Pseudoaneurisma da artéria glútea inferior após queda de bicicleta: relato de caso / Inferior gluteal artery pseudoaneurysm after fall from a bicycle: case report

Pseudoaneurysms of gluteal arteries are rare, especially involving the inferior gluteal artery. They are mainly associated with penetrating trauma, infections, or pelvic fractures. A minority of cases are caused by blunt traumas, with only six cases reported in English. We present a case of pseudoaneurysm of the right inferior gluteal artery after a bicycle fall, presenting with a large hematoma in the gluteal region, observed during clinical examination, and significantly reduced hemoglobin. CT angiography revealed a large hematoma, with contrast extravasation and pseudoaneurysm formation. Angiography revealed that the origin of the lesion was in the right inferior gluteal artery. This artery was embolized with coils. After the procedure, the patient was referred to an intensive care unit, from where he was later transferred to a different hospital, with bleeding controlled. Endovascular treatment of these cases is a safe, fast and an effective option

Pseudoaneurismas de artérias glúteas são raros, especialmente os que envolvem a artéria glútea inferior. Eles estão associados principalmente a traumas penetrantes, infecções ou fraturas de pelve. Em uma minoria de casos, são causados por traumas fechados, havendo somente seis casos relatados na literatura. Apresenta-se aqui um caso de pseudoaneurisma da artéria glútea inferior direita após queda de bicicleta, evoluindo com grande hematoma na região glútea ao exame clínico e queda hematimétrica significativa. A angiotomografia revelou um grande hematoma na região glútea, com extravasamento de contraste e formação de pseudoaneurisma no local. A angiografia revelou que a origem da lesão era na artéria glútea inferior direita. Foi realizada embolização dessa artéria com molas. Após esse procedimento, o paciente foi encaminhado para a unidade de terapia intensiva, de onde foi posteriormente transferido para outro hospital, com o sangramento controlado. Para esses casos, o tratamento endovascular é uma opção segura, rápida e efetiva

The vascular supply of hip joint and its clinical significant / Suministro vascular de la articulación de la cadera y su significado clínico

The hip joint gains its vascular supply from the superior gluteal arteries as well as from the medial and lateral circumflex femoral arteries with the first perforating artery. In gluteal trauma, the superior and inferior gluteal artery may be affected which may end with vascular insult of hip joint. The current study includes a dissection of 171 cadavers to examine the vascular supply of hip joint. In 99.3% of articular branch arises from the superior gluteal artery either directly or indirectly (95.4% or in 3.9%, respectively). In 81% of articular branch arises from the inferior gluteal artery either directly or indirectly in 78% or in 3%. In 20.3% of articular branch arises from the coexistence of sciatic artery either directly or indirectly (17.7% or in 2.6%, respectively). Infrequently, the internal pudendal artery gives articular branch in 0.4%. Further, there is no difference between male and female in hip joint supply in current study. Based on current study's result, the dominant articular branch of vascular supply of the hip joint comes from the superior gluteal artery whereas the inferior gluteal artery comes beyond due its congenital absence. The coexistence sciatic artery is a replacement artery for superior or inferior gluteal artery in case of congenital absence. Due to aneurysm of the three previous arteries after trauma, it is important to study their course and articular branches to avoid iatrogenic fault of joint vascular insult during surgical management of either true or false aneurysm.

