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A multidisciplinary approach and implementation of a specialized hemorrhage control team improves outcomes for
Albaro José Nieto-Calvache1, Lina María Vergara-Galliadi, Fernando Rodríguez
1From the Placenta Accreta Spectrum Clinic (A.J.N.-C., F.R., C.A.O., A.F.G., J.V., J.P.C., A.M.B., M.P.E., M.F.E., J.C., J.P.B.-C., J.M.B.), Clinical Research Center (L.M.V.-G., M.C.L., R.M.); Division of Trauma and Acute Care Surgery, Department of Surgery (F.R., C.A.O., A.F.G.); and Interventional Radiology Department (J.V., J.P.C.), Fundación Valle del Lili, Cali, Colombia.
Insights
As interdisciplinary teams improve skills for managing placenta accreta spectrum (PAS) complications, the need for endovascular techniques to control bleeding decreases. This study shows reduced blood loss and improved outcomes over time.
Area of Science:
- Obstetrics and Gynecology
- Vascular Surgery
- Maternal-Fetal Medicine
Background:
- Massive bleeding is the primary complication of placenta accreta spectrum (PAS).
- Endoarterial occlusion techniques are increasingly used in managing PAS.
- Developing interdisciplinary PAS teams can improve patient outcomes.
Purpose of the Study:
- To evaluate endovascular practice patterns for PAS patients over a 9-year period.
- To assess the impact of an interdisciplinary PAS team's developing skills on management outcomes.
- To compare clinical results based on different endovascular devices used.
Main Methods:
- Retrospective cohort study of 113 PAS patients (December 2011-November 2020).
- Comparison of clinical outcomes based on endovascular device type: internal iliac artery occlusion balloons, resuscitative endovascular balloons of the aorta, or no balloons.
- Analysis of outcomes stratified by year of treatment to reflect the PAS team's experience.
Main Results:
- Annual blood loss decreased significantly, from a median of 2,500 mL in 2014 to 1,394 mL in 2020.
- Patients treated without arterial balloons (Group 3) had the lowest bleeding volume (1,245 mL) and shortest operative time (173 minutes).
- Resuscitative endovascular balloons of the aorta (Group 2) showed lower bleeding volume and transfusion rates compared to internal iliac artery occlusion balloons (Group 1), with reduced hysterectomy rates.
Conclusions:
- Endovascular techniques for bleeding control in PAS become less critical as interdisciplinary teams enhance surgical and teamwork proficiency.
- Improved teamwork and surgical skills in PAS management correlate with reduced reliance on endovascular interventions.
- The study highlights the evolving role of endovascular techniques in PAS management as clinical expertise grows.
Introduction:
The main complication of placenta accreta spectrum (PAS) is massive bleeding. Endoarterial occlusion techniques have been incorporated into the management of this pathology. Our aim was to examine the endovascular practice patterns among PAS patients treated during a 9-year period in a low-middle income country in which an interdisciplinary group's technical skills were improved with the creation of a PAS team.
Methodology:
A retrospective cohort study including all PAS patients treated from December 2011 to November 2020 was performed. We compared the clinical results obtained according to the type of endovascular device used (group 1, internal iliac artery occlusion balloons; group 2, resuscitative endovascular balloons of the aorta; group 3, no arterial balloons due to low risk of bleeding) and according to the year in which they were attended (reflects the PAS team level of experience). A fourth group of comparisons included the woman diagnosed during a cesarean delivery and treated in a nonprotocolized way.
Results:
A total of 113 patients were included. The amount of blood loss decreased annually, with a median of 2,500 mL in 2014 (when endovascular occlusion balloons were used in all patients) and 1,394 mL in 2020 (when only 38.5% of the patients required arterial balloons). Group 3 patients (n = 16) had the lowest bleeding volume (1,245 mL) and operative time (173 minutes) of the entire population studied. Group 2 patients (n = 46) had a bleeding volume (mean, 1,700 mL) and transfusions frequency (34.8%) slightly lower than group 1 patients (n = 30) (mean of 2,000 mL and 50%, respectively). They also had lower hysterectomy frequency (63% vs. 76.7% in group 1) and surgical time (205 minutes vs. 275 in group 1) despite a similar frequency of confirmed PAS and S2 compromise.
Conclusion:
Endovascular techniques used for bleeding control in PAS patients are less necessary as interdisciplinary groups improve their surgical and teamwork skills.
Level Of Evidence:
Therapeutic care management, level III.
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