Distal Artery Research Articles

Total Arterial Revascularization: Evaluating the Length of the Radial Artery in a Composite Graft Configuration.

Reimplanting the radial artery in the left internal thoracic artery as a composite graft allows total arterial revascularization (TAR) without aortic manipulation. The limitation of this strategy is the length of the radial artery required to reach distal right coronary artery (RCA) branches. Our analysis focuses on the feasibility of this strategy. A total of 169 patients underwent TAR using the radial artery in a composite grafting configuration. Length of the radial artery, number of sequential anastomoses, heart size, target location, length of the arm, patient height, body surface area, and flow in the composite graft were prospectively collected. The mean length of the radial artery was 18.02 cm. Patients with a mean length of the radial artery of 15.9 cm needed an extension of the radial artery with another conduit to reach the RCA distal branches. When T-configuration is used, the length of the radial artery should be 0.53 cm per sequential anastomosis to reach the RCA distal branches. Our study shows that an average length of 18.02 cm of radial artery is needed to reach targets on the RCA distal branches in composite grafting. In T-configuration, we need 0.53 cm more length per anastomosis to achieve TAR.

Risk factors of unruptured intracranial aneurysms instability in the elderly.

Presently, a consistent strategy for determining the stability of unruptured intracranial aneurysms (UIAs) in elderly patients is lacking, primarily due to the unique characteristics of this demographic. Our objective was to assess the risk factors contributing to aneurysm instability (growth or rupture) within the elderly population. In this study, we compiled data from follow-up patients with UIAs spanning from November 2016 to August 2021. We specifically focused on patients aged ≥ 60years. Clinical histories were gathered, and morphological parameters of aneurysms were measured. The growth of aneurysms was determined using the computer-assisted semi-automated measurement (CASAM). Growth and rupture rates of UIAs were calculated, and both univariate and multivariate Cox regression analyses were conducted. Additionally, Kaplan-Meier survival curves were plotted. A total of 184 patients with 210 aneurysms were enrolled in the study. The follow-up period encompasses 506.6 aneurysm-years and 401.4 patient-years. Among all the aneurysms, 23 aneurysms exhibited growth, with an annual aneurysm growth rate of 11.0%, and 1 (4.5%) experienced rupture, resulting in an annual aneurysm rupture rate of 0.21%. Multivariate Cox analysis identified poorly controlled hypertension (P = 0.011) and high-risk aneurysms (including anterior cerebral artery (ACA), anterior communicating artery (AcoA), posterior communicating artery aneurysm (PcoA), posterior circulation (PC) > 4mm or distal internal carotid artery (ICAd), middle cerebral artery (MCA), and PC > 7mm) (P = 0.006) as independent risk factors for the development of unstable aneurysms. In the elderly, poorly controlled hypertension and high-risk aneurysms emerge as significant risk factors for aneurysm instability. This underscores the importance of rigorous surveillance or timely intervention in patients presenting with these risk factors.

Associations of Intracranial Artery Length and Branch Number on Time-of-Flight MRA With Cognitive Impairment in Hypertensive Older Males.

Hypertension-induced impairment of the cerebral artery network contributes to cognitive impairment. Characterizing the structure and function of cerebral arteries may facilitate the understanding of hypertension-related pathological mechanisms and lead to the development of new indicators for cognitive impairment. To investigate the associations between morphological features of the intracranial arteries distal to the circle of Willis on time-of-flight MRA (TOF-MRA) and cognitive performance in a hypertensive cohort. Prospective observational study. 189 hypertensive older males (mean age 64.9 ± 7.2 years). TOF-MRA sequence with a 3D spoiled gradient echo readout and arterial spin labeling perfusion imaging sequence with a 3D stack-of-spirals fast spin echo readout at 3T. The intracranial arteries were segmented from TOF-MRA and the total length of distal arteries (TLoDA) and number of arterial branches (NoB) were calculated. The mean gray matter cerebral blood flow (GM-CBF) was extracted from arterial spin labeling perfusion imaging. The cognitive level was assessed with short-term and long-term delay-recall auditory verbal learning test (AVLT) scores, and with montreal cognitive assessment. Univariable and multivariable linear regression were used to analyze the associations between TLoDA, NoB, GM-CBF and the cognitive assessment scores, with P < 0.05 indicating significance. TLoDA (r = 0.314) and NoB (r = 0.346) were significantly correlated with GM-CBF. Multivariable linear regression analyses showed that TLoDA and NoB, but not GM-CBF (P = 0.272 and 0.141), were significantly associated with short-term and long-term delay-recall AVLT scores. These associations remained significant after adjusting for GM-CBF. The TLoDA and NoB of distal intracranial arteries on TOF-MRA are significantly associated with cognitive impairment in hypertensive subjects. 2 TECHNICAL EFFICACY: Stage 3.

