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year-old man with group B bifurcation of left internal iliac artery (IIA). Lateral projection 3D volume-rendered reformatted CT angiogram shows left IIA dividing into two branches: internal pudendal artery (anterior division) (thin white arrows) and common gluteal trunk (posterior division) (arrowhead) of superior gluteal (thin black arrow) and inferior gluteal (thick white arrow) arteries. Thick black arrow indicates obturator artery arising from posterior division.
Source publication
Objective:
The purpose of this article is to review the CT angiographic and digital subtraction angiographic features of the male pelvic arteries.
Conclusion:
An increasing number of vascular procedures are being performed in the male pelvis that require profound knowledge of the angiographic anatomy of the internal iliac artery (IIA). The major...
Context in source publication
Context 1
... group B (Fig. 2) the IIA divides into two branches: the internal pudendal artery (ante- rior division) and the common gluteal trunk (posterior division) of the superior gluteal and inferior gluteal arteries. In this group the anterior division seems to be smaller be- cause it consists of only the internal puden- dal artery; the posterior division ...
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Transcatheter angiography and embolization has long been recognized as the gold standard for patients with hemodynamic instability secondary to blunt pelvic trauma. While often the bleeding source can be readily localized based on the distribution of extravasation on preprocedural Computed Tomographic Angiography, one should be cautious in assessme...
Citations
... Likewise in our series, most of the patients were unfit for radical surgery and the managing urologists advised against surgery. In such patients when conservative measures fail to control the hematuria, trans-catheter arterial embolization (TAE) of the vesical arteries is a good option and can yield results comparable to that of open ligation of the internal iliac artery [3,5]. Hald and Mygind initially described TAE in 1974. ...
... Further technical and instrumental developments took place to introduce different catheters, techniques, and embolic materials [4]. Refined results were achievable with the selective embolization of the anterior division of the internal iliac artery and super-selective embolization of the vesical arteries [5][6][7]. The latter technique was described by Kobayashi et al. in 1980 [7]. ...
This article was previously presented as an abstract at the 18th UAA Congress, Seoul, October 15-17, 2020, and the abstract was published in The International Journal of Urology. It was also presented as an e-poster at the 2021 BAUS Annual Meeting on June 22, 2021.
Introduction
In frail patients intractable hematuria secondary to advanced pelvic malignancies is a clinical challenge. Super-selective TAE of the vesical arteries is a suitable minimally invasive option. We present our experience in this patient cohort.
Patients and methods
All patients who underwent TAE from January 2014 to December 2019 were included. Super-selective TAE of the superior and inferior vesical arteries was done using 300-500µ polyvinyl alcohol (PVA) particles. Demographic data, cancer stage, associated urinary system obstruction, pre-embolization palliative treatment, chemotherapy, and radiotherapy were recorded. Technical and clinical success, time to cessation of hematuria, recurrence of hematuria, and complications were recorded. Data are presented as mean ± standard deviation, and statistical significance is set at p<0.05.
Results
From 2014 to 2019, seven patients underwent eight procedures. The average patient’s age was 60.6±10.3 years. All presented with gross hematuria, six due to locally advanced and/or metastatic bladder cancer, and one due to prostate cancer. The average time of hematuria clearance was 60 hours. The average hemoglobin levels at the time of the procedure, one month, and six months post-embolization were 9.6±1.7 g/dL, 10.6±1.5 g/dL (p<0.05), and 9.6±0.9 g/dL, respectively (p>0.05). Packed red blood cell (PRBC) requirements decreased from 7±2 units to 5±3 units after the procedure (p >0.05). The patients were followed up for an average of 13.6 months and four had a recurrence at an average of four months post-embolization.
Conclusion
Super-selective TAE is an effective palliative method in controlling intractable hematuria. The risks of major surgery and anesthesia are omitted, and the procedure can be repeated as needed. Furthermore, post-embolization complications, using this technique, are minor and manageable.
... Before performing vascular embolization, it is imperative to have a comprehensive understanding of the vascular anatomy of the pelvis and any potential variations. The primary arterial vascular supply of the pelvis is given by the dividing branches of the internal iliac arteries and, to a lesser extent, by the branches of the external iliac artery [14]. The internal iliac arteries are typically divided into anterior and posterior branches. ...
... About 30% of patients also have middle rectal arteries. These arteries usually originate together with prostatic arteries in the prostate-rectal trunk [14]. Both non-targeted embolization and recurrent hemorrhage can result from anastomoses with the superior and inferior rectal arteries, which are frequently seen [15]. ...
