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Vascular Interventions
Case Report
2023
:7;
9
doi:
10.25259/AJIR_1_2023

Corona mortis in the setting of pelvic trauma: Case series and review of the literature

Department of Health Sciences, South Carolina School of Medicine , Greenville, United States
Department of Pathology, Prisma Health Upstate, Greenville, United States
Department of Radiology, Heersink School of Medicine, Birmingham, United States
Department of Radiology, Prisma Health Upstate, Greenville, United States
Corresponding author: Christine M. G. Schammel, Department of Pathology, Prisma Health Upstate, Greenville, United States. christine.schammel@prismahealth.org
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Sealy EB, Schammel CM, Varma R, Devane AM. Corona mortis in the setting of pelvic trauma: Case series and review of the literature. Am J Interv Radiol 2023;7:9.

Abstract

Corona mortis is a variant vessel located posteriorly against the superior pubic ramus, “crowning” the pelvis; actual prevalence is unknown due to broad definitions: A connection between the obturator artery and an external iliac artery branch or the external iliac artery anastomosis, or any variant vessel behind the superior pubic ramus. Rapid identification and immediate treatment of injury to an arterial corona mortis resulting from pelvic trauma or pelvic surgeries are essential as hemorrhage or death may result. Interventional radiology can selectively target corona mortis and obstruct hemorrhage through catheter-guided embolization. We present four cases of corona mortis and pelvic trauma with successful embolization and include a comprehensive literature review to further educate regarding the morbidity and potential mortality associated with this important anatomic variant.

Keywords

Arterial corona mortis
Catheter embolization
Corona mortis
Variant pelvic vessel

INTRODUCTION

Corona mortis, or “crown of death,” has been defined as a variant vessel that originates from the external iliac artery system and dives deep into the pelvis, crossing the superior pubic ramus, potentially creating an arterial or venous anastomosis with branches of the internal and external ipsilateral iliac vessels.[1] The connections between the obturator artery, typically an internal iliac artery branch, and an external iliac artery branch or the external iliac artery have prompted a more comprehensive definition of corona mortis that reflects the potential problem for surgeons in the retropubic region, and not simply describing the anatomy.[2] Thus, corona mortis can be defined as any vessel crossing the superior pubic ramus.[3]

Corona mortis is not typically taught during medical training, with most anatomy textbooks labeling corona mortis as “anomalous,” “aberrant,” or “accessory” despite published reports noting an arterial prevalence of 17–25% and a venous prevalence of 41.7–42%.[4,5] In addition, training often fails to emphasize the importance of identifying corona mortis, particularly given the location behind the pubic ramus that predisposes the vessel to injury in pelvic surgeries and trauma, a bleeding control challenge intraoperatively when a lacerated vessel spasms.[4] Injury to the arterial corona mortis is associated with severe adverse outcomes, resulting in rapid hemodynamic instability and death if left unrecognized.[6]

Catheter-guided embolization provides a minimally invasive alternative to rapidly achieve prompt hemostasis in cases of pelvic trauma, as it can selectively embolize a particular vessel without exposing the patient to surgical risk.[7] Following Institutional Review Board approval utilizing universal consent, we outline four reports of pelvic trauma resulting in hemorrhage due to the presence of arterial corona mortis and successful catheter-guided embolization.

CASE REPORTS

Case 1

Following a motor vehicle collision, an 81-year-old male presented to the emergency department (ED). Contrast-enhanced computed tomography (CT) of the abdomen and pelvis revealed bilateral fractures of the pubic rami (superior and inferior); active contrast extravasation was present within the left gluteal musculature. A small abnormal branch of the left external iliac artery was noted [Figure 1a]. Emergent angiography was performed due to hypotension. The obturator artery was noted by angiogram to arise directly from the external iliac artery, extending into the deep pelvis, and creating corona mortis [Figure 1b]. Selective angiography of the obturator muscle bed further demonstrated active bleeding [Figure 1c]. Gelfoam (Pfizer, New York, NY) embolization was performed, followed by coil embolization (Concerto coils, Medtronic, Minneapolis, MN). Post-embolization angiogram confirmed hemostasis [Figure 1d]. Following fracture stabilization, the patient was discharged on hospital day 10.

