Anatomy - Aortobifemoral bypass for peripheral arterial disease Fontaine stage IIb

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Abdominal aorta
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Origin
- From the thoracic aorta after its passage through the aortic hiatus in the diaphragm at the level of T12
Course
- Retroperitoneal
- Left to the median plane and anterior to the spine
- Bifurcation into the common iliac arteries (bifurcatio aortae) at the level of the umbilicus / L4
Branches from superior to inferior
- Inferior phrenic artery, left and right
- Celiac trunk
- Middle suprarenal artery, left and right
- Superior mesenteric artery
- Renal artery, left and right
- Ovarian / testicular artery, left and right
- Lumbar arteries
- Inferior mesenteric artery
- Median sacral artery
Distribution
- Paired branches: Abdominal wall, paired retroperitoneal organs, gonads
- Unpaired branches: Spleen, unpaired intestinal organs

Paired branches of the abdominal aorta

Main branches	Course	Branches/rami and distribution
Inferior phrenic artery	Travels craniad along the underside of the diaphragm towards the diaphragmatic dome Network-like division into several terminal branches	Superior suprarenal artery: Suprarenal gland Terminal branches: Underside of the diaphragm
Middle suprarenal artery	Travels laterad to the suprarenal glands	Terminal branches: Suprarenal glands
Renal artery	Arises at the level of L1–2 Right renal artery: Travels posterior to the vena cava and pancreatic head to the right kidney Left renal artery: Travels posterior to the body of the pancreas to the left kidney	Inferior suprarenal artery: Suprarenal gland
Ovarian artery Testicular artery	Arises from the anterior wall of the aorta inferior to the renal arteries / L2 Travels across the psoas muscle, ureter, and external iliac artery to the suspensory ligament of ovary / deep inguinal ring and testis	Ovarian arteries: Ovaries, parts of the uterine tubes Testicular arteries: Testes, epididymides
Lumbar arteries (4 bilat.)	Travels lateroposteriad to the psoas muscle across L1–4 Anastomose with the arteries of the anterior abdominal wall (superior and inferior epigastric arteries; liliolumbar artery; deep circumflex iliac artery)	Spinal rami: Spinal canal Terminal branches: Abdominal wall, back muscles

Unpaired branches of the abdominal aorta

All unpaired branches of the abdominal aorta terminate in anastomoses maintaining organ perfusion via collateral blood supply:

Celiac trunk -> gastroduodenal artery -> superior mesenteric artery
Superior mesenteric artery -> middle and left colic artery -> inferior mesenteric artery (anastomosis of Riolan)
Inferior mesenteric artery -> superior and middle rectal artery -> internal iliac artery

1. Celiac trunk

Arises at the level of T12
Divides into the splenic, left gastric, and common hepatic arteries (biggest caliber of the celiac trunk)

Main branches	Course	Branches/rami and their course	Distribution
Splenic artery	Along the superior aspect of the pancreas Enters the splenorenal ligament and spleen	Pancreatic rami: Posterior to the pancreas Dorsal pancreatic artery: Posterior to the pancreas Anastomoses with the great pancreatic artery to the inferior pancreatic artery Dorsal pancreatic artery: Posteroinferior along the pancreatic tail Anastomoses with the dorsal pancreatic artery to the inferior pancreatic artery	Pancreas
		Posterior gastric artery: Travels in the phrenicosplenic ligament superior to the gastric fundus	Stomach (posterior wall of fundus)
		Short gastric arteries: Travel in the gastrosplenic ligament to the gastric fundus	Stomach (fundus and greater curvature)
		Left gastro-omental artery: Travels in the gastrocolic ligament to the greater curvature Anastomoses with the right gastro-omental artery	Stomach (fundus and greater curvature)
Left gastric artery	Travels to the lesser gastric curvature Anastomoses with the right gastric artery	Direct branches	Stomach (lesser curvature)
		Esophageal branches	Esophagus
Common hepatic artery	Travels to the hepatic portal on the right Bifurcates into the hepatic artery proper and gastroduodenal artery	Proper hepatic artery Main branch of the common hepatic artery Arises posterior to the pylorus Travels in the hepatoduodenal ligament together with the hepatic portal vein and common bile duct to the hepatic portal Divides into 3 branches :
		1. Right gastric artery: Travels in the minor omentum to the lesser gastric curvature Anastomoses with the left gastric artery	Stomach (lesser curvature on right)
		2. Right hepatic artery	Liver( right part) Gallbladder (cystic artery) Parts of caudate lobe
		3. Left hepatic artery	Liver( left part) Parts of caudate lobe
		Gastroduodenal artery Travels posterior to the lesser omentum to the pancreas Divides into 2 branches:
		1. Right gastro-omental artery: Runs to the greater gastric curvature Anastomoses with the left gastro- omental artery	Pancreas, duodenum, stomach
		2. Anterior and posterior superior pancreaticoduodenal artery together with branches of the inferior pancreaticoduodenal artery form a vascular plexus around the pancreatic head

