Hoehmann, et al.
Int J Cardiovasc Res 2016, 5:6
DOI: 10.4172/2324-8602.1000284
Review Article
The Artery of Adamkiewicz:
Vascular Anatomy, Clinical
Significance and Surgical
Considerations
Christopher L Hoehmann1*, Kyle Hitscherich2 and Joshua A
Cuoco2
Abstract
The artery of Adamkiewicz is the only major arterial supply
feeding the anterior spinal artery along the lower thoracic, lumbar
and sacral spinal cord. This vessel is clinically significant as injury
to this vital artery can occur during a variety of procedures, most
notably descending/thoracoabdominal aortic repairs. Injury to this
artery can cause consequential neurologic damage manifesting
as anterior spinal cord syndrome. New research on this topic has
supported preoperative identification of the artery of Adamkiewicz
prior to thoracic surgery as a means to protect the spinal cord.
Numerous radiological imaging techniques, such as digital
subtraction angiography, magnetic resonance angiography, and
three dimensional reconstruction using computer tomography
angiography, have been implemented to localize this vessel prior
to surgery, each with their own strengths and weaknesses. Here,
we review the variable vascular anatomy supplying the spinal
cord, clinical significance of the artery of Adamkiewicz, as well as
examine the various radiological imaging techniques currently used
to visualize this vessel prior to surgery.
Keywords: Vascular anatomy; Artery of Adamkiewicz; Spinal cord
syndrome; Radiological imaging
Abbreviations: AKA: Artery of Adamkiewicz, ASA: Anterior
Spinal Artery, T: Thoracic, L: Lumbar
Introduction
The artery of Adamkiewicz (AKA), also known as the arteria
radicularis magna, is the principal vessel that feeds the lower thoracic,
lumbar, and sacral portions of the spinal cord. This vessel exhibits
significant variability in its anatomy (e.g., branch point topography).
It derives from a single posterior intercostal artery originating from
the aorta between the levels of T (thoracic vertebrae) 9 to L (lumbar
vertebrae) 5, most commonly between T9 and T12 [1-4]. Localizing
this vessel is essential prior to thoracic and abdominal surgery in
order to prevent vessel disruption and, thus, spinal cord injury. Several
types of radiological imaging modalities are currently used to localize
the artery, each with significant strengths and weaknesses. In this brief
review, we discuss the vascular anatomy of the spinal cord, the clinical
relevance of the AKA, and various radiological imaging modalities
*Corresponding author: Christopher L Hoehmann, Department of Anatomy,
New York Institute of Technology College of Osteopathic Medicine 14 Graces
Way, Centereach, New York, 11720, USA, Tel: (631) 520-1416; E-mail:
choehman@nyit.edu
Received: August 10, 2016 Accepted: September 15, 2016 Published:
September 21, 2016
All articles published in International Journal of Cardiovascular Research are the property of SciTechnol, and is protected by
International Publisher of Science, copyright laws. Copyright © 2016, SciTechnol, All Rights Reserved.
Technology and Medicine
International Journal of
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currently used to identify the vessel prior to thoracic and abdominal
surgery.
Vascular Anatomy of the Spinal Cord
The spinal cord vasculature is a highly flexible and adaptive
unit (Figure 1) [1,2]. Its continuous and longitudinal nature of
interconnecting anastomoses allows injury to be avoided in the
event of ischemia [2,3,5]. The network of spinal cord vasculature is
extensive as it receives inputs from a multitude of sources. The spinal
cord arterial system consists of extrinsic and intrinsic vasculature
that directly supplies the spinal cord [1,2,6]. The extrinsic vasculature
feeds the intrinsic vessels [1,2,6]. The extrinsic vasculature includes
segmental vessels arising from lumbar and posterior intercostal
arteries, the subclavian arteries, the hypogastric arteries, and
vasculature of the paraspinous muscles [1,2,6]. This culminates as a
network of collateral vessels that allow the spinal cord to withstand a
disruption of blood flow from a single segmental artery. Therefore, a
region of the spinal cord receiving scant collateral circulation will not
be able to compensate if an arterial feeder is disrupted [1,2,3,7].
