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From the Society for Clinical Vascular Surgery

Consequences of hypogastric artery ligation,


embolization, or coverage
Gautham Chitragari, MBBS, Felix J. Schlosser, MD, PhD, Cassius Iyad Ochoa Chaar, MD, MS, and
Bauer E. Sumpio, MD, PhD, New Haven, Conn

Objective: Interruption of the hypogastric artery by ligation, embolization, or coverage frequently results in ischemic compli-
cations. The aim of this study was to compare the rate and risk factors for the development of ischemic complications after
interruption of the hypogastric artery in obstetrics and gynecology (OBG), vascular surgery, oncology, and trauma patients.
Methods: MEDLINE, Ovid, and Scopus were searched for articles containing data of patients who underwent interruption
of the hypogastric artery. Based on the indication, details of the procedure, and complications developed, data were
categorized and a systematic review was done to evaluate any significant differences.
Results: A total of 394 patients (median age, 48.5 years) from 124 papers were included in the study; 31% of the study
population was male and 69% was female. Indication for interruption was OBG related in 53.3%, vascular surgery related in
25.1%, oncology related in 17.5%, and trauma related in 4.1% of patients. Overall ischemic complication rate was 22.6%,
comprising buttock claudication in 12.2%, buttock necrosis in 4.8%, erectile dysfunction in 2.7%, spinal cord ischemia in 4.0%,
colonic ischemia in 2.5%, and bladder necrosis in 0.8%. Complications were fewer in patients younger than the median age of
48.5 years (12.8%) compared with those older than the median age (36.3%; P < .01), women compared with men (13.1% vs
41.7%; P < .01), OBG patients compared with vascular surgery patients (9.5% vs 37.4%; P < .01), patients after ligation
compared with embolization (9.4% vs 31.0%; P < .01), and proximal interruption compared with distal interruption (19.6% vs
51.4%; P < .01). No significant difference in complications was seen after bilateral interruption compared with unilateral
interruption (20.6% vs 27.1%; P > .05). Similarly, no significant difference in complication rate was seen with the type of
embolization material used. Among OBG patients, ligations resulted in fewer complications compared with embolization
(4.1% vs 16.7%; P < .01). Among vascular surgery patients, bilateral embolization resulted in a higher rate of complications
compared with bilateral ligation (83.3% vs 30.5%; P < .01). Among oncology patients, fewer complications were seen after
proximal interruption compared with distal interruption (25.5% vs 75%; P [ .01). No significant differences in outcome were
seen with regard to gender, laterality, and material used for embolization when patients were compared within each specialty.
Conclusions: Interruption of the hypogastric artery is relatively safe in young and OBG patients compared with vascular
surgery and oncology patients. Ligation of the hypogastric arteries is preferred to embolization, and proximal emboli-
zation should be preferred to distal embolization to decrease the risk of ischemic complications. Randomized controlled
trials with larger sample size are needed to definitively elucidate clear risk factors for development of complications after
hypogastric artery interruption. (J Vasc Surg 2015;62:1340-7.)