L-Lactate Treatment at 24 h and 48 h after Acute Experimental Stroke Is Neuroprotective via Activation of the L-Lactate Receptor HCA1.

Stroke is the main cause for acquired disabilities. Pharmaceutical or mechanical removal of the thrombus is the cornerstone of stroke treatment but can only be administered to a subset of patients and within a narrow time window. Novel treatment options are therefore required. Here we induced stroke by permanent occlusion of the distal medial cerebral artery of wild-type mice and knockout mice for the lactate receptor hydroxycarboxylic acid receptor 1 (HCA1). At 24 h and 48 h after stroke induction, we injected L-lactate intraperitoneal. The resulting atrophy was measured in Nissl-stained brain sections, and capillary density and neurogenesis were measured after immunolabeling and confocal imaging. In wild-type mice, L-lactate treatment resulted in an HCA1-dependent reduction in the lesion volume accompanied by enhanced angiogenesis. In HCA1 knockout mice, on the other hand, there was no increase in angiogenesis and no reduction in lesion volume in response to L-lactate treatment. Nevertheless, the lesion volumes in HCA1 knockout mice-regardless of L-lactate treatment-were smaller than in control mice, indicating a multifactorial role of HCA1 in stroke. Our findings suggest that L-lactate administered 24 h and 48 h after stroke is protective in stroke. This represents a time window where no effective treatment options are currently available.

ErbB3 Governs Endothelial Dysfunction in Hypoxia-Induced Pulmonary Hypertension.

Pulmonary hypertension, characterized by vascular remodeling, currently lacks curative therapeutic options. The dysfunction of pulmonary artery endothelial cells plays a pivotal role in the initiation and progression of pulmonary hypertension (PH). ErbB3 (human epidermal growth factor receptor 3), also recognized as HER3, is a member of the ErbB family of receptor tyrosine kinases. Microarray, immunofluorescence, and Western blotting analyses were conducted to investigate the pathological role of ErbB3. Blood samples were collected for biomarker examination from healthy donors or patients with hypoxic PH. The pathological functions of ErbB3 were further validated in rodents subjected to chronic hypoxia- and Sugen-induced PH, with or without adeno-associated virus-mediated ErbB3 overexpression, systemic deletion, or endothelial cell-specific ErbB3 knockdown. Primary human pulmonary artery endothelial cells and pulmonary artery smooth muscle cells were used to elucidate the underlying mechanisms. ErbB3 exhibited significant upregulation in the serum, lungs, distal pulmonary arteries, and pulmonary artery endothelial cells isolated from patients with PH compared with those from healthy donors. ErbB3 overexpression stimulated hypoxia-induced endothelial cell proliferation, exacerbated pulmonary artery remodeling, elevated systolic pressure in the right ventricle, and promoted right ventricular hypertrophy in murine models of PH. Conversely, systemic deletion or endothelial cell-specific knockout of ErbB3 yielded opposite effects. Coimmunoprecipitation and proteomic analysis identified YB-1 (Y-box binding protein 1) as a downstream target of ErbB3. ErbB3 induced nuclear translocation of YB-1 and subsequently promoted hypoxia-inducible factor 1/2α transcription. A positive loop involving ErbB3-periostin-hypoxia-inducible factor 1/2α was identified to mediate the progressive development of this disease. MM-121, a human anti-ErbB3 monoclonal antibody, exhibited both preventive and therapeutic effects against hypoxia-induced PH. Our study reveals, for the first time, that ErbB3 serves as a novel biomarker and a promising target for the treatment of PH.

DACA Aneurysm Presenting as Ischemic Stroke

AbstractAneurysms rarely present with features of ischemic stroke. The data on treatment of such strokes is limited. We present a case of multiple aneurysms and an ischemic stroke caused by distal anterior cerebral artery (DACA) aneurysm treated with flow diverter placement, the first case of endovascular treatment of DACA aneurysmal ischemic stroke reported to our knowledge.

