November 2015 / Published online: 23 December 2015
Ó Springer-Verlag France 2015
Abstract
Purpose While laparoscopic cholecystectomy can be a
routine procedure when biliary anatomy is normally loca-
ted, cystic artery variations can easily disorientate the
inexperienced surgeon to the anatomy of the hepatobiliary
triangle. This study presents the clinically important
anatomical variations of the cystic artery.
Methods PubMed, Medline, Cochrane Database of Sys-
tematic Reviews, and Google Scholar databases were
searched to conduct a review of the existing English lit-
erature on the clinically important cystic artery variations.
An aberrant vessel was defined as a vessel that originated
from an atypical source and/or one that was present in a
specimen in addition to the normal vessel.
Results The cystic artery originated typically from the
right hepatic artery (79.02 %) and was found in the hepa-
tobiliary triangle in only 5427 of 6661 (81.5 %) cases.
Clinically important cystic artery variations are (1) the
cystic artery located anterior to the common hepatic duct or
common bile duct found in 485 of 2704 (17.9 %) and 228
of 4202 (5.4 %) of cases, respectively, (2) the cystic artery
located inferior to the cystic duct found in 38 of 770
(4.9 %) of cases, (3) short cystic arteries found in 98 of
& M. Loukas
mloukas@sgu.edu
1
Department of Anatomical Sciences, St. George’s University,
School of Medicine, St. George’s, Grenada, West Indies
2
Department of Anatomy, Victor Babes University of
Medicine and Pharmacy, Timisoara, Romania
3
Department of Radiology, Tufts Medical School, Boston,
MA, USA
4
Pediatric Neurosurgery, Children’s Hospital, Birmingham,
AL, USA
•
1037 (9.5 %) cases and (4) multiple cystic arteries found in
(8.9 %) of cases.
Conclusion These variations are common in the general
population and can lead to inadvertent ligation of biliary
ducts or aberrant vessels. Therefore, it is important for the
hepatobiliary surgeon to be aware of these vascular
anomalies to avoid operative complications.
Keywords Hepatic artery abnormalities
Double cystic
arteries
Inferior cystic artery
Calot’s triangle

Hepatobiliary triangle
Gall bladder blood supply
Introduction
Calot in 1891 delineated an imaginary triangle in the
anatomical space bordered inconsistently by the cystic
artery. Hugh et al. later suggested the use of hepatobiliary,
hepatocystic, or cystohepatic triangle, as is the currently
accepted term, based on its boundaries: superiorly the
inferior border of the liver, medially the common hepatic
duct, and inferiorly the cystic duct [23]. The cystohepatic
triangle classically contains the right hepatic artery and its
branch; the cystic artery, the cystic node (Lund’s node or
Mascagni’s lymph node), lymphatics, and connective tissue
[36].
Laparoscopic cholecystectomy is the gold standard
treatment for cholelithiasis with operative times now down
to less than an hour [17]. However, despite laparoscopic
cholecystectomy being a routine procedure when biliary
anatomy is normal, vascular variations will distort the
anatomy of the cystohepatic triangle [4, 16, 17]. The cystic
artery is the second most common arterial variation of the
hepatic pedicle after the right hepatic artery [8]. Further-
more, the incidence of conversion of laparoscopic surgery
123
530
to open attributable to injury to the cystic artery alone is 1.5
per 1000 procedures [15–17].
The abdominal portion of the aorta starts at the T12/L1
intervertebral disc level. The celiac trunk is the first
unpaired anterior branch and, travels a short ventral
course before dividing into the common hepatic and
splenic arteries. The common hepatic artery continues as
the proper hepatic artery after giving rise to the gastro-
duodenal artery. The proper hepatic artery is then parent
to the left and right hepatic arteries. The right hepatic
artery may also arise from the superior mesenteric artery,
in which case it is termed the replaced right hepatic artery
[28]. The cystic artery typically arises from the right
hepatic artery and courses within the cystohepatic triangle
to the right of the common hepatic duct [2, 31]. It then
travels superior to the cystic duct at the gall bladder neck
after which it bifurcates into a deep and superficial branch
to supply the gallbladder and cystic duct [4, 10, 23]
(Fig. 1). The cystic artery may also supply liver par-
enchyma at the gallbladder fossa [4, 38].
These anatomical variations may be explained by
changes during embryological development, in particular
persistence of connecting channels or segmental arteries
[53]. Development commences in the third week of
embryogenesis as cells that originate from splanchnic
mesoderm extend underneath the lateral plate mesoderm to
become two dorsal aortas [28, 44]. Signal proteins
expressed by the notochord, such as Sonic hedgehog and
Fig. 1 Schematic drawing of
the cystic artery in its typical
location within the hepatobiliary
triangle
123
Surg Radiol Anat (2016) 38:529–539
vascular endothelial growth factor, drive these dorsal aortas
to later fuse and become the descending aorta [44]. Vitel-
line arteries are segmental vessels that develop from the
dorsal aortas and are linked through a ventral anastomotic
channel. The 10th, 13th, and 21st vitelline arteries persist
after birth to become the major branches of the aorta that
supply the gut [28]. Failure of the remaining vitelline
vessels to regress may lead to extensive variation [53].
Sufficient knowledge of the anatomy of the cystohepatic
triangle has been shown as an important factor in mini-
mizing perioperative complications [15, 27]. As a result a
comprehensive review was deemed necessary, we assessed
the literature for reported variations and their clinical
implications. Particular emphasis was placed on prevalence
of each variation and the complications during hepatobil-
iary surgery and cholecystectomy.
Materials and methods
PubMed, Medline, Cochrane Database of Systematic
Reviews and Google Scholar databases were searched to
conduct a review of the existing literature on cystic artery
variations. ‘Cystic artery’ was used as a keyword combined
with ‘anomaly’, ‘ectopic’, ‘aberrant’, ‘variations’, ‘Calot’s
triangle’, ‘hepatobiliary triangle’. Articles were included if
they were in English language and used human subjects.
There were no restrictions concerning age, sex, date of
 Table 1 Cystic artery origin and number
References N Number of RHA abRHA PHA PHA LHA abLHA CHA abCHA GDA Celiac SPDA SMA Other Unclassified Absent Multiple
cystic arteries Bif. artery (%)