The intrinsic vasculature of the spinal cord receives a dual blood
supply feeding both the anterior and posterior regions of the spinal
cord from the anterior spinal artery as well as the two posterior spinal
arteries, respectively [1,6,8,9]. The posterior spinal cord receives
significant collateral blood flow via the paired posterior spinal arteries,
thus affording substantial protection from neurological disease from
ischemia [1,6,8,9]. In contrast to the two posterior spinal arteries, there
is a single anterior spinal artery that receives scant collateral blood
flow. This makes the anterior portion of the spinal cord especially
susceptible to ischemia [1,2].
Diversity of the Vascular Anatomy of the Spinal Cord
in Animal Species
Recent research by Flesarova et al., demonstrated that greater
than 60% of segmental branches of the aorta feeding the ventral
and dorsal spinal arteries were left sided in mice [10]. This study
demonstrated that the segmental arteries in the left lumbar region
were not as common as those in the left thoracic region. Thus, the
authors concluded that the left lumbar region exhibits a higher risk for
ischemic injury than the left thoracic region in mice [10]. This study
localized the artery of Adamkiewicz in almost all samples of mice;
however it exhibited variable origination usually from either the third
or fourth lumbar artery [10].
Similar to the findings by Flesarova and authors, a study performed
by Mazensky et al., in rabbbits showed a predominance of left sided
arteries in the thoracic region compared to a more even distribution
of segmental arteries arising from the lumbar aorta [10,11]. Contrary
to mice studies, rabbits demonstrated fewer segmental feeders in the
thoracic region than in the lumbar region [11].
A study by Pais et al., exploring the spinal vasculature in dogs
found that the artery of Adamkiewicz was present in only about half
of specimens. The study demonstrated that dogs have a relative lack
of arteries supplying the thoracic spinal cord, which is similar to the
human model [12]. Although no animal model can perfectly emulate
human spinal anatomy, a foundational understanding of the spinal
Citation: Hoehmann CL, Hitscherich K, Cuoco JA (2016) The Artery of Adamkiewicz: Vascular Anatomy, Clinical Significance and Surgical Considerations.
Int J Cardiovasc Res 5:6.
Note: The spinal cord predominantly receives blood from three arteries
originating around the cervical-cranial junction. These arteries run
longitudinally along the spinal cord, terminating at the caudal end. These
three arteries, the anterior spinal artery and paired posterior spinal
arteries, receive their blood supply mainly from the vertebral arteries, as
well as the ascending cervical arteries, branches of the thyrocervical trunk.
The thyrocervical trunk additionally supplies the cervical spinal cord via
numerous anterior and posterior radiculomedullary arteries. These arteries
do not anastomose with the spinal arteries (anterior and posterior); rather,
they directly supply the spinal cord at the level they enter the vertebral canal.
As the spinal cord extends caudally, blood supply becomes scarce. Anterior
and posterior radiculomedullary branches from the thoracic and abdominal
aorta continue to supply the spinal cord directly, but the spinal arteries do
not receive any new anastomoses until the artery of Adamkiewicz at the
level of the lower thoracic or lumbar vertebra. The lumbar and sacral spinal
cord additionally receives blood from the median sacral artery anteriorly.
Magenta lines represent radiculomedullary arteries and yellow boxes
represent vertebrae.
Figure 1: An Overview of Blood Supply to the Spinal Cord.
cord vasculature in different species allows for a greater appreciation
for the spinal cord and its vasculature in humans.
