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. 2025 Sep 19;47(1):207. doi: 10.1007/s00276-025-03720-x

Preservation of parathyroid vascularization in thyroid surgery: morphological study and surgical implications

Catarina Melo 1,✉, António Bernardes 1, Luis Cardoso 2, António Miguéis 1
PMCID: PMC12449346  PMID: 40970952

Abstract

Purpose

The aim of this work was to study the vascularization of parathyroid glands (PTG) and determine the features that may influence its preservation. Based on those findings we propose surgical strategies to preserve the parathyroid vascular supply in thyroid surgery.

Methods

A study of the vascular supply of 110 PTG was performed in 30 cadaver specimens. The thyroid arteries were cannulated and injected with an isoprene polymer. Data collection included: number and location of PTG and information about their vascular supply: origin, number of arteries, length, course, relation with recurrent laryngeal nerve (RLN) and thyroid lobe. There were determined the most variable features and the most consistent features about PTG arteries.

Results

The vascular supply of PTG was provided by a terminal artery. The PTG’s hilum was related to the thyroid surface. The PTG received 1 vessel in most cases, with no significant difference between the superior and inferior PTG (P = 0.111). The superior PTG received a vessel from the posterior branch of inferior thyroid artery (ITA) in 49 cases (87.5%) and the inferior PTG received a vessel from the anterior branch of ITA in all 54 cases (100%). The length of the arteries was on average 7 mm and the arteries to inferior PTG were smaller (P = 0.004). The artery to superior PTG described a cranial course in 40 cases (71.4%) and the artery to the inferior PTG described a caudal course in 31 cases (57.4%) (P < 0.001). The parathyroid arteries were located anterior to the RLN in most cases. The arteries to superior PTG were all posterior to the thyroid lobe and the arteries for inferior PTG were posterior to the thyroid lobe in 48 cases (88.9%) and course through the thyroid parenchyma in 6 cases (11,1%). All PTG arteries were located lateral to the attachment of the pretracheal layer of the deep cervical fascia to the trachea.

Conclusions

The origin, number, course and length of the parathyroid arteries are variable, which influence its preservation. There are some consistent features that can guide thyroidectomy. The PTG should be retracted from medial-to-lateral direction from the thyroid surface to protect their hilum. The PTG located anterior to the thyroid lobe may need to be re-implanted, once their artery crosses thyroid parenchyma. The area posterior to the thyroid lobe, anterior to the recurrent laryngeal nerve and lateral to the pretracheal layer of the deep cervical fascia should be spared from dissection and vessel ligation, once is the main territory for PTG arteries.

Keywords: Thyroid surgery, Parathyroid glands, Hypoparathyroidism, Vascular anatomy, Cadaver study

Introduction

Thyroid surgery may be associated with complications that severely affects patient’s quality of life. Hypoparathyroidism (failure of parathyroid glands) is the most common complication after thyroidectomy. It is a challenging problem, being transient in 20–30% of patients or permanent in 1–4%, carrying additional therapy costs to patients and society [2, 9, 22, 25].

In order to minimize the incidence of postoperative hypoparathyroidism it is essential to preserve the parathyroid glands (PTG) in situ and assure their viability by preserving their vascular supply [1, 16, 21].

In thyroid surgery, fluorescence imaging angiography has been introduced as an intraoperative adjunct to study, identify and preserve the vascular supply of the PTG. This technique is based in the administration of an exogenous intravenous contrast and the application of a near infra-red light to access parathyroid vascularization before and after thyroid resection [6, 7, 18]. The use of fluorescence imaging angiography has brought the need to rethink about the principles of thyroid surgery regarding the preservation of PTG and may add changes to thyroid surgery principles. However helpful, this technique cannot replace the surgeon’s knowledge of thyroid and parathyroid vascular anatomy and there are several aspects regarding PTG vascularization that cannot be accessed during surgery.

In the literature, there are only a few studies that detail the anatomy of parathyroid vascularization. In light of these recent advances in thyroid surgery, there is the need to depict new highlights in parathyroid vascularization, which are helpful from a surgical perspective, not only to identify the vascular supply of PTG, but also to determine dissection strategies to preserve it.

The outcome of this work was to study the characteristics of the vascular anatomy of PTG that may influence the preservation of their vascular supply during thyroidectomy and therefore compromise their function leading to hypoparathyroidism. Based on those findings we propose surgical strategies to preserve PTG vascular supply during thyroid surgery.

Materials and methods

Specimens

There were used 30 cadaver specimens (anterior cervical organs) collected from autopsies in National Institute of Legal Medicine, following consultation of National registry of non-donners.

