Obturator Artery Research Articles

The Corona Mortis, a Frequent Vascular Variant Susceptible to Blunt Pelvic Trauma: Identification at Routine Multidetector CT

To determine if contrast-enhanced multidetector computed tomography (CT) can demonstrate the "corona mortis" (translated as "crown of death"), a common variant obturator artery originating from the external iliac artery system that is susceptible to pelvic trauma. A representative case study is described. The authors evaluated 50 consecutive patients undergoing routine clinically indicated, standard protocol, venous phase contrast-enhanced multidetector CT of the pelvis, 25 with a 16-slice scanner and 25 with a 64-slice scanner. Three data sets were created for each study, as follows: (a) 5 x 5-mm axial, (b) 1.25 x 1.0-mm axial, and (c) 1.25 x 1.0-mm coronal. Three radiologists independently reviewed the images for the presence or absence of corona morti. One hundred hemipelves in 50 patients were evaluated. In total, 29 corona morti were identified, including 10 on the 5-mm axial images, 25 on the 1.25-mm coronal images, and 29 on the 1.25-mm axial images. By consensus agreement, interpretation of challenging cases was easiest with the 64-slice images. The corona mortis variant can be identified on routine contrast-enhanced multidetector CT scans in about one-third of patients. Thin (1.25-mm) CT reconstructions demonstrate this variation much more frequently than 5-mm-thick images. This suggests that the corona mortis may be prospectively identified at contrast-enhanced multidetector CT in pelvic trauma patients and help guide subsequent endovascular embolization. However, further study in the trauma population is necessary to confirm this.

Rare case of femoral artery ramification and origin of the obturator artery

We observed two rare patterns of femoral artery ramification in the bilateral thighs of an 83-year-old male cadaver. In the right thigh, the lateral circumflex femoral and deep circumflex iliac arteries formed a common trunk, while in the left, the medial circumflex femoral, inferior epigastric, and obturator arteries formed a common trunk. In the left pelvis, the obturator artery comprised branches from the inferior epigastric, superior gluteal, and inferior gluteal arteries. We describe this rare case and discuss the genesis and clinical significance of these variations.

The Incidence and Anatomy of Accessory Pudendal Arteries as Depicted on Multidetector-Row CT Angiography: Clinical Implications of Preoperative Evaluation for Laparoscopic and Robot-Assisted Radical Prostatectomy

ObjectiveTo help preserve accessory pudendal arteries (APAs) and to ensure optimal postoperative sexual function after a laparoscopic or robot-assisted radical prostatectomy, we have evaluated the incidence of APAs as detected on multidetector-row CT (MDCT) angiography and have provided a detailed anatomical description.Materials and MethodsThe distribution of APAs was evaluated in 121 consecutive male patients between February 2006 and July 2007 who underwent 64-channel MDCT angiography of the lower extremities. We defined an APA as any artery located within the periprostatic region running parallel to the dorsal vascular complex. We also subclassified APAs into lateral and apical APAs. Two radiologists retrospectively evaluated the origin, course and number of APAs; the final APA subclassification based on MDCT angiography source data was determined by consensus.ResultsWe identified 44 APAs in 36 of 121 patients (30%). Two distinct varieties of APAs were identified. Thirty-three APAs (75%) coursed near the anterolateral region of the prostatic apex, termed apical APAs. The remaining 11 APAs (25%) coursed along the lateral aspect of the prostate, termed lateral APAs. All APAs originated from the internal obturator artery and iliac artery or a branch of the iliac artery such as the inferior vesical artery. The majority of apical APAs arose from the internal obturator artery (84%). Seven patients (19%) had multiple APAs.ConclusionAPAs are more frequently detected by the use of MDCT angiography than as suggested by previous surgical studies. The identification of APAs on MDCT angiography may provide useful information for the surgical preservation of APAs during a laparoscopic or robot-assisted radical prostatectomy.

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.

