External Diameters of the Abdominal Aorta and Iliac Arteries in

original papers
Adv Clin Exp Med 2011, 20, 6, 691–698
ISSN 1230-025X
© Copyright by Wroclaw Medical University
Michał Szpinda, Anna Szpinda, Małgorzata Dombek, Marcin Wiśniewski,
Marcin Daroszewski
External Diameters of the Abdominal Aorta
and Iliac Arteries in Human Fetuses
Średnice zewnętrzne aorty brzusznej i tętnic biodrowych
u płodów człowieka
Department of Normal Anatomy, the Ludwik Rydygier Collegium Medicum in Bydgoszcz,
Nicolaus Copernicus University in Toruń, Poland
Abstract
Background. Advances in perinatal medicine have required an exhaustive knowledge of fetal aorto-iliac diameters
in the prenatal diagnosis of congenital aorto-iliac abnormalities.
Objectives. This study defines the growth of absolute and relative external diameters of the abdominal aorta and
iliac arteries in human fetuses.
Material and Methods. Using anatomical dissection and digital-image analysis, the external diameters of the
abdominal aorta, and common, external and internal iliac arteries in 124 spontaneously aborted human fetuses
aged 15–34 weeks were examined.
Results. No significant sex differences were found (P > 0.05). The strongest developmental dynamics referred
to the abdominal aorta diameters, from 1.18 ± 0.25 to 5.19 ± 0.49 mm for its origin, and from 1.03 ± 0.23 to
4.92 ± 0.46 mm for its bifurcation. The intermediate values were found in both the common and internal iliac
arteries: from 0.66 ± 0.19 to 2.30 ± 0.42 mm on the right, and from 0.66 ± 0.14 to 2.16 ± 0.42 mm on the left for
the former, and from 0.52 ± 0.15 to 1.77 ± 0.44 mm on the right, and from 0.50 ± 0.14 to 1.65 ± 0.42 mm on the
left for the latter. The smallest values were related to the external iliac arteries, which increased from 0.35 ± 0.09
to 1.28 ± 0.26 mm and from 0.31 ± 0.05 to 1.21 ± 0.22 mm on the right and left sides, respectively. The external
diameter at the bifurcation of the abdominal aorta was relatively increasing throughout the study period. External
diameters of the three iliac arteries were found to decrease in their relative values in the age range of 4–5 months,
to start increasing gradually afterwards.
Conclusions. The absolute values of the external diameters of the aorto-iliac segment increase linearly throughout
gestation, whereas the relative values of the three iliac arteries decrease during the 4th–5th month period of gestation,
to start increasing afterwards (Adv Clin Exp Med 2011, 20, 6, 691–698).
Key words: abdominal aorta, common iliac artery, external iliac artery, internal iliac artery, external diameters,
digital image analysis, human fetuses.
Streszczenie
Wprowadzenie. Postęp w medycynie perinatalnej wymaga wyczerpującej wiedzy o średnicach aorty i tętnic biodrowych u płodu w diagnostyce prenatalnej wad wrodzonych tych naczyń.
Cel pracy. Praca ta definiuje wzrost bezwzględnych i względnych średnic zewnętrznych aorty brzusznej i tętnic
biodrowych u płodów człowieka.
Materiał i metody. Za pomocą dysekcji anatomicznej i cyfrowej analizy obrazu zbadano średnice zewnętrzne aorty
brzusznej i tętnic biodrowych wspólnych, zewnętrznych i wewnętrznych u 124 płodów człowieka w wieku 15–34 tygodni, które pochodziły z poronień samoistnych i porodów przedwczesnych.
