Branches Of Iliac Artery Research Articles

Haemodynamic instability resulting from a low energy pubic ramus fracture in a 78-year-old woman. A case report and review of the literature

Pelvic fractures with haemodynamic compromise are generally high energy injuries. Stable pelvic fractures in the form of pubic rami factures are comparatively common in elderly patients due to the combination of osteoporosis and incidence of falls, and tend to be regarded as benign. Rarely there is concomitant arterial injury. The artery responsible has been aptly named corona mortis, the ‘‘crown of death’’, for its potentially catastrophic haemorrhage and the difficulty in achieving haemostasis. We report the case of an elderly patient who suffered a stable pubic ramus fracture following a fall. The patient was originally haemodynamically stable but soon deteriorated and angiography showed major haemorrhage from branches of both external and internal iliac arteries that needed embolisation.

Technique of Reversed Flared Iliac Stent Graft for Iliac Aneurysms With Discrepant Size Diameters

Endovascular treatment of iliac artery aneurysms (IAAs) in patients with discrepancy in iliac artery diameters can be challenging because of limited availability of reversed flared stent graft limbs. The authors describe the technique of reversing a Cook Zenith (Bloomington, IN) iliac stent graft extension to accommodate for significant discrepancy in diameter between the common iliac artery (18 mm) and the external iliac artery (11 mm). A 75-year-old male patient with a 7.3-cm right internal IAA was treated with endovascular exclusion of distal internal iliac artery branches using Amplatzer plugs (AGA Medical Corp, Plymouth, MN) and coverage of the internal iliac artery origin using a reversed 12 × 20 mm Cook Zenith TLFE Iliac extension limb (Bloomington, IN). The 12 × 20 mm iliac extension limb was unsheathed on-site using a strict sterile technique, reversed within the introducer and resheathed. Following percutaneous bilateral femoral access and exclusion of the anterior and posterior divisional branches of the internal iliac artery, the reversed flared iliac limb device was deployed from the distal common to the external iliac artery. Completion angiography and follow-up computed tomography angiography revealed no endoleak. The patient was dismissed on postoperative day 1 without complications. The technique of reversed flared iliac stent graft limb is a feasible option in patients with iliac aneurysms and significant discrepancy in the diameter of the iliac arteries.

Branching patterns of the male internal iliac artery: imaging findings

The aim of this study was to establish the imaging findings of the main branching patterns of the male internal iliac arteries, using different imaging modalities (angio MR, angio CT and digital angiography). Twenty-one males (mean age 73.2years) underwent imaging evaluation with angio MR, angio CT and digital angiography to define the internal iliac artery anatomy before selective embolization of the pelvic arteries. All three modalities were used in 3 patients, angio MR and digital angiography in 17 patients, angio CT and digital angiography in 6 patients and only angio CT in 1 patient. Internal iliac arteries were classified into four groups using the Yamaki classification (modified from the Adachi's classification). Twenty-six pelvic sides were classified as Group A (61.9%), 13 as Group B (31%) and 3 as Group C (7.1%) with no cases of Group D found. Angio MR, angio CT and digital angiography were able to detect most branches of the internal iliac artery. Group A was the most frequent internal iliac artery branching pattern. Angio CT showed better detailed anatomy than angio MR and digital angiography was considered the gold-standard. Non-invasive vascular imaging with angio MR or angio CT is essential before invasive interventions, allowing better planning of the procedure.

Colonic Ischemia After Endovascular Exclusion of an Aortoiliac Aneurysm Using an Iliac Branch Device

To present the first case of colonic ischemia (CI) after endovascular exclusion of an aortoiliac aneurysm using an iliac branch device (IBD). A 69-year-old male patient with an abdominal aortic and right common iliac artery aneurysm underwent endovascular repair with an IBD. Completion angiography demonstrated good patency in 2 of the 3 main branches of the right internal iliac artery (IIA) whereas the left IIA patency was preserved. Preoperatively, the inferior mesenteric artery (IMA) was patent. Postoperatively, the patient presented moderate CI. He was treated conservatively and discharged 15 days later with recession of the symptoms. Although preservation of bilateral iliac artery patency is considered to diminish the incidence of pelvic ischemia, in case of an exclusion of a patent IMA, collaterals may not be adequate to ensure blood supply to the left colon.