Associations between atherosclerotic luminal stenosis in the distal internal carotid artery and diffuse wall thickening in its upstream segment.

Significant atherosclerotic stenosis or occlusion in the distal internalcarotid artery(ICA) may induce diffuse wall thickening (DWT) in the upstream arterial wall. This study aimed to assess the association of atherosclerotic steno-occlusive diseases in the distal ICA with DWT in the upstream ipsilateral ICA. Individuals with atherosclerotic stenosis in the distal ICA, detected by carotid MR vessel wall imaging using 3D pre- and post-contrast T1 volume isotropic turbo spin-echo acquisition (T1-VISTA) sequence, were enrolled. The associations of vessel wall thickening, the longitudinal extent of DWT, enhancement of the upstream ipsilateral ICA, and stenosis degree in the distal ICA were examined. Totally 64 arteries in 55 patients with atherosclerotic steno-occlusive distal ICAs were included. Significant correlations were found between distal ICA stenosis and DWT in the petrous ICA (r = 0.422, p = 0.001), DWT severity (r = 0.474, p < 0.001), the longitudinal extent of DWT in the ICA (r = 0.671, p < 0.001), enhancement in the petrous ICA (r = 0.409, p = 0.001), and enhancement degree (r = 0.651, p < 0.001). In addition, high degree of enhancement was correlated with both increased wall thickness and increased prevalence of DWT in the petrous ICA (both p < 0.001). DWT of the petrous ICA is commonly detected in patients with atherosclerotic steno-occlusive disease in the distal ICA. The degree of stenosis in the distal ICA is associated with wall thickening and its longitudinal extent in the upstream segments. Diffuse wall thickening is a common secondary change in atherosclerotic steno-occlusive disease in the intracranial carotid. This phenomenon constitutes a confounding factor in the distinction between atherosclerosis and inflammatory vasculopathies, and could be reversed after alleviated atherosclerotic stenosis. • Diffuse wall thickening of the petrous internal carotid artery is commonly detected in patients with atherosclerotic steno-occlusive disease in the distal internal carotid artery. • The phenomenon of diffuse wall thickening could be reversed after stenosis alleviation. • Carotid artery atherosclerosis with diffuse wall thickening should warrant a differential diagnosis from other steno-occlusive diseases, including moyamoya diseases and Takayasu aortitis.

Vascular resistance index and the immediate hemodynamic success of lower limb distal artery revascularization.

Revascularization surgery is used to attempt to restore blood flow to the foot in patients with critical ischemia (CI) caused by peripheral arterial occlusive disease of the lower limbs (LL). Ultrasonography with Doppler (USD) SAH emerged in recent years as a highly valuable method for planning this surgical intervention. To evaluate the relationship between the resistance index (RI), measured with USD, and immediate hemodynamic success of LL revascularization surgery in patients with CI. The study design was a prospective cohort assessing 46 patients with LL CLI who underwent operations to perform infrainguinal revascularization by angioplasty or bypass from August 2019 to February 2022. All patients underwent preoperative clinical vascular assessment with USD including measurement of the RI of distal LL arteries, LL arteriography, and measurement of the ankle-brachial index (ABI). All patients had their ABI measured again in the immediate postoperative period. Forty-six patients were assessed, 25 (54.3%) of whom were male. Age varied from 32 to 89 years (mean: 67.83). Hemodynamic success was assessed by comparison of preoperative and postoperative ABI, showing that hemodynamic success was achieved in 31 (67.4%) patients after revascularization surgery (ABI increased by 0.15 or more). A positive correlation (p ≤ 0.05) was observed between the RI of the distal revascularized LL artery and immediate hemodynamic success assessed by ABI (lower RI and hemodynamic success). This study observed a positive correlation between the resistance index of the distal artery and immediate hemodynamic success of lower limb revascularizations, as assessed by the ankle-brachial index, so that the lower the RI the greater the hemodynamic success achieved.

The Utility of the "LEONIS Mova" Steering Microcatheter in Flow Diverter Placement.