Anson [1] 600 676 415 90 78 23 40 – 3 – 17 2 1 6 1 – – 0.0

Ata [2] 200 218 160 – – – – – – – – – – – – 58 – 9.0
Bakheit [3] 160 160 125 – – – 3 – 27 – 5 – – – – – – 0.0
Balija et al. [4] 200 231 147 11 – – 2 – – – 9 – – – – 62 – 15.5
Bergamaschi 70 82 – – – – – – – – – – – – – 82 – 15.7
and Ignjatovic
[6]
Surg Radiol Anat (2016) 38:529–539

Browne [8] 279 362 153 20 – – 5 2 9 3 6 1 1 – – – 1 28.3

Carbajo et al. [9] 500 500 491 – – – – – – – – – – – – 9 – 0.0
Chen et al. [11] 2428 2638 – – – – – – – – – – – – – 2638 – 6.8
Chen et al. [10] 72 72 55 – 5 3 3 – 2 – 1 1 1 1 – – – 0.0
Daseler et al. [13] 580 660 419 90 – – 36 – 16 – 15 2 1 1 – 80 – 13.6
de Silva and 50 50 48 – – – – – 2 – – – – – – – – 0.0
Fernando [14]
Ding et al. [15] 600 682 440 18 – – – – – – 45 – – – 15 – – 13.7
Flint [18] 200 231 212 – – – 6 – – – 12 – 1 – – – – 15.5
Flisiński et al. [19] 34 35 29 – – 3 2 – – – 1 – – – – – – 2.9
Futara et al. [20] 110 121 89 – – – 7 – – – 8 – – – 17 – – 10.0
Halvorsen and 100 103 87 – 1 – 1 – 10 – 3 – – – – – 1 3.0
Myking [21]
Hasan et al. [22] 250 250 245 – – – – – – – – – – – – 5 – 0.0
Hugh et al. [23] 100 122 72 – – – – – – – – – – – 44 6 – 22.0
Imran et al. [24] 600 608 582 – – – – – – – – – – 9 – 17 9 3.0
Jayatilaka [25] 100 100 67 – – 23 5 – – – 2 1 – – 2 – – 0.0
Johnston and 35 41 34 6 – – – – – – – – – – 1 – – 17.1
Anson [26]
Larobina 186 188 186 – – – – – – – – – – – – – 2 0.0
and Nottle [27]
Lipshutz [29] 83 90 10 – – 7 9 – – – 3 – – 3 4 54 – 8.4
Michels [32] 200 246 152 22 – – – – 2 – 2 – – – 18 50 – 23.0
Mizumoto and 96 117 91 9 – 2 1 – – – – – – – 14 – – 30.2
Suzuki [33]
Mlakar et al. [34] 81 92 42 6 – – – – – – – – – – 22 22 – 13.6
Moosman [35] 482 554 289 87 – – – – – – – – – – – 178 – 14.9
Nowak [37] 115 143 – – – – – – – – – – – – – 143 – 21.7
Osemlak and 135 136 113 – – 12 – – – – – – – – 8 3 – 0.7
Siwek [40]
531