Explantation of the recipient internal iliac artery for bench-surgery during live donor renal transplants with multiple renal arteries

Transplantation of renal allografts with multiple arteries is challenging. We describe a simple technique to facilitate multiple anastomoses. The internal iliac artery and suitable branches are dissected and then explanted from the recipient by dividing the main trunk of the vessel. Multiple renal arteries can then be anastomosed end-to-end to suitable branches of the internal iliac graft over silastic catheters, on the back table, under cold storage conditions (Fig. 1). The kidney is then implanted by re-anastomosis of the internal iliac trunk to its parent main stem. This quicker and simpler arterial anastomosis optimises perfusion, reduces anastomosis time and warm ischaemic injury. Figure 1 Explanted internal iliac artery graft in position prior to anastomosis to the renal allograft.

The Use of Explanted Internal Iliac Artery Grafts in Renal Transplants With Multiple Arteries

The use of renal allografts with multiple arteries is challenging, particularly with respect to live kidney donation. With an ongoing shortage of cadaveric organs available, live donor programs continue to be an increasingly important source of kidneys for transplantation. The prevalence of multiple renal arteries in some series is estimated between 18% and 30% and is believed to be bilateral in 15% of cases (1). Previously, multiple arteries were considered as a relative contraindication to live donation and renal transplantation; however, there is now increasing evidence that transplantation of kidneys with multiple arteries is safe with no significant increase in immediate or long-term complications (2–4). We present a series of seven cases where we have successfully used explanted recipient internal iliac artery grafts in live donor renal transplants with multiple arteries. The use of internal iliac artery grafts has been described before (4, 5); however, only small numbers have been reported as part of larger series and no consecutive series have been described. We describe a slightly different technique, which we have successfully reproduced in consecutive renal transplants with multiple arteries. Technique The operative bed is prepared in the usual manner. The internal iliac artery and suitable branches are dissected and then explanted from the recipient after clamping the main trunk of the vessel. On the back table, under cold storage conditions, the internal iliac graft can then be anastomosed to the renal allograft. The individual arteries are anastomosed end-to-end in turn to the branches of the explanted arterial graft over silastic catheters. The kidney is then implanted by reanastomosis of the internal iliac trunk to its parent main stem. Other similar techniques describe the use of end-to-side anastomosis with the external iliac artery rather than to parent internal iliac artery. Patients Seven kidneys of 41 retrieved from live donors by laparoscopic nephrectomy over a 10-month period had multiple arteries. Six of the renal allografts had two renal arteries and one had three arteries. All allografts had single vein and ureter. The mean follow-up was 149 days (range 53–277 days). Demographic details of the seven patients are shown in Table 1.TABLE 1: Patient and transplant demographicsNo intraoperative complications were reported. Table 1 shows the anastomotic and cold ischemic times. There were no immediate vascular complications, and, in all cases, recovery room Doppler ultrasound imaging reported good perfusion throughout the transplanted kidneys. Primary graft function was established in all cases. Since transplantation, two of the seven recipients reported ipsilateral buttock claudication. Neither of these patients had had the contralateral internal iliac artery used previously. One of the recipients has had hypertension that was difficult to control, requiring multiple anti-hypertensive medications. No urological complications have been documented since transplantation. There have been no biopsy-confirmed acute rejection episodes. Summary In summary, this series demonstrates that explanted internal iliac artery grafts can be used successfully to anastomose renal allografts with multiple renal arteries. The main advantage of the technique is that the difficult anastomosis of small vessels can be performed on the back table under hypothermic conditions, and there is no pressure on the surgeon to consider the anastomotic warm time at that point. This technique, literally, takes the heat out of a difficult operative situation. Louisa C. Firmin Michael L. Nicholson Department of Transplant Surgery Leicester General Hospital Leicester, United Kingdom

