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Collateral pathways of the abdominal wall: anatomical
review and pathologic findings at 64-slice multidetector CT
angiography
Poster No.:
C-3062
Congress:
ECR 2010
Type:
Educational Exhibit
Topic:
Vascular
Authors:
L. Miranda Orella, J. M. Mellado Santos, N. Yanguas Barea, S.
Solanas Álava, R. Larrosa Lopez, J. Martín Cuartero; Tudela/ES
Keywords:
collateral pathways, abdominal wall, multidector CT
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Page 1 of 30
Learning objectives
•
•
To review the anatomy and variability of normal arteries and veins of the
abdominal wall.
To illustrate and discuss the arterial and venous collateral pathways of the
abdominal wall, as seen on 64-slice multidetector CT angiography.
Background
Collateral circulation of the abdominal wall is common in various vascular disorders.
Although scant mention of the topic is found in the radiologic literature, these collateral
pathways are clinically relevant, and may be characterized by multidetector CT
angiography.
TECHNICAL ASPECTS
Currently available MDCT offers the combined advantages of high speed, seamless
coverage of the entire abdomen, and outstanding spatial resolution, owing to available
isometric submillimeter voxel size.
These technical advances have significantly improved image quality of CT-angiographic
studies, where a number of injection protocols may be selected for adequate depiction
of arteries or veins.
Page 2 of 30
In addition, state-of-the-art MDCT equipment incorporates improved tridimensional
displays, including multiplanar reformations, maximum-intensity projections (MIP) and
coloured volume-renderings, which greatly contribute to the study of the small-caliber
vessels of the abdominal wall.
Imaging findings OR Procedure details
ANATOMICAL REVIEW
Summed anatomical review of the most important arteries and veins of the abdominal
wall is enclosed in the tables below.
Arteries of the abdominal wall
Artery
Source
Anastomoses
Inferior intercostal
Descending thoracic aorta
Superior and inferior
epigastric, deep circumflex
arteries
Superior epigastric
Internal mammary a.
Inferior epigastric and
intercostal arteries
Inferior epigastric
External iliac a.
Superior epigastric,
intercostal arteries.
Deep circunflex iliac
External iliac a.
Inferior intercostal and
lumbar arteries
Subcostal and lumbar
Abdominal aorta
Deep iliac circumflex,
inferior gluteal arteries
Veins of the abdominal wall
Page 3 of 30
Vein
Drains to
Main anastomoses
Superior epigastric
Internal mammary v.
Inferior epigastric v.
Inferior epigastric
External iliac v.
Superior epigastric v.
Thoracoepigastric
Lateral thoracic v.
Superficial circumflex v.
Superficial epigastric
Internal saphena v.
Tributaries of
paraumbilical veins and
thoracoepigastric v.
Paraumbililical
Left branch of portal v.
Inferior cava, superior and
inferior epigastric veins,
superficial epigastric v.
Superficial circumflex
Internal saphena v.
Thoracoepigastric v.
ARTERIAL COLLATERAL PATHWAYS
PATHOLOGIC CONDITIONS
OF
THE
ABDOMINAL
WALL
IN
Arterial collateral circulation is mainly found in chronic aortic and aortoiliac occlusive
disease:
•
When the stenosis occurs in the descending thoracic aorta, internal
mammary arteries connect subclavian arteries with the descending thoracic
aorta through the intercostal arteries and with the external iliac arteries
through the superior and inferior abdominal epigastric arteries.
Page 4 of 30
Fig.: Diagram 1.
References: Hospital of Tudela
•
If stenosis affects the suprarenal aorta, intercostal arteries may
anastomose the external iliac arteries through the superior and inferior
epigastric arteries or through the deep iliac circumflex arteries.
Page 5 of 30
Fig.: Diagram 2.
References: Hospital of Tudela
•
In infrarenal aorta and aortoiliac occlusion other collateral pathways
are possible: the lumbar arteries may supply the internal iliac arteries via
the inferior gluteal arteries or connect with external iliac arteries via the
circumflex arteries (Fig 1 on page 15, fig 2 on page 16, fig 3 on page
16).
Page 6 of 30
Fig.: Diagram 3.
