The Journal of Maternal-Fetal & Neonatal Medicine

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ijmf20

Arterial thrombosis after REBOA use in placenta

accreta spectrum: a case series

Albaro J. Nieto-Calvache , Alejandra Hidalgo-Cardona , Maria C. Lopez-Girón ,

Fernando Rodriguez , Carlos Ordoñez , Alberto F. Garcia , Mauricio Mejia ,
Manuel G. Pabón-Parra & Juan M. Burgos-Luna

To cite this article: Albaro J. Nieto-Calvache , Alejandra Hidalgo-Cardona , Maria C. Lopez-

Girón , Fernando Rodriguez , Carlos Ordoñez , Alberto F. Garcia , Mauricio Mejia , Manuel G.
Pabón-Parra & Juan M. Burgos-Luna (2020): Arterial thrombosis after REBOA use in placenta
accreta spectrum: a case series, The Journal of Maternal-Fetal & Neonatal Medicine, DOI:
10.1080/14767058.2020.1846178

To link to this article: https://doi.org/10.1080/14767058.2020.1846178

View supplementary material

Published online: 18 Nov 2020.

Submit your article to this journal

Article views: 16

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=ijmf20
THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE
https://doi.org/10.1080/14767058.2020.1846178

SHORT REPORT

Arterial thrombosis after REBOA use in placenta accreta spectrum: a

case series
Albaro J. Nieto-Calvachea , Alejandra Hidalgo-Cardonab, Maria C. Lopez-Giro
nc , Fernando Rodriguezd,
Carlos Ordon~ez , Alberto F. Garcia , Mauricio Mejia , Manuel G. Pabo
d d e

n-Parraa and
a
Juan M. Burgos-Luna
a
Fundaci
on Valle del Lili, Abnormally Invasive Placenta Clinic, Cali, Colombia; bUniversidad Icesi, Medicine Programe, Cali, Colombia;
c
Clinical Research Center, Fundaci
on Valle del Lili, Cali, Colombia; dFundaci
on Valle del Lili, Trauma and Emergency Surgery
Department, Cali, Colombia; eRadiology Department, Fundaci
on Valle del Lili, Cali, Colombia

ABSTRACT ARTICLE HISTORY

Background: The use of resuscitative endovascular balloon of the aorta (REBOA) is a useful Received 16 June 2020
strategy for bleeding control in placenta accreta spectrum (PAS) management. The incidence of Revised 19 August 2020
complications associated with this procedure is variable. We report three cases of arterial throm- Accepted 1 November 2020
bosis associated with REBOA, and we also analyze the factors that facilitated its occurrence.
KEYWORDS
Case report: Three women with PAS, presented common femoral and external iliac arterial Placenta accreta;
thrombosis after REBOA use. Among the contributing factors probably associated with throm- thrombosis; endovascu-
bosis, we identified the absence of ultrasound guidance for vascular access and the not using of lar procedures
heparin during aortic occlusion.
Conclusions: REBOA use is not exempt from complications and must be performed by experi-
enced groups applying strategies to reduce the risks of complications.

Introduction University Hospital in Colombia. Out of the total of

Placenta accreta spectrum (PAS) main and most
deadly complication is massive bleeding, which often
requires massive transfusions [1–3]. Therefore, strat-
egies to prevent and managed life-threatening bleed-
ing are a cornerstone of its treatment [4].
The resuscitative endovascular balloon of the aorta
(REBOA) has become an inviting alternative to use
either as prophylaxis or as an adjunct during PAS
bleeding. Its use has been associated with a lower
bleeding volume and improved transfusion outcomes
[5]. However, it has also associated with complications
in 0.8–10% of cases [6,7]. We report three cases of
arterial thrombosis related to the use of REBOA, and
we analyze the factors identified as contributing to
the presentation of this complication.
Cases
Between April 2016 and December 2019, a total of 44
women with a prenatal PAS diagnosis received presur-

n Valle del Lili,
gical-prophylactic REBOA at Fundacio
these patients, 3 (6.8%) presented arterial thrombosis
(Table 1).
Our REBOA insertion protocol was previously
described [8] and includes ultrasound-guidance for
arterial puncture and balloon placement in zone III of
the aorta by trauma surgeons. In all cases, 11 Fr sheath
compatible REBOA (8 Fr Primetime Medical, JOTEC E-
xpand) was used.
When we analyzed the possible contributing factors
to the appearance of thrombosis, we took into consid-
eration the occlusion time (OT), the time of the cath-
eter into the artery (TCIA), the use of ultrasound
guidance for arterial access, the heparinization of the
sheath and REBOA lumens, and the use of prophylac-
tic heparin in the postoperative period. All patients
received enoxaparin postoperative. In the 41 women
who did not present complications associated with
REBOA, the median OT, TCIA, and blood loss were
22 min (IQR 6–30 min), 118 min (IQR 92–148 min), and
1700 mL (IQR 1003–2150 mL) respectively.
Although the heparinization of REBOA lumen and
administration of 500 IU of intra-arterial heparin was