Background: Traumatic pelvic injuries are associated with high injury severity scores and significant morbidity and mortality. Active bleeding is the most common cause of death among those patients. Due to limitations of surgery for pelvic hematomas, angiographic treatment is at the forefront of pelvic trauma management.Objective: The present article aims to discuss the available endovascular treatment modalities, and common angiographic treatment strategies and techniques.Conclusion: Interventional radiologists plays a key role in the management of patients with pelvic trauma. New standardized protocols are needed to minimize the time spent on deciding the correct treatment for each patient.
... The age of the patients with PAE in our study was similar to other studies, usually in the middle-aged and elderly groups because the research subjects were often patients with BPH. Research by author Tiago Bilhim et al. [15] was conducted on 75 patients with an average age of 66 (from 50 to 80 years old). In the research by author Nguyen Xuan Hien et al. [16], there were 58 patients ranging in age from 53 to 91. ...
... Because the PA is small and its path is quite variable, the average diameter of each PA was calculated as the average of the diameter when measured at 3 locations, including the starting location of the PA (proximal point), the location about to branch (far point) and and the location between these two locations. The average diameter of the PA in our study was 1.5 mm, equivalent to the results of Wang et al. [11], Nguyen Xuan Hien et al. [16], and Tiago Bilhim et al. [15]. There was no statistically significant difference in PA diameter between the two groups in our study. ...
... In lesser cases, pelvic haemorrhages are of arterial origin [55,56]. In the middle part of the superior and inferior pubic rami, along the ischial ramus, in the apex of the greater sciatic notch and the vicinity of the ventral part of the sacroiliac joint, lie the arteries which run close to the bone, and fractures in this location are most at risk of arterial haemorrhage [57][58][59][60]. Therefore, vertically displaced fractures in these areas are worthy of strict follow-ups. ...
Introduction
Angioembolisation (AE) and/or pre-peritoneal pelvic packing (PPP) may be necessary for patients with complex pelvic fractures who are haemodynamically unstable. However, it remains unclear whether AE or PPP should be performed as an initial intervention and ongoing debates exist. This meta-analysis aimed to compare AE versus PPP in haemodynamically unstable patients with acute pelvic fractures. The primary outcomes of interest were to compare in-hospital mortality rate and number of blood units transfused. Secondary outcomes included evaluating differences in the time from diagnosis to treatment, as well as the length of stay in the intensive care unit (ICU) and hospital.
Methods
All clinically relevant studies comparing AE versus PPP in patients with complex pelvic fractures and haemodynamic instability were accessed. The 2020 PRISMA guidelines were followed. In September 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar and Embase, without constraint.
Results
Data from 320 patients were collected (AE: 174; PPP: 146). The mean age on admission was 47.4 ± 7.2 years. The mean Injury Severity Score (ISS) on admission was 43.5 + 5.4 points. Baseline comparability was observed in ISS (P = 0.5, Table 3) and mean age (P = 0.7, Table 3). No difference was reported in mortality rate (P = 0.2) or rate of blood units transfused (P = 0.3). AE had a longer mean time to the procedure of 44.6 min compared to PPP (P = 0.04). The mean length of ICU and hospital stay were similar in both groups.
Conclusion
Despite the longer mean time from admission to the procedure, no significant differences were found between AE and PPP in terms of in-hospital mortality, blood units transfused, or length of ICU, and hospital stay. These findings should be interpreted considering the limitations of the present study. High-quality comparative research is strongly warranted.
Level of evidence
Level IV, meta-analysis.
... The origin of the prostatic artery itself is highly variable, and knowledge of the branching patterns of the internal iliac artery (IIA) is helpful in the search for the small vessels that perfuse the gland. The anatomy of the IIA has been previously described using cadaveric dissections, but interest in PAE sparked several studies using modern imaging techniques such as digital subtraction angiography and computed tomography angiography [7,8]. These modalities have proved invaluable to our understanding of these arterial branches and their variants [9]. ...
... Parietal branches include the superior and inferior gluteal, obturator, iliolumbar, and inferior and superior lateral sacral arteries. Together, these twelve branches supply the majority of the perineum, pelvic viscera, pelvic walls, and gluteal areas [8]. ...
... An additional complication was the number of independent prostatic arteries per pelvic side. Bilhim et al. described the presence of two PAs in 24% of pelvic sides, while Zhang et al. reported a second PA in only 3.6% of pelvic sides [8,12]. ...
Purpose of Review
Prostatic artery embolization (PAE) is an emerging minimally invasive technique for lower urinary tract symptom reduction from benign prostatic hypertrophy (BPH). While the technique is becoming increasingly popular with patients and interventional radiologists, most urologists remain skeptical of the PAE’s long-term efficacy and comparative success to the gold standard transurethral resection of the prostate.
Recent Findings
PAE has been found in multiple meta-analyses to perform similarly to the gold standard transurethral resection of the prostate (TURP) with regard to patient-driven measures like IPSS and IPSS-QoL, while also performing favorably in objective measurements including Qmax and PVR out to at least 12 months post intervention. Furthermore, PAE has a demonstrated shorter hospital length of stay and fewer adverse events when compared to TURP.
