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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 71  |  Issue : 2  |  Page : 128-134

Analysis of Anatomical Variations of the Main Arteries Branching from the Abdominal Aorta by Multidetector Computed Tomography: A Prospective Study of 500 Patients in a Tertiary Center


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Date of Submission12-Aug-2021
Date of Decision13-Apr-2022
Date of Acceptance18-Apr-2022
Date of Web Publication30-Jun-2022

Correspondence Address:
Ritu Dhawan Galhotra


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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jasi.jasi_137_21

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  Abstract 


Introduction: Embryological development of the aorta being a complex process can lead to a variety of congenital variants. It may result in complications during abdominal laparoscopic and radiological interventions. Prior knowledge can identify the anatomy, which may require special attention at the time of surgery/interventions. Diagnostic imaging with multidetector computed tomography (MDCT) allows accurate and noninvasive preoperative evaluation. To identify and to evaluate the anatomical variation of major arteries branching from the abdominal aorta using MDCT. Material and Methods: Five hundred patients of different age groups referred to the Department of Radiodiagnosis, Dayanand Medical College and Hospital, Ludhiana, for MDCT abdomen were included in the study. It was performed on 128-slice MDCT Siemens Somatom Definition AS scan machine. Results: The results showed that anatomical variation occurs in a high percentage of patients. In the celiac axis, it occurred in 34.6% of cases, out of which the most common variant was a replaced right hepatic artery (3.7%). Celiacomesenteric trunk was observed in 0.2% of patient. Single renal artery was observed (43.2%) while accessory renal artery in 41.6% and early branching in 15.2%. Discussion and Conclusion: Prior knowledge of variations of these vessels can prevent iatrogenic injuries.

Keywords: Anatomical variations, celiac axis, multidetector computed tomography, renal arteries, superior mesenteric artery


How to cite this article:
Dabria N, Galhotra A, Galhotra RD, Galhotra A, Sharma I, Kakkar C, Gupta K, Saggar K. Analysis of Anatomical Variations of the Main Arteries Branching from the Abdominal Aorta by Multidetector Computed Tomography: A Prospective Study of 500 Patients in a Tertiary Center. J Anat Soc India 2022;71:128-34

How to cite this URL:
Dabria N, Galhotra A, Galhotra RD, Galhotra A, Sharma I, Kakkar C, Gupta K, Saggar K. Analysis of Anatomical Variations of the Main Arteries Branching from the Abdominal Aorta by Multidetector Computed Tomography: A Prospective Study of 500 Patients in a Tertiary Center. J Anat Soc India [serial online] 2022 [cited 2022 Aug 11];71:128-34. Available from: https://www.jasi.org.in/text.asp?2022/71/2/128/349528




  Introduction Top


Embryological development of the aorta being a complex process can lead to a variety of congenital variants.[1] It may result in complications during abdominal laparoscopic and radiological interventions. Recent trends are more toward minimally invasive surgeries, hence, raising the demand of detecting anatomical variations preoperatively. Diagnostic imaging with multidetector computed tomography (MDCT) allows accurate and noninvasive preoperative evaluation.[2],[3] The aim of our study is to analyze the prevalence of anatomical variations of the major branches of the abdominal aorta in regional population and to compare the results with the ones presented in the literature.[4],[5] In our study, we analyzed the variations in anatomy of celiac axis and its branches, superior mesenteric artery (SMA), and renal arteries as these are the most important branches of abdominal aorta due to their vascularization field.[6]

MDCT with the added value of postprocessed images may allow accurate identification of areas at risk for venous congestion or devascularization, potentially influencing surgical planning with regard to the extent of resection, or the need for vascular reconstructions.[7] If the variant anatomy remains unrecognized before surgery, it could prolong operative time, increase blood loss, cause iatrogenic injury, and/or increase morbidity.

Aims and objectives

To identify and to analyze anatomical variation of main arteries branching from the abdominal aorta using MDCT.


  Material and Methods Top


Method of collection of data

A prospective study was conducted in 500 patients of different age groups referred to the Department of Radiodiagnosis, Dayanand Medical College and Hospital, Ludhiana, for MDCT abdomen for different reasons.

Informed consent was obtained from all the subjects/guardians before the study. The clinical history and the spectrum of findings were recorded as per the pro forma. The study was performed on 128-slice MDCT Siemens Somatom Definition AS scan machine.

