Placenta accrete spectrum disorders (PAS) is a life-threatening obstetrical condition. Prenatal diagnosis of PAS is crucial in planning its management and has been shown to reduce maternal morbidity and mortality. Major guidelines for PAS recommend that patients diagnosed with PAS should be cared for in a specialist center by a multidisciplinary team with expertise. On the other hand, it is well known that placenta previa and previous cesarean deliveries are significant risk factors for PAS. From 2011, we have predicted PAS in pregnant women with placenta previa by using our original scoring system. In addition, in our hospital, patients with placenta previa suspected to have PAS receive preoperative internal iliac artery balloon occlusion catheter placement. We have improved our strategies for management of PAS in patients with placenta previa, and have performed uterine artery embolization followed by cesarean hysterectomy since 2015. Although guidelines do not recommend routine use of interventional radiology (IVR) techniques, we believe that surgical strategies combined with IVR are effective for reducing intraoperative blood loss in patients with PAS and placenta previa.

View full abstract

Postpartum hemorrhage remains a leading cause of maternal mortality, even in countries like Japan with advanced medical care. The incidence of placenta accreta spectrum disorders (PAS) is particularly increasing, primarily due to the rising rates of cesarean sections and assisted reproductive technologies. There is currently no standardized strategy for IVR support in PAS, despite attempts to mitigate blood loss through techniques such as arterial balloon occlusion, transcatheter arterial embolization (TAE), or a combination of these interventions.
At Kobe University Hospital, in collaboration with the Department of Obstetrics and Gynecology, the strategy involves conducting Internal Iliac Artery Balloon Occlusion (IIABO) for hem-orrhage control during cesarean section in pregnant women diagnosed with PAS. These pro-cedures are performed in a hybrid operating room, and TAE or Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) are utilized as needed in combination with IIABO.
To contribute effectively as a team member, an IVR physician requires a com-prehensive understanding of PAS and the ability to perform the necessary procedures promptly and accurately. Unlike IVR procedures performed in the angiography room, IVR during ce-sarean section necessitates specific technical tips and awareness of potential pitfalls. The aim of this article is to share these valuable insights through case studies.

View full abstract

With the global increase in the cesarean delivery rate, the incidence of placenta accreta spectrum (PAS) during second pregnancy has increased. Hysterectomy, which would permanently affect fertility, has been the major therapeutic choice, when life-threatening bleeding occurred with PAS subsequent to cesarean delivery. In the past few decades, prophylactic aortic balloon oc-clusion for PAS has been employed to prevent intraoperative and postoperative hemorrhage. However, its use remains controversial. There is no consensus about which artery is most effective for prophylactic aortic balloon occlusion (internal iliac, common iliac or aorta). Furthermore, the timing of balloon inflation before cesarean delivery or after fetal delivery and what type of balloon to use are also controversial.
In this paper, we present the contents, procedures, advantages, disadvantages, safety, and efficacy of prophylactic aortic balloon oc-clusion for PAS. In addition, inter-professional work is important in high-risk pregnancy, and we will discuss our approach and the role of IVR physicians. Large-scale prospective studies are needed to evaluate the efficacy and safety of prophylactic aortic balloon occlusion for PAS.

View full abstract

We have modified our treatment policy for placenta accreta. While we recommend a total hysterectomy in cases of obvious placenta accreta, we attempt to stop the bleeding with surgical techniques in cases where uterine preservation is the goal. In particular, ligation and hemostasis techniques from the uterine isthmus to the cervix are important. However, the success rate of ligation and hemostasis is limited, and TAE or total hysterectomy may be necessary. In some cases, techniques such as TAE and REBOA are used in collaboration with a radiologist. These two techniques are used in different situations. This article describes our treatment strategy for placenta accreta and our trial and error with TAE and REBOA. The indications for REBOA and TAE in placenta accreta vary from institution to institution. Among others, there is still no fixed strategy for the timing of REBOA use; the only way to clearly prove the efficacy of REBOA is through prospective studies, but if the safety associated with this insertion is better assured, it is likely to become more widespread.

View full abstract

We herein report two cases of venous thoracic outlet syndrome (VTOS) diagnosed by per-forming venography in the sitting position.
Case presentations: The first patient was a female in her 30s with a history of right subclavian vein thrombosis. Contrast-enhanced (CE) computed tomography (CT) did not indicate VTOS. Venous stenosis was observed when venography in the sitting position was performed on the patient. Stenosis was successfully resolved by surgery. The second patient was a female in her 30s with a history of left subclavian vein thrombosis. She repeatedly experienced discomfort in her left arm. CE-CT failed to in-dicate VTOS, whereas venography in the sitting position with her arm raised revealed venous occlusion. Surgery resolved her discomfort.
These two cases demonstrated the use-fulness of performing venography in the sitting position for diagnosis and treatment planning in patients with VTOS.

View full abstract