LEONIS Mova (SB-KAWASUMI LABORATORIES, Kanagawa, Japan, hereinafter called LEONIS Mova) is a steerable microcatheter (MC) that enables angle adjustment of the catheter tip using a hand-operated dial. LEONIS Mova may be useful for flow diverter placement when access to the distal parent artery with a conventional MC and microguidewire (MGW) is considered difficult or impossible. Here, we report three such cases encountered during flow diverter placement in large and giant internal carotid artery aneurysms. In Case 1, a strong S-shaped curve was observed in the proximal parent artery of a giant cerebral aneurysm, and the luminal structure of the parent artery was lost within the aneurysm. It was anticipated that the distal side of the parent artery would be difficult to access with conventional MC and MGW. By adjusting the tip of the LEONIS Mova toward the aneurysm outlet beyond the S-shaped curve, it was possible to induce the MGW to secure the distal parent artery easily. In Case 2, the inflow and outflow axes of the parent artery were completely misaligned at the site of the aneurysm, and stenosis was present in the distal parent artery. Firmly bending the catheter tip increased accommodation for the catheter, enabling the induction of an MGW to access the distal parent artery without kicking back. In Case 3, the lesion extended from the cavernous portion to the petrosal portion; however, by adjusting the tip of the LEONIS Mova toward the aneurysm outlet, it was possible to induce the MGW to secure the distal parent artery easily. In each case, the LEONIS Mova enabled more secure and prompt access to the parent artery than anticipated and facilitated flow diverter placement. Encountering difficult-to-access lesions is one reason endovascular treatment may be unsuccessful. The LEONIS Mova is an excellent device that can overcome this obstacle, and its utility in certain applications should be recognized.

Correlation between the vascular resistance index and arteriography for assessment of the distal arterial bed in chronic limb threatening ischemia.

Patients with chronic limb threatening ischemia (CLTI) of the lower limbs (LL) undergo arteriography for revascularization surgery planning. Doppler ultrasound (DU) is non-invasive and can provide information about the distal arteries through measurement of the resistance index (RI). To correlate the Rutherford Angiographic Classification with the RI for assessment of the distal arterial bed of the LL. A cross-sectional study, conducted at a public tertiary hospital with 120 patients with LL CLTI, from September 2019 to April 2022. The RI of arteries that were candidates for revascularization was compared with the images of the same arteries obtained using arteriography, using the Rutherford Angiographic Classification of the distal bed. A total of 120 LL were assessed in 120 patients with a mean age of 68.6 years. The sample was 50.0% male and 90.0% of the patients in the sample were classified as Rutherford category five. The RI values found for the arteries of the leg exhibited a statistically significant positive correlation with the Rutherford Classification (anterior tibial, p< 0.01; posterior tibial, p = 0.012 fibular, p = 0.034; and dorsalis pedis, p < 0.001). In this study, RIs for the arteries of the leg measured using Doppler ultrasound exhibited a positive correlation with the Rutherford Classification. This index could be useful for assessment of the distal arterial bed of the lower limbs of patients with chronic limb threatening ischemia.

Ultrasonographic Study of the Corkscrew Arterial Image in Buerger Disease Patients.

Objective: Thromboangiitis obliterans (Buerger disease) is known as an intractable vascular disease that has been reported as thrombosis in distal arteries and occasional venous occlusion, as well as inflammatory changes in the thrombus and vascular wall. Patients often require limb amputation due to limb necrosis. Corkscrew (CS), a small arterial coiling, is an important diagnostic finding that was mainly found with angiography. Recently, however, it can also be identified using a modern ultrasonographic technique. Methods: In these 22 cases, in 48 areas of study, we used the ultrasonographic technique to identify the CS, which allowed us to observe its relationship with the surrounding nerves and arteries. Results: In all cases, it was possible to identify the CS easily and it was confirmed that the CS and the nerve were carried down in their sheath. The sites of the CS existed in areas other than the area around the occluded main arteries and some CS that ran inside the nerve (16 areas) and some CS that accompanied the outside of the nerve (10 areas) were confirmed, suggesting the CS work as collateral blood supply vessels, with well-developed normal vessel-like anatomy. Conclusion: When we observe the CS, it is important to observe not only around the main trunk artery but also areas where nerves mainly run, even if they do not accompany the main trunk artery. (This is a translation of Jpn J Vasc Surg 2023; 32: 345-350.).

Contrast-enhanced echocardiography to define guidewire-related distal coronary artery perforation run-off and to rule out active intrapericardial bleeding.

Contrast-enhanced echocardiography to define guidewire-related distal coronary artery perforation run-off and to rule out active intrapericardial bleeding.

