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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)00983-0
10.1016/j.ijscr.2024.110202
110202
Case Series
Embolization of the hypogastric artery after surgical ligation: A case series of two patients
Aloui Haithem alouihaithem85@gmail.com
a⁎
Azouz Eya b
Frikha Hatem a
Binous Mohamed Mehdi a
Hammami Rami a
Abouda Saber Hassine a
a Tunis Faculty of Medicine El Manar University, Gynecology and Obstetrics Department C at the Tunis Maternity and Neonatology Center, Tunisia
b Tunis Faculty of Medicine El Manar University, Radiology Department La Rabta Hospital of Tunis, Tunisia
⁎ Corresponding author at: 20th Ahmed Chaouki street, Manoubah, Tunisia. alouihaithem85@gmail.com
20 8 2024
10 2024
20 8 2024
123 11020211 7 2024
15 8 2024
19 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction

The increasing incidence of obstetric complications, such as post-partum hemorrhage in the case of placenta accreta spectrum, calls for innovative and adapted therapeutic approaches. This presentation highlights the effectiveness of arterial embolization of the hypogastric artery, properly known as the internal iliac artery, in managing obstetric bleeding, even after initial surgical ligation. An approach never described in the literature.

Presenation of cases

1st Case: A 38-year-old patient, in her fourth pregnancy with two previous caesarean sections, was admitted for moderate metrorrhagia at 19 weeks gestation. Ultrasound showed a monofetal pregnancy at 17 WG with a 6 cm placental abruption and an anterior placenta with accretion signs. An emergency subtotal hysterectomy with triple Tsirulsikov arterial ligation was performed after transfusion. Due to persistent bleeding, bilateral hypogastric artery ligation and abdominal packing were added, but without improvement. The patient was referred for embolization after hemodynamic stabilization. The procedure was carried out successfully and no complications were reported.

2nd Case: A 35-year-old patient with vaginal bleeding from placenta accreta at 25 WG required hemostasis hysterectomy. Despite the procedure, bleeding continued, leading to bilateral hypogastric artery ligation and pelvic packing. The patient was hemodynamically stabilized and transferred for hypogastric artery ligation, which was successfully performed without complication.

Discussion

The role of interventional radiology in managing postpartum hemorrhage (PPH) is well established, with substantial literature supporting the benefits of uterine artery embolization as a lifesaving and often uterine-sparing procedure in PPH. While its indication for prevention is well-known, what about post-operatively? Our experience indicates that consulting a radiologist specializing in pelvic embolization can yield satisfactory outcomes despite technical difficulties.

Conclusion

Embolization of the hypogastric arteries as well as embolization followed by surgical ligation of these arteries have been well described in the literature, the originality in our case reports is the embolization performed after surgical ligation which has not been described before according to our knowledge and which despite its technical difficulty can be a satisfactory alternative for the control of post-partum hemorrhage.

Highlights

• Successful embolization after surgical ligation in two obstetric hemorrhage cases.

• Arterial embolization controls bleeding post-surgery, even with technical challenges.

• Femoral artery puncture and hyper-selective embolization used for hemostasis.

• Case 1: Subtotal hysterectomy failed; embolization stopped persistent bleeding.

• Case 2: Placenta accreta required hysterectomy; embolization stabilized bleeding.

Keywords

Postpartum hemorrhage
Percutaneous transcatheter
Arterial embolization
Pelvic embolization
Abnormal placentation
Case series
Abbreviations

WG weeks' gestation

PPH post-partum hemorrhage

PRBC packed red blood cells

FFP fresh frozen plasma

SAMU service d'aide medicale urgente (emergency medical service)
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pmc1 Introduction

We present two consecutive clinical cases demonstrating the successful embolization of the hypogastric artery, also known as the internal iliac artery, following surgical ligation, specifically in the context of postpartum hemorrhage due to placenta accreta spectrum (PAS). These cases were managed at the ‘C’ department of the Maternity and Neonatology Center in Tunis.

