The first step to evaluate the usefulness of arterial occlusion in placenta accreta spectrum is to establish its indications

Sir,

We read the Matsuo et al. article on the use of arterial balloons in the USA during a 3‐year period. ¹ We congratulate the authors for conducting a study with a very interesting analysis in a large population (6440 women with placenta accreta spectrum [PAS] in 806 centers), exposing some very important points, such as:

1. The benefits of arterial balloons in “mild” cases are not clear enough.

2. In the most severe cases, arterial balloons are likely to decrease bleeding and the risk of visceral injury.

3. It is likely that as interdisciplinary teams gain experience in pelvic dissection by treating a greater number of cases, it will be less and less necessary to use arterial occlusion devices.

The results of Matsuo et al. coincide with those observed in our hospital, where after universal use of arterial balloons before starting the surgery, and observing a lot of patients with “mild” cases of PAS that do not require the use of catheters already in place (highlighting that some of them suffer from the complications of those catheters), we decided to reserve this type of intervention only for “serious” cases. ²

In the transition period from universal use to individualized use, our main concern was how to properly identify which patients would require vascular devices. The answer to this question was the PAS topographic classification. ³

Between 2016 and 2018 we used the ultrasound findings of each case to select those with PAS in the lower uterine segment, lower parametrium, or cervix (uterine vascularization sector 2), knowing that this topography was associated with greater surgical difficulty and maternal morbidity. ⁴ We then reserved the arterial balloons for these patients. But even in this subgroup, arterial balloons implanted before surgery were occasionally not used. ³

It was necessary to gain confidence in the pelvic dissection of avascular spaces and the support of remote expert groups through telemedicine, so that we understood what strategy to apply that would allow us to modify our protocol and safely select the patients who really required vascular interventions.

Since 2019 we have been using “intraoperative staging” ³ —this is a simple dissection of the pelvic avascular spaces that allows the most serious cases to be identified, before generating intraoperative bleeding.

Taking into account that the majority of patients with PAS have involvement of the upper part of the uterus (vascular sector 1) ⁵ or superficial invasions (accreta), only a minority of patients seen by trained groups will actually require vascular occlusion devices.

Matsuo et al. correctly state that there are no practical guidelines for the use of intra‐arterial balloons in PAS. To evaluate their usefulness, the first step is to state the indications for their use clearly.

We propose the use of arterial occlusion techniques only in those patients with severe forms of PAS, after intraoperative staging. In this context we prefer techniques that do not require fluoroscopy (resuscitative endovascular balloon of the aorta, clamping/ligation/manual compression of the aorta).

We invite the authors to share their opinion on the usefulness of the topographic classification to identify those patients who will benefit most from arterial balloons.

Nieto‐Calvache AJ, Aryananda RA. The first step to evaluate the usefulness of arterial occlusion in placenta accreta spectrum is to establish its indications. Acta Obstet Gynecol Scand. 2022;101:379–380. doi: 10.1111/aogs.14307