collateral circulation in chronic arterial insufficiency ... · collateral circulation in chronic...

Article ID: WMC003426 ISSN 2046-1690

Collateral Circulation in Chronic ArterialInsufficiency of the Common Iliac Artery - CTAngiographic FindingsCorresponding Author:Dr. Atanas D Hilendarov,MD, Medical University, Volga 49, ap.14, 4002 - Bulgaria

Submitting Author:Dr. Atanas D Hilendarov,MD, Medical University, Volga 49, ap.14, 4002 - Bulgaria

Previous Article Reference: http://www.webmedcentral.com/article_view/3392

Article ID: WMC003426

Article Type: Case Report

Submitted on:04-Jun-2012, 06:46:04 PM GMT Published on: 05-Jun-2012, 11:56:28 AM GMT

Article URL: http://www.webmedcentral.com/article_view/3426

Subject Categories:ANGIOLOGY

Keywords:Aortoiliac occlusive disease, Pelvic collateral circulation, Inferior epigastric artery, CT angiography

How to cite the article:Hilendarov AD, Delchev S, Ivanov E, Velkova K, Sivkov S . Collateral Circulation inChronic Arterial Insufficiency of the Common Iliac Artery - CT Angiographic Findings . WebmedCentralANGIOLOGY 2012;3(6):WMC003426

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Collateral Circulation in Chronic ArterialInsufficiency of the Common Iliac Artery - CTAngiographic FindingsAuthor(s): Hilendarov AD, Delchev S, Ivanov E, Velkova K, Sivkov S

Abstract

Background: The collateral circulation in aortoiliacocclusive disease involves multiple pathways and thedominant type is determined by the level of occlusion.The aim of this report is to assess the collateralcirculation in patients with chronic occlusive disease ofthe iliac arteries using computed tomographyangiography and post-processing imagereconstruction.

Methods: A case of an 80-year-old patient withocclusion of the right common iliac artery is presented.Using computed tomography (CT) angiography wereevaluated arterial collaterals, providing blood flow tothe r ight lower l imb. The post-processingreconstruction of the image allowed additional spatialvisualization of some of the collaterals.

Results: It was found that two types of anastomoses -visceral and parietal intersystemic are committed toovercome the gradually occurred blockage of the rightcommon iliac artery. The first type was presented withthe anastomosis of the ipsilateral superior epigastricartery and inferior epigastric artery, as well as thecommunication of the latter through pubic branch withthe obturator artery. The second type was realizedthrough the visceral branches: superior rectal artery,left middle and inferior rectal arteries - right middle andinferior rectal arteries (pararectal); left vesical arteries -right vesical arteries (paravesical).

Conclusions: Complementation of CT angiographywith post-processing image reconstruction improvesvisualization and analysis of the collateral pathways inchronic occlusive disease of the iliac arteries, which isnecessary for adequate preoperative evaluation of thedominant of collateral circulation.

Background

The proper preoperative evaluation of the dominanttype collateral circulation in patients with chronicocclusive disease of the iliac arteries is important to

avoid undesirable consequences for the patient. Theinterruption of some of the actively functioningcollaterals can lead to ischemic failure and risk ofeventual loss of the limb [2]. The collateral circulationin aortoiliac occlusive disease involves multiplepathways and the dominant type is determined by thelevel of occlusion [8]. One group of collaterals areparietal intersystemic pathways via the intercostal,epigastric, lumbar and other parietal vessels, whichprovide collaterals to the external and internal iliacarteries. Some of the most important knownanastomoses are [1, 2, 8]: Internal thoracic (mammary)artery – superior epigastric artery – inferior epigastricartery („Winslow’s pathway”). Fourth lumbar arterywith iliolumbar artery (to internal iliac artery) or deepcircumflex iliac artery (to external iliac artery). Rightlateral sacral artery - median sacral artery - left lateralsacral artery. The other group of collaterals arevisceral intersystemic pathways through branches ofmesenteric arteries and internal iliac artery into thehaemorrhoidal plexus [8]: inferior mesenteric artery -superior rectal artery - middle rectal artery; as well asother arteries, forming networks around organs in thelesser pelvis. Various collateral pathways in the pelvishave been studied and demonstrated to clarify theperfusion of structures located distal to arterioscleroticvascular occlusion [6]. Using Doppler sonography ithas been found that after ligation of the common iliacarteries in experimental models paraorganic collateralsthrough pelvic vessels begin to function soon after thesurgery and provide sufficient blood flow to the limb[12]. Similar data for the involvement of collateralcirculation in the pelvis, identified angiographicallyhave also been reported in occluded infected aortoiliacdacron prosthesis [8]. In more recent publications,some of them referring to data from computedtomography (CT) angiography, cases withvisualization of pelvic vasculature [3, 5, 9] anddominanting part of the so-called "Winslow’s pathway"[2, 7, 11, 13, 14] have been presented. The aim of thiscommunication is to assess the collateral circulation inpatient with chronic occlusive disease of the iliacarteries by CT angiography and additional imagepost-processing.



