Arterial balloon occlusion of the internal iliac arteries for treatment of life-threatening massive postpartum haemorrhage: a series of 15 consecutive cases

Objective

To evaluate arterial balloon occlusion of the internal iliac arteries for treatment of life-threatening massive postpartum haemorrhage.

Study design

Retrospective cohort study at a tertiary referral perinatal centre in a teaching hospital in the Netherlands. All patients who delivered in our hospital between January 1998 and January 2008 were included in the study. A retrospective analysis of all cases of postpartum haemorrhage was performed. All 15 consecutive cases of massive postpartum haemorrhage were selected from an electronic database. The patients with massive postpartum haemorrhage (blood loss > 5000 ml) and the patients with postpartum haemorrhage treated with arterial balloon occlusion of internal iliac arteries were analyzed.

Results

In the study period 1246 (7%) of all 17,308 deliveries were complicated by postpartum haemorrhage. 15 (0.1%) patients suffered from massive postpartum haemorrhage. They were all treated with balloon occlusion of the internal iliac arteries. Hysterectomy was performed in 4 patients. All patients survived without any complications.

Conclusion

Arterial balloon occlusion of the internal iliac arteries is a safe and in most cases effective procedure for treatment of massive life-threatening postpartum haemorrhage.     

Color Doppler analysis of pelvic arteries following bilateral internal iliac artery ligation for severe postpartum hemorrhage

Objective

To compare Doppler blood flow characteristics of the uterine, arcuate, and ovarian arteries of women who underwent bilateral internal iliac artery ligation with those of controls.

Methods

Thirteen women who underwent bilateral internal iliac artery ligation for severe postpartum hemorrhage (PPH) were matched with 15 healthy women of reproductive age. Transvaginal color and pulsed (duplex) Doppler modes were used to visualize the pelvic arteries. The pulsatility index, the resistance index, the systolic/diastolic blood flow ratio, the peak systolic velocity, and the end-diastolic velocity were measured.

Results

The mean age was 26.1 ± 5.2 years in the study group and 27.0 ± 5.4 years in the control group. All participants had regular menstrual periods. There were no significant differences between the groups regarding each of the vascular indices for the uterine, arcuate, and ovarian arteries.

Conclusion

These findings are consistent with published data demonstrating that pelvic circulation is not compromised after bilateral internal iliac artery ligation.     

Novel Anastomotic Technique for Uterine Transplant Using Utero-ovarian Veins for Venous Drainage and Internal Iliac Arteries for Perfusion in Two Laparoscopically Harvested Uteri

Study Objective

To evaluate 2 cases of uterine transplant surgery that used utero-ovarian veins as outflow channels, internal iliac arteries for perfusion, and the organ harvest surgery performed laparoscopically.

The utility and effectiveness of an internal iliac artery balloon occlusion catheter in surgery for large cervical uterine fibroids

Objective

Surgery for uterine cervical fibroids is difficult because of restricted surgical access and risks such as intraoperative bleeding or injury to other organs. The internal iliac artery balloon occlusion catheter (IIABOC) provides effective hemostasis for placenta previa and atonic hemorrhage, and is increasingly used in surgery for uterine fibroids for controlling intraoperative hemorrhage. We investigated the efficacy and safety of the IIABOC for controlling intraoperative bleeding in total abdominal hysterectomies (TAH) and abdominal myomectomies (AM) for large cervical fibroids.

Single-port laparoscopy and extraperitoneal para-aortic lymphadenectomy: about fourteen consecutive cases

Objective

To report the feasibility and reproducibility of single port extraperitoneal para-aortic lymphadenectomy in locally advanced cervical cancer.

Methods

The same single port was used for the transperitoneal step and the extraperitoneal approach used thereafter (in the absence of peritoneal disease) for the lymphadenectomy. Para-aortic lymphadenectomy was performed via a left-sided extraperitoneal approach.

Results

Fourteen consecutive patients with cervical cancer underwent a laparoscopic staging procedure (3 stage IB2, 10 IIB and 1 stage IVA). No patient had para-aortic FDG uptake on PET/CT. In one case lymphadenectomy was unfeasible because of vascular anomalies of the renal vessels (low insertion of 2 left renal arteries). The median operative time was 190 min (range, 135–250). The median number of lymph nodes removed was 14 [range, 2–23]. The definitive pathological analysis revealed that three patients had metastatic disease. No conversion to conventional multiport laparoscopy was necessary.

