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Internal Iliac Artery Rupture Caused by Endovascular Balloons in a Woman with Placenta Percreta
CASE REPORT
Internal Iliac Artery Rupture Caused by Endovascular Balloons in a Woman with Placenta Percreta Jessica Papillon-Smith, MD,1 Sukhbir Sony Singh, MD, FRCSC,2 Cleve Ziegler, MD, FRCSC3 1
Department of Obstetrics and Gynecology, McGill University Health Centre, Montreal QC
2
Department of Obstetrics and Gynecology, The Ottawa Hospital, Ottawa ON
3
Department of Obstetrics and Gynecology, Jewish General Hospital, Montreal QC
Abstract Background: Prior to Caesarean section (CS) for morbidly adherent placenta (MAP), endovascular balloons are often placed prophylactically to minimize hemorrhage. However, there have been few reports describing complications of this intervention. Case: A 41-year-old woman with a diagnosis of placenta percreta had endovascular balloon catheters placed before CS. Intraoperatively the right internal iliac artery ruptured, requiring vascular repair, multiple transfusions of blood and plasma, and admission to the intensive care unit. Conclusion: Prophylactic placement of endovascular balloons to reduce maternal hemorrhage at CS for MAP may result in complications. Until more evidence becomes available supporting their use, safety guidelines must be instated in centres using them.
Résumé Contexte : Avant une césarienne pratiquée en raison d’une adhérence pathologique du placenta, on a souvent recours à l’insertion prophylactique de ballons endovasculaires pour réduire au minimum le risque d’hémorragie. Il existe toutefois quelques études de cas décrivant les complications de cette intervention. Cas : Une femme de 41 ans ayant un diagnostic de placenta percreta a subi l’insertion de cathéters à ballonnet endovasculaires avant une césarienne. Durant l’intervention, l’artère iliaque interne droite s’est rompue, nécessitant une réparation vasculaire, de multiples transfusions de sang et de plasma et l’admission au service de soins intensifs. Conclusion : L’insertion prophylactique de ballons endovasculaires pour réduire les hémorragies maternelles durant une césarienne pratiquée en raison d’une adhérence pathologique du placenta peut entraîner des complications. Jusqu’à ce qu’un plus grand volume de données
Key Words: Placenta percreta, internal iliac artery occlusive balloon, hemorrhage, complication Conflicting Interests: None declared. Received on February 10, 2016 Accepted on June 28, 2016 http://dx.doi.org/10.1016/j.jogc.2016.09.001
1024
l
NOVEMBER JOGC NOVEMBRE 2016
soit publié à l’appui de cette intervention, des directives de sécurité doivent être mises en place dans les centres qui la pratiquent. Copyright ª 2016 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
J Obstet Gynaecol Can 2016;38(11):1024e1027
INTRODUCTION
M
orbidly adherent placenta (MAP) is a disorder of placental implantation that develops when the loss of the decidua basalis allows uncontrolled invasion of the chorionic villi into the myometrium.1 Based on its depth of invasion, MAP is subdivided into three separate entities: placenta accreta, placenta increta, and placenta percreta. Placenta accreta, the most common but least severe form of MAP, involves superficial placental invasion through the decidua, while placenta percreta, the least common but most severe form of MAP, involves placental invasion through the uterine serosa with possible extension into adjacent organs.2 Despite rapidly evolving imaging and surgical technologies and growing surgical expertise, MAP remains an important cause of maternal morbidity and mortality.1 MAP is associated with life-threatening postpartum hemorrhage, with a 7% risk of maternal mortality.1 Risk factors associated with MAP include high parity, multifetal gestation, advanced maternal age, assisted reproductive technologies, placenta previa, and, most importantly, a history of Caesarean section or other uterine surgery.2 As rates of CS have increased, the rate of MAP has also risen.1 In a 2015 review of birth registries, Mehrabadi et al. noted an incidence of placenta accreta of 14.4 per 10 000 deliveries,3 increased from approximately four per 10 000 deliveries in 1980.4 Although MAP accounts for nearly 30% of peripartum hysterectomies and is associated with a rate ratio of 286 for
Internal Iliac Artery Rupture Caused by Endovascular Balloons in a Woman with Placenta Percreta
