Endovascular interventional modalities for haemorrhage control in abnormal placental implantation deliveries: a systematic review and meta-analysis

Objectives

To examine the evidence regarding the effectiveness and safety of endovascular interventional modalities for haemorrhage control in abnormal placentation deliveries.

Methods

MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched from inception to July 2017. Blood loss volume was regarded as the primary endpoint. Other important results are described. Random and fixed effects models were used for the meta-analysis.

Results

Of 385 studies identified, 69 (1,811 patients, mean age 32.9 years, range 23–39 years) were included. Mean gestational age at delivery was 35.1 weeks (range 27–38 weeks). Of 1,395 patients who underwent endovascular intervention, 587 (42%) had placenta accreta, 254 (18%) placenta increta and 313 (22%) placenta percreta. Prophylactic balloon occlusion of the internal iliac arteries (PBOIIA) was performed in 470 patients (33.6%), of the abdominal aorta (PBOAA) in 460 patients (33%), of the uterine artery (PBOUA) in 181 patients (13%), and of the common iliac arteries (PBOCIA) in 21 patients (1.5%). Primary embolization of the UA was performed in 246 patients (18%), of the pelvic collateral arteries in 12 patients (0.9%), and of the anterior division of the IIA in 5 patients (0.3%). Follow-up ranged from 0.5 to 42 months. Endovascular intervention was associated with less blood loss than no endovascular intervention (p < 0.001) with the lowest blood loss volume in patients who underwent PBOAA (p < 0.001). PBOAA was associated with a lower rate of hysterectomy (p = 0.030). Endovascular intervention did not result in increases in operative time or hospital stay.

Conclusions

Endovascular intervention is effective in controlling haemorrhage in abnormal placentation deliveries. PBOAA was associated with a lower rate of hysterectomy and less blood loss than other modalities.

Key points

? Endovascular intervention in abnormal placentation deliveries is effective in reducing blood loss. ? Endovascular intervention did not result in longer operative time or hospital stay. ? Prophylactic balloon occlusion of the abdominal aorta is superior to other modalities.

     

Endovascular management of delayed post-pancreatectomy haemorrhage

Objectives

To assess the patient outcome after endovascular treatment of delayed post-pancreatectomy haemorrhage (PPH) as first-line treatment.

Methods

Between January 2005 and November 2013, all consecutive patients referred for endovascular treatment of PPH were included. Active bleeding, pseudoaneurysms, collections and the involved artery were recorded on pretreatment CT. Endovascular procedures were classified as technical success (source of bleeding identified on angiogram and treated), technical failure (source of bleeding identified but incompletely treated) and abstention (no abnormality identified, no treatment performed). Factors associated with rebleeding were analysed.

Results

Sixty-nine patients (53 men) were included (mean 59 years old (32–75)). Pretreatment CT showed 27 (39 %) active bleeding. In 22 (32 %) cases, no involved artery was identified. Technical success, failure and abstention were observed in 48 (70 %), 9 (13 %) and 12 patients (17 %), respectively. Thirty patients (43 %) experienced rebleeding. Rebleeding rates were 29 %, 58 % and 100 % in case of success, abstention and failure (p?<?0.001). Treatment failure/abstention was the only factor associated with rebleeding. Overall, 74 % of the patients were successfully treated by endovascular procedure(s) alone.

Conclusion

After a first endovascular procedure for PPH, the rebleeding rate is high and depends upon the success of the procedure. Most patients are successfully treated by endovascular approach(es) alone.

Key Points

? After a first endovascular procedure for PPH the rebleeding rate is high ? The rebleeding rate is significantly associated with initial technical success ? Three-quarters of the patients are successfully treated by endovascular procedure(s) alone

     

Endovascular therapy in the management of moderate and massive haemoptysis

The aim of this study was to retrospectively evaluate 140 patients with severe (97 massive, 43 moderate) haemoptysis treated by bronchial artery embolisation. Between January 1997 and April 2005, 140 patients (120 males and 20 females, aged 23-71 years) with severe haemoptysis considered surgically inoperable because of limited pulmonary reserve were treated by embolisation. The cause of haemoptysis was tuberculosis in 136 patients and malignancy in four. Embolisation succeeded in controlling haemoptysis immediately after the intervention in 138 patients (98.5%) and at 1 month in 126 patients (90%). Severe haemoptysis recurred in 11 patients with prior massive haemoptysis and 3 patients with prior moderate haemoptysis in a mean time of 3.7 months (1-7 months) after the last intervention. The bleeding source was detected during angiography and embolised in 12 of these patients. Two patients with malignant tumour died because of abundant bleeding, following an asymptomatic period of 30 days. There were no procedure-related major complications. Bronchial artery embolisation is a safe and effective palliative treatment alternative in moderate and massive haemoptysis.     