Pelvic Arterial Embolisation in a Trauma Patient with a Pre-Existing Aortobifemoral Graft

Pelvic fractures secondary to blunt trauma are associated with a significant mortality rate due to uncontrolled bleeding. Interventional radiology (IR) can play an important and central role in the management of such patients, offering definitive minimally invasive therapy and avoiding the need for high-risk surgery. Rapid access to whole-body computed tomography has been shown to improve survival in polytrauma patients and allows rapid diagnosis of vascular injury and assessment of suitability for endovascular therapy. IR can then target and treat the specific area of bleeding. Embolisation of bleeding pelvic arteries has been shown to be highly effective and should be the treatment of choice in this situation. The branches of the internal iliac artery (IIA) are usually involved, and these arteries are accessed by way of IIA catheterisation after abdominal aortography. Occasionally these arteries cannot be accessed by way of this conventional route because of recent IIA ligation carried out surgically in an attempt to stop the bleeding or because (in the rare situation we describe here) these vessels are excluded secondary to previous aortoiliac repair. In this situation, knowledge of pelvic arterial collateral artery pathways is important because these will continue to supply pelvic structures whilst making access to deep pelvic branches challenging. We describe a rare case, which has not been previously reported in the literature, in which successful embolisation of a bleeding pelvic artery was carried out by way of the collateral artery pathways.

Abstract No. 202: Skin and muscle complications in pelvic trauma patients undergoing transcatheter embolization: Are there increased complications?

Pelvic infections, wound dehiscence, and skin complications occur in patients with complex pelvic trauma and bleeding. We assessed the role of embolization in increasing (or reducing) the incidence of skin and wound complications after embolization. Retrospective review of an institutional trauma database for pelvic fracture patients from Jan 1999 to Dec 2008 identified 4,744 patients Of these, 212 patients (146 males, 62 females, mean age, 42.1 ± 19.0 y; range, 13-88 y) underwent angiography for ongoing pelvic hemorrhage based upon CT imaging, expanding pelvic hematoma at laparotomy, or hemodynamic instability. Injuries included: blunt injuries, 192; crush injuries, 6; penetrating injuries, 10; and other, 4. The mechanisms of injury were similar among embolized and non-embolized groups, (p= 0.53). The injury severity score (ISS) were embolized patients, 31.80 ± 14.1; non-embolized patients, 28.92 ± 12.6, (p=0.08). Lengths of stay were embolized patients 102 ± 20.3; non embolized patients 106 ± 20.0, (p=0.13). Internal iliac artery branch embolization was performed in 104 patients: 78 unilateral, 26 bilateral. 58 patients were treated with gelfoam slurry, 42 with gelfoam and coils, and 4 with coils alone. The incidence of complications was 6/104 (5.8%) in embolized patients compared with 5/108 (4.6%) in the non- embolized cohort (p= 0.77) Embolized patients: wound dehiscences (2), pelvic infection (1), buttock decubiti (2), and postoperative hemorrhage (1). Nonembolized patients: pelvic infections (2) and buttock decubiti (3). Bilateral pelvic embolization was unassociated with increased incidence of complications (p = 0.48). Pelvic embolization is not associated with increased, nor reduced rates of pelvic infection, buttocks decubiti, or wound dehiscences. Bilateral pelvic embolization does not increase risks.

3D Reconstructed Contrast Enhanced MR Angiography: 1.5 Tesla versus 3 Tesla in Detection of the Different Branches of the Internal Iliac Artery before Uterine Artery Embolization

To compare the ability of the 1.5 Tesla (1.5T) MRI versus the 3 Tesla (3T) MRI in detecting the different branches of the internal iliac artery (IIA) in females before UAE using 3D reconstructed Contrast Enhanced MR Angiography (CE-MRA).

