Anatomy - Chimney Technique for Juxtarenal Aortic Aneurysm (Ch-EVAR)

• runs cranially on the underside of the diaphragm towards the diaphragmatic domes
• network-like division into several terminal branches

A. suprarenalis superior: Adrenal gland

Terminal branches: Underside of the diaphragm

• runs laterally to the adrenal glands

Terminal branches: Adrenal glands

• Origin approx. level L1 - 2
• A. renalis dextra: runs dorsal to V. cava inferior and pancreatic head to the right kidney
• A. renalis sinistra: runs dorsal to pancreatic body to the left kidney

A. suprarenalis inferior: Adrenal gland

• Origin below Aa. renales/L2 from the anterior side of the aorta
• run over psoas muscle, ureter and Aa. iliacae externae to the suspensory ligament of the ovary or to the deep inguinal ring of the inguinal canal and the testis

Aa. ovaricae: Ovaries, parts of the uterine tube,

Aa. testiculares: Testes, epididymis

• run laterally behind the psoas muscle over L1 – 4
• Anastomoses with the arteries of the anterior abdominal wall (Aa. epigastricae superior and inferior,  A. iliolumbalis, A. circumflexa ilium profunda)

Rr. spinales: Spinal canal

Terminal branches: Abdominal wall, back musculature

• along upper border of pancreas
• Entry into splenorenal ligament and spleen

Rr. pancreatici:

• dorsal to pancreas

A. pancreatica dorsalis:

• dorsal to pancreas
• anastomoses with A. pancreatica magna to form A. pancreatica inferior

A. pancreatica magna:

• dorsal pancreatic tail caudally
• anastomoses with A. pancreatica dorsalis to form A. pancreatica inferior

Pancreas

A. gastrica posterior:

• courses in phrenicosplenic ligament cranially to gastric fundus

Stomach (posterior surface fundus)

Aa. gastricae breves:

• course in gastrosplenic ligament to gastric fundus

Stomach (fundus and greater curvature)

A. gastroomentalis sinistra:

• courses in gastrocolic ligament to greater curvature
• anastomoses with A. gastroomentalis dextra

Stomach (fundus and greater curvature)

• extends to lesser gastric curvature
• anastomoses with A. gastrica dextra

direct branches

Stomach (lesser curvature)

Rr. oesophageales

Esophagus

• courses rightward to hepatic portal
• Division into A. hepatica propria and A. gastroduodenalis

A. hepatica propria

• Main branch of A. hepatica communis
• originates behind pylorus
• extends in hepatoduodenal ligament together with V. portae hepatis and common bile duct to hepatic portal
• gives off 3 branches:

1. A. gastrica dextra:

• courses in lesser omentum to lesser gastric curvature
• anastomoses with A. gastrica sinistra

Stomach (lesser curvature right)

2. A. hepatica dextra

Liver (right part)

Gallbladder (A. cystica)

partial caudate lobe

3. A. hepatica sinistra

Liver (left part)

partial caudate lobe

A. gastroduodenalis

• courses dorsal to lesser omentum to pancreas
• divides into 2 branches:

1. A. gastroomentalis dextra:

• extends to greater curvature
• anastomoses with A. gastroomentalis sinistra

Pancreas, duodenum, stomach

2. A. pancreaticoduodenalis superior anterior und - posterior:

• form with branches of A. pancreaticoduodenalis inferior a vascular plexus around pancreatic head

• courses in area of horizontal part of duodenum cranially to pancreatic head

R. anterior und posterior:

• anastomose with A. pancreaticoduodenalis anterior und posterior

Pancreatic head

• course in mesenteric root to jejunum and ileum
• form a vascular arcade among themselves

Aa. rectae

Jejunum, ileum

• courses in mesentery to ileocecal region

A. caecalis anterior und posterior

Cecum

A. appendicularis (Variant: Origin from A. caecalis posterior)

Appendix vermiformis

• courses in ascending mesocolon to ascending colon

divides into 2 branches, which anastomose with A. colica media or A. ileocolica

Ascending colon

• courses in transverse mesocolon to transverse colon

divides into 2 branches: right branch anastomoses with A. colica dextra (right flexure), left branch anastomoses with A. colica sinistra (left flexure)

Transverse colon

• courses in descending mesocolon to descending colon

divides into 2 branches, which anastomose with A. colica media or A. sigmoideae

Descending colon

• 2-4 arteries that form a vascular arcade in sigmoid mesocolon
• anastomose with A. colica sinistra and A. rectalis superior

several small branches to sigmoid

Sigmoid colon

• approaches rectum from dorsal
• anastomoses with A. rectalis media

several small branches to rectum

Upper rectum

• arises immediately caudal to the aortic bifurcation from the common iliac artery