Caesarean hysterectomy,3 its management remains a major obstetrical challenge with surrounding controversy. A major point of debate is the prophylactic placement of endovascular balloons prior to surgery. The goal of temporarily occluding the internal iliac arteries is to reduce uterine perfusion and decrease the rate of blood flow, thereby reducing blood loss, improving visualization during surgery, allowing for urgent arterial embolization (if required), and possibly preventing hysterectomy.5 Despite these potential advantages, some have questioned the routine use of endovascular balloons, claiming that the associated risks outweigh their benefits.6,7 We describe here the case of a 41-year-old parturient with a suspected placenta percreta who experienced a complication arising from the use of endovascular internal iliac artery occlusive balloons (IIAOBs). THE CASE
A previously healthy 41-year-old woman, gravida 3, para 2, was referred to our tertiary care obstetrical centre for the management of suspected placenta percreta. She had had two previous uncomplicated CSs for breech presentation at term. Her pregnancy had been conceived spontaneously. Her ultrasound assessment at 20 weeks’ gestation showed an anatomically normal fetus and a complete anterior placenta previa. At 33þ2 weeks’ gestation, ultrasound again confirmed a complete anterior placenta previa, with features suspicious for invasion of the bladder wall by the placenta. Fetal growth had been appropriate. Consultation and imaging with a tertiary level obstetrical unit suggested placental invasion of the CS scar over a width of 9 cm, with a high likelihood of placenta percreta penetrating through the bladder wall. The patient was given two doses of intramuscular betamethasone (12 mg per dose, 24 hours apart) and met with an interdisciplinary surgical team including consultants from urology, anaesthesia, and gynaecology. She was counselled regarding the severity of this condition and agreed to undergo an elective Caesarean hysterectomy. The patient was admitted for elective surgery at 35þ5 weeks’ gestation. In accordance with institutional protocol, prophylactic IIAOBs were placed shortly before surgery. The IIAOBs were placed using previously described radiologic techniques.8 Once the balloons had been positioned, the vascular sheaths, balloon catheters, and attached 3 mL syringes containing 0.6 mL of normal saline were secured to the patient’s thighs with sutures and adhesive bandages. The placement procedure was well tolerated and the
patient was transferred to the operating room for her scheduled Caesarean hysterectomy. General anaesthesia was induced and the patient was placed in stirrups in the dorso-lithotomy position. A midline skin incision was made and deepened to the abdominal cavity; at this point, it was obvious that the placenta was extending through the bladder wall into the broad ligament, anterior abdominal wall fascia, and pelvic sidewalls. A fundal midline hysterotomy incision was made, and a live male infant weighing 2680 g was delivered with Apgar scores of 9 and 10 at one and five minutes respectively. Following delivery of the infant, the hysterotomy incision was closed. With very mild manipulation of the uterus, heavy bleeding ensued, so the IIAOBs were inflated bilaterally. The left IIAOB was inflated using the pre-filled syringe. However, the plunger of the 3 mL syringe for the right IIAOB had come out of the barrel, leaving the syringe empty. Another 3 mL syringe was quickly filled with 2 mL of normal saline and attached to the right IIAOB, and the balloon inflated. Hysterectomy was then performed with rapid clamping and suture-ligation of pedicles. After achieving hemostasis, a significant bladder injury was identified, and the urology team performed primary bladder repair with placement of a suprapubic catheter. Prior to closure of the abdomen, the IIAOBs were deflated after a total inflation time of 90 minutes. Shortly after deflating the IIAOBs, a retroperitoneal hematoma developed and rapidly expanded along the right pelvic side wall. The vascular surgery service was therefore urgently consulted. During this time, the patient became hemodynamically unstable, with a blood pressure of 60/40 mm Hg, tachycardia of 130 beats/minute, and profound oxygen desaturation (SpO2 24%). The hospital’s massive transfusion protocol was initiated, and the patient received a total of eight units of packed red blood cells, four units of fresh frozen plasma, and 10 units of platelets. Exploration by the vascular surgeon identified rupture of the right internal iliac artery caused by the occlusive endovascular balloon. After controlling the bleeding, one litre of fresh blood was evacuated from the retroperitoneal space, the arterial defect was repaired, and the anterior branch of the right internal iliac artery was ligated for hemostatic purposes. The vascular surgeon then noted that the lower extremities were pale with no Doppler signals in the feet, raising the possibility of ischemia. An angiogram was performed
