| BackgroundCorona Mortis artery, also named as aberrant obturator artery, is a vascular connection between the external iliac system and obturator artery, and located behind the superior pubic ramus. The name of "crown of death artery" means its anatomical importance, as once injured due to pelvic and acetabula fractures or during surgeries, immediate massive hemorrhage or secondary hemorrhage may occur, which are very difficult to control.In recent years, there are more than ten reports by scholars about Corona Mortis artery.Most of the researches were based on anatomical method. This method,with the advantages of objectivity being intuitive, can derictly show the vessels’f shape and the relationship with other anatomical structures, but, due to the limited source of cadavers, a large sample size research about this vascular is difficult to perform, and anatomy method can’t reflect living alters under physiological state. In recent years, some scholars made use of laparoscopic, Digital Subtraction Angiography (DSA), computerized tomography angiography (CTA)to study this vascular. Although DSA is the "gold standard" for vessel examination, but it’s invasive, expansive, the images are affected by overlapping of vasculars, which has much bearing on the understanding of vascular anatomy, and it’s with multiple complications, besides all above, most researches using DSA and laparoscopic methods only involved half-pelvis, can’t compare the incidences between the two sides. Another important reason is both the two methods are invasive, the usage in scientific research is stuck with ethics. In the past few years, along with the innovation of CT equipment and related reconstruction software, CTA has been widely used in the clinic as a noninvasive and fast vessel examine technology, it’s with great scientific research value, and had already been used in the study of Corona Mortis artery by several foreign scholars. Currently, as for the Corona Mortis artery of Chinese, the researches were limited to anatomical and laparoscopic methods, no researches using CTA method have been reported.Pelvic fractures are often with a higher mortality rate (6.4%-12%), and the mortality depends primarily on the severity of the associated injury, almost half of the pelvic fractures patient’s death are caused by bleeding. Pelvic fractures may cause fatal haemorrhage, usually involves iliac arterial branches, including the lateral branch, iliac waist branch, obturator branch, bladder branch, and superior gluteal branch, Corona Mortis artery as a variation of obturator artery is also one of the potentially dangerous sources of bleeding.What’s more, Corona Mortis artery blood vessels is also an extremely important vessel both for iliac inguinal approach and Stoppa approach during pelvic and acetabulum surgery. Most of the time, as for ilioinguinal approach, doctors are more familiar with the anatomy location of external iliac vessels and femoral nerve during the operation, so they can offer good protection to these structures, rarely cause damage. However due to the fact that the Corona Mortis artery is a variant branch, whose anatomical morphology is not known by most doctors, thus they are easily be injured and will cause massive bleeding, if the surgeon operating on the superior pubis ramus region without considering the possibility of Corona Mortis artery’s existence, what’s worse, the hemorrhage may be hard to control because this artery crossing the surface of superior pubis ramus, running down into the obturator formamen and forming an anastomosis branch with obturator artery. Although Corona Mortis vessels can be well revealed and handled through modified Stoppa approach, the surgeon must be clear with the location of it and the dangerous zone of being injured. During the operation, after splitting rectus abdominis, cutting up the outs clearance of peritoneal, in order to avoid the injury to peritoneum, we usually tend to separate along the fracture hematoma to the deep, where you are likely to encounter Corona Mortis vessels.And as the vessels are adjacent to the quadrilateral body, fixed by the obturator membrane, sometimes may be covered or parceled by the hematoma, hence, it is necessary to operate carefully, separating and ligaturing the artery immediately, once discovered.Recently, digital orthopedics science as an emerging subject, gaining a good development, has become a frontier discipline, which provides a new effective and convenient method for the research on orthopaedic realm, it has played an important role no matter to the personalized design in clinic surgery or to the anatomical research,.Digital orthopedics owns the advantages of well repeatability, big sample size, three-dimensional visualization, personalization, etc, with it we can observe and research the anatomic forms of human’s bone and arteries in3-D space, even to the pelvic anatomy, which is quite complicated, with the advanced equipment and digital orthopaedic software, we can also get its complete and highly emulational three dimensional anatomic images.Medical imaging intercrossing (Mimics10.01) control system is one of the most, widely used digital orthopedic software, in the field of orthopedics, many scholars use this software to research bone tissues, however, few scholars apply it into the research of blood vessels related to bones, we combined CT examination and Mimics software in this study, built a large number of accurate3-D