THIEME

10 Original Article

Cystic Artery: An Anatomic Morphological Study and

Its Clinical Significance
Roopashree Ramakrishna1  Suman Tiwari2

1 East Point College of Medical Sciences and Research Centre, Address for correspondence Roopashree Ramakrishna, 145 DSR
Bangalore, Karnataka, India Elite Mahadevapura Main Road, Mahadevapura, Bangalore 560048,
2 MVJ Medical College and Research Hospital, Hoskote, Bangalore, Karnataka, India (e-mail: roopashree.ramakrshna@gmail.com).
Karnataka, India

Natl J Clin Anat 2019;8:10–13

Abstract Background  Cystic artery is one of the arteries which is of utmost surgical importance,
as it ­originates from the vast range of blood vessels, associated to the coeliac trunk and
superior ­mesenteric artery and its relation to the biliary ducts is variable. Cystic artery is
not only difficult to visualize, but difficult to approach during the surgery. This study was
undertaken to study the anatomy of arterial variations of cystic artery in the specimens
of liver and gallbladder by exploring the extrahepatic duct system, and in addition the
relations of cystic artery in the Calot’s triangle were also studied and observed.
Materials and Methods  The study was conducted on 50 human liver specimens with
intact gallbladder and extrahepatic duct system, collected from the Department of
Anatomy over a period of 5 years. The specimens obtained were fixed in 10% formalin
and were finely dissected. The specimens were observed for parameters like the origin
of the cystic artery, its length and diameter, mode and level of termination, relation to
the Calot’s triangle, and the extrahepatic duct system.
Results  Origin of the cystic artery was normal in 92% of cases and variations were
Keywords seen in approximately 8% cases. The most common origin of the cystic artery was
►►cystic artery from the right hepatic artery, which was in 92% of the cases. In the present study,
►►Calot’s triangle in 97% cases the cystic artery terminated by dividing into the superficial and deep
►►cholecystectomy branches. In the rest, the artery continued as a superficial branch, the deep branch
►►double cystic artery being replaced by the accessory cystic artery. In 64% cases, the cystic artery was seen
►►accessory cystic artery within the Calot’s triangle, and in 36% of cases, it was outside the Calot’s triangle. In
►►extrahepatic duct 67% cases, the cystic artery was medial to the cystic duct, in approximately 63% cases
system the cystic artery was lateral to the common hepatic duct, and in 30% of the cases the
►►variation cystic artery passed anterior to the cystic duct. Incidence of accessory cystic arteries
►►gallbladder in the present study was approximately 4%.

Introduction of the gallbladder, then it divides into superficial and

The main arterial supply to the gallbladder and the cystic
duct (CD) is the cystic artery (CA). CA commonly arises
from the right hepatic artery (RHA) in the angle between
the common hepatic duct (CHD) and CD. Normally, the
CA presents as single in number but sometimes also as
double. The CA usually passes posterior to the CHD and
anterior to the CD to reach the superior aspect of neck
deep branches and supplies the gallbladder. The most
common variation of CA is, when it originates from the
common hepatic artery (CHA) and when its origin is in
the lower down, sometimes from the left hepatic or gas-
troduodenal artery (GDA), and rarely from the superior
pancreaticoduodenal, celiac, right gastric, or superior
mesenteric arteries. In these cases, it crosses anterior (or
less commonly posterior) to the common bile duct (CBD)

DOI https://doi.org/ ©2019 Society of Clinical

10.1055/s-0039-1688516 Anatomists
ISSN 2277-4025.
eISSN 2321-2780.

