Bilateral Internal Iliac Artery Ligation as a Damage Control Approach in Massive Retroperitoneal Bleeding After Pelvic Fracture

Introduction: The management of massive retroperitoneal hemorrhage in unstable patients with pelvic fractures remains a considerable therapeutic challenge after blunt mechanisms of injury. We present our study using emergent bilateral ligation of the internal iliac arteries (BLIA) and pelvic packing as a damage control adjunct. Methods: We reviewed our experience during 22 months (May 2006 to March 2008) with damage control management of massive retroperitoneal hemorrhage caused by blunt pelvic injury encountered at the time of emergent laparotomy. Clinical courses were reviewed. Results: During the study period, 201 patients with pelvic fractures underwent operative intervention. Treatment of an expanding retroperitoneal hematoma was required in 33. Five of these patients were adequately stable for angioembolization, with a resultant 40% survival. Twenty-eight patients required BLIA and pelvic packing intraoperatively. The mean injury severity score of patients who underwent BLIA was 33.1, with 89.3% having an injury severity score of >= 16. Overall survival after BLIA was 35.7%. Causes of mortality included brain death, intraoperative arrest, refractory coagulopathy, and sepsis. Techniques used for BLIA included Rummel tourniquet (in 1), clip occlusion (in 5) and suture ligation (in 4). Four patients had subsequent removal of Rummel tourniquet or clips at 24 hours to 72 hours after initial procedure, with the remainder undergoing permanent ligation. No survivors after BLIA were noted to have apparent adverse ischemic sequelae. Conclusion: BLIA is a damage control tool potentially useful for a select group of patients with massive retroperitoneal hemorrhage after pelvic fracture. Further study is required to determine the appropriate selection criteria for this potentially life-saving maneuver.