Balloon occlusion of internal iliac arteries in placenta accreta!

Sir,

We read with interest the case report published by Khokhar et al.[1] The entire team did a fantastic job in managing the case successfully and uneventfully. With this communication, we want to take the discussion related to the tricky abnormal placentation cases a little more further.

Bilateral internal iliac artery occlusion is a procedure performed by the interventional radiologist in the cardiac catheterization laboratory (Cath lab). Parturients with abnormal placentation (placenta accreta, increta, percreta, and a few types of placenta previa) are candidates who can benefit with this intervention. Bilateral femoral arteries are punctured under local anesthesia, and balloon-tipped catheters are placed in bilateral internal iliac arteries under minimal fluoroscopic guidance after placing lead shield over the parturient to prevent radiation exposure to the fetus.[2] The parturient is then anesthetized in the operation theater. The balloons are inflated manually once the umbilical cord is clamped by the obstetrician during lower segment cesarean section.

This intervention decreases the uterine blood supply significantly which leads to a reduced blood loss during cesarean hysterectomy, less blood and blood products transfusion, a lesser surgical time, and an overall reduced stay in the Intensive Care Unit and Hospital. In several situations, an obstetric hysterectomy can also be avoided if the placental tissue is removed completely from the uterus. The amount of radiation exposure is minimal. Fetal blood flow is not affected as the balloons are inflated only after clamping the umbilical cord.

The procedure is not devoid of problems. As heparin is not used after catheter insertion due to an urgent surgical intervention, there are chances of thrombus formation.

Therefore, the occlusion time has to be minimum. The occlusion does not stop the uterine blood flow completely as there is a rich collateral network which means the intervention is not like a tourniquet which totally stops the blood supply.[3] Although the radiation exposure is minimal, fetal exposure to radiation might turn out to be excessive in difficult cases as in obese patients, patients with abnormal anatomy and preexisting anasarca.

Tan et al. published data of 13 parturients who had a diagnosis of placenta accreta confirmed of ultrasonography, color Doppler, and in indicated cases by a magnetic resonance imaging. They suggested that as the amount of blood loss and transfusion required after a prophylactic internal iliac artery balloon occlusion is significantly less, it should be considered an adjunct in cases of abnormal placentation in the present clinical practice.[4]

We conclude by mentioning that an obstetric hemorrhage team should also have a trained interventional radiologist who can help in such situations by performing minimally invasive procedures such as bilateral iliac artery balloon occlusion, pelvic artery catheterization, and abdominal aortic occlusion which are useful in managing cases of abnormal placentation.

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