Procedures

Arterial cannulation with a 22G catheter was performed in each thyroid artery and an isoprene polymer was injected (liquid latex). The arterial canulation of superior and inferior thyroid arteries was achieved in all specimens. In one specimen it was identified a middle thyroid artery that was cannulated as well. The injection of liquid latex was able to permeate the branches of the arteries to their terminal branches in thyroid parenchyma, allowing the identification of the collateral branches of the thyroid arteries, including the parathyroid arteries.

The cadaver specimens were dissected, using standard dissection techniques, under a surgical microscope (Leica® M230). Dissection procedures included isolation and retraction of the infrahyoid muscles (sternothyroid, sternohyoid and omohyoid muscles), dissection of the anterolateral surface of the thyroid gland, identification and dissection of superior and inferior thyroid arteries and middle thyroid artery (if present). The thyroid lobes were retracted towards the midline, allowing the identification of the collateral and terminal branches of the thyroid arteries, the parathyroid glands and parathyroid arteries. The arteries were dissected from their origin to their end.

Data collection and analysis

During dissection of the 30 cadaver specimens, there were recognized 110 PTG.

The following data was documented:

  • Location and branches (collateral and terminal) of main thyroid arteries;

  • Number and location of the PTG recognized in each specimen;

  • Vascular supply of PTG: origin, number of arteries, length, course, relation with recurrent laryngeal nerve (RLN) and thyroid lobe.

The data regarding the characteristics of parathyroid vascular supply was compared between superior PTG and inferior PTG. There were determined the features that are subject of variations and the features that are consistent regarding the parathyroid arteries.

Statistical analysis

Statistical analysis was performed using SPSS software version 20.0.

For comparative analysis, non-parametric tests for scale variables and Chi-Square and Fisher exact test for nominal variables were used.

A value of P less than 0.05 was considered statistically significant.

Results

During dissection of 30 cadaver specimens, 110 PTG were recognized (56 superior PTG and 54 inferior PTG): 4 PTG in 23 specimens, 3 in 4 specimens and 2 in 3 specimens.

The superior PTG were located posterior to thyroid lobe at the level of the cricothyroid junction in 55 cases (98.2%) and related to the apex of the thyroid lobe in 1 case (1.8%).

The inferior PTG were anterior to the thyroid lobe in 5 cases (9.3%), posterior in 23 cases (42.6%), lateral in 4 (7.4%) and inferior in 22 (40.7%). Five parathyroid glands were located under the thyroid capsule (sub-capsular) and were all inferior PTG.

The location of inferior PTG was more variable than superior PTG (p < 0.001).

Thyroid arteries

After cannulation and dissection of the thyroid arteries, it was verified that the main arteries approach the thyroid gland through the upper pole and posterior aspect of the thyroid lobe and not across the anterolateral surface.

The superior thyroid artery (STA) is found near the upper pole and usually divides into 3 to 4 branches that approach the upper pole of the thyroid lobe, giving collateral branches to pharynx and larynx.

The inferior thyroid artery (ITA) lies posterior to the base of the thyroid lobe and divides into an anterior branch and a posterior branch. The last one gives collateral branches to esophagus and trachea. The anterior branch of the ITA describes a lateral-to-medial course towards the base of thyroid lobe and the posterior branch describe a caudal-to-cranial course towards the upper third of the posterior aspect of the thyroid lobe.

Parathyroid vascularization

The vascular supply of the PTG was provided by a terminal artery in all glands.

The superior PTG received 1 vessel in 49 cases (87.5%), 2 in 4 cases (7.1%) and 3 in 3 cases (5.4%) and the inferior PTG received 1 vessel in 46 cases (85.2%) and 2 in 8 cases (14.8%) (P = 0.111). In the cases where there is more than one artery to the PTG, the vessels originate from the same branch of the thyroid artery, rather than from different branches, and were all terminal (Fig. 1).

Fig. 1.

Fig. 1

Fig. 1

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Arterial pedicles to parathyroid glands (blue arrows indicate the parathyroid arteries). A Left inferior parathyroid gland with one artery; B Right superior parathyroid gland with two arteries; C Right superior parathyroid gland (retracted) with three arteries and right inferior parathyroid gland with one artery. Note: PTG: parathyroid gland; SPTG: superior parathyroid gland; IPTG: inferior parathyroid gland; TG: Thyroid gland; RLN: recurrent laryngeal nerve; ITA PB: posterior branch of inferior thyroid artery; ITA AB: anterior branch of inferior thyroid artery

The PTG’s hilum was located on the posterior aspect of the glands, related to the thyroid surface (Fig. 2).

Fig. 2.