The hypogastric artery, properly known as the internal It supplies the pelvic viscera, pelvic wall, genitalia, buttocks,
iliac artery, has a prominent role throughout all phases of and medial side of the thigh.1
human life. In the fetus, it carries blood from the abdom- Howard Kelly performed hypogastric artery ligation to
inal aorta to the placenta through the paired umbilical ar- control bleeding from pelvic cancer in 1894.2 In the mod-
teries. Shortly after birth, the segment connecting the ern era, ligation, embolization, or coverage (LEC) of the
bladder to the umbilicus is obliterated. In adult life, the hy- hypogastric artery is performed for a variety of reasons
pogastric artery becomes the principal artery of the pelvis. (Table I). In vascular surgery, the hypogastric artery is
frequently interrupted during endovascular interventions.
For instance, although about 20% to 30% of infrarenal
From the Section of Vascular Surgery, Department of Surgery, Yale School abdominal aortic aneurysms have concomitant iliac aneu-
of Medicine.
Author conflict of interest: none.
rysmal disease that previously required an open repair, the
Presented as a poster at the Forty-third Annual Symposium of the Society availability of bifurcated endografts has made endovascular
for Clinical Vascular Surgery, Miami, Fla, March 29-April 2, 2015. repair of these abdominal aneurysms possible.3-5 When a
Additional material for this article may be found online at www.jvascsurg.org. suitable landing zone is not available for a bifurcated endog-
Correspondence: Bauer E. Sumpio, MD, PhD, Yale University School of
raft, the graft limb is frequently extended to the external iliac
Medicine, 333 Cedar St, BB 204, New Haven, CT 06520-8062
(e-mail: bauer.sumpio@yale.edu). artery, which interrupts blood flow to the internal iliac ar-
The editors and reviewers of this article have no relevant financial relationships tery. Moreover, to prevent type II endoleak, the hypogastric
to disclose per the JVS policy that requires reviewers to decline review of any arteries are frequently embolized. In obstetrics, hypogastric
manuscript for which they may have a conflict of interest. arteries are often ligated or embolized to treat uncontrolled
0741-5214
Copyright Ó 2015 by the Society for Vascular Surgery. Published by
postpartum hemorrhage. In gynecology, the hypogastric ar-
Elsevier Inc. teries are occasionally ligated to decrease operative blood
http://dx.doi.org/10.1016/j.jvs.2015.08.053 loss during hysterectomy, a majority of which are for benign

1340
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Volume 62, Number 5 Chitragari et al 1341

Table I. Routine indications for hypogastric artery study. Application of these inclusion and exclusion criteria
ligation, embolization, or coverage (LEC) in various to 2493 articles resulted in 124 articles that were analyzed
specialties in this study.
Data extraction. The two independent authors
Reason for interruption of selected and extracted data from the articles. Characteris-
Specialty hypogastric artery supply tics such as age, gender, indication, details of the proce-
Vascular surgery Coil embolization of a hypogastric dure, and complications were tabulated and compared by
artery aneurysm statistical analysis. Comparison between age groups was
Endovascular aneurysm repair of made using the median age of the study group as index.
infrarenal aorta Based on the indication for hypogastric artery LEC, the pa-
Obstetrics and gynecology To control postpartum hemorrhage
tients were divided into four major categories: OBG,
To decrease intraoperative blood
loss during hysterectomy vascular, oncology, and trauma.
Trauma To control pelvic hemorrhage Statistical analysis. Data analysis was performed with
Oncology To decrease intraoperative blood Statistical Package for the Social Sciences (version 19.0;
loss from pelvic tumors SPSS Inc, Chicago, Ill) software. For comparison between
variables of larger sample size, c2 and logistic regression
were used. For comparison between variables with smaller
conditions. In trauma patients with pelvic fractures, the hy- sample size, Fisher exact test was used. P value of # .05 was
pogastric arteries are ligated or embolized to control considered statistically significant.
bleeding from the wall plexus. During oncologic surgery, RESULTS
the hypogastric arteries are ligated or embolized to limit
operative blood loss or preoperatively to shrink some pelvic A total of 394 patients (from 124 articles) were
tumors. included in our study. Demographic and clinical character-
The aim of this study was to perform a comprehensive istics of our population of patients are presented in
literature review to compare the incidence of ischemic Table II. The age of these patients ranged between 1 and
complications after LEC of the hypogastric artery in obstet- 89 years (median, 48.5 years), and the male to female ratio
rics and gynecology (OBG), vascular surgery, oncology, was 1:2.2. The indication for LEC was OBG related in
and trauma patients. Special attention was devoted to 53.3%, vascular surgery related in 25.1%, oncology related
ascertaining the risk factors for development of ischemia af- in 17.5%, and trauma related in 4.1%. The most common
ter these different procedures. We hypothesized that the indications for LEC were aortoiliac aneurysm (vascular),
rate and type of complications after LEC of the hypogastric postpartum hemorrhage (OBG), pelvic hemorrhage
artery would vary for the different specialties and be depen- (trauma), and hemorrhage from pelvic cancer (oncology).
dent on the demographics of the populations studied. Less frequent indications were isolated internal iliac aneu-
rysm and control of intraoperative hemorrhage during hys-
terectomy. Details on the laterality and site of LEC, type of
METHODS procedure, and embolization agent (if used) are also
Selection of articles. MEDLINE, Ovid, and Scopus shown.
databases were searched from the earliest publications The overall ischemic complication rate (Table III) was
through January 2014 using all synonyms for hypogastric 22.6%. This comprised buttock claudication in 12.2%,
artery and embolization, ligation, and coverage (Appendix, buttock necrosis in 4.8%, erectile dysfunction in
online only) for English articles containing data of patients 2.7%, colonic ischemia in 2.5%, spinal cord ischemia in
who underwent hypogastric LEC for any reason. 4.0%, and bladder necrosis in 0.8%. Hereafter, the term
A total of 4195 articles were obtained in the search, but complication refers to any ischemic complications
1702 of them were found to be duplicates (Fig). The mentioned before. Older patients, defined as older than
remaining 2493 articles were reviewed by two independent the median age of 48.5 years, developed more complica-
investigators for relevance. Articles describing demographic tions compared with younger patients (<49 years;
characteristics, indications, details of the procedure per- 36.3% vs 12.8%; P < .0001). Overall, women developed
formed, and complications (if any) of at least one patient fewer complications compared with men (13.1% vs
who underwent hypogastric artery LEC were included in 41.7%; P < .0001). Complications were also fewer when
the study. Patients were considered not to have developed the indication was OBG related (9.5%; P < .01) compared
ischemic complications when it was explicitly stated or if with vascular (37.4%), oncologic (31.9%), and trauma
the words “no complications were found” were used any- (62.5%). Ligations resulted in a lower number of complica-
where in the article after mentioning the possibility of devel- tions compared with embolization (9.4% vs 31.0%;
opment of ischemic complications after the procedure. This P < .001). Fewer complications were seen when interrup-
was done to make sure that the absence of complications tion was done at the origin compared with distal interrup-
was not due to the author’s lack of knowledge of ischemic tion (19.6% vs 51.4%; P < .0001) or combined anterior
complications. Large case series (n > 3) describing only pa- and posterior trunk interruption (19.6% vs 45.4%;
tients who developed complications were excluded in our P ¼ .05). No significant difference in complication rate
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1342 Chitragari et al November 2015