Material and Methods

Eighty-year-old male was admitted in emergency tothe Clinic of vascular surgery for sudden pain in theright calf and thigh and in the right inguinal fold,accompanied with paleness and progressive bluenessof the right foot. The patient had long history ofintermittent claudication a result of poor blood flow tothe legs. In recent days, the patient could hardly walkmore than 50-60 feet away, and in the last 24 hoursthe same symptoms were present at rest. Pale, cool,painful right lower limb with sensory and motordeficiency were found on examination. Upon palpationthe pulse in the right femoral artery was weak andhardly palpable, and absent in the right popliteal anddorsalis pedis arteries. Emergency catheterthrombectomy of the right femoral artery was done toremove the blockage. During the procedureimpassable location was reached proximally at thebifurcation of the right common iliac artery. EmergencyCT angiography was performed using 16 spiralscanner in the supine position (Bright Speed, GE,USA). Power settings were 100–120 kV and 200–300mA, matrix of 512 X 512 pixels, collimation of 16 X1.25 mm (slice thickness 0.5 mm), pitch of 1.3.Post-processing with 3D reconstruction was performed.

Results

CT angiographic reconstruction revealed significantsclerotic changes along the aorta and iliac arteries.The left common iliac artery and its branches werecontrasted distally to the foot branches, despite thenarrowing from atheromatous plaques along theirentire length. The right common iliac artery was notdisplayed, but distally external iliac artery was shownfilled by collateral blood supply (Fig. 1). The level ofcol laterals was better displayed in furtherreconstructions. On successive cross-slices the rightinferior epigastric artery was traced on the posteriorsurface of rectus abdominis muscle, significantly morecongested than the lef t one (Fig. 2). Thepost-processing reconstruction allowed spatialvisualization of this artery and its anastomosis throughpubic branch with obturator artery (for the internalupper thight) (Fig. 3). Small collateral visceralbranches were visualized, perfusing the right internaliliac artery from branches of the left internal iliac arteryand from inferior mesenteric artery (Fig. 4).

Multiple narrowings presented distally in the right mainarteries - the femoral and popliteal artery, without

evidence of complete occlusion.

After diagnosing the above-described changes adecision for performing aortofemoral bypass wasmade. As a result, steady pulses of the right femoralartery appeared, warming of the limb, recoveredsensation and motor function and increase in theclaudication distance to over 300-350 meters.

Discussion

This communication is an attempt to trace the arterialcollaterals functioning in occlusion of large pelvicarterial vessels using CT angiography withpost-processing image reconstruction. Our data arelimited to the main collaterals that traced inangiographic series, contribute significantly to keep upthe blood flow.In our patient both types of anastomoses - visceraland parietal intersystemic are involved to overcomethe gradually developed occlusion of the right commoniliac artery. The first type of anastomoses are mainlyipsilateral: superior epigastric artery - inferiorepigastric artery. Additionally the inferior epigastricartery communicates via pubic branch with theobturator artery and consequently with the internal iliacartery. The visualized vessels in the right iliac fossashow inclusion of the fourth lumbar artery through theiliolumbal artery to the internal iliac artery and throughthe deep circumflex iliac artery to the external iliacartery.The second type is realized through the visceralbranches: middle and inferior left rectal arteries -middle and inferior right rectal arteries (pararectal) andleft vesical arteries - r ight vesical arteries(paravesical). Additional blood enters to the pararectalplexus through superior rectal artery, the continuationof the abdominal inferior mesenteric artery, and to alesser degree through median sacral artery. The bloodflow from this network fills the visceral branches of theright internal iliac artery. Some authors attribute majorimportance to the parietal intersystemic anastomosesas a collateral pathway in iliac occlusion [2, 7, 11, 13],and others – to the visceral intersystemicanastomoses through inferior mesenteric artery -rectal arteries, vesical arteries and other paraorganicplexuses [6, 8, 10, 12]. Studies show that the bloodflow in the collateral network increases two to threetimes depending on the level and extent of occlusion[10, 12]. In patients with chronic occlusive disease ofthe aortoiliac segment careful evaluation of the majorcollaterals is necessary due to the risk of seriousischemic complications after their interruption [2].These collateral pathways may be involved



equivocally, or one may dominate. In cases ofdeveloped communication via internal thoracic artery -inferior epigastric artery its interruption in crosssections of the anterior abdominal wall or use of theseareas as a flap in reconstructive surgery iscontraindicated [14]. Using internal thoracic artery incoronary bypass surgery requires further clarificationof the extent of involvement of the right and leftarteries by selective angiography [2, 14]. Developmentof the visceral collateral circulation in the lesser pelvisalso necessitates caution in surgical procedures in thisarea [3-5].

