Abstract
The objective of this review is to describe the normal and variant anatomy of the inferior mesenteric artery (IMA), including a brief overview of the relevant embryology, as well as proposing a classification system of the IMA vasculature, and clinical significance. A systematic review of articles published in Google Scholar and PubMed database using search terms: inferior mesenteric artery anatomy, inferior mesenteric artery variation, inferior mesenteric artery development, mesenteric circulation anatomy and variation, inferior mesenteric artery angiography. This was followed by review of the reference list of relevant publications to reveal publications missed during the initial search. Several standard anatomy and surgery text books were also referred for normal anatomy. The anatomy of the inferior mesenteric system is highly variant, with only a small proportion of anatomical, angiographic or surgical studies providing support for what is traditionally taught to be normal anatomy. Whilst the origin of the inferior mesenteric artery is less variant, the branching into left colic, sigmoidal and superior rectal arteries is variable between individuals in terms of origin of branches, number of branches and the presence or absence of certain branches. Whilst there did not appear to be a common classification system, similarities included three main variants of branching with a colo-sigmoid trunk, recto-sigmoid trunk or common trifurcation. There is a disparity between what is described in anatomical texts as the ‘normal’ IMA, and what is seen in anatomical, radiological and surgical research studies. The variable anatomy of the inferior mesenteric artery and its branches is significant in radiological interpretation and colorectal surgery from both an oncological perspective when considering resection, as well as in colonic ischaemia. A classification system has been introduced with a step-wise approach to the assessment of the IMA anatomy to avoid misleading nomenclature and provide a framework for surgeons to assess the vasculature.
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References
Abe T, Ujiie A, Taguchi Y, Satoh S, Shibuya T, Jun Y, et al. Anomalous inferior mesenteric artery supplying the ascending, transverse, descending, and sigmoid colons. Anat Sci Int. 2018;93:144–8. https://doi.org/10.1007/s12565-017-0401-2.
Beck DE, Wexner SD, Rafferty JF. Gordon and Nivatvongs’ principles and practice of surgery for the colon, rectum, and anus. New York: Thieme; 2018.
Bertrand MM, Delmond L, Mazars R, Ripoche J, Macri F, Prudhomme M. Is low tie ligation truly reproducible in colorectal cancer surgery? Anatomical study of the inferior mesenteric artery division branches. Surg Radiol Anat. 2014;36:1057–62. https://doi.org/10.1007/s00276-014-1281-y.
De Martino R. Normal and variant mesenteric anatomy. In: Oderich GS, editor. Mesenteric vascular disease. New York: Springer; 2015. https://doi.org/10.11007/978-14939-1847-8_2.
Deepa S, Ashalatha PR. A study of origin, course and variations of inferior mesenteric artery and its branches. IJAR. 2018;7:7660–3. https://doi.org/10.14260/jemds/2016/1728.
Eldeen EGMH, Mohomed AHAG. Anatomical pattern of the origins of the ventral branches of the abdominal aorta. Rev Arg de Anat Clin. 2016;8:192. https://doi.org/10.13140/RG.2.2.21642.47046/1.
Ferrari R, De Cecco CN, Iafrate F, Paolantonio P, Rengo M, Laghi A. Anatomical variations of the coeliac trunk and the mesenteric arteries evaluated with 64-row CT angiography. Radiol Med. 2007;112:988–98. https://doi.org/10.1007/s11547-007-0200-2.
Gangam RR, Sharon SS. Surgical significance of inferior mesenteric artery and its branching pattern. IJAR. 2016;4:2062–8. https://doi.org/10.16965/ijar.2016.141.
George R. Topography of the unpaired visceral branches of the abdominal aorta. J Anat. 1935;69:196–205.
Griffiths JD. Surgical anatomy of the blood supply of the distal colon. Ann R Coll Surg Engl. 1956;19:241–56.
Hazirolan T, Metin Y, Karaosmanoglu AD, Canyigit M, Turkbey B, Oguz BS, et al. Mesenteric arterial variations detected at MDCT angiography of abdominal aorta. Am J Roentgenol. 2009;192:1097–102. https://doi.org/10.2214/AJR.08.1532.
Horton KM, Fishman EK. Volume-rendered 3D CT of the mesenteric vasculature: normal anatomy, anatomic variants, and pathologic conditions. Radiographics. 2002;22:161–72. https://doi.org/10.1148/radiographics.22.1.g02ja30161.
