Sciatic Artery Research Articles

Emergency Endovascular Management of Gluteal Artery Pseudoaneurysm

Abstract Introduction: Gluteal artery pseudoaneurysms are rare, yet the most common in cases involving the superior gluteal artery. Pseudoaneurysms of the inferior gluteal artery are uncommon and are often related to blunt or penetrating trauma, infections and fractures of the pelvis. Presentation of Case: The authors describe a case of pseudoaneurysm which was presented to the emergency department. A thorough workup revealed a history of pelvic fracture that could constitute a probable cause of the pseudoaneurysm, which was treated with selective embolization of the artery during angiography. Discussion: The most common manifestation pseudoaneurysm of inferior gluteal artery is the presence of a painful mass in the buttock. However, both diagnosis and therapy are facilitated by catheter angiography. Conclusion: Although pseudoaneurysms are rare, pseudoaneurysms of the inferior gluteal artery require a high index of suspicion and careful physical examination by the physician in order to avoid misdiagnosis. In addition, the treatment performed using the endovascular technique is less invasive than the conventional technique, giving the patient better recovery.

Perineal defect reconstruction after surgery for advanced or locally recurrent rectal cancer involving organ resection: Multiple flaps combined with lining repair.

The aim of this study was to investigate the efficacy of multiple perineal perforator flaps in repairing deep perineal defects after pelvic exenteration for locally advanced or recurrent rectal cancer. We investigated the outcomes of eight patients whose repairs involved a novel method of using an internal pudendal artery perforator (IPAP) flap combined with an inferior gluteal artery perforator (IGAP) flap. There were four male and four female patients with a mean age of 56 years (36-72 years). Bilateral IPAP flaps combined with bilateral IGAP flaps were used in five patients, unilateral IPAP flaps combined with bilateral IGAP flaps were used in two patients and bilateral IPAP flaps were used in one patient. There were no functional limitations in daily activities during the 6-month follow-up period. Our study showed that using multiple perineal perforator flaps combined with lining repair is feasible for repairing deep perineal defects in patients who have undergone rectal cancer surgery that includes pelvic exenteration.

Anatomical Validation of Internal Iliac Vessels Assessed by Three-dimensional Angiographic Analysis.

Anatomical understanding of the internal iliac vessels is important with the increasing frequency of minimally-invasive pelvic surgery. We aimed to investigate the branch patterns of internal iliac vessels, especially the veins. This study included 30 patients with 60 half-pelvises who underwent minimally-invasive pelvic surgery. Branch patterns were assessed on surgical videos with a multi-detector computed tomography-based three-dimensional simulation. Branch patterns of the superior gluteal artery and vein (SGA and SGV), inferior gluteal artery and vein (IGA and IGV), internal pudendal artery and vein (IPA and IPV), and obturator artery and vein (ObA and ObV) were investigated. In the most frequent internal iliac vein (IIV) branch pattern, 67% of SGV branched from the IIV, 95% of the IGV branched from the IPV and 82% of the ObV branched from the IPV. According to Adachi's classification, 62% of IIVs were Type I and 33% Type IV. Although IIV branch patterns are heterogeneous, in individual patients with the most frequent branch patterns, good correlation (75-100%) of the branch patterns was observed between the internal iliac artery (IIA) and IIV, and between the right and left IIVs. This study clarified the branch patterns of IIV. In patients with the most frequent branch patterns, good correlation of the branch patterns was observed between the IIA and IIV, and between right and left IIV. We believe this helps secure the safety and standardization of minimally-invasive pelvic surgery.

Feasibility of Perineal Defect Reconstruction with Simplified Fasciocutaneous Inferior Gluteal Artery Perforator (IGAP) Flaps after Tumor Resection of the Lower Rectum: Incidence and Outcome in an Interdisciplinary Approach.

