Winslows Pathway: A Rare Collateral Channel in Infrarenal

Aortic Occlusion
ROBERT J. PRAGER, JOHN R. AKIN,2 GWYNN C. AKIN,3 AND ROBERT J. BINDER4

Introduction Discussion

Symptoms resulting from ischemia of the lower extrem- There are two collateral pathways by which arterial
ities are among the most common indications for arteni- blood usually reaches the lower extremities when the
(1)
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ography. Although many radiologists consider arteniog- infrarenal aorta is occluded : the visceral pathway
raphy for occlusive peripheral vascular disease a routine through the inferior mesentenic artery and then via rectal
procedure, many technical and diagnostic problems can collaterals into the various branches of the internal iliac,
occur. To provide guidance for the vascular surgeon and to external iliac, or femoral arteries; and (2) the systemic
avoid unexpected hazards, alternative collateral pathways pathway, via the lower intercostal, subcostal, and lumbar
should be explored when conventional angiography fails. arteries which supply collaterals to the iliolumbar and
superior gluteal arteries, thus filling the internal iliac
Case Report arteries in a retrograde fashion [1-41. A third, much less
A 47-year-old white male was admitted to the San Francisco common route involves the internal mammary arteries and
Veterans Administration Hospital with a 4 year history of pro- is sometimes called Winslows pathway. The internal mam-
gnessive claudication resulting in incapacitating pain after he had mary arteries are also usually filled by the intercostal
walked about 1 00 m. He had adult-onset diabetes mellitus, an 80 arteries, commonly causing rib notching.
pack per year smoking history. elevated serum cholesterol and To our knowledge, this is the first reported case of adult-
triglyceride levels, and a history of inferior and anteroseptal onset infrarenal aortic occlusion in which the internal
myocardial infarctions. He had undergone a right carotid throm- mammary arteries provided the sole arterial supply to the
boendarterectomy and aortocononany bypass, with a saphenous legs, excluding axillary-femoral grafts. In an autopsy study
vein graft, 5 months earlier.
of a child, Edwards et al. [5) demonstrated a dilated and
On physical examination, all pulses in the lower extremities
tortuous inferior epigastric artery entering an external
were absent, as were the right axillany, night brachial, and both
iliac artery, which increased in caliber beyond the com-
radial pulses. The left axillary and brachial pulses were diminished.
Bilateral subclavian artery bruits were present. munication. This provided morphologic evidence of hemo-
There was no x-ray evidence of rib notching, and a previous dynamically significant flow in the inferior epigastnic
aontognam demonstrated normal caliber intercostal arteries. artery. Our case illustrates a variation of Winslows path-
Anteniography was performed without complication using the way in which there is a prominent communication between
left axillary approach. An abdominal aortogram revealed a corn- the superior epigastnic artery and the upper portion of the
plete block of the infranenal aorta without demonstration of inferior epigastnic artery, resulting in substantial blood
enlarged intercostal or lumbar arteries (fig. iA). The inferior flow from the subclavian artery to the femoral artery.
mesentenic artery was occluded at its origin and filled through
In patients with complete obstruction of the abdominal
a large collateral branch of the superior mesenteric artery
aorta, the possibility of significant contribution to the
(central anastomotic vessel), which in turn filled the internal iliac
lower extremities via Winslows pathway should be con-
arteries through rectal collaterals (figs. lB and 1 C). Despite high
volume injection (Aenografin 76 at 1 5 mI/sec for 4 sec) and pro- sidered. While this channel is common in congenital
longed filming (30 sec), the abdominal aontic injection failed to coanctations of the aorta, it is very rare in adult-onset
demonstrate flow into the external iliac or femoral arteries. aortic obstruction. Therefore, if the injection in the abdom-
To explore other potential collateral pathways, the catheter inal aorta fails to define the external iliac and femoral
was withdrawn to the origin of the left subclavian artery. A test systems, the angiographer should perform an injection
injection during fluoroscopy demonstrated an enlarged left into the ascending aorta while filming the pelvis in order
internal mammary artery. An injection was then made in the
to delineate this possibility.
aortic arch while the pelvis was filmed. The common femoral
If a translumbar aortogram had been performed, it
arteries filled rapidly through enlarged inferior and superior
would have been impossible to define the patency of this
epigastnic and internal mammary arteries (fig. 1D). Thus it was
demonstrated that the entire arterial supply to the lower extrem- patients external iliac and femoral systems. Neither should
ties originated from the proximal aorta. Femoral arteries were an indiscriminate attempt be made to increase the amount
satisfactorily visualized and patent. The patient subsequently of injected contrast in order to demonstrate the femoral
underwent aortofemoral bypass grafting with relief of all system. This could result in a transverse myelitis because
symptoms and return of pedal pulses to normal. of massive amounts of contrast filling the spinal artery of

Received May 14, 1976; accepted June 30. 1976.

This work was supported in part by grant GM20980 from the National Heart and Lung Institute
, Department of Radiology. University of California, San Francisco. California 94143.
2Department of Radiology. San Francisco Veterans Administration Hospital. and University of California, San Francisco. California 94143. Address
reprint requests to J. R Akin at the University of California
3 Neuropsychiatric Institute, UCLA Center for the Health Sciences. Los Angeles. California. and Department of Anatomy. University of California.
San Francisco, California 94143
4 Department of Radiology. Alta Bates Community Hospital. Berkeley. California 94705

Am J Roentgenol 1 28:485-487, March 1977 485

 486 CASE REPORTS

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Fig 1 - Abdominal aortography. A. Complete blockage of infrarenal aorta. Large superior mesenteric branch (arrow) supplies blood to inferior mesen-
teric artery B. Inferior mesenteric artery (arrow) supplies rectal collaterals C. Rectal collaterals supply branches of internal iliac artery Note lack of
filling of femoral vessels. D. Inferior epigastric arteries (black arrows) fill common femoral arteries (white arrows) Injection made into ascending aorta.
Adamkiewicz, which originates above the level of the block. unusually large arterial flow retrograde through the in-
Doppler examination of the anterior abdominal wall using fenior epigastnic arteries and suggest the need for
a directional Doppler probe system might demonstrate examination of Winslows pathway.
 CASE REPORTS 487

A potentially hazardous situation could result if the in- arterial blood supply to the lower extremities, ischemia
ternal mammary artery is used in aortocoronary bypass would result.
surgery. Although our patient had bilateral common
carotid artery visualizations through a left axillary artery ADDENDUM
approach, and a cardiac catheterization 2 months earlier,
Since acceptance of this manuscript, another article on the
the internal mammary arteries were not included in angio-
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same subject has been published (Chait A: The internal mammary

grams nor in fluoroscopic examination in either study. In
artery: an overlooked collateral pathway to the leg. Radiology
patients with lower extremity claudication who are also 121:621-624, Dec 1976).
being evaluated for coronary bypass surgery. we recom-
mend that the internal mammary arteries be selectively
injected and visualized at the time of cardiac catheteni- REFERENCES
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formed in a patient with this collateral channel as the sole Proc 23:333-338, 1948