Selective Endovascular Balloon–Occlusion for Cesarean Delivery in Patients with Abnormal Placentation: Review of Literature and Presentation of a Case

Abstract

Background: Removal of abnormal placentation is associated with severe bleeding and is a recognized cause of maternal morbidity and mortality. Complications of abnormal placentation include excessive bleeding during placental removal and the need for cesarean hysterectomy. Newer technologic advances, in the form of obstetrical ultrasound and advanced computed tomography and magnetic resonance imaging, have enabled antenatal diagnosis of these abnormalities and, therefore, allow elective management, instead of on an emergency basis. Case: In this article, we report a case that demonstrates the use of electively placed, bilateral intravascular balloons guided within the common iliac arteries to control bleeding in a patient with placenta percreta. Review: We also complete a review on the literature pertaining to the role of vascular balloon occlusion in abnormal placentation. The use of occlusive balloons and=or embolization has recently been described to reduce postoperative blood loss in patients with abnormal placentation; however, several described anastomoses can explain the continued bleeding. A review of all publications was completed, regarding abnormal placentation, where an endovascular occlusive balloon and=or embolization were used to reduce blood loss. Conclusions: We conclude that a multidisciplinary approach between the interventional radiologist and the obstetrician are important for a favorable outcome. Prophylactic bilateral common iliac artery balloons placed immediately before surgery in patients with abnormal placentation is the safest method by which a reduction in blood loss may be obtained. However, further research and prospective studies are needed to properly assess the efficacy of each of the described techniques for better control of bleeding in these patients, as well as the most appropriate timing for repeated occlusive periods, to minimize unfavorable ischemic events. ( J GYNECOL SURG 25:113)

Staged Endovascular Balloon Occlusion versus Conventional Approach for Patients with Abnormal Placentation: A Literature Review

“…16 Three publications demonstrated the use of the CIA for balloon occlusion and all three showed favorable outcomes. 7,23,24 In a case series of 62 patients by Miller et al, blood loss during cesarean hysterectomy associated with placenta accreta without use of endovascular balloons or occlusive devices was quantified. 25 Estimated blood loss exceeded 2 L in 41 patients, 5 L in 9 patients, 10 L in 4 patients, and 20 L in 2 patients.…”

“…34 In his case series of 14 patients, Thon et al described 4 patients with complications, 1 patient had massive hemorrhage leading to cardiac arrest, and all 4 required intervention for catheter-related complications. 35 Two patients in whom CIA occlusion was used, 7,23 and the 3 patients in whom aortic occlusion was used [13][14][15] had a favorable outcome. With the favorable outcome reported with aortic cross-clamping in surgeries for abdominal aortic aneurysms, authors recommending aortic occlusive balloons have deemed this procedure relatively safe, because of the rich collateral web during pregnancy, in addition to the absence of complete occlusion of blood flow by the balloon catheter.…”

“…The sources of this collateral circulation have previously been described and it has been hypothesized that a more significant reduction of blood loss can be established through balloon occlusion of the common iliac arteries (CIA) instead of the IIA. 7 There has been a recent angiographic demonstration of the extensive collateral circulation to the placenta from the recruited blood vessels in cases of abnormal placentation ( Fig. 1a)with emphasis on the continuous flow in the IIA despite its ligation (Fig.…”

Late Postoperative Segmental Lung Infarction After Use of Recombinant Activated Factor VII to Achieve Hemostasis

“…2,3 The patient was prepared and draped in the normal sterile fashion. General endotracheal anesthesia was induced with sodium thiopental and succinylcholine, and anesthesia was maintained with sevoflurane.…”