2. Superior mesenteric artery

Arises from the aorta at the level of L1–2
Travels anterocaudad
Branches: Inferior pancreaticoduodenal artery; jejunal and ileal arteries; ileocolic arteries; right colic artery; middle colic artery

Main branches	Course	Branches/Rami	Distribution
Inferior pancreaticoduodenal artery	Travels from the horizontal part of duodenum craniad to the pancreatic head	Anterior/posterior ramus Anastomoses with the anterior/posterior pancreaticoduodenal artery respectively	Pancreatic head
Jejunal and ileal arteries	Travel in the root of the mesentery to the jejunum and ileum Anastomose with each other to form an arcade	Rectal arteries	Jejunum, ileum
Ileocolic artery	Travels in the mesentery to the ileocecal region	Anterior/posterior cecal artery	Cecum
		Appendicular artery (variant: arises from the posterior cecal artery)	Appendix
Right colic artery	Travels in the ascending mesocolon to the ascending colon	Bifurcates into 2 branches which anastomose with the middle colic and ileocolic artery respectively	Ascending colon
Middle colic artery	Travels in the transverse mesocolon to the transverse colon	Bifurcates into 2 branches: Right branch anastomoses with the right colic artery (right colic flexure). Left branch anastomoses with the left colic artery (left colic flexure)	Transverse colon

3. Inferior mesenteric artery

Arises from the aorta at the level of L3
Supplies the colon downstream of the left colic flexure via left colic artery, sigmoid arteries, and superior rectal artery

Main branches	Course	Branches/Rami	Supplies
Left colic artery	Travels in the descending mesocolon to the descending colon	Bifurcates into 2 branches which anastomose with the middle colic and sigmoid arteries	Descending colon
Sigmoid arteries	2–4 arteries anastomosing to an arcade in the sigmoid mesocolon Anastomose with the left colic and superior rectal arteries	several small branches to the sigmoid	Sigmoid
Superior rectal artery	Approaches the rectum from posterior Anastomoses with the middle rectal artery	several small branches to the rectum	Upper rectum

Arterial blood supply of the lesser pelvis

At the aortic bifurcation (at about L4), the abdominal aorta divides into both common iliac arteries
each common iliac artery in turn bifurcates into the internal and external iliac arteries
With its visceral branches, the internal iliac artery mainly supplies the pelvic organs, while with its parietal branches contribute to the blood supply of the lower limbs.
The external iliac artery contributes to the blood supply of the pelvis and becomes the femoral artery after passing through the vascular lacuna

