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A STUDY OF THE VARIATION OF THE POPLITEAL
ARTERY BRANCHING PATTERN AMONG MALE
MEDICAL UNDERGRADUATE STUDENTS IN IIUM
KUANTAN
BY
AHMAD RUZAIN SALEHUDDIN
A dissertation submitted in fulfilment of the requirement for
the degree of Master of Medical Sciences
Kulliyyah of Medicine
International Islamic University Malaysia
JUNE 2016
ABSTRACT
A wide range of variations can be seen in the vascular system of an adult human lower
limb. One of the important blood vessels that has been mentioned in the literature is
popliteal artery. Popliteal artery injury is frequently associated with lower limb trauma
or surgical procedures involving the knee joint and popliteal fossa. Therefore,
knowledge regarding the branching patterns of popliteal artery is essential because
any damage to its branches can be life- or limb-threatening. This study aimed to
measure the prevalence of popliteal artery variations in healthy subjects. Furthermore,
we would also like to determine the symmetrical characteristic of variations in the
same individual, and the correlation between luminal diameter of popliteal artery and
specific parameters. This is the first study done in Malaysia on popliteal artery
variations in vivo using colour Doppler ultrasonography. One hundred and fifty four
lower limbs (77 subjects of male medical undergraduate students of International
Islamic University Malaysia) were examined during this study. The area of interest
was the popliteal fossa. Among them, 4.5% (seven cases) were found to possess
variants. The two variants encountered in this study were Type I-B or trifurcation of
popliteal artery 1.9% (three cases), and Type II-A or high-origin anterior tibial artery
2.6% (four cases). With regard to the variants of popliteal artery branching pattern,
two subjects had Type II-A occurred bilaterally while three other subjects had
unilateral characteristic of Type I-B in combination with Type I-A. It was found that
luminal diameter of popliteal artery increased with body surface area and calf
circumference in both dominant and non-dominant legs respectively (p<0.001). In
conclusion, popliteal artery showed variations in branching pattern, and its diameter
increases with body surface area and calf circumference.
ii
‫خالصة البحث‬
‫هناك جمموعة واسعة من االختالفات ميكن أن ينظر إليها يف األوعية الدموية من االطراف السفلى‬
‫لالنسان البالغ ‪ .‬واحدة من األوعية الدموية اهلامة اليت مت ذكرها يف األدب هو الشراين املأبضي‪ .‬وكثريا ما‬
‫يرتبط إصابة الشراين املأبضي مع إصاابت األطراف السفلى أو العمليات اجلراحية اليت تتضمن مفاصل‬
‫الركبة واملبأبضية‪ .‬ولذلك‪،‬فان أمناط معرفه تفرع الشراين املأبضي ضروري ألن أي ضرر يف فروعها ميكن‬
‫أن يكون هتديدا حلياة االنسان أو هتديدا ألطرافة‪ .‬هدفت هذه الدراسة إىل قياس مدى انتشار‬
‫إختالفات الشرايني املأبضية يف االشخاص األصحاء‪ .‬وعالوة على ذلك‪ ،‬نود أيضا لتحديد اخلصائص‬
‫املتناررة من االختالفات يف نف الفرد والعالقة بني قطر الشراين املأبضي مع معايري حمددة‪ .‬هذه هي‬
‫الدراسة األوىل من نوعها اليت أجريت يف ماليزاي على إختالفات الشرايني املأبضية يف اجلسم احلي‬
‫ابستخدام دوبلر املوجات فوق الصوتية امللونة )‪ .(colour Doppler ultrasonography‬مت‬
‫فحص مائة وأربعة ومخسون طرف سفلى (‪ 77‬شخص ابلغ ذكر من طالب البكالوريوس يف كليه الطب‬
‫ابجلامعة اسإسالمية العاملية مباليزاي) خالل هذه الدراسة‪ .‬كانت املنطقة ذات االهتمام هي املأبضية‪ .‬من‬
