Anat Clin (1982) 3:279-287
~) Springer-Verlag 1982
Arterial Blood Supply to the Parathyroid Glands:
Implications for Thyroid Surgery
JB F l a m e n t x, J F D e l a t t r e 1, a n d M P l u o t 2
Laboratoire d'Anatomie, Faculte de M6decine de Reims, 51, rue Cognacq Jay, F-51095 Reims Cedex, France
2 Laboratoire d'Anatomie Pathologique, H6pital Robert Debr6, rue Alexis Carrel, F-51092 Reims Cedex, France
Summary. T h e a u t h o r s h a v e m a d e a s t u d y o f the
v a r i a t i o n s in b l o o d s u p p l y to the p a r a t h y r o i d g l a n d s ,
b a s i n g t h e i r r e p o r t o n 100 b l o c k d i s s e c t i o n s o f t h e
n e c k i n j e c t e d w i t h latex. T h e results a l l o w a b e t t e r
u n d e r s t a n d i n g o f c e r t a i n t y p e s o f p a r a t h y r o i d insuffi-
c i e n c y f o l l o w i n g s u r g e r y to the t h y r o i d gland. In al-
m o s t h a l f the cases the v a s c u l a r a r r a n g e m e n t was
sufficient to e x p l a i n h o w h y p o p a r a t h y r o i d i s m m i g h t
c o m e a b o u t f o l l o w i n g s u r g e r y to the t h y r o i d g l a n d .
Vascularisation art6rielle
des glandes parathyro'ides:
incidence en chirurgie thyro'idienne
R6sum6. Le a u t e u r s o n t 6tudi6 tes v a r i a t i o n s de la
v a s c u l a r i s a t i o n des g l a n d e s p a r a t h y r o f d i e n n e s fi p a r t i r
de l ' a n a l y s e de 100 pi6ces d ' 6 v i s c & a t i o n c e r v i c a l e in-
j e c t 6 e s a u L a t e x . Les r6sultats de cette 6tude p e r m e t -
t e n t de m i e u x c o m p r e n d r e c e r t a i n e s i n s u f f i s a n c e s
p a r a t h y r o i ' d i e n n e s c o n s 6 c u t i v e s fi la c h i r u r g i e d u c o r p s
thyroi'de. I1 existe en effet d a n s pr6s de la m o i t i 6
des cas u n d i s p o s i t i f v a s c u l a i r e s u s c e p t i b l e d ' e x p l i q u e r
u n e d 6 v a s c u l a r i s a t i o n p a r a t h y r o f d i e n n e lors de la
c h i r u r g i e d u l o b e thyroi'dien.
Key words: P a r a t h y r o i d glands - Blood supply
Thyroid surgery
The frequency and severity of hypoparathyroid com-
plications following total thyroidectomy for thyroid
cancer represent a major problem for endocrinolog-
ists. It seems p r o b a b l e t h a t m o s t cases result f r o m
accidental devascularization of the parathyroids rath-
er t h a n t h e i r excision. A w a r e n e s s o f c e r t a i n details
o f t h e surgical a n a t o m y a n d o f t h e v a s c u l a r i z a t i o n
Offprint requests to: JB Flament
o f the p a r a t h y r o i d g l a n d s w o u l d h e l p the s u r g e o n
ensure preservation of their function and structure
d u r i n g t h y r o i d surgery.
