D.O. Ott Research Institute of Obstetrics and Gynecology, Saint-Petersburg, Russian Federation.
Kirov Military Medical Academy, Saint-Petersburg, Russian Federation.
Eur J Obstet Gynecol Reprod Biol. 2021 Mar;258:23-28. doi: 10.1016/j.ejogrb.2020.12.022. Epub 2020 Dec 13.
The aim of this study was to compare two vascular control options for blood loss prevention and hysterectomy during cesarean delivery (CD): endovascular balloon occlusion of the aorta (REBOA) and open bilateral common iliac artery occlusion (CIAO) in women with extensive placenta accreta spectrum (PAS).
This was retrospective comparison of cases of PAS using either CIAO (October 2017 through October 2018) or REBOA (November 2018 through November 2019) to prevent pathologic hemorrhage during scheduled CD. Women with confirmed placenta increta/percreta underwent either CD then intraoperative post-delivery, pre-hysterectomy open vascular control of both CIA (CIAO group) or pre-operative, ultrasound-guided, fluoroscopy-free REBOA followed by standard CD and balloon inflation after fetal delivery (REBOA group). Intraoperative blood loss, transfusion volumes, surgical time, blood pressure, maternal and neonatal outcomes, hospitalization length and postoperative complications were compared.
The REBOA and CIAO groups included 12 and 16 women, respectively, with similar median age of 35 years and gestational age of 34-35 weeks. All REBOA catheters were successfully placed into aortic zone three under ultrasound guidance. The quantitated median intraoperative blood loss was significantly lower for the REBOA group, (541 [IQR 300-750] mL) compared to the CIAO group (3331 [IQR 1150-4750] mL (P = 0.001). As a result, the total volume of fluid and blood replacement therapy was significantly lower in the REBOA group (P < 0.05). Median surgical time in the REBOA group was less than half as long: 76 [IQR 64-89] minutes compared to 168 [IQR 90-222] minutes in the CIAO group (P = 0.001). None of the women with REBOA required hysterectomy, while 8/16 women in the CIAO group did (P = 0.008). Furthermore, the post-anesthesia recovery and hospital discharge times in the REBOA-group were shorter (P < 0.05). One thromboembolic complication occurred in each group. The only REBOA-associated complication was non-occlusive femoral artery thrombosis, with no surgical management required. No maternal or neonatal deaths occurred in either group.
Fluoroscopy-free REBOA for women with PAS is associated with improved vascular control, perioperative blood loss, the need for transfusion and hysterectomy and reduces surgical time when compared to bilateral CIAO.
本研究旨在比较两种用于剖宫产术中预防出血的血管控制方法：血管内主动脉球囊阻断（REBOA）和开放性双侧髂总动脉阻断（CIAO），以预防广泛胎盘植入谱系疾病（PAS）患者的出血。
这是一项回顾性比较研究，纳入了 2017 年 10 月至 2018 年 10 月期间使用 CIAO（胎盘植入/穿透组）或 2018 年 11 月至 2019 年 11 月期间使用 REBOA（胎盘植入/穿透组）预防计划性剖宫产病理性出血的 PAS 病例。经确认胎盘植入/穿透的患者行剖宫产术，术中行产后即刻、子宫切除前开放双侧 CIA 血管控制（CIAO 组）或术前超声引导、无射线透视的 REBOA 后行标准剖宫产术，胎儿娩出后行球囊充气（REBOA 组）。比较术中出血量、输血量、手术时间、血压、母婴结局、住院时间和术后并发症。
REBOA 组和 CIAO 组分别纳入 12 例和 16 例患者，中位年龄分别为 35 岁和 34-35 周，妊娠年龄相似。所有 REBOA 导管均在超声引导下成功置入主动脉区 3 区。REBOA 组术中出血量明显低于 CIAO 组（541 [IQR 300-750] mL 比 3331 [IQR 1150-4750] mL，P = 0.001）。因此，REBOA 组总液体和血液替代治疗量明显减少（P < 0.05）。REBOA 组的中位手术时间不到 CIAO 组的一半：76 [IQR 64-89] 分钟比 CIAO 组的 168 [IQR 90-222] 分钟（P = 0.001）。REBOA 组无患者需要行子宫切除术，而 CIAO 组 8/16 例（P = 0.008）。此外，REBOA 组的麻醉后恢复和出院时间较短（P < 0.05）。两组各有 1 例发生血栓栓塞性并发症。两组唯一的 REBOA 相关并发症为非闭塞性股动脉血栓形成，无需手术治疗。两组均无产妇或新生儿死亡。
与双侧 CIAO 相比，对于 PAS 患者，无射线透视的 REBOA 可更好地控制血管、减少围手术期出血量、输血和子宫切除术需求，并缩短手术时间。