‫بينهم‪ ،‬مت العثور على ‪ 7 ( ٪4.5‬حاالت) من األطراف السفلية وجدهبا إختالفات‪ .‬وكان اخليارين اليت‬
‫مت مواجهتها يف هذه الدراسة هو النوع االول‪-‬ب أو كما يطلق عليها االنفراق الثالثي من الشراين‬
‫املأبضي ‪( ٪1.9‬ثالث حاالت)‪ ،‬والنوع الثاين‪-‬أ أو كما يطلق عليها ارتفاع نقطة تفرع الشراين عظام‬
‫الساق األمامية (‪( ٪2.6 )high-origin anterior tibial artery‬أربع حاالت)‪ .‬وفيما‬
‫يتعلق ابالختالفات يف طرق تفرع الشراين املأبضي‪ ،‬كان شخصني من النوع الثاين‪-‬أ حيملوهنا يف كال‬
‫الطرفيني السفليني‪ ,‬بينما وجد يف ثالثة أشخاص أخرين يف طرف واحد النوع االول‪-‬ب مع النوع‬
‫االول‪-‬أ ‪ .‬وقد تبني أن قطر الشراين املأبضي يزداد مع مساحة سطح اجلسم ومنتصف الساق يف كال‬
‫الساقني (‪ .)p<0.001‬ويف اخلتام‪ ،‬أرهر الشراين املأبضي اختالفات يف منط التفرعات‪ ،‬ويزيد قطرها‬
‫مع حميط الساق ومساحة سطح اجلسم‪.‬‬
‫‪ABSTRACT IN ARABIC‬‬
‫‪iii‬‬
APPROVAL PAGE
I certify that I have supervised and read this study and that in my opinion, it conforms
to acceptable standards of scholarly presentation and is fully adequate, in scope and
quality, as a dissertation for the degree of Master of Medical Sciences.
…………………………………..
Zunariah Buyong
Supervisor
…………………………………..
Siti Kamariah Che Mohamed
Co-Supervisor
…………………………………..
Radhiana Hassan
Co-Supervisor
I certify that I have read this study and that in my opinion it conforms to acceptable
standards of scholarly presentation and is fully adequate, in scope and quality, as a
dissertation for the degree of Master of Medical Sciences.
…………………………………..
Emad
Mohamed
Nafie
AbdelWahab
Internal Examiner
This dissertation was submitted to the Department of Basic Medical Sciences and is
accepted as a fulfilment of the requirement for the degree of Master of Medical
Sciences.
…………………………………..
Zunariah Buyong
Head, Department of Basic
Medical Sciences
This dissertation was submitted to the Kulliyyah of Medicine and is accepted as a
fulfilment of the requirement for the degree of Master of Medical Sciences.
…………………………………..
Azmi Md. Nor
Dean, Kulliyyah of Medicine
iv
DECLARATION
I hereby declare that this dissertation is the result of my own investigations, except
where otherwise stated. I also declare that it has not been previously or concurrently
submitted as a whole for any other degrees at IIUM or other institutions.
Ahmad Ruzain Salehuddin
Signature ...........................................................
v
Date .........................................
COPYRIGHT PAGE
INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA
DECLARATION OF COPYRIGHT AND AFFIRMATION OF
FAIR USE OF UNPUBLISHED RESEARCH
A STUDY OF THE VARIATON OF THE POPLITEAL ARTERY
BRANCHING PATTERN AMONG MALE MEDICAL
UNDERGRADUATE STUDENTS IN IIUM KUANTAN
I declare that the copyright holders of this dissertation are jointly owned by the student
and IIUM.
Copyright © 2016 Ahmad Ruzain Salehuddin and International Islamic University Malaysia. All rights
reserved.
No part of this unpublished research may be reproduced, stored in a retrieval system,
or transmitted, in any form or by any means, electronic, mechanical, photocopying,
recording or otherwise without prior written permission of the copyright holder except
as provided below
1.
Any material contained in or derived from this unpublished research may
only be used by others in their writing with due acknowledgement.
2.