CONTACT Albaro J. Nieto-Calvache albaro.nieto@fvl.org.co Fundaci

on Valle Del Lili, Abnormally Invasive Placenta Clinic, Carrera 98 # 18–49, Cali
760032, Colombia
Supplemental data for this article can be accessed here.
ß 2020 Informa UK Limited, trading as Taylor & Francis Group
 2 A. J. NIETO-CALVACHE ET AL.

recommended in all patients before aortic occlusion,

12 months

500 IU heparin was administered in 35/41 patients. It was not administered in the first 4 patients in which the REBOA was used in our center (before this intervention was included in our protocol) and in 2 add-
GE: Gestational Age (weeks); US: Ultrasound guidance during arterial access; OT: Occlusion time (minutes); IO Bleed: Intraoperatory bleeding (mililiters); TCIA time of the catheter into the artery (minutes); OP: All
Follow-up
5 months

9 months

NA
this strategy was not applied to any of our three
patients (Table 1). Similarly, although ultrasound guid-
Thrombectomy ance was recommended for vascular access, in the
Thrombectomy
Treatment

Expectant
second case this resource was not used.

NA
In cases 1 and 3 placenta percreta was documented
with bleed of 1913 and 3372 mL respectively, and pro-
longed aortic OT (35 and 60 min respectively) were
Common femoral artery

Common femoral artery

required, as well as prolonged TCIA (181 and 185 min

External iliac artery
Thrombosis site

respectively). In case 2 the PAS diagnosis was ruled

out during surgery, and thus, aortic occlusion with
NA

REBOA was not performed.

In cases 1 and 2, the absence of pedial and poplit-

Other 41 REBOA user patients during the study period, who did not present complications associated with REBOA. Seven of them did not require aortic occlusion.
eal pulses was documented at the end of the c-sec-
4 weeks postoperatively. intermittent
At the end of the surgery,absence of

tion. In these cases, immediate confirmation of

At the end of the surgery, absence
of distal pulses. Ultrasonography

claudication. Angiotomography
distal pulses. Ultrasonography
Arterial thrombosis diagnosis

common femoral artery thrombosis was made by

ultrasonography, and thrombectomy was subsequently
performed. In the third case, the patient showed a sat-
isfactory postoperative evolution however, she
NA

returned fourth weeks later due to intermittent claudi-

cation. An angiotomography showed external iliac
artery thrombosis with distal reperfusion by collaterals
(Image 1. Supplementary material), and expectant
First and second insufflation of 25 min, alternating with periods of reperfusion of 10 min, and third occlusion for 10 min.

500 IU of unfractionated heparin were administered in the arterial lumen at the time of removal of the femoral sheath.
Table 1. Patients with arterial thrombosis associated with Aortic Endovascular Occlusion Balloon use.

management was defined. In all cases, the follow-up

(1003–2150)

showed normal distal pulses and gait without

IO bleed
1913

3372

1700
411

limitations.

Discussion
Accreta is ruled out
intraoperatively
uterine area

First insufflation of 25 min, with reperfusion period of 10 min and second occlusion for 10 min.
Sector 2e

Sector 2f
Percreta.

Percreta.
Affected

Our series of REBOA in PAS patients revealed throm-

None.

NA

botic complications in 6.8% of the patients treated

Right parametrium, cervix and anterior and posterior uterine segment, to the right side.

with this endovascular occlusion strategy. In all cases,

thrombosis of the external iliac artery or common
itional patients in the last year of observation due to forgetfulness of the team.
other REBOA user patients; NA: Does not apply. Median (Interquartile Range).
Heparinc

femoral artery occurred [9].

35/41
Nod

No

No

The frequency of complications due to REBOA use

Use of heparin in endoarterial devices lumens and punctured artery.

is variable [7] and depends on the experience of the

(92–148)

treating group, the device used, and the nature of

TCIA
181

185

118
72

PAS which generates different degrees of tissue injury

and variable vascular occlusion times [10]. Our 6.8%
(6–30)

incidence of femoral thrombosis was similar to the

60b
35a
OT

22
0

rate observed in 414 trauma patients treated with

REBOA [9], which shows 5.6% complications related to
Cervix and lower anterior uterine segment.
Sheath
11 Fr