NOVEMBER JOGC NOVEMBRE 2016
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CASE REPORT
intraoperatively through the vascular sheaths, showing that the sheaths were sub-occlusive but that the iliac, femoral, popliteal, and tibial vessels were patent with no evidence of thrombosis. The sheaths were immediately removed, and the peripheral pulses were slowly restored. The abdomen was then closed. Estimated blood loss during the procedure was approximately 4.5 L. The patient was transferred to the intensive care unit and remained intubated for 18 hours. She was discharged on the fifth postoperative day with a hemoglobin concentration of 87 g/L (preoperative hemoglobin was 114 g/L). Histopathology confirmed placenta percreta. No neurologic deficits in the lower extremities were noted at the patient’s six-week follow-up visit. DISCUSSION
In our centre, with approximately 3850 deliveries annually, an average of four Caesarean hysterectomies are performed each year. Of these, approximately two-thirds are performed because of abnormal placentation. In a 20-year review of the predictors of adverse outcomes following postpartum hysterectomy at our centre, Ibrahim et al. found that unplanned cases without preoperative placement of occlusive arterial balloons had a six-fold higher incidence of massive blood transfusion and a 20-fold higher incidence of coagulopathy.9 Although some confounding may account for this difference, IIAOBs have been used liberally at our centre since 2002 in the management of MAP when there is a suspicion of placenta percreta. It is likely that this patient’s arterial rupture occurred because the endovascular balloon was inflated with 2 mL of normal saline when it was initially calibrated to be inflated with only 0.6 mL. However, it is unclear how the syringe’s plunger became displaced from the barrel, leaving the syringe empty. This possibly occurred during transport of the patient from the angiography suite to the operating room or during the moving of the patient into a dorsolithotomy position. There appeared to be a break in communication between the interventional radiology department and the surgical team, leading to failure to calibrate the balloons correctly. Theoretically, other factors contributing to an increased risk of arterial rupture include substantial pregnancyrelated arterial endothelial remodelling and fluctuations in hemodynamics produced by the CS and hysterectomy. These may inherently make pregnant women more susceptible to arterial dissection and rupture.10,11
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It is impossible to determine whether the hysterectomy and bladder repair could have been managed as efficiently if the IIAOBs had not been inflated. In fact, if arterial rupture had not occurred, this case may have exemplified the advantages of using IIAOBs in the management of all cases of MAP. In reporting this complication, we do not wish to discredit the potential benefits of occlusive balloons. Rather, we wish to raise awareness about possible harm associated with the use of IIAOBs and the importance of establishing clear safety protocols to decrease IIAOBrelated morbidities. In response to this event, educational initiatives regarding the functioning and monitoring of these devices have been established, and a member of the interventional radiology team will be readily available in the operating room. At our morbidity and mortality rounds, as well as at our quality improvement meetings, the chiefs of gynaecology and interventional radiology have emphasized the importance of minimizing patient transit and positioning once the sheaths have been inserted and of identifying a staff member familiar with inflation of the balloon catheters. Complications related to the use of endovascular balloons in the management of MAPs are most often thromboembolic and ischemic. Greenberg et al. described a case of thrombosis of the common and external iliac arteries following 40 minutes of occlusion by IIAOBs; in this case, urgent thrombectomy was performed.12 Sewell et al. described a case in which the left popliteal artery became thrombosed following the use of IIAOBs; this also required an immediate procedure to preserve the patient’s lower limb.13 Although both of these patients recovered without further sequelae, Bishop et