IIUM or its library will have the right to make and transmit copies (print
or electronic) for institutional and academic purpose.
3.
The IIUM library will have the right to make, store in a retrieval system
and supply copies of this unpublished research if requested by other
universities and research libraries.
By signing this form, I acknowledged that I have read and understand the IIUM
Intellectual Property Right and Commercialization policy.
Affirmed by Ahmad Ruzain Salehuddin
….…………………………….
Signature
……..………………..
Date
vi
ACKNOWLEDGEMENTS
Alhamdulillah, all praises to ALLAH, The Sustainer and Provider for all universe,
Who has given me good health, strength and enough time for me to finish this study
and guided me in my life as a Muslim. May all the blessings and peace be upon our
beloved Prophet Muhammad, his family and companions.
First and foremost, I would like to take this opportunity to express my sincere
gratitude and appreciation to my supervisor, Asst. Prof. Dr. Zunariah Buyong for her
continuous support and patience during my study. I would also like to thank my cosupervisors, Assoc. Prof. Dr. Siti Kamariah Che Mohamed and Assoc. Prof. Dr.
Radhiana Hassan for their advices and encouragements. I am also grateful to
acknowledge the unreserved help and assistance offered by several individuals: Dr. Ye
Tun, Dr. Yi Yi Myint, Assoc. Prof. Dr. Jamalludin Ab. Rahman, Dr. Nurul Asyiqin
Yusof, Dr. Che Anuar Che Mohamad and Bander S. Ali Binjaabaan Al-Qahtani.
I wish to express my appreciation and thanks to the Postgraduate Office of
Kulliyyah of Medicine, IIUM including Assoc. Prof. Dr. Kamarul Ariffin Khalid
(Deputy Dean Postgraduate and Research) and his supporting staffs; IIUM Research
Ethics Committee and Research Management Centre for their continuous support and
advice during this study.
Thank you also to the Director of IIUM Breast Centre for the permission to use
the facilities and the supporting staffs for their technical support. Special thanks also
forwarded to Madeleine Eng Jiun Yi (Clinical Application Specialist US Ultrasound
from Healthcare Sector of Siemens Malaysia Sdn. Bhd.) for the intensive workshop
and calibration of the ultrasound machine used in this study. Finally, a million thanks
to the medical undergraduate students who participated in this study for without them
none of this would have been possible.
It is my utmost pleasure to dedicate this work to my dear parents, Rozana
Mudzir and Salehuddin Shamsuddin, thank you is not enough for all the sacrifices you
both made to ensure that I achieve success in my life. Not forgetting my dearly wife,
Zahrah Humaira Hii, for your unfailing love and support especially when I needed it
the most. My lovely daughter, Nur Sofiya Mardhiyah, you are the pride and joy of my
life. All my brothers, Ahmad Dzulkarnain, Ahmad Shamsuddin and Ahmad Suleiman
for always supporting me through good and bad times. All my dearest friend, Ahmed
Nuri, Raed and Raihana; for their advice, support and happy moment together during
this postgraduate study. Last but not least, I dedicate this work to my colleagues and
future students in the field of anatomy.