Summary
PAE provides patients with an alternative to transurethral options for the management of LUTS in the setting of bladder outlet obstruction. While long-term evidence demonstrating the durability of PAE is still forthcoming, the procedure has been demonstrated to be safe according to multiple meta-analyses. Patients deserve to be counseled on PAE as an alternative to surgery and made aware that while the overall treatment effect may not be as robust or durable, the procedure carries a favorable adverse event profile that is attractive to patients wishing to avoid a trans-urethral approach.
... Although some studies have evaluated the branches of the IIA including the IVA [7][8][9][10][11][12][13][14][15], there have been no published radiological or anatomical assessments of the origin of the SVA, especially its distance from the origin of the AT-IIA. In this retrospective study, we evaluated the site of SVA bifurcation by measuring the distance between the origins of the AT-IIA and VA. ...
Purpose: This study aims to assess and measure the origin of the superior vesical artery and its distance from the anterior trunk of the internal iliac artery, to which the anticancer drug is infused via double-balloon-occluded arterial infusion bladder-preserving therapy for locally invasive bladder cancer.
Material and Methods: The 160 pelvic sides of 80 patients were analyzed. Double-balloon catheters were bilaterally introduced into the contralateral superior gluteal artery via the internal iliac arteries using a bilateral transfemoral approach. The proximal balloon is placed at the internal iliac artery, proximally from superior gluteal artery bifurcation, whereas the distal balloon at the origin of the superior gluteal artery to isolate the anterior trunk of the internal iliac artery discharging to the targeted vesical arteries between the balloons. The side hole between the distal and proximal balloons was adjusted at the origin of the anterior trunk of the internal iliac artery to allow clear visualization of the angiographic flow into the bladder. After the distal and proximal balloons were inflated, three-dimensional rotational digital subtraction angiography was performed by simultaneous contrast injection from one extension tube connected to bilateral catheters. The distance (X) between the origins of anterior trunk of the internal iliac artery and superior vesical artery was measured on three-dimensional digital subtraction angiography images, and the origin of the inferior vesical artery was investigated.
Results: All superior vesical artery originated from anterior trunk of the internal iliac artery. The mean x was 7.2 mm (range 1.0-22.0 mm). All inferior vesical arterys branched from anterior trunk of the internal iliac artery or its branches.
Conclusions: Superior vesical artery commonly originates from the proximal portion of anterior trunk of the internal iliac artery close to superior gluteal artery bifurcation.
Fullsize Image
... The male pelvic arterial anatomy is complex, with multiple side branches arising from the internal iliac artery [1]. To facilitate the identification of all male pelvic arteries, it is easier to start with the identification of the four larger side branches: the superior and inferior gluteal arteries, internal pudendal artery, and obturator artery. ...
... Identification of all the internal iliac artery side branches becomes easier when steep oblique projections are used during PAE. The ipsilateral anterior oblique projections Korean kjronline.org of 35°-45° with caudal-cranial angulation of -10° are commonly used for identification of the prostatic artery (PA) [1][2][3]. After identifying the major internal iliac artery side branches, it became easier to identify the PA. ...
... One relevant variant of PA anatomy is the accessory pudendal artery (Fig. 8, Supplementary Video 12), which provides common vascularization to the penis and prostate kjronline.org and requires careful management to avoid non-target embolization of the penis [1,2]. Once the PA is reached, up to 60% of patients may have anastomoses that may require protective coil placement before embolization (Fig. 9, Supplementary Video 13). ...
... The lumbar branch also supplies a spinal branch to the cauda equina. 6 Spilling of embolic agent to the cauda equina could lead to paraesthesia and paralysis consequential to nerve damage. To minimise this risk, we performed a test run with a bolus of contrast medium prior to administration of NBCA glue to examine the flow dynamics. ...
... The ipsilateral anterior oblique views help to separate all the major internal iliac artery side branches and correctly identify the vesical, prostatic, and rectal arteries. 13,14 Most bladder arteries arise from the superior vesical artery that is always the first side branch of the anterior division of the internal iliac artery. The superior vesical artery should not be confused with the prostatic artery. ...
... Relevant variants to be aware of encompass: accessory pudendal arteries and penile anastomoses that could lead to penile nontarget embolization, rectal branches that could lead to rectal ischemia and aberrant obturator arteries that are outside the pelvic region and could originate the prostatic arteries in up to 1% of pelvic sides. 5, [13][14][15] The superior vesical artery is the most challenging anatomy. When the prostatic artery arises from the superior vesical artery, it can be very challenging to navigate past the bladder branches. ...