Extralevator abdominoperineal excision (ELAPE) is a relatively new surgical technique for low rectal cancers, enabling a more radical approach than conventional abdominoperineal excision (APE) with a potentially better oncological outcome. To date, no standard exists for reconstruction after extended or extralevator approaches of abdominoperineal (ELAPE) resection for lower gastrointestinal cancer or inflammatory tumors. In the recent literature, techniques with myocutaneous flaps, such as the VY gluteal flap, the pedicled gracilis flap, or the pedicled rectus abdominis flaps (VRAM) are primarily described. We propose a tailored concept with the use of bilateral adipo-fasciocutaneous inferior gluteal artery perforator (IGAP) advancement flaps in VY fashion after ELAPE surgery procedures. This retrospective cohort study analyzes the feasibility of this concept and is, to our knowledge, one of the largest published series of IGAP flaps in the context of primary closure after ELAPE procedures. In a retrospective cohort analysis, we evaluated all the consecutive patients with rectal resections from Jan 2017 to Sep 2021. All the patients with abdominoperineal resection were included in the study evaluation. The primary endpoint of the study was the proportion of plastic reconstruction and inpatient discharge. Out of a total of 560 patients with rectal resections, 101 consecutive patients with ELAPE met the inclusion criteria and were included in the study evaluation. The primary direct defect closure was performed in 72 patients (71.3%). In 29 patients (28.7%), the defect was closed with primary unilateral or bilateral IGAP flaps in VY fashion. The patients' mean age was 59.4 years with a range of 25-85 years. In 84 patients, the indication of the operation was lower rectal cancer or anal cancer recurrence, and non-oncological resections were performed in 17 patients. Surgery was performed in a minimally invasive abdominal approach in combination with open perineal extralevatoric abdominoperineal resection (ELAPE) and immediate IGAP flap reconstruction. The rate of perineal early complications after plastic reconstruction was 19.0%, which needed local revision due to local infection. All these interventions were conducted under general anesthesia (Clavien-Dindo IIIb). The mean length of the hospital stay was 14.4 days after ELAPE, ranging from 3 to 53 days. Since radical resection with a broad margin is the standard choice in primary, sphincter-infiltrating rectal cancer and recurrent anal cancer surgery in combination with ELAPE, the choice technique for pelvic floor reconstruction is under debate and there is no consensus. Using IGAP flaps is a reliable, technical, easy, and safe option, especially in wider defects on the pelvic floor with minimal donor site morbidity and an acceptable complication (no flap necrosis) rate. The data for hernia incidence in the long term are not known.

Comparison of inferior gluteal artery perforator flaps versus vertical rectus abdominis musculocutaneous flaps in the reconstruction of perineal wounds

Achieving a healed perineal wound following chemoradiotherapy and abdominoperineal resection (APR) is challenging for surgeons and patients. Prior studies have shown trunk-based flaps, including vertical rectus abdominis myocutaneous (VRAM) flaps, are superior to both primary closure and thigh-based flaps; however, there has been no direct comparison with gluteal fasciocutaneous flaps. This study evaluates postoperative complications after various methods of perineal flap closure of APR and pelvic exenteration defects. Retrospective review of patients who underwent APR or pelvic exenteration from April 2008 through September 2020 was analyzed for postoperative complications. Flap closure techniques, including VRAM, unilateral (IGAP), and bilateral (BIGAP) inferior gluteal artery perforator fasciocutaneous flaps, were compared. Of 116 patients included, the majority underwent fasciocutaneous (BIGAP/IGAP) flap reconstruction (n = 69, 59.6%), followed by VRAM (n = 47, 40.5%). There were no significant differences between group patient demographics, comorbidities, body mass index, or cancer stage. There were no significant differences between BIGAP/IGAP and VRAM groups in minor complications (57% versus 49%, p = 0.426) or major complications (45% versus 36%, p = 0.351), including major/minor perineal wounds. Prior studies have shown flap closure is preferable to primary closure after APR and neoadjuvant radiation but lack consensus on which flap offers superior postoperative morbidity. This study comparing outcomes of perineal flap closure showed no significant difference in postoperative complications. Fasciocutaneous flaps are a viable choice for the reconstruction of these challenging defects.