vii
TABLE OF CONTENTS
Abstract .................................................................................................................... …..ii
Abstract in Arabic .................................................................................................... ….iii
Approval Page .......................................................................................................... ….iv
Declaration ............................................................................................................... …..v
Copyright Page ......................................................................................................... ….vi
Acknowledgements .................................................................................................. …vii
List of Tables ........................................................................................................... …..x
List of Figures .......................................................................................................... ….xi
List of Abbreviations...................................................................................................xiv
CHAPTER ONE: INTRODUCTION .................................................................. …..1
1.1 Background ............................................................................................. …..1
1.1.1 Normal Anatomy of Lower Limb Arterial System ..................... …..2
1.1.1.1 Femoral Artery .................................................................. …..2
1.1.1.2 Popliteal Artery ................................................................. …..4
1.1.1.3 Anterior Tibial Artery........................................................ …..8
1.1.1.4 Posterior Tibial Artery ....................................................... …..9
1.1.1.5 Peroneal Artery .................................................................. …10
1.1.2 Embryology of Vascular System in Lower Limb ........................ …11
1.1.3 Physics of Ultrasound in Determining the Anatomy of
Lower Limb Arterial System ....................................................... …13
1.1.3.1 Ultrasound Instrumentation ............................................... …14
1.1.3.1.1 Real-time Ultrasound Units .................................... …14
1.1.3.1.2 Doppler Instruments ............................................... …17
1.1.3.2 Sonographic Findings of Lower Limb Arteries ................. …19
1.1.3.2.1 Gray-scale Image Characteristics of a
Normal Artery ........................................................ …19
1.1.3.2.2 Doppler Colour Flow Image Characteristics
of a Normal Artery ................................................. …20
1.1.3.2.3 Doppler Spectral Waveform Image
Characteristics of a Normal Artery ........................ …20
1.2 Justification ............................................................................................. …20
1.3 General Objective ................................................................................... …21
1.4 Specific Objectives ................................................................................. …21
CHAPTER TWO: LITERATURE REVIEW
2.1 Embryological Justification of Arterial Variations in Adult
Lower Limb
2.2 Classification of Lower Limb Arterial Variations in Popliteal
Region
2.2.1 Popliteal Artery Branching Pattern (Type I)
2.2.2 Popliteal Artery Branching Pattern (Type II)
2.2.3 Popliteal Artery Branching Pattern (Type III)
2.3 Clinical Significance of High-origin Anterior Tibial Artery and
Trifurcation of Popliteal Artery
viii
22
22
24
25
29
32
35
2.4 Other Studies Regarding Popliteal Artery
2.5 Concept of Lower Limb Dominance (Leg Dominance)
38
41
CHAPTER THREE: METHODOLOGY
3.1 Study Design
3.2 Population
3.3 Subjects
3.3.1 Inclusion Criteria
3.3.2 Exclusion Criteria
3.3.3 Subjects Recruitment Work Flow
3.3.4 Anthropometric Measurements
3.3.5 Ultrasound Examination Protocol of Lower Limb
Arterial System in Popliteal Region
3.4 Statistical Analysis
42
42
42
43
43
43
43
44
CHAPTER FOUR: RESULTS
4.1 Baseline Subjects Background
4.2 Descriptive Analysis of Popliteal Artery Branching Patterns
4.2.1 Type I-A (Usual Pattern)
4.2.2 Type I-B (Variant 1)
4.2.3 Type II-A (Variant 2)