11 Fr

11 Fr

NA

vascular access, including serious events such as limb

amputations.
Yes

Yes

Yes
No
US

Although patient 3 had a prolonged OT (60 min),

(34–37)

patient number 1 had 35 min of OT (Table 1), not too

35.1
GA
38

32

30

far from what was observed in women without throm-

bosis (mean OT 22 min, IQR 6 30 min). Additionally,
G4P1C1A1
gestations
Previous

G4A1C2
G2C1

patient 2 did not require aortic occlusion because PAS

NA

was ruled out in the surgery. The possibility that after

the preoperative placement of REBOA the aortic occlu-
Case

g
OP

sion is not required [11] and the presence of

1

g
h
e
a

f

complications even without inflating the balloon, justi-
fies thinking about an individualized REBOA use to
balance risks and benefits, reserving it for cases with a
higher risk of bleeding and possibly deferring its
implantation, in some doubtful cases, until the diagno-
sis is confirmed at laparotomy after dissecting the ves-
icouterine space [12].
Few authors report the factors associated with the
observed thrombotic events [7]. We tried to evaluate
factors related to the appearance of thrombosis.
Although all of our patients received heparin in
the postoperative period, two out of three reported
arterial thrombotic events occurring immediately after
surgery. Therefore, it is likely that the thromboprophy-
laxis routinely administered postoperatively will not
affect its incidence.
A controversial procedure is heparin infusion in the
REBOA lumen and directly in the aorta during occlusion
periods. Although the use of anticoagulants in patients
at risk of massive bleeding raises concern and their use
to prevent thrombosis of venous catheters has not
shown benefit over saline infusion [13] this strategy is
used by several authors during aortic occlusion [14–16]
and was included in our PAS care protocol, but it was
not administered in any of the three cases with throm-
bosis. The use of low doses of heparin (500 IU) directly
in the occluded artery at the time of inflating the bal-
loon, probably does not generate a systemic anticoagu-
lation, but a local effect in the column of blood that
stops its flow distal to the occlusion.
Heparin was administered in 85.4% (35 of 41 cases)
of the patients without complications, but it was for-
gotten in all patients with thrombosis. In case one,
500 IU of unfractionated heparin were administered in
the arterial lumen at the time of removal of the fem-
oral sheath (when the thrombus was probably already
formed during the period of absence of blood flow).
In the remaining two cases it was not administered
because the balloon was not inflated (case 2) or
because the team forgot it (Case 3). The usefulness of
this intervention should be evaluated in controlled
studies before establish a recommendation on its use
and special care should be taken in patients with
known coagulation defects
A widely accepted recommendation is the use of
ultrasound guidance for vascular access [10]. With this
measure, fewer punctures are made and the vascular
injury risk decrease. In case 2, no ultrasound guidance
was used, nor was aortic occlusion required, conse-
quently the additional arterial trauma (3 punctures
before vascular access) was considered a factor related
to the occurrence of thrombosis.
THE JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE 3
The use of multiple types of aortic balloons in PAS
has been reported, from those compatible with 5 Fr
sheath to series with 12 Fr sheath [14]. However, other
authors have described that the use of smaller diam-
eter devices (balloons compatible with 7 Fr sheath) is
related to fewer complications at the puncture site
[17,18]. Our patients received an 8 Fr intra-aortic bal-
loon, compatible with an 11 Fr sheath and this may be
a factor related to the reported thrombotic events.
The popularization of REBOA use for PAS motivates
the use of this device by groups with reduced experi-
ence in endovascular techniques and minimal training
in the procedure, for this reason sharing our complica-
tions analysis can be useful to avoid them in other
populations. Additionally, we consider that multicen-
tric studies are crucial to adequately assess the useful-
ness of the strategy and the risks associated with
aortic occlusion during PAS surgeries.
The analysis of these three cases of thrombosis
associated with REBOA highlights the importance of
the surveillance of the multiple tasks that the interdis-
ciplinary team must carry out during the management
of women with PAS [19], where involuntarily and des-
pite enough experience, details can be forgotten dur-
ing the performance of complex tasks. In this scenario,
strategies such as pre-surgical meetings, intraoperative
checklists use, and post-surgical debriefing are useful
[20]. The incorporation of REBOA use into an interdis-
