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OJHAS Vol. 10, Issue 1:
(Jan-Mar 2011) |
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| Morphological
Analysis of the Human Internal Iliac Artery
in South Indian Population |
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Naveen NS, Assistant
Professor, Department of Anatomy, KMCT Medical College, Calicut
University, Calicut, India,
Murlimanju BV, Assistant
Professor, Department of Anatomy, Kasturba Medical College,
Manipal University, Mangalore, India,
Vishal Kumar, Assistant
Professor, Department of Anatomy, KS Hegde Medical Academy, Nitte
University, Mangalore, India,
Jayanthi KS, Professor,
Department of Anatomy, Kempegowda Institute of Medical Sciences, Bangalore,
Krishna Rao, Professor,
Department of Anatomy, Kempegowda Institute of Medical Sciences, Bangalore,
Thejodhar Pulakunta, Assistant
Professor, Department of Anatomical Sciences, St. Matthew’s University
School of Medicine, Grand Cayman Islands, BWI. |
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Address for Correspondence |
Assistant
Professor,
Department of Anatomy,
Kasturba Medical College,
Manipal University,
Mangalore - 575004, India.
E-mail:
flutesnowmm@gmail.com |
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Naveen NS, Murlimanju BV, Kumar V, Jayanthi KS, Rao K, Pulakunta T. Morphological
Analysis of the Human Internal Iliac Artery
in South Indian Population. Online J Health Allied Scs.
2011;10(1):11 |
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Submitted: Feb 11,
2011 Accepted: Mar 31, 2011; Published: April 15, 2011 |
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| Abstract: |
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Objectives:
The accidental hemorrhage is common due to erroneous interpretation
of the variant arteries during surgical procedures, hence the present
study has been undertaken with reference to its morphological significance.
The objectives were to examine the level of origin, length and the branching
pattern of the human internal iliac artery in South Indian population. Methods:
The study included 60 human bisected pelvises irrespective of their
side and sex. The specimens were collected from the anatomy laboratory
and were fixed with the formalin. The branching patterns were studied
and demonstrated as per the guidelines of Adachi. Results:
The origin of internal iliac artery was at the level of S1 vertebra
in majority (58.3%) of the cases. The average length of internal iliac
artery was 37 ± 4.62 mm (range, 13-54 mm). The type I pattern of the
internal iliac artery was most common (83.5%) followed by types III
and II. The type IV and V pattern of adachi were not observed. Conclusions:
The results of this study were different from those reported by others
and may be because of racial and geographical variations. Prior knowledge
of the anatomical variations is beneficial for the vascular surgeons
ligating the internal iliac artery or its branches and the radiologists
interpreting angiograms of the pelvic region.
Key Words:
Anatomy; Branches; Classification; Internal iliac artery; Ligation; Variations
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The internal iliac artery (IIA) originates from the common iliac artery
at the level of sacroiliac joint,(1,2) descends posterior to the greater
sciatic foramen and divides into anterior and posterior divisions.(1,2)
The branches of the anterior division include superior vesical artery,
inferior vesical artery, middle rectal artery, vaginal artery, obturator
artery, internal pudendal artery and the inferior gluteal artery.(1,2)
The posterior division gives three branches i.e. iliolumbar artery,
lateral sacral artery and the superior gluteal artery.(1,2) As per the
previous observations, during the development, the most appropriate
channels enlarge and the others get retracted or disappear, which will
result in the final arterial pattern.(3) During development, the IIA
derives from the umbilical artery which persists in its proximal part
and the distal part gets obliterated postnatally.(4)
The proper knowledge and its branching pattern of the IIA will provide
the surgeon proper guidelines in ligating the artery and its branches
during various surgical procedures of the pelvic viscera. There are
only a few studies available in the literature regarding the morphology
of the IIA and from india are not reported. Hence the present study
has been undertaken with reference to its morphological significance.