Conclusions

This series reports that para-aortic lymphadenectomy technique via the extraperitoneal approach with a multichannel single port is feasible and reproducible.     

Extraperitoneal Laparoscopic Para-aortic Lymph Node Dissection

Extraperitoneal cervical cancer “staging” is considered superior to a transperitoneal approach. We developed an entirely extraperitoneal laparoscopic technique for para-aortic lymph node dissection in a pig model, followed by human subject application. Using latex balloon dissection technology, the technique is as follows. A retroperitoneal space is created via a 15-mm left flank incision. The collapsed balloon trochar is inserted and the balloon is inflated under direct visualization. Subsequently, a CO₂pneumoretroperitoneum is established with 12–15 mm Hg and dissection is carried out using a total of three to four left flank port sites. For initial technique development and improvement, four pigs were used. Excellent bilateral retroperitoneal exposure was achieved. A complete dissection was performed from the renal to the iliac vessels. Subsequently, a bilateral sampling procedure from the level of the inferior mesenteric artery to the iliac vessels was performed in four human subjects. A mean of 5 nodes (range 1–9) was removed with an EBL of <50 cc. Operative times were 120–140 min. There were no intra- or postoperative complications. This initial experience demonstrates that laparoscopic extraperitoneal para-aortic access and node sampling is feasible. Further study is ongoing to determine the extent of dissection possible using this approach. However, since this approach mimics the extraperitoneal laparotomy technique, it may have all the advantages of adhesion avoidance combined with an outpatient procedure.     

Neoadjuvant chemotherapy followed by robotic radical hysterectomy in locally advanced cervical cancer: A multi-institution study

Objective

Minimally invasive surgery has been performed in locally advanced cervical cancer (LACC) without adverse effect in patient's overall prognosis and survival. The aim of this report is to evaluate the feasibility and morbidity of total robotic radical hysterectomy (TRRH) with pelvic lymphadenectomy in patients with LACC after neo-adjuvant chemotherapy (NACT).

Methods

From February 2008 to April 2013 a retrospective data collection of women undergoing TRRH for cervical cancer stage FIGO IB2 to IIB, after neo-adjuvant chemotherapy, was conducted at “Regina Elena” National Cancer Institute of Rome and European Institute of Oncology of Milan. All patients deemed operable underwent TRRH with pelvic lymphadenectomy within 4 weeks from the last chemotherapy cycle.

Results

Median operative time was 225 min (range, 105–387 min). The median blood loss was 150 mL (range, 30–700 mL). The median number of removed pelvic lymph nodes was 23 (range, 8–69). Sixteen patients had an optimal response (12 PCR, 4 pPR1) to chemotherapy, 33 patients had a pPR2 and 11 patient showed stable disease. Adjuvant therapy was administrated in 36 patients (60%). We experienced one intra-operative complication and 19 post-operative complications, but no conversions to laparotomy were necessary to manage these complications. Six patients received a blood transfusion. At the time of this report, with a median follow-up of 28.9 months, 50 patients (83%) are free from recurrence.

Conclusion

This experience demonstrates the feasibility of TRRH pelvic lymphadenectomy after NACT in LACC with good accuracy and safety.     

髂内动脉球囊阻断术在凶险性前置胎盘治疗中的应用

凶险性前置胎盘(pernicious placenta previa,PPP)易导致突发难治性大出血,近年来介入治疗广泛应用于PPP,减少了剖宫产术中出血量,降低了子宫切除率。介入治疗主要包括球囊阻断术和动脉栓塞术,其中髂内动脉球囊阻断术能有效预防和减少PPP剖宫产术中出血,将抢救性治疗转变为预防性治疗。国内外研究持续探索髂内动脉球囊阻断术应用于PPP剖宫产术中的手术方式、球囊阻断时机、单次球囊阻断时间等。髂内动脉球囊阻断术在产科临床应用中具有一定效果,但该技术单独应用于穿透性胎盘植入病例时作用有限,其并发症主要包括血栓形成和栓塞、血管损伤、辐射的影响、缺损再灌注损伤等。综述髂内动脉球囊阻断术在PPP剖宫产术中的具体应用和存在的问题,为临床应用提供参考。     

Non-radical surgery for small early-stage cervical cancer. Is it time?