La articulación de la cadera obtiene su suministro vascular desde las arterias glúteas superiores, así como desde las arterias circunflejas femorales lateral y medial y la primera arteria perforante. En el trauma glúteo, las arteria glúteas superior e inferior pueden verse afectadas, lo que puede terminar con una lesión vascular de la articulación de la cadera. Este estudio incluyó la disección de 171 cadáveres con el fin de examinar el suministro vascular de la articulación de la cadera. El 99,3% de las ramas articulares se originan de la arteria glútea superior, ya sea directa o indirectamente (95,4% o en 3,9%, respectivamente). En 81% de los casos, la rama articular sse origina de la arteria glútea inferior, directa o indirectamente (78% y 3%, respectivamente). El 20,3% de la rama articular se origina de la conexistencia de la arteria ciática, ya sea directa o indirectamente (17,7% y 2,6%, respectivamente), y con poca frecuencia, la arteria pudenda interna origina una rama articular (0,4%). Además, los resultados no mostraron diferencia en el suministro de articulación de la cadera entre hombres y mujeres. En base a nuestros resultados, podemos señalar que la rama articular dominante de suministro vascular de la articulación de la cadera proviene de la arteria glútea superior, mientras que la arteria glútea inferior aporta de manera escasa debido a su ausencia congénita. La coexistencia de una arteria ciática, constituye un reemplazo de las arterias glútea superior o inferior en caso de ausencia congénita. En caso de un aneurisma de alguna de las tres arterias anteriores, posterior a un trauma, resulta importante estudiar su curso y ramas articulares para evitar una lesión vascular iatrogénica conjunta durante el tratamiento quirúrgico de aneurisma de tipo verdadero o falso.

Aspectos anatómicos y topográficos del nervio pudendo en la región glútea / Anatomical and topographical aspects of the pudendal nerve in gluteal region

El nervio pudendo distribuye ramos motores y sensitivos para la región perineal y órganos genitales externos. Tiene importancia funcional en la micción, defecación, erección y parto. Desde el punto de vista clínico, se realiza bloqueo anestésico del mismo en la práctica obstétrica, se electroestimula en casos de incontinencia fecal o urinaria, entre otros procedimientos. Investigaciones anatómicas han señalado que puede presentar variaciones en su conformación y topografía. Con el propósito de complementar el conocimiento sobre este nervio en su trayecto por la región glútea, se estudió su conformación, biometría y relaciones con los vasos pudendos internos y ligamentos adyacentes. Se disecaron 30 regiones glúteas de 15 cadáveres formolizados de individuos brasileños, adultos, de ambos sexos, observando la conformación del nervio, número de ramos, disposición respecto a los vasos pudendos internos y ligamentos sacrotuberoso y sacroespinoso, registrando también su ancho en el trayecto entre los forámenes isquiático mayor y menor. El nervio pudendo se presentó como tronco único en 53,3 por ciento de los casos y dividido en ramos en 46,7 por ciento (dos ramos en 36,7 por ciento, tres en 6,7 por ciento y cuatro en 3,3 por ciento). Cuando estaba dividido, en 36,7 por ciento los ramos permanecieron separados y en 10 por ciento se unieron antes de ingresar en el foramen isquiático menor. El nervio (único o dividido) fue medial a los vasos pudendo internos en 70 por ciento y lateral a ellos en 3,3 por ciento. En el 26,7 por ciento restante, estaba dividido en dos o tres ramos, que se situaban medial y lateralmente a los vasos o los cruzaban posteriormente. Su posición fue anterior al ligamento sacrotuberoso en 93,3 por ciento. El nervio pudendo presenta interesantes variaciones en su conformación y topografía, que deben ser consideradas durante los procedimientos clínicos y quirúrgicos que lo involucren.

The pudendal nerve distributes motor and sensory branches to the perineum and genital external organs. It has functional importance in the micturition, defecation, erection and labor. From the clinical point of view, anaesthetic blockade of the same one is realized in the obstetric practice, electroestimulation in cases of fecal or urinary incontinence, among other procedures. Anatomical investigations have indicated that it can present variations in its conformation and topography. The objective of this study was complete knowledge about this nerve in its course through the gluteal region, its conformation, biometry and its relationship with the internal pudendal vessels and adjacent ligaments were studied. We dissected 30 gluteal regions of 15 corpses fixed in formaldehyde 10 percent of Brazilian individuals, adult, of both sexes, observing the conformation of the nerve, number of branches, disposition with regard to the internal pudendal vessels and sacrotuberous and sacrospinous ligaments, also recording its external diameter in the distance between greater sciatic foramen and lesser sciatic foramen. The pudendal nerve appeared as a single trunk in 53.3 percent of the cases and divided in branches in 46.7 percent (two branches in 36.7 percent, three in 6.7 percent and four in 3.3 percent). When it was divided, in 36,7 percent the branches remained separated and in 10 percent they joined before the lesser sciatic foramen. The nerve (single or divided) was medial to the internal pudendal vessels in 70 percent and lateral to them in 3.3 percent. In 26.7 percent, it was divided in two or three branches, which were located medially and laterally to these vessels or crossing posterior to them. Its position was anterior to the sacrotuberous ligament in 93.3 percent. The pudendal nerve presents interesting variations in its conformation and topography which must be considered during the clinical and surgical procedures.

