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Staged Embolization and Hysterectomy in the IR Suite for Placenta Accreta: Associated with Improved Outcomes
Abstract Number: T-38
Abstract Type: Case Report/Case Series
The incidence of placenta accreta has increased recently at our institution, a tertiary referral center. Prior to 2011, elective cesarean hysterectomy for prenatally diagnosed placenta previa with accreta was performed in the main operating room suite. Internal iliac artery (IIA) balloon occlusion catheters were variably used, and emergent transfer to the interventional radiology (IR) suite was often required as a salvage measure when surgical hemostasis had failed.
In 2011, the obstetric anesthesia division lead our multidisciplinary team in instituting a major change in practice. Emulating the staged embolization and hysterectomy (SEH) technique described by Angstmann (1), we modified the approach so that the entire procedure would be performed in the IR suite. The new SEH protocol includes preoperative internal iliac artery (IIA) balloon placement under epidural or general anesthesia, depending on patient preferences and the airway assessment. Classical cesarean delivery ensues, with a hysterotomy performed away from the placental location. After delivery, the balloons are inflated and the uterine incision is promptly closed with the placenta in situ. Oxytocin is not given. Pelvic angiography with uterine embolization is performed. When uterine devascularization is deemed satisfactory, the uterus and placenta are removed en bloc by the gynecologic oncologists.
We reviewed the cases of elective cesarean hysterectomy for histologically confirmed placenta accreta in 2010 and 2011. All 3 cases in 2010 were performed in the operating room, and 4 cases were done in IR with the SEH approach in 2011. The mean intraoperative units of blood products transfused (PRBC, FFP, platelets, and cryoprecipitate), postoperative length of stay, and days on the ventilator were reduced in the 2011 cohort compared to the 2010 group: 16 units, 5.3 days, and 0.25 days vs. 67.3 units, 10.7 days, and 2 days.
Our experience suggests that performing SEH in a single IR location may reduce transfusion requirements, and thereby lead to substantial reductions in ICU utilization, total length of stay, and major morbidity. SEH is a more reliable method for reducing uteroplacental blood flow than balloon catheters alone. This approach also optimizes operating conditions for the interventional radiologists, and mitigates the risks associated with the transport and movement of acutely hemorrhaging patients.
1) Angstmann et al. Am J Obstet Gynecol. 2010 Jan;202(1):38.e1-9.