Materials and Methods
The study was based upon 112 specimens which were injected,
formalinised and then dissected. 100 of the specimens were consid-
ered to be of sufficiently high quality from the technical point
of view for detailed analysis, and results of their dissection are
reported here. The specimens were obtained from autopsy cases
(Laboratory of Pathological Anatomy of Prof T Caulet). They
consisted of complete block dissections of the neck including the
aortic arch with the origins of the great vessels, the tongue, and
laterally the pedicles of the jugulo-carotid vessels and the sternoclei-
domastoid muscles. Posteriorly the block reached as far as the
prevertebral plane. Injection was carried out using coloured latex
neoprene 601A through three catheters placed in the great arterial
trunks at the base of the neck. The peripheral ligatures were first
placed on the great vessels and the injection continued while simul-
taneously tying off smaller vessels in order to obtain sufficient
pressure to fill the parathyroid artery. The venous circulation was
subsequently filled by injection from above downwards using the
same technique. Once injection was completed the specimen was
preserved in 15% formalin and dissected 2 to 15 days later. The
dissection was carried out by the anterior approach first sectioning
the infrahyoid muscles in order to reach the thyroid. The field
was laid open for dissection by the use of traction sutures fixed
to a cork board. The thyroid lobes were exposed by drawing the
infrahyoid muscles superiorly and inferiorly and the carotid and
jugular vessels laterally. The dissection was subsequently carried
out from the center of the field outwards using only fine ophthal-
mological instruments. It took some twenty hours to study each
specimen this way. The results of each dissection were brought
together in a numbered file comprising diagrams of the whole
structure and of the details, written notes, histological results (histo-
logical examination of the parathyroid gland was carried out by
Prof M Pluot), polaroid photographs for immediate use, and slides.
All the complete specimens and all the parathyroid beds were
photographed, amounting eventually to some 4,000 colour slides.
Results
S u r g i c a l a n a t o m y will first be c o n s i d e r e d in r e l a t i o n
to the n u m b e r a n d s i t u a t i o n o f the p a r a t h y r o i d g l a n d s
0343-6098/82/0003/0279/$01.80
280
Fig. 1 a and b.
Dissection of an 'intramural' parathyroid gland obviously at risk from accidental excision
Dissection d'une parathyrofde ~intra murale)) ~videmmentexpos6e ~t un risque d'ex6r6se accidentelle
in order that the problems regarding their blood sup-
ply may be better understood.
N u m b e r o f Parathyroid G l a n d s
Lack of uniformity in the number of parathyroid
glands has never been contested. Lorin (1921) study-
ing 17 specimens found two glands to be present on
seven occasions, three glands on three occasions and
four glands on five occasions. In his thesis Gambarelli
(1952) confirmed that there were never more than
five or less than two. Four glands, however, appears
to be the commonest finding (Welti 1933, 50 subjects;
Gilmour 1938, 428 subjects; Grisoli 1945, 104 sub-
jects; Gambarelli 1952, 70 subjects; Wang 1976, 160
subjects). It is probable that in all published series,
increasing experience of the researcher plays an im-
portant role. We are no exception to this rule having
found a mean of: 3.2 parathyroids from the 1st to
15th specimen, 3.6 parathyroids from the 16th to the
45th specimen, 4.1 parathyroids from the 46th to the
100th specimen.
In the last 45 dissections we always found at least
4 glands. We are thus led to conclude that when
fewer than four are found it is probably because 'we
weren't able to find the f o u r ' (Lorin 1921). These
glands, better labelled as ' n o t f o u n d ' rather than ab-
sent (Grisoli and Dor 1943) are probably the same
glands that certain authors regard as ectopic.
Further analysis of the specimens where we were
JB Flament et al.: Arterial Blood Supply to the Parathyroid Glands
unable to find all four parathyroids show that in
up to 70% of cases the 'missing' gland was an inferior
parathyroid which is well known to be variable and
have an area of distribution considerably greater than
that of the superior parathyroids. The eventuality of
finding more than four parathyroids of normal size
in an adult is disputed. Most authors regard supernu-
merary glands as accessory parathyroids, whose phys-
iological role is doubtful (Salmon and Gaujoux 1943).
Wang (1976) studied 160 subjects and found one to
have 6 parathyroid glands and three others to have
5. Gilmour (1938) studied 1,713 glands from 428 sub-
jects and noted that 6.5% of the individuals possessed
more than 4 parathyroid glands. We found supernu-
merary parathyroids in 9 subjects (9%). In 8 of these
subjects all 5 parathyroids were verified histologically
and the supernumerary gland was, in 5 of these cases,
of normal size with no particular characteristics, mac-
roscopic or microscopic, to distinguish it from the
others. One of our subjects had 6 parathyroids: one
of the supernumerary glands was of normal size situ-
ated in the mediastinum the other was small and
situated at the inferior contralateral pole of the thyr-
oid. The frequency of supernumerary parathyroids
therefore appears to be greater than that suggested
by Gilmour (1938). Again, experience is of prime im-
portance since whereas we found no individual during
the first 55 dissections with more than 4 parathyroids,
there were 9 such cases (20%) amongst the last 45
dissections which had more than 4 glands verified
JB Flament et al.: Arterial Blood Supply to the Parathyroid Glands 281

Fig. 2.