Aneurisma verdadero en arteria ciática persistente: caso clínico / Persistent sciatic artery aneurysm: a case report

We report the case of a 71 years old female patient, who had a partially thrombosed true aneurysm in a persistent sciatic artery (PSA), treated in the Surgery Department of Hospital Dr. Eduardo Pereira of Valparaiso. The sciatic artery arises from the umbilical artery and during early embryological state is the main blood supply of the lower limbs. Later, the superficial femoral artery appears with the subsequent progressive involution of the sciatic artery. PSA is a rare congenital vascular anomaly that occurs when sciatic artery fails to regress during fetal development. This is associated with superficial femoral artery hipoplasia and the PSA becomes the dominant arterial inflow to the lower limb. This anatomic abnormality may be bilateral and can remain asymptomatic for many years, however, it has been described aneurysmal degeneration, like in this case, symptoms of sciatic nerve compression, aneurysm thrombosis and distal embolization.

Se reporta el caso de una paciente de 71 años, que presenta un aneurisma verdadero, parcialmente trombosado, en una Arteria Ciática Persistente (ACP), tratada en el Servicio de Cirugía del Hospital Dr. Eduardo Pereira de Valparaíso. La arteria ciática se origina en la arteria umbilical y durante las primeras fases embriológicas es el principal aporte sanguíneo de la extremidad inferior. Posteriormente aparece la arteria femoral superficial y se produce la progresiva involución de la arteria ciática. La ACP constituye una rara anomalía y ocurre por la falta de desarrollo de la arteria femoral superficial. La ACP se origina en el adulto en la arteria hipogástrica, transcurre hacia la región glútea a través de la escotadura ciática y sigue hacia distal por la parte posterior del muslo continuándose después con la arteria poplítea. Se acompaña de un variable menor desarrollo del eje arterial anterior de la arteria ilíaca externa y femoral superficial. Esta anomalía anatómica puede ser bilateral y puede permanecer asintomática durante muchos años, sin embargo, se ha descrito la degeneración aneurismática, como en este caso, y síntomas por compresión del nervio ciático, trombosis del aneurisma y embolización distal.

Anatomical study of the superior gluteal artery perforator (S-GAP) for free flap harvesting.

OBJECTIVE: To present the appropriate superior gluteal branch for free flap harvesting. MATERIAL AND METHOD: The characteristic and external diameter of the pedicles and the main perforators, and length of the pedicles were studied in both sides of 30 formalin-preserved cadavers. RESULTS: The patterns of the pedicle could be classified into four types, the vertical, the horizontal, the descending, and the penetrating main branches. The descending branch was the longest (7.33 +/- 1.3 cm). While the pedicle and perforator of the horizontal branches was the largest (2.7 +/- 0.6 mm and 1.2 +/- 0.2 mm, respectively). However, it was difficult to dissect the vertical and the horizontal branches because the vessel courses did not run in the direction of the muscle fiber. Whereas the penetrating main branches were observed in the intermuscular septum so, it was easy to approach the pedicle. The length (5.3 +/- 1.3 cm) and external diameter (2.17 +/- 0.5 mm) of the pedicle were adequate for free flap harvesting. CONCLUSION: In the anatomical study the penetrating pedicle was recommended to use for the S-GAP flap.

Anomalous Branch of Internal Pudendal Artery / Rama Anómala de la Arteria Pudenda Interna

The ischiatic artery classically described as a branch of the inferior gluteal artery, is a long and thin vessel that is related to the ischiatic nerve. In a dissection was observed that this artery emerges from the internal pudendal artery with a caliber larger than the ones described in the literature. The knowledge of anatomical variations is important to the surgeons, radiologists and anatomists.