With the rising incidence of obstetric complications, particularly postpartum hemorrhage, there is a pressing need for innovative and adaptable therapeutic approaches, especially in PAS [1]. This case series underscores the effectiveness of hypogastric artery embolization in controlling obstetric bleeding even after initial surgical arterial ligation, a scenario not previously documented in the literature. This work adheres to the PROCESS criteria [2].

2 Presentation of cases

1st Case: The patient, aged 38, undergoing her fourth pregnancy with two previous caesarean sections and one spontaneous miscarriage, was admitted for the management of moderate metrorrhagia at 19 weeks gestation (WG). Ultrasound examination revealed a progressive monofetal pregnancy at 17 WG biometry, with a suspicion of PAS.

The patient received a transfusion of 6 units of packed red blood cells (PRBC) and 3 units of fresh frozen plasma (FFP). Despite this, emergency surgery was required as the bleeding persisted, resulting in a decrease in hemoglobin from 10.6 to 8.5 g/dl. In the operating room, she underwent a subtotal hysterectomy with triple Tsirulnikov ligation and bilateral hypogastric artery ligation, along with abdominal and vaginal packing. Due to intraoperative hemodynamic instability, she received further transfusions of 8 units of PRBCs, 12 platelets, and 7 units of FFPs. Additionally, 2 g of tranexamic acid, 5 g of fibrinogen, and recombinant factor VIIa were administered, and noradrenaline was initiated.

Immediate postoperative vaginal bleeding persisted despite the use of a Bakri probe and vaginal packing, yielding no improvement. With this ongoing bleeding, the possibility of uterine artery embolization was considered, even in the presence of prior hypogastric artery ligation and packing.

Given the persistence of bleeding and the inability to perform further surgical interventions, the patient was referred for embolization following hemodynamic stabilization by the emergency medical service (SAMU).

The procedure involved puncturing the right and left femoral arteries and inserting two 5F introducers. Bilateral catheterization of the anterior trunks of the hypogastric arteries was performed. On the left side, where ligation was occlusive, arterial branches of the round ligament were accessed from the epigastric artery (Fig. 1).Fig. 1 A: Right side before embolization (case1), B: right side after embolization (case1), C: left side before embolization (case1), D: left side after embolization (case1).

Fig. 1

This allowed for hyper-selective access to the uterine arteries on the right side, due to incomplete ligation of the right hypogastric artery (Fig. 1).

Angiography revealed hypervascularization, likely of the uterine remnant, explaining the continued bleeding. Embolization was executed by slow injection of multiple 1 mm Spongel fragments until circulatory sub-arrest was achieved in the uterine arteries and the right cervicovaginal trunk arising from the obturator artery.

Following embolization, there was a cessation of bleeding and hemodynamic stabilization. No complications were noted.

2nd Case: 35-year-old patient presenting with vaginal hemorrhage related to PAS in a 25 WG, requiring hysterectomy for hemostasis. Despite this procedure, the hemorrhage remained uncontrolled, so the surgeons performed bilateral ligation of the hypogastric arteries and pelvic packing. Despite hysterectomy and bilateral surgical ligation of the hypogastric arteries, hemorrhage was not controlled. Hemodynamically stable, the patient was transferred to the radiology department for embolization of both hypogastric arteries.

bilateral catheterization of the anterior trunks of the hypogastric arteries followed by recanalization of the surgical ligatures was performed. Opacification then allowed visualization of hypervascularization, probably of the uterine and placental remnant (Fig. 2).Fig. 2 bilateral catheterization of the anterior trunks of the hypogastric arteries, which are occluded and despite pelvic packing (the marked fields).

Fig. 2

Embolization was then performed by slow injection of multiple 1 mm fragments of Spongel until circulatory sub-arrest was obtained in the uterine arteries and the right cervicovaginal trunk arising from the internal pudendal artery (Fig. 3).Fig. 3 uterine artery embolization (case 2). A B C D: Hypervascularization of the uterine and placental remnants. E, F: Achieving partial circulatory arrest at the level of the uterine arteries and the right cervicovaginal trunk originating from the internal pudendal artery.

