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Chin J Traumatol
Chin J Traumatol
Chinese Journal of Traumatology
1008-1275
1008-1275
Elsevier

S1008-1275(24)00076-2
10.1016/j.cjtee.2024.07.004
Systematic Review
Internal iliac artery ligation as a damage control method in hemodynamically unstable pelvic fractures: A systematic review of the literature
Li Hui
Ai Tao
Huang Guang-Bin
Yang Jun
Wei Gong-Bin
Gao Jin-Mou
He Ping
Cao Xue-Mei
Du Ding-Yuan dudingyuan@qq.com
⁎
Department of Trauma Surgery, Chongqing University Central Hospital, Chongqing Emergency Medical Center, Chongqing, 400014, China
⁎ Corresponding author. dudingyuan@qq.com
05 7 2024
9 2024
05 7 2024
27 5 288294
19 9 2023
20 6 2024
2 7 2024
© 2024 Production and hosting by Elsevier B.V. on behalf of Chinese Medical Association.
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/).
Purpose

Internal iliac artery ligation (IIAL) has been used as a damage control procedure to treat hemodynamically unstable pelvic fracture for many years. However, there is ongoing debate regarding the effectiveness and safety of this hemostatic method. Therefore, we performed a systematic literature review to assess the efficacy and safety of IIAL for pelvic fracture hemostasis.

Methods

Three major databases, PubMed, Embase, and Google Scholar, were searched to screen eligible original studies published in English journals. Two reviewers independently read the titles, abstracts, and full texts of all literature. Articles were included if they reported the use and effects of IIAL.

Results

A total of 171 articles were initially identified, with 22 fully meeting the inclusion criteria. Among the analyzed cases, up to 66.7% of patients had associated abdominal and pelvic organ injuries, with the urethra being the most frequently injured organ, followed by the bowel. The outcomes of IIAL for achieving hemostasis in pelvic fractures were found to be satisfactory, with an effective rate of 80%. Hemorrhagic shock was the leading cause of death, followed by craniocerebral injury. Notably, no reports of ischemic complications involving the pelvic organs due to IIAL were found.

Conclusion

IIAL has a good effect in treating hemodynamically unstable pelvic fracture without the risk of pelvic organ ischemia. This procedure should be considered a priority for hemodynamically unstable pelvic fracture patients with abdominal organ injuries.

Keywords

Internal iliac artery
Ligation
Embolization
Pelvic fracture
Laparotomy
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pmc1 Introduction

Hemodynamically unstable pelvic fractures (HUPFs) are a major cause of death in trauma patients and pose a significant challenge for trauma surgeons. Hemorrhagic shock is the primary cause of death in cases of unstable pelvic fractures, with a mortality rate of 8% – 50%.1, 2 To manage hemorrhage, a range of techniques have been employed for the early hemostasis of pelvic fractures, including pelvic belt fixation, bilateral internal iliac artery ligation (IIAL) or internal iliac artery embolization (IIAE), external pelvic fixator, preperitoneal pelvic packing, and resuscitative endovascular balloon occlusion of the aorta.3, 4, 5, 6, 7, 8

HUPF often occur in high-energy trauma and are prone to concomitant injuries to abdominopelvic organs and thoracic organs. The presence of abdominopelvic organ injury significantly increases the complexity of diagnosis and treatment of the pelvic fracture. Achieving a balance between managing pelvic fractures and abdominopelvic organ injuries at an early stage remains a challenge for trauma surgeons.

During the 1950s and 1960s, the use of IIAL was gradually adopted as a means of bleeding control associated with pelvic fractures and showed promising results.9 Although its efficacy was initially questioned, subsequent reports suggested that it was effective. However, with the advent of endovascular interventional procedures in the 1970s, IIAE rapidly became the dominant approach for pelvic fracture hemostasis.10 Nonetheless, IIAL still plays an important role in managing HUPF in certain situations and cannot be entirely replaced by IIAE. The purpose of this paper is to conduct a systematic review of the literature on the effectiveness and safety of IIAL for pelvic fracture hemostasis, and to discuss the indications for its use in managing pelvic fractures, providing insights into its appropriate use in clinical practice.

