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Interventional radiology for abnormally invasive placenta: do we need an alternative?
International Journal of Obstetric Anesthesia (2016) 27, 1–2 0959-289X/$ - see front matter Ó 2016 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijoa.2016.06.001
EDITORIAL
www.obstetanesthesia.com
Interventional radiology for abnormally invasive placenta: do we need an alternative? The opening lecture at the 2016 Obstetric Anaesthesia Meeting in Manchester was entitled ‘‘What’s New in Obstetric Anaesthesia”: it could be argued that there is relatively little which really is new. This may well reflect that we have made this field of anaesthesia very safe for our patients so that it is becoming difficult to be innovative. Furthermore, any development in medicine may be associated with morbidity and mortality which will be unknown until it has been used on a sufficient number of patients. As anaesthetists, we are very risk averse and if our morbidity and mortality figures are low it follows that we are reluctant to propose radical changes. However, one cannot help but feel a little depressed by repeatedly finding that despite guidance, recommendations or evidence, little seems to change. And so it would appear to be with the use of interventional radiology (IR) in obstetric anaesthesia. In 2008, the UK Confidential Enquiry into Maternal and Child Health (CEMACH)1 was the first to advocate consideration of IR in the management of abnormally invasive placenta (AIP). I am in the fortunate position of working in an institution where we have had access to the services of an interventional radiologist since 2002. Therefore, to me the results of a UK-wide survey into the availability of IR for the management of obstetric haemorrhage2 in 2010 were surprising. The survey reported that 31% of UK obstetric units had experience of using IR. Unsurprisingly, 46% of units reported having considered its use but access to IR was extremely variable and only 29% of units reported 24-hour access to a specialised radiologist. At Obstetric Anaesthesia 2016, three posters described the management of AIP. The authors reported the use of IR in 75%, 53% and 38% of cases, respectively. Of note, all three posters came from major UK tertiary referral centres. We can, therefore, safely conclude that our ability to follow the recommendation made in the CEMACH report almost a decade ago is limited even in the context of major UK obstetric centres. In 2002 the American College of Obstetricians and Gynecologists3 stated that there had been a 10-fold rise in the incidence of AIP over the past 50 years, a trend confirmed as ongoing by a more recent American publication.4 Accepting that the incidence of AIP is likely to further increase and that we have so far failed
to significantly improve the availability of IR, it seems prudent to look for alternatives. A review of the obstetric anaesthetic literature shows that the majority of papers report IR techniques which involve accessing the common and internal iliac arteries or the uterine arteries. In most cases balloon catheters are inserted which can be inflated prophylactically or reactively. Some case series also describe selective embolisation. Anaesthetists do not have the training and skills required to carry out these procedures and this results in our dependence on IR. A different approach has recently been reported,5 describing temporary occlusion of the abdominal aorta by a surgeon. In this case a 14-gauge Foley catheter was used to occlude the infra-renal abdominal aorta. Another case series published in 2015 reported temporary balloon occlusion of the abdominal aorta combined with uterine artery embolisation.6 This edition of the International Journal of Obstetric Anesthesia carries a further retrospective case series where prophylactic balloon occlusion of the abdominal aorta was used.7 At first sight these more recent publications appear to muddy the waters even further. We are still left with the absence of randomised controlled clinical trials and it remains unlikely that we will ever have the benefit of these. Readers of this journal might be forgiven for asking the Editorial staff why they decided to accept this paper for publication as it appears to increase the noise rather than providing more clarity. To answer the question we, as obstetric anaesthetists, have to leave our comfort zone and start looking at other areas of anaesthetic and emergency medicine practice. I ask the reader to take a leap of faith and accept that the prophylactic occlusion of arterial blood supply to the uterus does confer a benefit in the treatment of AIP patients. The level of evidence supporting this statement is poor, i.e. expert opinion only, and probably not even all experts will agree. If we take this leap of faith, we have to accept that we do not have the ability to offer this treatment to our patients reliably and in the current health economic climate it is highly unlikely that this will change rapidly. This is where the more recent case report5 and case series6,7 start to point to potentially different solutions. Rather than requesting the help of a specialist to whom the operating theatre is an alien, possibly hostile,