or CHD to reach the gallbladder. An accessory CA may
arise from the CHA or one of its branches. The CA when
presents as double, it often bifurcates close to its origin,
giving rise to two vessels before approaching the
gallbladder.1
Materials and Methods
The study was conducted on 50 human liver specimens
with intact gallbladder and extrahepatic duct in the regular
­dissection, collected from the Department of Anatomy over
a period of 5 years. The specimens obtained were fixed in
10% formalin and were finely dissected. The specimens
were observed for parameters like the origin of the CA, its
length and diameter, mode and level of termination, and
its relation to the Calot’s triangle, and the variations were
noted, photographed, and studied.
Observations and Results
The CA was found in all 50 cases, out of which in 46 cases
(92%) the artery originated from the RHA, 2% from the
left hepatic artery (LHA) shown in ►Fig. 1 2% from the
GDA, and in approximately 2 cases (4%) aberrant CA was
found. In the present study, the mean length of the CA was
17.60 mm and the range of length of the CA was between
3.5 and 42 mm where the shortest CA was 3.5 mm and the
Fig. 1  Cystic artery arising from left hepatic artery.
Fig. 2  Double cystic artery.
Cystic Artery  Ramakrishna, Tiwari 11
longest was 42 mm (4.2 cm). The mean length of the CA
in males was 17.40 mm and in females it was 17.88 mm.
All the values were statistically significant at a p-value of
≤ 0.001. Mean external diameter of the CA was 2.20 mm
and ranged between 1.1 and 3.2 mm. Mean external diam-
eter in males was 2.20 mm and in females it was 2.19 mm.
►Fig. 2 shows a double cystic artery, incidence of
accessory cystic arteries in the present study was 4% only.
In 32 cases, the CA was seen within the Calot’s triangle and
in 18 specimens the CA was outside the Calot’s triangle. In
67% cases, the CA was medial to the CD. In 63% cases, the CA
was lateral to the CHD and the CA was anterior to the CD in
30% of the cases. ►Fig. 3 shows the variation of cystic artery
arising outside the Calot’s triangle. The artery was found to
terminate in 96% of the cases by dividing into superficial and
deep branches. In one specimen Cystic artery was found give
three branches which is shown in ►Fig. 4. The artery was
found to continue as a superficial branch without dividing in
the remaining 4% of the cases.
Discussion
The explanation for the variations in the CAs is based
on the developmental pattern of the biliary system. The
extrahepatic biliary system during the development arises
as a diverticula from the developing gut, which supplied by
Fig. 3  Cystic artery arising outside the calot’s triangle.
Fig. 4  Cystic artery giving rise to 3 branches.
National Journal of Clinical Anatomy  Vol. 8  No. 1/2019
12 Cystic Artery  Ramakrishna, Tiwari

Table 1 Comparisons of various studies for cystic artery: its artery of origin
SI. Studies No. of cases Artery of origin
no. studied RHA PHA LHA GDA CHA CT SMA ARHA
1 Flisiński et al 14
34 82.3% 8.8% 5.8% 2.9% 0 0 0 0
2 Flint15 200 98% 0 1.5% 0.5% 0 0 0 0
3 Khalil et al 16
60 90% 2% 3% 2% 2% 0 0 0
4 Michels 17
200 77.5% 0 5% 4% 1.5% 0 0 12%
5 de Silva et al18 50 96% 0 4% 0 0 0 0 0
6 Pushpalatha and Shamsundar 19
50 54% 22% 0 8% 12% 0 2% 2%
7 Daseler et al20 580 71.7% 0 6.2% 2.6% 2.7% 0.35% 0.1% 16%
8 Tejaswi et al 7
100 92% 2% 1% 1% 0 0 0 4%
9 Kankhare Sonali et al 21
40 70% 0 5% 10% 7.5% 0 5% 0
10 Kumari et al13 36 94.4% 2% 2% 0 1.6% 0 0 0
11 Dandekar and Dandekar 8
82 79.3% 3.7% 1.2% 0 2.5% 0 0 3.7%
12 Present study 50 92% 0 2% 2% 0 0 0 4%
Abbreviations: ARHA, aberrant right hepatic artery; CHA, common hepatic artery; CT, Coeliac Trunk; GDA, gastroduodenal artery;
LHA, left hepatic artery; PHA, persistent hypoglossal artery; RHA, right hepatic artery; SMA, superior mesenteric artery.