2 Methods

The methodology used in this systematic review was based on the preferred reporting items for systematic reviews and meta-analyses group.

2.1 Search strategy and selection criteria

Relevant literature published from 1946 – 2023 was searched in PubMed, Embase, and Google Scholar databases. Keywords searched including internal iliac artery, hypogastric artery, ligation, pelvic fracture, shock, and hemorrhage. The study was limited to original studies on human subjects, published in English. The literature search was conducted independently by 2 reviewers and completed on April 10, 2023. Exclusion criteria included: animal experiments, IIAL performed for hemipelvis resection, non-English publications, reviews, or expert opinions. Two reviewers independently reviewed the titles and abstracts of all the literature to determine if they met the screening criteria, and then conducted a full-text review. If the references in the full text met the requirements, they were also included for analysis. Due to the scarcity of studies in this area, we attempted to collect all relevant case reports, case series, and studies pertaining to this procedure.

2.2 Data extraction

Our literature search failed to identify any randomized controlled studies. The final set of eligible literature comprised cohort studies, case series, and case reports. All literature meeting the inclusion criteria from each search route was imported into Mendeley to remove duplicates and screened based on title and abstract for relevance. Any publications deemed irrelevant were excluded, and the reasons for exclusion were recorded. If the relevance of a publication was unclear, the full text was reviewed. Finally, only literature that met the inclusion criteria was included, and a flow chart was generated to illustrate the screening process (Fig. 1).Fig. 1 Preferred reporting items for systematic reviews and meta-analyses diagram detailing search results.

Fig. 1

We developed a data extraction form to record pertinent data, including the year of publication, study design, level of evidence, and patient numbers. Information related to the performance of IIAL included: type of IIAL (temporary or permanent ligation, unilateral or bilateral ligation), and any complications occurred. Treatment outcomes data included hemostatic outcome, number of survivors, cause of death, mortality rates, and adjacent organ injuries. Given the small sample size of the included studies and the heterogeneity of the study population, a meta-analysis was not possible, so the results are presented in a narrative format.

3 Results

Based on the inclusion and exclusion criteria, 22 articles were finally identified for the subsequent analysis (Table 1).Table 1 Characteristics of the selected studies.

Table 1Study	Year	Country	Study design	Level of evidence	Duration	Number of cases	Per/Tem	ISS	Bi/Uni	Ischemia
complications	
Choi et al.11	2023	Korea	Cos	IV	5y	20	Per	42	Bi	None	
Bagaria et al.12	2022	India	CS	V	5y 9 m	66	Per	30	Bi	NM	
Bonnici et al.13	2022	US	CR	V	1	1	Tem	–	Bi	None	
Jang et al.14	2022	Korea	Cos	IV	4y	13	Per	–	Bi	NM	
Schellenberg et al.15	2022	US	Cos	IV	13	77	Tem	34	Bi	None	
Rankin et al.16	2020	UK	CS	V	11 y	4	Per	–	Bi	NM	
Huang et al.6	2019	China	CoS	IV	10 y	54	Per	32 ± 7	Bi	1 sexual dysfunction	
Chernobylsky et al.7	2018	US	CoS	IV	14y	51	Tem	33 ± 14	Bi	None	
Kim et al.5	2017	Korea	CR	V	1 y	1	Per	–	Bi	None	
Harris et al.17	2014	US	CS	V	11 y	3	Per	40 ± 14	Uni or NM	NM	
DuBose et al.18	2010	US	CoS	III	22 m	28	Per& Tem	33.1	Bi	None	
Yang et al.19	2008	China	CS	V	10 y	21	Per	41.4	Bi	None	
Gao et al.20	2005	China	CS	V	14 y	33	Per	32.43	Bi	1 impotence	
Williams et al.21	2005	UK	CR	V	–	1	Per	–	Uni	NM	
Fleming et al.22	1973	US	CR	V	–	1	Per	–	Uni	NM	
Kamal et al.23	1973	India	CR	V	–	1	Per	–	Bi	NM	
Motsay et al.24	1969	US	CR	V	2y	2	Per	–	Bi	NM	
Horton et al.25	1968	UK	CR	V	5 y	2	Per	–	2 Uni	NM	
Hauser et al.26	1965	US	CS	V	2y	4	Per	–	3 Uni & 1 Bi	NM	
Peltier et al.27	1965	US	CS	V	5y	3	Per	–	NM	NM	
Seavers et al.28	1964	US	CR	V	8 y	4	Per	–	2 Uni & 2 Bi	NM	
Miller et al.29	1963	US	CR	V	4y	2	Per	–	Uni	NM	
UK: United Kingdom; US: United States; CR: case report; CS: case series; CoS: Cohort study; y: year; m: month; Per: permanent; Tem: temporary; ISS: injury severity score; Bi: bilateral; Uni: unilateral; NM: not mention.

