Presence of Abnormal Obturator Artery and an Abnormal Venous Plexus at the Anterolateral Pelvic Wall

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Presence of abnormal obturator artery and an abnormal venous Anatomy plexus at the anterolateral pelvic wall SB Nayak1, SD Shetty1*, P Shetty1, R Deepthinath1, BM George1, S Mishra1, SR Sirasanagandla1, N Kumar1, P Abhinitha1

Abstract wall, accompanied by the OV and ON. cases, from the inferior gluteal or Introduction It leaves the pelvis by passing through internal pudendal arteries in 10% of Obturator artery (OA) is a branch of the obturator foramen. In the thigh, it cases and from the external iliac artery anterior division of the internal iliac supplies the muscles of the adductor in 1.1% of cases1. Its origin from the artery (IIA). It is accompanied by the compartment. It is accompanied by OV posterior division of the internal iliac obturator vein (OV) which terminates which terminates into IIV. In about artery has also been reported2. In some 20-25% cases, OA arises from IEA cases, an additional obturator artery is

into the internal iliac vein (IIV). In about 20-25% cases, OA arises from instead of IIA and then it is called seen supplementing the normal OA. the inferior epigastric artery (IEA) AOA. Such an artery is called accessory OA3. instead of the internal iliac artery Lateral wall of the pelvis has the Accessory OA is found to be present in (EIA) and then it is called an abnormal obturator internus muscle, covered by 30-40% of cases4,5. When both the obturator artery (AOA). Normally we the obturator fascia. The levator ani normal and accessory OA are present do not find a venous plexus on the muscle arises from the tendinous arch with rich anastomoses at the obturator lateral wall of the pelvis. of the fascia covering the obturator canal it is known as “corona mortis” or Case report internus muscle. Normally there is no “crown of death”6. In other words, it is We report the presence of an AOA venous plexus in the anterolateral the anastomosis between the pubic

arising from IEA. AOA was wall of the pelvis. ramus of the IEA and the OA. accompanied by an abnormal There are reports on the existence of obturator vein (AOV) which Case report a venous corona mortis also. It is more terminated into the inferior epigastric We report the vascular variations frequent than the arterial corona vein (IEV). In addition, there was a observed in the left half of the pelvis mortis6,7. In a study conducted by normal OV accompanying the of an adult male cadaver aged Darmanis et al., a very high incidence of obturator nerve (ON). It terminated approximately 70 years. The lateral either arterial or venous corona mortis by opening into the internal iliac vein wall of the pelvis had the ON and OV, was noted8. Rusu et al., have classified

(IIV). Further there was a prominent but normal OA was absent. AOA arose the venous corona mortis into three preparation, read and approved the final manuscript. manuscript. final the approved and read preparation,

venous plexus in relation to the from IEA and coursed backwards, types. In type I, OV drains into EIV; in t anterolateral wall of the pelvis. This crossed the superior ramus of the type II, OV drains into IEV and in type plexus communicated with prostatic pubis and entered the obturator III, OV anastomoses with IEV9. The and vesical venous plexuses foramen (Figure 1 and Figure 2). venous plexus that we are reporting anteriorly; inferior epigastric vein AOA was accompanied by AOV here does not belong to any of the (IEV) and external iliac vein (EIV) which terminated into IEV. The above categories. superiorly; and OV posteriorly. normal OV which accompanied the The area of the pelvic brim and lateral Conclusion ON, terminated by opening into IIV. pelvic wall is very important and it is the anchoring site for the repair of Knowledge of presence of AOA is very Further there was a prominent venous declared. None interests: of Conflict handy in reducing the strangulated plexus in relation to the anterolateral inguinal and femoral hernias. During femoral hernia. Knowledge of wall of the pelvis (Figure 1 and Figure surgery, the abdominal muscles are possibility of an abnormal venous 2). This plexus communicated with retracted laterally by applying pressure plexus on the lateral pelvic wall is prostatic and vesical venous plexuses on the lateral pelvic wall. Hence a very important in pelvic surgeries. anteriorly; IEV and EIV superiorly; good knowledge of arterio-venous and OV posteriorly. variations in this area is very important Introduction for surgeons10. OA is usually a branch of the anterior Discussion Knowledge of the current variations is division of internal iliac artery (IIA). It Variations in the origin of OA are not quite useful in Burch procedure, as they runs forwards on the lateral pelvic uncommon. It originates from might bleed significantly in this common iliac or anterior division of procedure11. The venous plexus that is being reported here is more dangerous