Persistent Sciatic Artery in Right Lower Extremity Complicated by Thrombosis: A Case Report.

Persistent sciatic artery (PSA) is a rare congenital vascular malformation with an incidence of approximately 0.025% to 0.04%. Persistent sciatic artery has major complications, such as aneurysms, thrombosis, and occlusion. Complications may lead to a range of serious clinical problems, and a timely diagnosis of this vascular variant is crucial to avoid life-threatening complications. A 65-year-old man was admitted to the hospital with pain and chills in the right lower extremity for 2 months, which gradually worsened. This was accompanied by numbness in the right foot for the last 10 days. Computed tomography angiography showed that the right inferior gluteal artery and right popliteal artery of the right internal iliac artery were connected, which is considered a congenital developmental variant. This was complicated by multiple thromboses of the right internal and external iliac arteries, and the right femoral artery. After admission to the hospital, the patient underwent endovascular staging surgery to relieve numbness and pain in the lower extremities. Treatment strategies can be selected based on the anatomical characteristics of PSA and superficial femoral artery. Asymptomatic patients with PSA can be closely monitored. Surgery or individualized endovascular treatment plans should be considered for patients with aneurysm formation or vascular occlusion. For the rare vascular variation of the PSA, clinicians must make a timely and accurate diagnosis. Ultrasound screening is essential, which requires experienced ultrasound doctors to be aware of vascular interpretation and develop personalized treatment plans for each patient. In this case, we adopt staged a minimally invasive intervention to solve the problem of lower limb ischemic pain for patients. This operation has the advantages of rapid recovery and less trauma, which has important reference significance for other clinicians.

Femoropopliteal Bypass With Interval Coil and Gelfoam Embolization for Persistent Sciatic Artery Aneurysm Presenting as Acute Limb Ischemia

Femoropopliteal Bypass With Interval Coil and Gelfoam Embolization for Persistent Sciatic Artery Aneurysm Presenting as Acute Limb Ischemia

The Middle Rectal Artery: Revisited Anatomy and Surgical Implications of a Neglected Blood Vessel.

Although the middle rectal artery is a relevant anatomical landmark for rectal resection and lateral lymph node dissection, descriptions of this entity are highly divergent. Dissection, visualization, morphometry, and 3-dimensional reconstruction of the middle rectal artery to facilitate its management in surgery. Macroscopic dissection, histologic study, morphometric measurements, and virtual modeling. University laboratory of applied surgical anatomy. This study includes formalin-fixed hemipelvis specimens (n=37) obtained from body donors (age, 67-97 y). The main outcome measures are photo documentation of origin, trajectory, diameter, and branching pattern; immunolabeling of lymphatics; and 3-dimensional reconstruction of the middle rectal artery. The middle rectal artery was present in 71.4% of body donors (21.4% bilateral, 50% unilateral), originated from the anterior division of the internal iliac artery, and branched either from the internal pudendal artery (45.5%), the inferior gluteal artery (22.7%), the gluteal-pudendal trunk (22.7%), or a trifurcation (9.1%). One to 3 branches of varying diameters (0.5-3.5 mm) entered the mesorectum from the ventrolateral (35.7%), lateral (42.9%), or dorsolateral (21.4%) aspect. The middle rectal artery was accompanied by podoplanin-immunoreactive lymphatic vessels and gave off additional branches (81.8%) to the urogenital pelvic organs. Three-dimensional reconstruction revealed the complex course of the middle rectal artery from the pelvic sidewall through the pelvic nerve plexus and parietal pelvic fascia into the mesorectum. Findings retrieved from body donors may be prone to age- and fixation-related processes. The investigation disclosed the rather high prevalence of the middle rectal artery, its 3-dimensional topographic anatomy, and its proximity to the autonomic pelvic nerves. These features play a role in the surgical management of this blood vessel. The data provide the anatomical rationale for the lateral lymphatic spread of rectal cancer and an anatomical basis for nerve-preserving lateral lymph node dissection.

