Anatomy, Abdomen and Pelvis, Internal Iliac Arteries


Article Author:
Nicolas Zaunbrecher


Article Editor:
Navdeep Samra


Editors In Chief:
Jasleen Jhajj
Cliff Caudill
Evan Kaufman


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
1/26/2019 9:14:06 PM

Introduction

Before discussing the blood supply to the pelvis, one must first know the origin of the larger vessels located upstream. The abdominal aorta travels toward the pelvis and bifurcates into the common iliac arteries which subsequently bifurcate into the internal and external iliac arteries. The internal iliac arteries (IIA) supply the majority of the pelvis and the structures within, and the external iliac artery continues down to supply the lower extremities. The arteries within the pelvis can have numerous variations and these become important during surgery within the pelvis.

Structure and Function

The abdominal aorta bifurcates at the fourth-fifth lumbar vertebra into the right and left common iliac arteries. After about 3 to 4 cm, the common iliac arteries will bifurcate again anterior to the sacroiliac joint, and they become the internal and external iliac arteries.[1][2] The internal iliac artery after the pelvic brim continues down inferomedially and has two parts which split at the upper margin of the greater sciatic foramen into the anterior trunk which supplies the pelvis, visceral organs, and posterior trunk which supplies the parietal structures.[1][2] The origin of the anterior division begins about 2.5-3.5 cm from where the IIA begins, and the posterior branch of IIA takes off before the anterior division.[2]

Embryology

In embryonic development, the cardiovascular system is the first major system to function in the embryo due to the necessity of having an adequate transport vessel for the delivery of oxygen to the growing cells. In the middle of the third week of embryonic development, the primordial heart and vascular system appear. The common iliac arteries bifurcate into internal and external iliac arteries at L5-S1 in adults.[3] In the 1st trimester the bifurcation level is at S1, but at full term, the location of most of the bifurcations is at L5, indicating that in the early fetal period the bifurcation level of the common iliac artery is more inferior compared to adults.[3] During fetal development, the internal iliac artery derives from the umbilical artery. The proximal aspect of the umbilical artery persists throughout development, but the distal end gets obliterated postnatally. Numerous variations can occur in a vascular pattern of the IIA.[4]

Blood Supply and Lymphatics

In general, the IIA supplies the pelvic wall, pelvic viscera, perineum, and the gluteal region. The internal iliac artery (IIA) starts at the level of the sacroiliac joint once the common iliac artery divides into the external and internal iliac branches. The internal iliac artery then divides again near the upper border of the greater sciatic foramen into an anterior and posterior division. The anterior division branches are the superior vesical, obturator, middle rectal, inferior vesical artery and internal pudendal artery. In females, the inferior vesical artery is replaced by the vaginal artery and gives an additional branch which is the uterine artery. Posterior division branches are iliolumbar, lateral sacral, and superior gluteal arteries. Among the various arteries that come from the internal iliac artery, many anomalies can occur.[4] 

Extra-pelvic branches of the internal iliac artery supply regions of the thigh located anteromedial and posterior, hip joint, and gluteal region.[5]

Visceral branches of the internal iliac artery in a man supply:

  • Rectum
  • Urinary bladder
  • Seminal vesicles
  • Ejaculatory ducts

Visceral branches of the internal iliac artery in a female supply:

  • Vagina
  • Uterus
  • Gonads
  • Rectum
  • Urinary bladder
  • Urethra[5]

The organs that the lymphatic system drains in the pelvis is the digestive tract, urinary organs, and genital organs. These organs have afferent lymph vessels that flow towards the nodes, and once it reaches the nodes, efferent vessels arise and take the lymphatic fluid to lymphatic collectors located superior to the nodes.[6]  The lymph nodes and lymphatic vessels travel along the common iliac artery, the internal iliac artery, and external iliac artery.[6]

Muscles

The internal iliac artery supplies the gluteal muscles, pelvic viscera, perineum, and pelvic walls. The anterior division is more involved with territorial blood supply to the pelvic viscera, and the posterior division provides blood flow to the gluteal region and body wall.[4]