La arteria isquiática se describe clásicamente como una rama de la arteria glútea inferior, es un vaso largo y delgado que se relaciona con el nervio isquiático. En una disección se observó que esta arteria surge de la arteria pudenda interna con un calibre más grande que lo descrito en la literatura. El conocimiento de variaciones anatómicas es importante para los cirujanos, radiólogos y anatomistas.

Absence of Inferior Gluteal Artery: A Rare Observation / Ausencia de la Arteria Glútea Inferior: Una Rara Observación

The gluteal region is an important anatomical and clinical area which contains muscles and vital neurovascular bundles. They are important for their clinical and morphological reasons. In this manuscript we report a rare case of absence of inferior gluteal artery. In the same specimen the superior gluteal artery was taking origin from the anterior division of internal iliac artery. The structures normally supplied by the inferior gluteal artery were supplied by a branch coming from the superior gluteal artery. The developmental and clinical significance of the anatomical variation is discussed.

La región glútea es una importante área anatómica y clínica, la cual contiene músculos y vitales elementos neurovasculares. Estos últimos son importantes por razones clínicas y morfológicas. En este trabajo describimos un raro caso de ausencia de la arteria glútea inferior. Encontramos también que la arteria glútea superior tenía su origen en la división anterior de la arteria iliaca interna. Las estructuras irrigadas normalmente por la arteria glútea inferior estaban irrigadas por una rama que se originaba de la arteria glútea superior. Son discutidos el desarrollo y el significado clínico de esta variación anatómica.

anatomical study of the relation between the descending branch of the inferior gluteal artery and the posterior cutaneous nerve of the thigh

The gluteal thigh flap is a myofascio-cutaneous flap receiving its blood supply from a descending branch of the inferior gluteal artery. The superior and inferior myocutaneous gluteal free flaps have been considered as valuable alternatives to the latissimus dorsi or TRAM flap since 1975. The purpose of this study was to gain a better understanding of the anatomical relationship between the posterior cutaneous nerve of the thigh, and the descending branch of the inferior gluteal artery. Twenty four posterior thigh specimens of adult human cadavers were dissected after latex injection of the internal iliac artery. The inferior gluteal artery and the posterior cutaneous nerve of the thigh were carefully dissected. The relation between the descending branch of inferior gluteal artery and the posterior cutaneous nerve of the thigh was studied and photographed. The external diameter and the length of the descending branch of the inferior gluteal artery were measured. The inferior gluteal artery gave off a descending branch that is accompanied by the posterior cutaneous nerve of the thigh. The descending branch was observing in all cadavers dissected. Its average external diameter was 0.3 +/- 0.07mm and it was arising about 7.15 +/- 0.68cm away from the tip of the greater trochanter of the femur. In 5 lower limbs [20.8%] the descending branch was passing medial to the posterior cutaneous nerve of the thigh. In the remaining cadavers the descending branch of the inferior gluteal artery was passing lateral to the posterior cutaneous nerve of the thigh in 19 out of 24 specimens [79.2% of lower limbs]. It was descending below the gluteal fold with the posterior cutaneous nerve of the thigh in a common connective tissue sheath in 21 out of 24 specimens. In all dissected lower limbs, one or two cutaneous branches of the descending branch of inferior gluteal artery and one or two cutaneous nerves were supplying the infragluteal perforator flap. Loop of nerves was found surrounding the inferior gluteal artery and its descending branch in 3 out of 24 lower limbs [12.5%]. Knowledge of the vascular anatomy extends the clinical applicability of the posterior thigh fasciocutaneous flap to patients who might otherwise be excluded because of prior injury or operative procedure

Rabdomiólise por síndrome compartimental glútea após cirurgia bariátrica: relato de caso / Rhabdomyolysis secondary to gluteal compartment syndrome after bariatric surgery: case report

