Hypogastric (Internal Iliac) Artery Ligation

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Hypogastric (internal iliac) artery ligation was pioneered by Howard Kelly for the treatment of intraoperative bleeding from cervical cancer prior to its application in postpartum hemorrhage (PPH). ^[1] Many studies have reported that hypogastric artery ligation can be life-saving in patients with massive pelvic bleeding. ^{[2, 3, 4, 5]}

Although other methods can stem hemorrhage in patients with pelvic bleeding due to trauma or PPH, it is essential for surgeons to be aware of the indications for and technique of internal iliac artery ligation. ^[6]

In the elective setting, the hypogastric artery is either ligated or embolized during endovascular repair of aortoiliac arterial aneurysms where the distal end of the endograft has to seal in the aneurysm-free external iliac artery. In this scenario, hypogastric artery ligation is essential in preventing a type 2 endoleak and a potentially nonexcluded pressurized aneurysm sac.

Ligation of the internal iliac arteries may be indicated as a life-saving procedure in the control of severe pelvic hemorrhage occurring spontaneously or operatively (when noninvasive methods are not indicated or feasible). Indications are as follows:

Relative indications include the following:

A study by Boynukalin et al suggested that bilateral hypogastric artery ligation may be an effective therapeutic option for severe PPH and is worth considering in the setting of an obstetric emergency. ^[11]

Management of an acquired uterine arteriovenous malformation by means of selective ligation of the internal iliac artery has been described. ^[12]

Pelvic ischemia due to bilateral hypogastric artery ligation was once a fear, but it has been shown that little morbidity, either short-term or long-term, results if the procedure is performed appropriately. ^{[3, 13, 14]}

In a literature review detailing follow-up of 634 patients undergoing hypogastric artery ligation, 28% developed buttock claudication and 18% sexual dysfunction. ^[15] Similarly, in a series of 39 patients undergoing bilateral internal iliac artery embolization before endovascular aneurysm repair (EVAR), postprocedural buttock claudication occurred in 31% of patients but remained in only 9% after 1 year; sexual dysfunction was seen in only 5% and spinal ischemia in 3%. ^[16]

Kelly H. Ligation of both internal iliac arteries for hemorrhage in hysterectomy for carcinoma uteri. Bull John Hopkins Hosp. 1894. 5:53.

Evans S, McShane P. The efficacy of internal iliac artery ligation in obstetric hemorrhage. Surg Gynecol Obstet. 1985 Mar. 160 (3):250-3. [Medline].

Clark SL, Phelan JP, Yeh SY, Bruce SR, Paul RH. Hypogastric artery ligation for obstetric hemorrhage. Obstet Gynecol. 1985 Sep. 66 (3):353-6. [Medline].

Kehila M, Derouich S, Chelli D, Touhami O, Marzouk SB, Khedher SB, et al. [Which surgical strategy to adopt for the management of postpartum haemorrhage and how to improve the effects of hypogastric arteries ligation?]. Pan Afr Med J. 2016. 25:96. [Medline]. [Full Text].

Rauf M, Ebru C, Sevil E, Selim B. Conservative management of post-partum hemorrhage secondary to placenta previa-accreta with hypogastric artery ligation and endo-uterine hemostatic suture. J Obstet Gynaecol Res. 2017 Feb. 43 (2):265-271. [Medline].

Kaya B, Damarer Z, Daglar K, Unal O, Soliman A, Guralp O. Is there yet a role for internal iliac artery ligation in obstetric hemorrhage with the current gain in popularity of other uterus sparing techniques?. J Matern Fetal Neonatal Med. 2017 Jun. 30 (11):1325-1332. [Medline].

Popovici LR, Ciulcu A, Dorobat B, Dumitraşcu M, Horhoianu VV, Cirstoiu M. Therapeutic approaches in pelvic bleeding of neoplastic origin. J Med Life. 2014 Sep 15. 7 (3):391-5. [Medline]. [Full Text].