The objectives were to note the level of origin of the IIA and to measure
the length of its trunk, to note the level of its division and its branching
pattern.
The study included 60 human cadaveric bisected pelvises which were available
in the department of anatomy and were preserved in 10% formaldehyde
solution. The study was performed as per the guidelines of the institutional
ethical committee. No particular emphasis was given to the side, gender
and age of the pelvises. No particular method was employed for the dissection
but care was taken to expose the branches of the IIA. The IIA along
with its anterior and posterior divisions and its further subdivisions,
were carefully delineated by separating it from the surrounding structures.
Morphometric measurements were taken using a vernier caliper of 2mm
accuracy with the pelvis in supine position and the specimens were photographed.
The measurements were taken from the point of bifurcation of the common
iliac artery to its point of division. To avoid bias,
the measurements were taken by two different authors. The level of origin
of IIA from the common iliac artery was also noted. The branching patterns
of IIA were studied and demonstrated as per the guidelines of Adachi.(5)
The Adachi’s pattern used in the present study, distinguishes the
IIA into five different types as follows (Fig. 1):
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Fig. 1:
Schematic Representation of Adachi’s types. H. internal iliac artery; I.G. inferior gluteal artery; P. internal pudendal artery; S.G. superior
gluteal artery; UMB. Umbilical artery. (Braithwaite J.L., 1952) |
Type I - The
superior gluteal artery arises separately from the IIA, the inferior
gluteal and internal pudendal vessels are given off by a common trunk.
If the latter divides within the pelvis it is considered to be Type
Ia, whereas if the bifurcation occurs below the pelvic floor it is classified
as Type lb. Type II - The superior and inferior gluteal arteries arise
by a common trunk and the internal pudendal vessel separately. In this
category, as in the previous one, two subtypes are described. Type IIa
includes those specimens in which the trunk common to the two gluteal
arteries divides within the pelvis and Type IIb those in which the division
occurs outside the pelvis. Type III - The three branches arise separately
from the internal iliac artery. Type IV - The three arteries arise by
a common trunk. The subtyping in this group is based on the sites of
origin of the superior gluteal and the internal pudendal arteries from
the parent stem. In Type IVa the trunk first gives rise to the superior
gluteal artery before bifurcating into the other two branches; in Type
IVb the internal pudendal is the first vessel to spring from the common
trunk, which then divides into superior and inferior gluteal arteries.
Type V - The internal pudendal and the superior gluteal arteries arise
from a common trunk and the inferior gluteal has a separate origin.
The origin of IIA was at the level of S1 vertebra in 35 cases (58.3%),
at the level of L5-S1 in 24 cases (40%) and in 1 case (1.7%), it was
at the level of L5 (Fig. 2A). From the morphometrical analysis, values
ranged between 13 and 54 mms and the average length being 37 ± 4.62
mms. The Adachi’s (5) guideline
was followed, where the IIA ends at the emergence of the gluteal artery.
It has been observed that the IIA divided proximal to the upper edge
of greater sciatic notch in all the 60 specimens. The distance from
the greater sciatic notch is 3 cms above in 18 cases (30.7%), 2 cms
above in 14 (23.1%) cases, 2.5 cms above in 12 specimens (19.8%), 4
cms above in 8 cases (13.2%), 3.5 cms above 4 cases (6.6%) and 5.5 cms
above the greater sciatic notch in 4 cases (6.6%). Fig. 2B shows the
incidence of the branching pattern of IIA, as per Adachi’s guidelines.
The branching pattern of IIA was Type Ia (Fig. 3A) in 46 (76.9%) of
the cases, Type 1b (Fig. 3B) in 4 (6.6%), Type IIa (Fig. 4A) in 4 (6.6%)
of cases and Type III (Fig. 4B) in 6 (9.9%) cases. The type IV and V
pattern of adachi (5) were not observed in the present study.
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Fig 2A.