Features of blood supply and results of transarterial infusion and embolization in spinal metastases

To study the features of blood supply and results of transarterial infusion and embolization in spinal metastases. Forty-one patients with spinal metastasis received transarterial infusion and embolization between March 2001 and June 2008. The inclusion criteria were: The metastatic lesion caused back pain; The metastatic lesion involved vertebra at or below T3 level. There were 29 males and 12 females with a mean age of 56.0 (33 - 71) years. Epirubicin was used as the chemotherapeutic agent. Lipoid Ultra-Fluid, Contour SE or gelfoam particles were used as embolitic material. The technical success of therapy was achieved in 52 vertebrae (100%) including 14 thoracic, 35 lumbar and 3 sacral vertebrae. 105 arteries were used for infusion and embolization (16 intercostal arteries, 78 lumbar arteries, 4 iliolumbar arteries, 4 branches of iliac arteries, and 3 median sacral arteries). Lipoid Ultra-Fluid (2 - 8 ml) was used in 15, Contour SE (300 approximately 500 microm, 20 - 100 mg) in 20, and gelfoam particles in 33 arteries. Three days after treatment, complete pain relief (CR) was achieved in 17 patients, partial pain relief (PR) in 20, and moderate pain relief (MR) in 4, with an effective rate of 90.2%. Two weeks after treatment, CR was achieved in 17 patients, PR in 21, and MR in 3, with an effective rate of 92.7%. No adverse nervous system effect occurred. 16 patients developed swelling and pain of normal tissues which were alleviated after symptomatic treatment. Transarterial infusion and embolization is an effective therapy in relieving pain resulting from spinal metastases.

Pseudoaneurysm Requiring Differential Diagnosis from Malignant Soft Tissue Tumor-A Case Report-

Arteriovenous malformation (AVM) is classified as a type of congenital venous malformations. It is sometimes difficult to distinguish AVM from malignant soft tissue tumor based on the clinical findings. The authors report a case of AVM that brought about pseudoaneurysm without any events.A 49-year-old female who recognized a tumor on her left thigh from one year ago complained of an increase in the size of the tumor and pain. Physical examination showed a large tumor from the medial to posterior part of the left thigh. The size of the tumor was about 31×27 cm, an elastic hard mass by palpation, and resembled arterial murmur by stethoscope.A malignant soft tissue tumor was suspected based on the rapid increase in size and physical findings at the first visit to our outpatient clinic. Ultimately, diagnosis was made as AVM with pseudoaneurysm using enhanced CT and angiography. Embolization procedures were required three times to prevent blood flow into the pseudoaneurysm, occluding the branches of superficial femoral artery and superficial iliac artery, which fed the AVM. Psudoaneurysm was occluded finally, but all feeders were not occluded because of broad AVM exposure. Continuous follow-up is necessary due to the risk of rebleeding from AVM.

A Case of Inflammatory Solitary Internal Iliac Artery Aneurysm Successfully Treated by an Endovascular Procedure

An inflammatory aneurysm localized in the iliac artery is very rare. Aneurysms of the common iliac artery have been reported sporadically, but there has been no report of internal iliac artery aneurysm. The patient was a 64-year-old male presenting with left lower abdominal pain and fever. Abdominal computed tomography (CT) revealed an aneurysm of 42 × 52 mm in the left internal iliac artery. The aneurysmal wall had thickened and mantle sign was positive. Since the aneurysm was expected to adhere tightly to surrounding tissues, the risk of open surgery was judged to be high, and coil embolization of the aneurysm and the peripheral branches of the internal iliac artery was performed. Postoperatively, the left lower abdominal pain disappeared, and signs of inflammation were mitigated. The endovascular procedure was extremely effective for the treatment of this inflammatory iliac artery aneurysm.