Anterior Spinal Artery and its Relationship to the
Artery of Adamkiewicz
The ASA (anterior spinal artery) provides perfusion to the
majority of the anterior region of the spinal cord [1]. This vessel arises
from the terminal ends of the vertebral arteries and courses on the
midline surface in the median longitudinal fissure of the spinal cord
while being supplied by several extrinsic contributory arteries (Figure
2) [6]. These reinforcing vessels generally originate from the cervical
or lumbar enlargements [1]. They enter the spinal cord through
intervertebral foramina to supply the ASA via radicular (or segmental
medullary) branches. The AKA, the largest anterior segmental artery,
is responsible for the perfusion of a sizeable region of the spinal cord
as it supplies the caudal two thirds of the ASA [1,3,7,13]. Arterial
blood flow calculations have determined that this artery supplies
68% of the perfusion to the lower thorax and upper lumbar areas of
the spine [2,14]. This artery is the only major vessel supplying this
zone, resulting in a watershed area that is particularly susceptible to
Volume 5 • Issue 6 • 1000284
doi: 10.4172/2324-8602.1000284
Note: The anterior spinal artery originates from the vertebral arteries
around the level of the cervical-cranial junction. Additionally, the anterior
spinal artery receives blood from the anterior radicular arteries (branches
of the vertebral arteries) and the ascending cervical arteries (branches from
the thyrocervical trunk). Following these original tributaries, the anterior
spinal artery does not receive blood from any other anastomosis until the
lower thoracic and lumbar areas via the Artery of Adamkiewicz (not shown).
The anterior spinal artery supplies the bulk of oxygenated blood to the
anterior spinal cord [5].
Figure 2: The Cervical Spinal Cord and Origin of the Anterior Spinal Artery.
ischemia [2,14]. The AKA usually originates from a left posterior
intercostal artery, a branch off of the thoracic aorta, at approximately
the levels of T9 to T12 [1,3,4]. However, the vessel may arise from
either the thoracic or abdominal aorta as its anatomical variability
allows it to originate between T9 and L5 [1,3].
An identifying feature specific to the AKA is its unique shape that
may be referred to as a “hairpin curve”, “hairpin loop”, “hairpin turn”,
or “hairpin configuration” (Figure 3) [1,3,15]. According to Prince
et al., the particular anatomy of this vessel is due to the differential
growth of the spinal cord and the vertebral column. During
embryologic development the AKA penetrates the meninges prior
to elongation of the embryo. As the vertebral column lengthens at a
rate faster than the spinal cord, the artery is dragged upward from its
original level, creating a “hairpin curve” contour [1]. Furthermore,
Melissano et al., suggested that only a few of the segmental branches
present during the 16th week of embryological development persist
through adulthood [16].
Anterior Spinal Cord Syndrome
The clinical picture seen in anterior spinal cord syndrome is due
to infarction of spinal cord contents fed by the ASA. The presentation
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Citation: Hoehmann CL, Hitscherich K, Cuoco JA (2016) The Artery of Adamkiewicz: Vascular Anatomy, Clinical Significance and Surgical Considerations.
Int J Cardiovasc Res 5:6.
Note: The artery of Adamkiewicz (AKA) originates most frequently as a
branch of the left posterior intercostal artery. The AKA is most commonly
found originating from a posterior intercostal artery branching from the aorta
between the spinal levels of T9 and T12; however, its variability allows it to
be found anywhere from the spinal levels of T9 and L5. Immediately following
its point of origin, the AKA extends through the intervertebral foramen of the
corresponding spinal level. It then ascends the anterior surface of the spinal
cord as many as two and a half vertebrae before it undergoes its characteristic
“hairpin curve” after which it immediately anastomoses with the anterior spinal
artery [5].
Figure 3: An Anatomical Depiction of the Artery of Adamkiewicz.
will vary depending on the spinal cord tracts and the spinal cord
level that is injured. Classically, anterior spinal cord syndromes will
infarct the entire anterior section of the spinal cord while sparing
the posterior columns. This results in motor paralysis (possibly
paraplegia) and loss of temperature and pain sensation beneath the
spinal level of the lesion [6-9,17].
