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Angiogram shows the internal iliac artery and its branches: the iliolumbar artery (1), lateral sacral arteries (2), superior gluteal artery (3), obturator artery (4), internal pudendal artery (5), inferior gluteal artery (6), and vesical arteries (7).
Source publication
Arterial hemorrhage is one of the most serious problems associated with pelvic fractures, and it remains the leading cause of death attributable to pelvic fracture. At many trauma centers, contrast material-enhanced computed tomography (CT) is increasingly used for initial diagnosis in the evaluation of patients with pelvic fractures. Extravasation...
Contexts in source publication
Context 1
... Somatic segmental branches: iliolumbar and lateral sacral. Usually, the superior gluteal and the two somatic segmental branches stem from the posterior division and the others from the anterior division (Figs 1, 2). ...
Context 2
... lateral sacral arteries arise from the poste- rior trunk of the internal iliac artery; there are usually two arteries, a superior and an inferior. They supply branches to the anterior surface of the sacrum, the sacral foramina and sacral canal, and the skin and muscles of the dorsal surface of the sacrum (Figs 8 -10). On CT scans, the lateral sacral arteries are seen to descend along the sa- crum and divide into branches that enter the sa- cral foramina. ...
Context 3
... CT images, it is located posterior to the ilium and superior to the piriformis muscle at the greater sciatic foramen. After leaving the pelvis, it divides into superficial and deep branches, which are noted in the fat planes between gluteus muscles on CT scans (Figs 11-13). ...
Context 4
... CT scans, the inferior gluteal artery is seen anterior to the piriformis muscle, posterior to the ischial spine, and above the sacrospinous ligament at the greater sciatic foramen. It travels down the posterior but- tock and is covered by the gluteus maximus muscle after leaving the pelvis (Figs 14 -16). ...
Context 5
... internal pudendal artery emerges from the pelvis through the lower part of the greater sciatic foramen. It crosses behind the ischial spine and reenters the pelvis through the lesser sciatic fora- men (Figs 17-21). On CT scans, the internal pu- dendal artery is easily identified posterior to the ischial spine and sacrospinous ligament after leav- ing the pelvis; it runs along the medial surface of the obturator internus muscle, which forms the lateral border of the ischiorectal fossa, after reen- tering the pelvis. ...
Context 6
... fracture lines involving the superior part of the obturator foramen, the supe- rior pubic ramus, or the pubic acetabulum are prone to cause injury to the obturator artery. On CT images, contrast material extravasation seen in the region of the pelvic sidewall or within an obturator internus muscle hematoma that is asso- ciated with fractures involving the superior pubic ramus or pubic acetabulum is highly suggestive of injury to the obturator artery (Fig 31). Pelvic arte- rial bleeding due to injury of visceral branches in patients with pelvic fracture is quite rare. ...
Context 7
... if no significant bleeding is seen on the aortogram, selective injection of the internal iliac arteries is necessary, because the bleeding may be intermit- tent and the characteristics of the arteries that may be injured are more evident (Fig 33). It is also important to selectively study the contralateral inter- nal iliac artery to search for other potential bleeding sites and collateral flow that may contribute to the original bleeding site (19) (Fig 31). CT-angiographic correlation for detection of bleeding from the vesical artery. ...
Similar publications
Objective:
To determine the quantifiable difference in pubic symphysis diastasis when comparing computed tomography (CT) and pelvic radiographs in individuals with anterior pelvic ring injuries.
Design:
Retrospective chart and radiographic review.
Setting:
Level 1 trauma center.
Patients/participants:
Between 2002 and 2013, all individuals r...
Background:
A 2015 AAST trial reported a 32% mortality for pelvic fracture patients in shock. Angioembolization (AE) is the most common intervention; the Maryland group revealed time to AE averaged 5 hours. The goal of this study was to evaluate the time to intervention and outcomes of an alternative approach for pelvic hemorrhage. We hypothesized...
Citations
... This complication tends to occur more frequently during the exposure stage rather than the actual procedure, primarily due to the intricate and often unfamiliar anatomy of this area to many neuro-and orthopedic surgeons [26]. Moreover, the ILA has close proximity to the sacroiliac joint, which can increase the risk of hemorrhage in cases of open-book or shearing fractures [1,22,33,34]. Additionally, this vessel may sustain damage during an anterior approach to the sacroiliac joint for arthrodesis or internal fixation [8]. ...
