Bilateral Absence of Common Iliac Artery: Abnormal anatomical variation of the Internal Iliac Artery During Ligation in Conservative Surgical Management of Placenta Previa Accreta

Abstract

Abnormal placental invasion has increased with persistent rise in cesarean delivery. Management depends on accurate diagnosis, and delivery should be planned at an institution with appropriate expertise and resources. Hemorrhage in pregnancy is the leading cause of maternal mortality in developing countries. Internal iliac artery ligation is one of the lifesaving procedures in intractable pelvic hemorrhage. The vascular malformations involving the abdominal aorta, common iliac artery and its branches are very rare. We present a case of placenta accreta which is a major risk for peripartum deaths. In this case, we tried to explain our conservative surgical approach in the form of cervico-isthmical transverse opposition suture with bilateral internal iliac artery ligation. Normally, the abdominal aorta bifurcates into the right and left common iliac arteries anterolateral to the fourth lumbar vertebra. In the present case, there was bilateral absence of common iliac arteries which are the terminal branches of the abdominal aorta. Internal iliac artery was extremely long and equal size to external one. The reason for the absence of common iliac artery may be attributed to the disappearance of the initial segment of the umbilical artery. Cesarean section and placenta previa are significant risk factors for placenta accreta which is associated with high fetomaternal morbidity and mortality. In order to avoid postpartum hemorrhage and fertility loosing hysterectomy, our approach which consists of bilateral hypogastric arterial ligation and transverse compression sutures in the lower uterine segment can be applied successfully. Proper identification of anatomical variations in pelvic vasculature is essential for surgical and radiological interventions to prevent complications. This article aims at sharing author’s experience about the anatomical variation of the artery especially long ones as in absent common iliac artery or even a high bifurcation.