ciplinary group, where it has not been used before,
must be carried out within a clear management proto-
col, including monitoring complications and its effect-
iveness evaluation.
Conclusion
REBOA use is not exempt from complications. We rec-
ommend formal surveillance of the REBOA use in PAS
patients to ensure that femoral puncture follows the
proposed rules in all cases.
Disclosure statement
No potential conflict of interest was reported by
the author(s).
ORCID
Albaro J. Nieto-Calvache http://orcid.org/0000-0001-
5639-9127
Maria C. Lopez-Giro
n http://orcid.org/0000-0002-
7846-7300
4 A. J. NIETO-CALVACHE ET AL.
References
[1] Belfort MA, Shamshirsaz AA, Fox KA. The diagnosis
and management of morbidly adherent placenta.
Semin Perinatol. 2018;42(1):49–58.
[2] Kaufman C, Tadros A. Endovascular interventions
for the morbidly adherent placenta. J Clin Med. 2018;
7(5):92.
[3] Nieto AJ, Echavarr
ıa MP, Carvajal JA, et al. Placenta
accreta: importance of a multidisciplinary approach in
the Colombian hospital setting. J Matern-Fetal
Neonatal Med. 2018;33(8):1321–1329.
[4] Eller AG, Porter TT, Soisson P, et al. Optimal manage-
ment strategies for placenta accreta. BJOG An Int J
Obstet Gynaecol. 2009;116(5):648–654.
[5] Manzano-Nunez R, Escobar-Vidarte MF, Naranjo MP,
et al. Expanding the field of acute care surgery: a sys-
tematic review of the use of resuscitative endovascu-
lar balloon occlusion of the aorta (REBOA) in cases of
morbidly adherent placenta. Eur J Trauma Emerg
Surg. 2018;44(4):519–526.
[6] Wu Q, Liu Z, Zhao X, et al. Outcome of pregnancies
after balloon occlusion of the infrarenal abdominal
aorta during caesarean in 230 patients with placenta
praevia accreta. Cardiovasc Intervent Radiol. 2016;
39(11):1573–1579.
[7] Luo F, Wu Z, Mei J, et al. Thrombosis after aortic bal-
loon occlusion during cesarean delivery for abnor-
mally invasive placenta. Int J Obstet Anesth. 2018;33:
32–39.
[8] Manzano-Nunez R, Escobar-Vidarte MF, Orlas CP, et al.
Resuscitative endovascular balloon occlusion of the
aorta deployed by acute care surgeons in patients
with morbidly adherent placenta: a feasible solution
for two lives in peril. World J Emerg Surg. 2018;13(1):
1–6.
[9] Manzano-Nunez R, Orlas CP, Herrera-Escobar JP, et al.
A meta-analysis of the incidence of complications
associated with groin access after the use of resusci-
tative endovascular balloon occlusion of the aorta in
trauma patients. J Trauma Acute Care Sur. 2018;85:
626–634.
[10] Davidson AJ, Russo RM, Reva VA, et al. The pitfalls of
resuscitative endovascular balloon occlusion of the
aorta: risk factors and mitigation strategies. J Trauma
Acute Care Surg. 2018;84(1):192–202.
[11] Whittington JR, Pagan ME, Nevil BD, et al. Risk of vas-
cular complications in prophylactic compared to
emergent resuscitative endovascular balloon occlu-
sion of the aorta (REBOA) in the management of pla-
centa accreta spectrum. J Matern Neonatal Med.
2020:1–4.
[12] Nieto A, Zambrano M, Herrera N, et al. Resective-
reconstructive treatment of abnormally invasive
placenta: inter Institutional Collaboration by telemedi-
cine (eHealth). J Matern Neonatal Med. 2019:1–311.
[13] Randolph AG, Cook DJ, Gonzales CA, et al. Benefit of
heparin in peripheral venous and arterial catheters:
systematic review and meta-analysis of randomised
controlled trials. Br Med J. 1998;316(7136):969–975.
[14] Xie L, Wang Y, Luo FY, et al. Prophylactic use of an
infrarenal abdominal aorta balloon catheter in preg-
nancies complicated by placenta accreta. J Obstet
Gynaecol. 2017;37(5):557–561.
[15] Russo RM, Girda E, Kennedy V, et al. Two lives, one
REBOA: hemorrhage control for urgent cesarean hys-
terectomy in a Jehovah’s Witness with placenta per-
creta. J Trauma Acute Care Surg. 2017;83(3):551–553.
[16] Chandraharan E, Hartopp R, Thilaganathan B, et al.
How to set up a regional specialist referral service for
Placenta Accreta Spectrum (PAS) disorders? Best Pract
Res Clin Obstet Gynaecol. 2020. http://www.science-
direct.com/science/article/pii/S1521693420301140
[17] Teeter WA, Matsumoto J, Idoguchi K, et al. Smaller
introducer sheaths for REBOA may be associated with
fewer complications. J Trauma Acute Care Surg. 2016;
81(6):1039–1044.
[18] Greer JW, Flanagan C, Bhavaraju A, et al. Right exter-
nal iliac artery thrombus following the use of resusci-
tative endovascular balloon occlusion of the aorta for
placenta accreta. J Surg Case Reports. 2018;2018(11):
rjy313.
[19] Shamshirsaz AA, Fox KA, Erfani H, et al. The role of
centers of excellence with multidisciplinary teams in
the management of abnormal invasive placenta. Clin
Obstet Gynecol. 2018;61(4):841–850.
[20] Walker MG, Pollard L, Talati C, et al. Obstetric and
anaesthesia checklists for the management of mor-
bidly adherent placenta. J Obstet Gynaecol Can. 2016;
38(11):1015–1023.