The Effects of Internal Iliac Artery Ligation in Women With Placenta Accreta Spectrum: A Systematic Review and Meta-Analysis

Objective: To evaluate the efficacy and safety of internal iliac artery (IIA) ligation in the management of placenta accreta spectrum (PAS). Methods: PubMed, Embase, Scopus, ScienceDirect, Cochrane Library, and Clinical Trials Registry were searched up to December 2024 for studies on IIA ligation in PAS. This PROSPERO-registered review followed PRISMA guidelines and included randomized controlled trials (RCTs) and non-RCTs comparing IIA ligation with no intervention, IIA balloon, uterine artery ligation, or temporary common iliac artery occlusion. Outcomes included intraoperative blood loss, transfusion needs, procedure duration, complications, intensive care unit admission, and hospital stay, with risk of bias assessed using Cochrane criteria and the Newcastle-Ottawa Scale, and evidence quality rated via GRADE. Effect estimates were reported as mean differences or odds ratios (95% confidence interval ( CI )) using fixed- or random-effects models based on heterogeneity ( I 2 ), with P < 0.05 considered significant. Results: A total of 13 studies, including five RCTs and eight non-RCTs, involving 939 participants, met the inclusion criteria and were included in the study. Intraoperative blood loss was evaluated in 10 studies involving 631 participants (299 undergoing IIA ligation and 332 controls). The mean difference was −177.10 mL (95% CI : −701.46–347.27; P = 0.51; I 2 = 95%). Postoperative hemoglobin reduction was analyzed in four studies with 233 participants (109 subjected to IIA ligation and 124 controls), yielding a mean difference of −0.17 g/dL (95% CI : −0.47–0.14, P = 0.29, I 2 = 1%). Blood transfusion was assessed in five studies enrolling 248 participants (125 in the IIA ligation group and 123 controls). The mean difference was found to be −0.06 units (95% CI : −2.08–1.95, P = 0.95, I 2 = 93%). The duration of the procedure was investigated in eight studies comprising 539 participants (271 undergoing IIA ligation and 268 controls). The mean difference was calculated as 12.85 minutes (95% CI : −7.2–32.9, P = 0.21, I 2 = 87%). Conclusion: Current evidence suggests that IIA ligation in PAS may not significantly reduce intraoperative blood loss, transfusion requirements, procedure duration, bladder injury, or hospital stay; however, the available studies are heterogeneous and of variable quality, and further high-quality research is needed to confirm these findings. Registration: CRD42024626882, Date 13/12/2024.