References: Hospital of Tudela
VENOUS COLLATERAL PATHWAYS OF THE ABDOMINAL WALL IN PATHOLOGIC
CONDITIONS
Page 7 of 30
Venous collateral circulation associates with superior vena cava obstruction, inferior vena
cava occlusion, and portal hypertension:
Superior vena cava stenosis is usually compensated by collateral circulation through
the azygos-hemiazygos system. Only when azygos vein is also occluded abdominal wall
collateral pathways are seen. Three routes are possible:
•
Deep route: Brachiocephalic v. # internal mammary # superior epigastric v.
# inferior epigastric v. # external iliac v. (Fig 4 on page 17, fig 5 on page
18)
Page 8 of 30
Fig.: Diagram 4
References: Hospital of Tudela
•
Superficial routes (Fig 5 on page 18, fig 6 on page 19, fig 7 on page
20, fig 8 on page 21, fig 9 on page 22):
- Lateral route: Subclavian v. # lateral thoracic v. # thoracoepigastric v. # superficial
circumflex iliac v. # internal saphena v.
- Medial route: Internal mammary v. # superficial tributaries of internal mammary v. #
superficial tributaries of paraumbilical v. # superficial epigastric v. # internal saphena v.
Fig.: Diagram 5.
References: Hospital of Tudela
•
Portal system: Small vessels from superior, inferior and superficial epigastric
veins can anastomose with paraumbilical v. and portal system (Fig 4 on
page 17, fig 5 on page 18, fig 6 on page 19).
Page 9 of 30
Fig.: Diagram 6.
References: Hospital of Tudela
With the Inferior vena cava obstruction (Fig 10 on page 23) can appear four major
collateral pathways through which blood returns from lower extremities and pelvis but
only the two last ones involve the abdominal wall:
•
Deep pathway: azygos-hemiazygos system.
•
Intermediate pathway: gonadal and periureteric vessels.
•
Abdominal wall pathways: Similar to those described for SVC occlusion but
with inverse blood flow.
•
Portal pathways:
Page 10 of 30
- Mesenteric pathway: Internal iliac v. # hemorroidal plexus # inferior mesenteric v. #
splenoportal axis.
- Superficial pathway: Epigastric vv. # paraumbilical v. # portal system.
Collateral circulation of the abdominal wall may also be caused by portal hypertension,
usually following the course of the paraumbilical veins.
Page 11 of 30
Fig.: Diagram 7.
References: Hospital of Tudela
Paraumbilical vein arise from the left portal vein and may anastomose with:
•
Superior epigastric or internal mammary veins and drain into the superior
vena cava (Fig 11 on page 24)
•
Inferior and superficial epigastric vein and drain into the external iliac and
internal saphena veins respectively. (Fig 12 on page 25, fig 13 on page
26)
Page 12 of 30
•
Lateral route (through the thoracoepigastric vein) may be also involved.
These connections in the periumbilical area are termed "caput medusae" (fig 14 on page
27)
Therefore, paraumbilical vein may be involved as collateral pathway in superior and
inferior vena cava stenosis and in portal hypertension, but blood flow direction is the
opposite.
Page 13 of 30
Page 14 of 30
Images for this section:
Fig. 1: 73-year-old man with chronic occlusion of the infrarenal aorta. A: Coronal MIP
shows complete occlusion of infrarenal aorta (black arrows), and repermeabilzation of
external iliac arteries (white arrows). B: Sagital MIP shows collateral pathways on the left
abdominal wall through superior epigastric (red arrow) and intercostal arteries (orange
arrows), which anastomose with inferior epigastric artery (white arrow). Inferior intercostal
Page 15 of 30
arteries (green arrows) are also seen, which connect with the external iliac artery through
the deep circumflex artery (yellow arrow).
Fig. 2: Volume rendering in the same patient (A) shows retrograde flow into inferior
epigastric (white arrows) and deep circumflex arteries (yellow arrows). Left inferior gluteal
artery (blue arrow) is also seen, which communicates with the homolateral lumbar arteries
(green arrows), as shown in axial MIP (B).
Page 16 of 30
Fig. 3: 75-year-old man with right common iliac and left external iliac occlusion. A:
Frontal volume rendered image shows communication between lumbar arteries (green
arrows) and deep circumflex arteries (yellow arrows). B: Lateral MIP reconstruction
shows anastomoses between inferior (white arrow) and superior (red arrow) epigastric
arteries in the same patient.