Physiologic Variants

One must be aware of the several types of anatomical variations that may present during a surgical procedure. The first significant variance is that the internal iliac artery origin varies and depends on several factors such as the length of the common iliac artery and when the internal iliac artery bifurcates. It can be at the level of the L5-S1 and S1 intervertebral disk and anterior to the sacroiliac joint.[4]

The obturator artery (OA) can arise from:

  • the posterior branch of the internal iliac artery
  • the inferior epigastric artery
  • the inferior vesical artery

Iliolumbar artery can come directly from the trunk of the internal iliac artery.[4]

Surgical Considerations

  • When accessing the internal iliac artery in a female one must cut the pelvic peritoneum which is continuous with the broad ligament to visualize the retroperitoneal area. In the retroperitoneum, the internal iliac artery and the other great vessels of the abdomen are visible.[1]
  • Two vessels that can give some blood supply to the femoral head is the piriformis branch of the inferior gluteal artery and the obturator artery via the foveal artery. Many anatomical variations occur with the obturator artery with the most common one being the corona mortis (crown of death).[7]
  • The corona mortis is an anastomotic branch between the inferior epigastric and obturator vessels in the obturator canal. The other variation involves an accessory obturator artery arising from the external iliac artery and forming a connection with the obturator artery coming off of the internal iliac artery. The accessory OA can traverse over the superior pubic ramus creating a risk of injury during mesh attachment for hernia repair.[8] Another significance of the corona mortis during surgery is that compression of the internal iliac will not wholly stop bleeding from this anomalous artery since it is also receiving blood flow from the external iliac artery. However, compression of the internal iliac artery can still be used to control the contribution of blood flow that is coming from the IIA to the corona mortis.[9]
  • During surgery in the pelvis, another critical vessel to be mindful of is the location of the ureter which is located at the medial aspect of the internal iliac artery. The space between the ureter and the IIA is known as the para-rectal space. During a hysterectomy, the surgeon needs to be mindful when ligating the uterine artery (a branch of IIA) because the ureter passes beneath this artery and is at risk for injury.[1]
  • It is essential to attempt to ligate the internal iliac artery distal to the posterior branch. Experience shows that proximal ligation of the internal iliac artery can result in claudication of buttocks and also necrosis.[4]

Clinical Significance

In acute situations involving the pelvic region knowledge of the level of the bifurcation of the common iliac artery and the level of division of the internal iliac artery is of paramount importance. Unilateral or bilateral ligation of the internal iliac artery can be lifesaving in a variety of patients, such as massive postpartum hemorrhage, hemorrhage after a vaginal and abdominal hysterectomy, massive broad ligament hematoma, cervical carcinoma, and retroperitoneal bleeding following a pelvic fracture.[4]

When trying to control a bleed in the pelvis, bilateral ligation of the internal iliac arteries will reduce the pelvic arterial blood flow by 49%.  Collateral arterial circulation will make up for the blood that was previously being supplied by the internal iliac artery. The main artery that collateral circulation comes from is the deep femoral artery. [2] Various anastomoses aid in re-vascularizing the internal iliac artery area such as superior gluteal artery and lateral femoral circumflex artery, obturator artery and medial femoral circumflex artery. In females, blood flow to the uterus via the ovarian artery and after bilateral internal iliac artery ligation reproduction potential is not affected, and it is still possible to have term pregnancies in many cases.[2]

Knowing the anatomical course of the ureter is vital because during acute situations to control hemorrhage damage to the ureter can occur. The ureter which is usually laying on the surface of the internal iliac artery requires identification before ligation performed.[4]

An anomalous origin of the obturator artery from the posterior division becomes vital because if damage occurs to the anterior branch of the internal iliac artery the blood supply to the head of the femur would not be affected.[4]


  • Image 2140 Not availableImage 2140 Not available
    Contributed by Gray's Anatomy Plates
Attributed To: Contributed by Gray's Anatomy Plates

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Anatomy, Abdomen and Pelvis, Internal Iliac Arteries - Questions

Take a quiz of the questions on this article.

