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Pelvic Arteries: Exclusion
T. Gregory Walker, MD, FSIR
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KEY FACTS

  • Terminology

    • Procedure

      • Outcomes

        TERMINOLOGY

        • Definitions

          • Iliac artery aneurysm (IAA): Abnormal arterial enlargement of ≥ 50% of normal vessel diameter
            • Common iliac artery (CIA) aneurysm defined as transverse diameter > 1.5 cm
              • Most IAAs associated with abdominal aortic aneurysms (AAA)
                • Iliac aneurysms present in roughly 20% of AAA
              • Isolated IAAs uncommon
                • 1-2% of all abdominal aneurysmal disease
            • Internal IAAs rare (≤ 0.4%)
              • Typically associated with aortic/CIA aneurysms
            • External IAAs exceedingly rare
          • Hemodynamically unstable pelvic fracture: Persistent systolic blood pressure < 90 mm Hg with associated pelvic fracture
            • Hemorrhage severity classified according to American College of Surgeons Advanced Trauma Life Support
              • Class I: Involves up to 15% of blood volume
              • Class II: Involves 15-30% of total blood volume
                • Tachycardia, peripheral vasoconstriction, pallor
                • Typically responds to volume resuscitation
              • Class III: 30-40% loss of circulating blood volume
                • Hypotension, peripheral hypoperfusion (shock)
                • Requires volume resuscitation and blood products
              • Class IV: Loss of > 40% of circulating blood volume
                • Requires aggressive resuscitation to avoid death
            • Class III-IV patients with pelvic ring disruption need immediate pelvic stabilization with external fixation
              • Continuing blood loss despite fracture stabilization and aggressive resuscitation mandates angiography to look for arterial bleeding source
                • May require transcatheter embolization; typically performed in lieu of surgical exploration
                • Embolization avoids contamination associated with operative ligation of bleeding vessels; preserves tamponade effect in retroperitoneum
        • Pertinent Pelvic Vascular Anatomy

          • CIA: Origin at aortic bifurcation; divides into external and internal iliac arteries
            • Typically 4-6 cm long; ≥ 1 cm in diameter
            • Extraperitoneal inferolateral course along medial psoas muscle margin; bifurcates at pelvic brim
          • External iliac artery: Extends from CIA bifurcation to inguinal ligament
            • Typically 8-10 cm long; 6-8 mm in diameter
            • Anteroinferior course along psoas muscle medially
            • Gives origin to 2 major branches
              • Inferior epigastric artery
                • Arises immediately above inguinal ligament; cephalad course deep to rectus abdominis
                • Anastomoses with superior epigastric artery (continuation of internal mammary artery)
                • May give rise to obturator/accessory obturator artery (anatomic variant seen in 30%)
              • Deep circumflex iliac artery
                • Courses along iliac crest of pelvis
                • Anastomoses with iliolumbar/superior gluteal artery; important collateral in iliac occlusions
          • Internal iliac (hypogastric) artery: Originates at CIA bifurcation; divides into 2 trunks
            • Anterior division branches
              • Obturator artery: Courses to obturator foramen; divides into anterior and posterior branches
              • Inferior gluteal artery: Largest anterior division branch; supplies buttock/posterior thigh
              • Umbilical artery: Patent part of embryonic umbilical artery; gives off 2 branches
                • Superior vesical artery: Supplies upper urinary bladder; may give rise to ductus deferens artery
                • Ductus deferens artery: Supplies vas deferens; accompanies into scrotum and testis
              • Uterine artery: Supplies uterus; courses in cardinal ligament (base of broad ligament)
              • Inferior vesical artery: Supplies lower urinary bladder; also seminal vesicles/prostate in male patients
              • Vaginal artery: Supplies vagina, bladder base, lower rectum; may arise from uterine artery
              • Middle rectal artery: Usually arises with inferior vesical artery; supplies rectum
              • Internal pudendal artery: Supplies perineum/external genitalia; multiple branches
                • Inferior rectal artery: Supplies anus; anastomoses with middle superior rectal arteries
                • Perineal artery: Supplies perineal muscles; posterior aspect of scrotum
                • Dorsal penile (clitoral) artery: Together with bulbourethral artery supplies penis/clitoris
            • Posterior division arterial branches
              • Iliolumbar artery: 1st branch of posterior division; supplies psoas/iliacus muscles
              • Superior gluteal artery: Largest branch of internal iliac artery; supplies gluteal muscles
              • Lateral sacral artery: Supplies erector spinae/pyriformis muscles; contents of sacral canal