A case of contact aspiration with microcatheter for occlusion of a distal middle cerebral artery M2: a case report

A case of contact aspiration with microcatheter for occlusion of a distal middle cerebral artery M2: a case report

Symptomatic idiopathic pulmonary artery aneurysm: a case report and a mini-review of the literature.

Pulmonary artery aneurysms (PAAs) are rare, more prevalent in younger population with equal sex incidence. Congenital, idiopathic, autoimmune, infectious, inflammatory, and malignant etiologies have been linked to PAAs. Commonly, patients with PAA are asymptomatic, even those with large PAAs. Presenting symptoms, if any, are non-specific. The management should target the underlying conditions and serial imaging follow-up. Signs and symptoms of disease progression should prompt a change in treatment strategy. Though there is no consensus, those who are symptomatic with a PAA diameter > 5 cm generally should undergo surgical repair. More recently, endovascular interventions are available for certain PAAs. We present a 78-year-old female who was referred to the cardiology clinic for cough and dyspnea. Using computed tomography (CTA) of the chest, she was diagnosed with aneurysm of the main pulmonary artery (PA), without involvement of distal pulmonary arteries or thoracic aorta. She underwent repair of the pulmonary artery using a 34-mm tubular graft with a complete resolution of her symptoms.

The Impact of Flow-Mediated Dilation on the Success Rate of Distal Radial Artery Puncture

The Impact of Flow-Mediated Dilation on the Success Rate of Distal Radial Artery Puncture

Thrombosed aneurysm of the internal carotid artery, complicated by the development of ischemic stroke followed by subarachnoid hemorrhage

Thrombosed cerebral aneurysms can cause embolism of the distal cerebral arteries and manifest as the development of ischemic stroke or transient ischemic attack. As a rule, thromboembolic complications develop with giant and large aneurysms, but they are also possible with sizes less than 1 cm. In case of such complications, according to the standards of treatment of ischemic stroke, antithrombotic therapy is necessary, which is associated with the risk of rupture of the aneurysm. The article presents our own clinical observation of the development of ischemic stroke against the background of an embolism from the sac of a thrombosed aneurysm of the internal carotid artery in a young patient, which was later complicated by aneurysm rupture and subarachnoid hemorrhage, which required urgent surgical intervention.

Gut microbiota-derived acetate promotes long-term recovery through angiogenesis guided by lymphatic ingrowth in older adults with stroke.

Ischemic stroke is a leading cause of morbidity and mortality in older adults. Therefore, in this study, we sought to understand the interplay between the microbiota, gut, and brain in the context of stroke in older adults. To determine whether gut microbiota from younger individuals promotes recovery through angiogenesis in both elderly stroke patients and aged stroke mice, we explored the changes in gut microbiota and the correlation between short-chain fatty acids (SCFAs) and angiogenesis in the aged stroke population. Then, we altered the gut microbiome in aged mice by transplanting microbiota from younger donors before inducing experimental stroke to explore the mechanism by which gut microbiota-derived SCFAs promote angiogenesis. Part I: We conducted a single-center, double-blind trial to compare gut microbiota diversity and SCFA levels in fecal samples from older stroke patients with those from younger stroke patients. Additionally, we measured levels of vascular endothelial growth factor (VEGF) and VEGFC levels in plasma to assess their correlation with SCFA levels. Part II: We performed fecal microbiota transplantation (FMT) 3 days before inducing ischemic stroke in aged male mice (16-18) via distal middle cerebral artery occlusion (dMCAO). The FMT was conducted using gut microbiomes from either young donors (2-3 months) or aged donors (16-18 months). In older stroke patients, gut microbiota diversity was significantly reduced compared to that in younger stroke patients. Furthermore, levels of acetate, a bacterially derived SCFA, were lower and positively correlated with angiogenesis markers (VEGF and VEGF-C). In aged stroke mice, transplantation of young microbiota improved stroke outcomes by promoting angiogenesis, which was facilitated by lymphatic ingrowth into the cortex. This protective effect was linked to gut microbiota-derived acetate, which enhanced lymphangiogenesis by replenishing acetyl coenzyme A. (a) Gut microbiota-derived acetate promotes angiogenesis post-stroke and (b) lymphatic ingrowth into the cerebral cortex was observed in post-dMCAO mice. These findings suggest that selectively promoting SCFA-producing bacteria, particularly acetate-producers, could be a promising therapeutic strategy to reduce functional impairments in older stroke subjects.

