Can the combination of internal iliac temporary occlusion and uterine artery embolization reduce bleeding and the need for intraoperative blood transfusion in cases of invasive placentation?

OBJECTIVES: Women with invasive placentation (IP) are at high risk of life-threatening hemorrhage. In the last two decades, less invasive surgical approaches combined with endovascular procedures have proven to be safe. Most case series describe the use of temporary balloon occlusion and embolization, either combined or not. Concerning hemorrhage rates, each separate interventional approach performs better than surgery alone does, yet it is not clear whether the combination of multiple interventional techniques can be beneficial and promote a lower incidence of intrapartum bleeding. We aim to evaluate whether combining temporary balloon occlusion of the internal iliac artery and uterine artery embolization promotes better hemorrhage control than do other individual interventional approaches reported in the scientific literature in the context of cesarean birth followed by hysterectomy in patients with IP. METHODS: This is a retrospective analysis of patients with confirmed IP who underwent temporary balloon occlusion and embolization of the internal iliac arteries followed by puerperal hysterectomy. We compared patient results to data extracted from a recent systematic review and meta-analysis of the current literature that focused on interventional procedures in patients with IP. RESULTS: A total of 35 patients underwent the procedure during the study period in our institution. The mean volume of packed red blood cells and the estimated blood loss were 487.9 mL and 1193 mL, respectively. Four patients experienced complications that were attributed to the endovascular procedure. CONCLUSION: The combination of temporary balloon occlusion and uterine artery embolization does not seem to promote better hemorrhage control than each procedure performed individually does

Temporary ballooning and embolization of the internal iliac arteries for intrapartum bleeding control in patients with placenta accreta

Introdução: Acretismo placentário é condição pouco frequente na qual há aderência anormal do tecido trofoblástico à parede uterina. É uma causa importante de hemorragia puerperal, associada a altas taxas de morbimortalidade maternofetal, grande necessidade de transfusão de hemoconcentrados. Os tratamentos propostos variam desde conduta conservadora até a histerectomia pós-parto, associada ou não a procedimentos endovasculares. Objetivo: O presente estudo visa descrever a técnica endovascular de balonamento temporário e embolização das artérias ilíacas internas durante o parto cesáreo, avaliar sua eficácia em reduzir o sangramento materno relacionado ao acretismo placentário, bem como relatar a segurança e o índice de complicações relacionadas ao tratamento endovascular. Materiais e métodos: Coorte retrospectiva de pacientes com diagnóstico pré-natal de acretismo placentário submetidas a tratamento endovascular de balonamento temporário e embolização das artérias ilíacas internas, seguido de histerectomia puerperal no nosso serviço, no período de janeiro de 2012 até novembro de 2016. Foram analisados dados relativos aos antecedentes gestacionais e cirúrgicos, achados de exames de imagem, achados histológicos, níveis de hemoglobina prévios, durante e após o parto, bem como volumes de hemoconcentrados administrados e taxa de complicações relacionadas ao procedimento endovascular. Resultados: Trinta e Siqueira FM 7 cinco pacientes foram submetidas ao manejo proposto durante o período estudado. Foi observado um volume médio de transfusão relacionado ao procedimento e perda sanguínea estimada de 540 ml e 1229 ml, respectivamente. Ocorreram complicações relacionadas ao procedimento endovascular em quatro pacientes, sendo um caso de necrose muscular glútea, um de lesão isquêmica cutânea superficial e dois casos de trombose arterial aguda de membros inferiores. Conclusão: O presente estudo demonstrou que o balonamento temporário e embolização das artérias ilíacas internas reduziu significativamente as necessidades transfusionais relacionadas ao parto nas pacientes com acretismo placentário, quando comparado com casos da literatura nos quais não foram realizadas intervenções endovasculares, com baixo índice de complicações relacionadas ao procedimento.Introduction: Placenta accreta (PA) is the infrequent condition in which there is abnormal adherence of the trophoblastic tissue to the uterine wall. It\'s considered a major cause of puerperal bleeding, associated with high maternal morbimortality and need for blood products transfusion. Proposed treatments range from conservative to postpartum hysterectomy, combined or not to endovascular techniques. Objectives: to describe the detailed endovascular technique of temporary balloon occlusion followed by embolization of the internal iliac arteries (IIA) during cesarean section, evaluate the ability in reducing birth-related blood loss in patients with diagnosed PA and to assess safety and complications related to the endovascular procedure. Materials and methods: retrospective cohort of patients diagnosed with PA submitted to temporary balloting and embolization of the IAA followed by puerperal hysterectomy in our institution from January 2012 to November 2016. We recorded patient data such as gestational and surgical history, pre-natal radiological image findings, histopathological description, pre e postoperative hemoglobin levels and volume of blood products transfused in all patients. Follow up accounted for possible complications related to the procedure. Results: thirty-five patients were submitted to the approach during the study period. The median volume of packed red blood cells (RBC) and estimated blood loss were 540 ml and 1229 ml respectively. A total of 4 patients had complications attributed to the endovascular procedure - one case of Siqueira FM 9 deep glute tissue necrosis, one of superficial tissue necrosis and two cases of acute arterial thrombosis of the inferior limbs. Conclusion: the present study demonstrated that temporary ballooning and embolization of the IAA was able to significantly reduce birth-related blood loss and transfusion needs in patients with PA when compared to other literature series where no endovascular procedures were performed, with a low rate of procedure-related complications

Two-layered susceptibility vessel sign is associated with biochemically quantified thrombus red blood cell content

International audienceBackground and purpose: Better characterization of the thrombus could be useful to determine acute ischaemic stroke (AIS) aetiology and predict response to thrombolysis and endovascular therapy (EVT). To test the hypothesis that susceptibility vessel sign (SVS) on baseline magnetic resonance imaging (MRI) is related to red blood cell (RBC) content of AIS thrombi, the total haemoglobin contents (HbCs) of AIS thrombi retrieved by EVT from patients with or without SVS or two-layered SVS (TLSVS) were compared. Methods: Baseline MRI of 84 anterior AIS patients was reviewed by neuro-radiologists blinded to clinical and biochemical data. Thrombi from these patients were retrieved by EVT and analysed for HbC by quantitative enzyme-linked immunosorbent assay and measurement of haem concentration. Results: Susceptibility vessel sign and TLSVS were respectively observed in 85.7% and 50.0% of cases. The median HbC content was 253 µg/mg thrombus (interquartile range 177–333) and the median haem content was 219 µg/mg thrombus (131–264). Thrombus HbC and haem content were highly correlated with thrombus RBC content determined by flow cytometry (r = 0.94). Thrombi from patients with TLSVS weighed more [31.1 (16.5–68.3) mg vs. 17.7 (11.7–33.3) mg; P = 0.005] and had a higher HbC content [278 (221–331) µg/mg vs. 196 (139–301) µg/mg; P = 0.010] compared to thrombi from patients without TLSVS. There was no difference in thrombus weight or HbC content according to SVS status. Conclusions: Our study shows that TLSVS is significantly associated with a higher thrombus weight and RBC content, as determined by quantitative assays