Ke J, Cai J, Wen X, Wu X, He Z, Zou Y, et al. Anatomic variations of inferior mesenteric artery and left colic artery evaluated by 3-dimensional CT angiography: insights into rectal cancer surgery. Int J Surg. 2017;41:106–11. https://doi.org/10.1016/j.ijsu.2017.03.012.
Kitamura S, Nishiguchi T, Sakai A, Kumamoto K. Rare case of the inferior mesenteric artery arising from the superior mesenteric artery. Anat Rec. 1987;217:99–102. https://doi.org/10.1002/ar.1092170113.
Kobayashi M, Morishita S, Okabayashi T, Miyatake K, Okamoto K, Namikawa T, et al. Preoperative assessment of vascular anatomy of inferior mesenteric artery by volume-rendered 3D-CT for laparoscopic lymph node dissection with left colic artery preservation in lower sigmoid and rectal cancer. World J Gastroenterol. 2006;12:553–5. https://doi.org/10.3748/wjg.v12.i4.553.
Lin PH, Chaikof EL. Embryology, anatomy, and surgical exposure of the great abdominal vessels. Surg Clin North Am. 2000;80:417–33. https://doi.org/10.1016/S0039-6109(05)70413-8.
Loukas M, Aparicio S, Beck A, Calderon R, Kennedy M. Rare case of right accessory renal artery originating as a common trunk with the inferior mesenteric artery: a case report. Clin Anat. 2005;18:530–5. https://doi.org/10.1002/ca.20194.
Mari G, Maggioni D, Costanzi A, Miranda A, Rigamonti L, Crippa J, et al. High or low inferior mesenteric artery ligation in laparoscopic low anterior resection: study protocol for a randomized controlled trial (HIGHLOW trial). Ann Surg. 2015;16:1018–24. https://doi.org/10.1186/s13063-014-0537-5.
McMinn RMH. Last’s anatomy. Regional and Applied. 9th ed. Edinburgh: Churchill Livingstone; 2003.
Michels NA, Siddharth P, Kornblith PL, Parke WW. The variant blood supply to the descending colon, rectosigmoid and rectum based on 400 dissections. Its importance in regional resections. A review of medical literature. Dis Colon Rectum. 1965;8:251–78.
Miyamoto R, Nagai K, Kemmochi A, Inagawa S, Yamamoto M. Three-dimensional reconstruction of the vascular arrangement including the inferior mesenteric artery and left colic artery in laparoscope-assisted colorectal surgery. Surg Endosc. 2016;30:4400–4. https://doi.org/10.1007/s00464-0164758-4.
Murono K, Kawai K, Kazama S, Ishihara S, Yamaguchi H, Sunami E, et al. Anatomy of the inferior mesenteric artery evaluated using 3-dimensional CT angiography. Dis Colon Rectum. 2015;58:214–9. https://doi.org/10.1097/dcr.0000000000000285.
Nassar L, Atweh LA, Jurjus A, Al Kutoubi A. Unusual arterial pattern of the gastrointestinal tract: inferior mesenteric artery arising from the iliac artery and corkscrew external iliac. Vasc Endovasc Surg. 2012;46:418–21. https://doi.org/10.1177/1538574412445217.
Nelson TM, Pollak R, Jonasson O, Abcarian H. Anatomic variants of the celiac, superior mesenteric, and inferior mesenteric arteries and their clinical relevance. Clin Anat. 1988;1:75–91. https://doi.org/10.1002/ca.980010202.
Osawa T, Feng X, Sasaki N, Nagato S, Matsumoto Y, Onodera M, et al. Rare case of the inferior mesenteric artery and the common hepatic artery arising from the superior mesenteric artery. Clin Anat. 2004;17:518–21. https://doi.org/10.1002/ca.10234.
Paul K, Herbert LA. Inferior mesenteric arterial patterns. Radiology. 1964;82:429–42. https://doi.org/10.1148/82.3.429.
Predescu D, Popa B, Gheorghe M, Predescu I, Jinescu G, Boeriu M, et al. The vascularization pattern of the colon and surgical decision in esophageal reconstruction with colon. A Selective SMA and IMA Arteriographic Study. Chirurgia (Bucur). 2013;108:161–71.
Ubolviroj P, Arjhansiri K. Multidetector computer tomography angiographic imaging of the inferior mesenteric artery: aberrant branches and branching patterns. Chula Med J. 2014;58:471–83.
Rosenblum JD, Boyle CM, Schwartz LB. The mesenteric circulation. Anatomy and physiology. Surg Clin North Am. 1997;77:289–306. https://doi.org/10.1016/s0039-6109(05)70549-1.