Objectives

Non-radical surgery has been proposed in women with early-stage cervical cancer to reduce morbidity. Our objective was to evaluate the outcomes of women with early-stage cervical cancer treated with non-radical surgery.

Methods

Between March 1991 and July 2013, 51 women with early-stage cervical cancer underwent simple hysterectomy or cone biopsy. All patients had assessment of pelvic lymph nodes. Patient demographics, stage, perioperative complications, pathology findings and disease-free interval were collected prospectively.

Results

Twenty-six women had squamous cell carcinoma (SCC), 22 adenocarcinoma (AC) and 3 adenosquamous (AS) carcinoma. Thirty women were FIGO stage 1A1, 8 women IA2, and 13 women 1B1. Twenty-two (43%) and 29 (57%) women underwent simple hysterectomy and cone biopsy respectively. Median measurable tumor size was 10 mm (range 2–11), and median depth of invasion was 2.0 mm (range 0.1–12 mm). Lymphovascular space invasion (LVSI) was present in 18 women (35%). Surgical margins were negative in all women. Two women received adjuvant chemoradiation (one had deep stromal invasion with LVSI, and one had two micrometastases to pelvic nodes). Forty-nine women (96%) had their Foley catheter removed on the day of surgery or post-operative day 1. No intraoperative or postoperative complications occurred and the median blood loss was 100 ml. Median follow-up was 21 months (range 1–112). None of the 51 women developed a recurrence during follow-up (95% CI: 0–6%).

Conclusion

Non-radical surgery in appropriately selected early-stage cervical cancer patients results in a low complication rate and excellent oncologic outcomes. This approach seems to be a reasonable option in well-selected patients.     

Placenta accreta and balloon catheterization: the experience of a single center and an update of latest evidence of literature

Purpose

We studied the efficacy of using pre-cesarean delivery (CD) temporary occlusion of internal iliac arteries with balloon catheters in case of placenta previa–accreta in terms of maternal and neonatal outcomes and to test accuracy of ultrasound (US) and magnetic resonance imaging (MRI) for prenatal diagnosis.

Methods

From March 2014 to January 2018, women with an US and/or MRI diagnosis of placenta previa–accreta and a planned delivery were enrolled and divided into two groups: balloon catheterization group (women treated with preoperative catheters and CD) and control group (women candidates to elective CD).

Results

37 patients were enrolled: 16 in balloon catheterization group and 21 in control group. Significant differences were detected in estimated blood loss. Prophylactic balloon catheterization could reduce intraoperative red blood cell transfusion. The incidence of hysterectomy was lower in balloon group. No statistical difference was found for neonatal outcomes. Both US and MRI have showed to be useful and complementary to diagnose placenta previa–accreta.

Conclusions

Temporal, perioperative, and prophylactic positioning of balloon vascular catheters is an effective method for managing severe hemorrhage caused by placenta previa–accreta as it reduced intraoperative blood loss, lessened perioperative hemostatic measures and intraoperative red cell transfusions, and reduced hysterectomies.

     

Detection of sentinel lymph nodes in minimally invasive surgery using indocyanine green and near-infrared fluorescence imaging for uterine and cervical malignancies

Objectives

Our primary objective was to assess the detection rate of sentinel lymph nodes (SLNs) using indocyanine green (ICG) and near-infrared (NIR) fluorescence imaging for uterine and cervical malignancies.

Methods

NIR fluorescence imaging for the robotic platform was obtained at our institution in 12/2011. We identified all cases planned for SLN mapping using fluorescence imaging from 12/2011–4/2013. Intracervical ICG was the fluorophobe in all cases. Four  cc (1.25 mg/mL) of ICG was injected into the cervix alone divided into the 3- and 9-o'clock positions, with 1 cc deep into the stroma and 1 cc submucosally before initiating laparoscopic entry. Blue dye was concurrently injected in some cases.

Results

Two hundred twenty-seven cases were performed. Median age was 60 years (range, 28–90 years). Median BMI was 30.2 kg/m² (range, 18–60 kg/m²). The median SLN count was 3 (range, 1–23 ). An SLN was identified in 216 cases (95%), with bilateral pelvic mapping in 179 (79%). An aortic SLN was identified in 21 (10%) of the 216 mapped cases. When ICG alone was used to map cases, 188/197 patients mapped, for a 95% detection rate compared to 93% (28/30) in cases in which both dyes were used (P = NS). Bilateral mapping was seen in 156/197 (79%) ICG-only cases and 23/30 (77%) ICG and blue dye cases (P = NS).

