1.

Pelvic & Lower Limb Arteries

At the level of L4, the aorta divides into the common iliac arteries, which pass
in front of the iliac veins and give off no major branches.
At the level of the mid-sacrum, they divide into the external and internal iliac
arteries.
The internal iliac arteries supply the pelvis and surrounding musculature.
They divide into anterior divisions, which supply the viscera, and posterior
divisions, which mainly supply the musculature.
The external iliac artery has no major branches, although it gives rise to the
inferior epigastric artery at the junction with the common femoral artery.
At the level of the inguinal ligament, the external iliac artery becomes the
common femoral artery—a short vessel that gives rise to the profunda femoris
(or deep femoral artery), which supplies the muscles of the thigh, and the
superficial femoral artery (SFA), which has no major branches and passes
distally.
At the level of the adductor canal, the SFA becomes the popliteal artery, which
gives rise to the vessels of the calf, which are the anterior and posterior tibial
arteries and the peroneal artery.
At the level of the ankle, the anterior tibial artery becomes the dorsalis pedis
artery and the posterior tibial artery divides into the medial and lateral plantar
arteries.
The anterior tibial artery is the most lateral calf vessel, whereas the posterior
tibial artery is the most medial. In the forefoot, the plantar arch is formed by
the lateral plantar branch of the posterior tibial artery and the dorsalis pedis
artery

2. Upper limb arteries

The subclavian artery extends to the lateral border of the first rib and
continues as the axillary artery.
The axillary artery extends to the lower border of the teres major muscle,
where it becomes the brachial artery.
At the elbow, the brachial artery gives rise to the radial artery and ulnar
arteries.
At the wrist, the radial artery gives rise to the deep carpal arch that
anastomoses with branches of the ulnar artery.
The ulnar artery gives rise to the superficial carpal arch. The digital arteries
originate from both arches

3. GI arteries

The coeliac axis and the superior mesenteric artery (SMA) usually arise at the
level of T12 and L1, respectively.
The inferior mesenteric artery (IMA) arises at the level of L3.
The coeliac axis and SMA anastomose with each other via the
pancreaticoduodenal arcades, whereas the superior and inferior mesenteric
arteries anastomose via the middle colic branch of the SMA and left colic
branch of the IMA just proximal to the splenic flexure

4. Renal access- anatomic factors

Renal Position
The kidneys lie in the perinephric space at the level of T12 to L2/L3 vertebral
bodies.
The upper pole is more medial than the lower, with a coronal axis tilt of
approximately 15 degrees.
The upper pole is also more posterior facing than the lower. In the short axis
the renal pelvis points anteromedially.

Relations of the Kidney

The important relations regarding renal access are those adjacent structures
that may be inadvertently injured—the liver, spleen, diaphragm, pleura/lung
and the colon.
Variant anatomy should also be remembered: for example, the splenic flexure
of the descending colon may be abnormally high and posterior (said to be
more common in obese women).
Pre-procedure ultrasound (US) will identify these hazards.

Pelvicalyceal Anatomy of the Kidney

The adult kidney has approximately eight to nine calyces.
Typically, the upper and lower pole calyces are fused and therefore larger and
easier to access.
Calyces will also vary in orientation, facing either relatively anterior or
posterior.
The posterior calyx is ideal for access, being closer to the skin surface.
Posterior calyces also allow better intrarenal navigation; for example, the route
from a posterior to an adjacent anterior calyx or the renal pelvis is more or
less in a straight line forward.
However, access to the pelviureteric junction (PUJ) and ureter is easier from
an interpolar or upper pole calyx.

Renal Vascular Anatomy

The main renal artery divides into a (larger) anterior division and smaller
posterior division, and each division further separates into segmental and
lobar divisions
Peripherally, the lobar and arcuate arteries skirt around the calyx.
Thus the safest place to puncture a calyx is its middle.
Puncture into the infundibulum or renal pelvis may lacerate larger arterial
branches.
A further potential hazard is the posterior division, which is the only major
renal arterial division that lies posterior to the collecting system.
Typically it lies behind the upper renal pelvis, but occasionally it is behind the
upper pole infundibulum, where it may be injured if entry is misdirected
towards the infundibulum rather than the upper pole calyx.
Normally there is a single renal artery and vein, but up to 25% of kidneys have
more than one renal artery and variant renal veins are seen in 3% to 17%.
These do not influence access but may explain the occasional vascular injury
that occurs despite adherence to safe anatomical principles.

Other Anatomical Factors Important for Renal Access

Part of either kidney will lie above the eleventh/twelfth rib, especially the left
kidney, and upper pole access may require an intercostal entry, placing the
intercostal artery or pleura at
risk.
The intercostal artery runs in a groove underneath the rib and is vulnerable
with angled cephalad needle puncture.
The posterior reflection of the parietal pleura is horizontal and reflected off the
lateral portions of the ribs, and puncture through the latter half of the
intercostal space is theoretically safer

Renal Anatomy and Percutaneous Entry

The safest point for calyceal puncture is the centre of the calyx, approached
through the relatively avascular plane (Brödel line) between the branches of
the anterior and posterior divisions of the renal artery.
Puncturing the centre of the calyx avoids injury to the arcuate divisions that
course around the infundibulum.