MDCT was performed with the patient positioned supine with the area of interest from diaphragm to symphysis pubis. 80–100 ml of nonionic contrast was injected at the rate of 3–3.5 ml/sec followed by saline flush through the antecubital vein. Arterial phase study was analyzed to look for the arterial variations. Patients with vascular diseases (thrombosis, stenosis, strictures, and collaterals), major abdominal surgery/trauma, were not included in the study.


  Observations and Results Top


This study was conducted in Dayanand Medical College and Hospital, Ludhiana. A total of 500 cases who underwent MDCT abdomen with arterial phase study were included in the study.

In our study, most of the cases were aged between 51 and 60 years (28.8%). The mean age was observed to be 53.20 ± 14.8 years.

Out of 500 cases, there were 287 (57.4%) male and 213 (42.6%) female. A total of 327 (65.4%) cases of the 500 cases had a normal celiac axis anatomy, which appeared as a hepato-gastrosplenic trunk and SMA originating separately from the aorta [Figure 1] and [Table 1].
Figure 1: Normal celiac axis anatomy and normal origin of SMA. SMA: superior mesenteric artery

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Table 1: Types of the celiac trunk observed in the cases included in the study

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Ten specific types of celiac axis anatomical variations were observed in our study. The most frequent variation was a replaced right hepatic artery (RHA) from the SMA, which was seen in 68 (13.4%) cases [Figure 2]. The next variation according to frequency was accessory left hepatic artery (LHA), originating from the left gastric artery (LGA) seen in 48 (9.6%) cases [Figure 3]. Replaced LHA was observed in 25 (5.0%) cases, and accessory RHA was observed in 7 (1.4%) cases [Figure 4]. Variations in the origin of the common hepatic (CHA) (from the aorta) were observed in 8 (1.6%) cases [Figure 5]. The RHA originated from the celiac axis in 5 (1.0%) cases and from the aorta in 1 (0.2%) patient [Figure 6]. LGA from the aorta was observed in 9 (1.8%) cases [Figure 7]. Splenic artery originating from the aorta was observed in 1 (0.2%) patient [Figure 8]. The common trunk of the celiac trunk and SMA is a rare variation in this research, it was observed in 1 (0.2%) patient [Figure 9]. In this study, the mean diameter of celiac axis orifice was observed to be 5.6 ± 1.0. The mean distance between celiac axis and SMA was observed to be 10.4 ± 2.1 [Table 2].
Figure 2: Image showing replaced right hepatic artery

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Figure 3: Image showing accessory left hepatic artery

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Figure 4: Image showing replaced left hepatic artery

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Figure 5: Image showing common hepatic from the aorta

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Figure 6: Image showing the right hepatic artery from the celiac axis

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Figure 7: Image showing the left gastric artery from the aorta

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Figure 8: Image showing splenic artery from the aorta

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Figure 9: Image showing celiac- Mesenteric Trunk

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Table 2: Types of the variants of the celiac trunk observed in the cases included in the study

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A total of 499 cases showed normal anatomical origin of SMA. The common trunk of the celiac trunk and SMA is a rare variation in this study, it was observed in 1 (0.2%) patient [Table 3]. No case showing hepatomesenteric trunk or absence of SMA was observed in our study. In this study, the mean diameter of SMA at orifice was observed to be 6 ± 1.0.
Table 3: Types of origin of superior mesenteric artery

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Out of 500 study cases, on evaluation for renal arteries, single renal artery was observed in 292/500 (58.4%) cases, while there was presence of accessory renal artery in 208/500 (41.6%) cases. The mean diameter of the orifice of the renal arteries was found to be 4 ± 0.9 mm [Table 4].
Table 4: Types of renal artery in the study group

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There was presence of accessory renal artery in 208/500 (41.6%) cases. Early branching was observed in 76/500 (15.2%) cases, while there was no accessory renal artery or early branching in 216/500 (43.2%) cases.

Renal arteries with early branching were observed in 76/500 (15.2%) cases, while in rest of the 424/500 (84.8%) cases, there was no early branching. The cases with accessory renal artery 208/500 were further categorized into [Table 5]:
Table 5: Types of accessory renal artery and their further distribution

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  1. Additional hilar artery: Right/left/bilateral
  2. Superior renal polar artery: Right/left/bilateral
  3. Inferior renal polar artery: Right/left/bilateral.