Figure 1:: An 81-year-old male with bilateral fractures of the pubic rami (superior and inferior) and active contrast extravasation within the left gluteal musculature following a motor vehicle accident. (a) Contrast-enhanced coronal CT image of the pelvis demonstrating a small vessel arising from the left external iliac artery (white arrow). (b) Left external iliac angiogram confirming a corona mortis (white arrow) arising directly from the left external iliac artery separate from the inferior epigastric artery (black arrow). (c) Selective angiogram of corona mortis with a microcatheter showing multiple small foci of arterial contrast extravasation (white arrows). (d) Angiogram status post coil embolization (white arrow) of corona mortis with resultant hemostasis.

Case 2

A 47-year-old male was admitted to the ED with injuries sustained in a motorcycle accident. Intravenous contrast-enhanced CT demonstrated an anterior-posterior compression III pelvic injury demonstrating sacroiliac joint widening; the left pelvis demonstrated contrast extravasation [Figure 2a]. Active arterial contrast extravasation was also noted by angiography from the left internal iliac artery near the left pubic symphysis [Figure 2b]. Embolization of the left internal iliac artery anterior division utilizing Gelfoam slurry was performed. Follow-up angiogram demonstrated active arterial extravasation from a corona mortis [Figure 2c], a branch of the left inferior epigastric artery originating from the left inferior epigastric artery in communication with the left internal iliac artery anterior division. Coil embolization (Concerto coils, Medtronic, Minneapolis MN) of the corona mortis was performed; a follow-up angiogram demonstrated no further hemorrhage [Figures 2d-f]. His pelvic fractures were internally fixated and he was discharged 15 days post-embolization.

Figure 2:: A 47-year-old male with an anterior-posterior compression III pelvic injury, sacroiliac joint widening, and active arterial contrast extravasation within the deep pelvis near the left pubic symphysis following a motorcycle accident. (a) Axial contrast-enhanced CT of the pelvis demonstrates active arterial extravasation of contrast (white arrow) anterior to a widened pubic symphysis. (b) Selective angiogram of the left internal iliac artery shows an active arterial bleed (white arrow) within the left deep pelvis due to reflux through the left external iliac artery. (c) Repeat right internal iliac artery angiogram after gelfoam embolization demonstrates bleeding (white arrow) arising from corona mortis arising from the right inferior epigastric artery (black arrow). (d) A 47-year-old male with an anterior-posterior compression III (APC) pelvic injury, sacroiliac joint widening, and active arterial contrast extravasation from the left internal iliac artery near the left pubic symphysis following a motorcycle accident. An angiogram of the left external iliac artery better demonstrates the bleed (white arrow) arising from corona mortis. (e) Post coil (white arrows) embolization of corona mortis showing no further hemorrhage. (f) Final angiogram of the right internal iliac artery demonstrating no further extravasation of contrast. Embolization coils are labeled with white arrows.

Case 3

A 61-year-old male presented to the ED with multiple pelvic fractures following a car accident. The patient presented as hemodynamically stable. Contrast-enhanced CT of the pelvis showed multiple displaced pelvic fractures, bilateral pelvic hematomas, and a right-sided corona mortis vessel [Figures 3a-c]. Angiography demonstrated multifocal blush on the right hemipelvis [Figure 3d]. The right corona mortis arising from the external iliac artery was readily identified, demonstrating active contrast extravasation on selective angiogram [Figure 3e]. The variant artery was successfully embolized with Gelfoam [Figure 3f]. The patient was discharged post-procedure on day 5.

Figure 3:: A 61-year-old male with multiple displaced pelvic fractures, bilateral pelvic hematomas, and multifocal blush on the right hemipelvis following a motor vehicle accident. (a) Right-sided corona mortis (arrowhead), the pubic branch of the inferior epigastric artery (blue arrow), obturator artery arising from the anterior division of the internal iliac artery (curved arrow), and lateral pelvic hematoma (star). (b) Oblique coronal and (c) oblique sagittal multiplanar reconstruction of the CTA images demonstrating the course of the right corona mortis (CM and arrow) originating from the external iliac artery (EIA and arrow), coursing behind the superior pubic ramus (SPR) and towards the obturator foramen (OF). (d) A volume-rendered CT pelvic angiogram shows the right obturator artery (arrow), that is, corona mortis arising from the right external iliac artery (arrowhead). (e) Selective angiogram through the right corona mortis (arrow) shows multiple areas of contrast extravasation in the region of the right obturator foramen (arrowheads). (f) Post-embolization images of the right corona mortis artery using gelfoam shows complete cessation of areas of extravasation (arrows).