3.1 Time distribution of studies

The first report on the use of IIAL for pelvic fracture hemostasis was published in 1963, with 2 cases reported.29 According to the literature, the earliest application of IIAL in the management of massive hemorrhage caused by pelvic fractures was in 1954.28 A total of 8 case reports or case series were published in the 10 years from 1963 to 1973. From 2005 to 2023, there have been a total of 14 consecutive publications documenting the application of IIAL in bleeding control associated with pelvic fractures.

3.2 The indication for IIAL and findings during laparotomy

According to the study of Chernobylsky et al.7, the most common indication for IIAL in pelvic fractures was hemodynamic instability, as reported in 51 patients with severe pelvic fractures, 25 of whom were unable to be moved to the interventional room due to hemodynamic instability. Bagaria et al.12 retrospectively analyzed 66 IIAL cases revealed that 23 cases (34.8%) were positive for preoperative ultrasound assessment, and of those, 11 (16.7%) had abdominal organ injuries, with 4 (4.1%) potentially leading to hemorrhagic shock. In study of Yang et al.19, 21 patients underwent laparotomy and bilateral IIAL. The most frequently observed adjacent organ injuries were bladder rupture, small intestinal rupture, and colorectal rupture, each with 6 cases. Additionally, the study reported 3 cases of splenic rupture, as well as 1 case each of liver, kidney, and pancreatic injury.

Based on the case reports included in this review, large retroperitoneal hematomas were identified in all cases. Among the 25 case reports, 18 cases documented intraoperative findings, with injuries involving the abdominal and pelvic organs in 12 cases, accounting for a proportion of 66.7% (12/18). Urethral injury was the most common type of adjacent organ injury, followed by injuries to the small intestine, colon, and rectum. Of the 3 cases with open pelvic fractures, 2 received sigmoid colostomy. It is noteworthy that one of the pelvic fractures combined with external iliac artery injury required laparotomy, resulting in a final laparotomy requirement of 72.2% (13/18), as detailed in Table 2.Table 2 Evaluation of the effect of IIAL and intraoperative findings.

Table 2Study	Year	No. of cases	No. of effective hemostasis	No. of survivors	Cause of death	Findings in abdominopelvic surgery	
Bonnici et al.13	2022	1	1	1	–	Profuse retroperitoneal and pelvic hemorrhage	
Kim et al.5	2017	1	1	1	–	Open pelvic fractures, sigmoid colostomy	
Harris et al.17	2014	3	3	3	–	–	
Williams et al.21	2005	1	1	1	–	Urethral rupture	
Fleming et al.22	1973	1	1	1	–	External iliac artery and vein injury, open pelvic fracture, sigmoid colostomy	
Kamal et al.23	1973	1	1	1	–	Open pelvic fracture, vaginal and urethral lacerations	
Motsay et al.24	1969	2	2	0	Both died of intracranial injury	1. Splenic laceration, external iliac vein injury;