al. described a case in which the use of IIAOBs led to a series of complications resulting in thrombosis of the right common iliac artery, with symptoms of claudication persisting months after surgery.14 Teare et al.10 and Chouliaras et al.11 described other procedures in which endovascular balloon placement resulted in long-term morbidity. These patients continued to suffer from chronic neuropathic pain due to iatrogenic thrombosis and required use of gabapentin, amitriptyline, or transcutaneous electrical nerve stimulation for relief of their symptoms. To our knowledge, this is the second reported case of a major vascular injury arising from the use of IIAOBs for MAP. Gagnon et al. described a case in which a 35-year-old woman underwent IIAOB placement for suspected placenta accreta and had an immediate procedure-related rupture of the internal iliac artery prior to CS.8 At the time of surgery, she was found to have a large retroperitoneal hematoma resulting in a need for massive blood
Internal Iliac Artery Rupture Caused by Endovascular Balloons in a Woman with Placenta Percreta
transfusion. The infant’s arterial pH at delivery was 6.95. The placenta in this case was removed without difficulty, and hysterectomy was not required. In this case, the catheter placement itself appears to have been responsible for the adverse outcome rather than the deployment of these devices. The case we describe highlights the need to consider the fetal risks related to disruption of uteroplacental blood flow following balloon placement as well as the maternal risks involved in post-delivery intraoperative balloon inflation. CONCLUSION
Prophylactic endovascular balloon occlusion is a controversial practice and has produced mixed results in women undergoing surgery for MAP. It is likely that in the case described in this report, arterial rupture occurred because of accidental over-inflation of the catheter balloon. While waiting for more robust evidence and clear recommendations on the role of occlusive devices in the management of MAP, we believe it is crucial that safety guidelines be developed and implemented in centres in which endovascular occlusive balloons are used to mitigate complications such as in this case. ACKNOWLEDGEMENT
The woman whose story is told in this report has given consent for its publication.
2. Bodner LJ, Nosher JL, Gribbin C, Siegel RL, Beale S, Scorza W. Balloonassisted occlusion of the internal iliac arteries in patients with placenta accreta/percreta. Cardiovasc Intervent Radiol 2006;29:354e61. 3. Mehrabadi A, Hutcheon JA, Liu S, Bartholomew S, Kramer MS, Liston RM, et al. Contribution of placenta accreta to the incidence of postpartum hemorrhage and severe postpartum hemorrhage. Obstet Gynecol 2015;125:814e21. 4. Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol 2005;192:1458e61. 5. Dilauro MD, Dason S, Athreya S. Prophylactic balloon occlusion of internal iliac arteries in women with placenta accreta: literature review and analysis. Clin Rad 2012;67:515e20. 6. Thon S, McLintic A, Wagner Y. Prophylactic endovascular placement of internal iliac occlusion balloon catheters in parturients with placenta accreta: a retrospective case series. Int J Obstet Anesth 2011;20:64e70. 7. Shrivastava V, Nageotte M, Major C, Haydon M, Wing D. Case-control comparison of cesarean hysterectomy with and without prophylactic placement of intravascular balloon catheters for placenta accreta. Am J Obstet Gynecol 2007;197:402.e1e5. 8. Gagnon J, Boucher L, Kaufman I, Brown R, Moore A. Iliac artery rupture related to balloon insertion for placenta accreta causing maternal hemorrhage and neonatal compromise. Can J Anaesth 2013;60:1212e7. 9. Ibrahim M, Ziegler C, Klam SL, Wieczorek P, Abenhaim HA. Incidence, indications, and predictors of adverse outcomes of postpartum hysterectomies: 20-year experience in a tertiary care centre. J Obstet Gynaecol Can 2014;36:14e20. 10. Teare J, Evans E, Belli A, Wendler R. Sciatic nerve ischaemia after iliac artery occlusion balloon catheter placement for placenta percreta. Int J Obstet Anesth 2014;23:178e81. 11. Chouliaras S, Hickling DJ, Tuck JS. Thromboembolism of the leg following prophylactic balloon occlusion of the uterine arteries. BJOG 2009;116:1278e9. 12. Greenberg JI, Suliman A, Iranpour P, Angle N. Prophylactic balloon occlusion of the internal iliac arteries to treat abnormal placentation: a cautionary case. Am J Obstet Gynecol 2007;197:470.e1e4. 13. Sewell MF, Rosenblum D, Ehrenberg H. Arterial embolus during common iliac balloon catheterization at cesarean hysterectomy. Obstet Gynecol 2006;108:746e8.
