Proximal Internal Iliac Artery Ligation in Obstetrics and Gynecology: An 11-Year Retrospective Single-Center Experience with No Clinically Detected Ischemic Complications.

Background: Proximal ligation of the internal iliac artery (IIA) is a life-saving procedure for uncontrollable pelvic bleeding, often underutilized because of concerns about secondary buttock or pelvic organ ischemia, especially when ligation is performed proximal to the posterior IIA division. Methods: The primary aim was to evaluate clinically detected postoperative ischemic complications after IIA ligation, with secondary aims including technical success, primary hemostatic success, and overall hemorrhage control. In this single-center retrospective study, we evaluated 61 patients undergoing IIA ligation at a tertiary center in Bulgaria between January 2014 and March 2025. Demographics, indication, surgical approach, ligation level and laterality, comorbidities, and postoperative outcomes were analyzed. Ischemic complications were assessed by clinical examination and structured symptom inquiry at each follow-up visit (two visits in the first postoperative month, then at months 2, 3, 5, and 6). Imaging was reserved for patients with symptoms suggesting ischemia; none required further imaging. Results: IIA ligation was performed for obstetric (n = 18), benign gynecologic (n = 13), or gynecologic oncologic (n = 30) indications. The median age was 31.5 years (range 21-42), 50 years (range 35-76), and 64 years (range 31-81) in the obstetric, benign gynecologic, and gynecologic oncology groups, respectively. Bilateral ligation was achieved in 54/61 (88.5%) cases and unilateral ligation in 7/61 (11.5%). Bilateral proximal ligation was performed in 49/61 (80.3%); in 59/61 (96.7%) patients, at least one side was ligated proximally. Technical success was achieved in all patients (61/61, 100%). Primary hemostatic success was achieved in 59/61 (96.7%) patients. Hemostatic failure requiring escalation occurred in 2/61 (3.3%) patients: one with placenta accreta spectrum and one with placental abruption complicated by disseminated intravascular coagulation. Both required packing/laparostomy with delayed abdominal closure. Overall hemorrhage control was achieved in all patients (61/61, 100%). No clinical signs of ischemic complications (buttock, pelvic organ, spinal cord, or neuropathic) were recorded during the six-month follow-up period. Conclusions: In this cohort, proximal (including bilateral) IIA ligation was not associated with clinically detected ischemic complications and supported rapid hemorrhage control when performed by experienced surgeons. Larger prospective and comparative studies with standardized ischemia assessment are needed.