Fig. Summary of the article selection process. LEC, Ligation, embolization, or coverage.

was seen with the type of embolization material used. Simi- and laterality of the procedure. Bilateral ligation produced
larly, when all procedures are combined, laterality of the more complications compared with bilateral embolization
procedure did not result in any significant difference in (83.3% vs 30.5%; P ¼ .01). Review of patients who devel-
outcome. Multivariate analysis was done to evaluate inde- oped complications after bilateral ligation showed that four
pendent risk factors, and results are shown in Table IV. of the five patients who developed complications had liga-
We analyzed the results on the basis of the specialty- tion of the inferior mesenteric artery during surgery. No
related indications. Because of the small sample size difference in complication rate was seen between unilateral
(n ¼ 16), meaningful analyses could not be made in the ligation and unilateral embolization.
trauma group. Among OBG patients (Table V), age ranged Among oncology patients (Table VII), the age ranged
between 17 and 69 years (median, 34.0 years). Buttock between 1 and 88 years (median, 63 years). Buttock clau-
claudication was seen in 5.2%, buttock necrosis in 1.4%, dication was seen in 17.3%, buttock necrosis in 5.8%, and
and spinal cord ischemia in 1.9%. None of the patients spinal cord ischemia in 2.9%. Colon ischemia was not re-
developed colonic ischemia or bladder necrosis. Bilateral ported. LEC at the origin produced fewer complications
ligation produced fewer complications compared with compared with LEC of distal branches (25.5% vs 75.0%;
bilateral embolization (3.9% vs 16.2%; P < .006); however, P ¼ .01). No significant difference was seen in complica-
no significant difference was found when the procedure tion rate with regard to the type and laterality of the proce-
was performed unilaterally (5.6% vs 18.2%; P ¼ NS). No dure or the embolization agent used.
significant difference in complications was found with re-
gard to age of the patient, site of embolization or ligation, DISCUSSION
and material used for embolization. Hypogastric artery LEC is commonly performed for
Among vascular surgery patients (Table VI), the age varied reasons across many surgical specialties. Although
ranged between 25 and 88 years (median, 74.0 years). it is generally considered a relatively benign procedure,
Buttock claudication was seen in 21.2%, buttock necrosis ischemic complications, such as buttock claudication or ne-
in 5.0%, erectile dysfunction in 2.7%, spinal cord ischemia crosis, erectile dysfunction, and rarely spinal cord ischemia
in 9.0%, and colonic ischemia in 7.0%. Nearly 60% of pa- or colonic ischemia, are not infrequent.
tients who experienced colonic ischemia developed spinal There have been several attempts to evaluate the risk
cord ischemia as well. No significant difference was found factors associated with the development of complications
in complication rate with regard to age of the patient, after LEC of the hypogastric artery. All of these studies
type of procedure, site of LEC, embolization agent used, were performed on a specific subset of patients with one
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Table II. Demographic and clinical characteristics of Table III. Complications based on indication and other
patients in our study group variables in overall study population