*Corresponding author the internal iliac artery in 41.4% of

All authors contributed to conception and design, manuscrip design, and conception to contributed authors All disclosure. of rules ethical (AME) Ethics Medical for Association the by abide authors All Email: [email protected] cases, from the inferior epigastric than the earlier mentioned venous declared. None interests: Competing corona mortis due to its extensive 1 artery in 25% of cases, from the Manipal University, Manipal, India superior gluteal artery in 10% of communications. It might bleed

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FOR CITATION PURPOSES: Nayak et al. Presence of abnormal obturator artery and an abnormal venous plexus at the anterolateral pelvic wall. OA Case Reports 2014 May 15;3(5):49. Page 2 of 2

Case report

significantly during orthopaedic and surgical procedures of this region and also can transmit the prostatic cancer to many regions.

Conclusion Though the occurrence of abnormal OA is not very uncommon, it is extremely rare to find a venous plexus on the anterolateral pelvic wall. This plexus might spread the prostate cancer in different directions and might bleed in surgical procedures involving lateral pelvic wall.

References 1. Bergman RA, Thompson SA, Afifi AK. Compendium of human anatomic Figure 1: Anterolateral wall of the left hemipelvis as seen from variations. Munich, Urban and above. (EIA – external iliac artery; EIV – external iliac vein; ON – Schwarzenberg. 1988; 84. obturator nerve; OV – obturator vein; PLX – abnormal venous plexus; 2. Kumar D, Rath G. Anomalous origin VD – vas deferens; AOV – abnormal obturator vessels; IEV – inferior epigastric vessels; RAM – rectus abdominis muscle; DCIV – deep of oburator artery from the internal circumflex iliac vessels; TV – testicular vessels). iliac artery. Int J Morphol. 2007; 25: 639–641. 3. Moore KL, Agur AMR. Thigh and gluteal region. In: Essential clinical anatomy. 3rd Ed., Philadelphia, Lippincott William and Wilkins. 2007; 332–397. 4. Gray H. The blood-vascular system.

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813–814. t 6. Sarikcioglu L, Sindel M, Akyildiz F, Gur S. Anastomotic vessels in the retropubic region: corona mortis. Folia Morphol (Warsz). 2003; 62: 179-

182. Figure 2: Closer view of the abnormal obturator artery (AOA) 7. Berberoglu M, Uz A, Ozmen MM, originating from the inferior epigastric artery (IEA). (EIA – external

Bozkurt MC, Erkuran C, Taner S, Tekin iliac artery; EIV – external iliac vein; ON – obturator nerve; OV – Conflict of interests: None declared. declared. None interests: of Conflict

A, Tekdemir I. Corona mortis: an obturator vein; PLX – abnormal venous plexus; VD – vas deferens; anatomic study in seven cadavers and RAM – rectus abdominis muscle; TV – testicular vessels). an endoscopic study in 28 patients. Surg Endosc. 2001; 15:72–75. 10. Gilroy AM, Hermey DC, 8. Darmanis S, Lewis A, Mansoor A, DiBenedetto LM, Marks SC Jr, Page Bircher M. Corona mortis: an DW, Lei QF. Variability of the anatomical study with clinical obturator vessels. Clin Anat. 1997; 10: implication in approaches to the 328–332. pelvis and acetabulum. Clinical 11. Negura A, Andreescu G, Marderos Anatomy. 2007; 20: 433–439. GG, Marderos GH and Margarit L. 9. Rusu MC, Cergan R, Motoc AG, Hemorrhagic risks in the Burch Folescu R, Pop E. Anatomical procedure. Int Urogynecol J. 1993;4:

considerations on the corona mortis. 310–313.

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FOR CITATION PURPOSES: Nayak et al. Presence of abnormal obturator artery and an abnormal venous plexus at the anterolateral pelvic wall. OA Case Reports 2014 May 15;3(5):49.