Intraluminal Treatment for Persistent Sciatic Artery Aneurysm with VIABAHN

Intraluminal Treatment for Persistent Sciatic Artery Aneurysm with VIABAHN

Endovascular repair of bilateral sciatic artery aneurysm with Covera® self expandable covered stents - case report

Resumo A persistência da artéria isquiática é um remanescente embriológico da artéria ilíaca interna que ocorre em 0,03% a 0,06% da população, podendo evoluir com degeneração aneurismática. A presença do aneurisma pode levar a embolização, com aumento de risco de perda do membro, principalmente se a artéria isquiática for seu principal suprimento arterial. O tratamento do aneurisma de artéria isquiática está indicado sempre que diagnosticado, devido ao alto risco de complicações. Entre as opções de tratamento, estão o tratamento aberto convencional, o tratamento endovascular e o tratamento híbrido. No presente estudo, será descrito o caso de um paciente apresentando persistência completa das artérias isquiáticas bilateralmente, com degeneração aneurismática de ambas, corrigida de forma endovascular com stent recoberto Covera® (Bard Medical, Geórgia, Estados Unidos).

Catheter-Directed Thrombolysis for Persistent Sciatic Artery Presenting with Acute Limb Ischemia

Persistent sciatic artery (PSA) is a rare congenital peripheral artery disorder that is usually detected incidentally on computed tomographic examination. PSA can also cause iliac aneurysm and acute thromboembolism, which are potentially associated with rest pain, claudication, and limb-threatening ischemia. Patients with PSA and leg ischemia should be treated with revascularization and appropriate management of PSA aneurysm. The authors often choose emergent bypass surgery or endovascular intervention for aneurysmal rupture and acute lower-extremity arterial occlusion. This report describes an emergency procedure using catheter-based thrombolysis for acute limb ischemia in a patient with PSA.

Persistent Sciatic Artery: A Cadaveric Case Study

Objective The persistent sciatic artery associated with birth is a rare anomaly with a high rate of abnormal dilatation, blockage and stenosis prompting in extreme thrombosis, caudal embolisation, or aneurysm rupture. This is a case report on cadaveric specimen (50-year-old) African female cadaver in the Human Anatomy Laboratory, Department of Human Anatomy, Uzima University. Methods: During routine cadaveric dissections by first year medical students a peculiar structure was noted behind the right thigh after exposure of gluteal muscles. Results: The structure, identified as persistent sciatic artery, entered the gluteal region through the greater sciatic foramen and lied superficial to the sciatic nerve. The vessel was large and it passed out of the pelvis through the greater sciatic foramen below the pirifomis and descended posterior to the sciatic nerve. Muscular and articular branches branched off from artery through its course. The artery descended behind the thigh and was traversed obliquely by the long head of the biceps femoris muscle posteriorly. The sciatic artery continued as the popliteal artery that lied alongside popliteal vein, which was retraced back from the infrapiriform fossa. The femoral arteries were hypoplastic and had no obvious connections with the sciatic artery. Conclusion: It is a vital practice to recognize the position and tendency of sciatic artery to develop aneurysms and subsequent deep vein thrombosis that may be life threatening. Furthermore, understanding of this principle changes the approach to surgical interventions that are required during the process of bypass grafting.

The anatomy of the uterine artery: A meta-analysis with implications for gynecological procedures.

The uterine artery (UA) is an arterial branch of the internal iliac artery in women, usually arising from the anterior division of the internal iliac artery. However, due to the high variability in the anatomy of the UA, embolization of this vessel may be challenging. Therefore, the objective of this meta-analysis was to provide physicians with transparent data on the anatomy of the UA, using the available data in the literature. Databases such as PubMed, Scopus, Embase, Web of Science, and Google Scholar were searched to find all the relevant studies regarding the UA. A total of 16 articles met the required criteria. The UA was found to originate most frequently from the internal iliac artery as the pooled prevalence was set to be 61.72% (95% CI: 41.31%-80.31%). A pooled prevalence of the UA originating from the umbilical artery was established at 13.93% (95% CI: 2.76%-30.44%). A pooled prevalence of the UA originating from the inferior gluteal artery was set to be 5.22% (95% CI: 0.00%-15.44%). In conclusion, we believe that this is the most accurate and up-to-date study regarding the highly variable anatomy of the UA. The UA originates most frequently from the internal iliac artery (61.72%), however, other origins, such as from the umbilical artery (13.93%) or the inferior gluteal artery (5.22%) may occur. It is hoped that the results of the present meta-analysis will be a helpful tool for surgeons performing pelvic or gynecological surgeries.