1. Internal iliac artery

Origin	arises from the common iliac artery directly inferior to the aortic bifurcation
Course	passes caudad over the superior margin of the sciatic foramen
Relationships	Posterior: Internal iliac vein, piriform muscle, lumbosacral plexus Anterior: Ureter Lateral: External iliac vein, greater psoas muscle Inferior: Obturator nerve
Branches/Rami	Visceral branches: Umbilical artery Inferior vesical artery Middle rectal artery In women: Uterine artery Parietal branches Iliolumbar artery Lateral sacral arteries Superior gluteal artery Inferior gluteal artery Obturator artery Internal pudendal artery
Distribution	Pelvic organs, gluteal muscles

1.1 Visceral branches of the internal iliac artery

Main branches	Course and branches	Distribution
Umbilical artery	Postnatal obliteration to median umbilical ligament Remaining branches: Superior vesical arteries, in men: Artery of ductus deferens Body of bladder In men: Ductus deferens
Inferior vesical artery	Divides into small branches at the fundus of the bladder Bladder In men: Prostate, seminal vesicles
Middle rectal artery	Divides at the level of the middle rectum Anastomoses with the inferior and superior rectal arteries Rectal ampulla In women: Vagina In men: Prostate
Uterine artery (women)	Crosses the ureter Tortuous course in the broad ligament of uterus Gives off numerous small branches Ovary Uterine tube Proximal vagina Uterus

1.2 parietal branches of the internal iliac artery

Main branches	Course and branches	Distribution
Iliolumbar artery	Travels obliquely craniad to the iliopsoas muscle Major psoas muscle Iliac muscle
Lateral sacral arteries	Superior ramus: runs mediad through the first or second anterior sacral foramen and leaves via the posterior sacral foramen Inferior ramus: runs across the piriform muscle and medial to the sacral foramina caudad on the sacrum Sacral canal Piriform muscle Muscles and skin posterior to the sacrum
Superior gluteal artery	Travels together with the superior gluteal nerve through the suprapiriform foramen and with branches to the gluteus maximus muscle (superficial branch) and gluteus medius muscle (deep branch) Gluteus maximus/medius/minimus muscles Piriform muscle Tensor muscle of fascia lata Skin over sacrum
Inferior gluteal artery	Travels caudad on the piriform muscle through the infrapiriform foramen Then passes together with the sciatic and cutaneous femoral nerves through the gluteus maximus muscle Gluteus maximus/medius/minimus muscles Piriform muscle Quadriceps femoris muscle Skin of the inferior buttocks and proximal thigh
Obturator artery	Travels anterocaudad along the lateral pelvic wall Branches to the iliac muscle and bone after passing through the obturator canal, further branches originate, including the . pubic ramus (anastomoses with the obturator ramus of the inferior epigastric artery to the corona mortis), acetabular ramus (-> ligament of head of femur (lig. capitis femoris), anterior ramus (anastomoses with the medial circumflex femoral artery), and posterior ramus Iliac bone Iliac muscle Adductor muscles of the thigh Pubic bone Lateral thigh muscles Head of femur
Internal pudendal artery	Travels anterior to the sacral plexus to the infrapiriform foramen Reenters the lesser pelvis through the lesser sciatic foramen, passes along the pudendal canal and terminates in numerous rami in the ischioanal (ischiorectal) fossa Distal third of rectum Anal canal Urethra Scrotal skin / labia Bulb of penis /vestibule of vagina Dorsum of penis / prepuce of clitoris

2. External iliac artery

Origin	Arises from the common iliac artery inferior to the internal iliac artery
Course	Travels along the greater psoas muscle to the inguinal ligament and becomes the femoral artery once it passes through the vascular lacuna
Relationships	The external iliac artery passes posterior to the ureter
Branches/Rami	Deep circumflex artery travels to the superior iliac spine and anastomoses with the iliolumbar and superior gluteal arteries Inferior epigastric artery runs craniad medial to the inguinal ring and between the transverse abdominal and rectus abdominis muscles, other branches include the cremasteric artery / artery of round ligament of uterus
Distribution	Iliac bone. Inferior abdominal wall

Anatomy - Aortobifemoral bypass for peripheral arterial disease Fontaine stage IIb–III

Abdominal aorta