Wyniki. Nie stwierdzono różnic płciowych (P > 0.05). Najsilniejszą dynamikę rozwojową wykazywały średnice
aorty brzusznej w zakresie 1,18 ± 0,25–5,19 ± 0,49 mm dla jej początku i 1,03 ± 0,23–4,92 ± 0.46 mm dla jej
rozdwojenia. Pośrednie wartości stwierdzono dla tętnic biodrowych wspólnych i wewnętrznych, odpowiednio od
0,66 ± 0,19 do 2,30 ± 0,42 mm po stronie prawej i od 0,66 ± 0,14 do 2,16 ± 0,42 mm po stronie lewej dla pierwszej
oraz od 0,52 ± 0,15 do 1,77 ± 0,44 mm po stronie prawej i od 0,50 ± 0,14 do 1,65 ± 0,42 mm po stronie lewej dla
drugiej. Najmniejsze wartości średnic zewnętrznych odnosiły się do tętnic biodrowych zewnętrznych, które wzra-
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stały od 0,35 ± 0,09 do 1,28 ± 0,26 mm i od 0,31 ± 0,05 do 1,21 ± 0,22 mm po stronie lewej. Względna średnica
zewnętrzna rozdwojenia aorty brzusznej wzrastała przez cały badany okres. Względne średnice zewnętrzne trzech
tętnic biodrowych zmniejszały się w przedziale 4–5 miesięcy, a następnie wzrastały.
Wniosek. Wartości bezwzględnych średnic zewnętrznych aorty brzusznej i tętnic biodrowych wzrastają liniowo
podczas ciąży, średnice względne trzech tętnic biodrowych natomiast zmniejszają swą wartość w ciągu 4–5 miesięcy, a następnie wzrastają (Adv Clin Exp Med 2011, 20, 6, 691–698).
Słowa kluczowe: aorta brzuszna, tętnica biodrowa wspólna, tętnica biodrowa zewnętrzna, tętnica biodrowa
wewnętrzna, średnice zewnętrzne, analiza cyfrowa obrazu, płody człowieka.
During fetal development, diameters of the
ascending aorta [1–10], aortic arch [1, 2, 4–6, 9],
thoracic aorta [1, 2, 4, 5, 9, 11], abdominal aorta
[12, 13], and common iliac arteries [14] present
a proportional increase in diameters. Advances
in perinatal medicine have required an exhaustive knowledge of fetal aorto-iliac diameters in the
prenatal diagnosis and monitoring of congenital
aorto-iliac abnormalities.
To the best of authors knowledge, no study
has investigated a comparative evolution of both
absolute and relative diameters of the abdominal aorta and iliac arteries. Therefore, to improve
knowledge of the quantitative morphology of the
abdominal aorta and common, external and internal iliac arteries, the authors aimed to investigate
the following: age-specific reference intervals for
their external diameters, their absolute growth in
external diameter, their relative growth in external
diameter, the influence of sex on the value of the
parameters studied.
Material and Methods
The examinations were performed on 124 human fetuses of Caucasian origin of both sexes
(60 males, 64 females) derived from spontaneous abortions or stillbirths. The fetal age varied
between 15 and 34 weeks. Legal and ethical considerations had been approved by the University
Research Ethics Committee (KB/217/2006). The
fetuses were free of malformation affecting cardiovascular anomalies. Gestational age was determined from measurements of the crown-rump
(CR) length on the basis of Iffy tables [15]. For
statistical analysis, the fetuses were divided into
six monthly groups, related to the 4th–9th month
of gestation. The arterial bed was filled with white
latex LBS 3060 through a catheter Stericath (diameter of 0.5–1 mm), introduced by lumbar access into the abdominal aorta. The arterial bed
filling was performed under controlled pressure
of 50–60 mm Hg, using a syringe infusion pump
SEP 11S (Ascor SA, Medical Equipment, Warsaw
2001). All specimens were immersed in 10% neutral formalin solution for 4–24 months for preservation, and then dissected under a stereoscope
with Huygens ocular at a magnification of 10.
Each fetus was dissected to expose its abdominal
aorta, and common, external and internal iliac arteries. The abdominal aorta and iliac arteries in
situ with a millimeter scale were placed vertically
to the optical lens axis, afterwards recorded using
a Nikon Coolpix 8400 camera, digitalized to TIFF
images (Fig. 1) and assessed using digital image
analysis (Leica QWin Pro 16, Cambridge), which
semi-automatically estimated the external diameters of the marked abdominal aorta and three
iliac arteries.
For each specimen the following eight external
diameters were evaluated: proximal external diameter of the abdominal aorta, measured just below
the aortic hiatus of the diaphragm; distal external
diameter of the abdominal aorta, measured just
above its bifurcation; proximal external diameters
of the right and left common iliac arteries, measured at their origins; proximal external diameters
of the right and left external iliac arteries, measured
at their origins; proximal external diameters of the
right and left internal iliac arteries, measured at
their origins.
