Anatomy - Endovascular bifurcation prosthesis for infrarenal AAA with simultaneous aneurysm of the right common iliac artery (EVAR with iliac side branch)

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 (kidneys, adrenal glands), gonads
- unpaired branches: spleen, liver, pancreas, unpaired digestive organs

Paired branches of the abdominal aorta

Main branches	Course	Branches and their supply areas
Inferior phrenic artery	extends cranially on the underside of the diaphragm towards the diaphragmatic domes network-like division into several terminal branches	Superior suprarenal artery: Adrenal gland Terminal branches: Underside of the diaphragm
Middle suprarenal artery	extends laterally to the adrenal glands	Terminal branches: Adrenal glands
Renal artery	Origin approx. at the level of L1 - 2 Right renal artery: runs dorsal to the inferior vena cava and pancreatic head to the right kidney Left renal artery: runs dorsal to the pancreatic body to the left kidney	Inferior suprarenal artery: Adrenal gland
Ovarian artery, Testicular artery	Origin below the renal arteries/L2 from the anterior aspect of the aorta run over the psoas muscle, ureter, and external iliac arteries to the suspensory ligament of the ovary or to the deep inguinal ring of the inguinal canal and the testis	Ovarian arteries: Ovaries, parts of the uterine tube, Testicular arteries: Testes, epididymides
Lumbar arteries (4 on each side)	extend laterally behind the psoas muscle over L1 – 4 Anastomoses with the arteries of the anterior abdominal wall (superior and inferior epigastric arteries, iliolumbar artery, deep circumflex iliac artery)	Spinal branches: 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 a collateral supply:
- Coeliac trunk → gastroduodenal artery → superior mesenteric artery
- Superior mesenteric artery → middle and left colic artery → inferior mesenteric artery (“Riolan anastomosis”, “Drummond arcade”, rarely the anastomosis according to William and Klopp)
- Inferior mesenteric artery → superior and middle rectal artery → internal iliac artery

1. Coeliac trunk

Origin at the level of T12
divides into the splenic artery, left gastric artery, and common hepatic artery (the largest-calibre branch of the trunk)

Main branches	Course	Branches and their course	Supply area

Splenic artery	Along the upper border of the pancreas Entry into the splenorenal ligament and spleen	Pancreatic branches: Dorsal to the pancreas Dorsal pancreatic artery: Dorsal to the pancreas Anastomoses with the great pancreatic artery to form the inferior pancreatic artery Great pancreatic artery: Dorsal to the pancreatic tail, running caudally Anastomoses with the dorsal pancreatic artery to form the inferior pancreatic artery	Pancreas
		Posterior gastric artery: Runs in the phrenicosplenic ligament cranially to the gastric fundus	Stomach (posterior surface of the fundus)
		Short gastric arteries: Run in the gastrosplenic ligament to the gastric fundus	Stomach (fundus and greater curvature)
		Left gastro-omental artery: Runs in the gastrocolic ligament to the greater curvature Anastomoses with right gastro-omental artery	Stomach (fundus and greater curvature)
Left gastric artery	Runs to lesser gastric curvature Anastomoses with right gastric artery	Direct branches	Stomach (lesser curvature)
		Oesophageal branches	Oesophagus
Common hepatic artery	Runs to the right towards the hepatic portal Divides into the proper hepatic artery and gastroduodenal artery	Proper hepatic artery Main branch of the common hepatic artery Arises behind the pylorus Runs in the hepatoduodenal ligament together with the hepatic portal vein and common bile duct to the hepatic portal Gives off 3 branches:
		1. Right gastric artery: Runs in the lesser omentum to the lesser gastric curvature Anastomoses with left gastric artery	Stomach (lesser curvature, right)
		2. Right hepatic artery	Liver (right part) Gallbladder (cystic artery) Partially caudate lobe
		3. Left hepatic artery	Liver (left part) Partially caudate lobe
		Gastroduodenal artery Runs dorsal to the lesser omentum to the pancreas Divides into 2 branches:
		1. Right gastro-omental artery: Runs to the greater curvature Anastomoses with 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
Runs anteroinferiorly
Branches: inferior pancreaticoduodenal artery, jejunal arteries and ileal arteries, ileocolic artery, right colic artery, middle colic artery

Main branches	Course	Branches	Supply area
Inferior pancreaticoduodenal artery	Runs in the region of the horizontal part of the duodenum cranially to the pancreatic head	Anterior and posterior branches: Anastomose with the anterior and posterior pancreaticoduodenal artery	Pancreatic head
Jejunal arteries and ileal arteries	Run in the mesenteric root to the jejunum and ileum Form a vascular arcade among themselves	Straight arteries	Jejunum, ileum
Ileocolic artery	Runs in the mesentery to the ileocaecal region	Anterior and posterior caecal artery	Caecum
		Appendicular artery (variant: origin from the posterior caecal artery)	Vermiform appendix
Right colic artery	Runs in the ascending mesocolon to the ascending colon	Divides into 2 branches, which anastomose with the middle colic artery or ileocolic artery	Ascending colon
Middle colic artery	Runs in the transverse mesocolon to the transverse colon	Divides into 2 branches: the right branch anastomoses with the right colic artery (right flexure), the left branch anastomoses with the left colic artery (left flexure)	Transverse colon

3. Inferior mesenteric artery

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

Main branches	Course	Branches	Supply area
Left colic artery	Runs in the descending mesocolon to the descending colon	Divides into 2 branches, which anastomose with the middle colic artery or sigmoid arteries	Descending colon
Sigmoid arteries	2-4 arteries that form a vascular arcade in the sigmoid mesocolon Anastomoses with left colic artery and superior rectal artery	Several small branches to the sigmoid	Sigmoid colon
Superior rectal artery	Approaches the rectum from the dorsal side Anastomoses with the middle rectal artery	Several small branches to the rectum	Upper rectum

Arterial Supply of the Pelvis

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

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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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