Evaluation Of The Arterial Folding Point During Flexion Of The Hip: about 37 dynamic angiographies

doi:10.21203/rs.3.rs-2217031/v1

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Evaluation Of The Arterial Folding Point During Flexion Of The Hip: about 37 dynamic angiographies

https://doi.org/10.21203/rs.3.rs-2217031/v1

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Purpose

The aim was to determine the location of the folding point of the arterial ilio-femoral axis and his angulation.

Materials and methods

Forty-five dynamic arteriographies were analyzed and 37 were included in the current study. Different lengths were measured, based on specific anatomical landmarks: the departure of the external iliac artery, the inguinal ligament and the bifurcation of the femoral artery. These lengths were measured in extension and during flexion of the hip in order to determine the folding point.

Results

In extension, some physiological angulations of the external iliac artery were measured.

During flexion of the hip joint, the distance from the folding point to the bifurcation of the common iliac artery was respectively 82 +/- 21 mm (range 48-116) on the right and 95 +/- 20 mm (range 59-132) on the left side. The distance from the folding point to the inguinal ligament was respectively 38 +/- 40 mm (range 12-138) on the right and 26 +/- 23 mm (range 8-136) on the left side. The distance from the folding point to the bifurcation of the femoral artery was respectively 45 +/- 29 mm (range 15-107) on the right and 27 +/- 12 mm (range 10-66) on the left side. During flexion, the angulation of the folding point of the ilio-femoral axis was 114 +/- 18 ° (range 81-136°).

Conclusions

The folding point was located cranially to the inguinal ligament and below the departure of the external iliac artery.

Flexion

external iliac artery

arteriography

folding point

inguinal ligament

The angulations of the ilio-femoral arterial axis during flexion of the hip joint is a matter that has been few studied (1–3). The precise location of the folding point has never really been measured (4). It has been demonstrated that the femoral artery had angulation during flexion of the hip and that the common femoral artery is a fixed segment during the movements of extension and flexion of the hip (5,6). Significant changes in length and twist occur in the femoral artery during movement and these modifications are symmetrical between the left and right sides (7–9). Also, physiological modifications appeared with age on the femoral artery, probably resulting from loss of arterial elasticity with age (10).

Knowing the location of the folding point is of paramount importance during positioning of endovascular stents in the external iliac artery (EIA) (2,11). Moreover, this knowledge is of interest in the management of patients with blood flow limitation in the iliofemoral axis, which is very common in the general population and especially in high level cyclists (12).

The purpose of this study was to focus on the modifications of angulations along the ilio-femoral axis during flexion of the hip joint and to determine the folding point with respect to different anatomical points.

Population

Forty-five patients, for whom a diagnosis of unilateral proximal external iliac endofibrosis was suspected between June 2008 and December 2012, underwent an aorto-ilio-femoral arteriography, according to the same protocol. They were free of any atheromatous cardiovascular diseases or cardiovascular risk factor.

The measurements were performed on the left side in 33 patients, and on the right side in 10 patients

Five patients were excluded for our study because of lack of usable images, data or of too many physiological angulations of the artery. Three patients were excluded because they couldn’t flex the hip.

Thirty-seven patients were included for study: 31 men, 6 women with a mean age of 44 +/- 11 (range 29-69 years).

Radiological protocol

For all patients, both sides were studied, to compare right and left.

Using Seldinger technique, a 0.035 hydrophilic guidewire was introduced in the contralateral femoral artery. A 5 F multiperforated angiographic catheter was guided by a crossover procedure, in the origin of the common iliac artery (CIA) on the side to be studied, for an unilateral injection.

Fluoroscopic images in neutral position of the hip joint were obtained in anteroposterior and lateral projections (30°) of the patient. Then, for the search of arterial length excess, the patients were requested to flex the hip at 90°, to be able to have other images in hip flexion with lateral projection.

Concerning neutral positions, only anteroposterior projections were used because of the low resolution of lateral projections images.

Measurement technique

From the digital images obtained, several points and data were measured.

Three vascular and ligament reference points were chosen to measure the location of the folding point:

the bifurcation of the CIA to the departure of the extern iliac artery (A),
the EIA to the radiological crossing line of the inguinal ligament on the ilio-femoral arterial axis (B). This line connected the anterior superior iliac spine to the pubic spine. It was traced on the anteroposterior incidence radiographs.
the inguinal ligament to the femoral bifurcation (C) (Fig 1).
The length of the EIA (distance A-B) was measured in the neutral position on the anteroposterior X-ray. In neutral position, it was noted if there was an arterial angulation, by excess of arterial length. It was measured in degrees, relative to the main axis of the ship.

During hip flexion, the point of arterial flexion (point D) was determined on the ilio-femoral arterial axis. Distances AD, DB, and DC, respectively representing the distance of the ilio-femoral flexion point from the origin of the EIA, from the inguinal ligament, and from the ipsilateral femoral bifurcation, were measured (Fig 2).