2. Splenic rupture

	
Horton et al.25	1968	2	2	2	–	1. Negative;

2. Sigmoid laceration

	
Hauser et al.26	1965	4	4	3	1 fat embolism	1. Small bowel resection anastomosis;

2. Negative;

3. Abdominal wall hernia;

4. Urethral, splenic and bladder rupture

	
Peltier et al.27	1965	3	0	0	3 cases of hemorrhagic shock	–	
Seavers et al.28	1964	4	3	3	1 case of hemorrhagic shock	1. Negative;

2. Progressive enlarging hematoma in the right buttock with a negative intra-abdominal cavity;

3. Uterine rupture;

4. Urethral rupture.

	
Miller et al.29	1963	2	2	0	1 fat embolism, 1 renal failure	1. Bladder, rectal and anal injuries;

2. Bladder and rectal injuries

	
Total		25	20	15			

3.3 The types of ligations

Before 2010, all the reported IIAL procedures for treating pelvic fractures were permanent. However, in a retrospective study published in 2010, Dubose et al.18 reported on 4 patients who underwent temporary IIAL. This approach restored blood supply to the internal iliac artery 24 − 72 h after injury and was accomplished using Rommel tourniquet and clip occlusion techniques. Two cases of temporary IIAL required re-ligation in the operating room due to the recurrence of bleeding caused by operator error.7 Permanent ligation has been proven to be a reliable method, with no reports of ligation loosening. Bilateral IIAL is the preferred approach, and to date, over 97% of cases have been performed bilaterally.

3.4 Hemostatic effect

As detailed outcome evaluation of each case after receiving IIAL was available in the case reports, we performed further analysis of the case reports to assess the effectiveness of IIAL in achieving hemostasis. In most studies, the results of IIAL hemostasis were satisfactory, and the combined data revealed an effective hemostatic rate of 80.0% (20/25). However, 5 of these patients had good effects after IIAL, but they died subsequently due to craniocerebral injury, fat embolism, and renal failure. In study the of Chernobylsky et al.7, 18 patients experienced re-bleeding after bilateral IIAL. Six of these cases proceeded to IIAE after the release of the ligature wire, 2 were delayed bleeding due to the loosening of the ligature wire and therefore re-ligated to stop the bleeding, and the remaining 10 returned to the operating room for re-packing. The author did not provide details on the 18 patients' prognosis.

3.5 Mortality

We analyzed the case series with ≥ 3 cases (Table 3) and identified 8 studies reported mortality data. The results showed that the mortality rate of pelvic fracture patients who received IIAL ranged from 21.2% to 100.0%, with a combined mortality rate of 44.2%. Hemorrhagic shock was the leading cause of death (55.8%), followed by craniocerebral injury (20.0%) and other causes such as acute respiratory distress syndrome and cardiac arrest, accounting for 24.2%.Table 3 Mortality in pelvic fractures treated with IIAL and distribution of causes of death.

Table 3Study	Year	No. of patients	No. of deaths	Mortality rate (%)	Cause of death, n (%)	
Hemorrhagic shock	Craniocerebral injury	Others	
Bagaria et al.12	2022	66	42	63.6	30 (71.4)	2 (4.8)	10 (23.8)	
Huang et al.6	2019	54	17	31.5	4 (23.5)	7 (41.2)	6 (35.3)	
DuBose et al.18	2010	28	18	64.3	8 (44.4)	7 (38.9)	3 (16.7)	
Yang et al.19	2008	21	5	23.8	3 (60.0)	0	2 (40.0)	
Gao et al.20	2005	33	7	21.2	4 (57.1)	2 (28.6)	1 (14.3)	
Hauser et al.26	1965	4	1	25.0	0 (0)	0 (0)	1 (100.0)	
Peltier et al.27	1965	3	3	100.0	3 (100.0)	0 (0)	0 (0)	
Seavers et al.28	1964	4	2	50.0	1 (50.0)	1 (50.0)	0 (0)	
In total		213	95	44.6	53 (55.8)	19 (20.0)	23 (24.2)	

