Hypogastric (Internal Iliac) Artery Ligation

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


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.



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]



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]