123
532 Surg Radiol Anat (2016) 38:529–539

Aberrant (ab): replaced or accessory vessels, common hepatic artery (CHA), gastroduodenal artery (GDA), left hepatic artery (LHA), proper hepatic artery (PHA), proper hepatic artery
publication or study methodology. Case reports or case
Multiple

8.90**
series were excluded, as determination of prevalence from

10.0

19.2
10.7

12.0
18.2
(%)

7.8
0.0

1.0
these reports is not reliable. An aberrant vessel was defined

–
as ‘‘replaced’’ if the vessel originated from a source dif-
Absent

0.34
ferent from the typical source and as an ‘‘accessory’’ if a

20

33
–

–
–

–
–
–
–
vessel originated from an atypical source and was present
Unclassified

in a specimen in addition to the typical vessel. A short

cystic artery was defined as one whose length was less than

36.40*
3948
270 1 cm. Our study presents the anatomical variations of the

258
13
–

–
–
–

–
cystic artery in the hepatobiliary triangle from a review of
Other

9836 arteriography, operative and cadaver dissections.

2.17
150
–

–
–
4
–
–
–
–
SMA

0.29
20
Results
–

–
–
–
–
–
–
–
SPDA

0.07

Variations in origin and number of vessels

–

–
–
–
–
–
–
–
5

Bifurcation (PHA Bif), right hepatic artery (RHA), superior mesentery artery (SMA), superior pancreaticoduodenal artery (SPDA)

Cystic artery origin of 9836 cases identified by; arteri-

Celiac
artery

0.10

ography, operative and cadaver dissections are summa-

–

–
–
–
–
–
–
–
7

rized in Table 1. Of 10846 cystic arteries reviewed in

GDA

1.94
134

this study, there were 36.4 % cases in which cystic

1

–
–
4
–
–
–
–

artery origin was not documented. Of the cases in which

abCHA

the origin and number of cystic arteries were docu-

0.04

mented, 79.02 % came from the right hepatic artery

–

–
–
–
–
–
–
–
3

(Figs. 2a, 3). In 0.34 % of cases the cystic artery was

CHA

1.06

absent, and in 8.9 % of cases there were more than one

73
1

–
–
1
–
–
–
–

cystic artery present (Fig. 2g).

abLHA

0.03

Variations in course
–

–
–
–
–
–
–
–
2
LHA

2.07
143
17

Cystic arteries with short trunks were found in 98 of

2

2
1

–
–
1
–

* Percentage of total arteries in which cystic artery origin was not documented

1037 (9.5 %) cases (Figs. 2f, 4). Only 5427 of 6661

PHA

1.32
13

91

(81.5 %) of cystic arteries were found in the hepatobil-

–

–
4
–
–
1
–

iary triangle (Table 2). The cystic artery typically ran to

PHA

1.23
Bif.

** Weighted percentage of total cases with multiple cystic arteries

the right of the common hepatic duct 407 of 1371

85
–

–
1
–
–
–
–
–

(29.7 %) and anterior to the cystic duct 856 of 2532

abRHA

(33.8 %) (Fig. 5). The cystic artery ran anterior to the

5.58
385
24

common hepatic duct and common bile duct in 485 of

–

–
–

–
–
–
2

2704 (17.9 %) and 228 of 4202 (5.4 %) cases, respec-

79.02
RHA

5451
225

293

tively, and inferior to the cystic duct in 38 of 770

17

95
43

25
–

(4.9 %) of cases (Table 3) (Fig. 2d–e).