Endovascular treatment in postpartum haemorrhage

Purpose

Postpartum haemorrhage (PPH) is one of the main causes of maternal mortality and occurs in 5% of total deliveries. In this study we consider the indications for and technique and results of endovascular treatment for this serious event.

Materials and methods

Between January 2004 and December 2010, we conducted a nonrandomised prospective study on ten women with severe PPH who were treated endovascularly in an emergency setting. The procedure was considered to be clinically successful when the PPH resolved completely without the need for further surgical intervention. Laboratory values and the number of transfused blood packs were assessed for each patient.

Results

The endovascular procedure completely stopped the bleeding in 8/10 women. After embolisation, the remaining two patients underwent a second laparotomy, which completely arrested the bleeding. No patient died as a result of PPH, and no patient with PPH who avoided hysterectomy before endovascular treatment underwent it after the procedure.

Conclusions

In keeping with the literature, our study indicates that endovascular therapy can significantly help reduce the rates of hysterectomy and mortality due to PPH. This treatment, when performed in the angiography room, is safe and effective and is probably relatively uncommon and underused.     

长期吸烟者隐原性大咯血的血管内栓塞治疗

目的 探讨血管内栓塞治疗长期吸烟者隐原性大咯血的临床价值.方法 对21例有长期吸烟史的隐原性大咯血者行经导管动脉栓塞术(TAE).术中行系统的主动脉和锁骨下动脉造影,对支气管动脉(BA)和非支气管性体动脉进行评估,并对发现的病理性体动脉进行血管造影和栓塞术.分析血管造影表现,随访观察TAE的临床效果和术后胸部CT表现.结果 21例患者的病理性体动脉均为BA,共35支,均有末梢不同程度的增生,累及右肺24支,累及上叶25支.BA主干增粗24支,正常11支.所有BA均成功完成血管内栓塞术.所有患者术后均获得即刻止血,在随访时间内除1例有偶发痰中带血外其余均未再复发咯血.随访的胸部CT示除原有肺气肿表现外,肺内均未见其他异常.结论 长期吸烟可致大咯血,责任血管为BA,血管内栓塞的效果显著.     

Endovascular treatment of massive retroperitoneal haemorrhage due to inferior adrenal artery injury. A case report

Massive retroperitoneal haemorrhage because of adrenal bleeding following blunt trauma is a rare entity. We describe a 23-year-old woman with massive retroperitoneal haemorrhage as a result of inferior adrenal artery (IAA) disruption following a car accident. Superselective transcatheter embolization of the IAA using polyvinyl alcohol particles was performed successfully to control haemorrhage. To our knowledge, this is the second report of massive retroperitoneal haemorrhage caused by IAA disruption successfully treated by transcatheter embolization.     

Iatrogenic secondary post-partum haemorrhage: apropos of two uncommon cases

In this article we would like to highlight uterine pseudoaneurysm as a cause of secondary post-partum haemorrhage following Caesarean section. We would like to stress Doppler ultrasound scan as the initial screening modality for this condition. We also describe angioembolization as the prudent treatment option for this condition rather than resorting to surgery.     

Transcatheter arterial embolisation for the management of obstetric haemorrhage associated with placental abnormality in 40 cases

Objective

To evaluate pelvic artery embolisation (PAE) in the emergency management of intractable postpartum haemorrhage (PPH) associated with placenta accreta (PA).

Methods

Forty such patients (PAE for PPH/PA) were retrospectively reviewed. Medical records were reviewed regarding the delivery and PAE procedure. Follow-up gynaecological outcomes after PAE were obtained by telephone interviews.