Page 17 of 30
Fig. 4: 47-years old woman with right lung cancer. A: Coronal MPR shows a tumoral mass
in the right upper lobe with superior vena cava and azygos (black arrow) obstruction. B:
Coronal MIP depicts retrograde flow through the tributaries of internal mammary veins
(blue arrows), musculophrenic veins (red arrows), superior epigastric veins (red arrows)
and a periumbilical branches (purple).
Page 18 of 30
Fig. 5: A: Lateral MIP partially shows two different collateral circulation systems:
superficial thoracic veins (white arrows) connect with periumbilical branches (purple
arrows) and superficial epigastric veins (orange arrows), which are tributaries of the
internal saphena veins; internal mammary veins (blue arrows) communicate with superior
epigastric veins (red arrow) which supply the external iliac veins through the inferior
epigastric veins (green arrows). B: Axial MIP shows the relationship between superficial
and inferior epigastric veins. Superficial circumflex veins are also seen (yellow arrows).
Page 19 of 30
Fig. 6: Volume rendering shows extensive collateral circulation on the surface of the
thoracic wall and its communication with the superficial collateral pathways on the
anterior abdominal wall. Two main routes are depicted: lateral thoracic veins connect
with the thoracoepigastric veins and these supply the internal saphena veins through
the superficial circumflex veins; superficial epigastric veins result from a complex net of
superficial veins on the anterior thoracoabdominal wall and flow into the femoral veins.
Page 20 of 30
Fig. 7: 58-year-old woman in chemotherapic treatment for colon cancer with liver
metastases. A: Coronal MIP shows a superior vena cava occlusion induced by the central
venous catheter (white arrow). B: Lateral MIP shows collateral venous circulation around
the superior vena cava and retrograde flow through the internal mammary vein (blue
arrows), which connect with a superficial vein on the epigastric region (black arrows).
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Fig. 8: Evolution of the abdominal wall superficial collateral circulation in the same patient.
Thrombosis of the superior vena cava is detected in January, and the central venous
catheter is removed. Nevertheless, thrombosis remains and collateral circulation on the
anterior abdominal wall progressively develops.
Page 22 of 30
Fig. 9: A: 86-year-old man with neoplastic mass in the right upper lobe, who presented
with left brachiocephalic vein obstruction. B: Collateral pathway communicates left
subclavian vein with the opposite superficial epigastric veins through a superficial
thoraco-abdominal anastomosing vein.
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Fig. 10: 74-year-old man with hypernephroma and tumoral thrombus in the left renal vein
and inferior vena cava (large arrows). Although intraabdominal collateral pathways are
seen (red arrows), abdominal wall collateral circulation could not be detected.
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Fig. 11: A: 79-year-old man with cirrhosis and possible malignant degeneration (white
arrows). Thrombosis of the left portal branch (black arrow) is seen. B: Coronal MIP shows
anastomoses between paraumbilical vein (purple arrow) and internal mammary veins
(blue arrows).
Page 25 of 30
Fig. 12: 78-year-old woman with alcohol-induced cirrhosis. Coronal MIP (A, B) show
collateral pathways through tortuous gastrorenal (small arrows) and spleno-renal shunts,
seen around the left kidney ( large arrows).
Page 26 of 30
Fig. 13: Abdominal wall collateral pathways in the same patient. A: Volume rendering
shows superficial epigastric veins (orange arrows), circumflex iliac veins (yellow arrows)
and thoracoepigastric veins (white arrows). B: Lateral MIP shows superficial and deep
abdominal wall collateral pathways arising from the periumbilical zone: superficial
epigastric vein (orange arrows) and thoracoabdominal superficial veins (purple arrows);
inferior epigastric (green arrows) and superior epigastric veins (red arrow).
Page 27 of 30
Fig. 14: 61-year-old woman with cirrhosis. Volume rendered image shows the
communication between paraumbilical vein and the superficial veins of the abdominal
wall, also called "caput medusae".
Page 28 of 30
Conclusion
64-slice multidetector CT angiography:
•
•
Allows superb depiction of arterial and venous collateral pathways of the
abdominal wall
Provides useful information about its etiology and significance.
Personal Information
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