Case 4

A 64-year-old female presented to the ED after falling at home. She was initially hemodynamically stable. Contrast-enhanced pelvic CT showed a right acetabular fracture with active extravasation and a pseudoaneurysm lateral to an aberrant right obturator artery [Figures 4a and 4b]; angiography was performed in the interventional radiology (IR) suite. Investigation of the right internal iliac artery demonstrated patency of the right internal iliac artery and branching vessels without evidence of active extravasation. An arteriogram of the right external iliac artery was performed, revealing a slight blush of contrast from an aberrant right obturator artery. This artery originated from the mid-right external iliac artery and shared a common trunk with the inferior epigastric artery [Figure 4c]. It then traveled over the superior pubic ramus before entering the obturator foramen, forming a corona mortis [Figure 4d]. Embolization of the corona mortis was then performed using Concerto detachable coils (Medtronic, Minneapolis, MN) with no further evidence of active bleeding or pseudoaneurysm [Figure 4e]. The patient was discharged on post-procedure day 7.

Figure 4:: A 64-year-old female with a right acetabular fracture with the right pelvic sidewall hematoma and a pseudoaneurysm lateral to an aberrant right obturator artery after falling at home. (a) Contrast-enhanced axial CT image shows a 6mm pseudoaneurysm (arrow) within the right lateral pelvic sidewall, pelvic hematoma (star), and right acetabular fracture (arrowhead). (b) Curved coronal reconstruction contrast-enhanced CT image demonstrating the aberrant right obturator artery arising from the external iliac artery representing the corona mortis (arrowhead). (c) The aberrant right obturator artery arising from the external iliac artery (EIA), represents the corona mortis (arrowhead). Note the common origin of the corona mortis and inferior epigastric artery (IEA). (d) Super-selective catheterization of the corona mortis showing the distribution of vasculature around the obturator foramen and the pelvic pseudoaneurysm (arrow). (e) DSA images post-coil embolization of the corona mortis (arrow). Concerto coils can be seen.

DISCUSSION

Management of pelvic trauma typically includes placement of a pelvic binder, with CT on the vast majority of patients and FAST for unstable patients. Patients positive for FAST are treated surgically with pre-peritoneal packing; if FAST is negative, IR is typically consulted for angioembolization. Corona mortis is defined as an “anastomosis between the obturator and the external iliac or inferior epigastric artery or vein” and any other vessels, posing a risk of hemorrhage to surgeons operating in the space posterior to the superior pubic ramus.[2,3,8] Corona mortis is classified by the Rusu et al. system into three main categories (I. Arterial, II. Venous, III. combined), with further classification into subcategories based on morphological patterns.[3] In our series, Cases 1 and 4 could be classified as the most common form, Rusu et al. type I.1 variant, while Cases 2 and 4 could be classified as Rusu et al. type I.2.

Various definitions have resulted in discrepancies in the documented prevalence of corona mortis. A comprehensive literature search identified corona mortis cases from cadaveric, intraoperative, radiologic, and individual case studies [Table 1[1-3,8-52] and 2[6,53-75] Figure 5]. Arterial corona mortis in cadaveric and intraoperative studies reported the widest range, with averages of 30.13% and 35.14%, respectively, possibly related to intraoperative spasm of a lacerated corona mortis, making definitive identification of corona mortis challenging.[8] Radiologic studies reported a lower prevalence, with a mean of 26.2%. Interestingly, two separate meta-analyses reported arterial corona mortis prevalence as 17% and 25%, respectively, which is much lower than our evaluation of the literature (8.3– 86%; [Tables 1 and 2]) Venous corona mortis prevalence was reported to be higher than arterial corona mortis, at approximately 50% overall.[4,5] Arterial corona mortis poses the greatest risk for surgeons and interventionalists in the setting of pelvic trauma, suggesting that corona mortis is not uncommon, and thorough mapping of the vasculature is essential.