JUSTIFICATIVA E OBJETIVOS: A cirurgia bariátrica tornou-se rotineira e muitas complicações têm sido relatadas. O objetivo deste relato foi apresentar um caso de síndrome compartimental glútea que evoluiu para insuficiência renal aguda após cirurgia bariátrica e discutir aspectos do diagnóstico e condutas profilática e terapêutica. RELATO DO CASO: Paciente do sexo masculino, 42 anos, branco, índice de massa corporal (IMC) 43, estado físico ASA II, submetido à cirurgia bariátrica tipo duodenal switch, sob anestesia geral associada à anestesia peridural. O procedimento transcorreu sem intercorrências. O tempo anestésico-cirúrgico foi de 3 horas e 30 minutos. No primeiro dia do pós-operatório o paciente apresentou dor na região lombossacral e nas nádegas, além de parestesia nos membros inferiores na distribuição do nervo isquiático. Durante o exame, as nádegas apresentavam discreta palidez, tensas, edemaciadas, dolorosas à palpação e à movimentação. Foi diagnosticada síndrome compartimental glútea que evoluiu com rabdomiólise e insuficiência renal aguda. Houve recuperação da função renal e nenhuma seqüela motora ou sensitiva foi detectada. CONCLUSÕES: Os pacientes obesos mórbidos submetidos à cirurgia bariátrica podem apresentar síndrome compartimental glútea. Quando não diagnosticada e tratada precocemente, podem evoluir com rabdomiólise e insuficiência renal aguda que representam grave ameaça à vida.

Anatomia dos ramos fasciocutâneos das artérias glútea inferior, primeira e segunda perfurantes / Anatomy of fascio-cutaneous branches of the gluteal, first, and second perforator arteries

Com o objetivo de auxiliar na preparaçäo de um retalho para a reconstruçäo das glútea e perineal, foi realizado estudo da anatomia dos ramos fasciocutâneos das artérias glútea inferior, primeira e segunda perfurantes. Após a dissecçäo de 40 coxas de cadáveres frescos, constatou-se que a artéria glútea inferior cursa medial e posteriormente ao nervo isquiático; o ramo descendente fasciocutâneo era medial ao nervo cutâneo posterior da coxa em 87,5 por cento das peças, com diâmetro médio de 0,61mm, situando-se ao lado da tuberosidade isquial à distância média de 3,66cm. Os ramos fasciocutâneos da primeira e segunda artérias perfurantes foram também examinados e tinham em média 1,21mm e 1,01mm de diâmetro, respectivamente. As distâncias médias da primeira e segunda artérias perfurantes ao grande trocanter do fêmur eram de 6,23cm e 12,19cm, respectivamente. A área cutânea nutrida por cada uma das artérias foi avaliada por meio da injeçäo de corante. A artéria glútea inferior corou as regiöes medial e lateral superiores. A primeira artéria perfurante corou a regiäo médio-lateral, a porçäo proximal da regiäo médio-medial e a porçäo distal das regiöes medial e lateral superiores. A segunda artéria perfurante nutria a porçäo distal das regiöes médio-medial e médio-lateral e a porçäo proximal da regiäo lateral inferior

Origin, course, distribution of the superior gluteal nerve and its relation to the superior gluteal artery and gluteal muscles

Ten pelvic halves of five Egyptian male cadavers were dissected in order to obtain a precise anatomical knowledge of the origin, course and distribution of the superior gluteal nerve and its relation to the corresponding artery. The more anterior parts of the glutei medius and minimus were innervated by branches of the superior gluteal nerve that were revealed to originate more cranially, and the tensor fasciae latae was innervated by the cranialmost element of the nerve. Based on these findings, it might be proposed that the course and distribution of the superior gluteal nerve are directly influenced by the anterior rotation of the gluteus medius

Aneurysm of the gluteal artery

One case of atherosclerotic gluteal artery aneyrysm (GAA) is presented. The diagnosis was made pre-operatively, and treatment involved ligation and division of the internal iliac artery only. This therapeutic option is discussed as the perferred one compared to the conventional two-step procedure

Pseudoaneurisma da artéria glútea superior esquerda: relato de um caso / False aneurysm of gluteal left superior artery: report of a case

Os autores relatam um caso de pseudoaneurisma da artéria glútea superior esquerda, analisando os métodos de diagnóstico, chamando a atençäo para o diagnóstico diferencial dos tumores localizados na regiäo glútea, descrevendo a técnica operatória e discutindo o caso.