Conclusion

CT angiographic evidence of the collateral circulationin our patient corresponds with the opinion of anumber of authors for the high informativeness of theimages obtained using multislice computedtomography in cases of vascular obstruction.Preoperative evaluation of actively functioningcollaterals and their identification is imperative to avoidischemic complications in the affected lower limb.Complementing CT angiography with post-processingimage reconstruction offers new opportunities forprecise diagnostic analysis of the type of collateralnetwork and spatial visualization of vessels involved inchronic occlusive disease of the iliac arteries.

Conflict of interest. The authors declare that theyhave no conflict of interest.

References

1. Bechara C, Cagiannos C, Chen C, Lin PH (2010)Aortoiliac occlusive disease. In: Brunicardi FC (ed)Schwartz’s Principles of Surgery, 9th edn. TheMcGraw-Hill, New York pp 1432-14362. Ben-Dor I, Waksman R, Salter LF et al (2010) Afurther word of caution before using the internalmammary artery for coronary revascularization inpatients with severe peripheral vascular disease.Catheter Cardiovasc Interv 75(2):195-2013. Bilhim T, Casal D, Furtado A et al (2011) Branchingpatterns of the male internal iliac artery: imagingfindings. Surg Radiol Anat 33:151-1594. Devine TJ, Myers KA, Slattery PG (1980) Severeleg ischaemia caused by anterior resection of therectum. Br J Surg 67(1):52-535. Ding HM, Yin ZH, Zhou XB et al (2008)Three-dimensional visualization of pelvic vascularity.Surg Radiol Anat 30:437-4426. Friedenberg MJ, Perez CA (1965) Collateral

circulation in aorto-ilio-femoral occlusive disease: asdemonstrated by unilateral percutaneous commonfemoral artery needle injection. Am J RoentgenolRadium Ther Nucl Med 94:145-1587. Kim J, Won JY, Park SI, Lee DY (2003) Internalthoracic artery collateral to the external iliac artery inchronic aortoiliac occlusive disease. Korean J Radiol4(3):179-1838. Kupic EA, Mackenzie JR (1968) Angiographicdemonstration of cross pelvic collateral circulationfollowing bilateral axillary femoral bypass. Am JRoentgenol Radium Ther Nucl Med 102(2):418-4239. Lin PH, Bechara C, Kougias P et al (2008)Assessment of aortic pathology and peripheral arterialdisease using multidetector computed tomographicangiography. Vasc Endovascular Surg 42(6):583-59810. Novosad EM (2003) Specific features of circulationin aorto-iliac arterial occlusion. Klin Khir 8:33-3411. Takahashi S, Kaneda H, Saito S (2007) Winslow’spathway in 64-slice multi-detector computedtomography. Eur Heart J 28(20):243712. Takebe K, Uchida H, Teramoto S (1994) Anexperimental hemodynamic study of the pelviccollateral circulation. Acta Med Okayama 48(1):31-3813. Yurdakul M, Tola M, Ozdemir E et al (2006)Internal thoracic artery-inferior epigastric artery as acollateral pathway in aortoiliac occlusive disease. JVasc Surg 43(4):707-71314. Zaizen H, Tamura A, Miyamoto K, Kadota J (2007)The collateral pathway from the left internal thoracicartery to the left external iliac artery detected bymultislice computed tomography. Int J Cardiol117(2):e56-e57



Illustrations

Illustration 1

Figure. 1 Vascular reconstruction in CT angiography. Total interruption of right common iliac artery (arrow) and presentation of deepvisceral collateral network in the pelvis. Elimination of the bone structures using software Auto Bone XPress



Illustration 2

Figure. 2 Axial CT scan with contrast, transverse image. Right inferior epigastric artery (arrow)



Illustration 3

Figure. 3 Post-processing 3D reconstruction of CT angiography and color presentation of contrasted vessels and pelvic bones.Anastomosis between right inferior epigastric artery and obturator artery through pubic branch (arrow)



Illustration 4

Figure. 4 Post-processing reconstruction of CT angiography with contrasted vessels. Pararectal and paravesical vessels (arrows). 1inferior mesenteric artery, 2 superior rectal artery, 3 right inferior epigastric artery



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