Is catheterization via distal transradial access feasible in children? From vessel diameter perspective.

Distal radial artery (DRA) access is an infrequent alternative access for pediatric catheterization. The feasibility of using the DRA for arterial catheterization in children depends on the vessel's size. This study aims to provide a reference for pediatric catheterization via DRA access by evaluating the diameter of the DRA in the anatomic snuffbox (AS). We conducted a retrospective review of clinical and vascular ultrasound data of 412 children (ages 3-12) who were scheduled for arterial blood gas analysis via the DRA due to serious respiratory diseases between June 2023 and October 2023. The corrected DRA diameter in the AS was 1.97 ± 0.37 mm overall, with no significant difference between males (1.98 ± 0.38 mm) and females (1.95 ± 0.35 mm) (p = 0.457). The anteroposterior, transverse, and corrected DRA diameters increased significantly with age (p < 0.05). The DRA diameter was significantly smaller than the proximal radial artery (PRA) diameter (1.97 ± 0.37 mm vs. 2.05 ± 0.33 mm, p < 0.001) but larger than the ulnar artery (UA) diameter (1.97 ± 0.37 mm vs. 1.88 ± 0.33 mm, p < 0.001). The proportions of patients with a DRA diameter greater than 2.0 mm and 1.5 mm were 38.83% and 86.89%, respectively. The proportions of patients with DRA diameters >2.0 mm and >1.5 mm increased significantly with age (p < 0.01). The percentages of individuals with a DRA/PRA ratio ≥1.0 were 55.10% overall, 52.12% in males, and 58.60% in females. DRA diameter showed significant correlations with age (r = 0.275, p < 0.01), height (r = 0.319, p < 0.01), weight (r = 0.319, p < 0.01), BMI (r = 0.241, p < 0.01), wrist circumference (r = 0.354, p < 0.01), PRA diameter (r = 0.521, p < 0.01), and UA diameter (r = 0.272, p < 0.01). The DRA diameter in children increases with age and size, making cardiac catheterization is theoretically feasible. Preoperative evaluation of the vessel diameter and intraoperative ultrasound-guided intervention are recommended for paediatric catheterization via the DRA access.

Subarachnoid Hemorrhage Caused by Ruptured Distal Middle Cerebral Artery Aneurysm Mimicking Trauma-associated Onset after a Closed Head Injury: A Case Report

Subarachnoid Hemorrhage Caused by Ruptured Distal Middle Cerebral Artery Aneurysm Mimicking Trauma-associated Onset after a Closed Head Injury: A Case Report

Angiographic Anatomy of the Prostatic Artery in the Korean Population: A Bicentric Retrospective Study.

The aim of this study was to analyze the origins of prostatic arteries (PAs) in the Korean population and compare them with those reported in the literature. From April 2018 to February 2024, 108 male (mean age ± standard deviation: 71.6 ± 9.7 years) with lower urinary tract symptoms (n = 102) or refractory hematuria (n = 6) underwent prostatic artery embolization (PAE). Computed tomography and angiography images were retrospectively reviewed. The branching pattern of the internal iliac artery (IIA) was classified according to the Yamaki system. The origin of the PA was categorized using the de Assis definition, and the incidence of each type was recorded. A systematic literature review was conducted and the most common types of PA were investigated. PAE was successfully implemented on 211 of the 216 pelvic sidewalls. PA cannulation failed in five sidewalls due to a steno-occlusive state. The most common IIA type was type A, in which the IIA was divided into the superior gluteal artery and gluteal-pudendal trunk (77%). Of 226 PAs analyzed, including 15 in 211 sidewalls exhibiting dual PAs, the most common PA origin was the internal pudendal artery (type IV, 35%), followed by the superior vesical (type I, 25%) and obturator (type III, 21%) arteries. Anterior division of IIA (type II) was less common (10%). Type V (uncommon origins) occurred in 8% of cases, including five distal internal pudendal arteries, four quadfurcations, three inferior gluteal arteries, three trifurcations, two medial femoral circumflex arteries, and two rectal arteries. Two of the five patients with surgically or endovascularly altered anatomy were successfully treated via PAs originating from the medial femoral circumflex arteries. Globally, type I is the most common PA type. In the Korean population, the most common IIA pattern and PA origin were types A and IV, respectively.