REFERENCES 1. Committee on Obstetric Practice. Committee Opinion No. 529: placenta accreta. Obstet Gynecol 2012;120:207.
14. Bishop S, Butler K, Monaghan S, Chan K, Murphy G, Edozien L. Multiple complications following the use of prophylactic internal iliac artery balloon catheterisation in a patient with placenta percreta. Int J Obstet Anesth 2011;20:70e3.
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Internal Iliac Artery Rupture Caused by Endovascular Balloons in a Woman with Placenta Percreta Jessica Papillon-Smith, MD,1 Sukhbir Sony Singh, MD, FRCSC,2 Cleve Ziegler, MD, FRCSC3 1
Department of Obstetrics and Gynecology, McGill University Health Centre, Montreal QC
2
Department of Obstetrics and Gynecology, The Ottawa Hospital, Ottawa ON
3
Department of Obstetrics and Gynecology, Jewish General Hospital, Montreal QC
Abstract Background: Prior to Caesarean section (CS) for morbidly adherent placenta (MAP), endovascular balloons are often placed prophylactically to minimize hemorrhage. However, there have been few reports describing complications of this intervention. Case: A 41-year-old woman with a diagnosis of placenta percreta had endovascular balloon catheters placed before CS. Intraoperatively the right internal iliac artery ruptured, requiring vascular repair, multiple transfusions of blood and plasma, and admission to the intensive care unit. Conclusion: Prophylactic placement of endovascular balloons to reduce maternal hemorrhage at CS for MAP may result in complications. Until more evidence becomes available supporting their use, safety guidelines must be instated in centres using them.