Fig. 3

the operation was a success, the only complication was 2 cm of bruising at the catheter insertion points, which resolved spontaneously.

3 Discussion

Two clinical cases demonstrate successful hypogastric artery embolization following surgical ligation for postpartum hemorrhage due to placenta accreta spectrum. Both cases highlight the effectiveness of embolization in controlling persistent bleeding, achieving hemodynamic stabilization, and providing a viable intervention even after initial surgical approaches failed.

Placenta accreta spectrum poses a significant risk of catastrophic hemorrhage. Such situations often arise when attempting manual separation of the placenta from its bed, leading to the opening of large vessels. Managing this obstetric emergency presents considerable challenges [3].

The contribution of interventional radiology in addressing postpartum hemorrhage (PPH) is firmly established, with ample literature supporting the advantages of uterine artery embolization (UAE), which is performed by passing the catheter through the hypogastric artery, as a lifesaving and frequently uterus-preserving intervention for PPH, including instances related to placenta accreta spectrum (PAS) [4]. However, in more severe cases or if embolization of the uterine arteries is not sufficient, the hypogastric arteries may also be embolized to further reduce blood flow and control the hemorrhage [8].

In a study conducted in China, ten patients diagnosed with placenta accreta were managed conservatively. Uterine artery embolization proved effective in controlling postpartum hemorrhage among those patients [5].

In a study conducted in France with 10 female participants, pelvic embolization effectively halted the hemorrhaging. An emergency hysterectomy was necessary for two women experiencing persistent bleeding, both diagnosed with placenta percreta [6].

While its use for preventive measures is widely acknowledged, what about its post-operative application? Our firsthand experience suggests that consulting with a radiologist specializing in pelvic embolization post-operatively may yield a favorable outcome, even in the face of technical challenges.

Arterial ligation remains the predominant approach in countries like ours. It stands as the sole conservative option due to the inconsistent availability and high cost of interventional radiology [7].

The study demonstrates the successful use of hypogastric artery embolization following surgical ligation, highlighting its effectiveness in managing severe postpartum hemorrhage due to PAS. The multidisciplinary approach involving obstetrics, surgery, and interventional radiology underscores the collaboration required to manage complex cases. The detailed procedural steps and positive outcomes provide valuable insights into a novel intervention, showcasing its potential as a life-saving measure in obstetric emergencies.

A key limitation is the small sample size, with only two cases presented, which limits the generalizability of the findings. While effective in these cases, the novel technique may carry potential risks and complications if applied to a larger population. Contraindications such as incomplete arterial occlusion or patient instability must be carefully considered. Additionally, the reliance on specialized interventional radiology resources may not be feasible in all clinical settings, highlighting the need for further research and validation in diverse environments.

4 Conclusion

These case reports highlight the successful application of hypogastric artery embolization following surgical ligation in the management of postpartum hemorrhage, a practice never reported in the literature. Despite the challenges posed by prior arterial ligation, embolization emerged as an effective intervention, demonstrating its utility in controlling hemorrhage in obstetric emergencies. This case underscores the importance of considering embolization as a viable option, particularly when surgical alternatives are limited or ineffective after hemodynamic stabilization. Further research and dissemination of such cases are warranted to enhance awareness and understanding of this valuable therapeutic approach in obstetric practice.

Ethical approval

Ethical approval for this study was provided by the local Ethical Committee of Maternity and Neonatology Center of Author Form Tunis, Tunis, Tunisia on 24 October 2023 (Approval Number: 52/2023).

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CRediT author statement

Haithem Aloui, Rami Hammami: study concept or design.

Eya Azouz: data collection.

Hatem Frikha: data analysis or interpretation.

Mohamed Mehdi Binous: writing the paper.

Saber Hassine Abouda: Supervision.

Guarantor

Haithem Aloui.

Consent

Written informed consent was obtained from the patients for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Declaration of competing interest

We declare on our honor to have respected the ethics and anonymity of women in the use of data. We declare no conflict of interest.
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