3.6 Complications

Before 2005, no case report or case series described the presence of complications of pelvic organ ischemia. In the retrospective study of Gao et al.20, mild impotence was found in 1 patient with urethral injury. Huang et al.6 reported 1 patient with postoperative sexual dysfunction, but the authors did not analyze whether this complication was associated with IIAL. Due to a lack of long-term follow-up data, the progression of this complication over time is unclear. Seven other studies reported no ischemia complications in the pelvic organs.5,7,11,13,15,18,19

4 Discussion

IIAL has been used for the treatment of HUPF for nearly 70 years. The technique had a wide interest in its early years, but from the mid-1970s, reports on IIAL dropped sharply, possibly due to the rapid popularity of the interventional method. And possibly due to complexity of the procedure during emergency (safety concern) and its associated complications like inadvertant ligation of common iliac arteries or external iliac arteries. Some even believe that the procedure itself is not effective (due to high failure rates) as there is a rich retroperitoneal collateral blood supply to the pelvis. However, as a damage control procedure, IIAL should be mastered by more trauma surgeons. This systematic review evaluates the status and value of the application of IIAL by analyzing the relevant literature over the past 60 years to provide a better understanding of this method to a wider range of practitioners.

4.1 Hemostatic effect

The effectiveness of IIAL in achieving hemostasis for pelvic fractures has been a topic of debate. Some experts believe that blood flow from the collateral circulation may cause continued bleeding at the fracture site even after IIAL, thus limiting its hemostatic effect. Furthermore, venous bleeding is more prevalent after pelvic fractures, and IIAL is not directly effective in controlling such bleeding, which further limits its utility. However, this systematic review found that IIAL can achieve hemostasis in pelvic fractures with an effective rate of 80%, indicating that IIAL can stabilize the patient's blood pressure and serve as a valuable damage control procedure.

The effectiveness of hemostatic treatment can be evaluated by the amount of blood products required during resuscitation. In the study of Fleming et al.22, the amount of blood transfused in the first 24 h was compared between the 2 groups of patients who received IIAL and those who did not. The results showed that the IIAL group required only 13.6 units, while the unligated group required 16.5 units. Furthermore, in the following 48 h, the IIAL group only required 2.8 units, which was significantly lower than the 14.8 units required by the unligated group.

In the 1960s, Horton et al.25 reported that bleeding from the internal iliac artery and its branches was a major cause of massive retroperitoneal hematoma and that compression and the coagulation mechanism could quickly limit pelvic venous bleeding. However, the effectiveness of IIAL may be reduced in cases of large vein injuries. Peltier et al.27 reported 3 cases of IIAL where all patients with pelvic fractures died, and all of them had internal iliac vein injuries. It is worth noting that these patients underwent internal iliac vein ligation. It has been suggested that repairing the internal iliac vein after injury instead of ligating it may be more effective as ligation can lead to increased bleeding from injured collateral circulation, resulting in a failed hemostatic intervention.30

4.2 Physiological mechanisms of IIAL for hemostasis

The hemostatic effect of IIAL is achieved by significantly reducing pelvic artery perfusion. In a classic study published in 1968, it was reported that after bilateral IIAL, the internal iliac artery pulse pressure could be decreased by 85%, and ipsilateral and contralateral reductions of 77% and 14%, respectively, could be achieved after unilateral IIAL.31 From our experience, many trauma patients with HUPF have experienced rapid stabilization of blood pressure after receiving bilateral IIAL. A similar scenario can be observed in patients undergoing IIAE, where rapid cessation of arterial bleeding and immediate restoration of blood pressure can often be observed during the operation. As blood flow slows down after passing through the collateral circulation, bleeding rates are reduced, and the hammer effect due to arterial pulsation is significantly diminished. Consequently, blood clots are more likely to form at the bleeding site and are less likely to dislodge, thus facilitating better hemostasis. IIAL can directly limit arterial bleeding while also enabling the body's coagulation process to overcome bleeding by reducing perfusion of the pelvic arteries, ultimately achieving complete hemostasis.

