Internal Iliac (Hypogastric) Artery Ligation

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.

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:

• 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]} )
• Postprostatectomy bleeding
• Damage control in a select group of patients with massive retroperitoneal hemorrhage after pelvic fracture

Relative indications include the following:

• 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
• 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]

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.

In the transabdominal or transperitoneal approach to internal iliac (hypogastric) artery ligation, the patient is adequately prepared “from nipples to knees” with 1% iodine in 70% alcohol or 0.5% chlorhexidine in 70% alcohol. Drapes are appropriately placed to expose the lower abdomen. In the retroperitoneal approach, this same area is adequately prepared with povidone-iodine or chlorhexidine. Drapes are placed appropriately to expose the lower abdomen. In the endovascular approach, the patient’s groin is adequately prepared for percutaneous arterial access.

Anesthesia

General or regional anesthesia is used for the transabdominal, transperitoneal, or retroperitoneal approach to internal iliac artery ligation. General, local, or regional anesthesia is used for the endovascular approach.

Positioning

The patient is placed supine.

Ligation of the internal iliac (hypogastric) artery can be performed either via an open approach (intraperitoneal or extraperitoneal) or via an endovascular approach. Laparoscopic internal iliac artery ligation has also been described.[21, 22]

In an emergency situation, bilateral retroperitoneal approaches to control both the right and the left internal iliac artery are time-consuming; accordingly, this approach is often reserved more for elective settings.

In general, ligation of the hypogastric arteries is preferable to embolization; if the latter is performed, proximal embolization is preferable to distal embolization, in that it decreases the risk of ischemic complications.[23]

A midline incision is made. Viscera are packed away to the contralateral side of the pelvis. The bifurcation of the iliac artery is identified via two landmarks, the sacral promontory and an imaginary line through both anterior superior iliac spines.

On the left side, the sigmoid mesocolon is mobilized via an incision over the lateral peritoneum. The peritoneum can be incised longitudinally directly over the iliac bifurcation, and the incision can be extended proximally and distally for a few centimeters. The medial peritoneal flap and medial pelvic contents are retracted medially and the lateral flap retracted laterally. Blunt dissection is then performed around the vessels, opening the areola tissue.

Once the bifurcation is exposed, the internal iliac artery is confirmed as the branch coming off at right angles and coursing medially and inferiorly. The external iliac artery is visually confirmed as traversing laterally and superiorly over the psoas muscles to form the common femoral artery beneath the inguinal ligament. Careful and meticulous dissection is performed to separate the internal iliac artery from the veins.

A right-angle forceps is used to separate the plane between artery and vein and to isolate and control the artery with a Silastic loop. The internal iliac artery is then ligated with ligature clips or suture ties, as required.

A transverse curvilinear skin incision is made over the lower abdomen. The incision is started two fingerbreadths above the midpoint between the umbilicus and pubis and is extended laterally from the edge of the rectus muscle obliquely upward to a point two fingerbreadths above and medial to the anterior superior iliac spine. The external and internal oblique and transverse abdominal muscles are divided in line with this incision.

The extraperitoneal plane is entered and bluntly developed superiorly and inferiorly, and the peritoneal sac is retracted medially to expose the iliac vessels. The internal iliac artery is controlled by careful dissection in the plane between the artery and the vein, and the vessel is controlled and ligated as described above.

A percutaneous approach is made by directing a 19-gauge puncture needle into the common femoral artery in a retrograde fashion and angled at approximately 45-60° cranially. The use of ultrasonography (US) to guide the approach facilitates the positioning of the puncture.

A wire is passed into the artery through the needle, and an appropriately sized arterial sheath is advanced into the artery via the Seldinger technique, then secured in place.

The index internal iliac artery can be approached from either the ipsilateral or the contralateral side after the aortic bifurcation is crossed. Appropriately shaped catheters are used to advance a hydrophilic guide wire into the artery. Once the index internal iliac artery has wire access, the sheath can be advanced into the artery, and either the vessel can be coil-embolized[24] or an Amplatzer plug can be deployed to occlude the vessel.

Specific complications of internal iliac artery ligation may include the following:

• Infertility and impotence in men
• Buttock and thigh claudication
• Damage to the ureter
• Ischemic limb from damage to the common or external iliac artery
• Damage to other pelvic vessels
• Damage to pelvic nerves, including the hypogastric plexus
• Spinal ischemia
• Bladder gangrene (rare) ^[25]

It has been suggested that internal iliac artery ligation may reduce ovarian reserve in the short term.[26]