4.3 Statistical Analysis of Popliteal Artery Branching Patterns
4.3.1 Percentage of Popliteal Artery Branching Patterns
4.3.2 Percentage of Popliteal Artery Branching Patterns
In Relation with Leg Dominance
4.3.3 Percentage of Subjects Having the Same (Symmetrical)
or Different (Non-symmetrical) Popliteal Artery
Variants in Both Lower Limbs
4.3.4 Luminal Diameter of Popliteal Artery and Anterior
Tibial Artery
4.3.5 Luminal Diameter of Other Arteries
(Tibial-peroneal Trunk, Posterior Tibial Artery and
Peroneal Artery)
4.3.6 Correlation between Luminal Diameter of Popliteal
Artery and Body Surface Area, Calf Circumference in
Dominant and Non-dominant Legs
53
53
54
54
58
62
66
66
CHAPTER FIVE: DISCUSSION
5.1 Overall Prevalence of Popliteal Artery Variations
5.2 Recommendations and Conclusion
73
73
75
REFERENCES
76
APPENDIX A: ETHICAL APPROVAL (IREC)
APPENDIX B: INFORMED CONSENT FORM (ENGLISH AND MALAY)
APPENDIX C: INFORMATION SHEET (ENGLISH AND MALAY)
APPENDIX D: LIST OF PRESENTATION
80
82
84
86
ix
46
52
66
67
68
68
69
LIST OF TABLES
Table 2.1
Normal level of division of popliteal artery (below the tibial plateau) 26
Table 2.2
High division of popliteal artery (above the tibial plateau)
30
Table 2.3
Hypoplastic-aplastic infrapopliteal vessels with altered arterial
supply to the foot
33
Frequency of popliteal arterial variations among different
studies
41
Table 4.1
Baseline parameters of 77 subjects recruited in this study
53
Table 4.2
Popliteal artery branching patterns in 154 lower limbs
66
Table 4.3
Popliteal artery branching patterns in dominant and nondominant legs
67
Unilateral and bilateral occurrence of popliteal artery variants
in 77 subjects
67
Mean, standard deviation for luminal diameter of popliteal
artery and anterior tibial artery
68
Frequency of tibial-peroneal trunk, posterior tibial artery and
peroneal artery in 77 subjects
68
Mean, standard deviation for luminal diameter of tibialperoneal trunk, posterior tibial artery and peroneal artery
69
Table 2.4
Table 4.4
Table 4.5
Table 4.6
Table 4.7
x
LIST OF FIGURES
Figure 1.1
Left thigh region showing femoral artery common stem from
where profunda femoris artery and medial circumflex femoral
artery arise
3
Right thigh region showing femoral artery and its branches in
the femoral triangle
3
Dissection of right popliteal region showing adductor hiatus
where femoral artery continues downward as popliteal artery
and femoral vein becomes popliteal vein after passing through
the hiatus
5
Figure 1.4
Structures in the right popliteal fossa (popliteal vein omitted)
6
Figure 1.5
Dissection of right popliteal region showing the bifurcation of
popliteal artery
7
Course of the popliteal artery genicular branches in right
popliteal region
8
Dissection of right popliteal region showing the origin and
course of posterior tibial artery and peroneal artery
10
Figure 1.8
Development of the arterial system in the lower limb
13
Figure 1.9
Various types of ultrasound transducer
16
Figure 1.2
Figure 1.3
Figure 1.6
Figure 1.7
Figure 1.10 Two basic real-time scanning formats for cross-sectional
imaging
16
Figure 1.11 Image of A-mode and M-mode with real-time sector B
scanning
17
Figure 1.12 Triphasic spectrum at rest
18
Figure 1.13 Bifurcation of a normal brachial artery (red) with parallel running
vein (blue) in colour duplex sonography
19
Figure 2.1
Embryologic development of arteries to leg
23
Figure 2.2
Arterial supply to the left lower limb
24
Figure 2.3
Normal level of popliteal arterial branching
26
Figure 2.4
Normal termination of popliteal artery in the right lower limb
27
Figure 2.5
Normal branching pattern of popliteal artery
27
xi
Figure 2.6
Trifurcation of popliteal artery in the right lower limb
28
Figure 2.7
Trifurcation of popliteal artery
28
Figure 2.8
Dissection of both popliteal regions in the same cadaver showing
high-origin anterior tibial artery proximal to the upper border of
popliteus muscle
29
Embryological pattern of arteries near the knee shows that
30
Figure 2.9
Figure 2.10 High division of popliteal artery
31
Figure 2.11 High-origin anterior tibial artery
31
Figure 2.12 High-origin posterior tibial artery
32
Figure 2.13 Hypoplastic or aplastic branching with altered distal supply
33
Figure 2.14 Aplastic posterior tibial artery