Histogram showing the incidence of the origin of IIA at different levels
(n = 60) 2B. Histogram showing the incidence of the branching
pattern of IIA (as per Adachi) (n = 60) |
Fig 3A: Internal Iliac Artery Type Ia (1 – a common trunk from AD
giving IPA, IGA & IVA; 2 - a common trunk from AD giving UMB &
SVA; 3 – ILA arising from the trunk of IIA)
3B: Internal Iliac
Artery Type Ib (1 – a common trunk from AD giving UMB, SVA, IVA &
OBT; 2 - a common trunk from AD giving IGA & IPA outside (DOP) the
pelvis)
(IIA
– internal iliac artery, UMB – umbilical artery, OBT
– obturator artery, SVA – superior vesical artery, IVA
– inferior vesical artery, SGA – superior gluteal artery, IGA
– inferior gluteal artery, IPA – internal pudendal artery, MRA
– middle rectal artery, LSA – lateral sacral artery, ILA
– iliolumbar artery, AD – anterior division, PD
– posterior division)
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Fig 4A: Internal Iliac
Artery Type IIa (1 – a common trunk from PD giving SGA, IGA &
OBT; 2 – LSA arising from IGA)
4B: Internal Iliac Artery Type
III (1 – UMB arising separately from AD; 2 – IPA arising separately
from AD; 3 – IGA arising separately from AD; 4 – IVA arising from
OBT; 5 – LSA arising from trunk of IIA; 6 – MRA arising from IPA)
(IIA
– internal iliac artery, UMB – umbilical artery, OBT
– obturator artery, SVA – superior vesical artery, IVA
– inferior vesical artery, SGA – superior gluteal artery, IGA
– inferior gluteal artery, MRA – middle rectal artery, IPA
– internal pudendal artery, LSA – lateral sacral artery, ILA
– iliolumbar artery, AD – anterior division, PD
– posterior division)
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The accidental hemorrhage is common due to erroneous interpretation
of the variant arteries by the surgeons and a thorough knowledge of
the anatomy of the branches of the IIA is essential. Hemorrhage has
been considered as the leading cause of maternal deaths in the developing
countries.(6) The ligation of the IIA to control hemorrhage during pelvic
surgeries has been described by Kelly HA(7) as early as in 1894. Recent
reports opine that the efficacy of the IIA ligation during any obstetrics
and gynecology surgery varies between 42–75%.(8,9) So it is obvious
that, for the successful ligation of IIA the surgeon should have a sound
knowledge of the anatomy of its anterior and the posterior divisions.
The visceral branches of IIA supply the urinary bladder, rectum, prostate,
seminal vesicles, ejaculatory ducts in males and the gonads, uterus,
vagina, urinary bladder, urethra in females.
The gluteal region, posterior and antero-medial regions of the thigh
and the hip joint are supplied by the extra pelvic branches of the IIA.
It was reported that the examination of IIA is very useful clinically
because of its large territory of distribution, its role in the embryo-fetal
circulation and the possibility of its atrophic ligature in non-surgical
malignancies.(10,11) The first attempt to group the variations of the
parietal branches of the IIA was undertaken by Jastschinski.(12) In
an extensive study of the polish subjects, he classified the vessels
into those of large caliber, those of medium caliber and those of small
caliber. He found that only the first category showed sufficient regularity
in origin to enable them to be grouped into definite types, of which
he described four. Adachi (5) modified the Jastschinski’s (12) method
slightly, adding a fifth type of variation and subtypes, in a study
from japanese subjects. Now there are a few reports available (5,12-14)
on the morphology of IIA and the authors of those reports classified
the IIA based on the variations in the origin of parietal branches.
Jastschinski (12) and Adachi (5) noted four main parietal branches of
IIA namely umbilical, superior gluteal, inferior gluteal and internal
pudendal artery. Ashley and Anson (14) in their study from 130 specimens
observed the inferior and superior gluteal artery arising from one common
stem in 58% of the cases, the internal pudendal and umbilical arteries
arising from other common stem in 17%, the inferior and superior gluteal
arteries from one common stem, the internal pudendal and umbilical from
other common stem in 8% of the cases, the umbilical and internal pundendal
arteries arose separately above the common stem for gluteal artery.