Résumé Contexte : Avant une césarienne pratiquée en raison d’une adhérence pathologique du placenta, on a souvent recours à l’insertion prophylactique de ballons endovasculaires pour réduire au minimum le risque d’hémorragie. Il existe toutefois quelques études de cas décrivant les complications de cette intervention. Cas : Une femme de 41 ans ayant un diagnostic de placenta percreta a subi l’insertion de cathéters à ballonnet endovasculaires avant une césarienne. Durant l’intervention, l’artère iliaque interne droite s’est rompue, nécessitant une réparation vasculaire, de multiples transfusions de sang et de plasma et l’admission au service de soins intensifs. Conclusion : L’insertion prophylactique de ballons endovasculaires pour réduire les hémorragies maternelles durant une césarienne pratiquée en raison d’une adhérence pathologique du placenta peut entraîner des complications. Jusqu’à ce qu’un plus grand volume de données
Key Words: Placenta percreta, internal iliac artery occlusive balloon, hemorrhage, complication Conflicting Interests: None declared. Received on February 10, 2016 Accepted on June 28, 2016 http://dx.doi.org/10.1016/j.jogc.2016.09.001
1024
l
NOVEMBER JOGC NOVEMBRE 2016
soit publié à l’appui de cette intervention, des directives de sécurité doivent être mises en place dans les centres qui la pratiquent. Copyright ª 2016 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
J Obstet Gynaecol Can 2016;38(11):1024e1027
INTRODUCTION
M
orbidly adherent placenta (MAP) is a disorder of placental implantation that develops when the loss of the decidua basalis allows uncontrolled invasion of the chorionic villi into the myometrium.1 Based on its depth of invasion, MAP is subdivided into three separate entities: placenta accreta, placenta increta, and placenta percreta. Placenta accreta, the most common but least severe form of MAP, involves superficial placental invasion through the decidua, while placenta percreta, the least common but most severe form of MAP, involves placental invasion through the uterine serosa with possible extension into adjacent organs.2 Despite rapidly evolving imaging and surgical technologies and growing surgical expertise, MAP remains an important cause of maternal morbidity and mortality.1 MAP is associated with life-threatening postpartum hemorrhage, with a 7% risk of maternal mortality.1 Risk factors associated with MAP include high parity, multifetal gestation, advanced maternal age, assisted reproductive technologies, placenta previa, and, most importantly, a history of Caesarean section or other uterine surgery.2 As rates of CS have increased, the rate of MAP has also risen.1 In a 2015 review of birth registries, Mehrabadi et al. noted an incidence of placenta accreta of 14.4 per 10 000 deliveries,3 increased from approximately four per 10 000 deliveries in 1980.4 Although MAP accounts for nearly 30% of peripartum hysterectomies and is associated with a rate ratio of 286 for
Internal Iliac Artery Rupture Caused by Endovascular Balloons in a Woman with Placenta Percreta
Caesarean hysterectomy,3 its management remains a major obstetrical challenge with surrounding controversy. A major point of debate is the prophylactic placement of endovascular balloons prior to surgery. The goal of temporarily occluding the internal iliac arteries is to reduce uterine perfusion and decrease the rate of blood flow, thereby reducing blood loss, improving visualization during surgery, allowing for urgent arterial embolization (if required), and possibly preventing hysterectomy.5 Despite these potential advantages, some have questioned the routine use of endovascular balloons, claiming that the associated risks outweigh their benefits.6,7 We describe here the case of a 41-year-old parturient with a suspected placenta percreta who experienced a complication arising from the use of endovascular internal iliac artery occlusive balloons (IIAOBs). THE CASE
A previously healthy 41-year-old woman, gravida 3, para 2, was referred to our tertiary care obstetrical centre for the management of suspected placenta percreta. She had had two previous uncomplicated CSs for breech presentation at term. Her pregnancy had been conceived spontaneously. Her ultrasound assessment at 20 weeks’ gestation showed an anatomically normal fetus and a complete anterior placenta previa. At 33þ2 weeks’ gestation, ultrasound again confirmed a complete anterior placenta previa, with features suspicious for invasion of the bladder wall by the placenta. Fetal growth had been appropriate. Consultation and imaging with a tertiary level obstetrical unit suggested placental invasion of the CS scar over a width of 9 cm, with a high likelihood of placenta percreta penetrating through the bladder wall. The patient was given two doses of intramuscular betamethasone (12 mg per dose, 24 hours apart) and met with an interdisciplinary surgical team including consultants from urology, anaesthesia, and gynaecology. She was counselled regarding the severity of this condition and agreed to undergo an elective Caesarean hysterectomy. The patient was admitted for elective surgery at 35þ5 weeks’ gestation. In accordance with institutional protocol, prophylactic IIAOBs were placed shortly before surgery. The IIAOBs were placed using previously described radiologic techniques.8 Once the balloons had been positioned, the vascular sheaths, balloon catheters, and attached 3 mL syringes containing 0.6 mL of normal saline were secured to the patient’s thighs with sutures and adhesive bandages. The placement procedure was well tolerated and the