The IIAL technique decreases the perfusion of the pelvic arteries, which, in turn, reduces venous backflow. While there is limited clinical evidence that blocking the internal iliac artery reduces internal iliac vein hemorrhage, Sherman et al.32 conducted animal research using the pig model demonstrated a significant reduction in internal iliac vein blood flow after IIAE. After unilateral IIAE, there was an average reduction of 36% in ipsilateral internal iliac vein blood flow, while bilateral IIAE resulted in a 54% reduction, thus providing a theoretical basis for decreasing venous bleeding in IIAL. Therefore, devascularization of the internal iliac artery, whether through ligation or embolization, should not be overlooked in patients with pelvic trauma even without definite evidence of arterial bleeding. Instead, any measure contributing to bleeding control should be considered during resuscitation of an extremely hemodynamically unstable pelvic fracture.

4.3 Indications of IIAL

HUPF combined with abdominal or pelvic organ injury represents the best indication for performing IIAL. Given that pelvic fractures are frequently accompanied by adjacent organ injuries, IIAL has become a vital intervention in the management of these complex injuries. A systematic review based on 9 case reports and case series revealed a high incidence rate of 66.7% of intra-abdominal organ injuries in patients who underwent IIAL (Table 2). Furthermore, in a retrospective analysis of 3221 severe pelvic fractures, Cho et al.4 reported a staggering 34.3% incidence rate of adjacent abdominal and pelvic organ injury. Other studies have also demonstrated that up to 21% – 45% of pelvic fractures require an emergent laparotomy for associated injuries.33,34

Meanwhile, early signs of hollow visceral injury in patients with pelvic fractures may not be obvious. CT is not highly sensitive for hollow organ injuries caused by blunt injuries. One study reported that approximately 13% of patients with small bowel rupture after blunt injury had a negative CT scan.35

Additionally, open pelvic fractures that necessitate colostomy are also a significant indication for laparotomy. In this systematic review, 3 cases of open pelvic fractures were reported, and 2 of these cases required sigmoid colostomy.

Another indication for laparotomy is when a patient's vital signs are extremely unstable, and they can only be safely transferred to the operating room for damage control surgery. HUPF often do not permit contrast-enhanced CT scans, which can result in a delayed diagnosis of abdominal injuries. Additionally, it can be challenging to detect hollow organ injuries using ultrasound alone during the initial survey. In this scenario, implementing IIAL can achieve dual benefits by simultaneously addressing pelvic fracture hemorrhage and exploring the abdominal viscera.

In recent decades, IIAE has become the preferred treatment option instead of IIAL, even if the patient's vital signs are not stable enough. However, this approach can carry significant risks for unstable pelvic fracture patients who undergo IIAE in an interventional room without adequate resuscitation resources.

The hybrid operating equipment, which enables patients to undergo IIAE without being moved after undergoing laparotomy, has the potential to address this issue and improve the survival rate of patients with pelvic fractures. However, due to the high cost of this equipment, it is challenging to widely implement this technique. Therefore, when dealing with HUPF, performing laparotomy with IIAL simultaneously should be given priority.