2 environment the case report describes a surgical approach to temporarily occlude the aorta. In the UK this would invariably require a vascular surgeon to assist but the advantage of the technique lies in the fact that no image intensifier is required and the equipment used for the temporary occlusion of the abdominal aorta is relatively cheap. However, this approach has one major disadvantage which is that the aorta can only be identified and occluded once the fetus has been delivered. In many cases delivery of the fetus is followed by the start of major haemorrhage making this surgical task complex. In both case series the target for temporary occlusion was the infra-renal abdominal aorta and in both cases this was done by an interventional radiologist leaving the anaesthetist with the same problem of access to their services. Intra-aortic balloon catheters are not a new invention8 but more recent developments in trauma anaesthesia and emergency medicine have seen intra-aortic balloon catheters used in the resuscitation of trauma victims.9–12 Resuscitative endovascular balloon occlusion of the aorta (REBOA) is still in its infancy but what is interesting about this technique is that the insertion of the balloon catheter is variably performed by trauma surgeons, anaesthetists or emergency physicians. The skills required to place the sheath and catheter are those most anaesthetists already possess, i.e. cannulating the femoral artery using a Seldinger technique and identifying the anatomy with ultrasound. The technique has been used successfully in pre-hospital medicine,13 where positioning of the balloon catheter was achieved without the use of fluoroscopy. New purpose-designed catheters are being developed which will benefit from smaller sheaths allowing removal of the catheter outside the operating theatre and haemostasis to be achieved by compression only. Occlusion of any vessel with a balloon catheter does carry a number of potential complications which have been well described.14 For the purpose of stopping haemorrhage from AIP we would target zone III of the aorta, i.e. below the lower of the two renal arteries and above the bifurcation of the aorta, for occlusion. This carries additional risks compared to the more prevalent techniques of IR, such as unintentional occlusion of the renal arteries, a potential significant increase in arterial pressure and a greater risk of lactic acidosis from ischaemia of the lower limbs. Other risks of IR are, however, reduced by necessitating one rather than two arterial punctures. The questions obstetric anaesthetists have to ask are: ‘‘Is it time to admit that we have not significantly improved access to IR and do we now need to acquire skills that will allow us to manage these patients ourselves?”
Editorial Bernhard Heidemann Department of Anaesthesia Simpson Centre for Reproductive Health Royal Infirmary Edinburgh, UK E-mail address: [email protected]
References 1. Cooper GM, McClure JH. Anaesthesia chapter from Saving mothers’ lives; reviewing maternal deaths to make pregnancy safer. Br J Anaesth 2008;100:17–22. 2. Webster VJ, Stewart R, Stewart P. A survey of interventional radiology for the management of obstetric haemorrhage in the United Kingdom. Int J Obstet Anesth 2010;19:278–81. 3. Committee on Obstetric Practice. ACOG committee opinion. Placenta accreta. Int J Gynaecol Obstet 2002;77:77–8. 4. Creanga AA, Bateman BT, Butwick AJ, et al. Morbidity associated with cesarean delivery in the United States: is placenta accreta an increasingly important contributor? Am J Obstet Gynecol 2015;213:384. 5. Long Mai-lian, Cheng Chun-xia, Xia Ai-bin, Li Rui-zhen. Temporary loop ligation of the abdominal aorta during caesarean hysterectomy for reducing blood loss in placenta accrete. Taiwan J Obstetr Gynecol 2015;54:323–5. 6. Duan XH, Wang YL, Han XW, et al. Caesarean section combined with temporary aortic balloon occlusion followed by uterine artery embolisation for the management of placenta accreta. Clin Radiol 2015 Sep;70:932–7. 7. Wei Xin, Zhang Jie, Chu Qinjun, et al. Prophylactic abdominal aorta balloon occlusion during caesarean section: a retrospective case series. Int J Obstet Anesth 2016;27:3–8. 8. Hughes CW. Use of an intra-aortic balloon catheter tamponade for controlling intra-abdominal hemorrhage in man. Surgery 1954;36:65–8. 9. Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma 2011;71:1869–72. 10. Martinelli T, Thony F, Decle´ty P, et al. Intra-aortic balloon occlusion to salvage patients with life-threatening hemorrhagic shocks from pelvic fractures. J Trauma 2010;68:942–8. 11. Brenner ML, Moore LJ, DuBose JJ, et al. A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. J Trauma Acute Care Surg 2013;75:506–11. 12. Moore LJ, Brenner M, Kozar RA, et al. Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage. J Trauma Acute Care Surg 2015;79:523–32. 13. London’s Air Ambulance. http://londonsairambulance.co.uk/ourservice/news/2014/06/we-perform-worlds-first-pre-hospital-reboa [accessed May 2016]. 14. Heidemann B. Interventional radiology in the treatment of morbidly adherent placenta: are we asking the right questions? Int J Obstet Anesth 2011;20:279–81.