cystic arteries
Number of

Prevalence (%)

Discussion
110

299
270
306

260
21

45

27

9836 10846

The cystic artery typically arises from the right hepatic

20

45

25
102

234
244
300

220

artery (79.02 %) where it makes an L-shaped bend within

N

the hepatobiliary triangle on its way to supply the right

Table 1 continued

Sebben et al. [46]

Suzuki et al. [50]

Talpur et al. [51]

Zubair et al. [55]

Sugita et al. [49]

Wang et al. [54]

lobe of the liver (Table 1). In laparoscopic examination,

Saidi et al. [43]
Osler and Dow

the cystic artery is found superior and slightly deep to the

References

cystic duct, while in open cholecystectomy the artery

Average
[41]

appears laterally displaced from the duct [4, 15, 39]. The
Total

superficial branch of the cystic artery runs below the

123
Surg Radiol Anat (2016) 38:529–539
Fig. 2 Illustration of the most commonly found and, clinically
important variations of the cystic artery. a Indicates the cystic artery
originating from right hepatic artery or aberrant right hepatic artery.
b shows the cystic artery originating from left hepatic artery and
serosal tunic on the left side of the gallbladder, while the
deep branch courses between the gallbladder and the
gallbladder fossa before anastomosing with the superficial
branch [4, 39].
Although the cystic artery typically arises from the right
hepatic artery, it may also originate aberrantly from other
branches of the celiac axis. It arose from an aberrant (re-
placed or accessory) right hepatic artery in 385 of 6898
(5.58 %) cases, the left hepatic artery in 143 of 6898
(2.07 %) and from the gastroduodenal artery in 134 of
6898 (1.94 %) cases (Fig. 2a–c). Even rarer still, the cystic
artery arose from the proper hepatic artery, celiac artery,
proper hepatic bifurcation, superior pancreaticoduodenal
artery, superior mesentery artery, or other origin (Table 1).
A replaced right hepatic artery often travels close to and
donates numerous branches to the cystic duct and gall-
bladder. On laparoscopic examination, the replaced right
533
c from the gastroduodenal artery. d illustrates the cystic artery
traveling anterior to common hepatic duct while in e it travels anterior
to common bile duct and inferior to cystic duct. A short cystic artery
is seen in f and multiple cystic arteries in g
hepatic artery appears to be a large cystic artery. Acci-
dental ligation of this vessel may cause liver hypoxia
however, variations such as this may be more important
during liver transplantation procedures. The cystic artery
that originates from the left hepatic or gastroduodenal
artery cannot be visualized within the hepatobiliary triangle
during laparoscopic cholecystectomy and is in danger of
accidental ligation. When the cystic artery arises from the
common hepatic artery, it may follow the right border of
the hepatoduodenal ligament towards the fundus of the
gallbladder before turning towards the body and neck of
the gallbladder. This recurrent cystic artery is also prone to
injury during laparoscopic cholecystectomy [4].
Variations are not limited to the origin of the vessel but
can also be found in the pathway the artery to the gall-
bladder. The cystic artery traveled, at least in part, through
the hepatobiliary triangle in 5427 of 6661 (81.5 %) of cases
123
534
Fig. 3 Cadaveric dissection indicating a cystic artery (demarcated
with an asterisk *) passing anterior to the cystic duct as it travels to
the gall bladder (GB). It branches of a right hepatic artery (RHA)
which also passes anterior to the common bile duct (CBD). The
proper hepatic artery (PHA) lies anterior to the portal vein (PV) as
expected
Fig. 4 This cadaveric dissection shows an example of a short cystic
artery (demarcated with an asterisk *) arising from the right hepatic
artery (RHA) as it travels through the hepatobiliary triangle to supply
the gall bladder (GB). The left hepatic artery (LHA) (arrow) can be
seen arising from the proper hepatic artery (PHA). The RHA runs
posterior to the common hepatic duct which joins with the cystic duct
inferiorly to form the common bile duct (CBD)
