Utilizations and outcomes of intra‐arterial balloon occlusion at cesarean hysterectomy for placenta accreta spectrum

Abstract

Introduction This study examined national‐level trends, characteristics, and perioperative outcomes of women who had intra‐arterial balloon occlusion at cesarean hysterectomy for placenta accreta spectrum (PAS). Material and methods This was a population‐based retrospective observational study that queried the National Inpatient Sample from October 2015 to December 2018. Study population was women who underwent hysterectomy at cesarean delivery for PAS (n = 6440 in 806 centers). Exposure allocation was the use of intra‐arterial balloon occlusion. Main outcome measures were (a) characteristics associated with intra‐arterial balloon occlusion use, and (b) perioperative outcome including hemorrhage, blood transfusion, coagulopathy, shock, urinary tract injury, intra‐arterial balloon occlusion‐related complication (arterial injury, arterial thrombosis, and lower extremities ischemia), and death, assessed in multivariable analysis. Results Intra‐arterial balloon occlusion was used in 420 (6.5%) women in 64 (7.9%) centers. Utilization of intra‐arterial balloon occlusion during cesarean hysterectomy for placenta accreta decreased significantly over time (from 6.3% to 3.1%, p < 0.001), but not in placenta increta (from 12.8% to 9.3%, p = 0.204) or placenta percreta (from 21.3% to 17.5%, p = 0.344). In a multivariable analysis, patient factors (younger age, earlier year, obesity, diabetes mellitus), pregnancy factors (placenta increta/percreta, previous cesarean delivery, placenta previa, and early gestational age), and facility factors (large bed capacity, urban teaching status, and Northeast/West regions) represented the independent characteristics for using the intra‐arterial balloon occlusion (all, p < 0.05). In a classification‐tree model, the absolute difference in intra‐arterial balloon occlusion use among 18 utilization patterns was 48% (range, 0%–48%). In perioperative outcome analysis, women who received intra‐arterial balloon occlusion were more likely to have coagulopathy (adjusted odds ratio [aOR] 3.43) and arterial thrombosis (aOR 9.82) in placenta accreta, but less likely to have hemorrhage (aOR 0.25) in placenta increta, and blood transfusion (aOR 0.60) and urinary tract injury (aOR 0.28) in placenta percreta compared with those who did not (all, p < 0.05). Conclusions There is a wide range in the utilization of intra‐arterial balloon occlusion at cesarean hysterectomy for PAS based on patient, pregnancy, and facility factors, which implies that there is a lack of universal practice guidelines in this surgical procedure. Whether the use of intra‐arterial balloon occlusion in the severe forms of PAS improves surgical outcome merits further investigation.

Peripartum hysterectomy due to severe postpartum hemorrhage: A hospital‐based study

“…Almost every woman in the study had long‐lasting surgery; thus, we speculated that a PAS disorder or an aortic balloon occlusion probably contributed to the thrombosis. A study conducted in South America 27 described three cases of arterial thrombosis after an aortic balloon occlusion, and a recent study by Matsuo et al demonstrated that the risk of arterial thrombosis increased after an intra‐arterial balloon occlusion during a cesarean hysterectomy 28 …”

Association of Placenta Previa With Severe Maternal Morbidity Among Patients With Placenta Accreta Spectrum Disorder

“…Because findings from single-center and small-sample studies 28 , 30 were inconsistent regarding the association between placenta previa and worse maternal outcomes, the present study included 3793 patients with PAS from a national multicenter database and found that placenta previa was an independent risk factor associated with overall severe maternal and surgical morbidities. Unlike previous studies that included only patients with PAS who had undergone cesarean delivery 4 , 51 and/or hysterectomy, 52 the current study included all patients with a PAS diagnosis and conducted sensitivity analyses among those who received cesarean delivery and hysterectomy. We also examined surgical procedure and resource use among patients with PAS who did and did not have placenta previa, which could inform both the clinical and financial aspects of risk.…”

Can topographic classification of placenta accreta spectrum disorders predict the need for endovascular arterial occlusion during surgery?

“…2 However, there is a key difference between our two studies that must be noted. 2,4 Nieto-Calvache et al used REBOA, whereas all cases in our study had only internal iliac intra-arterial occlusion. REBOA has been recognized as an alternative to aortic crossclamping via open thoracotomy to achieve hemostasis in patients with severe trauma.…”

“…4 In less severe forms of PASD, in contrast, the use of intra-arterial occlusion was associated with increased risks of coagulopathy and arterial thrombosis without improving surgical morbidity. 4 These results are consistent with their study. 2 However, there is a key difference between our two studies that must be noted.…”

“…Ensign Endowment for Gynecologic Cancer Research Shinya Matsuzaki 1,2 Ariane C. Youssefzadeh 2 Rachel S. Mandelbaum 2,3 Koji Matsuo 2,4…”