• passes over the upper margin of the greater sciatic foramen caudally

• dorsal: internal iliac vein, piriformis muscle, lumbosacral plexus
• ventral: ureter
• lateral: external iliac vein, psoas major muscle
• caudal: obturator nerve

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

• Pelvic organs, gluteal muscles

• postnatal obliteration to the medial umbilical ligament
• remaining branches: superior vesical arteries, in men: artery of the ductus deferens

• Urinary bladder body
• in men: ductus deferens

• branching in the urinary bladder fundus into small branches

• Urinary bladder
• in men: prostate, seminal vesicles

• branching in the middle rectal section
• anastomoses with superior and inferior rectal arteries

• Rectal ampulla
• in women: vagina
• in men: prostate

• passes over the ureter
• tortuous course in the broad ligament of the uterus
• gives off numerous small branches

• Ovary
• Uterine tube
• proximal vagina
• Uterus

• runs obliquely upward to the iliopsoas muscle

• Psoas major muscle
• Iliacus muscle

• Superior branch: runs medially through the 1st or 2nd anterior sacral foramen and exits again through the posterior sacral foramen
• Inferior branch: passes over the piriformis muscle and medial to the sacral foramina on the sacrum caudally

• Sacral canal
• Piriformis muscle
• Muscles/skin dorsal to the sacrum

• passes 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, and minimus muscles
• Piriformis muscle
• Tensor fasciae latae muscle
• Skin over the sacrum

• passes on the piriformis muscle caudally through the infrapiriform foramen
• then runs together with the posterior femoral cutaneous nerve and sciatic nerve through the gluteus maximus muscle

• Gluteus maximus, medius, and minimus muscles
• Piriformis muscle
• Quadriceps femoris muscle
• Skin of the lower buttock and proximal thigh

• runs along the lateral pelvic wall forward and downward
• branches to the ilium and iliacus muscle
• after passing through the obturator canal, gives off further branches, including pubic branch (anastomoses with the inferior epigastric artery to form the corona mortis) and posterior branch (branch: acetabular artery -> artery of the femoral head)

• Ilium
• Iliacus muscle
• Thigh adductors
• Pubis
• External hip muscles
• Femoral head

• runs ventral to the sacral plexus to the infrapiriform foramen
• re-enters the lesser pelvis via the lesser sciatic foramen, through the pudendal canal, and branches in the ischiorectal fossa

• Distal third of the rectum
• Anal canal
• Urethra
• Scrotal skin/labia
• Bulb of penis/vestibule
• Dorsum of penis/clitoral prepuce

• arises caudal to the internal iliac artery from the common iliac artery

• runs along the psoas major muscle to the inguinal ligament, through the vascular lacuna, and becomes the femoral artery here

• Right external iliac artery runs under the ureter

• Deep circumflex iliac artery runs to the anterior superior iliac spine and anastomoses with the iliolumbar artery and superior gluteal artery
• Inferior epigastric artery runs medial to the deep inguinal ring cranially and between the transversus abdominis muscle and rectus abdominis muscle, further branches including cremasteric artery or round ligament artery

• Ilium, lower portion of the abdominal wall

• External iliac artery, which becomes the femoral artery after passing under the inguinal ligament

• runs between iliopsoas muscle and pectineus muscle (= iliopectineal fossa) covered by fascia lata
• is accompanied by the sartorius muscle up to the middle of the thigh
• passes together with femoral vein and saphenous nerve through the adductor canal
• transitions into the popliteal artery after passing through the adductor hiatus

• Superficial epigastric artery
• Superficial circumflex iliac artery
• Deep femoral artery (main artery for supplying the thigh!)
• External pudendal arteries
• Descending genicular artery

• Thigh 
• Skin of the abdominal wall
• External genitalia
• Knee joint and proximal/medial lower leg

• Ø

• Skin of the abdominal wall up to the umbilical region

• Ø

• Anterior superior iliac spine

• Medial circumflex femoral artery runs between iliopsoas muscle and pectineus muscle dorsally → trochanteric fossa; anastomosis with  lateral circumflex femoral artery
• Lateral circumflex femoral artery runs between rectus femoris muscle and vasti muscles laterally; anastomosis with medial circumflex femoral artery
• Perforating arteries run through the adductors to the back of the thigh

• Thigh

• Ø

• External genitalia
• Scrotum or labia majora

• Articular branches → genicular arterial network
• Saphenous branch → runs medially together with great saphenous vein and saphenous nerve to the calf

• Knee
• Proximal medial calf