Results

Technical success was achieved in all women (100 %). The initial clinical success rate was 82.5 % (33/40). Three patients with PA underwent hysterectomy after PAE failed to stop the bleeding within 24 h after the embolisation. The other three patients underwent re-embolisation (two patients underwent re-embolisation on the next day and one patient had undergone re-embolisation 6 h after the first embolisation), and bleeding had stopped eventually. The clinical success rate was 92.5 %. There were four cases of immediate complications, such as, pelvic pain, nausea and urticaria. There were three late minor complications, temporary menopause, but no late major complications. After the procedure, 35 patients resumed normal menstruation, including two uncomplicated pregnancies. One patient expired owing to disseminated intravascular coagulopathy and intracerebral haemorrhage, despite successful embolisation.

Conclusion

PAE can be performed safely and effectively for patients with PPH and PA and can preserve the uterus in many patients.

Key Points

? Pelvic artery embolisation (PAE) is an important therapeutic option for postpartum haemorrhage. ? It seems safe and effective for PPH with placenta accreta (PA). ? PAE preserves the uterus and does not impair subsequent menstruation. ? PAE has few major complications.     

经导管动脉栓塞术治疗骨盆骨折大出血

目的评价经导管髂内动脉栓塞术治疗骨盆骨折大出血的疗效。方法35例骨盆骨折伴大出血患者,其中车祸23例、坠落伤5例、重物砸伤4例、挤压伤3例。有合并伤18例。选择腹股沟区无血肿侧或血肿相对轻侧穿刺股动脉,将导管选择性地插入髂内动脉造影,明确出血部位后,超选择进入出血动脉分支;不能超选者,则于髂内动脉主干注入明胶海绵颗粒栓塞至血流明显缓慢,再以直径5～8mm弹簧圈栓塞髂内动脉主干。对于骨盆双侧或中心部骨折者行双侧髂内动脉栓塞。结果35例患者造影均见有不同程度动脉痉挛,其中29例见对比剂外溢,呈斑片状或条状染色。栓塞后于患侧髂总或髂内动脉造影复查,对比剂外溢现象消失。35例患者血压均于术后2h内逐步平稳回升,24h内恢复至正常水平。1例出现拇趾远端皮肤轻度坏死。未出现与栓塞有关的严重并发症。结论经导管动脉栓塞术治疗骨盆骨折大出血,措施简捷、微创、安全,疗效满意。     

CTA在动脉性大出血介入栓塞治疗中的应用

目的 探讨CT血管造影（CTA）在动脉性大出血介入栓塞治疗中应用的策略及临床效果.方法 120例动脉性大出血患者在介入栓塞治疗前行CTA检查,在介入手术中寻找所有的出血动脉,并逐一进行检塞治疗.88例患者栓塞治疗2周后复查CTA检查.对CTA在动脉性大出血介入栓塞治疗中的应用效果进行回顾性总结评价.结果 120例动脉性大出血的患者在介入栓塞治疗前行动脉CTA检查,共找到162支病变的出血动脉,介入手术中共找到178支出血动脉并成功栓塞治疗.术前CTA检查诊断的准确率为91.01％（162/178）.88例患者栓塞治疗后CTA检查显示所有已栓塞的出血动脉栓塞效果良好.结论 介入栓塞治疗前CTA检查可以为栓塞治疗中寻找出血动脉提供准确的定位作用.栓塞治疗后行CTA检查有利于对栓塞疗效的准确判定.     

盆腔内急性大出血介入治疗的临床应用价值

目的:探讨介入治疗在盆腔内急性大出血中的应用价值.方法:收集25例盆腔内急性大出血病例,以Seldinger's技术单侧股动脉穿刺行双侧髂血管造影,显示出血部位,以明胶海绵对髂内动脉及其分支行栓塞治疗.结果:25例患者行髂内动脉或其分支栓塞术后止血效果满意.结论:髂血管造影栓塞止血是盆腔内急性大出血的安全、迅速、有效的急救止血方法.     

