Case Report

By Dr. Atanas D Hilendarov , Dr. Slavi Delchev , Dr. Evgeni Ivanov , Dr. Kitchka Velkova , Dr. Stephan Sivkov
Corresponding Author Dr. Atanas D Hilendarov
Medical University, Volga 49, ap.14 - Bulgaria 4002
Submitting Author Dr. Atanas D Hilendarov
Other Authors Dr. Slavi Delchev
Ph.D., Department of Anatomy, Histology and Embryology, - Bulgaria 4002

Dr. Evgeni Ivanov
Department of Cardiovascular Surgery, Medical University , - Bulgaria 4002

Dr. Kitchka Velkova
Department of Diagnostic Imaging, Medical University , - Bulgaria

Dr. Stephan Sivkov
Department of Anatomy, Histology and Embryology, Medical University , - Bulgaria


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

Hilendarov AD, Delchev S, Ivanov E, Velkova K, Sivkov S. Collateral Circulation in Chronic Arterial Insufficiency of the Common Iliac Artery - CT Angiographic Findings. WebmedCentral ANGIOLOGY 2012;3(6):WMC003426
doi: 10.9754/journal.wmc.2012.003426

This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Click here
Submitted on: 04 Jun 2012 06:46:04 PM GMT
Published on: 05 Jun 2012 11:56:28 AM GMT


Background: The collateral circulation in aortoiliac occlusive disease involves multiple pathways and the dominant type is determined by the level of occlusion. The aim of this report is to assess the collateral circulation in patients with chronic occlusive disease of the iliac arteries using computed tomography angiography and post-processing image reconstruction.

Methods: A case of an 80-year-old patient with occlusion of the right common iliac artery is presented. Using computed tomography (CT) angiography were evaluated arterial collaterals, providing blood flow to the right lower limb. The post-processing reconstruction of the image allowed additional spatial visualization of some of the collaterals.

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

Conclusions: Complementation of CT angiography with post-processing image reconstruction improves visualization and analysis of the collateral pathways in chronic occlusive disease of the iliac arteries, which is necessary for adequate preoperative evaluation of the dominant of collateral circulation.


The proper preoperative evaluation of the dominant type collateral circulation in patients with chronic occlusive disease of the iliac arteries is important to avoid undesirable consequences for the patient. The interruption of some of the actively functioning collaterals can lead to ischemic failure and risk of eventual loss of the limb [2]. The collateral circulation in aortoiliac occlusive disease involves multiple pathways and the dominant type is determined by the level of occlusion [8]. One group of collaterals are parietal intersystemic pathways via the intercostal, epigastric, lumbar and other parietal vessels, which provide collaterals to the external and internal iliac arteries. Some of the most important known anastomoses are [1, 2, 8]: Internal thoracic (mammary) artery – superior epigastric artery – inferior epigastric artery („Winslow’s pathway”). Fourth lumbar artery with iliolumbar artery (to internal iliac artery) or deep circumflex iliac artery (to external iliac artery). Right lateral sacral artery - median sacral artery - left lateral sacral artery. The other group of collaterals are visceral intersystemic pathways through branches of mesenteric arteries and internal iliac artery into the haemorrhoidal plexus [8]: inferior mesenteric artery - superior rectal artery - middle rectal artery; as well as other arteries, forming networks around organs in the lesser pelvis. Various collateral pathways in the pelvis have been studied and demonstrated to clarify the perfusion of structures located distal to arteriosclerotic vascular occlusion [6]. Using Doppler sonography it has been found that after ligation of the common iliac arteries in experimental models paraorganic collaterals through pelvic vessels begin to function soon after the surgery and provide sufficient blood flow to the limb [12]. Similar data for the involvement of collateral circulation in the pelvis, identified angiographically have also been reported in occluded infected aortoiliac dacron prosthesis [8]. In more recent publications, some of them referring to data from computed tomography (CT) angiography, cases with visualization of pelvic vasculature [3, 5, 9] and dominanting part of the so-called "Winslow’s pathway" [2, 7, 11, 13, 14] have been presented. The aim of this communication is to assess the collateral circulation in patient with chronic occlusive disease of the iliac arteries by CT angiography and additional image post-processing.

