What is the management for conditions affecting the inferior gluteal arteries?

Management of Conditions Affecting the Inferior Gluteal Arteries

For traumatic inferior gluteal artery injuries (pseudoaneurysms or active bleeding), endovascular embolization is the preferred first-line treatment, offering rapid hemorrhage control with minimal morbidity compared to open surgical approaches. 1, 2, 3

Clinical Presentation and Diagnosis

Traumatic Injuries (Most Common)

Inferior gluteal artery pathology typically presents following trauma—either blunt or penetrating—though blunt trauma cases are notably rare with only six reported in English literature prior to 2018. 1

Key clinical features to identify:

• Post-traumatic gluteal swelling or hematoma that may initially mimic gluteal abscess 2
• Significant hemoglobin drop indicating ongoing hemorrhage 1
• Pulsatile mass in the gluteal region (though not always present) 3
• Variable time to presentation: symptoms can emerge immediately or be delayed, with diverse clinical pictures 3

Diagnostic approach:

• CT angiography is the initial imaging modality of choice, revealing hematoma with contrast extravasation and pseudoaneurysm formation 1
• Formal angiography remains the diagnostic gold standard and enables simultaneous therapeutic intervention 2, 3
• Critical pitfall: Standard aortic flush angiography may miss inferior gluteal artery lesions; superselective angiography of the internal iliac branches is often required to delineate the anatomy 3
• Doppler ultrasound and MRI are alternative diagnostic tools but less definitive 2

Treatment Algorithm

For Acute Traumatic Pseudoaneurysms or Active Bleeding

1. Endovascular embolization (First-line, Class I equivalent based on outcomes):

• Coil embolization of the inferior gluteal artery is safe, fast, and effective 1
• Provides immediate hemorrhage control with minimal invasive morbidity 1, 2
• Can be performed during diagnostic angiography, reducing time to treatment 2
• Post-procedure management: ICU monitoring until hemodynamic stability confirmed 1

2. Open surgical repair (Reserved for embolization failure or unavailability):

• Historically used but associated with greater morbidity 3
• Consider only when endovascular approach fails or is not technically feasible 3

For Occlusive Disease (Aortoiliac Inflow Disease Context)

While the inferior gluteal artery itself is a branch of the internal iliac artery, gluteal claudication typically indicates proximal aortoiliac occlusive disease affecting blood flow to the internal iliac system. 4

Clinical recognition:

• Buttock and thigh claudication with diminished femoral pulses or femoral bruit should raise suspicion for inflow disease 4
• Bilateral internal iliac artery involvement may cause vasculogenic erectile dysfunction in men 4
• Confirm with noninvasive vascular laboratory studies demonstrating aortoiliac stenoses 4

Management hierarchy for symptomatic aortoiliac disease:

Initial conservative management (mandatory first step):

• Supervised exercise therapy 5
• Pharmacotherapy (cilostazol if no heart failure) 6
• Risk factor modification 6

Intervention only if:

• Vocational or lifestyle-limiting disability persists despite conservative therapy 4
• Never perform prophylactic intervention in asymptomatic patients 4, 6

Revascularization approach when indicated:

1. Endovascular intervention preferred for focal aortoiliac disease with favorable risk-benefit ratio 4
2. Stenting is effective as primary therapy for common and external iliac artery stenoses/occlusions 4
3. Aortobifemoral bypass for diffuse aortoiliac disease in surgical candidates unresponsive to conservative or endovascular options 4

For Iatrogenic or Surgical Considerations

During pelvic/sacral tumor resection:

• Computer-assisted navigation systems can visualize and preserve the inferior gluteal artery at the greater sciatic notch, maintaining gluteus maximus perfusion 7
• Preservation reduces postoperative complications related to flap insufficiency 7

Anatomical Variants

Rare anatomical considerations:

• Atypical inferior gluteal arteries may pass through the piriformis muscle rather than below it 8
• Such variants could theoretically cause ischemic symptoms in the lower buttocks and proximal posterior thigh if compressed, though clinical significance remains speculative 8

Critical Pitfalls to Avoid

• Misdiagnosing pseudoaneurysm as abscess: Always maintain high clinical suspicion for vascular injury in post-traumatic gluteal swelling 2
• Inadequate angiographic technique: Standard aortic imaging may miss inferior gluteal lesions; demand superselective views 3
• Premature surgical intervention: Endovascular embolization should be attempted first for traumatic injuries 1, 2
• Intervening on asymptomatic stenoses: This provides no benefit and carries unnecessary risk 4, 6
• Bypassing conservative therapy: Exercise and pharmacotherapy must be trialed before revascularization for claudication 4