Because of the different sizes of the fetuses
the authors expressed each external diameter as
a ratio of the proximal external diameter of the
abdominal aorta. Both absolute and relative external diameters were correlated to fetal age in order
to represent their growth. The results obtained
were assessed using a one-way ANOVA test for
unpaired data and post hoc RIR Tukey test. Regression analysis was used to determine the significance of the relation between gestational age and
each diameter studied. Correlation coefficients (r)
between particular external diameters and fetal age
were estimated. Results were considered significant at P < 0.05.
Results
No significant differences were found in the external diameters studied according to sex (P > 0.05).
Therefore, the values obtained for the external diameters of the abdominal aorta and common, external and internal iliac arteries have been summarized in Table 1, without regard to sex.
693
Aorto-Iliac Diameters
Fig. 1. The abdominal aorta and iliac arteries in a female
fetus aged 24 weeks: A) aortic hiatus of the diaphragm,
B) aortic bifurcation, 1 – abdominal aorta, 2 – right common iliac artery, 3 – left common iliac artery, 4 – right
external iliac artery, 5 – right internal iliac artery, 6 – left
external iliac artery, 7 – left internal iliac artery
Ryc. 1. Aorta brzuszna i tętnice biodrowe u płodu płci
żeńskiej w wieku 24 tygodni: A) rozwór aortowy przepony, B) rozdwojenie aorty, 1 – aorta brzuszna, 2 – tętnica
biodrowa wspólna prawa, 3 – tętnica biodrowa wspólna
lewa, 4 – tętnica biodrowa zewnętrzna prawa, 5 – tętnica biodrowa wewnętrzna prawa, 6 – tętnica biodrowa
zewnętrzna lewa, 7 – tętnica biodrowa wewnętrzna lewa
The numerical data revealed the approximately linear increase in the absolute arterial diameters during gestation (Fig. 2). Correlation coefficients between the external diameters and fetal
age were statistically significant (P = 0.0000) for
each age group and obtained the following values: r1, 2 = 0.96 for the origin and bifurcation of
the abdominal aorta, r3 = 0.86 and r4 = 0.88 for the
right and left common iliac arteries, r5 = 0.88 and
r6 = 0.90 for the right and left external iliac arteries, and r7 = 0.82 and r8 = 0.83 for the right and left
internal iliac arteries, respectively.
The strongest developmental dynamics referred to the abdominal aorta diameters, from
1.18 ± 0.25 to 5.19 ± 0.49 mm for its origin, and
from 1.03 ± 0.23 to 4.92 ± 0.46 mm for its bifurcation. The intermediate values in external diameter
were found in both the common and internal iliac
arteries. The values of the common iliac artery diameter varied from 0.66 ± 0.19 to 2.30 ± 0.42 mm
on the right, and from 0.66 ± 0.14 to 2.16 ± 0.42 mm
on the left. The external diameters of the internal iliac arteries increased from 0.52 ± 0.15 to
1.77 ± 0.44 mm on the right and from 0.50 ± 0.14
to 1.65 ± 0.42 mm on the left for the 4-month and
9-month groups of gestation, respectively. The
smallest values in external diameter were related
to the external iliac arteries, which increased from
0.35 ± 0.09 to 1.28 ± 0.26 mm and from 0.31 ± 0.05
to 1.21 ± 0.22 mm on the right and left sides, respectively.
The external diameters of the right iliac arteries were found to be greater in comparison to
the common (in 84 fetuses – 66.7%), external (in
88 fetuses – 71%), and internal (in 81 fetuses –
65.3%) ones. In 48 fetuses (38.7%) the three iliac
arteries were stronger on the right, and in 8 fetuses
(6.5%) – on the left side.
The relative growth of the external diameters
of the abdominal aorta and iliac arteries was more
differentiated than their absolute increase in values
(Fig. 3) when compared to the proximal external
diameter of the abdominal aorta. The relative external diameter of the abdominal aorta at its bifurcation was increasing throughout the study period.
A different tendency was observed for the relative
external diameters of the common, external and
internal iliac arteries. They were found to decrease
in their values in the age range of 4–5 months and
to start increasing gradually afterwards.