EDITORIAL
www.obstetanesthesia.com
Interventional radiology for abnormally invasive placenta: do we need an alternative? The opening lecture at the 2016 Obstetric Anaesthesia Meeting in Manchester was entitled ‘‘What’s New in Obstetric Anaesthesia”: it could be argued that there is relatively little which really is new. This may well reflect that we have made this field of anaesthesia very safe for our patients so that it is becoming difficult to be innovative. Furthermore, any development in medicine may be associated with morbidity and mortality which will be unknown until it has been used on a sufficient number of patients. As anaesthetists, we are very risk averse and if our morbidity and mortality figures are low it follows that we are reluctant to propose radical changes. However, one cannot help but feel a little depressed by repeatedly finding that despite guidance, recommendations or evidence, little seems to change. And so it would appear to be with the use of interventional radiology (IR) in obstetric anaesthesia. In 2008, the UK Confidential Enquiry into Maternal and Child Health (CEMACH)1 was the first to advocate consideration of IR in the management of abnormally invasive placenta (AIP). I am in the fortunate position of working in an institution where we have had access to the services of an interventional radiologist since 2002. Therefore, to me the results of a UK-wide survey into the availability of IR for the management of obstetric haemorrhage2 in 2010 were surprising. The survey reported that 31% of UK obstetric units had experience of using IR. Unsurprisingly, 46% of units reported having considered its use but access to IR was extremely variable and only 29% of units reported 24-hour access to a specialised radiologist. At Obstetric Anaesthesia 2016, three posters described the management of AIP. The authors reported the use of IR in 75%, 53% and 38% of cases, respectively. Of note, all three posters came from major UK tertiary referral centres. We can, therefore, safely conclude that our ability to follow the recommendation made in the CEMACH report almost a decade ago is limited even in the context of major UK obstetric centres. In 2002 the American College of Obstetricians and Gynecologists3 stated that there had been a 10-fold rise in the incidence of AIP over the past 50 years, a trend confirmed as ongoing by a more recent American publication.4 Accepting that the incidence of AIP is likely to further increase and that we have so far failed
to significantly improve the availability of IR, it seems prudent to look for alternatives. A review of the obstetric anaesthetic literature shows that the majority of papers report IR techniques which involve accessing the common and internal iliac arteries or the uterine arteries. In most cases balloon catheters are inserted which can be inflated prophylactically or reactively. Some case series also describe selective embolisation. Anaesthetists do not have the training and skills required to carry out these procedures and this results in our dependence on IR. A different approach has recently been reported,5 describing temporary occlusion of the abdominal aorta by a surgeon. In this case a 14-gauge Foley catheter was used to occlude the infra-renal abdominal aorta. Another case series published in 2015 reported temporary balloon occlusion of the abdominal aorta combined with uterine artery embolisation.6 This edition of the International Journal of Obstetric Anesthesia carries a further retrospective case series where prophylactic balloon occlusion of the abdominal aorta was used.7 At first sight these more recent publications appear to muddy the waters even further. We are still left with the absence of randomised controlled clinical trials and it remains unlikely that we will ever have the benefit of these. Readers of this journal might be forgiven for asking the Editorial staff why they decided to accept this paper for publication as it appears to increase the noise rather than providing more clarity. To answer the question we, as obstetric anaesthetists, have to leave our comfort zone and start looking at other areas of anaesthetic and emergency medicine practice. I ask the reader to take a leap of faith and accept that the prophylactic occlusion of arterial blood supply to the uterus does confer a benefit in the treatment of AIP patients. The level of evidence supporting this statement is poor, i.e. expert opinion only, and probably not even all experts will agree. If we take this leap of faith, we have to accept that we do not have the ability to offer this treatment to our patients reliably and in the current health economic climate it is highly unlikely that this will change rapidly. This is where the more recent case report5 and case series6,7 start to point to potentially different solutions. Rather than requesting the help of a specialist to whom the operating theatre is an alien, possibly hostile,