        PREPROCEDURE

        • Indications

          • Contraindications

            • Preprocedure Imaging

              • Getting Started

                PROCEDURE

                • Patient Position/Location

                  • Procedure Steps

                    • Alternative Procedures/Therapies

                      POST PROCEDURE

                      • Things to Do

                        OUTCOMES

                        • Complications

                          • Expected Outcome

                            Selected References

                            1. Filiberto DM et al: Preperitoneal pelvic packing: technique and outcomes. Int J Surg. 33(Pt B):222-224, 2016
                            2. Froberg L et al: Mortality in trauma patients with active arterial bleeding managed by embolization or surgical packing: An observational cohort study of 66 patients. J Emerg Trauma Shock. 9(3):107-14, 2016
                            3. Qasim Z et al: Resuscitative endovascular balloon occlusion of the aorta. Resuscitation. 96:275-9, 2015
                            4. Ali A et al: Bladder necrosis secondary to internal iliac artery embolization following pelvic fracture. Urol Ann. 6(2):166-8, 2014
                            5. Auerbach AD et al: Selective transcatheter arterial embolization of the internal iliac artery does not cause gluteal necrosis in pelvic trauma patients. J Orthop Trauma. 26(5):290-5, 2012
                            6. Heye S et al: Embolization of an internal iliac artery aneurysm after image-guided direct puncture. Cardiovasc Intervent Radiol. 35(4):807-14, 2012
                            7. Libicher M et al: Occlusion of the internal iliac artery prior EVAR: comparison of coils and plugs. Vasc Endovascular Surg. 46(1):34-9, 2012
                            8. Parlani G et al: Long-term results of iliac aneurysm repair with iliac branched endograft: a 5-year experience on 100 consecutive cases. Eur J Vasc Endovasc Surg. 43(3):287-92, 2012
                            9. Barentsz MW et al: Clinical outcome of intra-arterial embolization for treatment of patients with pelvic trauma. Radiol Res Pract. 2011:935484, 2011
                            10. Bilhim T et al: Branching patterns of the male internal iliac artery: imaging findings. Surg Radiol Anat. 33(2):151-9, 2011
                            11. Cherry RA et al: Intraoperative angioembolization in the management of pelvic-fracture related hemodynamic instability. J Trauma Manag Outcomes. 5:6, 2011
                            12. Cullinane DC et al: Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture--update and systematic review. J Trauma. 71(6):1850-68, 2011
                            13. Chemelli A et al: Endovascular repair of isolated iliac artery aneurysms. J Endovasc Ther. 17(4):492-503, 2010
                            14. DuBose J et al: Bilateral internal iliac artery ligation as a damage control approach in massive retroperitoneal bleeding after pelvic fracture. J Trauma. 69(6):1507-14, 2010
                            15. Ferreira M et al: Technical aspects and midterm patency of iliac branched devices. J Vasc Surg. 51(3):545-50, 2010
                            16. Maleux G et al: Outcome of proximal internal iliac artery coil embolization prior to stent-graft extension in patients previously treated by endovascular aortic repair. J Vasc Interv Radiol. 21(7):990-4, 2010
                            Related Anatomy
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                            Related Differential Diagnoses
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                            References
                            Tables