celiac axis as its blood supply and the developing superior be avulsed from the origin or the gallbladder if there is
mesenteric axis. The developing CA originates from any an excessive traction applied to the gallbladder by the
other artery in the vicinity of the biliary apparatus.2 The CA surgeons.10 In the present study, the mean length of the
is always found to be variant in its number, origin, course, CA was found to be 17.60 mm and the range of length of
and its relations to biliary ducts. These abnormalities have the CA was between 3.5 and 42 mm where the shortest
been mentioned from time to time by various studies CA was 3.5 mm and the longest was 42 mm (4.2cm). The
in the literature.3–5 The CA normally originates from the mean length in males was 17.40 mm and in females it was
RHA which is a branch of the celiac trunk and the CA has 17.88 mm.
a tendency to originate from one of the many branches ►Table  2 shows the site of the CA in relations to the
of the celiac trunk. In these cases, it arises from the LHA, Calot’s triangle and also shows the comparisons with other
CHA, hepatic artery pseudoaneurysm (HAP), aberrant studies. In a normal Calot’s triangle, the artery is seen inside
right hepatic artery, GDA, superior mesenteric artery the triangle and medial to the CD.7,8 Ding et al describe a
(SMA), celiac trunk, or aorta. The variations in the origin of type of classification in their study of anatomic variations of
the CA along with comparisons of the various studies have the CA encountered during laparoscopic cholecystectomy
been shown in ►Table 1. In a study by McVay, the CA has where the CA is classified based on its relation to the
been c­ lassified based on its origin (parent vessel) which
is classified into four categories: Category I: (1) from the
Table 2 Site of origin of the CA with relation to the Calot’s
RHA, (2) from the HAP at the point of division, (3) from
triangle
the LHA, and (4) from the HAP proximal to the point of
division; Category II: from the GDA or superior pancreati- Site of origin of CA
coduodenal artery; ­C ategory III: from the same arteries Authors Inside Calot’s Outside Calot’s
mentioned in Category I but differing from them in the triangle triangle
deviation of the parent vessel; and Category IV: from the Michels17 81% 19%
right gastric artery, CHA, celiac trunk, or SMA which is Bakheit22 25% 75%
similar to the present study.6
Flint 15
84% 16%
The mean length of the CA found in the study by Tejaswi
et al was 17.6 mm with a range of 3.7 to 42 mm.7 In a study Tejaswi et al 7
65% 35%
by Taimur et al where the CA is described according to Gawali23 90% 10%
its length and divided into three groups, short (less than Saidi et al 24
2% 98%
1 cm = 7%), normal (1–3 cm = 82%), and long (more than Daseler et al20 69.8% 30.2%
3 cm = 8%), similar classification is reported in a study by
Taimur et al 9
88% 9%
Dandekar and Dandekar where they also grouped of the
Ding et al 11
87% 13%
CA based on the length and the occurrences were 17.1,
73.2, and 9.7%, respectively.8,9 From these studies its can be Dandekar and 62.2% 37.8%
concurred that the length of the CA cannot be neglected. Dandekar8
Nagral in his study states that the length of the CA has Present study 64% 36%
the most surgical importance, as a short CA may easily Abbreviation: CA, cystic artery.