Figure 5:: Illustration. An illustration representing the two variants of corona mortis noted in our case series. In two of the four cases, the corona mortis was found as a branch off of the external iliac artery (Rusu type I.1). In two cases the corona mortis was identified as a branch of the inferior epigastric artery, which communicated with the anterior division of the internal iliac artery (similar to Rusu type I.2).
Table 1:: Comprehensive literature review – Case series.
Study Population Type Hemipelvises Average age (range) Gender CMOR prevenance (%) Distance from pubic symphysis (mm), (range) Distance from lacunar ligament Diameter (mm), (range) Laterality
Teague, 1996[9] USA Cadaveric 79 71 (56–88) 55% M 43 Arterial, 59 Venous
Tornetta, 1996[10] USA Cadaveric 50 84 62 (30–90) (2–4)
Missankov, 1996[11] South Africa Cadaveric 98 45–80 71.4% F 69 Arterial, 46 Venous
Gilroy, 1997[12] USA, China Cadaveric 105 38 Arterial, 82 Venous (USA)
33 Arterial, 67 Venous (China)
USA arterial: Bilateral 20%, Unilateral 35%, Absent 45%
China arterial: 17% Bilateral, 33% Unilateral, 50% Absent
USA venous: Bilateral 75%, Unilateral 15%, Absent 10%
China venous: 50% Bilateral, 33% Unilateral 17% Absent
De Kleuver, 1998[13] Netherlands Cadaveric 12 74.5% M 50
Bereroglu, 2001[14] Turkey Cadaveric 14 86 Arterial, 100 Venous 40.4 (33.2–52.7) Arterial or Venous 0.98 (0.6–1.2) Arterial, 3.3 (2.2–4.9) Venous
Sarikcioglu, 2003[8] Turkey Cadaveric 54 92.5% M 0 Arterial, 20.37 Venous 39.79 (28.37–51.21) Arterial or Venous 12.18 (8.63–15.73) Arterial or Venous
Okcu et al., 2004[1] Turkey Cadaveric 150 40 (16–78) 77.3% M 19 Arterial, 52 Venous, 9 Mixed 64 (45–90) Arterial, 56 (37–80) Venous 28% Bilateral
Ersoy, 2004[15] Turkey Cadaveric 10 61.4 (52–71) 100% F 100 Venous
Drewes, 2005 USA Cadaveric 30 77 (46–95) 100% F 33 Arterial, 60 Venous 54 12% Bil arterial
33% Bil venous
Pungpapong, 2005[17] Thailand Cadaveric 66 54.5% F 13.6 Arterial, 77.3 Venous 52.8
Darmanis et al., 2007[2] UK Cadaveric 80 67.5% M 36 Arterial, 60 Venous, 27.5 Mixed 71 (42–88) Arterial, 65 (39–82) Venous 14 (11–16) 2.6 (1.6–3.5)
Namking, 2007[18] Thailand Cadaveric 204 20–95 54.4% M 22.5 Arterial, 70.6 Venous, 17.2 Mixed Arterial: Right 20.8%, Left 24.3%
Venous: Right 70.3%, Left 70.9%
Mixed: Right 14.9%, Left 19.4%
Pathi, 2009[19] USA Cadaveric 24 79 (65–96) 100% F 25 Arterial, 67 Venous
Mahato, 2009[20] India Cadaveric 50 40–60 88% M 40 Venous, 22 Mixed Venous: Right 36%, Left 43%
Mixed: Right 23%, Left 21%
Rusu et al., 2010[3] Romania Cadaveric 40 60% M 25 Arterial, 15 Venous, 40 Mixed
Kacra, 2011[21] Turkey Cadaveric 10 20 Venous, 20 Mixed
Stavropoulou
-Deli, 2013[22]
Greece Cadaveric 70 100% F 11.43 Arterial, 14.29 Venous 52.4 (40–75) Arterial, 46.7 (35–55) Venous 3 Arterial, 3.1 Venous Arterial: 37.5% Right, 12.5% Left, 50% Bilateral
Venous: 20% Left, 80% Bilateral
Bible, 2014[23] USA Cadaveric 10 60 Arterial, 80 Venous
Nayak, 2016[24] S India Cadaveric 73 50–80 94.5% M 51 Venous
Tajra, 2016[25] Brazil Cadaveric 24 66.7% M 22.72 Arterial Arterial: Right 27.27%, Left 18.18%
Al Talawah, 2016[26] Austria Cadaveric 208 73% M 12 Arterial
Pillay, 2017[27] India Cadaveric 67 63% M 12.5 Arterial, 60.7 Venous, 26.78 Mixed 54.5 (38–79) 20.8% Bilateral
Leite, 2017[28] Brazil Cadaveric 60 83.3% M 45 Arterial 49.62 2.66