Variable Percentage, No. Complication rate,


Variable % (No.) P value
Gender (n ¼ 363)
Male 30.85 (112) All patients 22.6 (89/394)
Female 69.15 (251) Gender (n ¼ 363) <.0001
Age, years (n ¼ 387) Male 41.7 (47/112)
Range 01-89 Female 13.1 (33/251)
Mean age 43.0 6 21.2 Age (n ¼ 387) <.0001
Median age 48.5 #48.0 years 12.8 (28/219)
Reason for LEC (n ¼ 394) $49.0 years 36.3 (61/168)
Obstetric/gynecologic 53.3 (210) Indication for LEC (n ¼ 394)
Vascular 25.1 (99) Vascular 37.4 (37/99) Reference
Oncologic 17.5 (69) Obstetric/gynecologic 9.5 (20/210) <.0001
Trauma 4.1 (16) Oncologic 31.9 (22/69) NS
Laterality of LEC (n ¼ 394) Trauma 62.5 (10/16) NS
Unilateral 29.9 (118) Laterality (n ¼ 394) NS
Bilateral 70.1 (276) Unilateral 27.1 (32/118)
Type of procedure (n ¼ 394) Bilateral 20.6 (57/276)
Ligation 37.8 (149) Type of procedure (n ¼ 394)
Embolization 58.1 (229) Ligation 9.4 (14/149) Reference
Coverage 4.1 (16) Embolization 31.0 (71/229) <.001
Site of LEC (n ¼ 394) Coverage 25.0 (4/16) NS
Origin 76.4 (301) Site of LEC (n ¼ 394)
Anterior branch 10.9 (43) Origin 19.6 (59/301) Reference
Posterior branch 1.0 (4) Anterior or posterior branch 14.9 (7/47) NS
Anterior and posterior branch 2.8 (11) Anterior and posterior branch 45.4 (5/11) .05
Distal branches 8.9 (35) Distal branches 51.4 (18/35) <.0001
Embolization agent (n ¼ 185) Embolization agent (n ¼ 185)
Gelfoam 37.8 (70) Coils 37.9 (25/66) Reference
Coils 35.7 (66) Gelfoam 25.7 (18/70) NS
Gelfoam and coils 18.9 (35) Gelfoam and coils 22.9 (8/35) NS
Isobutyl cyanoacrylate 5.4 (10) Isobutyl cyanoacrylate 50.0 (5/10) NS
Amplatzer vascular pug 2.2 (4) Amplatzer vascular plug 25.0 (1/4) NS

LEC, Ligation, embolization, or coverage. LEC, Ligation, embolization, or coverage; NS, not significant.