Anatomical variation of obturator vessels and its practical risk: a case report from an anatomic study

Obturator artery is frequently a branch of anterior division of the internal iliac artery. It has drawn attention of pelvic surgeons, anatomists and radiologists because of the high frequency of variations in its course and origin. The obturator vein is usually described as a tributary of the internal iliac vein. During routine dissection classes to undergraduate medical students we have observed obturator artery arising from external iliac artery, obturator vein draining into external iliac vein, communicating vein between obturator vein and external iliac vein and inferior epigastric artery arising from the obturator artery. The anomalous obturator vessels and inferior epigastric artery in the present case may be in a dangerous situation in pelvic surgeries that require dissection or suturing along the pelvic rim. Developmental reasons and clinical significances of the variations are discussed.

Inferior epigastric artery arising from the obturator artery as a terminal branch of the internal iliac artery and consideration of its rare occurrence

The origins of the inferior epigastric and obturator arteries and the relationship between these arteries have been determined macroscopically in examinations of 706 body-halves of Japanese subjects. Three very rare inferior epigastric arteries were found to arise from the obturator artery leaving the internal iliac artery. The intimate relationship between these arteries has been documented by the obturator artery arising from the inferior epigastric artery and the anastomosis between them. It is generally interpreted that such anomalies occur as remnant or partial disappearance of the connection between the pubic branches of the inferior epigastric and obturator arteries. The inferior epigastric artery arising from the obturator artery is also thought to be a similar anomaly. Since the obturator artery from the inferior epigastric artery represents one form of extreme anomaly, and the inferior epigastric artery from the obturator artery represents another form, it would seem that these two forms of extreme anomaly should occur at similar frequencies. However, in our research, the incidence of the former was 10.5% while that of the latter was a very low 0.4%. During normal development, the inferior epigastric artery is established at an earlier stage than the obturator artery as a channel for blood supply. We suppose that the difference of blood flow resulting from this time lag is one of the reasons why the inferior epigastric artery from the obturator artery is very rare in comparison to the obturator artery from the inferior epigastric artery.

The location of the obturator nerve: a three-dimensional description of the obturator canal

Satisfactory analgesia cannot be achieved in every obturator nerve block. To attempt to improve the success rate of obturator nerve block, this study describes the detailed anatomy of the obturator region and canal. Eleven (5 female and 6 male) cadavers, totally 22 sides were dissected. Anatomical positions of the structures entering and leaving the canal were defined. The position of the obturator nerve and its branches and their relation with the obturator artery, vein, and with the internal iliac and femoral veins were investigated. A mould of the canal and a model were created. Detailed measurements were performed on the cadavers and models. The obturator canal was in the shape of a funnel compressed from superior to inferior, with anterior and posterior openings. At the entrance of the canal, the nerve lay superiorly; the artery was in the middle, and the vein lay inferiorly. The obturator nerve ran close to the lateral wall of the obturator canal. The distance of lateral wall of obturator canal to the median plane was 41.4 +/- 1.1 mm. After leaving the canal, the nerve lay laterally while the anterior branch of the artery was medial. A venous plexus lay between the two structures. The presence of the branches of the obturator artery and vein alongside the obturator nerve may increase the risk of injury to these structures during anaesthetic procedures. The anterior division of the obturator nerve has a close relationship with these vessels. To provide complete analgesia, the obturator nerve should be blocked in the obturator canal or at its external orifice.

Pharmacoangiographic Evidence of the Presence and Anatomical Dominance of Accessory Pudendal Artery(s)