                            Tables

                            KEY FACTS

                            • Terminology

                              • Procedure

                                • Outcomes

                                  TERMINOLOGY

                                  • Definitions

                                    • Iliac artery aneurysm (IAA): Abnormal arterial enlargement of ≥ 50% of normal vessel diameter
                                      • Common iliac artery (CIA) aneurysm defined as transverse diameter > 1.5 cm
                                        • Most IAAs associated with abdominal aortic aneurysms (AAA)
                                          • Iliac aneurysms present in roughly 20% of AAA
                                        • Isolated IAAs uncommon
                                          • 1-2% of all abdominal aneurysmal disease
                                      • Internal IAAs rare (≤ 0.4%)
                                        • Typically associated with aortic/CIA aneurysms
                                      • External IAAs exceedingly rare
                                    • Hemodynamically unstable pelvic fracture: Persistent systolic blood pressure < 90 mm Hg with associated pelvic fracture
                                      • Hemorrhage severity classified according to American College of Surgeons Advanced Trauma Life Support
                                        • Class I: Involves up to 15% of blood volume
                                        • Class II: Involves 15-30% of total blood volume
                                          • Tachycardia, peripheral vasoconstriction, pallor
                                          • Typically responds to volume resuscitation
                                        • Class III: 30-40% loss of circulating blood volume
                                          • Hypotension, peripheral hypoperfusion (shock)
                                          • Requires volume resuscitation and blood products
                                        • Class IV: Loss of > 40% of circulating blood volume
                                          • Requires aggressive resuscitation to avoid death
                                      • Class III-IV patients with pelvic ring disruption need immediate pelvic stabilization with external fixation
                                        • Continuing blood loss despite fracture stabilization and aggressive resuscitation mandates angiography to look for arterial bleeding source
                                          • May require transcatheter embolization; typically performed in lieu of surgical exploration
                                          • Embolization avoids contamination associated with operative ligation of bleeding vessels; preserves tamponade effect in retroperitoneum
                                  • Pertinent Pelvic Vascular Anatomy

                                    • CIA: Origin at aortic bifurcation; divides into external and internal iliac arteries
                                      • Typically 4-6 cm long; ≥ 1 cm in diameter
                                      • Extraperitoneal inferolateral course along medial psoas muscle margin; bifurcates at pelvic brim
                                    • External iliac artery: Extends from CIA bifurcation to inguinal ligament
                                      • Typically 8-10 cm long; 6-8 mm in diameter
                                      • Anteroinferior course along psoas muscle medially
                                      • Gives origin to 2 major branches
                                        • Inferior epigastric artery
                                          • Arises immediately above inguinal ligament; cephalad course deep to rectus abdominis
                                          • Anastomoses with superior epigastric artery (continuation of internal mammary artery)
                                          • May give rise to obturator/accessory obturator artery (anatomic variant seen in 30%)
                                        • Deep circumflex iliac artery
                                          • Courses along iliac crest of pelvis
                                          • Anastomoses with iliolumbar/superior gluteal artery; important collateral in iliac occlusions
                                    • Internal iliac (hypogastric) artery: Originates at CIA bifurcation; divides into 2 trunks
                                      • Anterior division branches
                                        • Obturator artery: Courses to obturator foramen; divides into anterior and posterior branches
                                        • Inferior gluteal artery: Largest anterior division branch; supplies buttock/posterior thigh
                                        • Umbilical artery: Patent part of embryonic umbilical artery; gives off 2 branches
                                          • Superior vesical artery: Supplies upper urinary bladder; may give rise to ductus deferens artery
                                          • Ductus deferens artery: Supplies vas deferens; accompanies into scrotum and testis
                                        • Uterine artery: Supplies uterus; courses in cardinal ligament (base of broad ligament)
                                        • Inferior vesical artery: Supplies lower urinary bladder; also seminal vesicles/prostate in male patients
                                        • Vaginal artery: Supplies vagina, bladder base, lower rectum; may arise from uterine artery
                                        • Middle rectal artery: Usually arises with inferior vesical artery; supplies rectum
                                        • Internal pudendal artery: Supplies perineum/external genitalia; multiple branches
                                          • Inferior rectal artery: Supplies anus; anastomoses with middle superior rectal arteries
                                          • Perineal artery: Supplies perineal muscles; posterior aspect of scrotum
                                          • Dorsal penile (clitoral) artery: Together with bulbourethral artery supplies penis/clitoris
                                      • Posterior division arterial branches
                                        • Iliolumbar artery: 1st branch of posterior division; supplies psoas/iliacus muscles
                                        • Superior gluteal artery: Largest branch of internal iliac artery; supplies gluteal muscles
                                        • Lateral sacral artery: Supplies erector spinae/pyriformis muscles; contents of sacral canal