Conclusions

NIR fluorescence imaging with intracervical ICG injection using the robotic platform has a high bilateral SLN detection rate and appears favorable to using blue dye alone and/or other modalities. Combined use of ICG and blue dye appears unnecessary.     

Balloon occluded arterial infusion (BOAI) therapy in patients with progressive cervical carcinoma

Ten patients with progressive cervical carcinoma were treated with intra-arterial infusion by BOAI (balloon occluded arterial infusion) in order to secure high concentrations of anti-tumor agents. This study included 9 cases (2 stage IIb, 5 stage IIIb, and 2 stage IV) with squamous cell carcinoma and 1 case (stage IIIb) with adenocarcinoma. Cis-platin (CCDP) 100 mg/body and bleomycin (BLM) 20-30 mg/body and and/or aclacinomycin (ACM) 30-40 mg/body were infused after the bilateral internal iliac arteries were occluded. 1. The serum concentration of free-Pt reached its maximum 15-30 min after BOAI therapy and returned to an undetectable level in 3 hours. 2. The free-Pt concentration following BOAI therapy was 2 to 3 times greater than those found with intravenous infusion. 3. The free-Pt concentration in internal iliac arteries was twice as great as those observed in the femoral arteries or peripheral veins. 4. The tissue concentration of Pt after BOAI was significantly (p less than 0.05) greater than those found with intra-venous infusion. 5. BOAI treatment resulted in 2 cases of partial response, 6 cases of minor response and 2 cases with no change. These results demonstrate that BOAI therapy is effective for the treatment of progressive cervical carcinoma by increasing intratumoral concentrations of the drugs.     

Depression of uterine blood flow during total umbilical cord occlusion in sheep

The effect of total umbilical cord occlusion upon maternal blood flow in the internal iliac and median uterine arteries was studied in eight chronically instrumented pregnant sheep. Occlusion of the umbilical cord was performed with an inflatable balloon occluder around the total cord. Blood flow was measured with electromagnetic flow transducers. Total umbilical cord occlusion of short duration (mean 40.1 s) caused a significant decrease in blood flow in the maternal internal iliac and median uterine arteries at the end of the occlusion to respectively 93.9% and 91.7% of the control values.The decrease in internal iliac and median uterine artery blood flow is attributed to an elevated fetal capillary pressure in the placenta, leading to an increased fetal placental tissue pressure which in turn compresses the maternal placental capillaries, resulting in a heightened vascular resistance and a decrease in uterine blood flow.     

Alternative approaches to surgical hemostasis in patients with morbidly adherent placenta undergoing fertility-sparing surgery

Aim: To evaluate the efficacy of different methods of surgical hemostasis, including the ligation of internal iliac arteries (IIA), temporary occlusion of the common iliac artery (CIA) and combined compression hemostasis, during cesarean section in patients with morbidly adherent placenta (MAP).

Materials and methods: The study included 54 patients with MAP. All patients underwent cesarean section with application of surgical hemostasis techniques. In Group 1 (n?=?15), ligation of IIA was performed, in Group 2 (n?=?18) extravasal temporary occlusion of CIA, and in Group 3 (n?=?21) combined compression hemostasis was applied. The latter technique included placement of bilateral tourniquets on the upper uterine pedicles and on the cervicoisthmic segment, and controlled Zhukovsky balloon tamponade of the uterus, with subsequent resection of the uterine wall with abnormal placental invasion, evacuation of placenta from the uterine cavity and closure of the uterine wall defect with a double suture. The studied outcomes were total blood loss, duration of surgery, the hemoglobin level alteration, hysterectomy rate, and length of postoperative hospital stay.

Results: Total blood loss in Group 1 was 2440?±?1215?ml, in Group 2 – 2186?±?1353?ml, and in Group 3 – 1295?±?520.3?ml (p?=?.0045). In Group 3, the lowest number of cases with blood loss >2000?ml was observed [8 (53.3%) versus 9 (50.0%) and 2 (9.5%), respectively; p?=?.0411]. The duration of surgery, the hemoglobin level alteration, hysterectomy rate, and length of hospital stay after delivery did not differ significantly between the groups.