Endovascular management in liver transplantation

Liver transplantation was developed for the treatment of hepatic failure,and the first human liver transplantation was done in 1963.From the 1990 s, liver transplantation was generally accepted as a treatment modality for both end-stage liver disease and selected liver malignancies.Initially,liver     

Endovascular management of massive hemoptysis due to covid-19 related pulmonary artery pseudoaneurysm: A rare entity

Pulmonary artery pseudoaneurysms are rare causes of massive hemoptysis, even less common in setting of COVID-19 pneumonia. We describe and discuss an index case of cavitating COVID-19 pneumonia complicated by a pulmonary artery pseudoaneurysm without concomitant pulmonary thromboembolism. The patient presented with severe hemoptysis and was managed by endovascular coil embolization. Good technical and clinical success was achieved with complete resolution of hemoptysis.     

Endovascular management of carotid-cavernous fistulas

Objective To investigate endovascular treatment of traumatic direct carotid-cavernous fistulas （CCF） and their complications such as pseudoaneurysms. Methods： Over a five-year period, 22 patients with traumatic direct CCFs were treated endovascularly in our institution. Thirteen patients were treated once with the result of CCF occluded, 8 twice and 1 three times. Treatment modalities included balloon occlusion of the CCF, sacrifice of the ipsilateral internal carotid artery with detachable balloon, coll embolization of the cavernous sinus and secondary pseudoaneurysms, and covered-stem management of the pseudoaneurysms. Results All the direct CCFs were successfully managed endovascularly. Four patients developed a pseudoaneurysm after the occlusion of the CCF with an incidence of pseudoaneurysm formation of 18.2% （4/22）. A total number of 8 patients experienced permanent occlusion of the ICA with a rate of ICA occlusion reaching 36.4% （8/22）. Followed up through telephone consultation from 6 months to 5 years, all did well with no recurrence of CCF symptoms and signs. Conclusion Traumatic direct CCFs can be successfully managed with endovascular means. The pseudoaneurysms secondary to the occlusion of the CCFs can be occluded with stent-assisted coiling and implantation of covered stents.     

Endovascular treatment of spontaneous extraperitoneal haemorrhage: immediate and long-term clinical efficiency

Purpose

This study aimed to evaluate the effectiveness of transcatheter embolisation in the treatment of spontaneous extraperitoneal haemorrhage (SEH).

Materials and methods

We retrospectively evaluated the technical and clinical success in terms of immediate and long-term mortality in a series of patients who underwent endovascular treatment of SEH from January 2005 to December 2010. A statistical comparison of pre- and postoperative transfusion requirements was performed by using the Student’s t test, with statistical significance set at p < 0.005.

Results

In the period considered, 30 patients (16 women and 14 men; mean age, 73.3 years ±15.6) with SEH underwent endovascular treatment. Technical success was obtained in all cases (100 %), and a statistically significant reduction in blood transfusion requirements was observed (mean preoperative requirement: 7.5 U/day ±3; mean postoperative requirement 2.8 U/day) (p < 0.005). We observed a postoperative mortality of 10 % (3/30 patients) and mortality at 6 and 12 months was 14.8 % (4/27 patients) and 26 % (6/23 patients), respectively.

Conclusion

According to our experience and to the literature, transcatheter arterial embolisation represents the treatment of choice in patients with SEH, as it ensures complete therapeutic success.     

Endovascular management of thoracic aortic aneurysms

The overall survival of patients with thoracic aortic aneurysm (TAA) has improved significantly in the past few years. Endovascular treatment, proposed as an alternative to surgery, has been considered a therapeutic innovation because of its low degree of invasiveness, which allows the treatment of even high-surgical risk patients with limited complications and mortality. A major limitation is the lack of adequate evidence regarding long-term benefit and durability because follow-up has been limited to just a few years even in the largest series. The combination of endovascular exclusion with visceral branch revascularization for the treatment of thoraco-abdominal aortic aneurysms involving the visceral aorta has also been attempted. As an alternative, endografts with branches represent a technological evolution that allows treatment of complex anatomy. Even if only small numbers of patients and short follow-up are available, this technical approach, which has with limited mortality (<10%) and paraplegia rates, to expand endovascular treatment to TAA seems feasible. With improved capability to recognize proper anatomy and select clinical candidates, the choice of endovascular stent-graft placement may offer a strategy to optimize management and improve prognosis.