National Journal of Clinical Anatomy  Vol. 8  No. 1/2019


Calot’s triangle. In their study, the CA is divided into
three groups: (1) inside the Calot's triangle type 85.5%;
(2) outside the Calot’s t­ riangle 13%; and (3) compound type,
1.5%, which is similar to the classification presented in the
present study.11 In the present study, in 64% cases the CA
was seen within the Calot’s t­ riangle and in 36% specimens
the CA was outside the Calot’s triangle. In 67% cases, the
CA was medial to the CD. In 63% cases, the CA was lateral
to the CHD and passed anterior to the CD in 30%. Incidence
of double CAs in the present study was only 4%. Ahmed
and Sylvia have concurred and reported similar method of
classifying CA.12
Due to the vast variability in the occurrence, origin, and
course of the CA seen in this study, an operating surgeon
needs to be conscious in studying the course of the CA and
CD during both laparoscopic and conventional approach
of cholecystectomy. Hence, a few per-operable surgical
significances are that the CA originating outside the Calot’s
­t riangle usually passes anterior to the bile duct and may be
posterior to the CD; therefore, it could be the first structure
encountered during exploration of the Calot’s triangle
which is prone to injury. As the CA courses anterior to the
CHD or CBD, it increases the chances of injuries to both the
CHD and CBD. An accessory CA is liable to bleed or tear if
not explored thoroughly.13
Conclusion
The importance of a thorough knowledge of arterial supply
of the extrahepatic biliary ductal system especially arterial
supply of the gallbladder could always present with variations.
It requires an extensive in situ exploration before approaching
the artery, which helps in reducing uncontrolled b ­leeding
which may increase the risk of i­ntraoperative lesion to vital
vascular and biliary structures. A h ­ emorrhagic episode or a bile
leakage which may commonly occur due to variations of the
Calot’s triangle ­structures can be avoided if the artery has been
explored for its variations in o
­ rigin, course, and its number. The
extensive bleed or bile leak may be one of the most common
causes for conversion of l­aparoscopic cholecystectomy to
open cholecystectomy during surgery. To avoid hemorrhagic
accidents involving vessels or the CBD during laparoscopic
cholecystectomy, with or without choledochotomy, it
commands a thorough exploration of the Calot’s triangle and
the hepatoduodenal ligament. We hope to shed some light
on the variations of the CA which is of utmost anatomical and
surgical importance to reduce the incidence of bile duct and
artery injuries during l­aparoscopic cholecystectomy.
Conflict of Interest
None.
Funding
None.
Ethical Approval
Not required.
Cystic Artery  Ramakrishna, Tiwari 13
References
1 Strandring S, ed. Gray’s Anatomy. The Anatomical Basis of
Clinical Practice. 40th ed. Edinburg: Elsevier Chuchill Living-
stone; 2008:1218–1219
2 Nowak M. Variation of the cystic artery in man. Folia Morphol
(Warsz) 1977;36(2):89–98
3 Michels NA. The hepatic, cystic and retroduodenal arteries and
their relations to the biliary ducts with samples of the entire
celiacal blood supply. Ann Surg 1951;133(4):503–524
4 Rocko JM, Di Gioia JM. Calot’s triangle revisited. Surg Gynecol
Obstet 1981;153(3):410–414
5 Hugh TB, Kelly MD, Li B. Laparoscopic anatomy of the cystic
artery. Am J Surg 1992;163(6):593–595
6 McVay CB. Surgical Anatomy. 6th ed. Philadelphia, PA: W.B.
Saunders Company; 1984
7 Tejaswi HL, Dakshayani KR, Ajay N. Prevalence of anatomical
variations of cystic artery in South Indian cadavers. J Res Med
Sci 2013;1:424–428
8 Dandekar U, Dandekar K. Cystic artery: morphological study
and surgical significance. Anat Res Int 2016;2016:7201858
9 Taimur M, Hasan A, Ullah S, Masood R, Imran M. Vascular vari-
ations in the Calot’s triangle seen on laparoscopic cholecystec-
tomy. Pak Armed Forces Med J 2011;61(4):16–20
10 Nagral S. Anatomy relevant to cholecystectomy. J Minim Access
Surg 2005;1(2):53–58
11 Ding Y-M, Wang B, Wang W-X, Wang P, Yan JS. New classi-
fication of the anatomic variations of cystic artery during
laparoscopic cholecystectomy. World J Gastroenterol
2007;13(42):5629–5634
12 Ahmed Md K, Sylvia. Origin of cystic artery & its position in
relation to biliary duct & Calot’s triangle. J Evolution Med Den-
tal Sci 2015;4(1):1–5
13 Kumari R, Kumari S, Prasad A, Britto NJ, Nag S. Variations in
origin and course of cystic artery and its relation with Calot’s
triangle. IOSR J Dental Med Sci 2016;15(7):24–27
14 Flisiński P, Szpinda M, Flisiński M. The cystic artery in human
foetuses. Folia Morphol (Warsz) 2004;63(1):47–50
15 Flint ER. Abnormalities of the right hepatic, cystic and
gastroduodenal arteries and of the bile ducts. Br J Surg
1923;10:509–519
16 Khalil M, Sultana ZR, Rahman HR, et al. Origin and position of
cystic artery in Bangladeshi corpse. J Bangladesh SocPhysiol
2008;3:66–70
17 Michels NA. Variational anatomy of the hepatic, cystic, and
retroduodenal arteries; a statistical analysis of their origin,
distribution, and relations to the biliary ducts in two hundred
bodies. AMA Arch Surg 1953;66(1):20–34
18 de Silva M, Fernando D. Anatomy of the Calot’s triangle and
its relevance to laparoscopic cholecystectomy. Ceylon Med J
2001;46(1):33–34
19 Pushpalatha K, Shamsundar NM. Variation in the origin of cys-
tic artery. J Anat Soc India 2010;59(1):35–37
20 Daseler EH, Anson BJ, Hambley WC, Reimann AF. The cystic
artery and constituents of the hepatic pedicle; a study of 500
specimens. Surg Gynecol Obstet 1947;85(1):47–63
21 Kankhare Sonali B, Patil Anjali D, Kate Sarika P. A study of an
anomalous origin of cystic artery and its relation with calot’s
triangle – cadaveric study. Int J Cur Res Rev 2016;8(15):39–42
22 Bakheit MA. Prevalence of variations of the cystic artery in the
Sudanese. East Mediterr Health J 2009;15(5):1308–1312
23 Gawali RA. A study on variations of origin and course of cystic
artery and its relation to the Calot’s triangle. Intl J Med Phar-
maceut Sci 2014;5(3):15–19
24 Saidi H, Karanja TM, Ogengo JA. Variant anatomy of the cystic
artery in adult Kenyans. Clin Anat 2007;20(8):943–945
National Journal of Clinical Anatomy  Vol. 8  No. 1/2019