The different angulations in extension were also measured because of their presence in several patients (Fig 3).

After femoral access, a marked catheter was advanced into the contralateral proximal common iliac artery, and an oblique image was taken, in 90° hip flexion, using an selective injection. The arterial folding point was determined only on the side without catheter.

On the oblique image, lines parallel to the central arterial line were drawn above and below the folding point, and the angle formed by the two lines was bisected. The arterial folding point was determined as the point where the line bisecting the angle.

Statistical analysis

Mean and standard deviation were calculated for each measurement. Spearman correlation analysis was used to determine the correlation coefficient between the patient’s age and the distance from the folding point to the femoral bifurcation. A second correlation analysis was made between the total length of the ilio-femoral axis and the location of the folding point.

Physiological angulations in extension

Twenty-one patients (57%) had physiological angulations of the artery without any flexion.

Nine of them had angulations on the right ilio-femoral axis. Among them, 7 patients had an angulation to the departure of the iliac extern artery with a mean angulation of 142°+/-13,4 (range 129-156) and 4 of them had an angulation to the inguinal ligament with a mean angulation of 150°+/- 10,8 (range 133-164).

Five of them had angulation on the left side. Among them, 4 patients had an angulation to the departure of the iliac extern artery with a mean angulation of 137°+/- 12,9 (range 122-167) and 2 of them had an angulation to the inguinal ligament with a mean angulation of 139°+/- 11,1 (range 120-164).

Seven had angulations on both ilio-femoral axis. All of them had an angulation around the departure of the iliac extern artery (Table 1).

Angulations during flexion of the hip joint

The arterial folding point was located cranially to the inguinal ligament and the hip joint, but below the departure of the EIA.

The distance from the folding point to the bifurcation of the CIA on the right ilio-femoral axis was 82 +/- 21 mm (range 48-116 mm).

The distance from the folding point to the inguinal ligament on the right ilio-femoral axis was 38 +/- 40 mm (range 12-138 mm).

The distance from the folding point to the bifurcation of the femoral artery on the right ilio-femoral axis was 45 +/- 29 mm (range 15-107 mm).

The total length of the right ilio-femoral axis was 165 +/- 46 mm (range 117-254 mm).

The distance from the folding point to the bifurcation of the CIA on the left ilio-femoral axis was 95 +/- 20 mm (range 59-132 mm).

The distance from the folding point to the inguinal ligament on the left ilio-femoral axis was 26 +/- 23 mm (range 8-136 mm).

The distance from the folding point to the bifurcation of the femoral artery on the left ilio-femoral axis was 27 +/- 12 mm (range 10-66 mm).

The total length of the left ilio-femoral axis was 146 +/- 32 mm (range 93-234 mm) (Table 2-3).

The angulation of the folding point of the ilio-femoral axis was 114 +/- 18 ° (range 71-139°).

Table 2. Average measurements of the iliac arterial plication zone during hip flexion at 90°, in relation to certain landmarks.

	Lengths of the native arterial axis		Values concerning the kink point
	Total lengths of the ilio-femoral axis (mm)	Lengths to the inguinal ligament (mm)	Folding point angulation (degree)	Distance to the bifurcation of the common iliac artery (mm)	Distance to the bifurcation of the femoral artery (mm)
Right side	218	93	111	60	59
Left side	215	91	120	64	67

Correlations with age and total length of the ilio-femoral axis

The correlation between the ages of the patients of the folding point of the ilio-femoral axis was determined. It was small but significant (r=0,004). The location of the folding point was estimated as: 0,0129 x age + 108,7 (R² = 1E-05) (Table 4).

The correlation between the total length of the ilio-femoral axis and the location of the folding point was strong: the longer was the ilio-femoral axis, the further the folding point (R²=0,89). The location of the folding point was estimated at: 0,7865 x total length + 2,9176 (Table 5).

While the mechanical stresses in flexion-extension, compression-elongation and torsion have been studied many times and better understood at the level of the femoro-popliteal arterial axis during knee flexion, knowledge of the mechanical stresses which can be exercised on the ilio-femoral axis during hip flexion, remains to be determined (13). The conformational changes of the ilio-femoral artery is a subject that has been studied only a few times, especially on the determinism of the location of the arterial folding point.

Indeed, it has already been demonstrated that the femoral artery presented with a change of its direction during flexion of the hip and that the common femoral artery is a fixed segment during these movements.

This anatomo-radiological study, allows us to confirm that the folding point of the ilio-femoral axis was located cranially to the inguinal ligament but below the departure of the extern iliac artery. The arterial kink zone was located between 82 and 95mm from the common iliac bifurcation. This corresponded to an average distance varying from 26 to 38mm, if the fictitious line of the inguinal ligament was taken as a reference.