Background:
The arterial anatomy of the pelvic region is highly variable, and variations in the anatomy of the ILA may often be observed in its point of origin. The main objective of the present meta-analysis was to provide the most up-to-date and evidence-based data regarding the complete anatomy of the iliolumbar artery (ILA. It is hoped that our results may aid in reducing possible complications associated with various procedures performed in the pelvis.
Materials and methods:
To perform this meta-analysis, major online medical databases — PubMed, Scopus, Embase, Web of Science, Cochrane Library, and Google Scholar — were searched through to find all studies considering the anatomy of the ILA.
Results:
The pooled prevalence of the ILA originating from the Internal Iliac Artery, in the overall analysis, was found to be 93.62% (95% CI: 82.96–99.63%). Mean diameter of the ILA was found to be 2.67 mm (Standard Error = 0.19 ; Lower Limit = 2.29 ; Upper Limit = 3.05). Mean length of the ILA was established at 12.50 mm (Standard Error = 1.64 ; Lower Limit = 9.28 ; Upper limit = 15.73).
Conclusions:
The anatomy of the ILA was found to be quite constant, in contrast to what has been discussed in the literature. The said artery originated most frequently from the internal iliac artery (93.62%). Most frequently, this artery originated from the internal iliac artery (observed in approximately 93.62% of cases). Notably, the results of our current meta-analysis indicate that the average distance between the ILA’s point of origin, the lower margin of the L5 vertebra, and the bifurcation site of the common iliac artery were 43.20 mm and 28.58 mm, respectively.
Keywords
iliolumbar artery, pelvis, anatomy, internal iliac artery, endovascular
... The undisputed indications for performing angiography are active extravasation of contrast medium on CT, the presence of pseudoaneurysms, and the presence of arteriovenous fistulas [1]. Nevertheless, the sensitivity of a CT scan in detecting active bleeding after trauma is known to be between 60 and 90% [24,25]. There are several cases in which angiography may be necessary even in the absence of evidence of arterial injury on CT examination, such as, for example, in patients with persistent hemodynamic instability after PPP or in the presence of a large (>500 cm 3 ) pelvic hematoma even in the absence of active blush on CT examination [26]. ...
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 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]. ...
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.
... The reported mortality rate is as high as 23-40% and over 10% of these patients may die before reaching the hospital [2][3][4]. The major causes of death in these patients are early exsanguination and late sequelae of prolonged shock (multisystem organ failure) and mass transfusion [5][6][7]. ...
Pelvic fractures are life-threatening injuries with mortality as high as 40%. The major cause of death is pelvic exsanguination. Extraperitoneal pelvic packing has been suggested in recent years to be an effective method for hemorrhage control. This article briefly reviews the various aspects related to this procedure with emphasis on history, outcomes, technique and complications.
... However, in the cases where intra-pelvic arterial bleeding is present further measures to control the bleeding are necessary. 10,11 The most important issue that needs to be addressed as soon as possible is whether there is active arterial extravasation at present. ...
One of the most important complications of pelvic injuries is hemorrhage which can be attributed to the venus plexus of the pelvis, the damaged bone on the fracture site, or in 15% of cases to arterial cause. In the last case mortality could reach 70%. Clinical case presentation, a 77-year-old man, presented in the emergency department of our hospital hemodynamically unstable due to fall from height (3 meters) with comminuted bilateral fractures of the pubic rami, right sacral and iliac wing fracture, right acetabular fracture, fractures of transverse processes of the first, second, and fifth lumbar spine vertebrae and a periprothetic fracture of the right femur. Advanced trauma life support (ATLS) protocol was followed throughout. Computed tomography (CT) scans and CT angiography performed, showed the above mentioned pelvic fractures that did not require stabilization, without further injuries, and a well described retroperitoneal hematoma without any evidence of active bleeding. During the resuscitation process the patient developed cardiac arrest and cardiopulmonary resuscitation (CPR) protocol was followed. The patient was intubated and retained his cardiac rhythm. However, he remained unstable and an angiography was then performed that revealed internal iliac artery bleeding and embolism of the internal iliac artery was performed. The patient was stabilized and was transferred to the intensive care unit for further management. Arterial hemorrhage due to pelvic injury is less common, however presents with high rates of mortality. CT angiography may in some cases not reveal existing active bleeding, misleading the clinician. Therefore, in patients with high clinical suspicion of arterial pelvic hemorrhage who remain unstable during the initial resuscitation and do not present with other primary source of bleeding, an angiography and embolism should be performed as soon as possible.