Material and Methods

Eighty-year-old male was admitted in emergency to the Clinic of vascular surgery for sudden pain in the right calf and thigh and in the right inguinal fold, accompanied with paleness and progressive blueness of the right foot. The patient had long history of intermittent claudication a result of poor blood flow to the legs. In recent days, the patient could hardly walk more than 50-60 feet away, and in the last 24 hours the same symptoms were present at rest. Pale, cool, painful right lower limb with sensory and motor deficiency were found on examination. Upon palpation the pulse in the right femoral artery was weak and hardly palpable, and absent in the right popliteal and dorsalis pedis arteries. Emergency catheter thrombectomy of the right femoral artery was done to remove the blockage. During the procedure impassable location was reached proximally at the bifurcation of the right common iliac artery. Emergency CT angiography was performed using 16 spiral scanner in the supine position (Bright Speed, GE, USA). Power settings were 100–120 kV and 200–300 mA, matrix of 512 X 512 pixels, collimation of 16 X 1.25 mm (slice thickness 0.5 mm), pitch of 1.3. Post-processing with 3D reconstruction was performed.


CT angiographic reconstruction revealed significant sclerotic changes along the aorta and iliac arteries. The left common iliac artery and its branches were contrasted distally to the foot branches, despite the narrowing from atheromatous plaques along their entire length. The right common iliac artery was not displayed, but distally external iliac artery was shown filled by collateral blood supply (Fig. 1). The level of collaterals was better displayed in further reconstructions. On successive cross-slices the right inferior epigastric artery was traced on the posterior surface of rectus abdominis muscle, significantly more congested than the left one (Fig. 2). The post-processing reconstruction allowed spatial visualization of this artery and its anastomosis through pubic branch with obturator artery (for the internal upper thight) (Fig. 3). Small collateral visceral branches were visualized, perfusing the right internal iliac artery from branches of the left internal iliac artery and from inferior mesenteric artery (Fig. 4).

Multiple narrowings presented distally in the right main arteries - the femoral and popliteal artery, without evidence of complete occlusion.

After diagnosing the above-described changes a decision for performing aortofemoral bypass was made. As a result, steady pulses of the right femoral artery appeared, warming of the limb, recovered sensation and motor function and increase in the claudication distance to over 300-350 meters.


This communication is an attempt to trace the arterial collaterals functioning in occlusion of large pelvic arterial vessels using CT angiography with post-processing image reconstruction. Our data are limited to the main collaterals that traced in angiographic series, contribute significantly to keep up the blood flow.
In our patient both types of anastomoses - visceral and parietal intersystemic are involved to overcome the gradually developed occlusion of the right common iliac artery. The first type of anastomoses are mainly ipsilateral: superior epigastric artery - inferior epigastric artery. Additionally the inferior epigastric artery communicates via pubic branch with the obturator artery and consequently with the internal iliac artery. The visualized vessels in the right iliac fossa show inclusion of the fourth lumbar artery through the iliolumbal artery to the internal iliac artery and through the deep circumflex iliac artery to the external iliac artery.
The second type is realized through the visceral branches: middle and inferior left rectal arteries - middle and inferior right rectal arteries (pararectal) and left vesical arteries - right vesical arteries (paravesical). Additional blood enters to the pararectal plexus through superior rectal artery, the continuation of the abdominal inferior mesenteric artery, and to a lesser degree through median sacral artery. The blood flow from this network fills the visceral branches of the right internal iliac artery. Some authors attribute major importance to the parietal intersystemic anastomoses as a collateral pathway in iliac occlusion [2, 7, 11, 13], and others – to the visceral intersystemic anastomoses through inferior mesenteric artery - rectal arteries, vesical arteries and other paraorganic plexuses [6, 8, 10, 12]. Studies show that the blood flow in the collateral network increases two to three times depending on the level and extent of occlusion [10, 12]. In patients with chronic occlusive disease of the aortoiliac segment careful evaluation of the major collaterals is necessary due to the risk of serious ischemic complications after their interruption [2]. These collateral pathways may be involved equivocally, or one may dominate. In cases of developed communication via internal thoracic artery - inferior epigastric artery its interruption in cross sections of the anterior abdominal wall or use of these areas as a flap in reconstructive surgery is contraindicated [14]. Using internal thoracic artery in coronary bypass surgery requires further clarification of the extent of involvement of the right and left arteries by selective angiography [2, 14]. Development of the visceral collateral circulation in the lesser pelvis also necessitates caution in surgical procedures in this area [3-5].


CT angiographic evidence of the collateral circulation in our patient corresponds with the opinion of a number of authors for the high informativeness of the images obtained using multislice computed tomography in cases of vascular obstruction. Preoperative evaluation of actively functioning collaterals and their identification is imperative to avoid ischemic complications in the affected lower limb. Complementing CT angiography with post-processing image reconstruction offers new opportunities for precise diagnostic analysis of the type of collateral network and spatial visualization of vessels involved in chronic occlusive disease of the iliac arteries.