Conclusions: All surgical techniques used in the study were effective to decrease the blood loss during cesarean section in patients with MAP; however, the combined compression hemostasis showed the highest efficacy.     

The feasibility and safety of same-day discharge after robotic-assisted hysterectomy alone or with other procedures for benign and malignant indications

Objective

This study aimed to report the feasibility and safety of same-day discharge after robotic-assisted hysterectomy.

Methods

Same-day discharge after robotic-assisted hysterectomy was initiated 07/2010. All cases from then through 12/2012 were captured for quality assessment monitoring. The distance from the hospital to patients' homes was determined using http://maps.google.com. Procedures were categorized as simple (TLH +/− BSO) or complex (TLH +/− BSO with sentinel node mapping, pelvic and/or aortic nodal dissection, appendectomy, or omentectomy). Urgent care center (UCC) visits and readmissions within 30 days of surgery were captured, and time to the visit was determined from the initial surgical date.

Results

Same-day discharge was planned in 200 cases. Median age was 52 years (range, 30–78), BMI was 26.8 kg/m² (range, 17.4–56.8), and ASA was class 2 (range, 1–3). Median distance traveled was 31.5 miles (range, 0.2–149). Procedures were simple in 109 (55%) and complex in 91 (45%) cases. The indication for surgery was: endometrial cancer (n = 82; 41%), ovarian cancer (n = 5; 2.5%), cervical cancer (n = 8; 4%), and non-gynecologic cancer/benign (n = 105; 53%). One hundred fifty-seven (78%) had successful same-day discharge. Median time for discharge for these cases was 4.8 h (range, 2.4–10.3). Operative time, case ending before 6 pm, and use of intraoperative ketorolac were associated with successful same-day discharge. UCC visits occurred in 8/157 (5.1%) same-day discharge cases compared to 5/43 (11.6%) requiring admission (P = .08). Readmission was necessary in 4/157 (2.5%) same-day discharge cases compared to 3/43 (7.0%) requiring admission (P = .02).

Conclusions

Same-day discharge after robotic-assisted hysterectomy for benign and malignant conditions is feasible and safe.     

Glassy cell carcinoma of the cervix: A systematic review and meta-analysis

Objective

The purpose of this study is to summarize the data on the incidence, clinical behavior and overall survival of patients with glassy cell cervical carcinoma (GCCC).

Methods

Twenty-four case series and fifteen case reports identified by searching PubMed database qualified for inclusion in this study. The published cases were combined with data from a retrospective chart review of patients with GCCC in two major teaching hospitals in Brooklyn, NY.

Results

A total of 292 cases were collected through our literature and chart review. Median age at diagnosis was 45 years old (range 12–87 years of age). GCCC incidence ranges from 0.2 to 9.3% of all cervical cancers and 2 to 30.2% of cervical adenocarcinomas. The stage distribution is similar to squamous cell carcinoma with 79% of the patients being diagnosed with Stage I or II disease. Most common sites of recurrence for Stage I patients are the vagina and pelvis. In Stage II patients locoregional and distant metastases are equally common. Recurrence rate was higher among patients treated only with surgery (32.7%), as compared to patients treated with surgery followed by radiation (11%) or patients treated with radiation only (10%). Median overall survival (OS) was 25 months (95% CI 8.4–41.6). Overall 5-year survival for all stages is lower when compared to all cervical cancers (54.8% vs 75%). There was no interaction between race and OS (p = 0.66).

Conclusion

GCCC is a rare histologic type of cervical cancer that presents at a younger age, is associated with high risk for distant failure and carries worse prognosis as compared to the squamous cell type. Radiation therapy is associated with decreased risk of recurrence.     

A novel modification of conventional laparoscopic myomectomy using manual assistance for multiple uterine myomas

Objectives

To evaluate the efficacy and feasibility of finger-assisted laparoscopic myomectomy for multiple myomas.

Study design

A total of 565 patients with symptomatic myomas underwent finger-assisted laparoscopic myomectomy between January 2006 and March 2011 to remove multiple myomas at our center. Laparoscopic myomectomy technique was modified, and involved the insertion of two fingers into the vagina to elevate the uterus, while one or two fingers of the other hand were inserted into the abdomen through a suprapubic 15-mm trocar port for palpation of small myomas, which did not distort the uterine contour.