Midterm Results From Internal Iliac Artery Branched Endovascular Stent Grafts

To evaluate the midterm feasibility, efficacy and safety of internal iliac artery branch grafts for endovascular repair of aortoiliac, common iliac, and internal iliac artery aneurysms. Between December 2006 and September 2008, 8 patients underwent elective endovascular repair of aortoiliac, common iliac, and internal iliac artery aneurysms. Computed tomography aortography (CTA) was used to detect postoperative endoleak, stent migration, branch patency, and aneurysm sac expansion. All stent grafts were correctly implanted. However, intraoperative branch occlusion occurred in 2 of 8 cases. Both occlusions have been managed conservatively, with only 1 patient suffering detrimental symptoms. One endoleak was found. Median follow up by CT was 402 days (range 77 to 718 days). No patients died. Midterm results are encouraging for endovascular branch grafts to include the internal iliac artery. However, patient selection is of great importance and our series illustrates the value of caution and multidisciplinary teamwork.

Intraoperative Buttock Ischemia with Postoperative Necrosis following Infrainguinal Bypass Surgery

Buttock necrosis is a rare presentation of severe pelvic ischaemia. It has been reported following open abdominal aortic repair and after internal iliac embolisation prior to endovascular treatment of aortic aneurysm. The internal iliac arteries are the major blood supply to the pelvis and buttocks. Collateral connections between the rectal and gluteal branches of the internal iliac artery and the deep femoral artery are well recognised. Iatrogenic interruption of this collateral circulation following rectal surgery resulting in limb ischaemia has been described. We present an exceptional case of buttock necrosis following infrainguinal bypass in a patient with bilateral internal iliac and left external iliac artery occlusions. The case is the first such reported to our knowledge.

A Rare Variety of Origin of Obturator Artery- A Case Report

A rare variety of origin of obturator artery was found while doing dissection on a 54-year-old Indian male. The artery originated from the posterior division of the internal iliac artery. The rest of its course, as well as other branches of the internal iliac artery were normal. Knowledge of such a variation in the origin of obturator artery is important while doing various gynecological, surgical and orthopedic operations. Obturator artery develops due to uneven growth of the anastomosis between developing internal and external iliac arteries. Obturator artery is last to develop amongst the branches of internal iliac artery. This is likely to be the cause of such a variation

Outcome of emergency endovascular treatment of large internal iliac artery aneurysms with guidewires

Purpose Guidewires have been reported as a useful occlusion material for large aneurysms of different locations with good short-term results. In this study we retrospectively evaluate long-term results of emergency embolization technique with guidewires in symptomatic internal iliac artery aneurysm (IIAA) impending rupture. Patients and methods In four patients presented with acute abdominal pain, multidetector computed tomography revealed unstable, 7–14 cm large, IIAAs. Two patients were treated with coil embolization of distal branches followed by occlusion of aneurysmal sac with guidewires. In two patients embolization of aneurysmal sac alone was performed. Results In three patients complete or near complete occlusion of the aneurysmal sac was achieved and abdominal pain ceased within hours. Two patients treated with embolization of distal iliac artery branches and aneurysmal sac developed claudication that lasted up to 1 year. Their aneurysms remained thrombosed and they were without symptoms until they died 31 and 56 months later of causes unrelated to IIAA. Two patients treated with embolization of the aneurysm alone were free of ischemic symptoms. Because of incomplete embolization of the sac in one patient open surgery treatment in a non-emergency setting was performed. Complete filling of aneurysmal sac was achieved in other patient but 2 years later his aneurysm re-opened and required open surgery treatment. Conclusion Embolization of aneurysmal sac of large IIAA with guidewires may be effective for immediate treatment of impending rupture. Long-term results were better when embolization of the aneurysmal sac was combined with embolization of distal IIA branches.