Fig. 2

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Right inferior parathyroid gland retracted from thyroid lobe, to show the location of the hilum on its posterior surface (blue arrow indicate the parathyroid artery). Note: PTG: Parathyroid gland; TG: Thyroid gland; RLN: recurrent laryngeal nerve; ITA AB: anterior branch of inferior thyroid artery

The length of the PTG arteries was on average 7.61 mm (min. 3 mm; max. 18 mm) for superior parathyroid arteries and 5.81 mm (min. 2 mm; max 17 mm) for inferior parathyroid arteries. There was found a significant difference between the length of superior and inferior PTG arteries (P = 0.004), being the length of the arteries to the inferior PTG smaller (Fig. 3).

Fig. 3.

Fig. 3

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Most common origin of the parathyroid arteries for superior and inferior parathyroid glands (blue arrows indicate the parathyroid arteries). A Right inferior parathyroid gland receives a collateral of the anterior branch of inferior thyroid artery; B Right superior parathyroid gland receives a collateral of the posterior branch of inferior thyroid artery. Note: PTG: Parathyroid gland; TG: Thyroid gland; ITA: inferior thyroid artery; ITA AB: anterior branch of inferior thyroid artery; ITA PB: posterior branch of inferior thyroid artery

The superior PTG received a collateral from the posterior branch of ITA in 49 cases (87.5%), anterior branch of ITA in 2 cases (3.6%), and STA in 5 cases (8.9%). The inferior PTG received a collateral of the anterior branch of ITA in all 54 cases (100%). (Fig. 3) Therefore, the arterial supply to the superior PTG is more variable than to the inferior PTG (P < 0,001).

The artery to the superior PTG describe a cranial course in 40 cases (71.4%); caudal in 2 cases (3.6%) and lateral in 14 cases (25%). The artery to the inferior PTG describe a caudal course in 20 cases (37%), lateral in 3 cases (5.7%) and medial in 31 cases (57.4%). There was a significant difference in the direction of the superior and inferior arteries, being the tract of the inferior arteries more variable (P < 0.001).

All the parathyroid arteries were located lateral to the attachment of the pretracheal layer of the deep cervical fascia to the trachea.

The superior parathyroid arteries were located anterior to the RLN in 53 cases (94.6%); posterior in 1 case (1.8%) and lateral in 2 cases (3.6%) and the inferior parathyroid arteries were located anterior to the RLN in all 54 cases (100%) (P = 0.226). Their location was not affected by the course of RLN regarding the branches of ITA.

The arteries to the superior PTG were located posterior to the thyroid lobe in all 56 cases (100%), and the arteries to the inferior PTG were located posterior to the thyroid lobe in 48 cases (88.9%) and passed through the thyroid parenchyma in 6 cases (11,1%) (the 5 inferior PTG located anterior to the thyroid lobe, and one inferior PTG located posterior to the thyroid lobe) (P = 0.507). In these 6 cases there was the need to dissect though the thyroid parenchyma in order to recognize the parathyroid vessel until it reaches the gland (Fig. 4).

Fig. 4.

Fig. 4

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Tow cases of inferior parathyroid glands located anterior to the thyroid lobe: there was the need to dissect though the thyroid parenchyma to recognize the parathyroid vessel (blue arrows indicate the parathyroid arteries). Note: PTG: Parathyroid gland; TG: Thyroid gland; RLN: recurrent laryngeal nerve; ITA AB: anterior branch of inferior thyroid artery

Table 1 summarize the characteristics of parathyroid arteries and the difference found between superior and inferior PTG.

Table 1.

Characteristics of parathyroid arteries and differences between superior and inferior parathyroid glands

Parathyroid arteries Superior PTG
(n = 56)		 Inferior PTG
(n = 54)		 P value
Number
 1 49 (87.5%) 46 (85.2%) 0.111
 2 4 (7.1%) 8 (14.8%)
 3 3 (5.4%) 0
Length (mm)
 Mean (± SD) 7.61 (± 3.53) 5.81 (± 3.31) 0.004
 Min. 3 2
 Max. 18 17
Origin
 STA 5 (8.9%) 0 < 0.001
 ITA AB 2 (3.6%) 54 (100%)
 ITA PB 49 (87.5%) 0
Course
 Cranial 40 (71.4%) 0 < 0.001
 Caudal 2 (3.6%) 20 (37%)
 Lateral 14 (25%) 3 (5.7%)
 Medial 0 31 (57.4%)
Relation to RLN
 Anterior 53 (94.6%) 54 (100%) 0.226
 Posterior 1 (1.8%) 0
 Lateral 2 (3.6%) 0
Relation to thyroid lobe
 Posterior 56 (100%) 48 (88.9%) 0.507
 Intraparenchymal 0 6 (11.1%)
Open in a new tab

PTG: parathyroid gland; STA: superior thyroid artery; ITA AB: anterior branch of inferior thyroid artery; ITA PB: posterior branch of inferior thyroid artery; RLN: recurrent laryngeal nerve; SD: standard deviation

Discussion

This study contributes to understand the vascular supply of PTG. There were recognized several features that, for their variability, increase the risk of PTG devascularization in thyroidectomy. There were also determine the features that are consistent in most cases and that must be considered to avoid the occurrence of hypoparathyroidism. Based on that, there can be suggested surgical strategies to preserve PTG vascularization in thyroidectomy.