category of specialty-related indication, such as vascular this. First, OBG patients are younger than the other groups.
surgery or trauma.6,7 In gynecology patients, a majority Collaterals of the hypogastric arteries may be patent because
of hypogastric interruptions are performed during hysterec- of the low incidence of atherosclerotic disease in that age
tomy. Nearly 85% of these hysterectomies are performed in group but may also be relatively smaller in caliber. In addi-
the perimenopausal period (48-55 years) for benign condi- tion, elevated estrogen levels may help keep the vessels
tions such as leiomyomas, adenomyosis, and dysfunctional dilated, thereby decreasing systemic vascular resistance,
uterine bleeding.8 Vascular surgery and oncology patients leading to enhanced pelvic blood supply after LEC of hypo-
tend to be relatively old.7,9-12 This may play a role in the gastric arteries.15 Vascular and oncology patients are rela-
different rates and types of complications reported in tively older and more likely to have atherosclerotic
different groups (Table VIII). It is widely appreciated blockage of collaterals of the hypogastric system, leading
that increased age is an independent risk factor for the to higher complications after LEC. Furthermore, in
development of atherosclerosis, which leads to occlusive oncology patients, cancer-related hypercoagulability may
disease.13 Because blood flow to the pelvis after hypogastric also play a role in the higher complication rate.
artery LEC is dependent on collaterals, differences in oc- Endovascular procedures routinely involve the use of
clusion of vessels caused by atherosclerosis in older patients guidewires and sheaths, which increases the risk of athe-
could account for the differences in outcome. Further- roembolism to distal arteries.16-18 This may partially
more, it is postulated that younger patients develop signif- explain why embolization of the hypogastric arteries pro-
icantly higher complications compared with older patients duces more complications compared with open proce-
because of higher physical activity, resulting in increased dures, such as ligation. Moreover, most of the
notice of symptoms.14 embolization procedures involve release into the hypogas-
In this systematic review, we demonstrate that ischemic tric system of materials such as Gelfoam, coils, cyanoacry-
complications after LEC of the hypogastric artery are fewer late, or polyvinyl alcohol, which could potentially enter
in OBG patients compared with vascular surgery, oncology, the collateral arteries and result in occlusion.19 Similar to
and trauma patients. Several factors may be responsible for the observations of other studies, we found that LEC at
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1344 Chitragari et al November 2015

Table IV. Multivariate analysis of variables tested as risk factors for development of complications after hypogastric artery
interruption

Model 1 Model 2 Model 3 Model 4 Model 5

Variable (reference) OR (CI) P OR (CI) P OR (CI) P OR (CI) P OR (CI) P

Gender (female)
Male 4.0 (2.2-7.3) <.01 1.6 (0.7-3.9) .26
Laterality (bilateral)
Unilateral 0.8 (0.4-1.5) .49 0.9 (0.5-1.8) .96 1.1 (0.6-2.1) .76
Procedure (ligation)
Embolization 4.2 (2.2-8.1) <.01 3.4 (1.7-6.8) .93 4.6 (2.3-9.1) <.01 2.8 (1.4-5.6) <.01
Covering 1.9 (0.4-8.3) .38 0.9 (0.2-4.2) .07 2.3 (0.5-10.3) .26 1.1 (0.2-4.9) .93
Site (origin)
Anterior or posterior 0.1 (0.03-0.6) <.01
Anterior and posterior 1.2 (0.3-5.4) .79
Posterior division 3.2 (0.4-26.0) .28
Distal branches 2.8 (1.3-6.2) .01
Age group (41-50 years)
10-20 years 4.4 (0.9-22.4) .07
21-30 years 0.5 (0.2-1.8) .34
31-40 years 0.8 (0.3-2.4) .70
51-60 years 2.5 (0.7-9.2) .17
61-70 years 3.1 (1.1-9.3) .02
71-80 years 1.9 (0.5-7.3) .04
81-90 years 0.4 (0.1-2.4) .31
Specialty (vascular surgery) <.01
OBG 0.3 (0.1-0.7) <.01
Oncology 1.0 (0.4-2.3) .96
Trauma 2.7 (0.8-8.9) .09

CI, Confidence interval; laterality, laterality of interruption; OBG, obstetrics and gynecology; OR, odds ratio.
Statistically significant values (P < .05) are listed in bold.

