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 the V. cava inferior and pancreatic head to the right kidney A. renalis sinistra: runs dorsal to the pancreatic body to the left kidney	A. suprarenalis inferior: Adrenal gland
A. ovarica, A. testicularis	Origin below the Aa. renales/L2 from the anterior side of the aorta run over the 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 (4 on each side)	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 a collateral supply:
- Truncus coeliacus -> Aa. 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. Truncus coeliacus

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

Main branches	Course	Branches and their course	Supply area

A. splenica	along the upper border of the pancreas entry into the splenorenal ligament and spleen	Rr. pancreatici: dorsal to the pancreas A. pancreatica dorsalis: dorsal to the pancreas anastomoses with A. pancreatica magna to form A. pancreatica inferior A. pancreatica magna: dorsal to the pancreatic tail, extending caudally anastomoses with A. pancreatica dorsalis to form A. pancreatica inferior	Pancreas
		A. gastrica posterior: courses in the phrenicosplenic ligament cranially to the gastric fundus	Stomach (posterior surface of the fundus)
		Aa. gastricae breves: course in the gastrosplenic ligament to the gastric fundus	Stomach (fundus and greater curvature)
		A. gastroomentalis sinistra: courses in the gastrocolic ligament to the greater curvature anastomoses with A. gastroomentalis dextra	Stomach (fundus and greater curvature)
A. gastrica sinistra	extends to the lesser gastric curvature anastomoses with A. gastrica dextra	direct branches	Stomach (lesser curvature)
		Rr. oesophageales	Oesophagus
A. hepatica communis	courses rightward to the hepatic portal Division into A. hepatica propria and A. gastroduodenalis	A. hepatica propria Main branch of A. hepatica communis originates behind the pylorus extends in the hepatoduodenal ligament together with V. portae hepatis and the common bile duct to the hepatic portal gives off 3 branches:
		1. A. gastrica dextra: courses in the lesser omentum to the 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 the lesser omentum to the pancreas divides into 2 branches:
		1. A. gastroomentalis dextra: extends to the greater curvature anastomoses with A. gastroomentalis sinistra	Pancreas, duodenum, stomach
		2. A. pancreaticoduodenalis superior anterior and posterior: together with branches of A. pancreaticoduodenalis inferior, form a vascular plexus around the pancreatic head

2. Superior Mesenteric Artery

originates from the aorta at the level of L1–2
extends anteroinferiorly
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 the area of the pars horizontalis duodeni cranially to the pancreatic head	R. anterior and posterior: anastomose with A. pancreaticoduodenalis anterior and posterior	Pancreatic head
Aa. jejunales and Aa. ileales	course in the mesenteric root to the jejunum and ileum form a vascular arcade among themselves	Aa. rectae	Jejunum, ileum
A. ileocolica	courses in the mesentery to the ileocecal region	A. caecalis anterior and posterior	Caecum
		A. appendicularis (variant: origin from A. caecalis posterior)	Appendix vermiformis
A. colica dextra	courses in the ascending mesocolon to the ascending colon	divides into 2 branches, which anastomose with A. colica media or A. ileocolica	Ascending colon
A. colica media	courses in the transverse mesocolon to the 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 the level of L3 from the aorta
supplies the colon beyond the left flexure via A. colica sinistra, Aa. sigmoideae, and A. rectalis superior

Main branches	Course	Branches	Supply area
A. colica sinistra	courses within the descending mesocolon to the descending colon	divides into 2 branches, which anastomose with A. colica media and Aa. sigmoideae, respectively	Descending colon
Aa. sigmoideae	2-4 arteries that form a vascular arcade in the sigmoid mesocolon anastomose with A. colica sinistra and A. rectalis superior	several small branches to the sigmoid colon	Sigmoid colon
A. rectalis superior	approaches the rectum from the dorsal aspect anastomoses with A. rectalis media	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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