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

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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. level 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 side 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 (bilateral 4)	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 collateral supply:
- Celiac trunk → Gastroduodenal artery → Superior mesenteric artery
- Superior mesenteric artery → Middle and left colic artery → Inferior mesenteric artery (“Riolan anastomosis”, “Drummond arcade”, rarely anastomosis according to William and Klopp)
- Inferior mesenteric artery → Superior and middle rectal artery → Internal iliac artery

1. Celiac trunk

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

Main branches	Course	Branches and their course	Supply area

Splenic artery	Along upper border of pancreas Entry into splenorenal ligament and spleen	Pancreatic branches: Dorsal to pancreas Dorsal pancreatic artery: Dorsal to pancreas Anastomoses with great pancreatic artery to form inferior pancreatic artery Great pancreatic artery: Dorsal to pancreatic tail caudally Anastomoses with dorsal pancreatic artery to form inferior pancreatic artery	Pancreas
		Posterior gastric artery: Runs in phrenicosplenic ligament cranially to gastric fundus	Stomach (posterior surface of fundus)
		Short gastric arteries: Run in gastrosplenic ligament to gastric fundus	Stomach (fundus and greater curvature)
		Left gastro-omental artery: Runs in gastrocolic ligament to 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)
		Esophageal branches	Esophagus
Common hepatic artery	Runs to the right to hepatic portal Divides into proper hepatic artery and gastroduodenal artery	Proper hepatic artery Main branch of common hepatic artery Arises behind pylorus Runs in hepatoduodenal ligament together with hepatic portal vein and common bile duct to hepatic portal Gives off 3 branches:
		1. Right gastric artery: Runs in lesser omentum to 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 lesser omentum to pancreas Divides into 2 branches:
		1. Right gastro-omental artery: Runs to greater curvature Anastomoses with left gastro-omental artery	Pancreas, duodenum, stomach
		2. Anterior and posterior superior pancreaticoduodenal artery: Form vascular plexus with branches of inferior pancreaticoduodenal artery around pancreatic head

2. Superior mesenteric artery

Arises from aorta at level of L1-2
Runs anterior-inferior
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 area of horizontal part of duodenum cranially to pancreatic head	Anterior and posterior branches: Anastomose with anterior and posterior pancreaticoduodenal artery	Pancreatic head
Jejunal arteries and ileal arteries	Run in mesenteric root to jejunum and ileum Form vascular arcade among themselves	Straight arteries	Jejunum, ileum
Ileocolic artery	Runs in mesentery to ileocecal region	Anterior and posterior cecal artery	Cecum
		Appendicular artery (Variant: Origin from posterior cecal artery)	Vermiform appendix
Right colic artery	Runs in ascending mesocolon to ascending colon	Divides into 2 branches, which anastomose with middle colic artery or ileocolic artery	Ascending colon
Middle colic artery	Runs in transverse mesocolon to transverse colon	Divides into 2 branches: right branch anastomoses with right colic artery (right flexure), left branch anastomoses with left colic artery (left flexure)	Transverse colon

3. Inferior mesenteric artery

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

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