the origin of the hypogastric artery produces fewer compli- hypogastric artery should be preserved.11,22,23 It has been
cations compared with LEC of distal arteries because suggested that use of an Amplatzer plug produces fewer
patency of collaterals is important for maintaining pelvic complications compared with conventional emboliza-
circulation after embolization.20 We were not able to find tion.24 Although the procedure involves the risk of athe-
any significant difference between unilateral and bilateral roembolism, placement of the plug does not involve the
LEC. Rayt et al10 reported similar results in their systematic release of particulate matter like Gelfoam and in our review
review on vascular surgery patients. No statistically signifi- appears to have fewer complications. However, because of
cant difference in the incidence of buttock claudication a small sample size (n ¼ 4), it is difficult to make definitive
or erectile dysfunction was noticed in patients undergoing conclusions.
unilateral or bilateral hypogastric artery embolization In OBG patients, bilateral ligation produced fewer
before endovascular aneurysm repair. Similarly, in a study complications compared with bilateral embolization, and
done by Mehta et al,11 the incidence of buttock claudica- this can be explained by the reasons mentioned before.
tion was found to be similar after unilateral or bilateral hy- Although unilateral ligation produced fewer complications
pogastric artery interruption. However, few other studies compared with unilateral embolization, it failed to reach
demonstrated a difference. For instance, Morrissey et al21 statistical significance because of the smaller sample size.
identified an increase in complication rate after bilateral Likewise, although distal LEC produced more complica-
embolization compared with unilateral embolization. Dif- tions than LEC at the origin of the hypogastric artery, sta-
ference could be due to variation in interruption method, tistical significance was not achieved, possibly because of
embolization agent used, and inadequate sample size. the smaller number of the distal LEC group (n ¼ 11).
Although female patients showed fewer complications Comparable to the entire study group, no difference in
compared with male patients in our study, we believe it is complication rate was noticed with regard to site of LEC
most likely due to the fact that most of the female patients or the material used.
in the study belong to the OBG group, in which fewer Among vascular surgery patients, buttock claudication
complications developed overall. rate (21.2%) and overall ischemic complication rate (37.4%)
No difference was observed with regard to the laterality were comparable to other studies.22,25,26 Unlike the overall
of the procedure, even after comparing embolization and study group and OBG patients, no significant difference was
ligation separately. Other studies have concluded that suf- seen in complication rate with ligation vs embolization,
ficient evidence does not exist to support the belief that one possibly because of previously blocked collaterals by
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Table V. Complications developed by obstetrics and Table VI. Complications developed by vascular surgery
gynecology patients patients