(Table 2). A short cystic artery was defined as one whose
length was less than 1 cm [24]. Cystic arteries with short
trunks were found in 98 of 1037 (9.5 %) cases (Table 2). A
short cystic artery arising from the right hepatic artery is
another important variation that may lead to inadvertent
injury to the right hepatic artery [8] (Fig. 2a, f).
The cystic artery was found to travel anterior to the
cystic duct in 856 of 2532 (33.8 %) of cases. When the
cystic artery travels inferior to the cystic duct (38 of 770
123
Surg Radiol Anat (2016) 38:529–539
(4.9 %) of cases), it becomes the first structure met during
laparoscopic cholecystectomy [45] (Table 3) (Fig. 2e). The
cystic artery in this position, therefore, often necessitates
division to allow proper visualization of the cystic duct
[23]. The cystic artery was typically located to the right of
the common hepatic duct in 407 of 1371 (29.7 %) cases
(Table 3). There is a danger of bile spillage if the cystic
artery courses anterior to the common hepatic or common
bile ducts due to frequent handling with the forceps during
cholecystectomy [5, 6, 8]. In our study the cystic artery was
located anterior to the common hepatic duct or common
bile duct found in 485 of 2704 (17.9 %) and 228 of 4202
(5.4 %) of cases, respectively (Table 3) (Fig. 2d–e).
Because of its high occurrence, the anterior cystic artery
should be carefully identified during cholecystectomy [8].
Interestingly, Suzuki et al. [50] describe ‘cystic artery
syndrome’ where the cystic artery arises from the right
hepatic artery, but unusually takes a course that wraps
around the cystic duct. Suzuki et al. [50] proposed that this
course may lead to diminished flow through the cystic duct,
which manifests clinically in the patient as cholelithiasis.
This syndrome was found to occur in less than 2 % of the
cases studied by Zubair et al. [55].
In 8.9 % of cases there were multiple cystic arteries
present (Table 2) with the highest number of cystic arteries
reported in a single patient was four [11]. The double cystic
artery represents occasions in which the superficial and
deep branches of the cystic artery have separate origin [32]
(Fig. 2g). The deep branch of the cystic artery typically
will originate from the right hepatic artery, while the
superficial branch will be derived from another source [7].
Accidental ligation of double cystic arteries can occur in
the instance where one of the vessels, unexpectedly to the
surgeon, arises far from the bile ducts [8]. The congenitally
absent cystic artery was documented in 33 of 9836
(0.34 %) cases (Table 1).
Conventional aortography can be used to demonstrate
anomalous branches of the celiac trunk, but it is invasive
and harbors a risk of catheter site complications, throm-
bosis of the small arteries, nephrotoxicity and idiosyncratic
reactions to the radiographic contrast. Some patients may
also require sedation or general anesthesia [42]. Alterna-
tively, computed tomography angiography (CTA) is faster,
less invasive and can be performed with less radiation
exposure. CTA provides an accurate and reliable depiction
of cystic artery vessels in 92 % of cases (95 % CI,
87–98 %) [42, 49].
To aid in the identification of the cystic artery during
laparoscopic cholecystectomy, traction is applied to the
fundus of the gallbladder over the liver margin, with lateral
traction applied to the infundibulum of the gallbladder
[30]. This allows for clear visualization of the cystic artery
 Table 2 Cystic artery location with respect to the cystohepatic triangle
References (N) Number of Arteries found in Artery position relative to cystic Artery position relative to Artery position relative to Short trunks
cystic arteries cystohepatic triangle duct common bile duct common hepatic duct (%)

Bakheit [3] 160 160 40 of 160 (25 %) Anterior: 85 of 160 (53 %) Anterior: 3 of 160 (2 %) Anterior: 11 of 160 (7 %) –
Posterior: 21 of 160 (13 %)
Balija et al. [4] 200 231 218 of 231 (94.4 %) – – – –
Bergamaschi 70 82 75 of 82 (91.5 %) – – – –
and Ignjatovic [6]
Surg Radiol Anat (2016) 38:529–539