Take Quiz
The lower one-third of the anal canal differs from the rest of the anal canal in that it is ectodermal in origin, and therefore the epithelium is non-keratinized squamous epithelium. Superior to the pectinate line the epithelium is columnar. Blood supply superior and inferior to the pectinate line is also different. The anterior branch of the internal iliac artery supplies inferior to the pectinate line. Which artery from the anterior branch supplies the anal canal below the pectinate line?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 50-year-old male comes to the emergency department following a motor vehicle collision (MVC). The patient arrived unconscious with a blood pressure of 70/40 mmHg. After an x-ray of the patient's pelvis, a fracture is discovered. Which of the following structures would most likely have reduced blood flow if the internal iliac artery was transected?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 17-year-old male comes to the emergency department following a gunshot wound to his medial right thigh. A CT angiography scan reveals both an external and internal iliac artery bilaterally, and the external iliac artery quickly tapered into muscular soft tissue beds. A physical exam was performed, and the patient has 2+ dorsalis pedis artery, and popliteal artery pulses and the right leg appears to be adequately perfused. Upon further examination, the femoral pulses are absent bilateral. Patient has stable vitals and minimal blood loss. What is the most probable diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A first-year student is in the cadaver lab and is dissecting the pelvis. The instructor asked the student to point out the bifurcation of the internal iliac artery. Which location correctly identifies the bifurcation of the internal iliac artery in the majority of people?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Anatomy, Abdomen and Pelvis, Internal Iliac Arteries - References

References

Selçuk İ,Yassa M,Tatar İ,Huri E, Anatomic structure of the internal iliac artery and its educative dissection for peripartum and pelvic hemorrhage. Turkish journal of obstetrics and gynecology. 2018 Jun;     [PubMed]
Selçuk İ,Uzuner B,Boduç E,Baykuş Y,Akar B,Güngör T, Step by step ligation of internal iliac artery Journal of the Turkish German Gynecological Association. 2018 Nov 30;     [PubMed]
Ozgüner G,Sulak O, Development of the abdominal aorta and iliac arteries during the fetal period: a morphometric study. Surgical and radiologic anatomy : SRA. 2011 Jan;     [PubMed]
Mamatha H,Hemalatha B,Vinodini P,Souza AS,Suhani S, Anatomical Study on the Variations in the Branching Pattern of Internal Iliac Artery. The Indian journal of surgery. 2015 Dec;     [PubMed]
Wolfram-Gabel R, [Anatomy of the pelvic lymphatic system]. Cancer radiotherapie : journal de la Societe francaise de radiotherapie oncologique. 2013 Oct;     [PubMed]
Zlotorowicz M,Czubak-Wrzosek M,Wrzosek P,Czubak J, The origin of the medial femoral circumflex artery, lateral femoral circumflex artery and obturator artery. Surgical and radiologic anatomy : SRA. 2018 May;     [PubMed]
Al Talalwah W, A new concept and classification of corona mortis and its clinical significance. Chinese journal of traumatology = Zhonghua chuang shang za zhi. 2016 Oct 1;     [PubMed]
Karkare N,Yeasting RA,Ebraheim NA,Espinosa N,Scheyerer MJ,Werner CM, Anatomical considerations of the internal iliac artery in association with the ilioinguinal approach for anterior acetabular fracture fixation. Archives of orthopaedic and trauma surgery. 2011 Feb;     [PubMed]
Fătu C,Puişoru M,Fătu IC, Morphometry of the internal iliac artery in different ethnic groups. Annals of anatomy = Anatomischer Anzeiger : official organ of the Anatomische Gesellschaft. 2006 Nov;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Optometry-Basic Science. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Optometry-Basic Science, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Optometry-Basic Science, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Optometry-Basic Science. When it is time for the Optometry-Basic Science board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Optometry-Basic Science.