The anteromedial aspect of the spinal cord contains the
corticospinal and corticobulbar tracts that relay motor output from
the brain towards the body. The anteromedial location of these
structures renders them solely dependent on the ASA [8,17]. Damage
to these tracts will result in motor paralysis. The anterolateral aspect of
the spinal cord contains the spinothalamic and spinocerebellar tracts
and is responsible for relaying pain, temperature and proprioception
from the body towards the brain [8,17]. This zone is a watershed
region receiving dual supply from both the posterior and anterior
spinal arteries; however, it is typically infarcted in an anterior spinal
artery syndrome [6,10]. Patients will also commonly present with
neuropathic pain, areflexia and autonomic dysfunction resulting
in orthostatic hypotension, sexual dysfunction, or loss of bowel or
bladder functions [6,8,17]. Patients will retain vibratory sensation
and proprioception because the posterior fasciculus cuneatus and
gracilis of the dorsal columns in the spinal cord are responsible for
relaying such information and are solely perfused by the posterior
spinal arteries [6,8,17]. A partial syndrome is possible, which has a
propensity to infarct the gray matter; sensory and sphincter function
is often retained [17].
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Lesion to the Artery of Adamkiewicz
Disruption of the AKA may be related to numerous etiologies,
including: aortic dissection, fibrocalcific emboli, gas emboli,
aneurysm, syphilitic arteries, lumbar spine injury, trauma, or from
aortic atheroma [13,14,17-21]. Damage to the AKA will result in
decreased perfusion of the thoracoabdominal region of the ASA
because of a lack of collateral blood flow and poor anastomoses to
this region [1,2,5,6,8,9,17,18]. As such, anterior spinal syndrome may
ensue due to a non-functioning AKA and/or non-functioning ASA at
the thoracoabdominal region [8,9].
Albeit rare, spinal cord ischemia caused by iatrogenic damage
to the AKA is a feared and devastating complication [6,9,17]. Such a
complication may occur as a result of a number of surgical procedures,
including: aortic aneurysm repair, bronchial artery embolization,
minimally invasive spinal surgery, and aortic dissection repair
[6,7,14,23-25]. This is likely related to the large degree of variation in the
anatomy of this vessel leading to uncertain identification and damage
during surgical procedures [7,14,22]. Spinal ischemia is considered
to be a rare complication, but its risk can vary per procedure [17].
For example, neurologic deficits due to a lesion of the AKA has been
reported to occur in 5 to 16% of thoracoabdominal aortic aneurysm
repair cases, 2.7 to 6.5% of cases of isolated thoracic aortic aneurysm
repair cases, and 3.7 to 12% of cases using endovascular aortic repair
[23]. However, more recent data shows that the incidence of injury
to the spinal cord has been lowered to 3.5 to 5.0%, due to effective
preventative measures [28].
Treatment and Prevention
A variety of techniques are being studied to prevent spinal cord
ischemia as a complication of AKA disruption [14,26 27]. The AKA
supplies the majority of blood flow to the lower thorax and upper
lumbar region of the aorta; therefore, revascularization of that region
has been shown to be an effective measure to prevent complication
due to artery injury [23,28]. Revascularization, specifically of the
posterior intercostal artery, may be accomplished by using a grafted
internal mammary artery [23]. Novel endovascular stent techniques
are also being considered as a means to reconstruct the AKA using
various stent-grafts that preserve the luminal patency of the posterior
intercostal artery or the thoracic aorta [24,25]. Active cooling may
be used to induce mild or deep hypothermia and has been shown
to be an effective method to prevent spinal cord ischemia [6,28].
Cerebrospinal fluid drainage has been shown to be effective by
improving spinal perfusion pressure, which will prevent spinal cord
ischemia [6,28].
Preoperative Imaging
Although clinicians have numerous options to prevent spinal cord
injury via AKA disruption, arguably the most practical technique
involves preoperative imaging to assist in maintaining the integrity
of the artery during surgical intervention [7,14,24,26]. For instance,
Japan has already adopted the widespread practice of preoperative
identification of the AKA in order to prevent spinal cord ischemia
from damage of this vessel [27].
The AKA can be identified as a vessel typically originating from
the left radiculomedullary branch of the posterior intercostal or
lumbar artery and terminating at the ASA [29]. On angiography,
the AKA undergoes an identifying “hairpin curve” just prior to
anastomosing with the ASA [4,29,30]. Despite current knowledge
of the specific course and characteristic turn of the artery, it is still
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Citation: Hoehmann CL, Hitscherich K, Cuoco JA (2016) The Artery of Adamkiewicz: Vascular Anatomy, Clinical Significance and Surgical Considerations.