Male patients over 50 years with lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH) are potential candidates for prostatic artery embolization (PAE). PAE is not a perfect fit for all BPH patients. Careful pre- and postpostprocedural evaluation/consultation with correct selection of patients should be tailored on an individual basis. Evaluated parameters include the following: LUTS severity quantification with validated questionnaires as the international prostate symptom score (IPSS) and quality of life (QoL), erectile and ejaculatory evaluation with validated questionnaires, blood tests including full blood count, coagulation profile, renal function and total/free prostate-specific antigen (PSA), prostate volume measured by multiparametric magnetic resonance (mpMR) of the prostate and/or transrectal ultrasound, uroflowmetry measuring the peak urinary flowrate (Qmax), and postvoid residual urine (PVR). Correct arterial anatomy identification with either computed tomography (CT) angiography, MR angiography, or intraprocedural cone-beam CT (CBCT) are suggested for a confident procedure and avoiding potential complications. The minimally invasive nature of PAE with a faster recovery, preserving the sexual function, and comparable results to standard prostatic surgery make the procedure an attractive choice for many male patients suffering with this condition. Patients should be informed about the potential for higher retreatment rates and shorter duration of treatment effect when compared with standard prostatic surgery. In this comprehensive review, we provide an updated toolbox for all interventional radiologists interested in the PAE practice for patients with BPH. We explain how to evaluate patients during consultation before and after PAE, describe the preprocedural imaging required, explain the technique, and narrate how to optimize outcomes. Finally, we review the level of evidence of PAE for BPH.
... If the back rake angle or the diameter of the screw is rather large, it is easy for the screw to pierce the posterior wall and damage the sciatic nerve and inferior gluteal vessels. The internal pudendal artery accompanied by the pudendal nerve passes out of the pelvis from the inferior foramen of the piriformis, travels around the sacrospinous ligament to the posteromedial side of the sciatic spines, and enters the pelvis from the sciatic foramen [12]. The median distances between the internal pudendal artery and the sciatic spines, between the pudendal nerve and the sciatic spines were 4 mm (range 0-8 mm) and 0 mm (range 0-9 mm) [11], respectively. ...
Background: Research into minimally-invasive fixation of acetabular posterior column fracture has mostly focused on anatomic measurement through the ischial tuberosity in a retrograde manner, and few anatomic studies have been carried out on anterograde percutaneous Magic screws. The purpose of this paper was to discuss the entry point, entry direction and fixation range of Magic screws for fixation of acetabular posterior column fracture.
Method: Materialise’s Interactive Medical Image Control System (Mimics) 19.0 software was used to carry out three-dimensional (3-D) reconstruction based on the Computed tomography (CT) data of the pelvises of 100 cases. A virtual Magic screw was placed in the acetabular posterior column, and the screw entry point, entry direction, length, diameter, safety range and fixation range were determined. Osteotomy modeling was performed on the acetabular posterior column with virtual Magic screw fixation, and the changing law of the width of the screw channel was observed. The narrowest distance and position between the screw edge and the acetabulum were measured.
Results: The bone entry point of the Magic screw on the posterior side to the anterior inferior iliac spine and cephalad side to the acetabular top for the males were 33.32 ± 5.52 mm and 13.42 ± 3.68 mm, respectively; and those for females were 33.94 ± 5.43 mm and 9.11 ± 3.82 mm, respectively. The screw for males had a back rake angle of 57.37 ± 6.53° and a leaning inside angle of 52.12 ± 5.61°, with an angle of 15.16 ± 3.45° to the iliac wing. For females, those angles were 55.61 ± 7.94°, 51.53 ± 5.59° and 9.76 ± 3.69°, respectively. The maximum screw diameter was 6.97 ± 0.98 mm for males and 6.39 ± 0.85 mm for females. The screw length was 76.73 ± 9.20 mm for males and 63.64 ± 8.37 mm for females. The safety ranges of back rake angle and leaning inside angle of the 5.5 mm diameter screws for the males were 7.18 ± 3.32° and 9.42 ± 3.96°, respectively, and those of 5.2 mm diameter screws for females were 8.39 ± 2.83° and 10.37 ± 3.92°, respectively. For 60% of the male specimens, the screw fixation range was above the acetabular top, with a length of 60.45 ± 5.92 cm; and for 40% of the male specimens, the screw fixation range was below the acetabular top, with a length of 50.68 ± 6.49 cm. For females, 24% of the specimens were above the acetabular top, with a length of 52.19 ± 7.76 cm; and 76% of the specimens were below the acetabular top, with a length of 38.40 ± 4.35.
Conclusion: Percutaneous Magic screws provide a minimally-invasive fixation method for acetabular posterior column fracture with high surgical difficulty, and can be used to fix fractures located in the middle and upper segment of the posterior column.