Complication rate, Complication rate,


Variable % (No.) P value Variable % (No.) P value

Age (n ¼ 203) NS Gender (n ¼ 85) NS


#34.0 years 9.2 (10/109) Male (n ¼ 74) 27.0 (20/74)
$35.0 years 10.6 (10/94) Female (n ¼ 11) 18.2 (2/11)
Laterality (n ¼ 210) NS Age (n ¼ 99) NS
Unilateral 12.5 (5/40) #73.0 years 47.6 (20/42)
Bilateral 8.8 (15/170) $74.0 years 29.8 (17/57)
Type of procedure (n ¼ 210) .002 Laterality (n ¼ 99) NS
Ligation 4.1 (5/120) Unilateral 35.7 (20/56)
Embolization 16.7 (15/90) Bilateral 39.5 (17/43)
Site of LEC (n ¼ 197) NS Type of procedure (n ¼ 99) NS
Origin 9.1 (15/164) Ligation 41.6 (5/12)
Anterior or posterior branch 6.0 (2/33) Embolization 35.9 (28/78)
Anterior and posterior branch 50.0 (1/2) Coverage 44.4 (4/9)
Distal branches 18.1 (2/11) Site of LEC (n ¼ 99) NS
Embolization agent (n ¼ 73) NS Origin 32.4 (24/74)
Coils 0.0 (0/3) Anterior or posterior branch 60 (3/5)
Gelfoam 15.6 (7/45) Anterior and posterior branch 33.3 (2/6)
Gelfoam and coils 20.0 (5/25) Distal branches 57.1 (8/14)
Type of procedure .006 Embolization agent (n ¼ 68) NS
(bilateral only) (n ¼ 170) Coils 39.6 (21/53)
Ligation 3.9 (4/102) Gelfoam 0.0 (0/2)
Embolization 16.2 (11/68) Gelfoam and coils 25.0 (2/8)
Type of procedure NS Isobutyl cyanoacrylate 0.0 (0/1)
(unilateral only) (n ¼ 40) Amplatzer vascular plug 25.0 (1/4)
Ligation 5.6 (1/18) Type of procedure
Embolization 18.2 (4/22) (bilateral only) (n ¼ 43)
Ligation 83.3 (5/6) Reference
LEC, Ligation, embolization, or coverage; NS, not significant. Embolization 30.5 (11/36) .01
Coverage 100.0 (1/1) NS
Type of procedure NS
(unilateral only) (n ¼ 56)
atherosclerotic disease. No significant difference in complica- Ligation 0.0 (0/6)
tion rate was found with regard to site of LEC and emboliza- Embolization 40.48 (17/42)
tion material. Surprisingly, bilateral ligation produced more Coverage 37.5 (3/8)
complications than bilateral embolization (P ¼ .01). After LEC, Ligation, embolization, or coverage; NS, not significant.
repeated review of patient data, we discovered that the inferior
mesenteric artery was also ligated in 80% of the patients who
developed complications after bilateral hypogastric artery difference in complication rate was seen with regard to
ligation. In addition, a very high incidence of spinal cord embolization agent used.
ischemia (9%) and colonic ischemia (8%) was noticed in our Although patients could not be categorized on the ba-
study group compared with the European Collaborators on sis of type of procedure, site of LEC, and laterality because
Stent/graft Techniques for aortic Aneurysm Repair (EURO- of smaller sample size (n ¼ 16), we noticed a strikingly
STAR) analysis (0%-3%).27,28 One study reported spinal cord higher rate of buttock necrosis in trauma patients. This
ischemia as high as 11.5%.29 However, we believe that the may be due to associated injury to collateral vessels during
higher incidence in our study could possibly be because of trauma, leading to reduced pelvic blood supply.30
our selection criteria of articles. Case reports are usually pub- Some studies show that complications after hypogastric
lished reporting rare complications like spinal cord ischemia artery interruption are underdiagnosed. For instance,
and colonic ischemia. Because a significant portion of our Jaquinandi et al31 have found that the rate of buttock clau-
study group was obtained from case reports, it is expected dication detected after aortobifemoral bypass is more when
that we would see a higher incidence in rare complications treadmill test is used compared with detection by sponta-
among our study group. neous reporting by patients. Similarly, use of adjuncts
Among oncology patients, we noticed a significantly such as colonoscopy and magnetic resonance imaging for
higher rate of complications after distal LEC compared colonic ischemia and spinal cord ischemia, respectively,
with LEC at the trunk, which is explained by reasons might improve early detection of complications.32 Howev-
mentioned before. Similar to the vascular group, complica- er, the optimal method and time of diagnosis of these com-
tions were not fewer after ligation compared with emboliza- plications after hypogastric interruption are not yet clear.
tion, possibly because of atherosclerotic occlusion of Limitation. Because of the retrospective nature of this
collateral vessels. Similar to other groups, no significant study, it was difficult to obtain complete information for
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1346 Chitragari et al November 2015