Rusu MC, Vlad M, Voinea LM, Curca GC, Sisu AM. Detailed anatomy of a left accessory aberrant colic artery. Surg Radiol Anat. 2008;30:595–9. https://doi.org/10.1007/s00276-008-0362-1.
Singh R. Variations in the branching pattern in inferior mesenteric artery: a series of five cases. J Morphol Sci. 2016;33:193–6. https://doi.org/10.4322/jms.098315.
Sinkeet S, Mwachaka P, Muthoka J, Saidi H. Branching pattern of inferior mesenteric artery in a black African population: a dissection study. ISRN Anat. 2013;2013:962904. https://doi.org/10.5402/2013/962904.
Songur A, Toktaş M, Alkoç O, Acar T, Uzun I, Baş O, et al. Abdominal aorta and its branches: morphometry - variations in autopsy cases. Eur J Gen Med. 2010;7:321–5. https://doi.org/10.29333/ejgm/82876.
Standring S. Gray’s anatomy: the anatomical basis of clinical practice. 41st ed. Philadelphia: Elsevier; 2015.
Strom BG, Winberg T. Percutaneous selective angiography of the inferior mesenteric artery. Acta Radiol. 1962;57:401–10. https://doi.org/10.3109/00016926209171768.
VanDamme JP. Behavioral anatomy of the abdominal arteries. Surg Clin North Am. 1993;73:699–725. https://doi.org/10.1016/S0039-6109(16)46081-0.
Wang KX, Cheng ZQ, Liu Z, Wang XY, Bi DS. Vascular anatomy of inferior mesenteric artery in laparoscopic radical resection with the preservation of left colic artery for rectal cancer. World J Gastroenterol. 2018;24:3671–6. https://doi.org/10.3748/wjg.v24.i32.3671.
Yada H, Sawai K, Taniguchi H, Hoshima M, Katoh M, Takahashi T. Analysis of vascular anatomy and lymph node metastases warrants radical segmental bowel resection for colon cancer. World J Surg. 1997;21:109–15. https://doi.org/10.1007/s002689900202.
Yi S, Li J, Terayama H, Naito M, Iimura A, Itoh M. A rare case of inferior mesenteric artery arising from the superior mesenteric artery, with a review of the review of the literature. Surg Radiol Anat. 2008;30:159–65. https://doi.org/10.1007/s00276-007-0298-x.
Yoo SJ, Ku MJ, Cho SS, Yoon SP. A case of the inferior mesenteric artery arising from the superior mesenteric artery in a Korean woman. J Korean Med Sci. 2011;26:1382–5. https://doi.org/10.3346/jkms.2011.26.10.1382.
Zarokosta M, Piperos T, Chrysikos D, Nikou E, Flessas I, Skarpas G, et al. Anatomic variation of the relation between the inferior mesenteric artery and the bifurcation point of abdominal aorta during lower anterior resection: a rare case report. Int Surg Case Rep. 2018;51:385–7. https://doi.org/10.1016/j.ijscr.2018.09.002.
Zebrowski W, Augustyniak E, Zajac S. Variations of origin and branching of the interior mesenteric artery and its anastomoses. Folia Morphol (Warsz). 1971;30:575–83.
Zeng J, Su G. High ligation of the inferior mesenteric artery during sigmoid colon and rectal cancer surgery increases the risk of anastomotic leakage: a meta-analysis. World J Surg Oncol. 2018;16:157. https://doi.org/10.1186/s12957-018-1458-7.
Zimmerman P, Huseynova K, Lakshmikumar P. In: Yeo CJ, McFadden DW, Pemberton JH, Peters JH, Matthews JB, editors. Shackelford’s surgery of the alimentary tract. 7th ed. Elsevier: Philadeplphia; 2013.
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The authors are thankful to Dr. Chamath Ranaweera for providing information related to surgical practices on distal colon.
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Lakal Dissabandara: Project development; manuscript writing/editing; reviewed all versions of the manuscript and approval for submission. William McSweeney: Literature review, analysis, manuscript writing and approval for submission. R Kotakadeniya: Critical review of the manuscript and approval for submission.
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McSweeney, W., Kotakadeniya, R. & Dissabandara, L. A Comprehensive Review of the Anatomy of the Inferior Mesenteric Artery: Branching Patterns, Variant Anatomy and Clinical Significance. SN Compr. Clin. Med. 2, 2349–2359 (2020). https://doi.org/10.1007/s42399-020-00541-4
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DOI: https://doi.org/10.1007/s42399-020-00541-4