Results

The mean (SD; range) patient age was 38.26 years (5.84; 25–48 years). The diameter of the largest myoma in each case was 6.13 cm (1.21; 4–15 cm). The total number of myomas enucleated in the initial enucleation was 2228. There were 597 additional myomas enucleated with finger-assisted guidance. The mean diameter of the additionally enucleated myomas was 1.1 cm (range, 0.2–2.5 cm), which was significantly smaller than those of the initially enucleated myomas (p = 0.002). The mean operative time was 97.1 min (30.2; 35–180 min). The decrease in postoperative hemoglobin concentration was 1.6 g/dL (0.7; 0.4–3.2 g/dL). During the operation, no patients required a blood transfusion. Six patients developed postoperative fever. There was no occurrence of bowel or urinary tract injury. The mean postoperative hospital stay was 3.2 days (0.9; 2–6 d). All procedures were successfully completed without the need for laparotomy.

Conclusions

Finger-assisted laparoscopic myomectomy is a feasible and safe approach in the surgical treatment of multiple myomas.     

A prospective randomized comparison of vaginal hysterectomy,laparoscopically assisted vaginal hysterectomy,and total laparoscopic hysterectomy in women with benign uterine disease

Objectives

To compare the clinical results of three minimally invasive hysterectomy techniques: vaginal hysterectomy (VH), laparoscopically assisted vaginal hysterectomy (LAVH), and total laparoscopic hysterectomy (TLH).

Study design

A prospective, randomized study was performed at a tertiary care center between March 2004 and October 2005. A total of 125 women indicated to undergo hysterectomy for benign uterine disease were randomly assigned to three different groups (40 VH, 44 LAVH, and 41 TLH). Outcome measures, including operating time, blood loss, rate of complications, inflammatory response, febrile morbidity, consumption of analgesics, and length of hospital stay, were assessed and compared between groups.

Results

Vaginal hysterectomy had the shortest operating time (66 min) and smallest drop in hemoglobin. However, there were technical problems with salpingo-oophorectomy from the vaginal approach (3/20 cases) and this group had a significantly higher rate of febrile complications (20%) compared to LAVH (2.3%) and TLH (7.3%). The increase in inflammatory markers was higher in vaginal hysterectomy patients. Laparoscopically assisted vaginal hysterectomy had an acceptable operating time (85 min), a low complication rate, lack of severe post-operative complications, and the lowest consumption of analgesics. However, it had the highest blood loss. Total laparoscopic hysterectomy had the longest operating time (111 min) and severe complications occurred only in this group. Conversions to another hysterectomy method occurred in all three groups, most of these conversions were to LAVH.

Conclusions

Based on our results, in women with non-malignant disease of the uterus, LAVH and VH seem to be the preferred hysterectomy techniques for general gynecological surgeons. Vaginal hysterectomy had the shortest operating time and least drop in hemoglobin, making it a suitable method for women for whom the shortest duration of surgery and anesthesia is optimal. LAVH is a versatile procedure, combining the advantages of both the vaginal and laparoscopic approach, and is preferable in cases when oophorectomy is required. Total laparoscopic hysterectomy did not appear to offer any significant benefits over the other two methods and should be strictly indicated in women where neither VH nor LAVH are feasible and should only be performed by very experienced laparoscopists.     

Risk of hemorrhage in abnormally invasive placenta according to its management

Severe hemorrhage is a major concern during operative procedures for abnormally invasive placenta (AIP). We reviewed published literature with the objective to provide evidence of blood loss with the most common treatment options for AIP. We selected 54 articles that fulfilled the inclusion criteria. Cesarean hysterectomy, with or without occlusion balloons in the internal iliac arteries, was the treatment associated with the greatest blood loss. Major blood loss was also associated with the placenta left in situ (reported in 3 of 10 articles), and with uterine artery embolization (reported in 3 of 15 articles). The best outcomes were seen for cesarean hysterectomy with balloon occlusion of the common iliac arteries (CIA; 9 patients, including 1 with major blood loss), balloon occlusion of the abdominal aorta (27 patients, no major blood loss) and conservative surgery (99 patients, including one with major blood loss). In conclusion, cesarean hysterectomy with balloon occlusion of the CIA or abdominal aorta, and conservative treatments seem to have the best outcomes. However, our results are based on a small number of articles. Hence, it is necessary to have available more reports on the outcomes of these treatments, to arrive at a more definitive conclusion.