Inferior parathyroid gland supplied by two arterial pedicles. This arrangement can prevent the effects of accidental vascular damage

Parathyroi'de inf6rieure vascularis+e par deux p6dicules art~riels. Ces dispositifs peuvent pr6venir les effets d'une d+vascularisation acciden-
telle de la glande

Fig. 3.
In this specimen the superior parathyroid pedicle is in contact with the thyroid parenchyma; in such cases the short communicating
artery to the parathyroid gland may be considered at risk during thyroid lobectomy

Sur cette pibce on volt que le p6dicule de la parathyro~de sup6rieure est au contact du parenchyme thyroidien; dans ces cas, on
peut penser que la parathyroiite court le risque d'etre d6vascularis6e au cours de la lobectomie thyroiitienne

histologically. Supplementary glands are most fre-
quently situated low down, mediastinal and posterior.
Situation of the Parathyroids
The F r e n c h authors following Lorin (1921), Welti
and Jung (1933) and Grisoli (1945) have tended to
classify the position o f the p a r a t h y r o i d in relation
to the posterior aspect of the thyroid which they have
divided into three segments: a superior segment ob-
lique d o w n w a r d s and backwards, a vertical middle
segment and an inferior segment oblique d o w n w a r d s
and forwards. However, only the superior parathy-
roids, lying more posteriorly and medially m a y be
regularly located in this way. The inferior parathy-
roids are more variable in position. They are f o u n d
either lower down or m o r e laterally or m o r e anterior.
It is therefore m o r e logical to treat the superior and
inferior parathyroids independently. The location of
the superior parathyroids seems remarkably constant:
the glands are frequently f o u n d attached close to-
gether by a short pedicle at the p o s t ~ i o r margin of
the thyroid, or deeply e m b e d d e d in a fissure of the
parenchyme close to this border. They tend to be
located in the middle segment mentioned above: the
' j u x t a - c r i c o i d ' parathyroids o f W a n g (1976). We have
only rarely observed superior parathyroids to lie inde-
pendently of the posterior margin of the thyroid.
W h e n such was the case their location was very vari-
able: either applied closely to the inferior constrictor
muscle, on the deep aponeurosis, or retro-oesopha-
geal. On the other hand, we noted asymmetry between
the right and left side: in our series high superior
parathyroids were m o r e frequently encountered on
the left side than on the right. The inferior parathy-
282
roids were much more variable in position than the
superior.
They lay generally more anteriorly and frequently
as much anteriorly as inferiorly. They were also more
lateral than t h e superior parathyroids, generally
speaking independent of the thyroid lobe, embedded
in the fatty tissue which surrounds the lower poles.
In 8.6% of our cases the inferior parathyroid was
to be found on the lateral surface of the thyroid lobe,
a position on which Millzner (1972) laid emphasis.
In this case the glands are closely related to the cap-
sule and body of the thyroid by a very short pedicle.
These parathyroids which might be termed 'mural'
run the risk of accidental excision during thyroid lo-
bectomy. Here again we found major variation be-
tween the right and left sides: glands on the left side
were frequently lower than those on the right. Thus
we might conclude from our own series that as a
whole parathyroids on the right side tend to be situ-
ated within the middle segment of Welti, while t h o s e
on the left side tend to be more widely dispersed,
the superior glands often being found higher up and
the inferior glands lower down. Only Pyrtek and
Painter (1964) have previously remarked on this dif-
ference in arrangement of the glands, in a study of
100 cases. While we have no precise explanation for
this observation its seems reasonable to assume that
it relates to the asymmetry between left and right
sides which is known to occur during embryological
development.
Arterial Blood Supply to the Parathyroids
While knowledge of the situation and number of para-
thyroid glands is clearly important when they are
being sought during operation, the detailed awareness
of their blood supply becomes fundamental when
thyroid surgery is to be undertaken. Occurrence of
fatal tetany following total thyroidectomy at the be-
ginning of the century gave impetus to the first studies
on this subject.