Table VII. Complications developed by oncology surgery and oncology patients. Ligation of the hypogastric
patients arteries is preferred to embolization, and proximal
embolization should be preferred to distal embolization in
Complication rate, terms of risk of ischemic complications. Although LEC of
Variable % (No.) P value
hypogastric arteries is relatively safe and sometimes life-
Gender (n ¼ 51) NS saving, patients should be made aware of the higher rate
Male (n ¼ 25) 28.0 (7/25) of complications. Randomized controlled trials with larger
Female (n ¼ 26) 30.8 (8/26) sample size should be performed to elucidate clear
Age (n ¼ 69) NS risk factors for development of complications after
#63.0 years 27.6 (8/29)
hypogastric LEC.
$64.0 years 35.0 (14/40)
Laterality (n ¼ 69) NS We greatly appreciate the help of Ravi Teja Pasam in
Unilateral 20.0 (3/15) statistical analysis.
Bilateral 35.2 (19/54)
Type of procedure (n ¼ 69) NS
Ligation 25.0 (4/16)
Embolization 39.1 (18/46) AUTHOR CONTRIBUTIONS
Coverage 0.0 (0/7) Conception and design: GC, FS, CC, BS
Site of LEC (n ¼ 69)
Origin 25.5 (13/51) Reference Analysis and interpretation: GC, FS, BS
Anterior or posterior branch 25.0 (2/8) NS Data collection: GC, FS
Anterior and posterior branch 50.0 (1/2) NS Writing the article: GC
Distal branches 75.0 (6/8) .01 Critical revision of the article: FS, CC, BS
Embolization agent (n ¼ 35) NS
Coils 25.0 (2/8)
Final approval of the article: GC, FS, CC, BS
Gelfoam 41.2 (7/17) Statistical analysis: FS
Gelfoam and coils 0.0 (0/1) Obtained funding: Not applicable
Isobutyl cyanoacrylate 55.6 (5/9) Overall responsibility: BS
Type of procedure NS
(bilateral only) (n ¼ 54)
Ligation 25.0 (4/16)
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JOURNAL OF VASCULAR SURGERY
1347.e1 Chitragari et al November 2015

APPENDIX (online only). OR “occluded”[Title/Abstract] OR “occluded”[Title/Ab-


Following is the search string used. stract] OR “embolization”[Title/Abstract] OR “emboli-
(“internal iliac artery ligation” OR “internal iliac artery zed”[Title/Abstract] OR “embolize”[Title/Abstract] OR
occlusion” OR “internal iliac artery embolization” OR “hy- “embolisation”[Title/Abstract] OR “embolised”[Title/Ab-
pogastric artery ligation” OR “hypogastric artery occlusion” stract] OR “embolise”[Title/Abstract] OR “cover”[Title/
OR “hypogastric artery embolization” OR “hypogastric liga- Abstract] OR “covered”[Title/Abstract] OR “coverage”[-
tion” OR “hypogastric occlusion” OR “hypogastric emboli- Title/Abstract] OR “coil”[Title/Abstract] OR “coils”[-
zation” OR “internal iliac ligation” OR “internal iliac Title/Abstract] OR “coiling”[Title/Abstract] OR
occlusion” OR “internal iliac embolization” OR “ligation “hydrocoil”[Title/Abstract] OR “hydrocoils”[Title/Ab-
of internal iliac artery” OR “occlusion of internal iliac artery” stract] OR “hydrocoiling”[Title/Abstract] “foam”[Title/
OR “embolization of internal iliac artery” OR “ligation of hy- Abstract] OR “foaming”[Title/Abstract] OR “plug”[Ti-
pogastric artery” OR “occlusion of hypogastric artery” OR tle/Abstract] OR “plugs”[Title/Abstract] OR “particle”[Ti-
“embolization of hypogastric artery”) OR ((“internal iliac”[- tle/Abstract] OR “particles”[Title/Abstract] OR
Title/Abstract] OR “internal iliacs”[Title/Abstract] OR “microsphere”[Title/Abstract] OR “microspheres”[Title/
“iliaca interna”[Title/Abstract] OR “hypogastric”[Title/ Abstract] OR “bead”[Title/Abstract] OR “beads”[Title/
Abstract] OR “hypogastrics”[Title/Abstract]) AND (“liga- Abstract] OR “Ligation”[MeSH] OR “Therapeutic Occlu-
tion”[Title/Abstract] OR “ligated”[Title/Abstract] OR sion”[MeSH] OR “Balloon Occlusion”[MeSH] OR
“ligate”[Title/Abstract] OR “occlusion”[Title/Abstract] “Embolization, Therapeutic”[MeSH]))

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