Discussion
Reference data for the normal growth of external diameters of the abdominal aorta and iliac
arteries are scarce in human fetuses. Therefore, in
this autopsy study, digital image analysis (Leica
N
16
24
30
22
21
11
Fetal age
– months
(Wiek płodowy
– miesiące)
4
5
6
7
8
9
5.19
4.37
↓(P < 0.01)
3.31
↓(P < 0.01)
2.79
↓(P < 0.001)
1.94
↓(P < 0.001)
1.18
↓(P < 0.001)
mean
0.49
0.50
0.51
0.35
0.32
0.25
SD
at its origin (1)
4.92
4.05
↓(P < 0.001)
3.02
↓(P < 0.001)
2.55
↓(P < 0.001)
1.75
↓(P < 0.001)
1.03
↓(P < 0.001)
mean
0.46
0.48
0.50
0.35
0.32
0.23
SD
at its end (2)
abdominal aorta
2.30
1.86
↓(P < 0.01)
1.29
↓(P < 0.01)
1.04
↓(P < 0.05)
0.81
↓(P < 0.05)
0.66
↓(P > 0.05)
mean
0.42
0.47
0.30
0.23
0.25
0.19
SD
2.16
1.79
↓(P < 0.01)
1.29
↓(P < 0.01)
0.99
↓(P < 0.001)
0.76
↓(P < 0.01)
0.66
↓(P > 0.05)
mean
left (4)
0.42
0.42
0.27
0.14
0.17
0.14
SD
1.28
1.05
↓(P < 0.01)
0.76
↓(P < 0.001)
0.54
↓(P < 0.001)
0.40
↓(P < 0.05 )
0.35
↓(P > 0.05 )
mean
0.26
0.22
0.16
0.10
0.09
0.09
SD
1.21
0.99
↓(P < 0.001)
0.72
↓(P < 0.01)
0.50
↓(P < 0.05)
0.37
↓(P < 0.05)
0.31
↓(P > 0.05)
mean
left (6)
external iliac artery
right (5)
External diameters – mm
(Średnice zewnętrzne – mm)
common iliac artery
right (3)
Tabela 1. Średnice zewnętrzne aorty brzusznej i tętnic biodrowych u płodów człowieka
Table 1. External diameters of the abdominal aorta and iliac arteries in human fetuses
0.22
0.15
0.16
0.09
0.08
0.05
SD
1.77
1.39
↓(P < 0.01)
0.94
↓(P < 0.001)
0.74
↓(P < 0.01)
0.59
↓(P < 0.05)
0.52
↓(P > 0.05)
mean
right (7)
0.44
0.35
0.26
0.22
0.20
0.15
SD
1.65
1.32
↓(P < 0.01)
0.93
↓(P < 0.001)
0.68
↓(P < 0.01)
0.52
↓(P < 0.01)
0.50
↓(P > 0.05)
mean
left (8)
internal iliac artery
0.42
0.37
0.23
0.14
0.13
0.14
SD
695
Aorto-Iliac Diameters
Fig. 2. Growth of the absolute external diameters of the abdominal aorta and iliac arteries
Ryc. 2. Wzrost bezwzględnych średnic zewnętrznych aorty brzusznej i tętnic biodrowych
QWin 16 Pro, Cambridge) was used to provide an
objective comparative evolution of both absolute
and relative external diameters of the aorto-iliac
segment.
No significant difference between the two sexes
was demonstrated in this series, in keeping with
most previous studies in fetuses [12, 14], children
[16, 17] and adults [18]. On the other hand, Poutanen et al. [19] found in children and adolescents
that aortic diameters were greater in males than females. Nevertheless, the values were independent
of sex when indexed to BSA.
A linear growth of all the analyzed external
diameters in fetuses was confirmed in this study.
Correlation coefficients between the absolute external diameters and fetal age were statistically
significant (P = 0.0000) and the highest for the abdominal aorta (r1.2 = 0.96), the intermediate for the
right (r3 = 0.86) and left (r4 = 0.88) common iliac,
and right (r5 = 0.88) and left (r6 = 0.90) external
iliac arteries, and the lowest (r7 = 0.82; r8 = 0.83) for
the right and left internal iliac arteries. As it turned
out, the decreasing sequence of external diameters
with gestational age was presented by the following
vessels: the abdominal aorta, right and left common iliac artery, right and left internal iliac artery,
and right and left external iliac artery.