... Obviously, important attributes of the nutrient foramen and AIF are their contents in life. In humans the artery that enters the nutrient foramen is a branch of the iliolumbar a., which is itself the first branch of the posterior trunk of the internal iliac a. (Ebraheim, Lu, Biyani, & Yang 1997;Yoon et al., 2004). The nutrient artery usually enters the iliac fossa posteroinferiorly. ...
The human ilium is significantly shorter and broader than are those of all other primates. In addition, it exhibits an anterior inferior iliac spine that emerges via a secondary center of ossification. It is also unique to hominins. Here we track the ontogeny of the ilium in human and subadult primate ossa coxae. We find that its ontogeny is exclusive among primates from anlagen to adulthood and that the fusion of the anterior inferior iliac spine is a capstone event of a unique growth process that repositions the anterior gluteal muscles for control of pelvic drop during upright walking. This novel growth process is therefore a hominin synapomorphy that can be used to assess the presence of bipedal locomotion in extinct taxa.
We recently reported that a unique physis modulates broadening of the hominin ilium and shortening of its isthmus. We report here the discovery of a large, constant vascular foramen which lies close to the novel growth plate and serves as a central structure in the hominin ilium’s vascular network. No likely homologues appear in Old World Monkeys but are sometimes present in African great ape pelves. However, the human foramen (the Anterior Iliac Foramen) is significantly larger than the same individual’s nutrient foramen, and when corrected for body size, the human anterior iliac foramen is substantially larger than are those of apes. Those of Pan and Gorilla do not differ significantly from one another when so corrected, establishing that a small foramen is primitive and that its enlarged state is derived in hominins. This likely reflects amplification of the blood supply to the novel hominin physis during growth. Its presence in hominin fossil ilia can therefore provide evidence of iliac ontogenetic specialization for bipedality. The unique presence of this synapomorphy provides robust evidence that non-saltatory bipedality is a singular adaptation restricted to hominins, and that it has occurred only once in known primates.
... Acute arterial bleeding is characterized by active extravasation of contrast medium in the arterial phase of the CT exam, and its attenuation value is like the aorta's one [51,52]. This hyperattenuating extravascular collection has an irregular shape and tends to increase in the following phases of the examination, allowing the differential diagnosis between active bleeding and vascular malformation, such as pseudoaneurysm and arteriovenous fistula [53]. ...
Pelvic ring fractures are common in high-energy blunt trauma, especially in traffic accidents. These types of injuries have a high rate of morbidity and mortality, due to the common instability of the fractures, and the associated intrapelvic vascular and visceral complications. Computed tomography (CT) is the gold standard technique in the evaluation of pelvic trauma because it can quickly and accurately identify pelvic ring fractures, intrapelvic active bleeding, and lesions of other body systems. To properly guide the multidisciplinary management of the polytrauma patient, a classification criterion is mandatory. In this review, we decided to focus on the Young and Burgess classification, because it combines the mechanism and the stability of the fractures, helping to accurately identify injuries and related complications.
... Studies showed that arterial bleeding is one of the severe problems associated with pelvic fractures, and it remains the leading cause of death attributed to pelvic fractures. 2 The mortality rate of pelvic fracture patients with haemorrhagic shock ranges from 36.4% to 54% .life; threatening haemorrhages related to pelvic fractures may originate from fractured bone, venous plexus, significant veins and iliac arterial branches 3 . ...