Our results are consistent with literature showing that the femoral artery is fixed and the folding point is located above the inguinal ligament (5).

Sung Il Park et al, who took as a reference acetabular roof and inguinal ligament, came to the same conclusion (1). They had also reported a correlation between age and distance to the inguinal ligament.

Our radio-anatomical study was carried out thanks to the iconographic and numerical results of the ilio-femoral angiographic examinations requested in the case of the diagnostic and pre-therapeutic assessment of a suspected involvement of iliac arterial endofibrosis. Our study population was homogeneous, young and free from any calcified arterial pathology, which can induce a displacement of the plication zone. The lesion of arterial endofibrosis is a lesion of endoluminal myointimal hyperplasia, of low thickness, which cannot disturb the physico-elastic properties of the artery during flexion (14). Furthermore, since the contralateral intra-arterial injection catheter was positioned upstream, at the ostium of the CIA, it could not induce any disturbance in the arterial plication zone. The measures of the other published studies were confronted with this bias.

However, the measurements were performed with the patient lying on the examination table, in supine position. As other authors, we hypothesize that there might be some difference in the location of the bend point between standing and supine position. This hypothetical difference seems to be insignificant for us, given the orders of magnitude in length of the arteries studied.

In addition, if our study confirms several works and data, on the constraints in bending which the arterial axis undergoes, it does not allow us to evaluate the modifications in torsion and in compression of the ilio-femoral axis, during the hip flexion.

Like other authors, we chose several anatomical landmarks, such as the inguinal ligament or the origin of the EIA (1,11,15). These anatomical reference points are recognized in other published studies. They are very easily identified on all the examinations currently available to us.

Knowledge of the location of the arterial flexion point during hip flexion is of considerable clinical and therapeutic importance in vascular pathology.

Arterial iliac kinking during flexion of the hip joint or during the pedalling motion, is well reported in high-performance athletes. The fact that the kink was located within the EIA, support the etiopathogenic hemodynamic hypotheses of arterial endofibrosis (14). Repetitive hip movements are responsible of turbulent flux in the EIA, creating shear stress on the bench artery wall. This may explain the preferentially iliac external arterial location of this non-atheromatous lesion.

Endovascular treatment is the reference surgical treatment for ilio-femoral atherosclerotic stenotic lesions. However, the implantation of a stent in the kind of flexible arterial segment, can be complicated by early thrombosis, restenosis by myointimal hyperplasia, stent fracture (16). These poor results result in these external iliac location, among other things, from the inadequacy of the physico-elastic properties of the biomaterials, to withstand the repeated stresses in elongation-compression, plication and torsion of the arterial axis, during hip flexion movements (17). Even if hip joint is less vigorously mobile than the knee joint, the last 5 cm of the EIA should be now considered as a high-stress zone for intravascular implantable devices, given the verified anatomical changes. These data are to be taken into consideration with great importance in determining the positioning of stents or endoprostheses, in the choice of their physical characteristics, when covering vascular lesions in this area.

In conclusion, the arterial folding point of the ilio-femoral axis, was located cranial to the inguinal ligament but below the departure of the EIA. The arterial kink zone is located about 3cm upstream of the inguinal ligament. Knowledge of the anatomical modifications of the arterial axes of the flexion zones, during movements, contributes to the improvement of therapeutic management and monitoring in many indications.

The authors did not receive support from any organization for the submitted work

The authors have no conflicts of interest to declare that are relevant to the content of this article

Availability of data and material (data transparency): yes

Code availability: Not applicable

Authors' contributions

TM: Data collection, data analysis, manuscript writing

MM: Data collection, data analysis, manuscript writing

PF: Protocol development, manuscript editing

AV: Protocol development, manuscript editing

the study was approved (or granted exemption) by the appropriate institutional and/or national research ethics committee (including the name of the ethics committee) and certify that the study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards

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Tables 1, 3, 4, & 5 are available in the Supplementary Files section.

No competing interests reported.

Table1.png
Table 1. Means of length in extension
Table3.png
Table 3. Means of length during flexion of the hip
Table4.png
Table 4. Spearman correlation analysis between the patients’ age and the distance from the external iliac artery to the folding point.
Table5.png
Table 5. Spearman correlation analysis between the total length of the ilio-femoral axis and the distance from the external iliac artery to the folding point.

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Version 1

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Evaluation Of The Arterial Folding Point During Flexion Of The Hip: about 37 dynamic angiographies

Archived Versions:

Version 1

Abstract

Figures

Introduction

Patients And Methods

Population

Radiological protocol

Measurement technique

Statistical analysis

Results

Physiological angulations in extension

Angulations during flexion of the hip joint

Correlations with age and total length of the ilio-femoral axis

Discussion

Conclusion

Declarations

References

Tables

Additional Declarations

Supplementary Files

Archived Versions:

Version 1