patient was transferred to the operating room for her scheduled Caesarean hysterectomy. General anaesthesia was induced and the patient was placed in stirrups in the dorso-lithotomy position. A midline skin incision was made and deepened to the abdominal cavity; at this point, it was obvious that the placenta was extending through the bladder wall into the broad ligament, anterior abdominal wall fascia, and pelvic sidewalls. A fundal midline hysterotomy incision was made, and a live male infant weighing 2680 g was delivered with Apgar scores of 9 and 10 at one and five minutes respectively. Following delivery of the infant, the hysterotomy incision was closed. With very mild manipulation of the uterus, heavy bleeding ensued, so the IIAOBs were inflated bilaterally. The left IIAOB was inflated using the pre-filled syringe. However, the plunger of the 3 mL syringe for the right IIAOB had come out of the barrel, leaving the syringe empty. Another 3 mL syringe was quickly filled with 2 mL of normal saline and attached to the right IIAOB, and the balloon inflated. Hysterectomy was then performed with rapid clamping and suture-ligation of pedicles. After achieving hemostasis, a significant bladder injury was identified, and the urology team performed primary bladder repair with placement of a suprapubic catheter. Prior to closure of the abdomen, the IIAOBs were deflated after a total inflation time of 90 minutes. Shortly after deflating the IIAOBs, a retroperitoneal hematoma developed and rapidly expanded along the right pelvic side wall. The vascular surgery service was therefore urgently consulted. During this time, the patient became hemodynamically unstable, with a blood pressure of 60/40 mm Hg, tachycardia of 130 beats/minute, and profound oxygen desaturation (SpO2 24%). The hospital’s massive transfusion protocol was initiated, and the patient received a total of eight units of packed red blood cells, four units of fresh frozen plasma, and 10 units of platelets. Exploration by the vascular surgeon identified rupture of the right internal iliac artery caused by the occlusive endovascular balloon. After controlling the bleeding, one litre of fresh blood was evacuated from the retroperitoneal space, the arterial defect was repaired, and the anterior branch of the right internal iliac artery was ligated for hemostatic purposes. The vascular surgeon then noted that the lower extremities were pale with no Doppler signals in the feet, raising the possibility of ischemia. An angiogram was performed
NOVEMBER JOGC NOVEMBRE 2016
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CASE REPORT
intraoperatively through the vascular sheaths, showing that the sheaths were sub-occlusive but that the iliac, femoral, popliteal, and tibial vessels were patent with no evidence of thrombosis. The sheaths were immediately removed, and the peripheral pulses were slowly restored. The abdomen was then closed. Estimated blood loss during the procedure was approximately 4.5 L. The patient was transferred to the intensive care unit and remained intubated for 18 hours. She was discharged on the fifth postoperative day with a hemoglobin concentration of 87 g/L (preoperative hemoglobin was 114 g/L). Histopathology confirmed placenta percreta. No neurologic deficits in the lower extremities were noted at the patient’s six-week follow-up visit. DISCUSSION
In our centre, with approximately 3850 deliveries annually, an average of four Caesarean hysterectomies are performed each year. Of these, approximately two-thirds are performed because of abnormal placentation. In a 20-year review of the predictors of adverse outcomes following postpartum hysterectomy at our centre, Ibrahim et al. found that unplanned cases without preoperative placement of occlusive arterial balloons had a six-fold higher incidence of massive blood transfusion and a 20-fold higher incidence of coagulopathy.9 Although some confounding may account for this difference, IIAOBs have been used liberally at our centre since 2002 in the management of MAP when there is a suspicion of placenta percreta. It is likely that this patient’s arterial rupture occurred because the endovascular balloon was inflated with 2 mL of normal saline when it was initially calibrated to be inflated with only 0.6 mL. However, it is unclear how