Anatomy - EVAR – Endovascular repair of abdominal aortic aneurysm (Y-graft)

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Abdominal aorta
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Origin
- It is the extension of the thoracic aorta after it passes through the aortic hiatus at the level of 12th thoracic vertebra (T12)
Course
- Retroperitoneal
- Left of midline, anterior to spine
- At the level of umbilicus/4th lumbar vertebra (L4) dividing (aortic bifurcation) into the common iliac arteries
Cephalocaudal branches
- Inferior phrenic arteries
- 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 (kidneys, adrenal glands), gonads
- Unpaired branches: spleen, liver, pancreas, unpaired digestive organs

Paired branches of the abdominal aorta

Main branches	Course	Branches and their distribution
Inferior phrenic artery	o Courses craniad on inferior aspect of diaphragm toward its dome o Reticular division into several terminal branches	Superior suprarenal artery: adrenal gland Terminal branches: Inferior aspect of diaphragm
Middle suprarenal artery	o Courses laterad to the adrenal glands	Terminal branches: adrenal glands
Renal artery	o Arises at around the level of the first / second lumbar vertebra (L1-2) o Right renal artery: courses posterior to inferior vena cava and head of pancreas to right kidney o Left renal artery: courses posterior to body of pancreas to left kidney	Inferior suprarenal artery: adrenal gland
Ovarian artery, Testicular artery	o Arises inferior to the renal arteries /second lumbar vertebra (L2) from anterior aspect of aorta o Crosses over psoas muscle, ureter and external iliac arteries to suspensory ligament of ovary / deep inguinal ring and testes	Ovarian artery ovary, parts of uterine tube Testicular artery: testes, epididymides
Lumbar arteries (bilateral 4)	o Run laterad posterior to psoas muscle over 1st to 4th lumbar vertebra (L1–4) o Anastomose with 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, muscles of the back

Unpaired branches of the abdominal aorta

All unpaired branches of the abdominal aorta form anastomoses maintaining organ perfusion via collaterals:
- Celiac trunk→ gastroduodenal artery→ superior mesenteric artery
- Superior mesenteric artery -> middle and left celiac artery -> inferior mesenteric artery (“Riolan anastomosis”, marginal artery of Drummond, rarely accessory intermesenteric anastomosis (Williams and Klop)))
- Inferior mesenteric artery→ superior and middle rectal artery→ internal iliac artery

1. Celiac trunk

Arises at the level of the 12th thoracic vertebra (T12)
Divides into splenic artery, left gastric artery and common hepatic artery (largest-caliber branch of trunk)


Main branches	Course	Branches and their course	Distribution
Splenic artery	o Along superior margin of pancreas o Enters the splenorenal ligament and spleen	Pancreatic branches: o Posterior to pancreas Dorsal pancreatic artery: o Posterior to pancreas o Anastomoses with greater pancreatic artery and continues as inferior pancreatic artery Greater pancreatic artery: o Caudad along the posterior aspect of tail of pancreas o Anastomosis at pancreatic tail with dorsal pancreatic artery and inferior pancreatic artery	Pancreas
		Posterior gastric artery: o Runs craniad in phrenicosplenic ligament to gastric fundus	Stomach (posterior aspect of fundus)
		Short gastric arteries: o Course in gastrosplenic ligament to gastric fundus	Stomach (fundus and greater curvature)
		Left gastro-omental artery: o Courses in gastrocolic ligament to greater curvature o Anastomosis with right gastro-omental artery	Stomach (fundus and greater curvature)
Left gastric artery	o Runs to lesser curvature of stomach o Anastomosis with right gastric artery	Direct branches	Stomach (lesser curvature)
		Esophageal branches	Esophagus
Common hepatic artery	o Runs right to hepatic portal o Divides into proper hepatic artery and gastroduodenal artery	Proper hepatic artery o Main branch of common hepatic artery o Arises posterior to pylorus o Runs in hepatoduodenal ligament together with hepatic portal vein and common bile duct to hepatic portal o Gives rise to three branches:
		1. Right gastric artery: o Runs in lesser omentum to lesser curvature of stomach o Anastomosis with left gastric artery	Stomach (right lesser curvature)
		2. Right hepatic artery	Liver (right half) Gallbladder (cystic artery) Part of caudate lobe
		3. Left hepatic artery	Liver (left half) Part of caudate lobe
		Gastroduodenal artery o Courses posterior to lesser omentum to pancreas o Divides into 2 branches:
		1. Right gastro-omental artery: o Runs to greater curvature o Anastomosis with left gastro-omental artery	Pancreas, duodenum, stomach
		2. Anterior and posterior superior pancreaticoduodenal arteries: o Form a vascular plexus around the pancreatic head with branches of the inferior pancreaticoduodenal artery

2. Superior mesenteric artery

Arises from aorta at the level of L1-2
Courses anteroinferiorly
Branches: Branches: inferior pancreaticoduodenal artery, jejunal arteries and iliac arteries, ileocolic artery, right colic artery, middle colic artery

