Collateral-pathway-oriented clinico-angiographic framework for inferior epigastric artery-related hemorrhage: embolization planning and clinical outcomes.

BACKGROUND/OBJECTIVES: Although inferior epigastric artery (IEA)-related hemorrhage can occur in diverse settings, outcomes following transcatheter arterial embolization (TAE) vary according to collateral anatomy and physiologic severity. We aimed to describe a collateral-pathway-oriented clinico-angiographic framework for IEA-related hemorrhage and evaluate technical and clinical outcomes of TAE across these categories. Predictors of the composite clinical failure endpoint and a simple exploratory descriptive score were assessed as exploratory secondary analyses.

METHODS: We retrospectively reviewed 62 consecutive patients with IEA-related hemorrhagic events treated with TAE; cases were categorized into four collateral-pathway-oriented clinico-angiographic categories (Types A-D) based on CT/DSA findings together with the clinical context, to reflect the dominant collateral circuit relevant to embolization planning. The categories were Type A (isolated abdominal wall, n = 28), Type B (round ligament/postpartum, n = 15), Type C (corona mortis/pelvic fracture, n = 16), and Type D (iatrogenic puncture-related, n = 3). Technical success was defined as angiographic disappearance of the extravasation/pseudoaneurysm. Clinical success was defined as hemodynamic stabilization within 24 h without repeat TAE or surgery. Clinical failure comprised lack of clinical success and/or in-hospital death. Rebleeding from the treated IEA territory was also assessed separately. Logistic regression was performed after excluding Type D patients (n = 59) owing to complete separation as an exploratory analysis of factors associated with the composite clinical failure endpoint. A point-based score was derived descriptively from these factors.

RESULTS: Technical success was achieved in all cases (62/62, 100%). The overall clinical success rate was 82.3% (51/62). Clinical success rates varied across categories: Type A 96.4%; Type B, 80.0%; Type C, 56.3%; and Type D, 100%. Rebleeding from the treated IEA territory occurred in 3 patients (4.8%), all of whom had Type C. In-hospital mortality was 12.9% (8/62), concentrated in Type C. In exploratory multivariable analysis (n = 59), Type C category (aOR, 4.6), DIC (aOR, 3.7), and SBP < 80 mmHg (aOR, 3.1) were associated with the composite clinical failure endpoint. A descriptive three-factor score (Type C = 2, DIC = 2, and SBP < 80 mmHg = 1) showed a stepwise increase in this composite endpoint from 7.1 to 71.4%.

CONCLUSIONS: A collateral-pathway-oriented clinico-angiographic framework may support systematic evaluation of the external iliac/IEA system during embolization planning. Poorer outcomes in pelvic fracture-related Type C cases should be interpreted cautiously because they may reflect trauma burden, coagulopathy, and systemic derangement rather than IEA embolization failure alone.