Therapeutic effect of Internal iliac artery ligation and uterine artery ligation techniques for bleeding control in placenta accreta spectrum patients: A meta-analysis of 795 patients

Abstract

Placenta accreta spectrum (PAS) can cause complications like hysterectomy or death due to massive pelvic bleeding. We aim to evaluate the efficacy of two different arterial ligation techniques in controlling postpartum haemorrhage and minimizing bleeding complications. We searched six databases. 11 studies were finally included into our review and analysis. We graded their quality using the Cochrane tool for randomized trials and the NIH tool for retrospective studies. Our analysis showed that internal iliac artery ligation has no significant effect on bleeding control (MD = −248.60 [−1045.55, 548.35] P = 0.54), while uterine artery ligation significantly reduced the amount of blood loss and preserved the uterus (MD = −260.75, 95% CI [−333.64, −187.86], P < 0.00001). Uterine artery ligation also minimized the need for blood transfusion. Bleeding was best controlled by combining both uterine artery ligation with uterine tamponade (MD = 1694.06 [1675.34, 1712.78], P < 0.00001). This combination also showed a significant decrease in hysterectomy compared to the uterine artery ligation technique alone. Bilateral uterine artery ligation in women with placenta accreta spectrum can effectively reduce the amount of bleeding and the risk of complications. The best bleeding control tested is a combination of both, uterine artery ligation and cervical tamponade. These techniques may offer an easy and applicable way to preserve fertility in PAS patients. Larger randomized trials are needed to define the best technique.

The anesthetic approach to a patient with placenta accreta spectrum

“…Hence the result is reduced perioperative blood loss but not prevention of massive bleeding. An example of this is seen in a meta-analysis published in 2022 where all standard methods of intraoperative hemostasis for placenta accreta resulted in 3-4, or even 5, liters of blood loss [36].…”

Internal Iliac Artery Ligation in Obstetrics and Gynecology: Surgical Anatomy and Surgical Considerations

“…The internal iliac vein is located below and slightly medial to the IIA. Clearing the adventitia of the artery may help to identify the correct dissection plane [ 11 , 44 , 45 , 46 , 47 , 48 ]. The artery can be gently elevated without injuring the vein.…”

“…The primary hemodynamic effect following bilateral IIA ligation is the nearly complete elimination of blood pressure in small arteries distal to the ligation, effectively transforming the arterial system into a venous one. As a result, a hemostatic mechanism develops, leading to the formation and retention of clots [ 44 , 59 , 60 , 61 ]. The pulse pressure and arterial blood pressure distal to the ligation decrease by 85% (with bilateral IIA ligation) and 25% (bilateral IIA ligation), respectively [ 59 , 60 , 61 ].…”

Foley Catheter as a Tourniquet for Hemorrhage Prevention during Peripartum Hysterectomy in Patients with Placenta Accreta Spectrum (PAS)—A Hospital-Based Study

“…Its ability to exert controlled pressure on vessels, temporarily halting blood flow, makes it a strong contender for managing hemorrhage during CS in PAS patients. While some sources discuss temporary clamping or ligation of uterine vessels or the internal iliac artery with surgical tools, these techniques are technically more demanding compared to the Foley catheter [ 14 ].…”