The origin of the parathyroid arteries to the superior PTG is variable, although in most cases is a collateral branch of the ITA (posterior branch of ITA in 49 cases (87.5%), anterior branch of ITA in 2 cases (3.6%), STA in 5 cases (8.9%)). The number of the arteries received by the PTG was also variable (superior PTG: 1 vessel in 49 cases (87.5%), 2 in 4 cases (7.1%), 3 in 3 cases (5.4%); inferior PTG: 1 vessel in 46 cases (85.2%), 2 in 8 cases (14.8%)), although originated from the same branch of the thyroid artery. The length of the arteries was variable and there was found that the arteries to the inferior PTG were shorter than those to the superior PTG (P = 0.004).

The course of the arteries was also variable. Not all arteries describe the same course and the arteries to superior and inferior PTG vary in direction. The arteries to superior PTG described a cranial course almost parallel to the trachea in 40 cases (71.4%), caudal in 2 cases (3.6%) and lateral in 14 cases (25%). The arteries to inferior PTG described a lateral-to-medial course in 31 cases (57.4%), caudal in 20 cases (37%) and lateral in 3 cases (5.7%).

The location of inferior PTG regarding the thyroid lobe was also variable, which can influence the preservation of their vascular supply, especially when they are located anterior to the thyroid lobe—in these cases, there was verified that the parathyroid artery crosses through the thyroid parenchyma, which precludes its preservation.

There are few anatomical studies about the vascular supply of PTG, mentioning the vascular arrangements that can increase the risk of devascularization of PTG, leading to postoperative hypoparathyroidism. In these studies, there are some controversies regarding the main aspects that can compromise the preservation of PTG vascular supply.

Halsted and Evans conducted a cadaveric study, stating that each PTG receives a single artery [11].

However, Flament et al., studied 357 PTG demonstrating the variability of the parathyroid pedicles: in 80.3% of PTG there was only one artery and in the other cases there may be up to 4 arteries to each PTG. They also reported some factors, present in only 10% of cases, that influence the occurrence of hypoparathyroidism: the parathyroid artery crosses thyroid parenchyma; parathyroid artery length < 2 mm and the absence of ITA, being the length of the parathyroid artery the most important factor [10].

Delattre et al., in cadaver study with 100 specimens, stated that 38.2% of the parathyroid arteries were at risk during thyroid surgery and that the most important factor for devascularization is the parathyroid artery location rather than the length of the parathyroid artery [8].

In literature, only a few studies combine the evaluation of vascularization and location of PTG [5, 13]. A study performed by Burger et al., considered not only the vascular arrangement but also the parathyroid location in order to provide an anatomical mapping that may help create surgical strategies to prevent postoperative hypoparathyroidism. They describe also that 8.2% of PTG receive their blood supply from the thyroid gland [5].

Other authors studied the importance of anatomical landmarks for preservation of parathyroid vascularization [14, 19, 20, 26], however its utility in surgery may be problematic, due to the numerous anatomical variations in neck structures and morphological alterations attributed to thyroid pathology.

All these studies refer to the variability in vascular arrangements as features that increase the risk of devascularization of PTG. However, during thyroidectomy these features are difficult to appraise, once it is not possible and not recommended to explore and dissect the arteries to the PTG.

The use fluorescence imaging angiography was proposed to intraoperative evaluation of PTG vascular supply [1, 13, 23, 24]. Some studies used fluorescence imaging angiography in order to map the vascular anatomy of PTG, defining patterns of parathyroid arteries that can guide thyroid dissection, although in most cases it was difficult to identify a well-defined vessel or vascular pattern [3, 16]. Therefore, the importance the study in cadaver specimens, which provides a useful tool to access the characteristics of PTG arteries, once it is possible to achieve a wider vascular dissection than during surgery and withdrawal surgical strategies for thyroid dissection.