4.4 Incidence and characteristics of internal iliac artery injury in HUPF

Studies have indicated that pelvic fractures primarily result in venous bleeding. However, the high incidence of arterial bleeding in HUPF cannot be overlooked. In one study of 27 cadavers who died due to pelvic fractures, angiography of the internal iliac artery system revealed that contrast extravasation of arterial origin occurred in 23 cases, of which 6 were unilateral, 17 were bilateral, and 14 showed significant contrast extravasation in more than 2 sites.36

Chernobylsky et al.7 reported 112 cases of pelvic fracture in which IIAE was performed, and visible bleeding sites were found on CT in 57 of these cases. In the study of Tanizaki et al.37, 286 patients with blunt pelvic injuries, 90 patients underwent internal iliac arteriography. Of these patients, 36 had hemodynamic instability, 88 had signs of internal iliac artery branch injury, and only 2 had no injury to the internal or external iliac artery. These findings suggest that patients with HUPF are at a high risk of injury involving the internal iliac artery system. Therefore, surgical procedures that primarily target the internal iliac artery, such as IIAL and IIAE, should be widely used in the treatment of HUPF. The high incidence of arterial injury supports the effectiveness of IIAL.

It is worth noting that the aforementioned cadaver study's findings have also been widely cited as the theoretical basis for preperitoneal pelvic packing in managing HUPF.36,38 However, we found that the citing authors have misunderstood the methodology and results of the original research, leading to opposing conclusions. Regarding the practical value of preperitoneal pelvic packing recent studies suggest an increased incidence of infection and thrombotic complications, and do not consider it advantageous in the treatment of HUPF.39, 40, 41

4.5 Timing of IIAL

Traumatic coagulopathy is a critical factor that can affect the efficacy of IIAL. Performing IIAL before coagulopathy sets in can reduce perfusion of the internal iliac artery and facilitate hemostasis by promoting clot formation at the injured site. According to the research of Fang et al.42, a lack of clotting factors can lead to suboptimal clot formation, and coagulation dysfunction is a major contributor to treatment failure in IIAE. However, none of the IIAL reports mentioned the patients' preoperative period or whether they had coagulation dysfunction at the time of surgery. These findings suggest that it is challenging to reverse the coagulopathy process through blood transfusion alone. Thus, damage control surgery should be performed as early as possible to avoid the onset of traumatic coagulopathy.26

4.6 Complications

The concern over the risk of pelvic organ ischemia due to IIAL has been a significant factor inhibiting its clinical use. Previous reports have indicated that internal iliac artery devascularization can lead to ischemic complications, including incisional infection43,44, gluteal muscle necrosis43,45, and nonunion of pelvic fractures44. However, no case of ischemic necrosis of the gluteal muscle caused by IIAL or trunk embolization have been reported in the author's institution to date6,19,20, which is consistent with the view described in Trauma, 9th edition46. Kritpracha et al.47 found that peripheral embolism of the branches of the internal iliac artery is the main cause of pelvic organ ischemia. Mehta et al.48 conducted an observational study of 154 cases and found that proximal coil embolization of the internal iliac artery did not lead to complications such as gluteal muscle necrosis or colonic ischemia. Therefore, the author believes that it is safe to obstruct the blood supply of the internal iliac artery near the main stem.48 In addition, IIAL is usually performed at the proximal main stem, and pelvic organs can maintain sufficient blood supply through small collateral circulation, so ischemic complications will not occur.

In the study by Velmahos et al.49, the incidence of postoperative sexual dysfunction in patients with pelvic fractures who underwent non-selective IIAE did not differ significantly from the non-embolized group. Four studies in this systematic review explicitly mentioned the absence of ischemic complications. While 2 studies reported sexual dysfunctions in patients after undergoing IIAL, they did not analyze whether it was caused by pelvic fracture or IIAL. Therefore, this systematic review found no evidence to suggest that IIAL leads to pelvic ischemic complications, and the available literature indicates that this method is safe.