Browne [8] 279 360 153 of 279 (54.8 %) – Anterior: 21 of 360 (5.8 %) Anterior: 25 of 360 (6.9 %) 46 of 153
Inferior: 7 of 360 (1.9 %) Posterior: 2 of 360 (0.6 %) (30 %)
Inferior: 37 of 360 (10.3 %)
Chen et al. [11] 2428 2638 2064 of 2428 (85 %) – Anterior: 169 of 2428 – –
(7.0 %)
Posterior: 121 of 2428
(5.0 %)
Inferior: 73 of 2428 (3.0 %)
Chen et al. [10] 72 72 62 of 72 (86.1 %) Inferior: 10 of 72 (13.9 %) – Anterior: 17 of 72 (23.6 %) –
Posterior: 45 of 72 (62.5 %)
Daseler et al. [13] 580 660 405 of 580 (69.8 %) Anterior: 6 of 580 (1.05 %) Anterior: 17 of 580 (3 %) Anterior: 131 of 580 (22.6 %) –
Posterior: 1 of 580 (0.17 %) Posterior: 3 of 580 (0.52 %) To the right: 5 of 580 (1 %)
Posterior: 12 of 580 (2 %)
Ding et al. [15] 600 682 513 of 600 (85.5 %) Anterior: 440 of 600 (73.3 %) – – –
Flint [18] 200 231 – – – Anterior: 32 of 200 (16 %) –
To the right: 168 of 200 (84 %)
Flisiński et al. [19] 34 35 33 of 34 (97.1 %) To the left: 1 of 35 (2.86 %) – Posterior: 23 of 34 (67.6 %) 18 of 34
Superior: 10 of 35 (29.4 %) (52.9 %)
Futara et al. [20] 110 121 89 of 110 (80.9 %) – – Anterior: 31 of 110 (28.2 %) –
Posterior 12 of 110 (10.9 %)
Halvorsen and 100 103 81 of 100 (81 %) Anterior: 3 of 100 (3 %) Anterior: 1 of 100 (1 %) Anterior 28 of 100 (28 %) –
Myking [21] Posterior: 5 of 100 (5 %)
To the right: 54 of 100 (54 %)
Hasan et al. [22] 250 250 247 of 250 (98.8 %) – Anterior: 5 of 250 (2 %) – 4 of 250
Posterior: 3 of 250 (1.2 %) (1.6 %)
Hugh et al. [23] 100 122 72 of 100 (72 %) Superior: 72 of 100 (72 %) – – –
Inferior: 6 of 100 (6 %)
535

123
 536

123
Table 2 continued
References (N) Number of Arteries found in Artery position relative to cystic Artery position relative to Artery position relative to Short trunks
cystic arteries cystohepatic triangle duct common bile duct common hepatic duct (%)

Imran et al. [24] 600 591 – – – – 30 of 600

(5 %)
Jayatilaka [25] 100 100 – Anterior: 1 of 100 (1 %) – Anterior: 91 of 100 (91 %) –
Posterior: 8 of 100 (8 %)
Johnston and Anson 35 41 14 of 35 (40 %) Anterior: 9 of 35 (25.7 %) – Anterior: 11 of 35 (31.4 %) –
[26] Posterior 1 of 35 (2.9 %)
Larobina and Nottle 186 192 – Anterior: 17 of 192 (8.9 %) – – –
[27] Posterior: 171 of 192 (89.1 %)
Superior: 4 of 192 (2.1 %)
Lipshutz [29] 83 90 – Anterior: 12 of 83 (14.5 %) Posterior: 2 of 83 (2.4 %) Anterior: 10 of 83 (12 %) –
Inferior: 5 of 83 (6 %)
Lateral: 2 of 83 (2.4 %)
Superior: 9 of 83 (10.8 %)
Michels [32] 200 246 160 of 200 (80 %) Inferior: 2 of 246 (0.8 %) Anterior: 8 of 200 (16 %) Anterior: 50 of 200 (25 %) –
To the right: 150 of 200 (75 %)
Moosman [35] 482 554 463 of 482 (96.1 %) – – – –
Osler and Dow [41] 20 22 15 of 22 (68.2 %) Anterior: 1 of 22 (4.5 %) Anterior: 1 of 22 (4.5 %) Anterior: 2 of 22 (9.1 %) –
To the right: 15 of 22 (68.2 %)
Posterior: 1 of 22 (4.5 %)
To the left: 1 of 22 (4.5 %)
Saidi et al. [43] 102 110 – – Anterior: 3 of 102 (2.9 %) Anterior: 46 of 102 (45.1 %) –
Posterior: 4 of 102 (3.9 %) Posterior: 47 of 102 (46.1 %)
Scott-Conner and 51 51 – Posterior: 1 of 51 (2 %) – – –
Hall [45]
Sugita et al. [49] 245 279 215 of 279 (77.1 %) – – – –
Suzuki et al. [50] 244 269 216 of 269 (80.3 %) Anterior: 218 of 269 (81 %) – To the right: 15 of 269 (5.6 %) –
Posterior: 8 of 269 (3 %)
Superior: 13 of 269 (4.8 %)
Lateral: 7 of 269 (2.6 %)
Inferior: 15 of 269 (5.6 %)
Surg Radiol Anat (2016) 38:529–539
Surg Radiol Anat (2016) 38:529–539 537

