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

Abstract

Objective: Abnormal placentation is a serious complication of pregnancy, and is associated with significant morbidity and mortality. There has been recent debate regarding the deployment of occlusive balloons as an adjuvant to surgery to minimize blood loss in these patients. This article reviews the literature on the use of occlusive balloons for management of placenta accreta and outlines some proposals for future management that may improve outcomes. Design: This is a review of published literature regarding endovascular approaches to minimizing hemorrhage during cesarean,delivery in patients with placenta accreta, increta, and percreta. Materials and Methods: Articles published in the English language between 1995 and 2011 regarding the surgical extirpative or conservative approach to placenta accreta, increta, and percreta were reviewed using the search engine, MEDLINE Ò. Key words used were abnormal placentation, internal iliac occlusive balloons, placenta accreta, and uterine embolization. Articles were analyzed for patient demographics, site of balloon occlusion, estimated blood loss, volume of blood transfused, length of hospital stay, and complications. Results: Nineteen publications that described 57 patients were included in the review. Five additional comparative studies were also found and reviewed separately. Most studies deployed the intravascular balloon in the internal iliac artery, whereas others deployed the balloon in the common iliac artery and even the infrarenal aorta. Conclusions: The results of this review support the clinical utility of endovascular devices, but also disclosed significant variability among the published reports. Future multicenter studies should be completed in centralized locations of care, with a selected number of operating obstetricians and efficient teams.

Does temproray bilateral balloon occlusion of the common iliac arteries reduce the need for intra‐operative blood transfusion in cases of placenta accretism?

“…The majority of prior studies have selected the internal iliac artery (IIA) or even uterine arteries for balloon placement . In our centre, Fogarty balloons are placed in the CIA by the interventional radiologist in the angiography suite.…”

“…The rationale for choosing the CIA is to try to minimise the extensive collateral supply to the uterus through branches of the external iliac artery most importantly via the obturator artery . On account of the fewer steps involved in occluding the common iliac artery than the internal iliac or uterine, especially for those with unusual vascular anatomy, this is likely a faster procedure which may reduce the radiation dose to both the foetus and the mother . Only a few small studies to date have been performed using the technique of balloon inflation within the CIA which is performed in our centre.…”

Preokliuzinių balionėlių naudojimas perioperaciniam kraujavimui mažinti esant invazyviai placentai: tretinio lygio stacionaro patirtis ir literatūros apžvalga

“…Invazyvios placentos sukelto kraujavimo valdymas yra labai sudė-tingas, todėl ankstyva ir išsami antenatalinė diagnostika yra ypač svarbi [5]. Siekiant įvertinti placentos invazijos gylį, aplinkinių struktūrų įtraukimą į patologinį procesą, dažniausiai atliekami ultragarsinis (UG) ir magnetinio rezonanso tyrimai (MRT) [6].…”

“…Aortos okliuzija užtikrina efektyvų kraujo pritekė-jimo stabdymą mažajame dubenyje, tačiau aorta šiai procedūrai pasirenkama retai, nes sustabdyta kraujotaka lemia galūnių išemiją, o ilgiau užtrukus operacijai gali sukelti aortos intimos atsisluoksniavimą, reperfuzijos sindromą ar trombozes [4,5]. Vidinių klubinių arterijų okliuzija sumažina pulsinį spaudimą distaliau balionė-lio, dėl to sumažėja ir kraujo pritekėjimas į gimdą.…”

“…Vidinių klubinių arterijų okliuzija sumažina pulsinį spaudimą distaliau balionė-lio, dėl to sumažėja ir kraujo pritekėjimas į gimdą. Tačiau to gali nepakakti efektyviam kraujavimo stabdymui operacijos metu, nes gimdą krauju aprūpina ir išorinės klubinės arterijos šakos [5,12]. Literatūroje taip pat aprašomi atvejai, kai operacijos metu balionėliai buvo perkelti į bendrąsias klubines arterijas, nes operuojančiam gydytojui nepavyko kontroliuoti didelio kraujavimo esant vidinių klubinių arterijų okliuzijai [4].…”