Additional hilar artery was seen in 83/208 (39.9%) cases on the right side, 58/208 (27.9%) cases on the left side and 25/208 (12%) cases on both the sides.

Superior renal polar artery was seen in 19/208 (9.2%) cases on the right side, 14/208 (6.8%) cases on the left side and 3/208 (1.4%) cases on both the sides. Inferior renal polar artery was seen in 3/208 (1.4%) cases on the right side, 3/208 (1.4%) cases on the left side, while there was no single case with bilateral inferior polar artery.

The polar arteries were seen in total 42 cases. In 36/42 cases, there was superior renal polar artery [Figure 10]. In 6/42 cases, there was inferior renal polar artery [Figure 11].
Figure 10: Image showing superior renal polar artery

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Figure 11: Image showing inferior renal polar artery

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The cases with early branching were further divided into three categories: early branching on the right side seen in 43/500 (8.6%) cases and on the left side seen in 29/500 (5.8%) cases and on both the sides in 4/500 (0.8%) cases [Table 6].
Table 6: Distribution of the cases with single renal artery and with early branching

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  Discussion Top


During human embryogenesis, four roots of omphalomesenteric artery arise from abdominal aorta and are interconnected by a ventral longitudinal anastomosis. Two central roots of these four aortic branches disappear during embryogenesis, and the first and fourth roots connect to each other with longitudinal anastomosis. The splenic, left gastric, and CHA will come from this longitudinal anastomosis and the SMA from the fourth roots of the omphalomesenteric artery. Remain or regression of any of these arteries leads to the development of vascular variations of the celiac trunk or SMA.[8] In the past, preoperative evaluation of hepatic resection candidates consisted of both noninvasive and invasive studies, including computed tomography (CT), MRI, CT arterial portography, and conventional angiography.[9],[10],[11] More recently, CT has been combined with three-dimensional CT angiography for the depiction of the vascular anatomy. Preoperative knowledge of variant arterial anatomy may reduce extensive exploration during surgery and consequently decrease the risk of vascular damage. In the classic anatomy, the celiac trunk was divided into three branches, LGA and then CHA and splenic artery. The CHA artery bifurcates into the gastroduodenal artery and the proper hepatic artery. Hepatic artery proper divides into RHA and LHA. In this study, classical hepatic arterial anatomy was seen in 327 (65.4%) of the patients who underwent CT abdomen, while the previous studies showed different results, i.e., 89% by Michel,[12] 51% by Winston et al.,[13] 66% by De Cecco et al.,[11] 89% by Song et al.,[14] and 91% by Sureka et al.[15] The most common frequent variant in this study was a replaced RHA originating from SMA, seen in 68 (13.6%) of patients. It was found in 15% and 9.2% of patients in a study of Winston and Cecco, respectively. Accessory arteries provide an additional source of blood supply to the hepatic lobes. These accessory arteries needed to be occluded separately when surgeons want to control inflow to hepatic lobes. Replaced LHA was observed in 25 (5.0%) of patients. The prevalence of this variation in Cecco et al.'s study was 5.2%, and it was observed in 8% of patients in the study of both Winston and Michel. Before the left hepatectomy, this variant should be identified and ligated.[11],[12],[13],[16],[17] Accessory RHA was observed in 7 (1.4%) patients. On the other hands, variant arterial anatomy has an important role in chemotherapy as an adjuvant to resection in controlling hepatic disease. The hepatic variant artery can result in a nonuniform perfusion of the chemotherapeutic agent through the liver so a replaced or accessory artery should be ligated during chemotherapy.[18],[19],[20],[21] The common trunk of the celiac artery and the SMA is a rare variation and according to the earlier studies, it has been observed in <2% of patients.[22],[23] In our research, it was observed in 1 (0.2%) of patients. In 5 (1.0%) patients, the RHA was seen to arise directly from the celiac trunk. In 1 (0.2%) patient, the RHA was seen to arise directly from aorta. An unusual course of RHA that originates from the celiac axis or aorta may result in iatrogenic injury to this vessel if the location of the vessel is unknown for the surgeon. Eight (1.6%) patients had CHA artery from the aorta and 9 (1.8%) patients had LGA directly from the aorta. Splenic artery arising directly from the aorta was observed in 1 (0.2%) patient in our study.

Among all abdominal aorta ramifications, renal arteries show the highest anatomical variability. In our study, variants of the renal arteries were significantly more frequent (56.8%) than the variants of the celiac trunk (34.6%) of patients or of the variant origin of SMA (0.2%).