4.7 Types of IIAL

The ligation of the internal iliac artery is typically a permanent procedure. However, temporary IIAL can be performed by occluding the artery with suture ligation, Rummel tourniquet, or clip occlusion, and then releasing it once the patient's vital signs have stabilized, as reported by Dubose et al.18 This approach is a useful alternative to permanent IIAL in patients with pelvic fractures who require temporary closure after emergency laparotomy. If hemostasis is insufficient after temporary IIAL, the ligature can be loosened, and IIAE can be performed. Chernobylsky et al.7 reported 6 cases of pelvic fractures in which temporary IIAL was followed by loosening of the ligature for gelatin sponge embolization due to persistent bleeding. However, temporary IIAL is a relatively complex procedure, and its reliability may be compromised due to the likelihood of loosening. Moreover, loosening the ligation requires re-opening the retroperitoneum, which may increase blood loss. Currently, no studies have compared the safety and efficacy of temporary vs. permanent IIAL for pelvic fractures.

4.8 Outlook on the use of IIAL

Patients with pelvic fractures often have multiple injuries and may require coordination among several departments, especially in hospitals without a trauma center. Orthopedic surgeons are typically responsible for treating the pelvic fracture, while general surgery, urology, gynecology, or vascular surgery may be needed to manage injuries to abdominal or pelvic organs. However, surgeons who specialize in abdominal surgery may be reluctant to perform IIAL because it falls outside their area of expertise, and orthopedic surgeons may have insufficient training in surgeries within the pelvic cavity. The aforementioned factors contribute to the limited adoption of IIAL in clinical practice. Therefore, fostering interdisciplinary collaboration and providing additional training opportunities for surgeons in both orthopedics and abdominal surgery could enhance the utilization of IIAL. With the increasing prevalence of trauma centers, the adoption of interdisciplinary surgical procedures, exemplified by IIAL, has the potential to enrich the array of hemostatic interventions available for managing pelvic fractures.

4.9 Limitations of this study

To the best of our knowlege, this article represents the first systematic review of the use of IIAL for HUPF. However, the main limitations of this review were the small number of included studies and their low quality. All studies on IIAL for pelvic fracture were retrospective, consisting mostly of case series and case reports, with no high-quality randomized controlled trials or prospective cohort studies available. Although most reports indicate that IIAL has an excellent therapeutic effect on hemorrhage caused by pelvic fractures, the possibility of publication bias cannot be ruled out. Therefore, the findings of this study should be interpreted with caution. This systematic review provides objective evidence for the use of IIAL for HUPF, but due to the lack of other hemostatic treatments as a control, no definitive recommendation can be made.

The use of IIAL for major pelvic fracture hemorrhage remains a topic of debate, but evidence suggests that it has a satisfactory effect in treating HUPF without causing pelvic organ ischemia. In cases where there is suspected abdominal organ injury or high risk of IIAE due to hemodynamic instability, laparotomy and bilateral IIAL should be considered a priority. For hospitals with limited resources, bilateral IIAL is a viable option for controlling severe pelvic fracture bleeding. As an important damage control approach, IIAL needs to be better known and implemented by trauma surgeons. However, the current clinical evidence on IIAL is limited, with mostly retrospective case series and case reports. Further high-quality clinical studies are needed to demonstrate its effectiveness.

Funding

This project was supported by the Joint Fund of Chongqing Municipal Science and Technology Bureau and Health Bureau, China (Grant ID:2022QNXM025 )，National Trauma Regional Medical Center (Jointly Constructed by the Commission and the Municipality) Major Research Project (jjzx2021-gjcsqyylzx01 ); Research Project of Chongqing Talent Program (cstc2022ycjh-bgzxm0245 ).

Ethical statement

Not applicable.

Declaration of competing interest

The authors declare no conflicts of interest.

Author contributions

Ding-Yuan Du: conceptualization, supervision, review and editing; Hui Li and Tao Ai: methodology, investigation, analysis and writing; Guang-Bin Huang, Jun Yang, Gong-Bin Wei, Jin-Mou Gao, Ping He, Xue-Mei Cao: writing, review and editing.

All authors have read and agreed with this version to be published.

Acknowledgements

We thank Dr. Demetrios Demetriades from USC + LAC medical center for his helpful advice in the preparation of this paper.

Peer review under responsibility of Chinese Medical Association.
==== Refs
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