There are undoubtedly many important studies
already published regarding the blood supply to the
parathyroids, in particular those of the Marseillaise
school (Grisoli 1943 to 1976) which provide important
information. However the results of these studies are
not always concordant and it therefore seemed worth-
while to us to take a further look at the question
and study in detail the blood supply to all four glands
in a single subject.
Number of Arteries Supplying the Parathyroids
According to Halsted and Evans (1907) the parathy-
roid and its artery are classically described a 'cherry
JB Flament et al.: Arterial Blood Supply to the Parathyroid Glands
suspended by its stalk', the blood supply to the gland
being assured by a single, nondividing artery. Having
studied 357 pedicles we found a single artery in only
287 (80.3%) cases. This artery was simple, that is
to say conforming to the classical description in 186
(52.1%) cases, bifurcating before its entry into the
gland in 86 cases and dividing into 3 in 15 cases.
In 53 subjects we have observed two distinct arteries,
on 13 occasions there were 3 and in 3 cases even
4 separate arteries. On the other hand we only found
on two occasions a parathyroid gland supplied by
two arteries arising from independent branches of
the inferior thyroid arteries. At the same time it was
exceptional to find two parathyroid glands supplied
from the same arterial trunk. Lazorthes et al. (1961)
studied 36 glands from 10 subjects and found such
an arrangement in 6 of them. In our series the fre-
quency was much lower (0.5%).
Finally, in one case the two parathyroid arteries,
each with its own origin, were linked by a fine anasto-
motic branch (55). Thus when two or more arteries
existed they were most frequently found to have ori-
gins very close to one another from the same thyroid
vessel, and the ligature applied to one would inevita-
bly influence the other (Welti and Jung 1953). Other
arrangements were rare in our experience, and the
classical description was observed in only half of our
cases.
Length of the Parathyroid Arteries
Classically the length of the artery is very variable
(l to 40 ram) usually lying between 8 and 12 ram.
When long, the arteries are commonly tortuous and
their length does not always reflect the distance sepa-
rating the gland from the origin of its vascular pedi-
cles. When a pedicle is short (1 to 3 ram), it tends
to hold the parathyroid hard down against its vessel
of origin (Virenque and Gaubert 1962) making its
mobilization and dissection difficult. When formed
from two or more arteries the pedicles are usually
short: thus in our own study of 13 parathyroids sup-
plied by 3 arteries, 8 had pedicles of less than 3 mm
in length; the longest was only 7 ram. On the other
hand a single pedicle which does not divide can be
very short. We have found, like other authors, major
differences in length between the pedicles of the inferi-
or and superior parathyroid's: generally speaking the
pedicles of the superior parathyroids are shorter than
those of the inferior (this is almost certainly related
to the embryological development of the parathyroids
and the migration which the inferior parathyroids
undergo). Thus in 16 parathyroids which have a pedi-
cle equal to or greater than 30 ram, 13 amongst them
were inferior parathyroids. Numerous authors (Proye
JB Flament et al.: Arterial Blood Supply to the Parathyroid Glands 283

et al. 1980, Gouillat et al. 1979, Tiziano 1976) have

proposed for protective reasons that each gland
should be identified and mobilized, separately, which
they claimed could be undertaken without risk of
damaging the pedicles. However our own experience
leaves us in some doubt over this. We found that
certain parathyroids had such a short pedicle that
mobilization was not possible. This was almost always
the case for inferior parathyroids flattened against
the inferior pole of the thyroid.
Neither was this arrangement rare, since it oc-
curred in 20 cases (5.5%). Excision of the parathyroid
in this situation would seem inevitable in the event
of lobectomy of the thyroid. On the other hand, while
a long pedicle might allow mobilization of the para-
thyroid in relation to the thyroid lobe it would in
no way obviate risk of damaging the pedicle during
subsequent lobectomy. It would in effect be necessary
to mobilize the origin of the pedicle. In our studies
we came across mediastinal parathyroids whose pedi-
cle measuring 40 mm would have been irrevocably
damaged during lobectomy thus we feel that the
length of the pedicle is not in itself a sufficient guide
to the risk or otherwise for interrupting the parathy-
roid supply during surgery.
