Interventional vascular, Pelvis, Vascular, Catheter arteriography, CT, Ultrasound-Colour Doppler, Arterial access, Catheters, Embolisation, Blood, Haemorrhage
S. Cayón Somacarrera, M. C. Iniesta González, M. L. Parra Gordo, A. Mingo Basail, I. Galán González
Findings and procedure details
First of all, we have to know how to differentiate the different types of active bleeding. Arterial bleeding is depicted as a contrast extravasation in arterial phase that increases in the successive phases (portal and delayed phases). Venous bleeding is shown as a contrast extravasation in portal phase that increases in the delayed phase (abscence of bleeding in the arterial phase). It is also important to know the findings that allow us to determine the existence of a pseudoaneurysm. It manifests as a hyperdense focal zone in arterial phase with progressive washout in successive phases (portal and delayed phases).
Below we depict examples of arterial pelvic lesions, including active bleedings and pseudoaneurysms, located in the different vascular zones shown above:
1. Abdominal aorta:
- Lumbar arteries: there are five pairs of lumbar arteries. The first two pairs are direct branches of the abdominal aorta and the fifth pair is a branch of the middle sacral artery. They supply the muscles of the posterior abdominal wall, lumbar vertebrae, spinal cord and meninges.
- Median sacral artery: it arises from the iliac bifurcation and supplies L4, L5 vertebrae and the sacrum.
2. External iliac artery:
- Inferior epigastric artery: it arises from the external iliac artery and ascends to supply the rectus abdominis muscle, anastomosing with the superior epigastric artery which is a branch of the internal mammary artery.
- Femoral and Deep circumflex iliac arteries: the common iliac artery bifurcates into the internal and the external iliac arteries. After travelling under the inguinal ligament, the external iliac artery changes its name to common femoral artery. The external iliac artery gives off two branches, the inferior epigastric artery and the deep circumflex iliac artery. The deep circumflex artery supply the muscles of the anterolateral abdominal wall.
3. Internal iliac artery:
- Anterior trunk:
- Obturator artery: it supplies the external obturator muscle and the hip adductors.
- Inferior gluteal artery: it supplies gluteus maximus, piriformis, internal obturator, superior and inferior gemelli and quadratus femoris muscles.
- Internal pudendal artery: it supplies the muscles of anal and urogenital region.
- Posterior trunk:
- Iliolumbar artery: it supplies psoas major, quadratus lumborum and iliacus muscles.
- Lateral sacral artery: it supplies the erector spinae and piriformis muscles, and the sacrum.
- Superior gluteal artery: it supplies piriformis, internal obturator, gluteus maximus, medius and minimus and tensor fasciae latae muscles.
We should also be aware of a common anatomic variant called the corona mortis which is present in up to 30% of patients. It is an aberrant anastomotic connection between the obturator artery and the inferior epigastric artery. It should be considered as a bleeding source if the internal iliac arteriography does not reveal a pelvic source of the bleeding. In such instances, arteriography of the external iliac artery should be performed to exclude bleeding from the corona mortis.