What is the management of conditions affecting the superior gluteal artery?

Management of Superior Gluteal Artery Conditions

For traumatic superior gluteal artery injury with active bleeding, urgent angiography with transcatheter embolization is the treatment of choice, as it provides definitive hemorrhage control while avoiding the morbidity of difficult surgical access to this deep pelvic vessel. 1, 2, 3

Acute Traumatic Injury

Clinical Presentation and Diagnosis

• Superior gluteal artery (SGA) injury typically occurs with pelvic fractures (particularly posterior pelvic ring or acetabular fractures) or direct blunt buttock trauma, though it can rarely occur without fracture 1, 3

• Suspect SGA injury in patients with:

  • Hemodynamic instability refractory to resuscitation after pelvic trauma 1
  • Delayed onset shock (hours to days post-injury) following pelvic or lumbar vertebral fractures 1
  • Expanding gluteal hematoma or mass 4
  • Massive transfusion requirements with pelvic trauma 2

• Urgent CT angiography (CTA) is the diagnostic modality of choice to identify active arterial bleeding in hemodynamically stable patients 5

• Proceed directly to catheter angiography in hemodynamically unstable patients with high clinical suspicion, as it allows simultaneous diagnosis and treatment 2, 3

Treatment Algorithm

Primary Management:

• Transcatheter embolization is first-line therapy for confirmed SGA bleeding, using coil embolization or other embolic agents 1, 2, 4, 3

• Early angiography with intent to embolize any identifiable bleeding source is the optimal initial maneuver to prevent exsanguination in patients with extensive pelvic trauma and major blood requirements 2

• Embolization is preferred over surgery due to the deep anatomic location of the SGA at the greater sciatic notch, which makes surgical access extremely difficult and morbid 2, 3

Surgical Intervention:

• Reserve open surgery only for:
  • Failed embolization attempts
  • Patients too unstable to undergo angiography
  • Concurrent need for laparotomy or pelvic stabilization

Critical Pitfalls

• Do not miss delayed arterial bleeding: SGA injury can present with delayed massive hemorrhage hours to days after initial trauma, even when initial hemodynamics were stable 1

• Maintain high index of suspicion with any combination of pelvic fracture, lumbar vertebral fracture, or direct buttock trauma, even without initial instability 1, 3

• Avoid needle biopsy or aspiration of gluteal masses without first ruling out pseudoaneurysm with Doppler ultrasound or CT, as intervention can precipitate catastrophic hemorrhage 4

Chronic/Non-Traumatic Conditions

Pseudoaneurysm

• Post-traumatic pseudoaneurysms may present as delayed gluteal masses weeks to months after injury 4

• Diagnosis requires vascular imaging: Doppler ultrasound or CTA to confirm vascular nature before any intervention 4

• Treatment is transcatheter coil embolization, which successfully obliterates the pseudoaneurysm while preserving collateral flow 4

Atherosclerotic Stenosis (Buttock Claudication)

• Percutaneous transluminal angioplasty (PTA) with or without stenting is effective for symptomatic stenosis of the internal iliac or superior gluteal arteries causing buttock claudication 6

• Use coronary angioplasty equipment for these small-caliber vessels 6

• Consider intervention when buttock claudication significantly impairs quality of life and medical management has failed 6

Post-Intervention Care

• Antiplatelet therapy should be continued indefinitely after any revascularization procedure for peripheral arterial disease 5

• Serial clinical monitoring for recurrent symptoms, expanding hematoma, or hemodynamic changes in the acute post-trauma period 1

• Follow-up imaging may be warranted for pseudoaneurysms to confirm complete thrombosis after embolization 4