Origin of the Parathyroid Arteries
The superior and inferior parathyroid glands most
frequently borrow their blood supply from the inferi-
or thyroid artery (Lorin 1921, Gr6goire 1931, Welti
and Jung 1933, Grisoli and Dor 1943, Virenque and
Gaubert 1962, Bismuth et al. 1975). Our own findings
were in general confirmatory, but certain features of
the blood supply, not mentioned by previous authors,
seem worth considering. In particular the source of
blood supply to the parathyroid in the absence of
an inferior thyroid artery was not mentioned in the
publications which we consulted.
Superior Parathyroid Glands. The blood supply of the
183 superior parathyroid glands which we studied
was assured : in 141 cases by the inferior thyroid artery
(77.1%) in 28 cases by the superior thyroid artery
(15.3%), in 13 cases by anastomoses running between
two systems the length of the posterior border of
the thyroid lobe, and in one case by an artery arising
from a middle thyroid artery. These figures are in
general agreement with the authors of previous series,
who attribute blood supplies of the superior parathy-
roids to the inferior thyroid artery in around 80'/0
of cases.
When the superior thyroid artery supplies the su-
perior parathyroid (a possibility dismissed by Lorin
(1921) but upheld by Halsted and Evans (1907) and
Fig. 4.
Absence of inferior thyroid artery in which the parathyroid gland
receives its blood supply from a branch of the anterior division
of the superior thyroid artery
Parathyrofde vascularis6e,en l'absence d'art6re thyroi'dienneinf6r-
ieure, par une branche de division ant6rieure de l'art~re thyroi-
dienne sup6rieure
Welti and Jung (1933)), the supply almost always
came from the posterior branch or from an artery
arising from the posterior branch and destined for
the oesophagus or the larynx. However, it seems
worthwhile noting the considerable asymmetry which
we observed between the right and left side. In effect,
of the 28 parathyroids whose blood supply was drawn
from a superior thyroid artery, 22 were found on
the left and the next 6 on the right. This observation
concurs with the asymmetry of situation between the
two sides which we noticed earlier: the superior para-
thyroid is higher on the left side than on the right
and more frequently vascularized by the superior ar-
tery on the left than on the right. We have not been
able to find earlier mention of this arrangement in
the publications we have consulted where the authors
have compared the blood supply to the parathyroid
in relation to their vertical position (high, low or
middle), but without comparing left and right.
Inferior Parathyroids. Our observations regarding the
inferior parathyroids diverge considerably from the
literature. Previous authors without exception state
that the blood supply to the inferior parathyroid
gland arises from the inferior thyroid artery, but we
have this arrangement in only 90.3% of cases (166/
184). In 10 cases the inferior parathyroid was vascu-
284 JB Flament et al.: Arterial Blood Supply to the Parathyroid Glands
JB Flament et al.: Arterial Blood Supply to the Parathyroid Glands 285

larized by the superior thyroid artery, in 1 case by
anastomosis between the two systems and in 7 cases
by an artery of Neubauer. This divergence, which
is not negligible, probably comes about through the
failure of previous authors to take account of cases
in which a inferior thyroid artery was absent.
The frequency of agenesis of the inferior thyroid
artery is variously reported in the literature. It is re-
ported to be present in between 1 and 6% of cases
and apparently more frequently in the female. Adachi
(1928) dissected 286 parathyroid pairs and found 17
cases of agenesis of the inferior thyroid artery. It
was however absent in 1 out of every 10 females.
We found complete agenesis of the inferior thyroid
artery in 9 out of 200 dissections (4.5% of cases).
The inferior thyroid artery was thus absent on one
side in 9% of our cases (we found no instance of
bilateral agenesis). The anomaly is readily explained
in terms of the phylogenetic and embryological pre-
ponderance of the superior thyroid pedicle (Alexandre
and Chevrel 1965).
