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Arteries of the Lower Limb — Detailed Notes for Medical Students

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Overview: Arterial Sequence

Abdominal Aorta
    └── Common Iliac Artery
            ├── Internal Iliac Artery (gluteal/obturator supply)
            └── External Iliac Artery
                    └── Femoral Artery (at inguinal ligament)
                            └── Popliteal Artery (at adductor hiatus)
                                    ├── Anterior Tibial Artery → Dorsalis Pedis Artery
                                    └── Posterior Tibial Artery
                                            └── Fibular (Peroneal) Artery

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1. External Iliac Artery

• Arises as one of the two terminal branches of the common iliac artery
• Descends along the medial border of the psoas major muscle
• Passes under the inguinal ligament through the lacuna vasorum to enter the thigh
• Becomes the femoral artery at the level of the inguinal ligament

Branches of the External Iliac Artery

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2. Femoral Artery

1. Enters the femoral triangle on the anterior thigh
2. Palpable midway between the ASIS and pubic symphysis, just inferior to the inguinal ligament
3. Descends through the femoral triangle, then continues into the adductor canal (Hunter's canal)
4. Exits through the adductor hiatus in the adductor magnus → becomes the popliteal artery

Clinical note: The femoral artery is the most common site for vascular access (cardiac catheterization, angiography). The vessel is also used to palpate the pulse in shock.

Branches of the Femoral Artery

a) Superficial cutaneous branches (arise in the femoral triangle)

b) Deep Artery of the Thigh (Profunda Femoris)

• Largest branch of the femoral artery
• Arises from the lateral side of the femoral artery in the femoral triangle, ~3–5 cm below the inguinal ligament
• Passes posteriorly between pectineus and adductor longus, then between adductor longus and adductor brevis, eventually perforating adductor magnus to anastomose with popliteal artery branches behind the knee
• Main blood supply to the thigh

• Arises from the lateral side of the profunda femoris (occasionally from the femoral artery directly)
• Passes deep to sartorius and rectus femoris; divides into three branches:
  • Ascending branch → passes deep to tensor fasciae latae → circles femoral neck → anastomoses with medial circumflex femoral artery → supplies femoral head and neck
  • Descending branch → descends deep to rectus femoris → pierces vastus lateralis → anastomoses with popliteal branches near knee
  • Transverse branch → circles the proximal femoral shaft → joins the cruciate anastomosis (with medial circumflex femoral, inferior gluteal, and first perforating arteries)

• Arises from the posteromedial aspect of the profunda femoris
• Passes medially between pectineus and iliopsoas, then between obturator externus and adductor brevis
• Gives a small branch through the acetabular notch → supplies femoral head (anastomoses with obturator artery's acetabular branch)
• Divides into two major branches deep to quadratus femoris:
  • One branch → trochanteric fossa → connects with gluteal and lateral circumflex femoral arteries
  • Other branch → forms part of the anastomotic network around the hip (cruciate anastomosis)

Clinical importance: The medial circumflex femoral artery is the primary blood supply to the femoral head. Fracture of the femoral neck can disrupt this vessel → avascular necrosis of the femoral head.

• All three penetrate the adductor magnus near its attachment to the linea aspera to enter the posterior compartment of the thigh
• First originates above adductor brevis, second anterior to it, third below it
• They form an interconnected longitudinal channel:
  • Superiorly → anastomose around the hip (cruciate anastomosis)
  • Inferiorly → anastomose with popliteal artery branches

c) Descending Genicular Artery

• Arises from the femoral artery just before it exits the adductor hiatus
• Contributes to the anastomotic network around the knee joint

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3. Popliteal Artery

• Runs through the popliteal fossa (deepest structure in the fossa)
• Passes between the gastrocnemius and popliteus muscles
• Passes under the tendinous arch of the soleus muscle
• Divides at the inferior border of the popliteus into:
  • Anterior tibial artery
  • Posterior tibial artery

Clinical note: The popliteal artery is the second most common site for peripheral aneurysms. It is also the most common site of entrapment (popliteal artery entrapment syndrome). The pulse is palpable in the popliteal fossa with the knee slightly flexed.

Branches of the Popliteal Artery

The superior and inferior genicular vessels form an arterial anastomotic network around the knee — clinically important as a collateral pathway when the popliteal artery is obstructed.

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4. Anterior Tibial Artery

• Immediately passes anteriorly through the aperture in the upper part of the interosseous membrane
• Enters and supplies the anterior compartment of the leg
• Descends between tibialis anterior and extensor hallucis longus
• Passes under the extensor retinaculum at the ankle
• Continues onto the dorsum of the foot as the dorsalis pedis artery

Branches of the Anterior Tibial Artery

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5. Dorsalis Pedis Artery

• Passes over the dorsal surface of the talus, navicular, and intermediate cuneiform
• Passes inferiorly between the two heads of the first dorsal interosseous muscle → becomes the deep plantar artery → joins the deep plantar arch in the sole

Branches of the Dorsalis Pedis Artery

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6. Posterior Tibial Artery

• Descends through the deep region of the posterior compartment of the leg
• Lies on the superficial surfaces of tibialis posterior and flexor digitorum longus
• Passes through the tarsal tunnel behind the medial malleolus
• Divides in the sole into:
  • Medial plantar artery
  • Lateral plantar artery

Branches of the Posterior Tibial Artery

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7. Fibular (Peroneal) Artery

• Arises from the posterior tibial artery shortly after it enters the leg
• Descends in the posterior compartment along the medial crest of the fibula, between tibialis posterior and flexor hallucis longus
• Supplies adjacent muscles and bone in the posterior compartment
• Also sends branches laterally through the intermuscular septum → fibular (peroneal) muscles in the lateral compartment
• Distally gives a perforating branch → passes anteriorly through the inferior aperture in the interosseous membrane → anastomoses with a branch of the anterior tibial artery
• Terminates in a network over the lateral surface of the calcaneus

The fibular artery is often the dominant leg artery when the anterior or posterior tibial arteries are absent or hypoplastic (a common anatomical variant).

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8. Plantar Arteries (Sole of the Foot)

Medial Plantar Artery

• Smaller terminal branch of the posterior tibial artery
• Passes along the medial side of the sole
• Divides into:
  • Superficial branch → supplies hallux and skin of medial sole
  • Deep branch → anastomoses with the deep plantar arch

Lateral Plantar Artery

• Larger terminal branch; passes laterally and anteriorly across the sole
• Curves medially across the bases of the metatarsals as the deep plantar arch
• Deep plantar arch (formed by lateral plantar artery + deep plantar artery from dorsalis pedis) gives rise to:
  • Plantar metatarsal arteries (×4) → common plantar digital arteries → proper plantar digital arteries to all toes

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9. Gluteal Arterial Supply (from Internal Iliac)

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10. Cruciate Anastomosis

• Inferior gluteal artery (internal iliac)
• Medial circumflex femoral artery (transverse branch)
• Lateral circumflex femoral artery (transverse branch)
• First perforating artery (from profunda femoris)

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11. Genicular Anastomosis (around the knee)

• Femoral artery (descending genicular artery)
• Popliteal artery (medial and lateral superior genicular, middle genicular, medial and lateral inferior genicular)
• Anterior tibial artery (anterior tibial recurrent artery)
• Circumflex fibular artery

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Summary Table: Key Pulses to Palpate

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Clinical Correlates

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