There are a few theories about the embryonic origin of the renal vasculature.[24],[25] Vasculature development is strictly dependent on the cephalic migration of the kidneys during embryogenesis. If their final location is atypical, renal vasculature may also be atypical, which can be explained by arterial vasculature adjustments to the location of the kidneys.[26] In our study group, the atypical kidney location was not observed, and thus, the additional renal arteries were probably the remains of the mesonephric blood vessels, giving rise to the renal artery.[27] Renal vessel variations are not contraindications for transplant surgery, but having knowledge about the presence of these vessels and their courses will prevent the possible injuries or bleedings and prolonged ischemia of graft. Therefore, all accessory or polar arteries must be anastomosed in order to reduce surgery duration and risk of graft ischemia.

In our study, including 500 patients, the prevalence of accessory renal artery was observed in 208 (41.6%) patients with additional hilar artery observed in 166 patients, superior renal polar arteries observed in 36 patients, and inferior renal polar arteries observed in 6 patients. We observed more accessory RAs on the right side, studies done by Ozkan et al.,[28] Holden et al.,[29] and Ugurel et al.[30] reported that accessory renal arteries were more frequently observed on the right side.

Most of the studies that have investigated the prevalence of accessory renal arteries were based on autopsy or digital subtraction angiography (DSA) findings. The prevalence of accessory renal arteries varies between 9% and 76% in the literature, and the general average in postmortem studies is 28%–30%.[31],[32] In the study by Ozkan et al., including DSA examinations obtained in 855 patients, the prevalence of accessory renal artery was 24%. In a study by Ugurel et al., the incidence of the accessory renal artery was 42% and accessory renal arteries were on the right side in the majority of patients.[30]

Although Khamanarong et al.[31] detected higher polar arteries than hilar arteries in their study, we detected higher frequency for hilar arteries than for polar arteries.

In our study, the pattern of early branching was observed in 76 (15.2%) patients with early branching on the right was in 43 cases, on the left in 29 cases. In the literature, the prevalences reported for early branching in the main renal artery vary between 4.3% and 13%.[33],[34] In the study by Raman et al.,[35] the early branching frequency on the right side was 15% and 21% on the left side. The rate of early branching we determined is slightly higher than the rate specified in the literature for early branching.

To provide an easier hemorrhage control, the renal artery incision should be done 1.5–2 cm distal from the aortic origin. Therefore, it is very important to determine early branching of the main renal artery. It is also essential to measure the length and caliber of hilar and polar arteries (though not done in our study) and look for branches arising from these arteries as anomalous origin of testicular arteries can be seen from polar arteries in rare cases.[36]

Hence, anatomical variations in the origin, number, and branching of renal arteries are very useful for planning and performing endovascular and laporoscopic surgeries for urological pathologies and can be helpful for the development of new medical devices for future treatment strategies.[37]


  Conclusion Top


The results of the present study showed that anatomical variation occurs in a high percentage of patients. In the celiac axis, it occurred in 34.6% of cases out of which most common variant was a replaced RHA in 3.7% cases. The second most common was an accessory LHA arising from LGA 9.5%. Replaced LHA was observed in 5.0% of patients, and accessory RHA was observed in 1.4% of patients. Origin of the CHA (from the aorta) was observed in 1.6% of patients. RHA originated from the celiac axis in 1.0% of patients and from the aorta in 0.2% of patient. LGA from the aorta was observed in 1.8% of patients. Splenic artery originating from the aorta was observed in 0.2% of patient.

Celiaco-mesenteric trunk was observed in 0.2% of patients.

Out of 500 cases, on evaluation for renal arteries, single renal artery was observed in 43.2% cases, while there was presence of accessory renal artery in 41.6% cases and early branching in 15.2% cases. The accessory hilar artery was observed in 39.9% cases on the right side, 27.9% cases on the left side and 12% on both the sides.

The superior renal polar artery was observed in 9.2% of cases on the right side, 6.8% of cases on the left side and 1.4% of cases on both the sides.

Inferior renal polar artery was observed in 1.4% of cases on the right side, 1.4% of cases on the left side, while there was no single case with bilateral inferior polar artery.

Early branching on the right side was observed in 8.6% of cases, early branching on the left side seen in 5.8% cases, and early branching on both the sides in 0.8% cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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