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Background <p>The aortic bifurcation (AoB) and common iliac artery bifurcations (CIABs) represent critical landmarks for anterior lumbar approaches, pelvic surgery, and endovascular procedures. However, most studies describe only their vertical vertebral location and disregard horizontal variation, bilateral asymmetry, and positional correlations.</p> Objectives <p>To introduce and apply a novel imaging-based classification system that integrates vertical (vertebral-third) and horizontal (coronal-plane) positioning of the AoB and CIABs, and to assess gender differences and anatomical correlations relevant to surgical planning.</p> Methods <p>Retrospective anatomo-imaging study of 100 computed tomography angiograms (60 males, 40 females). Vertical levels were classified into 16 types (subdividing vertebral bodies into thirds from L3 to S2), and horizontal levels into six types (median to sacroiliac joint). Statistical analyses (linear regression, ANOVA, and Chi-squared tests) were used to identify correlations between bifurcation positions and gender.</p> Results <p>The AoB occurred predominantly at L4 (49% for types 5–7 combined), most commonly at the upper third (type 5, 20.0%). Horizontally, the AoB was located at the midline (type I, 47%) or to the left of the midline (type II-L, 46%). The right CIAB was predominantly at the lateral vertebral body level (type III, 92%) and lower third of L5 vertically (type 11, 21%). The left CIAB showed greater horizontal variation between types III (57%) and IV (36%), with the latter occurring most commonly at the sacral promontory (type 13, 24%). Vertical AoB levels showed moderate correlations with vertical CIAB levels on both sides (left: r = 0.42, <i>p</i> &lt; 0.001; right: r = 0.38, p &lt; 0.001) and a weaker correlation with the horizontal position of the left CIAB (r = 0.24, <i>p</i> = 0.016). Female sex was associated with a more lateral left CIAB position (mean type 3.52 vs. 3.18; <i>p</i> = 0.040).</p> Conclusions <p>This classification system reveals previously underreported horizontal variation, consistent bilateral asymmetry, and predictable AoB–CIAB correlations. These findings enhance anatomical mapping for preoperative planning and help prevent vascular complications during anterior lumbar and pelvic procedures.</p>

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The Aortic and Iliac Bifurcations: A Detailed Anatomo-Imaging Study with Novel Horizontal Classification and Positional Integration

  • 期刊论文

  • 发表日期：

    2025年12月23日

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  • Paris Ionescu,
  • Bogdan Adrian Manta,
  • Marius Ioan Rusu,
  • Răzvan Costin Tudose,
  • Adelina Maria Jianu,
  • Mugurel Constantin Rusu

摘要

Background

The aortic bifurcation (AoB) and common iliac artery bifurcations (CIABs) represent critical landmarks for anterior lumbar approaches, pelvic surgery, and endovascular procedures. However, most studies describe only their vertical vertebral location and disregard horizontal variation, bilateral asymmetry, and positional correlations.

Objectives

To introduce and apply a novel imaging-based classification system that integrates vertical (vertebral-third) and horizontal (coronal-plane) positioning of the AoB and CIABs, and to assess gender differences and anatomical correlations relevant to surgical planning.

Methods

Retrospective anatomo-imaging study of 100 computed tomography angiograms (60 males, 40 females). Vertical levels were classified into 16 types (subdividing vertebral bodies into thirds from L3 to S2), and horizontal levels into six types (median to sacroiliac joint). Statistical analyses (linear regression, ANOVA, and Chi-squared tests) were used to identify correlations between bifurcation positions and gender.

Results

The AoB occurred predominantly at L4 (49% for types 5–7 combined), most commonly at the upper third (type 5, 20.0%). Horizontally, the AoB was located at the midline (type I, 47%) or to the left of the midline (type II-L, 46%). The right CIAB was predominantly at the lateral vertebral body level (type III, 92%) and lower third of L5 vertically (type 11, 21%). The left CIAB showed greater horizontal variation between types III (57%) and IV (36%), with the latter occurring most commonly at the sacral promontory (type 13, 24%). Vertical AoB levels showed moderate correlations with vertical CIAB levels on both sides (left: r = 0.42, p < 0.001; right: r = 0.38, p < 0.001) and a weaker correlation with the horizontal position of the left CIAB (r = 0.24, p = 0.016). Female sex was associated with a more lateral left CIAB position (mean type 3.52 vs. 3.18; p = 0.040).

Conclusions

This classification system reveals previously underreported horizontal variation, consistent bilateral asymmetry, and predictable AoB–CIAB correlations. These findings enhance anatomical mapping for preoperative planning and help prevent vascular complications during anterior lumbar and pelvic procedures.