Int J Cardiovasc Res 5:6.
difficult to correctly identify with radio imaging, particularly with
computed tomography angiography (CTA). With the AKA running
adjacent to the vertebrae, bony artifact may mistakenly present upon
imaging [31]. Moreover, the AKA has a significantly narrow diameter,
0.5-1.5mm, further contributing to the difficulty in capturing images
of the AKA [31]. The anterior radiculomedulary vein and the anterior
spinal vein both run parallel to the AKA with similar spatial position
and course. As such, the timing of imaging studies is imperative
to assure that contrast during angiography still remains within
the desired arterial structure rather than diffusing into the named
vascular structures, predisposing to pseudo identification of the AKA
[31]. Preoperative imaging of the AKA can be performed utilizing a
number of imaging modalities. The premier choice of imaging used,
however, is currently a topic of heavy research and debate as each
modality carries a unique array of benefits and shortcomings that we
will now discuss.
Radiologic Imaging Studies and Related Current
Research
There is currently debate as to what the most beneficial method
for identification of the AKA is. As of late, digital subtraction
angiography (DSA) is the gold standard for visualization of the AKA
[32]. Although DSA is very sensitive in the spatial detection of the
AKA, CTA has proven comparably sufficient in identifying the AKA
while additionally providing more extensive anatomical information
for preoperative preparation [32]. Use of CTA also allows for the
application of single CT acquisition which quickly supplies extensive
anatomical mapping of a large section of vasculature. This has proven
beneficial in older and more critically injured patients, both of
which are more likely to undergo surgery for both abdominal aortic
aneurysm and dissection [32].
Research into the use of magnetic resonance angiography (MRA)
has shown efficacy in identification of the AKA in the preoperative
setting [15,29,31]. Certain studies have demonstrated greater
sensitivity for identification of the AKA compared to CTA alone
[29,31]. This is likely due to bony artifact produced by vertebra on
CTA as well as resolution of the temporal constraints of CTA allowing
for greater assurance of identification of arterial structures compared
to those of vascular origin [31]. Care must be taken when using
gadolinium contrast during MRA procedures, as renal impairment
is often a complication with abdominal aortic aneurysms and
dissections, and can lead to further contrast-induced nephropathy
[31]. Although MRA has shown these advantages, it remains a far
more expensive and time-consuming examination technique while
providing less valuable information for pre-surgical planning. As
such, recent research suggests that CTA should be considered as the
first choice for identifying AKA prior to surgery, and MRA should
only be used during high priority of AKA identification in the event
of a negative CTA result [31].
Current literature suggests that angiographic identification of
the AKA prior to a potentially risky procedure may contribute to the
prevention of complications related to AKA disruption [7,14,24,26].
Fanous et al., showed that angiographic identification of the AKA
prior to surgery significantly altered the surgical decision process in
54% of cases of thoracolumbar corpectomy [14]. An altered surgical
approach could include a variety of adjustments, such as operating via
the contralateral side or at a different spinal level [14]. The same study
also showed that in 25% of cases the AKA was properly localized,
however it did not result in altering the surgical decision-making
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doi: 10.4172/2324-8602.1000284
process. Therefore, the authors recommended the common use of
preoperative imaging as it altered the surgical decision making process
in most cases of thoracolumbar corpectomy [14]. Furthermore,
Estrera recognized advancements of techniques preventing spinal
cord ischemia, but questioned the efficacy of preventative spinal
angiography. This study concluded that angiography is only efficacious
if it changes surgical planning, which is not always the case [26].
Conclusion
In this brief review, we have discussed the vascular anatomy of
the spinal cord, the clinical relevance of the AKA, and the strengths
and weaknesses of the varying imaging modalities currently used to
identify the vessel prior to thoracic surgery.
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Int J Cardiovasc Res 5:6.
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Author Affiliations Top
Department of Anatomy, New York Institute of Technology College of
1
Osteopathic Medicine, Old Westbury, New York, USA
Department of Biomedical Sciences, New York Institute of Technology
2
College of Osteopathic Medicine, Old Westbury, New York, USA
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