Intra-abdominal Aortic Balloon Occlusion in the Management of Placenta Percreta
Placenta accreta spectrum (PAS) disorders represent a range of conditions where the placenta abnormally adheres to or invades the uterine myometrium. Among these, placenta percreta (PP) is the most severe form, characterized by the placenta penetrating through the uterine serosa and potentially invading adjacent organs. This condition poses significant risks, with massive bleeding being the primary concern during management. Over the past few decades, the incidence of PAS disorders has risen significantly, largely attributed to the increasing rate of cesarean deliveries, which is a well-established risk factor for these conditions.
The management of PP is complex and often requires a multidisciplinary approach. One of the techniques employed to mitigate the risk of severe hemorrhage is intra-abdominal aortic balloon occlusion (IABO). This method involves the temporary occlusion of the abdominal aorta to reduce blood flow to the pelvis, thereby minimizing blood loss during surgery. However, the efficacy and safety of IABO in the management of PP remain uncertain due to the lack of large-scale studies. This paper aims to provide a comprehensive analysis of the outcomes associated with IABO in patients with PP, focusing on maternal and neonatal outcomes.
Background and Significance
Placenta accreta spectrum disorders, including PP, are among the most life-threatening conditions in obstetrics. The increasing prevalence of these disorders is closely linked to the rising cesarean delivery rates, particularly in countries like China, where the universal two-child policy has further exacerbated the issue. PP, in particular, is associated with a high risk of severe hemorrhage, which can lead to maternal morbidity and mortality. Traditional management strategies often involve cesarean hysterectomy, but there is a growing trend towards conservative management, especially for patients who wish to preserve their fertility.
IABO is one of the techniques used in conservative management to reduce blood loss during surgery. By occluding the abdominal aorta, blood flow to the pelvis is temporarily halted, providing a clearer surgical field and reducing the risk of severe hemorrhage. Despite its potential benefits, the use of IABO in PP management is not without controversy. The procedure carries risks of complications such as arterial damage, infection, and thrombosis. Moreover, the efficacy of IABO in reducing blood loss and the need for hysterectomy has not been conclusively established.
Study Design and Methods
This study is a retrospective analysis of clinical data from six tertiary centers in China, conducted between January 2011 and December 2015. The study included 321 cases of PP, of which 132 patients underwent IABO, while 189 did not. To minimize selection bias, propensity score matching (PSM) was employed, resulting in 132 matched pairs for analysis. The primary outcomes assessed were postpartum hemorrhage (PPH), defined as blood loss exceeding 1000 mL within 24 hours of delivery, and the rate of hysterectomy. Secondary outcomes included the rate of repeated surgery and neonatal Apgar scores.
The IABO procedure involved the insertion of a compliant balloon catheter into the right femoral artery under local anesthesia. The balloon was positioned in the infrarenal abdominal aorta, above the aortic bifurcation, and inflated to occlude blood flow. The catheter was securely fixed to the skin to prevent dislodgement. The procedure was performed by experienced interventional radiologists, and the occlusion time was carefully monitored to minimize the risk of complications.
Results
The analysis of the matched pairs revealed significant differences in maternal outcomes between the IABO and control groups. The rate of PPH was significantly lower in the IABO group (68.9%) compared to the control group (87.9%). Similarly, the rate of hysterectomy was markedly reduced in the IABO group (8.3%) compared to the control group (65.2%). The need for repeated surgery, including dilation and curettage and laparotomy, was also significantly lower in the IABO group (1.5%) compared to the control group (12.1%).
In terms of neonatal outcomes, there were no significant differences between the two groups. The Apgar scores at 1 minute and 5 minutes were comparable, with no significant differences in the proportion of neonates with low Apgar scores. Birth weight was also similar between the two groups, indicating that IABO did not have a detrimental effect on neonatal outcomes.
Discussion
The findings of this study suggest that IABO is an effective strategy for reducing blood loss and the need for hysterectomy in patients with PP. The significant reduction in PPH and hysterectomy rates in the IABO group highlights the potential benefits of this procedure in the conservative management of PP. Moreover, the absence of adverse effects on neonatal outcomes further supports the safety of IABO in this context.
The efficacy of IABO in reducing blood loss can be attributed to its ability to occlude blood flow at the level of the infrarenal abdominal aorta, thereby blocking pelvic collaterals more effectively than other techniques such as internal iliac artery occlusion. This is particularly important in patients with PP, who often have developed rich pelvic collateral circulations. By providing a clearer surgical field and reducing intraoperative blood loss, IABO can facilitate safer and more effective surgical management of PP.
However, the use of IABO is not without risks. Complications such as arterial damage, infection, and thrombosis have been reported in previous studies. To minimize these risks, it is essential that the procedure is performed by experienced interventional radiologists, and that appropriate occlusion times and postoperative anticoagulation therapy are employed. The radiation exposure associated with IABO is another consideration, although the mean dose of 4.20 mGy is well below the threshold of 100 mGy, which is considered safe for the fetus.
Conclusion
In conclusion, this study provides strong evidence supporting the use of IABO in the management of PP. The procedure significantly reduces blood loss, the need for hysterectomy, and the rate of repeated surgery, without compromising neonatal outcomes. For patients with PP who wish to preserve their fertility, conservative management with IABO can be a safe and effective option. However, further prospective studies are needed to fully assess the risk-benefit ratio of IABO and to identify strategies for minimizing complications.
doi.org/10.1097/CM9.0000000000001944
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