Zhou, 2017[29] China Cadaveric 20 38.3 (21–60) 65.8% M 15% Arterial, 55% Venous 65.30
Kashyap, 2019[30] N India Cadaveric 24 68 (54–82) 91.7% M 8.3 Arterial, 58.3 Venous, 8.3 Mixed 41 (35–70) Venous 83% were<4 mm 20.8% Right, 37.5% Left, 41.7% Bilateral
Cardeiro, 2019[31] Brazil Cadaveric 80 67.5% M 22.5 Arterial
Dias, 2019[32] India Cadaveric 50 44.8 88% M 4 Arterial, 40 Venous
Du, 2020[33] China Cadaveric 16 62.5% M 18.75 Arterial, 43.75 Venous, 12.5 Mixed 59.0 (53.9–65.2) 2.5 (1.6–3.5)
Kati, 2021[34] Turkey Cadaveric 12 70.8 (59–80) 66.7% M 83 Arterial or Venous 47.7 (43–55)
Wada, 2021[35] Japan Cadaveric 122 85 (65–106) 52.5% F 28.3 Arterial, 76.1 Venous Anteroposterior view: 47.7 (45.9–49.6), Inlet view: 59.4 (57.3–61.5)
Karakurt, 2002[36] Turkey Angiography (prospective) 98 55 (23–73) 60.2% M 28.5 Arterial 33.4 (21.4–41)
Smith, 2009[37] USA CT (prospective) 100 26 (18–87) 54% F 29 Arterial 56 (41–72) 2.5 mm (1.6–3.5) Arterial: 28% Left, 30% Right, 22% Bilateral
Requarth and Miller, 2011[38] USA Angiography (Retrospective) 243 50.6% F Arterial
38.4% of all hemipelvises, 55.1% in all pts
Arterial: 37.7% Right, 39.1% Left 21.7% Bilateral
Castellani, 2016[39] Italy CT (Prospective) 94 100% F 27.7 69% Bilateral
Wada, 2017[30] Japan CTA (Retrospective) 196 66 (54–78) 63.3% M 14.3 Arterial
Han, 2017[2] China CTA (Prospective) 660 43 (11–72) 100% F 14.1% Arterial, 51.1% Venous 59.6 (43–82) Arterial, 66.87 (41–119) Venous 2.56 Arterial, 3.63 Venous Arterial: 6.06% Bilateral, venous: 34.24% Bilateral
Steinberg, 2017[42] Isreal CTA (Retrospective) 200 67 (19–96) 66% M 33 Arterial 55.2 (45–72) Right, 57.2 (35–71) Left Right: 2.4 (1.4–3.7), Left: 2.24 (1.6–3.5) Arterial: 45.5% Left, 54.5% Right, 45.5% Bilateral
Duenas-Garcia, 2018[43] USA 3D-Imaging from CTA 87 66.9 100% F 27.9 Arterial 51.3 (37–59) Right, 52.7 (36–58) Left
Perandini, 2018[44] Italy CTA (Retrospective) 300 73 (22–95) 74% M 30 Arterial 50 (42–72) 1.7 (0.8–3.2) Arterial: 45.4% Left, 55.6% Right, 35.6% Unilateral
64.6% bilateral
Zlotorowicz, 2018[45] Poland CTA 100 46.7 (14–80) 72% F 33 Arterial Arterial: 56% Right, 44% Left, 52% Bilateral
Bhoil, 2020[46] India CTA (Prospective) 200 40 (22–74) 67% M 14 Arterial 54.55 (Range 42–68) Right, 54.26 (Range 40–66) Left Right: 2.6 (1.7–3.0), Left: 2.3 (1.6–3.2) 20% Unilateral
4% Bilateral
Teague, 1996[9] USA Intraoperative (Prospective) 38 31 (13–67) 78.9% M 37
Bereroglu, 2001[14] Turkey Intraoperative 36 86 Arterial, 94 Venous Arterial<1 mm
Lau, 2003[47] Hong Kong, China Intraoperative (Prospective) 141 64 (49–79) 96.7% M 22 Arterial, 27 Venous Arterial: 41.9% Left, 58.1% Right Venous: 52.6% Left, 47.4% Right
Darmanis et al., 2007[2] UK Intraoperative (Retrospective) 492 34 (7–80) 71.5% M 0.01 Arterial Or Venous
Pellegrino, 2014[48] Italy Intraoperative 50 59 (46–68) 100% F 8 Arterial, 48 Venous, 23 Mixed Right 60%, Left 28%, Bilateral 12%
Jensen, 2015[49] Switzerland Intraoperative (Retrospective) 130 51 (38–70) 66.2% M 41.5
Ates, 2016[50] Turkey Intraoperative (Retrospective) 391 46
(37.4–54.6)
83.5% M 28.4 Arterial 22.8% <2 mm, 5.5% >2 mm
Kinaci, 2016[51] Turkey Intraoperative 475 46
(36.9–55.1)
84% M 31.3 Arterial, 5.8 Venous 25.05% <2 mm, 6.32% >2 mm
Guzel, 2020[52] Turkey Intraoperative 34 43.5 (21–65) 77.4% M 23 Arterial, 45 Venous, 26 Mixed 35.9 (21.6–48.7)

