Prophylactic aortic balloon occlusion for placenta accreta spectrum disorders: Occlusion where?
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Prophylactic aortic balloon occlusion for placenta accreta spectrum disorders: Occlusion where? Shigeki Matsubara1 · Hironori Takahashi1 · Yuji Takei1 · Hiroyasu Nakamura2 · Takashi Yagisawa3 Received: 8 October 2019 / Accepted: 3 January 2020 © Springer-Verlag GmbH Germany, part of Springer Nature 2020
Dear Editors, We commend He et al. [1] for providing a systematic review: hemorrhage was reduced by prophylactic aortic balloon occlusion (ABO) in patients with pernicious placenta previa (PPP), i.e., previa with the placenta covering the previous cesarean scar. PPP frequently accompanies placenta accreta spectrum (PAS) disorders. Since the International Federation of Gynecology and Obstetrics recommends using the terminology of PAS and the context of this paper regards PAS, we wish to use PAS here for simplicity. In PAS surgery, we initially occluded the internal iliac arteries [2], then the common iliac arteries, and now the abdominal aorta. This was based on our experience. He et al.’s paper gave us a rationale to use ABO. We wish to raise one important point. Where should the aorta be occluded? He et al. describe only “abdominal aorta occlusion”, without mentioning the point of occlusion. The uterine artery is a major source of hemorrhage in PAS-related surgery; however, some arteries * Shigeki Matsubara [email protected] Hironori Takahashi [email protected] Yuji Takei [email protected] Hiroyasu Nakamura [email protected] Takashi Yagisawa [email protected] 1
Department of Obstetrics and Gynecology, Jichi Medical University, 3311‑1 Yakushiji, Shimotsuke, Tochigi 329‑0498, Japan
Department of Radiology, Jichi Medical University, Shimotsuke, Tochigi, Japan
2
3
Department of Renal Surgery and Transplantation, Jichi Medical University, Shimotsuke, Tochigi, Japan
directly originating from the aorta also supply blood flow to the uterus [3, 4]. This is the main reason to employ ABO [1, 4]. Let us summarize the anatomy (location/origination) of these arteries: from distal (bifurcation) to proximal, the inferior mesenteric artery (IMA) → ovarian artery (OA) → renal artery (RA) [3]. All these arteries (IMA, OA, and RA) can cause PAS-related hemorrhage, depending on the situation [4, 5]. There are four possible occlusion points. From distal to proximal, the occlusion at bifurcation–IMA maintains the flow of IMA, OA, and RA. That at IMA–OA occludes IMA, maintaining the flow of OA and RA. The occlusion at OA–RA occludes IMA and OA, maintaining RA flow. The occlusion at RA stops all flow (RA occluded). In ABO, “below RA occlusion” is usually employed. This is to avoid ischemic renal damage caused by RA occlusion [4]. However, there is no agreement as to what “below RA occlusion” indicates. The area between bifurcation and RA is below RA, making the situation even more complicated, OA sometimes originates from RA: “the anomalous origin of the left OA from the left RA” is well known [3, 4], in which occlusion at RA is required to occlude OA [4]. Actually, a recent study [4] reported
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