Understanding the anatomical priorities of the field of Obstetrics and Gynecology

Given the reduced number of hours allotted to basic science medical education, educators must prioritize the topics we emphasize in our lessons. In order to maximize long‐term retention of information, it is useful to understand how our students will encounter our subjects in their later careers. Female pelvic anatomy is a notoriously difficult topic in gross anatomy, and Obstetrics & Gynecology (ObGyn) clinicians rely heavily on having a strong conceptual understanding of anatomy. In this study, ObGyn attending physicians were asked to rank the clinical importance of a wide range of topics in female pelvic anatomy on a Likert scale of 1‐10 (unimportant to essential). These were categorized as perineum, vagina/cervix, uterus/adnexa, urinary system, gastrointestinal system, pelvic floor, peritoneal spaces and blood supply topics. Three topics were consistently rated most important: the layers of the uterus, the locations of the ureters relative to other structures, and the branches of the internal iliac artery. Lymphatic drainage of all structures was consistently ranked as a low priority (note however that no ObGyn oncologists were surveyed). When asked to prioritize what they would like medical students to understand before they start their clinical service, most attendings emphasized the relative positions of pelvic structures, blood supply to the pelvic structures, and the pelvic floor.

The applied anatomy of anterior approach for minimally invasive hip joint surgery

The anterior approach for minimally invasive hip joint surgery is one of the common approaches utilized in hip joint surgery. Here, we report the results of dissections in 60 sides of human adult cadavers. We observed and measured the branches of the superficial circumflex iliac artery, the lateral femoral cutaneous nerves, the lateral circumflex femoral artery, and the superior gluteal nerves in the experiment via the anterior approach for minimally invasive hip joint surgery. The relationship between these structures and the anterior approach was studied. The present study provides important data demonstrating the location, path of dominant structures that might be encountered during the surgery and their relationships with the surgical incision. These data may allow surgeons performing the anterior approach for hip joint surgery to minimize the risk of neurovascular injury.

Transarterial Embolization for Inferior Epigastric Artery Injury

The inferior epigastric artery represents a potentially overlooked source of pelvic arterial hemorrhage. The authors describe 3 patients with massive inferior epigastric artery bleeding following cesarean section, paracentesis, and blunt trauma that were successfully treated with transarterial embolization. The inferior epigastric artery should be considered as a possible source of arterial hemorrhage if arteriography of internal iliac artery branches does not yield a bleeding source.

Three-dimensional Reconstructed Contrast–enhanced MR Angiography for Internal Iliac Artery Branch Visualization before Uterine Artery Embolization

To evaluate the feasibility of three-dimensional (3D) reconstructed contrast-enhanced (CE) magnetic resonance (MR) angiography in mapping the pelvic arteries in women before uterine artery embolization (UAE). CE MR angiography studies before UAE in 49 women (age range, 38-57 years; mean, 47.04 y +/- 4.7 [SD]) who underwent UAE for uterine leiomyomas between February 2005 and February 2007 were retrospectively evaluated by two radiologists in consensus. Studies were performed on a 1.5-T MR unit with a 3D fast low-angle shot sequence in the coronal direction. Reconstruction was performed with 3D computed tomographic angiography reconstruction software. In the current study, 98 internal iliac arteries (IIAs) from 49 women were studied. The superior and inferior gluteal arteries were visualized in all cases (N = 98; 100%), the lateral sacral artery in 86 cases (88%), the iliolumbar artery in 84 (86%), the obturator artery in 81 (83%), the internal pudendal artery in 96 (98%), and the uterine artery in 95 (97%). The superior vesical and middle rectal arteries were seen in 21 (21%) and 11 (11%) cases, respectively. The mean length of the uterine artery was 12.56 cm (range, 4.6-22.2 cm), and it showed the longest traceable length among all branches. The uterine artery showed five patterns of origin. The superior gluteal artery showed constant origin from the posterior division of the IIA, whereas the iliolumbar and obturator arteries showed the most variations in origin. Three-dimensional reconstructed CE MR angiography can detect most branches of the IIA in addition to their point of origin. Therefore, it can be used as a mapping tool of the pelvic arterial tree before UAE.