Hypogastric (Internal Iliac) Artery Ligation 

Updated: Aug 18, 2020
Author: Chee Weng (David) Leong, MBBS; Chief Editor: Vincent Lopez Rowe, MD 

Overview

Background

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.

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:

  • Spontaneous hemorrhage due to advanced pelvic cancer, [7] control of postoperative pelvic hemorrhage, [8] intraoperative control of hemorrhage, and prophylactic ligation prior to extensive pelvic surgery [9] (though some studies have found that prophylactic ligation does not reduce intraoperative blood loss [10, 11] )
  • 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 [12]

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.[13]

Management of an acquired uterine arteriovenous malformation by means of selective ligation of the internal iliac artery has been described.[14]

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, 15, 16]

In a literature review detailing follow-up of 634 patients undergoing hypogastric artery ligation, 28% developed buttock claudication and 18% sexual dysfunction.[17] 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%.[18]

 

Periprocedural Care

Patient Preparation

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

Positioning

The patient is placed supine.

 

Technique

Approach Considerations

Ligation of the hypogastric (internal iliac) artery can be performed either via an open approach (intraperitoneal or extraperitoneal) or via an endovascular approach. In an emergency situation, bilateral retroperitoneal approaches to control both the right and the left hypogastric 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.[19]

Transabdominal/Transperitoneal Approach

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 anterosuperior 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 hypogastric 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.

Retroperitoneal Approach

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 hypogastric 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.

Endovascular Approach

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. Ultrasonographic guidance facilitates 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 hypogastric 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 hypogastric artery. Once the index hypogastric artery has wire access, the sheath can be advanced into the artery, and either the vessel can be coil-embolized[20] or an Amplatzer plug can be deployed to occlude the vessel.

Complications

Specific complications of hypogastric artery ligation may include the following:

  • Infertility and impotence in men
  • Buttock and thigh claudication
  • Damage to the ureter
  • Ischemic limb from damage to common or external iliac artery
  • Damage to other pelvic vessels
  • Damage to pelvic nerves, including the hypogastric plexus
  • Spinal ischemia
  • Bladder gangrene (rare) [21]

It has been suggested that internal iliac artery ligation may reduce ovarian reserve in the short term.[22]