In these 9 cases an inferior parathyroid was absent
on one occasion, and in two its blood supply was
drawn from the thyroidea ima artery. In 6 cases the
superior thyroid artery supplied blood to the inferior
parathyroid gland. In these latter 6 cases the blood
supply was always assured by a large anterior branch
which ran along the thyroid lobe and terminated on
the deep surface of the sternothyroid muscle in its
inferior part. This seems to us a particularly risky
arrangement from a vascular point of view because
the branch concerned is inevitably damaged during
mobilization of the superior pole during lobectomy
of the thyroid. We also came across 4 cases in which
the inferior parathyroid was supplied by the superior
thyroid artery despite the presence of an inferior thy-
roid artery. In these cases there was always a large
anterior branch (Fig. 4) arising from the superior
thyroid artery. It was surprising to note in these 4
cases that the superior parathyroid obtained its blood
supply from the inferior thyroid artery. These were
unexpected findings, but may be explained by the
embryological development of the region.
Finally, we came across one case in which the
inferior parathyroid gland, on the left side, obtained
its blood supply from neither thyroid artery but rather
from a branch of the brachiocephalic (innominate)
artery which supplied the deep surface of the sterno-
thyroid without giving off a thyroid branch.
Discussion: the Risk to the Parathyroids
The question remains open as to whether the arteries
supplying the parathyroid glands are terminal vessels
or not. The experimental studies of Leriche and Jung
(1933), which consisted of tying off all the afferent
vessels to the thyroid, gave inconsistent results: 2 dogs
out of 6 died of tetany with histological necrosis of
the parathyroid glands. The presence o f nume~rous
anastomoses between the 4 vascular territories of the
thyroid, oesophagus, trachea and infrahyoid muscles
have long been known (De Quervain and Curtis 1930)
as well as the richness of the anastomosis between
a superior thyroid and inferior thyroid territories (Vi-
renque and Gaubert 1962). The semi-microscopic ra-
diographic techniques of the Toulouse school pro-
vided a useful means of establishing the value of these
anastomoses and their eventual connection with the
parathyroid blood vessels, but these methods are diffi-
cult to apply on a large scale. Macroscopically howev-
er, certain practical observations are worth making:
classically the parathyroid arteries always arise from
thyroid branches of the thyroid arteries and are con-
sidered terminal. Halsted and Evans (1907) and Welti
and Jung (1933) showed that the origin of the parathy-
roid artery is often situated at the level of the oesopha-
geal tracheal or muscular branch. According to La-
zorthes et al. (1961) the parathyroid artery gives off
an artery to neighbouring organs in a quarter of cases.
In our own series the relationships between the para-
thyroid arteries and the neighbouring arteries varied
considerably according to their level.
The blood supply to the parathyroids in the mid-
dle plane almost always arises from a branch of the
inferior thyroid artery destined for the thyroid gland
itself. One third of the parathyroids situated in a

Fig. 5a-e. Parathyroid blood supply at risk. In these 3 cases the gland is in contact with the sub-isthmic tissues and its blood supply
is afforded by a very fine ramus

Dispositlfs dangereux de la vascularisation parathyrofdienne. Dans ces 3 cas, la glande est au contact des tissus sous-isthmiques et
vascularis6e par un tr6s fin rameau
Fig. 6. In this specimen the left superior parathyroid gland is supplied by a ramus of the superior thyroid artery which has traversed
the thyroid parenchyma
Sur cette pi6ce, la parathyro[de sup~rieure gauche est vascularis6e par un rameau de l'art6re thyro[dienne sup6rieure qui a travers6
le parenchyme thyroi'dien
Fig. 7. This parathyroid gland is suspended on its pedicle 'like a cherry on its stalk' (Halsted 1907). This is the classical arrangement

Cette parathyroi'de est eppendue fi son p6dicule ~<comme une cerise/t sa tige)> (Halsted 1907). C'est l'aspect qui correspond 5_la description
classique
286
high position obtain their blood supply from the oeso-
phageal or pharyngeal branch. More than half the
parathyroids situated low down are fed by a muscular
(sternothyroidal) or tracheal branch. Moreover, a
third of parathyroid arteries give off a small branch
to the thyroid. This branch is particularly easily com-
promised because it penetrates the gland immediately
and provides only a very short communication be-
tween the parathyroid pedicle and the thyroid gland.