Conflict of interest. The authors declare that they have no conflict of interest.


1. Bechara C, Cagiannos C, Chen C, Lin PH (2010) Aortoiliac occlusive disease. In: Brunicardi FC (ed) Schwartz’s Principles of Surgery, 9th edn. The McGraw-Hill, New York pp 1432-1436
2. Ben-Dor I, Waksman R, Salter LF et al (2010) A further word of caution before using the internal mammary artery for coronary revascularization in patients with severe peripheral vascular disease. Catheter Cardiovasc Interv 75(2):195-201
3. Bilhim T, Casal D, Furtado A et al (2011) Branching patterns of the male internal iliac artery: imaging findings. Surg Radiol Anat 33:151-159
4. Devine TJ, Myers KA, Slattery PG (1980) Severe leg ischaemia caused by anterior resection of the rectum. Br J Surg 67(1):52-53
5. Ding HM, Yin ZH, Zhou XB et al (2008) Three-dimensional visualization of pelvic vascularity. Surg Radiol Anat 30:437-442
6. Friedenberg MJ, Perez CA (1965) Collateral circulation in aorto-ilio-femoral occlusive disease: as demonstrated by unilateral percutaneous common femoral artery needle injection. Am J Roentgenol Radium Ther Nucl Med 94:145-158
7. Kim J, Won JY, Park SI, Lee DY (2003) Internal thoracic artery collateral to the external iliac artery in chronic aortoiliac occlusive disease. Korean J Radiol 4(3):179-183
8. Kupic EA, Mackenzie JR (1968) Angiographic demonstration of cross pelvic collateral circulation following bilateral axillary femoral bypass. Am J Roentgenol Radium Ther Nucl Med 102(2):418-423
9. Lin PH, Bechara C, Kougias P et al (2008) Assessment of aortic pathology and peripheral arterial disease using multidetector computed tomographic angiography. Vasc Endovascular Surg 42(6):583-598
10. Novosad EM (2003) Specific features of circulation in aorto-iliac arterial occlusion. Klin Khir 8:33-34
11. Takahashi S, Kaneda H, Saito S (2007) Winslow’s pathway in 64-slice multi-detector computed tomography. Eur Heart J 28(20):2437
12. Takebe K, Uchida H, Teramoto S (1994) An experimental hemodynamic study of the pelvic collateral circulation. Acta  Med Okayama 48(1):31-38
13. Yurdakul M, Tola M, Ozdemir E et al (2006) Internal thoracic artery-inferior epigastric artery as a collateral pathway in aortoiliac occlusive disease. J Vasc Surg 43(4):707-713
14. Zaizen H, Tamura A, Miyamoto K, Kadota J (2007) The collateral pathway from the left internal thoracic artery to the left external iliac artery detected by multislice computed tomography. Int J Cardiol 117(2):e56-e57

Source(s) of Funding


Competing Interests



This article has been downloaded from WebmedCentral. With our unique author driven post publication peer review, contents posted on this web portal do not undergo any prepublication peer or editorial review. It is completely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscript but also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions before submitting any information that requires obtaining a consent or approval from a third party. Authors should also ensure not to submit any information which they do not have the copyright of or of which they have transferred the copyrights to a third party.
Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater to the needs of an individual patient. The web portal or any content(s) therein is neither designed to support, nor replace, the relationship that exists between a patient/site visitor and his/her physician. Your use of the WebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harm that you may suffer or inflict on a third person by following the contents of this website.

0 reviews posted so far

0 comments posted so far

Please use this functionality to flag objectionable, inappropriate, inaccurate, and offensive content to WebmedCentral Team and the authors.


Author Comments
0 comments posted so far


What is article Popularity?

Article popularity is calculated by considering the scores: age of the article
Popularity = (P - 1) / (T + 2)^1.5
P : points is the sum of individual scores, which includes article Views, Downloads, Reviews, Comments and their weightage

Scores   Weightage
Views Points X 1
Download Points X 2
Comment Points X 5
Review Points X 10
Points= sum(Views Points + Download Points + Comment Points + Review Points)
T : time since submission in hours.
P is subtracted by 1 to negate submitter's vote.
Age factor is (time since submission in hours plus two) to the power of 1.5.factor.

How Article Quality Works?

For each article Authors/Readers, Reviewers and WMC Editors can review/rate the articles. These ratings are used to determine Feedback Scores.

In most cases, article receive ratings in the range of 0 to 10. We calculate average of all the ratings and consider it as article quality.

Quality=Average(Authors/Readers Ratings + Reviewers Ratings + WMC Editor Ratings)