Clampless In-Situ Immobilized Branching (CLIMB) to Reconstruct the Internal Iliac Artery.

Surgical reconstruction of the internal iliac artery (IIA) or its branches is sometimes demanding because of difficulty in distal clamping and suturing in the narrow pelvic space. Here we present a hybrid technique of ClampLess In-situ imMobilized Branching (CLIMB) to reconstruct IIA. in the CLIMB technique, an 8 mm artificial graft is sutured onto the surface of the common iliac artery (CIA) without clamping. Following puncture of the CIA wall, stent grafts are bridged from IIA to the graft. Finally, the graft is sutured to the ipsilateral external iliac artery (EIA). Concomitant endovascular aneurysm repair or IIA branch embolization can also be performed. We applied this technique to the patients unsuited for other IIA reconstruction. eleven patients underwent the current technique. All but one patient underwent contralateral IIA interruption. Seven patients had a history of aorto-iliac repair before the index surgery. Iliac extender, internal iliac component, Viabahn VBX or Fluency covered stent were used for bridging the graft. Simultaneous IIA branch embolization was performed in 2 patients. Distal landing zones were IIA in 7 grafts, superior gluteal artery in 4 grafts and inferior gluteal artery (IGA) in 1 graft. Technical success was achieved in all cases. No patient complained of buttock claudication or other ischemic symptoms on the treatment side. During a mean follow-up period of 38 months, 11 out of 12 grafts were patent without any related endoleak. One IGA graft occluded at 56 months after surgery. the CLIMB technique is a viable alternative to preserve IIA with an acceptable mid-term durability.

Bilateral Persistent Sciatic Arteries.

Online supplemental material is available for this article.

Occlusion of a Persistent Sciatic Artery With an Aneurysm.

Occlusion of a Persistent Sciatic Artery With an Aneurysm.

Anatomical study of the origin of obturator artery in Indian cadavers

Obturator artery (OA) originates from the anterior division of the internal iliac artery (IIA) and gives various branches to the pelvic cavity, medial compartment of the thigh, and hip joint. Studies in literature illustrate variable origin from the posterior division of the IIA, external iliac artery (EIA), or the branches of both the IIA and EIA. Understanding the pelvic vascular anatomy pertaining to the OA is crucial in averting the risk of its injury in pelvic surgeries. Present study reports on the variant anatomy of the origin of the OA in the Indian population. The study included 61 specimens from 25 formalin-embalmed cadavers (male-19, female-6) and 11 hemipelvis (male-9, female-2) utilized for undergraduate teaching in the Department of Anatomy. After dissecting the peritoneum and mobilizing the pelvic organs, the origin of OA was examined for variations. The OA originated from the IIA in 83.61%. It was a branch from the anterior division of the IIA in 65.58% and the posterior division in 18.03%. OA was also given off at the site of the bifurcation of IIA into anterior and posterior divisions in 3.28%, from EIA in 4.92%, from an inferior epigastric artery (IEA) in 8.2%, and from the inferior gluteal artery and umbilical artery in 1.64% each. This study recognizes the variant anatomy of the origin of the OA. Anticipating these variations will be valuable in pelvic surgeries and laparoscopic procedures such as herniorrhaphy to avoid any untoward traumatic haemorrhage.

Radiographic Study Evaluating Perforator Vessels in the Ischiorectal Fossa for Safe Elevation of Island Flaps.

