Background
Internal iliac (hypogastric) 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 this measure 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, 7]
In the elective setting, the internal iliac 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, internal iliac artery ligation is essential in preventing a type 2 endoleak and a potentially nonexcluded pressurized aneurysm sac.
Indications
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:
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Spontaneous hemorrhage due to advanced pelvic cancer, [8] control of postoperative pelvic hemorrhage, [9] intraoperative control of hemorrhage, and prophylactic ligation prior to extensive pelvic surgery [10] (though some studies have found that prophylactic ligation does not reduce intraoperative blood loss [11, 12] )
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Postprostatectomy bleeding
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Damage control in a select group of patients with massive retroperitoneal hemorrhage after pelvic fracture
Relative indications include the following:
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Type 2 endoleak from the hypogastric artery after endovascular repair of an abdominal aortic aneurysm, in which the stent-graft limbs have been extended into the external iliac arteries
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Hypogastric artery aneurysms, which can present as urinary retention [13]
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. [14]
Management of an acquired uterine arteriovenous malformation by means of selective ligation of the internal iliac artery has been described. [15]
Outcomes
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, 16, 17]
In a literature review detailing follow-up of 634 patients undergoing internal iliac artery ligation, 28% developed buttock claudication and 18% sexual dysfunction. [18] 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%. [19]
A study by Schellenberg et al (N = 77) assessed complications after temporary bilateral internal iliac artery ligation for control of pelvic hemorrhage in the setting of trauma. [20] Over the 13-year study period, there were no local complications (gluteal necrosis, iatrogenic injury, fascial dehiscence, surgical-site infection) after the procedure. In the view of the authors, these results suggested that a high degree of concern for gluteal necrosis after temporary bilateral internal iliac artery ligation in severely injured trauma patients is unfounded and should not prevent the use of this technique in such patients.
