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?

Abstract

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.

Figure 1

Balloon catheter placement and testing. (A) Inflated balloon catheter positioned in the left internal iliac artery. (B) Retrograde contrast injection through the left femoral sheath confirming the correct placement of the balloon and the absence of flow distally into the internal iliac branches.

Figure 2

(A) Angiographic images obtained before embolization depicting the enhancement of the uterine vessels. (B) Final angiographic results after embolization. Note the absence of enhancement in the uterine territory and the flow arrest at the left internal iliac artery branches.

Figure 3

(A, B) Hysterectomy specimens submitted to postoperative posterior longitudinal hysterotomy. Embolic microspheres (arrows) deep in the placental tissue (P). Note the narrowing of the myometrium (M) in the lower uterine segment where there is contact between the placenta and the uterine serosa (S), which is a typical characteristic of placenta percreta.