Marma Science is one of the most distinctive concepts of Ayurveda. There are 107 marma sites in the body, and they are the conglomeration of muscles, veins, ligaments, bones, and joints. This peculiarity makes Marmamarma a somewhat vulnerable point, and any injury can lead to disability, dysfunction and demise. The cause of the damage can either be traumatic or iatrogenic; therefore, it becomes a necessity to rule out the exact location of the marma and anatomical structure responsible for the traumatic effects. Katiktarun being a Prishthagata marma, is prone to get injured during significant surgeries of the gluteal region and spine. Its injury can lead to delayed death. The aim of this study revolves around the anatomical entity responsible for delayed death caused by katiktarun injury. By identifying the location and structure involved in the marma, it might be possible to repair the structure and deferment the delayed end. Based on Ayurvedic literature and cadaveric observations, the superior margin of the sciatic notch (suprapiriform foraman) is considered as the position of Katiktarun Marma, whereas the neurovasculature associated with suprapiriform foramen is the causative structure of marma trauma symptoms.
... About 85% of pelvic hemorrhage cases are caused by bony structure destruction and venous bleeding, and 10%-15% of patients present with arterial bleeding [1,2,6,10,11]. Pelvic angiography is the method of choice for controlling arterial bleeding. ...
... Nevertheless, although many studies have reported on the indications for pelvic angiography, precise guidelines have yet to be established. Many investigations have been carried out to determine the clinical predictors according to clinical or radiologic findings such as contrast extravasation on CT or fracture pattern on radiography [1,10,[14][15][16]. However, there are still controversies in determining the need for angiography and embolization [2,17,18]. ...
Purpose:
Unstable pelvic fracture with bleeding can be fatal, with a mortality rate of up to 40%. Therefore, early detection and treatment are important in unstable pelvic trauma. We investigated the early predictive factors for possible embolization in patients with hemodynamically unstable pelvic trauma.
Methods:
From January 2011 to December 2013, 46 patients with shock arrived at a single hospital within 24 hours after injury. Of them, 44 patients underwent CT scan after initial resuscitation, except for 2 who were dead on arrival. Nine patients with other organ injuries were excluded. Seventeen patients underwent embolization. A single radiologist measured the width (longest length in axial view) and length (longest length in coronal view) of pelvic hematoma on CT scans. Demographic, clinical, and radiological data were reviewed retrospectively.
Results:
Among 35 patients with hemodynamically unstable pelvic fracture, 22 (62.9%) were men. Width (P = 0.002) and length (P = 0.006) of hematoma on CT scans were significantly different between the embolization and nonembolization groups. The predictors of embolization were width of pelvic hematoma (odds ratio [OR], 1.07; P = 0.028) and female sex (OR, 10.83; P = 0.031). The cutoff value was 3.35 cm. More embolization was performed (OR, 12.00; P = 0.003) and higher mortality was observed in patients with hematoma width >3.35 cm (OR, 4.96; P = 0.048).
Conclusion:
Patients with hemodynamically unstable pelvic trauma have a high mortality rate. CT is useful for the initial identification of the need for embolization among these patients. The width of pelvic hematoma can predict possible embolization in patients with unstable pelvic trauma.
... The superior gluteal, inferior gluteal, obturator, and internal pudendal arteries supply the limb and perineum and the iliolumbar and lateral sacral arteries are the somatic segmental branches of it. [19] Injury of the arterial wall secondary to trauma, inflammation, or infection may result in pseudoaneurysm formation. Gluteal artery pseudoaneurysm comprises <1% of all the arterial aneurysms and the majority of them are associated with the SGA. ...
Gluteal compartment syndrome (CS) secondary to the superior gluteal artery (SGA) injury and pseudoaneurysm formation is a very rare condition. When it does occur, it usually manifests with acute and life-threatening hemorrhage resulting in early hypov-olemic changes. Delayed presentation of the gluteal CS (GCS) after trauma has been described in the literature seldom and these cases were demonstrated with sciatic nerve palsy, hemodynamic instability, decreased hemoglobin levels, increasing buttock pain, and a large gluteal hematoma. In this report, we present a case of GCS presenting with the palsy of the peroneal division of the sciatic nerve secondary to SGA pseudoaneurysm following ballistic injury, with a delay of nearly 20 days in diagnosis and treatment with normal hemodynamic findings. The patient required emergent angiographic embolization and then fasciotomy which were approx-imately 13 days after the onset of the symptoms. The patient made a positive recovery with no further neurologic deterioration and none local wound or systemic complications. This case emphasizes the importance of early diagnosis and treatment of this rare condition.