Main branches	Course	Branches	Distribution
Inferior pancreaticoduodenal artery	o At horizontal part of duodenum it runs craniad to pancreatic head	Anterior and posterior branch: o Anastomosis with anterior and posterior superior pancreaticoduodenal artery respectively	Pancreatic head
Jenunal and iliac arteries	o Course in the mesenteric root to jejunum and Ileum o Form a vascular arch	Terminal branches (Aa. rectae)	Jejunum, Ileum
Ileocolic artery	o Runs in mesentery to ileocecal region	Anterior and posterior cecal artery	Cecum
		Appendicular artery (variant: branch of the posterior cecal artery)	Vermiform appendix
Right colic artery	o Runs in ascending mesocolon to ascending colon	Divides into 2 branches that anastomose with the middle colic artery and ileocolic artery respectively	Ascending colon
Middle colic artery	o Runs in transverse mesocolon to transverse colon	Divides into 2 branches: right branch anastomoses with right colic artery (right flexure), left branch with 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 with left colic artery, sigmoid arteries and superior rectal artery
All unpaired branches of the abdominal aorta form anastomoses maintaining organ perfusion via collaterals:
- Celiac trunk→ gastroduodenal artery→ superior mesenteric artery
- Superior mesenteric artery -> middle and left celiac artery -> inferior mesenteric artery (“Riolan anastomosis”, marginal artery of Drummond, rarely accessory intermesenteric anastomosis (Williams and Klop)))
- Inferior mesenteric artery→ superior and middle rectal artery→ internal iliac artery

1. Celiac trunk

Arises at the level of the 12th thoracic vertebra (T12)
Divides into splenic artery, left gastric artery and common hepatic artery (largest-caliber branch of trunk)


Main branches	Course	Branches and their course	Distribution
Splenic artery	o Along superior margin of pancreas o Enters the splenorenal ligament and spleen	Pancreatic branches: o Posterior to pancreas Dorsal pancreatic artery: o Posterior to pancreas o Anastomoses with greater pancreatic artery and continues as inferior pancreatic artery Greater pancreatic artery: o Caudad along the posterior aspect of tail of pancreas o Anastomosis at pancreatic tail with dorsal pancreatic artery and inferior pancreatic artery	Pancreas
		Posterior gastric artery: o Runs craniad in phrenicosplenic ligament to gastric fundus	Stomach (posterior aspect of fundus)
		Short gastric arteries: o Course in gastrosplenic ligament to gastric fundus	Stomach (fundus and greater curvature)
		Left gastro-omental artery: o Courses in gastrocolic ligament to greater curvature o Anastomosis with right gastro-omental artery	Stomach (fundus and greater curvature)
Left gastric artery	o Runs to lesser curvature of stomach o Anastomosis with right gastric artery	Direct branches	Stomach (lesser curvature)
		Esophageal branches	Esophagus
Common hepatic artery	o Runs right to hepatic portal o Divides into proper hepatic artery and gastroduodenal artery	Proper hepatic artery o Main branch of common hepatic artery o Arises posterior to pylorus o Runs in hepatoduodenal ligament together with hepatic portal vein and common bile duct to hepatic portal o Gives rise to three branches:
		1. Right gastric artery: o Runs in lesser omentum to lesser curvature of stomach o Anastomosis with left gastric artery	Stomach (right lesser curvature)
		2. Right hepatic artery	Liver (right half) Gallbladder (cystic artery) Part of caudate lobe
		3. Left hepatic artery	Liver (left half) Part of caudate lobe
		Gastroduodenal artery o Courses posterior to lesser omentum to pancreas o Divides into 2 branches:
		1. Right gastro-omental artery: o Runs to greater curvature o Anastomosis with left gastro-omental artery	Pancreas, duodenum, stomach
		2. Anterior and posterior superior pancreaticoduodenal arteries: o Form a vascular plexus around the pancreatic head with branches of the inferior pancreaticoduodenal artery

2. Superior mesenteric artery

Arises from aorta at the level of L1-2
Courses anteroinferiorly
Branches: Branches: inferior pancreaticoduodenal artery, jejunal arteries and iliac arteries, ileocolic artery, right colic artery, middle colic artery

Main branches	Course	Branches	Distribution
Inferior pancreaticoduodenal artery	o At horizontal part of duodenum it runs craniad to pancreatic head	Anterior and posterior branch: o Anastomosis with anterior and posterior superior pancreaticoduodenal artery respectively	Pancreatic head
Jenunal and iliac arteries	o Course in the mesenteric root to jejunum and Ileum o Form a vascular arch	Terminal branches (Aa. rectae)	Jejunum, Ileum
Ileocolic artery	o Runs in mesentery to ileocecal region	Anterior and posterior cecal artery	Cecum
		Appendicular artery (variant: branch of the posterior cecal artery)	Vermiform appendix
Right colic artery	o Runs in ascending mesocolon to ascending colon	Divides into 2 branches that anastomose with the middle colic artery and ileocolic artery respectively	Ascending colon
Middle colic artery	o Runs in transverse mesocolon to transverse colon	Divides into 2 branches: right branch anastomoses with right colic artery (right flexure), left branch with 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 with left colic artery, sigmoid arteries and superior rectal artery

Main branches	Course	Branches	Distribution
Left colic artery	o Runs in descending mesocolon to descending colon	Divides into 2 branches that anastomose with the middle colic artery and sigmoid arteries respectively	Descending colon
Sigmoid arteries	o 2-4 arteries forming a vascular arch in the sigmoid mesocolon o Anastomosis with left colic artery and superior rectal artery	Several small branches to sigmoid colon	Sigmoid colon
Superior rectal artery	o Joins the rectum from posterior o Anastomosis with middle rectal artery	Several small branches to rectum	Upper rectum

Arterial pelvic blood supply

The abdominal aorta divides at the aortic bifurcation (around level L4) into both common iliac arte

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Abdominal aorta
Paired branches of the abdominal aorta
Unpaired branches of the abdominal aorta
Arterial pelvic blood supply
Femoral artery

Anatomy - EVAR – Endovascular repair of abdominal aortic aneurysm (Y-graft) – Vascular Surgery

Abdominal aorta

Paired branches of the abdominal aorta

Unpaired branches of the abdominal aorta

1. Celiac trunk

2. Superior mesenteric artery

3. Inferior mesenteric artery

1. Celiac trunk

2. Superior mesenteric artery

3. Inferior mesenteric artery

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vascular surgery