34
Figure 2.15 Hypoplastic anterior tibial artery
34
Figure 2.16 Hypoplastic or aplastic posterior tibial artery and anterior
tibial artery
35
Figure 2.17 Example of a high-origin anterior tibial artery
37
Figure 2.18 Levels of osteotomy for
37
Figure 2.19 Diagram shows the posterior view of the new patterns
40
Figure 3.1
Measuring tape was used to record the calf circumference
45
Figure 3.2
Colour doppler ultrasound machine used in this study
49
Figure 3.3
Surface marking of the popliteal fossa on the right lower limb
49
Figure 3.4
Sagittal scan from a posterior approach
50
Figure 3.5
Transverse scan from a posterior approach
50
Figure 3.6
Landmark for each peripheral pulses of the right lower limb
51
Figure 3.7
Flowchart for measurement of arteries luminal diameter at the
level of popliteus muscle
51
Figure 3.8
Luminal diameter measurements in bifurcation of popliteal artery
52
Figure 3.9
Luminal diameter measurements in trifurcation of popliteal artery
52
xii
Figure 4.1
Type I-A, branching pattern of the right popliteal artery in
sagittal view
55
Figure 4.2
Popliteal artery and its branches in transverse view
56
Figure 4.3
Sagittal view of Type I-A, branching pattern of the right
popliteal artery
57
Doppler spectral waveform image and schematic diagram
of the right popliteal artery
58
Type I-B, branching pattern of the right popliteal artery in
sagittal view
59
Sagittal view of Type I-B, branching pattern of the right
popliteal artery
60
Doppler spectral waveform image and schematic diagram
of the right
61
Type II-A, branching pattern of the left popliteal artery
in sagittal view
63
Sagittal view of Type II-A, branching pattern of the left
popliteal artery
64
Figure 4.4
Figure 4.5
Figure 4.6
Figure 4.7
Figure 4.8
Figure 4.9
Figure 4.10 Doppler spectral waveform image and schematic
diagram of the left
65
Figure 4.11 Luminal diameter of popliteal artery in relation to body
surface area in dominant and non-dominant legs
70
Figure 4.12 Luminal diameter of popliteal artery in relation to calf
circumference in dominant legs
71
Figure 4.13 Luminal diameter of popliteal artery in relation to calf
circumference in non-dominant legs
72
xiii
LIST OF ABBREVIATIONS
ASIS
Anterior superior iliac spine
ATA
Anterior tibial artery
BSA
Body surface area
CTA
Computed tomography angiography
DPA
Dorsalis pedis artery
DSA
Digital subtraction angiography
FA
Femoral artery
IIUM
International Islamic University Malaysia
IREC
IIUM Research Ethics Committee
LEA
Lower extremity artery
MDCT
Multidetector computed tomography
PA
Popliteal artery
PAES
Popliteal artery entrapment syndrome
PM
Popliteus muscle
PRA
Peroneal artery
PTA
Posterior tibial artery
PV
Popliteal vein
SPSS
Statistical Packaged for the Social Sciences
SS
Sample size
TKA
Total knee arthroplasty
TPT
Tibial-peroneal trunk
xiv
CHAPTER ONE
INTRODUCTION
1.1 BACKGROUND
A wide range of anatomical variations can be seen in the vascular system of adult
human lower limb. The knowledge of these variations which is determined by
embryonic vascular development is rather interesting not only for radiologists, but
also for surgeons who are responsible to plan the correct management (Ozgur, Ucerler
& Ikiz, 2009; Lappas, Stavropoulos, Noussios, Sakellariou & Skandalakis, 2012).
Vascular injury is frequently associated with lower limb trauma involving the
knee joint and popliteal fossa (Cross, Hall, Howdieshell, Colborn & Gale, 2000). In
the management of peripheral vascular disease and in surgery involving the knee joint,
it is important to know the course and termination of popliteal artery (PA). Knowledge
regarding the branching patterns of popliteal artery is essential because any damage to
its branches can be life- or limb-threatening (Tindall, Shetty, James, Middleton &
Fernando, 2006).
According to literature review, the earliest study pertaining to popliteal artery
variations was done by Quain and Maclise in 1844. This study was observed in
Europeans. The incidence of popliteal artery variations among American Whites and
Negroes was studied by Trotter in 1940. In 1989, Kim, Orron and Skillman introduced
a revised classification of popliteal artery branching patterns based on previous study
done by Lippert and Pabst (1985).
