A communicating arterial branch between the inferior mesenteric artery and superior gluteal artery

A 56-year-old man had presented with a 2-week history of progressive left forefoot pain at rest and paresthesia. He had a history of hypertension, hypercholesterolemia, and tobacco smoking. On examination, he had absent lower leg pulses bilaterally, including the femoral pulses, with the left leg pale and cool to touch. Computed tomography angiography revealed extensive abdominal aortic thrombus, aneurysmal dilatation of the right common iliac artery with reduced flow due to stenosis/thrombus, and complete occlusion of the left common, internal, and external iliac arteries. Acute on chronic limb threatening left lower limb ischemia was diagnosed, with underlying TASC (Inter-Society Consensus for the Management of Peripheral Arterial Disease) class D aortoiliac occlusive disease.1Norgren L. Hiatt W.R. Dormandy J.A. Nehler M.R. Harris K.A. Fowkes F.G. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II).J Vasc Surg. 2007; 45: S5-S67Abstract Full Text Full Text PDF PubMed Scopus (4282) Google Scholar A large vessel (A/Cover) was identified coursing from the origin of the inferior mesenteric artery (IMA; B, red arrow) to the left superior gluteal branch of the posterior division of the left internal iliac artery (B, blue arrow). He subsequently underwent complete endovascular revascularization of the aortic bifurcation,2Goverde P.C. Grimme F.A. Verbruggen P.J. Reijnen M.M. Covered endovascular reconstruction of aortic bifurcation (CERAB) technique: a new approach in treating extensive aortoiliac occlusive disease.J Cardiovasc Surg (Torino). 2013; 54: 383-387PubMed Google Scholar with embolectomy of the left common iliac and superficial femoral arteries, and left common femoral endarterectomy. Digital subtraction angiography confirmed the presence of a communicating branch between the IMA and left superior gluteal artery (C). Postoperative computed tomography angiography demonstrated successful stent placement (D). Knowledge of the vascular anatomic variations is important owing to the possibility of abnormal communicating arteries being misidentified and injured, which can result in severe complications, such as massive bleeding and bowel ischemia.3Ke 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—a retrospective observational study.Int J Surg. 2017; 41: 106-111Crossref PubMed Scopus (29) Google Scholar,4Nayak S.R. Prabhu L.V. Krishnamurthy A. Kumar C.G. Ramanathan L.A. Acharya A. et al.Additional branches of celiac trunk and its clinical significance.Rom J Morphol Embryol. 2008; 49: 247-249Google Scholar In the present case, the patient had complete occlusion of the left common iliac artery but was spared buttock pain, theoretically because of the bypassing blood supply via this communicating branch from the IMA. Collaterals from the iliac to mesenteric system have been previously described.5Roncati L. Manenti A. Gasparri P. Gallo G. Farinetti A. A pathogenetic focus on the aortoiliac-mesenteric steal syndrome.Ann Vasc Surg. 2020; 65: e302-e303Abstract Full Text Full Text PDF Scopus (1) Google Scholar Flow from the iliac system can reconstitute the IMA in cases of mesenteric arterial disease.6Shiraev T. Neilson W. “Aortoiliac-mesenteric steal syndrome” treated with inferior mesenteric to common iliac artery transposition.Ann Vasc Surg. 2019; 58: 377.e9-377.e11Abstract Full Text Full Text PDF Scopus (3) Google Scholar Also, the IMA has been postulated to supply the lower limbs in cases of aortoiliac disease.7Patelis N. Papoutsis K. Liakopoulos D. Koutsoumpelis A. Bakogiannis C. Georgopoulos S. Postprandial lower limb pain: an unusual presentation of visceral arteries occlusion.Vascular. 2015; 23: 316-318Crossref PubMed Scopus (2) Google Scholar The present patient experienced no postoperative gastrointestinal symptoms or buttock claudication and was discharged well on the third postoperative day. The patient provided written informed consent to the use of his related medical history and images for educational purposes.