Potency preservation is one of the principal concerns surrounding newer developments in the management of organ confined carcinoma prostate. Nerve sparing techniques may not solely preserve erectile function and it is known that vascular factors may be an etiology of the dysfunction. The role of accessory pudendal arteries in the etiology and prevention of erectile dysfunction after radical prostatectomy is at present unclear. We reviewed pudendal angiograms in patients with erectile dysfunction to evaluate the prevalence and importance of these vessels. Selective pudendal pharmacoangiograms were obtained in 79 consecutive patients with a history of erectile dysfunction. The aim was to identify accessory pudendal arteries, their origin and their significance relative to all identifiable pudendal arteries and the dorsal penile artery with respect to penile arterial inflow. An accessory pudendal artery was identified in 28 (35%) of the patients. The most common origin was the obturator artery. In 15 of the 28 men (54%) in whom an accessory artery was identified it appeared angiographically to be the dominant penile artery. In 3 patients it was apparently the only major arterial inflow to the penis. Accessory pudendal arteries may be identifiable with pharmacoangiograms in approximately a third of all men. Because they may be the dominant source of blood supply to the penis in some cases, their preservation during radical prostatectomy could be critical to erectile function following radical prostatectomy.

Arterial vascularization of the bony acetabulum

The arterial supply of the acetabulum is studied in 30 human hip-pelvis specimens utilizing conventional angiography, 3 D-CT and maceration. 3 specimens out of 30 had to be excluded due to extravasation and incomplete filling. The arteries of the pelvis were filled with barium sulfate in 16 cases and in 11 cases with a solution of resin and lead powder. Conventional angiograms were performed in all specimens. In preparations with resin/lead powder additional CT with 3 D reconstructions of the surface of the acetabulum and arteries were done. 3 D-CTs show precise relationship of the arteries to the acetabulum. Filling with resin and lead powder is optimal for anatomical studies. It permits comparative 3 D-CT and conventional X-ray examination and subsequent preparation of the vessels in corrosion technique. The central parts of the acetabulum are vascularized by the obturator artery, the cranio-lateral part by the a. glutea superior and the ischial parts by the a. glutea inferior. The arterial supply of the acetabulum can be saved knowing the way and entry of the arteries into the bone. This is of importance for triple osteotomies of the pelvis but as well for difficult total hip replacements and revisions. The described method can be used for anatomical studies of the vessel to bone correlation in different anatomical sites.

Ultrasound anatomy of the fetal hip joint with special reference to the blood supply

Study of the anatomy of the fetal hip joint in 115 pregnancies between 13. to 40.th weeks of gestation by ultrasound. Sonoanatomy was studied by high resolution ultrasound (Acuson 128). For investigation of vascular supply of the fetal hip, colour-coded Doppler sonography was performed. In-vivo studies on vascular supply were correlated with histological sections of 34 fetal hip specimens, according to the conceptional age of 13-35 weeks. Vascular studies of the proximal end of the human femur showed a supply by the lateral and medial femoral circumflex arteries branched from the femoral artery or the deep femoral artery. After 22 weeks of gestation the acetabular artery supplied by the obturator artery was visible by means of Doppler sonography. At the end of pregnancy, large numbers of intraosseous blood vessels are demonstrable within the femoral head and neck. The basic arterial pattern of the hip joint is established at birth. Proximal end of the growing femur, acetabulum, os ilium and labrum acetabulare are clearly visible by ultrasound.

Angioarchitecture of the root of the equine penis

Equine penile vascular casts were prepared by perfusion with Batson's compound via the abdominal aorta in post mortem specimens of adult male ponies to clarify vascular features of the penile root (bulb and crura). Casts revealed vascular details of (1) the bulb and corpus spongiosum penis (CSP), the bulb having slightly larger diameter than the continuing CSP; (2) vascular spaces of the two crura, each with the proximal‐most part of the corpus cavernosum penis (CCP), and (3) proximal portion of the penile body, indicated by fusion of the two CCP. Each internal pudendal artery gave rise to only the artery of the bulb; there was no branch that supplied the CCP at the crus or that continued distally as the dorsal artery of the penis as found in other domestic mammals. The deep artery of the penis into the CCP for effecting penile erection was found to come solely from a branch of the obturator artery. In contrast to illustrations/descriptions in many veterinary anatomy atlases/texts, we were unable to demonstrate any anastomostic connections between the internal pudendal arterial and obturator arterial supply to the penile root. Multiple small, short veins passed from each crus to join the ipsilateral side of the plexiform dorsal vein at ischial arch level. Multiple small short veins rather than one large vein may enhance restriction of venous outflow from the crus during ischiocavernosus muscular contraction for erection.

