The purpose of this presentation is to show the management of pelvic hemorrhage following a reconstructive pelvic surgery using pelvic artery embolization, when it is applicable, how to perform it, and what to expect from the procedure. There are procedures in reconstructive pelvic surgery when we are accessing spaces in the pelvis that are difficult to stop bleeding. These procedures include sacrospinous ligament fixation and retropubic dissection. The use of trocars in blind spaces increases these risks even more. Arterial bleeding following pelvic reconstructive surgery is a complex situation which requires swift management. A calm, stepwise approach will enable the surgeon to successfully manage this potentially lethal problem. Vascular complications with mesh placement are rare, but clinically relevant. In a large registry of TVT complications, the risk of bleeding requiring surgical management was 0.8%. There have been case reports of vascular injury after placement of commercially available mesh delivery systems for prolapse. Preoperatively, we ask patients about alternative medication supplements that can increase the beta-carotene, fish oil, garlic, ginkgo, ginseng, St. John's wort, and vitamin E. Despite being minimally invasive, all pelvic mesh placement procedures have the potential for serious complications. Trainees may have an unrealistic picture of the complications from the potential spaces based on training videos showing a bloodless dissection in these lateral spaces. Offline options for tamponade include re-operation with, suture ligation, topical hemostatic agents, packing, clipping of the involved artery. Another alternative for treating a vascular complication is pelvic artery embolization. Pelvic artery embolization is a minimally invasive technique that is an alternative to vaginal exploration or laparotomy. Pelvic vessel embolization has been used for complicated hemorrhage following obstetric cases, GYN oncologic surgery, fibroids, and for reconstructive pelvic surgery. The goals of embolization include slowing blood loss to allow physiologic control of hemorrhage, limiting tissue ischemia to the smallest possible area, and performing the procedure expeditiously. The indications for pelvic artery embolization include hemorrhage and failed conservative management. Relative contraindications for pelvic artery embolization include negative findings on angiography. We consider coagulopathy a relative contraindication to elective interventional procedures. However, under emergency situations, it can be performed as a life-saving measure, even with coagulopathy. Prior pelvic irradiation may weaken tissue. Finding deep, bleeding retroperitoneal vessels in one of these potential spaces via exploratory laparotomy is often difficult. Even if a bilateral hypogastric ligation is done, this decrease in pulse pressure fails to halt the hemorrhage in approximately 50% of patients due to extensive collateralization of the pelvic vessels. In order to illustrate the successful use of pelvic artery embolization, we report on two patients who underwent transvaginal and suburethral mesh placement, presenting with pelvic hematomas in potential spaces. In order to illustrate the application of pelvic artery embolization in the paravesical space, we present a 73-year-old para 4 complaining of bulge symptoms who desired uterine conservation. The pelvic examination revealed the presence of stage 2 uterovaginal prolapse. After extensive consultation, she was consented for a bilateral sacrospinous hysterocopopexy with synthetic mesh implant, anterior colporaphy, transvaginal tape obturator approach, and cystoscopy. During the operation, the paravesical space was dissected with the bladder mobilized away from the vagina. Estimated blood loss was 250 milliliters. Six hours after surgery, the patient developed hypotension, tachycardia, and dizziness. The pelvic examination was suspicious for a vaginal mass. Laboratory analyses revealed an acute blood loss anemia with a drop of 5 grams per deciliter to a hemoglobin of 8.3. We performed an arteriogram. The arteriogram showed the presence of a pelvic retroperitoneal hematoma supplied by the left inferior vesicle artery that could be embolized. On angiogram, there was active extravasation from the left inferior vesicle artery. The goal of pelvic artery embolization is the blockage and endovascular ligation of a bleeding artery in the pelvis. Access is achieved through the femoral artery, and a guide wire and microtip catheter are placed. Fluoroscopy and IV contrast are used to perform a concomitant angiogram of the pelvic vasculature to guide the guide wire and microtip catheter to the bleeding artery. The left internal iliac artery was selectively catheterized and confirmed the presence of contrast media extravasation at the inferior vesicle artery originating from the common trunk of the internal iliac artery. Once the inferior vesicle artery was identified, several 2 millimeter by 3 millimeter platinum coils were inserted. After the procedure, she was clinically stable, and serial blood counts confirmed the return of hemoglobin to 8 grams per deciliter. A second case illustrates pelvic hemorrhage into the obturator space following prolapse and incontinence repair. Our technique for managing hemorrhage is demonstrated in a 70-year-old para 2 woman who presented with complaints of increased pelvic pressure and stress urinary incontinence, who developed stage 2 uterovaginal prolapse. We reviewed the patient's medications, confirming that she was not taking aspirin, anticoagulants or herbal medications at her preoperative visit. Her preoperative hemoglobin was 12.5 grams per deciliter. The patient underwent a total vaginal hysterectomy, utero-sacral ligament colpopexy, anterior colporaphy, transvaginal tape obturator sling, and cystoscopy. Estimated blood loss was 50 milliliters. Twelve hours after the operation, the patient encountered a drop in hemoglobin from 12.5 to 6.1 grams per deciliter. Vaginal examination revealed no palpable hematoma. The patient underwent a computed tomography scan of the abdomen and pelvis, revealing a hematoma in the space of Rhetzius. CT imaging with intravenous contrast prior to undergoing angiography can assist in procedural guidance in physiologically stable patients. Imaging can also allow for the assessment of pertinent atherosclerotic and or occlusive disease involving the arteries to be catheterized, particularly in elderly patients. The pelvic hematoma measured 9 by 15 by 9 centimeters and exerted a mass effect on the urinary bladder. Subsequently, on angiogram, there was active extravasation from a branch of the right obturator artery. Super-selective cannulation and embolization of these bleeding vessels was achieved with multiple 2 millimeter by 3 millimeter platinum coils, which were deployed in the target artery and the bleeding ceased. Post-embolization angiography showed all other branches of the anterior division of the right internal iliac artery remained patent. In total, the patient was transfused with 4 units of packed red blood cells to avoid intravascular depletion. Serial blood counts confirmed the return of hemoglobin to 8 grams per deciliter. Post-operative care following pelvic artery embolization includes sandbag to femoral access site, avoid flexion and extension of the leg, oral, IV, epidural, and or patient-controlled analgesia. After 2 days, normal activity is permitted. Fortunately, complications from pelvic artery embolization are rare. Complications noted in the literature include transient fever, lower abdominal pain, non-target embolization, gluteal infarction. Embolization making and mobilization of personnel and appropriate equipment take time and in some cases a significant delay is likely before the pelvic vessel can be occluded. Laparotomy should be performed if the woman is not stable enough to wait for the embolization procedure. Both mesh kits and midurethral slings involve dissection in extraperitoneal spaces with vasculature that can be difficult to access via laparotomy or transvaginal surgical re-exploration. In our patients, embolization of the inferior vesicle artery and a branch of the obturator artery provided a valuable option for treatment of pelvic hemorrhage that proved to be safe, effective, and eliminated the need for invasive surgical interventions.

pelvic hemorrhage

reconstructive pelvic surgery

pelvic artery embolization

arterial bleeding

minimally invasive technique