Greyed boxes indicate variables that the study did not address. CTA: Computed tomography angiography; Table 1 references detailed in the Supplemental material.

Table 2:: Comprehensive literature review – Individual cases.
Case Imaging Age/Gender Hemodynamics Clinical Situation Transfusion Requirement Laterality Type Rusu classification Tx Distance from pubic symphysis (mm) Diameter (mm)
Meyers, 2000[53] Angiography 86/F
43/M
Initially stable, rapid decompensation while in ED (BP 70/40, HR 100s)
BP 109/80, HR 126
Pubic rami fractures s/p 4-ft fall
Pubic rami fractures s/p 20-ft fall
7 U blood
10 U blood
Left
Right
Pubic branch of the inferior epigastric artery Embolization
Daeubler, 2003[54] CT with contrast/Angiography 46/M Initial BP was 133/107. Decompensated while in CT with BP of 100/65, pulse of 120 bpm. Superior and inferior pubic ramus fracture secondary to car versus cyclist in which the pt was the cyclist. 6 U whole blood, 8 U PRBCs, 2 U FFP Left Obturator artery originating from inferior epigastric artery I2 Embolization with microparticles and 0.018 in coils
Macdonald, 2006[55] Angiography 71/F Initially stable, developed hypotension and tachycardia after admission. Hemoglobin decreased from 13.2 to 6.3 g/dL Superior ramus fracture s/p fall 10 U PRBCs, 3 U FFP Left Pubic branch of left inferior epigastric artery Embolization with coils
Henning, 2007[56] CT with contrast/Angiography 81/F Became hemodynamically unstable during overnight stay with hemoglobin decreasing from 13.3 to 8.1 g/dL and BP of 92/54. Superior and inferior left pubic ramus fracture after fall. 7 U PRBC, 4 U FFP Left Distal branch of interior epigastric artery Embolization with microparticles and 2 mm in coils
Smith, 2009[57] CT with contrast/Angiography 19/M Stable on arrival but patient became tachycardic in CT scanner and interval hemoglobin showed decrease from 13.1 to 11.3 g/dL. Post procedural hemoglobin was 9 g/dL. Fractures of left superior pubic ramus, left ischiopubic ramus, and first sacral segment after high speed MVA. 4 U of PRBCs Left Obturator artery originating from inferior epigastric artery I2 Embolized with alcohol particles and and gelgoam slurry
Larsson, 2010[58] Intraoperative 53/F Stable, however, hemoglobin decreased from 13.0 to 12.2 g/dL postoperatively Intraabdominal bleeding postop TVT-Secur procedure Left Surgical ligation
Rehder, 2010[59] CT 46/F Stable Retropubic hematoma following invasive MUS for stress urinary incontinence Left Anastomoses between obturator and inferior epigastric artery I3 Conservative management
Dixon, 2011[60] CTA 70/F Stable Type II endoleak found on 10-year follow up s/p open surgical aortobiilac graft placement for isolated internal iliac artery aneurysm Right Anastomoses between obturator and inferior epigastric artery I3 Embolization with three 6 mm Tornado coils, 4mL of thrombin, and Glubran 2
Ferrada, 2011[61] CT with contrast/Angiography 72/M Initially stable with BP of 172/83 but later decompensated to systolic of 100 s Fractures to bilateral inferior pelvic rami after MVC Bilateral Obturator arteries arising from inferior epigastric arteries bilaterally I2 Embolization
Theodorides
et al., 2011[6]
Angiography 78/F Initially stable, became unstable within 2 h Superior pubic ramus fracture s/p fall 8 U blood, 4 U FFP Right Embolization with gelfoam
Garrido-
Gómez, 2012[62]
Angiography 70/F Initially stable and discharged home. Returned 72 h later with BP 95/64, HR 140 Iliopubic rami fracture and a nondisplaced right ischiopubic rami fracture s/p fall 6 U Left distal portion of a small branch of the obturator artery Embolization