There are still some aspects regarding parathyroid vascular supply that are subject of discussion and study. In thyroid surgery, the acknowledgment that there is essential to preserve the PTG vascular supply to assure their function after surgery carried the need to better understand the vascular anatomy of the PTG and add new insights concerning the surgical technique of thyroidectomy.

In the present study there were found several variations in the characteristics of the PTG arteries that may compromise their preservation: the origin, the number of arteries, the length and the course of the arteries to the PTG. All these variations represent an additional challenge in the preservation of parathyroid vascular supply, once it’s difficult to determine which is the best dissection strategies to avoid ligation of PTG arteries.

In this study, it was possible to identify some vascular features that were consistent in almost all cases. The main arterial territories surrounding the thyroid gland are located near the upper pole and the posterior aspect of the thyroid lobe, although the thyroid arteries can also be subject to several variations [4, 17].

There were also found some aspects that were constant regarding the parathyroid arteries. The location of PTG’s hilum on the posterior surface of the gland, which is related to the thyroid surface. The location of the parathyroid arteries in the area anterior to the recurrent laryngeal nerve, posterior to the thyroid lobe and lateral to the insertion of the pretracheal layer of the deep cervical fascia to the trachea. The only exception to this, was when the PTG are located anterior to the thyroid lobe. In these cases, the artery to the parathyroid gland course through the thyroid parenchyma limiting the possibility to its preservation.

Once it is difficult to guide thyroid dissection based in the features that are subject of morphological variations, there must be considered the features that are constant when suggesting dissection strategies for thyroidectomy.

According to the vascular features of parathyroid arteries there can be proposed some principles to consider during thyroid surgery, in order to minimize the devascularization of PTG.

The anterolateral aspect of the thyroid gland is not related to major arteries and can be dissected in order to retract the thyroid lobe and expose the posterior aspect were the PTG are more commonly located.

Dissection should be carefully performed in the area anterior to recurrent laryngeal nerve and lateral to the insertion of the pretracheal layer of the deep cervical fascia to the trachea, for this is the area where the parathyroid arteries are more constantly located. The surgeon should prevent the ligature of any vessels in this location.

Depending on the proximity of PTG to thyroid parenchyma, to avoid ligation of parathyroid arteries, the PTG should be retracted from medial-to-lateral direction, separating them from the thyroid surface, in order to preserve their hilum which is related to the thyroid surface.

Inferior parathyroid glands located anterior to the thyroid lobe are at risk of devascularization. Their vascular supply is very difficult to preserve once it may pass through thyroid parenchyma. In these cases, if they cannot be retracted from the thyroid, they may need to be re-implanted in a cervical muscle.

The limitation of this study was that ectopic or intrathyroidal parathyroids were not studied or searched, as the intent of this study was to search for concepts useful in surgery, and during thyroid surgery the ectopic PTG are not routinely searched and intrathyroidal cannot be preserved in order to achieve complete thyroid resection. All the difficulties or limitations encountered in this study are related to the vast anatomical variability in both parathyroid location and vascular anatomy. Therefore, the need for additional studies to add information about a matter that is still currently object of investigation and debate.

Conclusions

The vascular supply of PTG is subject of several variations that may challenge its preservation in thyroid surgery, leading to parathyroid failure and hypoparathyroidism. The origin, number, course and length of the parathyroid arteries are variable and there is a significant difference between the superior and inferior PTG.

Some consistent features regarding parathyroid arteries can be used to determine surgical strategies to preserve PTG vascular supply. The location of the hilum in the posterior aspect of the PTG, related to the thyroid surface, dictate that the PTG should be retracted from medial-to-lateral direction. The location of PTG regarding the thyroid influence the preservation of their vascular supply, especially if located anterior to the thyroid lobe, and thus these PTG may need to be re-implanted. The arteries to PTG are located in the area posterior to the thyroid lobe, anterior to the recurrent laryngeal nerve and lateral to the pretracheal layer of the deep cervical fascia, and therefore dissection and ligation of vessels in this area should be minimized.

Acknowledgements

The authors express their gratitude to those who donated their bodies, enabling anatomical studies to be performed. We also thank the National Institute of Legal Medicine and Forensic Science for their collaboration in specimens’ collection.

Author contributions

C.M., A.B., L.C. and A.M.: Investigation; Study design; Data collection; Data analysis, Writing of the manuscript. All authors reviewed the manuscript.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Competing interests

The authors declare no competing interests.

Ethical approval

The study was approved by the Faculty of Medicine of University of Coimbra’s ethics committee (CE-025/2023) and by the National Institute of Legal Medicine and Forensic Science’s ethics committee (CE-28/2023).

Footnotes

Publisher’s note

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Associated Data

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Data Availability Statement

No datasets were generated or analysed during the current study.

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