The importance of popliteal artery branching patterns in surgery had been
previously evaluated by different techniques such as cadaveric method, angiographic
1
studies and Doppler ultrasonography. Those reports were studied in many other
countries, but not in Malaysia. Therefore, this study is aimed to evaluate the popliteal
artery branching patterns and related measurements using Doppler ultrasonography in
healthy subjects. It is hoped that this study will be beneficial and add up to the
existing knowledge of vascular anatomy of lower limb.
1.1.1
Normal Anatomy of Lower Limb Arterial System
1.1.1.1 Femoral Artery
Femoral artery (FA) is the chief artery which provides the main arterial supply to the
lower limb (Moore & Dalley, 1999; Standring, 2004; Snell, 2011; Chaurasia, 2013;
Nafis, 2013).
Femoral artery which is the continuation of external iliac artery, begins deep to
inguinal ligament, midway between anterior superior iliac spine (ASIS) and pubic
symphysis, descends on the adjacent borders of iliopsoas and pectineus forming the
floor of femoral triangle, passes deep to sartorius and enters through the adductor
(subsartorial) canal, then exits through an opening in adductor magnus (adductor
hiatus) near the junction of middle and distal thirds of the thigh before entering the
popliteal fossa as popliteal artery (Moore & Dalley, 1999; Standring, 2004; Snell,
2011; Chaurasia, 2013; Nafis, 2013).
In the femoral triangle, femoral artery gives off three superficial and three
deep branches (Figure 1.1 and Figure 1.2). Superficial branches are superficial
epigastric artery which supplies the skin and fasciae at the lower part of anterior
abdominal wall; superficial circumflex iliac artery which supplies the skin along iliac
crest; and superficial external pudendal artery which supplies the skin of external
genital organs. Deep branches are profunda femoris, the chief artery which supplies all
2
the three compartments of the thigh (anterior, medial & posterior); deep external
pudendal artery which supplies the external genital organs; and muscular branches
which supply the sartorius, vastus medialis and adductors (Moore & Dalley, 1999;
Standring, 2004; Snell, 2011; Chaurasia, 2013; Nafis, 2013).
Figure 1.1 Left thigh region showing femoral artery common stem from where
profunda femoris artery and medial circumflex femoral artery arise
(Modified from Suthar, Patil, Mehta, Patel, Prajapati & Bhatt, 2013).
SUPERFICIAL EPIGASTRIC ARTERY
SUPERFICIAL CIRCUMFLEX ILIAC ARTERY
FEMORAL ARTERY
PROFUNDA FEMORIS ARTERY
Figure 1.2 Right thigh region showing femoral artery and its branches in the femoral
triangle (Modified from Pradip, Alpa, Monika, Ashish, Ankit & Suresh, 2015).
3
1.1.1.2 Popliteal Artery
Popliteal artery, which is the continuation of femoral artery, enters the popliteal fossa
through an opening (adductor hiatus) in adductor magnus (Figure 1.3). Popliteal artery
is the deepest structure in the popliteal fossa and runs close to the articular capsule of
the knee joint. It ends by dividing into anterior tibial artery (ATA) and posterior tibial
artery (PTA) at the level of inferior border of popliteus muscle (PM) (Moore &
Dalley, 1999; Standring, 2004; Snell, 2011; Chaurasia, 2013; Nafis, 2013).
In popliteal artery surgery, radiologists and surgeons prefer to use another
description of popliteal artery and its main branches where anterior tibial artery arising
first followed by tibial-peroneal trunk (TPT), which then gives rise to the posterior
tibial artery and the peroneal artery (PRA) (Day & Orme, 2006) (Figure 1.4 and
Figure 1.5).
Popliteal artery has genicular and muscular branches. Articular capsule and
ligaments of the knee joint are supplied by five genicular branches of popliteal artery
namely the lateral superior, medial superior, middle, lateral inferior and medial
inferior genicular arteries (Figure 1.6). They participate in the formation of network of
vessels around the knee joint which is called the genicular anastomosis (Moore &
Dalley, 1999; Standring, 2004; Chaurasia, 2013; Nafis, 2013).