digital models, and successfully built the3-D visualization of Corona Mortis artery images. This study aims to analyze Corona Mortis artery existence rate, origin, location and its existence pelvic CTA original data (160half-pelvis) on3-D images reconstructed by Mimics10.01software, and the relationship between age and the for pelvic acetabulum fracture surgery iliac groin and Stoppa access to provide the anatomical basis.Objective1. Reconstructed original data of abdominal aorta CTA with Mimics10.01 software.2. To investigate the incidence, origin, location of Corona Mortis artery and measure the distance between the superior pubis ramus and the pubic symphysis edge by means of3D reconstruction of computerized tomography angiography (CTA), with a purpose of providing a preoperative anatomical aid for the treatment of pelvic and acetabular fractures via ilioinguinal and Stoppa approaches.3. To discuss the relationship between the incidence of Corona Mortis artery and age.4. To discuss the value and significance of abdominal aorta CTA inspection in pelvic and acetabular anterior approaches as preoperative examination.Methods1. Collection of images and reconstruct the3-dimensional model of pelvisWe collected original data (. DICOM fromat) eligible for the present study from50patients (100hemi-pelvises) who had undergone abdominal aorta CTA (limited to abdominal and pelvic area) at the Medical Imaging Center of Nanfang Hospital from December2010to May2012.All cases were exclded pelvic and abdominal injury history, they were34males and46females, aged from19to84years (average,47.21years). Of them,49were below50years old and31above50years old. The reasons for undergoing CTA included gynecological diseases (43cases), lower limb vascular disease (22cases) and orthopaedic diseases (15cases). Equipments:the dual-source CT (SOMATOM Definition) produced by Siemens company Germany, contrast medium:nonionic contrast agent (iopromide, Ultravist370, Bayer Schering Pharma, Berlin-Wedding, Germany) Ultravist (370mgL/mL, Germany Schering Guangzhou pharmaceutical co., LTD.). Scanning conditions:voltage120kV, tube current320mA, Scanning layer thickness5mm, interlamellar spacing5mm, matrix512x512.2. Reconstructing3-D model of pelvises including arteriesImporting the CTA original data(.DICOM format) into personal computer system, medical imaging intercrossing control system (Mimics10.01, Belgium) was used, defining the threshold as110Hu-1593Hu, then select regional growth for3-D reconstruction. 3. Observation Corona Mortis artery in the3-D reconstruction pelvis modelInclusion criteria:the cases that abdominal arteries can be observed clearly on the3-D reconstruction pelvis model in this research was included, observatiing the arteries crossing the surface of superior pubis ramus into obturator (Corona Mortis artery), recording the origin, shape and numeber of the artery.4. Measuring the position of the Corona Mortis arteryMeasuring the distance between the point Corona Mortis artery crossing the superior pubis ramus to the edge of the pubic symphysis with Measure3-D Distance function in Mimics software, and recording the results.5. Statistics and analysisFor statistical evaluation,the experimental data was analyzed with the use of SPSS13.0software, the chi-squared test was used to analyze different incidences of Corona Mortis arteries between the two hemi-pelvises, two genders and two age groups (<50versus>50), and P<0.05was considered significant.Results3-D CTA reconstruction images distinctly demonstrated the full smooth morphology of pelvic arterial system, can show common iliac artery, internal artery, external iliac artery and their first level branch artery very clearly, as well as the origin and shape of the superior epigastric artery and abnormal obturator artery what’s more, we can resizing the3-D images of at will, rotate the pelvis in multi-dimension in order to faciliate observation.In terms of hemi-pelvis, the incidences of Corona Mortis artery was18.1%(29/160),17.5%(14/80) on the left and18.8%(15/80) on the right,17.4%(16/92) in females,19.1%(13/68) in males, respectively. There were no significant differences between hemi-pelvises (x2=0.042, P=0.837, P=0.799) or genders (x2=0.079, P=0.779).14hemi-pelvic Corona Mortis arteries were found in the age group≤50years the incidence was14.3%(14/98),15in the age group>50years,with the incidence of24.2%(15/62). There were no significant differences between the two groups (χ2=.2512, P=0.113). The Corona Mortis arteries all originating from the external iliac artery, running vertically downward into the obturator formamen, along the surface of superior pubis ramus,the average distance between the point Corona Mortis artery crossing the superior pubis ramus to the edge of the pubic symphysis was (53.70±4.00)mm..Conclusions1.3-D CTA images reconstructed by Mimics software can clearly demonstrate Corona Mortis artery2. Abdominal aorta CTA should be routinely performed before operative treatment of pelvic and acetabula fractures via the ilioinguinal and Stoppa approaches to ensure no operative accidents will occur due to the presence of Corona Mortis artery.3. We should be alert to the variation of this variation artery, when stripping the area of suprapubic,(53.70±4.00) mm to the edge of pubic symphysis.4. Further large-scale researches should be carried out to determine the associations of Corona Mortis artery with age and other possible factors. |
PDF Full Text Request