Yamaki et al. (15) from their study based on the dissection of 645 pelvic
halves of japanese cadavers, the branching of IIA was classified into
4 groups. Almost 80% of the specimens were included in group A, i.e,
the IIA dividing into two major branches, the superior gluteal artery
and the common trunk for the inferior gluteal and internal pudendal
arteries. According to Adachi (5) (Fig. 1), the type I pattern was found
in 51.2% of the cases, type II in 23%, type III in 18% and type IV in
4.1% of the cases. In contrast, Fatu et al.(16) found type I pattern
in 60 out of 100 cases, type II in 20 cases, type III in 10 cases, type
IV in one case and type V was found in 18 cases. From a study conducted
by Braithwaite,(17) type I arrangement was seen in 58.5 % of cases,
type III in 22.5 % and type II in 15.3 %. The type IV was less frequent
and occurred in 3.86 % of specimens. According to a study by Inomata
et al.(18) from 78 cadavers, the type I pattern of Adachi was observed
in 56.1% of the cases followed by types III, II, IV and V.
In the present study from guidelines of Adachi,(5) the branching pattern
of IIA was type I (a) in majority of the specimens. The type I ending
was seen in 83.5% of the cases which includes type I (a) and type I
(b). This finding is similar to other reports,(12,13) in which the common
branching pattern was type I. In the present study, the types IV and
V were not observed and there were a few different observations made,
from the other studies. This may be because the racial and geographical
variations seemed to exist.
According to Williams et al.(1) the IIA arises at the level of the L5-S1
intervertebral disc and anterior to sacroiliac joint. However, in the
present study, the origin of IIA was at the level of S1 in majority
of the specimens. It was reported that the length of IIA is variable,
depends on the length of the common iliac artery and the level of division
of the IIA.(19) It was also reported(19) that the length of the IIA
may be as short as 1.2 cms or as long as 7.5 cms and it is seldom less
than 2.5 cms in length. The same authors reported that, in some cases
the branches arise without the artery dividing into anterior and posterior
divisions and one or more branches arise above the division. According
to Fatu et al,(16) the length of the IIA ranged between 20 and 90 mm,
mean value being 49 mm. The average length of IIA was 27.0 (range, 0-52)
mm, according to Bleich et al.(20) In the present study,
the average length of IIA was 37 ± 4.62 (range, 13-54) mms. This is
slightly lesser compared to Fatu et al.(16) finding and may be because
of racial variations. The gracile indian subjects may have shorter arteries
than more robustly built subjects from other ethnic groups. According
to Williams et al,(1) the IIA divides at the level of superior edge
of greater sciatic notch. In the present study it has been observed
that the IIA divided proximal to the upper edge of greater sciatic notch
in all the 60 specimens and the distance from the greater sciatic notch
is 3 cms in majority of the specimens.
This study highlights the variations seen in origin, length, division
and branching pattern of IIA in the South Indian population. Understanding
the approximate location, orientation and anatomic relationships of
the IIA should aid in preventing the blood loss and other potentially
severe complications such as ureteral injury, vein laceration and ligation
of the external iliac artery. In the event of acute hemorrhage, a detailed
dissection of the IIA is not always feasible, if the surgeon has the
detailed knowledge about the morphology of IIA, many such complications
can be avoided. The other implications of this knowledge are to guide
the interventional radiologists in intraarterial procedures during arterial
embolization for hemorrhage control of pelvic fractures, during selective
catheteterization for intraarterial chemotherapy and embolizations for
pelvic tumors. We believe that this study aims to explain the important
aspects of the vascular anatomy of the IIA, not only for anatomists
and morphologists, also for the radiologists, general and vascular surgeons.
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