                                  PREPROCEDURE

                                  • Indications

                                    • Contraindications

                                      • Preprocedure Imaging

                                        • Getting Started

                                          PROCEDURE

                                          • Patient Position/Location

                                            • Procedure Steps

                                              • Alternative Procedures/Therapies

                                                POST PROCEDURE

                                                • Things to Do

                                                  OUTCOMES

                                                  • Complications

                                                    • Expected Outcome

                                                      Selected References

                                                      1. Filiberto DM et al: Preperitoneal pelvic packing: technique and outcomes. Int J Surg. 33(Pt B):222-224, 2016
                                                      2. Froberg L et al: Mortality in trauma patients with active arterial bleeding managed by embolization or surgical packing: An observational cohort study of 66 patients. J Emerg Trauma Shock. 9(3):107-14, 2016
                                                      3. Qasim Z et al: Resuscitative endovascular balloon occlusion of the aorta. Resuscitation. 96:275-9, 2015
                                                      4. Ali A et al: Bladder necrosis secondary to internal iliac artery embolization following pelvic fracture. Urol Ann. 6(2):166-8, 2014
                                                      5. Auerbach AD et al: Selective transcatheter arterial embolization of the internal iliac artery does not cause gluteal necrosis in pelvic trauma patients. J Orthop Trauma. 26(5):290-5, 2012
                                                      6. Heye S et al: Embolization of an internal iliac artery aneurysm after image-guided direct puncture. Cardiovasc Intervent Radiol. 35(4):807-14, 2012
                                                      7. Libicher M et al: Occlusion of the internal iliac artery prior EVAR: comparison of coils and plugs. Vasc Endovascular Surg. 46(1):34-9, 2012
                                                      8. Parlani G et al: Long-term results of iliac aneurysm repair with iliac branched endograft: a 5-year experience on 100 consecutive cases. Eur J Vasc Endovasc Surg. 43(3):287-92, 2012
                                                      9. Barentsz MW et al: Clinical outcome of intra-arterial embolization for treatment of patients with pelvic trauma. Radiol Res Pract. 2011:935484, 2011
                                                      10. Bilhim T et al: Branching patterns of the male internal iliac artery: imaging findings. Surg Radiol Anat. 33(2):151-9, 2011
                                                      11. Cherry RA et al: Intraoperative angioembolization in the management of pelvic-fracture related hemodynamic instability. J Trauma Manag Outcomes. 5:6, 2011
                                                      12. Cullinane DC et al: Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture--update and systematic review. J Trauma. 71(6):1850-68, 2011
                                                      13. Chemelli A et al: Endovascular repair of isolated iliac artery aneurysms. J Endovasc Ther. 17(4):492-503, 2010
                                                      14. DuBose J et al: Bilateral internal iliac artery ligation as a damage control approach in massive retroperitoneal bleeding after pelvic fracture. J Trauma. 69(6):1507-14, 2010
                                                      15. Ferreira M et al: Technical aspects and midterm patency of iliac branched devices. J Vasc Surg. 51(3):545-50, 2010
                                                      16. Maleux G et al: Outcome of proximal internal iliac artery coil embolization prior to stent-graft extension in patients previously treated by endovascular aortic repair. J Vasc Interv Radiol. 21(7):990-4, 2010