Kuhn T, Martimucci K, Al-Khan A, Bilinski R, Zamudio S, Alvarez-Perez J. Prophylactic Hypogastric Artery Ligation during Placenta Percreta Surgery: A Retrospective Cohort Study. AJP Rep. 2018 Apr. 8 (2):e142-e145. [Medline]. [Full Text].

Hussein AM, Dakhly DMR, Raslan AN, Kamel A, Abdel Hafeez A, Moussa M, et al. The role of prophylactic internal iliac artery ligation in abnormally invasive placenta undergoing caesarean hysterectomy: a randomized control trial. J Matern Fetal Neonatal Med. 2018 Apr 25. 1-7. [Medline].

Mwipatayi BP, Naidoo NG, Dreyer C, Jadwat S, Beningfield SJ. Isolated internal iliac artery false aneurysm presenting as urinary retention. EJVES Extra. 2004. 8:86-9.

Boynukalin FK, Boyar H, Gormus H, Aral AI, Boyar N. Bilateral hypogastric artery ligation in emergency setting for intractable postpartum hemorrhage: a secondary care center experience. Clin Exp Obstet Gynecol. 2013. 40 (1):85-8. [Medline].

Raherinantenaina F, Rajaonanahary TM, Randriamandrato TA, Rakoto Ratsimba HN. [Successful management of an acquired uterine arteriovenous malformation by selective ligation of the internal iliac artery]. J Mal Vasc. 2015 May. 40 (3):182-6. [Medline].

Papp Z, Tóth-Pál E, Papp C, Sziller I, Gávai M, Silhavy M, et al. Hypogastric artery ligation for intractable pelvic hemorrhage. Int J Gynaecol Obstet. 2006 Jan. 92 (1):27-31. [Medline].

Fiori O, Deux JF, Kambale JC, Uzan S, Bougdhene F, Berkane N. Impact of pelvic arterial embolization for intractable postpartum hemorrhage on fertility. Am J Obstet Gynecol. 2009 Apr. 200 (4):384.e1-4. [Medline].

Rayt HS, Bown MJ, Lambert KV, Fishwick NG, McCarthy MJ, London NJ, et al. Buttock claudication and erectile dysfunction after internal iliac artery embolization in patients prior to endovascular aortic aneurysm repair. Cardiovasc Intervent Radiol. 2008 Jul-Aug. 31 (4):728-34. [Medline].

Bratby MJ, Munneke GM, Belli AM, Loosemore TM, Loftus I, Thompson MM, et al. How safe is bilateral internal iliac artery embolization prior to EVAR?. Cardiovasc Intervent Radiol. 2008 Mar-Apr. 31 (2):246-53. [Medline].

Chitragari G, Schlosser FJ, Ochoa Chaar CI, Sumpio BE. Consequences of hypogastric artery ligation, embolization, or coverage. J Vasc Surg. 2015 Nov. 62 (5):1340-7.e1. [Medline].

Kim MK, Oh BC, Kim HJ, Kim YG, Jeong YB. Complete bladder gangrene caused by bilateral hypogastric artery ligation during laparoscopic radical hysterectomy. J Minim Invasive Gynecol. 2009 Jan-Feb. 16 (1):76-7. [Medline].

Mathyk BA, Cetin BA, Atakul N, Koroglu N, Bahat PY, Turan G, et al. Ovarian reserve after internal iliac artery ligation. J Obstet Gynaecol Res. 2018 Sep. 44 (9):1761-1765. [Medline].

Chee Weng (David) Leong, MBBS Resident Medical Officer, Royal Perth Hospital, Australia

Disclosure: Nothing to disclose.

B Patrice Mwipatayi, MD Professor, School of Surgery, University of Western Australia, Royal Perth Hospital, Australia

Disclosure: Nothing to disclose.

Vikram Vijayan, MBChB, MRCS, FRCS Consultant in Vascular and Endovascular Surgery, Royal Perth Hospital, Western Australia

Disclosure: Nothing to disclose.

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Surgical Association, Pacific Coast Surgical Association, Society for Clinical Vascular Surgery, Society for Vascular Surgery, Western Vascular Society

Disclosure: Nothing to disclose.

Hypogastric (Internal Iliac) Artery Ligation

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