# Prophylactic bilateral internal iliac artery balloon occlusion with immediate sheath removal for placenta accreta spectrum

## TL;DR

This study shows that a specific endovascular technique helps manage severe placenta conditions safely during childbirth.

## Contribution

The study evaluates the safety and effectiveness of a new method for managing placenta accreta spectrum with immediate sheath removal.

## Key findings

- No endovascular complications occurred in 15 patients using PIIABO with immediate sheath removal.
- Radiation exposure decreased by 90% as institutional experience increased over the study period.
- Three patients preserved their uterus, with no long-term maternal or neonatal complications.

## Abstract

Consistent with global trends, the incidence of placenta accreta spectrum (PAS) is increasing in Australia. Prophylactic internal iliac arterial balloon occlusion (PIIABO) is an endovascular intervention utilised to assist haemorrhage control during caesarean delivery in women with PAS, offering a potentially uterus-preserving alternative to hysterectomy. However, existing outcomes remain heterogeneous. This study aimed to evaluate the endovascular safety of PIIABO with immediate sheath removal in the management of PAS, with a secondary assessment of haemostatic and procedural outcomes.

A 10-year retrospective, single-centre cohort study of all patients with suspected PAS who underwent PIIABO was conducted with data obtained from electronic medical records and Radiology Information System (RIS)/Picture Archiving and Communication System (PACS).

Fifteen patients underwent PIIABO. The mean maternal age was 34.1 years, with a mean gravidity of 4.2 and a parity of 2.3; all had prior caesarean delivery and 93% had concurrent major placenta praevia (n = 14). Mean gestational age at delivery was 34.9 weeks. Diagnosis was established by MRI (n = 11, 87.5% concordance) and ultrasound (n = 4, 50% concordance). Twelve patients underwent hysterectomy, confirming 1 accreta, 3 increta, and 8 percreta; 3 patients preserved uterus, with intraoperative evidence of percreta (n = 2) or normal placentation (n = 1). Mean estimated blood loss was 2273 mL, and 11 patients received blood transfusions, including four who required ≥ 4 units of packed red blood cells. Mean balloon inflation time was 129.9 min, sheath dwell time 265.5 min, and operating theatre time 265.7 min. Mean dose-area product was 55.03 Gy.cm2 with a mean fluoroscopy time of 10.7 min. Radiation exposure decreased by approximately 90% over the study period with increasing institutional experience. No endovascular complications or reinterventions occurred, and all mothers and neonates were discharged without long-term morbidity.

PIIABO with immediate sheath removal demonstrated favourable procedural outcomes and a low complication rate in patients with PAS, supporting its safe implementation within a multidisciplinary care pathway.