Muscular branches of popliteal artery can be divided into superior muscular
and inferior muscular or sural branches. Superior muscular branches supply the
adductor magnus and hamstrings, and have clinically important anastomoses with the
terminal part of deep femoral and gluteal arteries. Gastrocnemius, soleus and plantaris
are supplied by the inferior muscular or sural branches (Moore & Dalley, 1999;
Standring, 2004; Chaurasia, 2013).
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Figure 1.3 Dissection of right popliteal region showing adductor hiatus where femoral
artery continues downward as popliteal artery and femoral vein becomes popliteal
vein after passing through the hiatus.
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Figure 1.4 Structures in the right popliteal fossa (popliteal vein omitted) (O’Rahilly,
Muller, Carpenter & Swenson, 1982).
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Figure 1.5 Dissection of right popliteal region showing the bifurcation of popliteal
artery.
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Tibia
Fibula
Figure 1.6 Course of the popliteal artery genicular branches in right popliteal region
(Modified from Chaurasia, 2013).
1.1.1.3 Anterior Tibial Artery
The smaller terminal branch of popliteal artery which is anterior tibial artery, begins at
the inferior border of popliteus muscle. It passes anteriorly through a gap in the
superior part of interosseous membrane and descends on the anterior surface of this
membrane between tibialis anterior and extensor digitorum longus (Figure 1.4 and
Figure 1.5). Anterior tibial artery is the main arterial supply for anterior compartment
of the leg (Moore & Dalley, 1999; Standring, 2004; Snell, 2011; Chaurasia, 2013;
Nafis, 2013).
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Anterior tibial artery has muscular branches which supply adjacent muscles
and anastomotic branches which are given to the knee and ankle joints. Anterior and
posterior tibial recurrent branches take part in the anastomoses around the knee joint.
Anterior medial malleolar and anterior lateral malleolar branches take part in the
anastomoses around the ankle joint (Standring, 2004; Snell, 2011; Chaurasia, 2013;
Nafis, 2013).
Anterior tibial artery ends at the ankle joint, midway between malleoli, where
it becomes dorsalis pedis artery (DPA) or dorsal artery of the foot (Moore & Dalley,
1999; Standring, 2004; Snell, 2011; Chaurasia, 2013; Nafis, 2013).
1.1.1.4 Posterior Tibial Artery
Posterior tibial artery, which provides the main arterial supply to the posterior
compartment of the leg and the foot, is the larger terminal branch of popliteal artery. It
begins at the inferior border of popliteus muscle and passes downward deep to the
gastrocnemius, soleus and deep transverse fascia of the leg (Figure 1.4 and Figure
1.7). After giving off peroneal artery, its largest branch, posterior tibial artery passes
inferomedially on the posterior surface of tibialis posterior (Moore & Dalley, 1999;
Standring, 2004; Snell, 2011; Chaurasia, 2013; Nafis, 2013).
During its descend in the leg, posterior tibial artery is accompanied by tibial
nerve and veins. Posterior tibial artery runs downward and slightly medially, to reach
the posteromedial side of the ankle, midway between medial malleolus and medial
tubercle of calcaneum. Deep to the origin of abductor hallucis and flexor retinaculum,
posterior tibial artery divides into lateral and medial plantar arteries (Moore & Dalley,
1999; Standring, 2004; Snell, 2011; Chaurasia, 2013; Nafis, 2013).
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Other important branches of posterior tibial artery are muscular branches
which are distributed to the muscles in posterior compartment of the leg; anastomotic
branches which join other arteries around the ankle joint and a nutrient artery which is
given off to the tibia (Moore & Dalley, 1999; Standring, 2004; Snell, 2011; Chaurasia,
2013; Nafis, 2013).
Figure 1.7 Dissection of right popliteal region showing the origin and course of
posterior tibial artery and peroneal artery.
1.1.1.5 Peroneal Artery
Peroneal artery is the largest branch and the most important branch of posterior tibial
artery. It begins 2.5 centimetre (cm) below the inferior border of popliteus muscle and
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