Background:Perforator flaps based on the ischiorectal fossa (IRF) (ie, internal pudendal artery perforator flaps) are useful for perineal reconstruction. The three-dimensional characterization of perforator arteries in the IRF remains unclear, as the IRF contains thick adipose tissue as well as organs, such as the rectum, vagina, and urethra. This study aimed to evaluate perforators in the IRF to guide the safe elevation of skin flaps designed based on the IRF.Methods:IRF vessels were examined in 200 bilateral computed tomography angiography scans performed in 100 patients. We examined branching patterns arising from the internal iliac artery and the origins of the skin perforators in the IRF.Results:The branching patterns of the internal iliac artery were divided into three groups: perforators derived exclusively from the internal pudendal artery (78%), perforators derived from the internal pudendal artery and the inferior gluteal artery (18%), and perforators derived exclusively from the inferior gluteal artery (4%). The average number of perforators in the IRF was 1.5 ± 0.7. The number of perforators was significantly higher in women than in men. The perforator arteries were found exclusively around the medial and dorsal sides of the ischial tuberosity.Conclusions:We found that perforators in the IRF were stable. All cases had more than one skin perforator, which was mainly derived from the internal pudendal artery. Although perforators cannot be identified during flap elevation because the fatty tissue in the IRF is very thick, physicians must focus on preserving the perforator-containing fatty tissue around the ischial tuberosity.

Sacroperineal Reconstruction With Inferior Gluteal Artery Perforator Flaps After Resection of Locally Advanced Primary and Recurrent Anorectal Malignancy.

Modern interdisciplinary concepts with involvement of various surgical specialties can considerably reduce perioperative morbidity after sacroperineal resection of locally advanced primary or recurrent anorectal malignancies. Resultant defects can represent a major challenge for reconstruction particularly with chemoradiotherapy. The aim is to assess the long-term outcomes of sacroperineal reconstruction using inferior gluteal artery perforator flaps.We performed a retrospective data analysis on 31 patients who were treated with inferior gluteal artery perforator flaps (n = 61) over the period 2009-2021. The demographic data, comorbidities, operative details, and outcomes with special focus on wound infection and dehiscence were recorded.The median age was 42 year (range, 25-82 years) with preponderance of males (n = 21). The follow-up period ranged from 6 to 80 months. Early minor complications included superficial wound dehiscence (3), which was managed conservatively, whereas the major (2) included deep wound collection and infection (1), which required surgical drainage, and perineal hernia, which required repair. All flaps survived completely.Inferior gluteal artery perforator flaps are safe, robust, and reliable with less donor side morbidity and positive impact on quality of life. It should be considered as a valuable tool in the reconstructive armamentarium of sacroperineal defects within a multidisciplinary setting.

A National Survey on Perineal Reconstruction Following Standard and Extralevator Abdominoperineal Excision: Current Practices and Trends in the UK.

BackgroundChallenging perineal defects resulting from extralevator (ELAPE) and standard abdominoperineal excision (APE) have given rise to an emerging multidisciplinary approach between colorectal and plastic surgeons. At present, there is a relative paucity of evidence on best practice. This study sought to assess current national practice concerning perineal reconstruction following APE/ELAPE in the United Kingdom (UK) and to determine the factors involved in reconstruction choice.MethodologyAn anonymised survey was circulated to consultant plastic surgeons at all 48 UK centres performing perineal reconstruction following APE/ELAPE. Responses were collected between October 2021 and April 2022.ResultsComplete responses were received from 24 units nationally. All units had a dedicated APE/ELAPE service. Overall, 70% adopted a standardised reconstructive approach, the most common being the inferior gluteal artery perforator flap (n = 11). Significant variation was identified in the reconstructive technique. Similar differences were observed in the perceived importance of surgical factors guiding the reconstructive decision-making process, the top priorities being the size of the defect and previous radiotherapy.ConclusionsThe variability of responses suggests a lack of national consensus on optimal reconstruction following APE/ELAPE, despite the majority of centres employing a standardised approach to reconstruction. Our study highlights important surgical decision-making factors and provides valuable insight to aid in developing national collaborative evidence-based guidelines on best practice.