Kong and Tsai, 2012[63] CT with contrast/Angiography 58/F Initially stable, became hypotensive (77/48) within 2 h Simple pubic ramus fracture s/p MVC 4 U PRBCs, 4 U FFP Right Pubic branch of right inferior epigastric artery Embolization
Pua, 2012[64] CT/Angiography 55/M Right superior and inferior pubic rami fracture and diastasis of the right SI joint s/p MVC Bilateral Bilateral obturator arteries arising from CM as a branch distal to the right inferior epigastric I2 Embolization with gelatin sponge slurry and coil
Ten Broek, 2014[65] Angiography 79/F Initially stable, became hypotensive (82/43) the following day
Hemoglobin 5.5 mmol/L
Superior pubic rami fracture s/p fall 2 U PRBCs Right Branch of internal iliac artery communicating with inferior epigastric artery Likely I3 Embolization
Ramser, 2014[66] Intraoperative 97/F Stable Incidental finding during laparoscopic obturator hernia repair Right None required
Kandhari, 2015[67] CTA 40/F Stable Patent CMOR preserved blood flow to lower extremity of a patient with blocked external iliac artery after failed fixation of fractured acetabulum causing avascular necrosis of the hip Left Anastomosis between obturator and external iliac artery None
Cerda, 2016[68] Cadaver M Incidental finding during routine dissection Bilateral Obturator artery originating from inferior epigastric artery Likely I2 Left: 47.24, Right: 49.23 Left: 2.77, Right: 2.8
Pinochet, 2016[69] Cadaveric 81/F Cadaveric study Bilateral Left: obturator vein draining into inferior epigastric vein, Right: External iliac vein into the obturator canal Left: Type II2, Right: unclassified 65 Left, 67 Right 8 Left, 3 Right
Xu, 2018[70] CT with contrast/Angiography 88/M When transferred from outside hospital, pt became diaphoretic, tachycardic and hypotensive with BP of 81/56. Superior pubic ramus fracture following a fall. 16 U PRBCs, 3.5 L FFP Right Distal branch of right external iliac artery Embolization with balloon-assisted coiling
Babinski, 2018[71] Cadaveric M Incidental finding during dissection Right Venous and arterial anastomoses between inferior epigastric and obturator vessels I3 and II3 3 mm
Yasuda, 2018[72] Intraoperative 66/M On POD 1, BP 79/54 and hemoglobin decreased from 14.7 to 12.7 g/dL. POD 2, BP was 9.6 g/dL. Corona mortis vein was injured by the tip of the electric cautery during transabdominal preperitoneal laparoscopic hernioplasty. Unknown amount Left Vein across Cooper’s ligament Exploratory laparoscopy with evacuation of hematoma and application of surgical clips
Herskowitz, 2019[73] CTA/Angiography 50/M Initial BP 91/58, hemoglobin decreased fromo 13.2 to 7.3 g/dL on repeat labs. Pelvic fracture (diastasis of the symphysis pubis, avulsion fracture of the medial aspect of the left superior pubic ramus, separation of the left sacroiliac joint) secondary to MVA. 6 U PRBC, 5 U FFP, 1 pack platelets Bilateral Right: branch off of inferior epigastric artery, Left: aberrant pubic branch off external iliac arery Right: I2, Left: unclassified Embolization with 0.018 coils and gelfoam slurry
Han, 2020[74] CT with contrast/Angiography 71/M Stable but was readmitted with episodes of near-syncope, abdominal distension and anemia on POD 6 CMOR pseudoaneurysm in causing delayed intermittent hemoperitoneum after robotic radical prostatectomy Left Embolization
Pisanno, 2021[75] CT with contrast 60/M CMOR pseudoaneurysm 12 weeks after RALP Left Branch of external iliac artery which gave origin to inferior epigastric artery, pseudoaneurysm cavity, and obturator artery. Embolization

