What are the management options for conditions affecting the obturator artery?

Management of Obturator Artery Conditions

For obturator artery injuries causing active hemorrhage, transcatheter arterial embolization (TAE) is the first-line treatment, achieving technical success in 100% of cases with no procedure-related complications, particularly in trauma settings. 1

Acute Hemorrhage Management

Traumatic Obturator Artery Injury

Immediate anticoagulation is contraindicated in active bleeding from obturator artery injury. 2 The management algorithm depends on hemodynamic stability and mechanism of injury:

For Penetrating Trauma (Gunshot Wounds, Iatrogenic Injury)

• Obtain computed tomographic angiography (CTA) immediately to identify the bleeding source, pseudoaneurysm formation, or contrast extravasation 3, 1
• Proceed directly to coil-embolization of the obturator artery if CTA demonstrates active bleeding or pseudoaneurysm 3
• A multidisciplinary approach involving trauma surgery, interventional radiology, and colorectal surgery is essential given the high mortality from concurrent rectal injuries in pelvic gunshot wounds 3

For Blunt Pelvic Trauma

• Look specifically for superior pubic ramus or pubic acetabulum fractures on imaging, as these warrant heightened suspicion for aberrant obturator artery (corona mortis) bleeding 1
• Super-selective TAE of the corona mortis is indicated when imaging shows positive bleeding signs (pseudoaneurysm or extravasation) in patients with ipsilateral superior ramus fractures 1
• TAE demonstrates 100% technical success with zero procedure-related complications in this population 1

For Iatrogenic Surgical Injury

• Intraoperative recognition requires immediate surgical exploration and arterial ligation when identified during hip fracture surgery or periacetabular osteotomy 4, 5
• If recognized postoperatively (6+ hours after surgery) with retroperitoneal hematoma but no active extravasation on CT, exploratory laparotomy with arterial ligation and retroperitoneal decompression is indicated 4
• Review intraoperative fluoroscopy images to identify hardware protrusion as the causative mechanism 4

Obturator Artery Involvement in Aortic Dissection

When aortic dissection extends to involve branch vessels including the obturator artery territory:

Static Obstruction

Direct branch vessel stenting is indicated when a significant pressure gradient exists between the branch artery and the supplying aortic lumen. 6 This approach achieves flow restoration in >90% of obstructed vessels 6

Dynamic Obstruction

• Percutaneous balloon fenestration of the dissecting membrane plus stenting of the aortic true lumen is the treatment of choice 6
• Stenting may be necessary to keep the fenestration open, particularly in chronic dissection with fibrosed membranes 6
• Reassess aortic true lumen pressures after flow restoration, as stenting large arterial branches can alter hemodynamics 6

Timing Considerations

For acute type A dissection with malperfusion of peripheral branches (including pelvic vessels), perform percutaneous revascularization first before surgical aortic repair to allow ischemic injury to resolve 6

Critical Pitfalls and Anatomic Considerations

Anatomic Variations

• The obturator artery may arise from the external iliac artery (aberrant obturator artery or "corona mortis") rather than its typical origin from the internal iliac artery 7, 1
• In pelvic trauma with superior pubic ramus fractures, actively search for corona mortis bleeding as this variant is clinically significant and frequently injured 1
• The artery may be accompanied by two obturator veins with distinct paths rather than the typical single vein 7

Delayed Presentation

Maintain high clinical suspicion for delayed internal hemorrhage from obturator arteries following pelvic trauma or surgery, as bleeding may not be immediately apparent 3

Surgical Risk Zones

• During periacetabular osteotomy, the obturator artery is at highest risk at the medial base of the iliopectineal eminence during osteotomy 5
• During hip fracture surgery, review all intraoperative fluoroscopy for hardware protrusion beyond the medial cortex, as even 0.8 cm protrusion can damage the obturator artery 4

Post-Intervention Monitoring

Following successful embolization or surgical repair:

• Monitor hemoglobin levels serially for the first 24-48 hours 4
• Assess for compartment syndrome if limb ischemia was present, with fasciotomy indicated for clinical evidence or elevated creatine kinase 2
• No specific antiplatelet therapy is recommended for isolated obturator artery embolization in the trauma setting 6