2 environment the case report describes a surgical approach to temporarily occlude the aorta. In the UK this would invariably require a vascular surgeon to assist but the advantage of the technique lies in the fact that no image intensifier is required and the equipment used for the temporary occlusion of the abdominal aorta is relatively cheap. However, this approach has one major disadvantage which is that the aorta can only be identified and occluded once the fetus has been delivered. In many cases delivery of the fetus is followed by the start of major haemorrhage making this surgical task complex. In both case series the target for temporary occlusion was the infra-renal abdominal aorta and in both cases this was done by an interventional radiologist leaving the anaesthetist with the same problem of access to their services. Intra-aortic balloon catheters are not a new invention8 but more recent developments in trauma anaesthesia and emergency medicine have seen intra-aortic balloon catheters used in the resuscitation of trauma victims.9–12 Resuscitative endovascular balloon occlusion of the aorta (REBOA) is still in its infancy but what is interesting about this technique is that the insertion of the balloon catheter is variably performed by trauma surgeons, anaesthetists or emergency physicians. The skills required to place the sheath and catheter are those most anaesthetists already possess, i.e. cannulating the femoral artery using a Seldinger technique and identifying the anatomy with ultrasound. The technique has been used successfully in pre-hospital medicine,13 where positioning of the balloon catheter was achieved without the use of fluoroscopy. New purpose-designed catheters are being developed which will benefit from smaller sheaths allowing removal of the catheter outside the operating theatre and haemostasis to be achieved by compression only. Occlusion of any vessel with a balloon catheter does carry a number of potential complications which have been well described.14 For the purpose of stopping haemorrhage from AIP we would target zone III of the aorta, i.e. below the lower of the two renal arteries and above the bifurcation of the aorta, for occlusion. This carries additional risks compared to the more prevalent techniques of IR, such as unintentional occlusion of the renal arteries, a potential significant increase in arterial pressure and a greater risk of lactic acidosis from ischaemia of the lower limbs. Other risks of IR are, however, reduced by necessitating one rather than two arterial punctures. The questions obstetric anaesthetists have to ask are: ‘‘Is it time to admit that we have not significantly improved access to IR and do we now need to acquire skills that will allow us to manage these patients ourselves?”
Editorial Bernhard Heidemann Department of Anaesthesia Simpson Centre for Reproductive Health Royal Infirmary Edinburgh, UK E-mail address: [email protected]
References 1. Cooper GM, McClure JH. Anaesthesia chapter from Saving mothers’ lives; reviewing maternal deaths to make pregnancy safer. Br J Anaesth 2008;100:17–22. 2. Webster VJ, Stewart R, Stewart P. A survey of interventional radiology for the management of obstetric haemorrhage in the United Kingdom. Int J Obstet Anesth 2010;19:278–81. 3. Committee on Obstetric Practice. ACOG committee opinion. Placenta accreta. Int J Gynaecol Obstet 2002;77:77–8. 4. Creanga AA, Bateman BT, Butwick AJ, et al. Morbidity associated with cesarean delivery in the United States: is placenta accreta an increasingly important contributor? Am J Obstet Gynecol 2015;213:384. 5. Long Mai-lian, Cheng Chun-xia, Xia Ai-bin, Li Rui-zhen. Temporary loop ligation of the abdominal aorta during caesarean hysterectomy for reducing blood loss in placenta accrete. Taiwan J Obstetr Gynecol 2015;54:323–5. 6. Duan XH, Wang YL, Han XW, et al. Caesarean section combined with temporary aortic balloon occlusion followed by uterine artery embolisation for the management of placenta accreta. Clin Radiol 2015 Sep;70:932–7. 7. Wei Xin, Zhang Jie, Chu Qinjun, et al. Prophylactic abdominal aorta balloon occlusion during caesarean section: a retrospective case series. Int J Obstet Anesth 2016;27:3–8. 8. Hughes CW. Use of an intra-aortic balloon catheter tamponade for controlling intra-abdominal hemorrhage in man. Surgery 1954;36:65–8. 9. Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma 2011;71:1869–72. 10. Martinelli T, Thony F, Decle´ty P, et al. Intra-aortic balloon occlusion to salvage patients with life-threatening hemorrhagic shocks from pelvic fractures. J Trauma 2010;68:942–8. 11. Brenner ML, Moore LJ, DuBose JJ, et al. A clinical series of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control and resuscitation. J Trauma Acute Care Surg 2013;75:506–11. 12. Moore LJ, Brenner M, Kozar RA, et al. Implementation of resuscitative endovascular balloon occlusion of the aorta as an alternative to resuscitative thoracotomy for noncompressible truncal hemorrhage. J Trauma Acute Care Surg 2015;79:523–32. 13. London’s Air Ambulance. http://londonsairambulance.co.uk/ourservice/news/2014/06/we-perform-worlds-first-pre-hospital-reboa [accessed May 2016]. 14. Heidemann B. Interventional radiology in the treatment of morbidly adherent placenta: are we asking the right questions? Int J Obstet Anesth 2011;20:279–81.