Greyed boxes indicate variables that the study did not address. POD: Post-operative day. CTA: Computed tomography, Computed tomography angiography, RALP: Robot-assisted laparoscopic prostatectomy, U: Units, ED: Emergency Department; BP: Blood Pressure; HR: Heart Rate; PRBC: Packed Red Blood Cells; FFP: Fresh Frozen Plasma; MVA: Motor Vehicle Accident; MCV: Motor Vehicle Collision; TVT: Tension Free Vaginal Tape; MUS: Muscuskeletal Ultrasound; SI: sacroiliac; s/p: status-post; CMOR: Corona Mortis; CM: Corona Mortis; Tx: Therapy. Supplementary Table 1 references in Supplementary Material.

An isolated pubic ramus fracture can often be treated with conservative management; however, in cases involving a corona mortis, patients are at risk of delayed hemorrhage.[63] These vessels are deep within the pelvis and are often challenging to identify during surgery due to spasm.[8] It is not surprising that, of the traumas that documented fracture of the pubic rami (n = 13) and of 12 traumas that mentioned hemodynamic status, all of the patients exhibited delayed hemorrhage [Table 2]. Interestingly, of the four patients in which corona mortis was identified intraoperatively, 50% were hemodynamically stable, and 50% had delayed hemorrhage. The three corona mortis identified post-operatively (n = 3) had only one (33%) with delayed hemorrhage, suggesting more success in corona management during non-trauma operative procedures. Awareness and early recognition of the corona mortis variant by radiologists in cases of trauma are vital.

The sensitivity and specificity of CT angiography (CTA) in identifying corona mortis in non-pelvic fracture patients are 90% and 100%, respectively. This vessel could be missed on initial CT without angiography as the sensitivity and specificity decrease to 63.6% and 92.3% in the setting of pelvic fracture.[38] However, an evaluation of the case reports [Table 2] indicated that all trauma cases utilized CTA successfully to identify corona mortis. More importantly, all of the cases were successfully managed using embolization.

CONCLUSION

In the setting of pelvic fracture, it is essential to identify corona mortis as an injury may result in a life-threatening hemorrhage due to its position over the superior pubic ramus. Thus, careful radiological evaluation of corona mortis is key to preventing delayed life-threatening hemorrhage, as this entity is more common than previously thought. The interventionist needs to focus on the external iliac artery during catheter angiography in all cases of pelvic trauma, as the data suggest that the obturator artery may arise from that location in greater than 25% of cases.

In the setting of pelvic injury or pelvic surgery, catheter-guided embolization provides quick and successful management of hemorrhage.[7]

Acknowledgments

Olivia Corso developed the illustration. These data were presented at the 17th Annual SC Upstate Research Symposium (pg 197–200) and at the 2022 ARRS virtual meeting May 1–5, 2022.

Declaration of patient consent

Institutional Review Board (IRB) permission obtained for the study.

Conflicts of interest

There are no conflicts of interest.

Financial support and sponsorship

Nil.

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