Intraoperative Multivessel Embolization Reduces Blood Loss by Half Compared to Balloon Placement During Caesarian Hysterectomy for Placenta Accreta Spectrum

Intraoperative Multivessel Embolization Reduces Blood Loss and Transfusion Requirements Compared to Internal Iliac Artery Balloon Placement during Caesarian Hysterectomy for Placenta Accreta Spectrum

Clinical Question

Is prophylactic multivessel selective embolization (MVSE) safer and more effective than internal iliac artery occlusion balloon (IIABO) placement in patients undergoing caesarian hysterectomy for placenta accreta spectrum (PAS)?

Take Away Point

MVSE demonstrated more than 50% reduction in median blood loss compared to the IIABO along with significantly reduced percentage of cases requiring packed red blood cells transfusions and median number of cases used. However, the former demonstrated increased procedural time, radiation dosage, and contrast usage.

Reference

Berman Z, Boone C, Melber DJ, et al. Intraoperative Multivessel Embolization Reduces Blood Loss and Transfusion Requirements Compared to Internal Iliac Artery Balloon Placement during Cesarean Hysterectomy for Placenta Accreta Spectrum. Journal of Vascular and Interventional Radiology. 2023;34(11). doi:https://doi.org/10.1016/j.jvir.2023.07.024

Study Design

Retrospective, observation, and cohort studies ultimately comprising of 54 patients, 20 of which received embolization and 34 of which received balloon placement

Funding Source

No reported funding

Setting

Academic, Keck School of Medicine, Los Angeles, CA
Academic, Stanford University, Stanford, CA

Figure

Summary

Placenta accreta spectrum (PAS) has been associated with an increased risk of severe hemorrhage during delivery. Traditionally, it was managed by Caesarian section followed by hysterectomy, leaving placenta in situ in order to minimize hemorrhage. A meta-analysis of 13 studies consisting of over 800 patients demonstrated significantly lower mean estimated blood loss (EBL) among patients who underwent balloon-occlusion in internal iliac artery or infrarenal aorta compared to the patients in the control group who did not undergo any endovascular intervention prior to C-section. At present, no optional treatment strategies are available, and the authors of this paper set out to compare the safety and efficacy of multivessel selective embolization (MVSE) versus internal iliac artery balloon occlusion (IIABO).

The authors of this study performed a retrospective study. The researchers searched through the database from January 2010 to January 2021 of all the patients with PAS that underwent C-section, yielding 20 patients in the embolization group and 34 patients in the balloon-occlusion group. The primary endpoints of this study were EBL and transfusion requirements, with the secondary endpoints being fluoroscopic time, radiation doses, and IR procedural time. Adverse events were also recorded.

The results of the study demonstrated the following: Median EBL was significantly less in the MVSE group compared to IIABO group (713 mL versus 2 L, respectively). The percentage of cases requiring transfusion among embolization cases was 20% versus 65% in the balloon occlusion cases. These results were well within statistical significance. The embolization group demonstrated higher contrast usage, increased fluoroscopic times, and subsequently increased radiation dosages compared to the balloon occlusion group.

Despite the disadvantages of MVSE including increased procedural timing and radiation dosages on the patient, MVSE was shown by this study to be a safe and more effective alternative for the management of PAS patients undergoing Caesarian hysterectomy.

Commentary

The authors in this study were investigating the safety and efficacy of MVSE compared to IIABO in patients with PAS. The data demonstrated favorable results of the former when comparing EBL and transfusion requirements at the cost of fluoroscopy time and radiation dosage.

In my opinion, the advantages of potentially reducing adverse events and blood transfusion requirements outweigh the disadvantages posed by length of procedure time and radiation dosage, provided that optimal strategies are implemented to minimize radiation exposure. Additionally, MVSE was shown to be associated with decreased length of stay in the hospital, an important benefit to the patient and to the healthcare system in general.

Post author

Naeem Patel, DO
Radiology Resident, PGY4
Department of Radiology, Interventional Radiology Division
Hartford Hospital, Hartford, CT
@Naeemp7Patel