Short trunks

98 of 1037
(9.5 %)
(%)

–
Artery position relative to
common hepatic duct

***
–

–
Artery position relative to
common bile duct

Fig. 5 A cadaveric dissection showing an example of a cystic artery

(demarcated with an asterisk) branching off the common hepatic
artery (CHA) and passing anterior to the common bile duct (CBD).
The left (LHA) and right hepatic (RHA) arteries branch off the proper
hepatic artery as expected and lies anterior to the portal vein (PV).
***

The cystic artery travels along the entire inferior surface of the gall
–

bladder (GB) before terminating

Artery position relative to cystic

To the right: 2 of 303 (0.4 %)

Anterior: 56 of 88 (63.6 %)
Posterior: 4 of 303 (0.8 %)

as it runs within the hepatobiliary triangle [12, 32]. How-

Anterior: 8 of 303 (2.6 %)

Posterior: 4 of 88 (4.5 %)

ever variations such as short cystic, origin from aberrant

hepatic artery or origin from another vessel entirely will
result in the cystic artery not passing through the cysto-
hepatic triangle. In these cases visualization by the
approach above will not always be possible. The cystic
node often lies superficial to the cystic artery within the
duct

***

hepatobiliary triangle and can be used as a landmark in

–

locating the artery [47]. Moosman’s area is a circular

5427 of 6661 (81.5 %)

subdivision of the hepatobiliary triangle within which most

cystohepatic triangle

204 of 260 (78.5 %)

aberrations of the hepatic pedicle can be found [48].

88 of 88 (100 %)
Arteries found in

Conclusion
–

We consolidated the information in the literature on the

anatomical variations of the cystic artery, their prevalence
cystic arteries

and respective clinical importance. According to our

Number of

analyses of the literature the most important variations

303

260
8943
88

clinically with their prevalence are; (1) the cystic artery

located anterior to the common hepatic duct or common
88
300

220
8139

bile duct (17.9 %), (2) the cystic artery located inferior to
(N)

the cystic duct (4.9 %), (3) short cystic arteries (9.5 %) and
(4) multiple cystic arteries (8.9 %). Although the preva-
Table 2 continued

Talpur et al. [51]

Zubair et al. [55]

Torres et al. [52]

lence of these variations seem low reports indicate that

*** See Table 3

these variations may increase the handling of ducts and

References

possible ligation of unintended vessels. It appears that

knowledge of these four variations is imperative for the
Total

hepatobiliarry surgeon. We hope our review will increase

123
538
Table 3 Cystic artery position
Position Cystic duct
relative to bile duct system
Anterior 856 of 2532 (33.8 %)
Posterior 210 of 1643 (12.8 %)
Inferior 38 of 770 (4.9 %)
Superior 98 of 644 (15.2 %)
To the left 1 of 35 (2.9 %)
To the right 11 of 655 (1.7 %)
awareness of potential variations with subsequent decrease
in intra- and perioperative complications.
Acknowledgments The authors wish to thank Jessica Holland
(CMI), MS, Medical Illustrator for the creation of her illustrations
used in this publication. The authors also wish to extend their grati-
tude to the individuals who donated their bodies without whom this
review would not have been possible.
Compliance with ethical standards
Conflict of interest All authors declare that there are no financial
associations and no conflict of interest.
Ethical considerations This study used already publicly available
data and is therefore exempt from review by the IRB. The specimens
used for images are protected under IRB approval (06014) as issued
by St. George’s University.
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