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

Anatomy Perioperative management Technique Complications Evidence Total Video

Abdominal Aorta
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Origin
- from the thoracic aorta after its passage through the aortic hiatus of the diaphragm at the level of T12
Course
- retroperitoneal
- left of the median plane ventral to the vertebral column
- at the level of the umbilicus/L4 division (aortic bifurcation) into the common iliac arteries
Branches from cranial to caudal
- Inferior phrenic arteries
- Celiac trunk
- Middle suprarenal artery, right and left
- Superior mesenteric artery
- Right or left renal artery
- Ovarian artery - or testicular artery right and left
- Lumbar arteries
- Inferior mesenteric artery
- Median sacral artery
Supply area
- paired branches: abdominal wall, paired retroperitoneal organs, gonads
- unpaired branches: spleen, unpaired digestive organs

Paired branches of the abdominal aorta

Main branches	Course	Branches and their supply areas
A. phrenica inferior	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
A.suprarenalis media	runs laterally to the adrenal glands	Terminal branches: Adrenal glands
A. renalis	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
A. ovarica, A. testicularis	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
Aa. lumbales (both sides 4)	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

Unpaired Branches of the Abdominal Aorta

All unpaired branches of the abdominal aorta form anastomoses that maintain organ perfusion via collateral supply:
- Celiac Trunk -> A. gastroduodenalis -> A. mesenterica superior
- A. mesenterica superior -> A. colica media und sinistra -> A. mesenterica inferior (“Riolan Anastomosis”)
- A. mesenterica inferior -> A. rectalis superior und media -> A. iliaca interna

1. Celiac Trunk

Origin at level of T12
divides into A. splenica, A. gastrica sinistra, and A. hepatica communis (largest caliber branch of the trunk)

Main Branches	Course	Branches and Their Course	Supply Area

A. splenica	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)
A. gastrica sinistra	extends to lesser gastric curvature anastomoses with A. gastrica dextra	direct branches	Stomach (lesser curvature)
		Rr. oesophageales	Esophagus
A. hepatica communis	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

2. Superior Mesenteric Artery

originates from aorta at level of L1-2
extends anterior-inferior
Branches: A. pancreaticoduodenalis inferior, Aa. jejunales and Aa. ileales, A. ileocolica, A. colica dextra, A. colica media

Main Branches	Course	Branches	Supply Area
A. pancreaticoduodenalis inferior	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
Aa. jejunales and Aa. ileales	course in mesenteric root to jejunum and ileum form a vascular arcade among themselves	Aa. rectae	Jejunum, ileum
A. ileocolica	courses in mesentery to ileocecal region	A. caecalis anterior und posterior	Cecum
		A. appendicularis (Variant: Origin from A. caecalis posterior)	Appendix vermiformis
A. colica dextra	courses in ascending mesocolon to ascending colon	divides into 2 branches, which anastomose with A. colica media or A. ileocolica	Ascending colon
A. colica media	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

3. Inferior Mesenteric Artery

originates at level of L3 from aorta
supplies colon beyond left flexure with A. colica sinistra, Aa. sigmoideae, and A. rectalis superior

Main Branches	Course	Branches	Supply Area
A. colica sinistra	courses in descending mesocolon to descending colon	divides into 2 branches, which anastomose with A. colica media or A. sigmoideae	Descending colon
Aa. sigmoideae	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
A. rectalis superior	approaches rectum from dorsal anastomoses with A. rectalis media	several small branches to rectum	Upper rectum

Arterial Supply of the Pelvis

Abdominal aorta divides at the aortic bifurcation (approx. level L4) into the two common iliac arte

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Abdominal Aorta
Paired branches of the abdominal aorta
Unpaired Branches of the Abdominal Aorta
Arterial Supply of the Pelvis
Femoral artery

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