Complications of Pelvic Lymphadenectomy in 1,380 Patients Undergoing Radical Retropubic Prostatectomy Between 1993 and 2006

We evaluated the perioperative complications associated with pelvic lymphadenectomy in patients undergoing radical retropubic prostatectomy. In particular the influence of the extent of pelvic lymphadenectomy and of other possible risk factors on the complication rate was examined. All intraoperative and early postoperative complications in 1,380 patients who underwent radical retropubic prostatectomy were documented. Complications related to pelvic lymphadenectomy were described and evaluated statistically to explore the role of possible risk factors. Limited pelvic lymphadenectomy was performed in 867 patients and an extended procedure was done in 434. In 60 cases pelvic lymphadenectomy was not specified and in 19 pelvic lymphadenectomy was omitted. Intraoperative complications associated with pelvic lymphadenectomy were rare events (8 cases). Early postoperative complications included hemorrhage of the obturator artery in 1 patient, symptomatic lymphocele in 72, thromboembolic sequelae in 6 and lymphocele infection in 2. Lymphocele formation depended on the extent of pelvic lymphadenectomy (p <0.0001), the number of lymph nodes removed (p = 0.0038) and the operating surgeon (p = 0.0073). Thromboembolic events (p = 0.001) and re-interventions (p <0.0001) were more frequent in patients with a lymphocele. Multivariate analysis confirmed extended pelvic lymphadenectomy as an independent risk factor for lymphocele and re-intervention. Pelvic lymphadenectomy is the cause of a relevant number of perioperative complications in patients undergoing radical retropubic prostatectomy. Lymphocele formation, and the associated re-interventions and thromboembolic sequelae account for by far the highest percent of these complications. In the current study lymphocele formation depended on the extent of pelvic lymphadenectomy, the number of lymph nodes removed and the operating surgeon.

Clinical study on the improvement of ischemia condition with stem cell transplantation in 122 cases necrosis of femoral head

To observe the curative effects of bone marrow stem cell (BMSC) and peripheral blood stem cell (PBSC) transplantations on the avascular necrosis of femoral head (ANFH). Totally 122 ANFH patients (211 coxae) treated by BMSC or PBSC transplantations were enrolled from July 2004 to December 2006. All of them were classed to different stages according to the ARCO. Control group were desired as themselves before and after treatment. The puncture of femoral artery was conducted with digital subtraction angiography (DSA), and the tubes were inserted into medial femoral circumflex artery, lateral femoral circumflex artery and obturator artery with the cell suspensions were gradually poured into the arteries. The joint pain, joint functions and walking distance of 122 patients were detected for the follow-up. Compared with before treatment, the calibers thickened; vessels increased and blood velocity quickened of femoral head blood-supply artery were observed in 15 patients after 6 months checked by DSA. The reduced areas of femoral head necrosis in 8 patients indicated the new bone formation between 12 and 24 months. Autologous BMSC and PBSC transplantation results in the new bone formation and improvement of ischemia in areas of femoral head necrosis at 6 months. The change of angiography was observed about 12 to 24 months after cell transplantation. The stem cell transplantation is convenient, safe and effective in the treatment of the ANFH with no adverse reaction, and can be considered as a new therapy of ANFH.