The external diameter of the abdominal aorta
was observed to be greater at its origin than its bifurcation, being attributed to a gradual decrease
in flow volume as blood is supplied to abdominal
organs [20–25]. Özgüner and Sulak [12] reported
that the proximal and distal external diameters of
the abdominal aorta varied from 1.20 ± 0.2 mm
and 1.12 ± 0.2 mm in fetuses aged 9–12 weeks to
8.28 ± 0.7 mm and 6.26 ± 0.6 mm respectively in
fetuses aged 38–40 weeks. Of note, in fetuses aged
13–37 weeks, which could be comparable to ours, external diameters at the origin and bifurcation of the
abdominal aorta increased from 2.85 ± 0.7 mm and
2.37 ± 0.6 mm to 5.77 ± 0.8 mm and 4.50 ± 0.4 mm,
respectively.
696
M. Szpinda et al.
Fig. 3. Growth of the relative external diameters of the abdominal aorta and iliac arteries
Ryc. 3. Wzrost względnych średnic zewnętrznych aorty brzusznej i tętnic biodrowych
The external diameters of the common iliac arteries under examination were in keeping with results reported by Gościcka et al. [14]. According to
Özgüner and Sulak [12], the external diameters of
the common iliac arteries during the 9th–40th week
period increased from 0.92 ± 0.1 to 4.13 ± 0.3 mm
on the right, and from 0.92 ± 0.7 to 4.07 ± 0.3 mm
on the left. It is noteworthy that in fetuses aged
13–37 weeks, the external diameters of the common
iliac arteries rose from 1.69 ± 0.3 to 3.06 ± 0.5 mm
on the right, and from 1.63 ± 0.3 to 2.94 ± 0.5 mm
on the left.
It is worth mentioning that the external diameters of the internal iliac arteries were found to be
nearly 50% greater than those of the external iliac
arteries. As predominant vessels, the internal iliac
arteries supply pelvic organs, and then continue
as the umbilical arteries to reach the placenta.
Beyond doubt, in fetuses the pelvic organs need
more blood supply than the lower limbs and the
umbilical arteries are funtional ones. Therefore, in
contrast to adults, in fetuses the diameters of the
internal iliac arteries are greater than those of the
external iliac arteries [12, 14].
Data obtained in the material under examination led authors to conclude that right-sided iliac
arteries were stronger than left-sided ones when
compared to common (66.7%), external (71%)
and internal (65.3%) iliac arteries. All three iliac
arteries were found to be stronger on the right – in
38.7% of specimens than on the left – in 5.5% of
individuals (Fig. 1). Present findings are partly in
disagreement with Gościcka et al. [14], who stated
that the left iliac arteries were always thinner than
the right ones. Conversely, Özgüner and Sulak [12]
emphasized no right-left difference in relation to
the common, external and internal iliac arteries.
To date, there has been no information concerning the relative external diameters of the abdominal aorta and iliac arteries – something new
which has been addressed by this study. Present
results showed that the external diameter of the
Aorto-Iliac Diameters
abdominal aorta at its bifurcation indicated a relative increase in values throughout gestation. The
other external diameters presented during the 4th–
5th month of gestation showed a relative decrease
in their values, and then were increasing gradually
afterwards. In authors opinion, this fact suggests
that blood flow through the iliac arteries increases
from the 6th month of gestation to provide more
and more blood to developing pelvic organs and
lower limbs.
697
The external diameters of the abdominal aorta
and iliac arteries do not show male-female differences. The absolute values of the external diameters
of the abdominal aorta and iliac arteries increase
linearly throughout gestation. The relative values
of the external diameters of the aortic bifurcation
and three iliac arteries decrease during the 4th–5th
month period of gestation, to start increasing afterwards.
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Address for correspondence:
Michał Szpinda
Department of Normal Anatomy
Ludwik Rydygier Collegium Medicum in Bydgoszcz
Karłowicza 24
85-092 Bydgoszcz
Poland
Tel.: +48 52 5853705
E-mail: [email protected]
Conflict of interest: None declared
Received: 5.08,2011
Revised: 18.08.2011
Accepted: 7.12.2011