In practice, as Welti and Jung (1933) have already
emphasized, it is very difficult to establish the termin-
al character of the parathyroid artery. Most frequent-
ly a branch of the thyroid artery gives off branches
successively to the oesophagus and thyroid gland
(Seldinger 1954). As these branches are of very similar
calibre it is difficult to say whether it is a question
of an oesophageal branch giving off the parathyroid
artery or the parathyroid artery giving off an oesopha-
geal branch. This question is problematic enough
for the superior parathyroids, but even more difficult
for the inferior parathyroids. In the latter case, is
it a question of a sternothyroidal muscular branch
giving off a parathyroid artery or the parathyroid
branch giving off a muscular ramus? This difficulty
presents itself in more than half the cases and the
problem may be tackled in a number of ways. In
fact this discussion is largely academic, and we tend
to believe that the parathyroid artery is always termin-
al in character above a certain level: this level is
that at which a ligature invariably produces ischaemia
of the gland.
The fine branches which the parathyroid arteries
give off to the fat surrounding the parathyroid glands
do not have a supply function because they end in
the fatty tissue and it is always easy to enucleate
the parathyroids with their fat in order to liberate them.
In our view it is the position of the parathyroid
artery in relation to the thyroid parenchyma which
is the most important factor when considering the pos-
sible consequences of thyroid lobectomy on the blood
supply to the parathyroid gland. In effect the parathy-
roid artery arises most commonly at the point of
contact with the thyroid parenchyma and in many
cases it appears impossible to avoid devascularization
of the parathyroid during thyroidal excision.
The notion of 'dangerous disposition' or of
'threatened gland' has been frequently emphasized
in the literature. In a further study of the problem
we have followed the vascular network of each para-
thyroid gland as far as the trunk of the thyroid artery
on which it depended, always preserving the collater-
als in order to estimate the risk of damage to the
parathyroid artery or to one of its feeding vessels
during the course of surgical lobectomy. Our analysis
of 338 pedicles suggested that the risks outlined above
JB Flament et al.: Arterial Blood Supply to the Parathyroid Glands
were considerable: 133 of the parathyroids we dis-
sected were at risk from devascularization, even when
using ultrafine ligatures of Halsted at the points of
contact with the thyroid parenchyma.
The risk was greater for the superior than for
the inferior parathyroids. 205 of the parathyroid
glands were not exposed sufficiently to place an ultra-
fine ligature in contact with the parenchyma. But from
our own particular point of view, it seemed worthwile
to look upon the blood supply to all four glands,
in order to attempt to obtain an overall view of the
vascularization of the functional tissue of the parathy-
roid in the individual subject.
We have evaluated the risks in 72 subjects in
whom all four glands were clearly identified. We
found that all four glands were at risk from devascu-
larization in 10% of cases, one gland alone was at
risk in 25% of cases, 2 glands in 40% and 3 glands
in 15% of cases; it is again worth restating that 4
parathyroids ran the risk of devascularization in 10%
of our cases. Nevertheless care should be taken in
interpretation because, as we have seen, a supplemen-
tary parathyroid may be present. Moreover one can
never know what becomes of ischaemic glands which
are left in place. The experiments of Leriche and Jung
(1933), using selective ligatures in the dog, showed
that necrosed tissue may yet be surrounded by normal
parenchyma.
Conclusion
Our observations would lead us to suggest that the
surgeon should keep the following points in mind
during surgery on the thyroid gland. Systematic iden-
tification of the parathyroid glands allowed Blondeau
to reduce the postoperative frequency of parathyroid
insufficiency following sub-total thyroidectomy for
Graves' disease from 9.2 to 5.4%. By conserving the
posterior part of the thyroid gland it is possible to
reduce the frequency of insufficiency to around 1% ;
however this technique presents certain difficulties
and the operation may require a total thyroidectomy
for cancer. The advice offered long ago by Halsted
is as true today as it was in 1907 ; conservative surgery
including the use of ultrafine ligatures flush with the
thyroid parenchyma is a major step in reducing the
frequency of iatrogenic hypoparathyroidism.
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