the syringe’s plunger became displaced from the barrel, leaving the syringe empty. This possibly occurred during transport of the patient from the angiography suite to the operating room or during the moving of the patient into a dorsolithotomy position. There appeared to be a break in communication between the interventional radiology department and the surgical team, leading to failure to calibrate the balloons correctly. Theoretically, other factors contributing to an increased risk of arterial rupture include substantial pregnancyrelated arterial endothelial remodelling and fluctuations in hemodynamics produced by the CS and hysterectomy. These may inherently make pregnant women more susceptible to arterial dissection and rupture.10,11
1026
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NOVEMBER JOGC NOVEMBRE 2016
It is impossible to determine whether the hysterectomy and bladder repair could have been managed as efficiently if the IIAOBs had not been inflated. In fact, if arterial rupture had not occurred, this case may have exemplified the advantages of using IIAOBs in the management of all cases of MAP. In reporting this complication, we do not wish to discredit the potential benefits of occlusive balloons. Rather, we wish to raise awareness about possible harm associated with the use of IIAOBs and the importance of establishing clear safety protocols to decrease IIAOBrelated morbidities. In response to this event, educational initiatives regarding the functioning and monitoring of these devices have been established, and a member of the interventional radiology team will be readily available in the operating room. At our morbidity and mortality rounds, as well as at our quality improvement meetings, the chiefs of gynaecology and interventional radiology have emphasized the importance of minimizing patient transit and positioning once the sheaths have been inserted and of identifying a staff member familiar with inflation of the balloon catheters. Complications related to the use of endovascular balloons in the management of MAPs are most often thromboembolic and ischemic. Greenberg et al. described a case of thrombosis of the common and external iliac arteries following 40 minutes of occlusion by IIAOBs; in this case, urgent thrombectomy was performed.12 Sewell et al. described a case in which the left popliteal artery became thrombosed following the use of IIAOBs; this also required an immediate procedure to preserve the patient’s lower limb.13 Although both of these patients recovered without further sequelae, Bishop et al. described a case in which the use of IIAOBs led to a series of complications resulting in thrombosis of the right common iliac artery, with symptoms of claudication persisting months after surgery.14 Teare et al.10 and Chouliaras et al.11 described other procedures in which endovascular balloon placement resulted in long-term morbidity. These patients continued to suffer from chronic neuropathic pain due to iatrogenic thrombosis and required use of gabapentin, amitriptyline, or transcutaneous electrical nerve stimulation for relief of their symptoms. To our knowledge, this is the second reported case of a major vascular injury arising from the use of IIAOBs for MAP. Gagnon et al. described a case in which a 35-year-old woman underwent IIAOB placement for suspected placenta accreta and had an immediate procedure-related rupture of the internal iliac artery prior to CS.8 At the time of surgery, she was found to have a large retroperitoneal hematoma resulting in a need for massive blood
Internal Iliac Artery Rupture Caused by Endovascular Balloons in a Woman with Placenta Percreta
transfusion. The infant’s arterial pH at delivery was 6.95. The placenta in this case was removed without difficulty, and hysterectomy was not required. In this case, the catheter placement itself appears to have been responsible for the adverse outcome rather than the deployment of these devices. The case we describe highlights the need to consider the fetal risks related to disruption of uteroplacental blood flow following balloon placement as well as the maternal risks involved in post-delivery intraoperative balloon inflation. CONCLUSION
Prophylactic endovascular balloon occlusion is a controversial practice and has produced mixed results in women undergoing surgery for MAP. It is likely that in the case described in this report, arterial rupture occurred because of accidental over-inflation of the catheter balloon. While waiting for more robust evidence and clear recommendations on the role of occlusive devices in the management of MAP, we believe it is crucial that safety guidelines be developed and implemented in centres in which endovascular occlusive balloons are used to mitigate complications such as in this case. ACKNOWLEDGEMENT
The woman whose story is told in this report has given consent for its publication.
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