Popliteal artery branching patterns—an angiographic study
Introduction
In the radiological and surgical treatment of peripheral vascular disease it is important to know the course of the popliteal artery. In particular it is important to be aware of any variations in the branching pattern in order to plan correct treatment. Kim et al.1 described a unified classification of the anatomical variation in the branching pattern of the popliteal artery based on angiographic appearances, itself a modification of the classification by Lippert and Pabst.2 The classical anatomical description of the popliteal artery describes the level of branching usually below the inferior border of popliteus. Angiographically this cannot be determined accurately, and therefore the tibial plateau can be used as the reference point.
Type I branching patterns of the popliteal artery occur at the normal level taken to be below the tibial plateau and is further subdivided according to the origin of the infrapopliteal vessels–anterior tibial artery (AT), posterior tibial artery (PT), peroneal artery (PR) and the tibial–peroneal trunk (TPT) summarized in Table 1. Type II branching patterns of the popliteal artery occur when one of the branches arise above the tibial plateau (Table 2). AT usually passes posterior to popliteus but may pass anterior to this muscle. When this is present the vessel is seen to take a medial course initially before resuming its usual lateral course. This is the basis of the division of II-A1 and II-A2. Type II-C pattern (high origin of PR) was first described by Kim et al. in which PR arises above the tibial plateau and there is an anterior TPT. Type III branching patterns involve hypoplasia–aplasia of the one or more of the infrapopliteal vessels with abnormal blood supply to the foot (Table 3). Usually PR communicates with the AT and PT via small branches just after its termination above the ankle joint. When hypoplasia–aplasia of the AT or PT occurs the dorsalis pedis artery (DP) or distal PT arise directly from PR at the ankle joint.
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Materials and methods
The femoral angiograms of 1037 lower limbs in 568 patients were examined. The popliteal artery branching pattern of 512 right limbs and 525 left limbs were classified according to the system used by Kim et al.1 (Table 1, Table 2). The infrapopliteal vessels were assessed in 662 limbs from the same cohort of patients and classified according to the system used by Kim et al.1 (Table 3). The remaining 375 limbs were excluded from this part of the study because the severity of disease prevented
Type I and II branching patterns
Nine hundred and seventy-seven (94.2%) limbs had a normal level of popliteal artery branching (Table 4, Fig. 1). Of these 941 (90.7%) had the usual branching pattern (Type I-A). Trifurcation pattern (Type I-B) was observed in 33 (3.2%) limbs. Three limbs had an anterior TPT (Type I-C).
Sixty (5.8%) limbs had a high division of the popliteal artery at or above the level of the tibial plateau (Table 4, Fig. 2). The AT followed a normal course in 22 (2.1%) limbs (Type II-A1). In 25 (2.4%) limbs the
Discussion
This is the largest angiographic study of variations of the popliteal artery branching patterns and infrapopliteal vessel patterns, and the first large angiographic study of a European population. For Type I and II popliteal branching patterns, the present results compare well with previous angiographic studies.1, 3, 4, 5 In the present study two limbs had a high origin of the PR (Type II-C), and are believed to be the second and third reported cases of this anomaly, which is a rare variant
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