Pudendal-thigh flap: anatomic basis and application in repairing and reconstructing male perineal region

To investigate the anatomic feature of pudendal-thigh flap and to provide anatomic guide for clinical design and application of the flap in repairing and reconstructing male perineal region. The clinical anatomy of blood supply and refluence and nerve innervation of the perineal region in 15 male cadavers (30 sides) were investigated. Then reasonable flaps were designed for male patients needing repair and reconstruction of the perineal regions based on the anatomic findings. Perineal region has adequate arterial blood supply, abundant venous refluence and reliable nerve innervation. The area has multi-source blood supplies: external pudendal artery, anterior cutaneous branches of obturator artery, bole and lateral branch of arteriae scrotales posteriores. The locations of the arteries were mainly uniform in the 30 sides. Three vasoganglion composed by these arteries and their branches connecting superior, central and inferior parts of the flap. In the 23 cases, the largest flap was 17 cm x 9 cm, and the smallest was 8 cm x 5 cm. The flaps survived and recovered well, with perfect appearance and sensation. The patients were all satisfied with the operation results. The pudendal-thigh flap has abundant blood supply. It can be incised conveniently and covers donor sites well. The flap can be used to repair and reconstruct male perineum with ideal appearance and sensation.

Anomalous Origin of Obturator Artery from the Internal Iliac Artery

La arteria obturatriz es frecuentemente una rama de la division anterior de la arteria iliaca interna o uno de los ramos parietales de la arteria iliaca interna. Sin embargo, ella atrae la atencion de cirujanos pelvicos, anatomistas y radiologistas por la alta frecuencia de variaciones, tanto en su origen como en su trayecto. Este reporte muestra un caso en que la arteria obturatriz se origina de la parte posterior de la arteria iliaca interna en 316 pelvis examinadas, una rara observacion en la poblacion de la India. Esta variacion es correlacionada con el desarrollo y se discuten sus implicancias clinicas

VID-01.08: Nerve sparing robotic prostatectomy – preserving the accessory obturator artery

VID-01.08: Nerve sparing robotic prostatectomy – preserving the accessory obturator artery

Obturator artery disruption associated with acetabular fracture: A case study and anatomy review

Obturator artery disruption associated with acetabular fracture: A case study and anatomy review

Embolization of Postsurgical Obturator Artery Pseudoaneurysm

The anatomy of the obturator artery in the pelvis makes this vessel and its branches prone to iatrogenic injury during pelvic surgery. We present a postoperative obturator artery pseudoaneurysm treated by transcatheter embolization. Normal and variant obturator vascular anatomy, as well as pathology related to traumatic injury of this vessel, are subsequently discussed.

In reply to Drs. Rubin and Hansen

We appreciate the detailed anatomic review of the major pelvic vessels provided by Dr. Rubin. Our nodal clinical target volume (CTV) is designed based on a practical application of anatomy into radiation treatment planning. It includes data on positive nodes obtained from real patients and acknowledges the limits of computed tomography or magnetic resonance (MR) without angiography to define smaller vessels. Defining the anterior division of the iliac vessels is difficult; defining the obturator artery is harder still.

Bilateral femoral hernia in a male cadaver with vascular variations: case report and review of the literature

Femoral hernia, which is a less common occurrence than inguinal hernia, is not congenital in most cases and is uncommon in young males. It is considered to be more common in females than in males due to an enlarged femoral ring in the former. A case of bilateral femoral hernia in a 64-year-old male cadaver is described within the framework of an anatomical approach. On the right side, the protrusion of the viscus appeared as a small intestine coil, whereas on the left side the protruded viscus appeared as a pelvic colon's appendix appiplocae. On both sides, the protruded viscus was located in front of an aberrant obturator artery, which oriented from the external iliac artery and not from the internal iliac artery as should be the case. The puberal branch of the inferior epigastric artery was absent. The cadaver's medical history and his skin examination excluded an abdominal surgery. In the literature, case reports of bilateral femoral hernia appear only seldom, especially those of male patients who had not undergone inguinal hernia repair surgery. In femoral hernias more often than in other types of hernia, the protruded viscus is strangulated and undergoes a tissue necrosis. Morbidity and mortality for complicated femoral hernia is high. Knowledge of vascular variation such as presented by the cadaver under study is extremely useful to the surgeon because any iatrogenic injury of the aberrant obturator artery during a laparoscopic repair may result in dangerous hemorrhage.