A Review and Comparison of the Efficacy of Prophylactic Interventional Radiological Arterial Occlusions in Placenta Accreta Spectrum Patients: A Meta-analysis

Published:November 12, 2022DOI:

      Rationale and Objectives

      Placenta accreta spectrum (PAS) disorders are increasingly common and associated with significant maternal and neonatal morbidity and mortality due to the associated risk of massive haemorrhage. Currently prophylactic interventional radiology (IR) arterial occlusion is being performed occluding either the internal iliac artery (IIA), abdominal aorta (AA) or uterine artery (UA) in order to prevent this blood loss. The aim of this meta-analysis is to identify whether these IR procedures are effective in reducing estimated blood loss (EBL) and hysterectomy rates and if so which method achieves the optimal results


      A literature search was conducted to acquire case-control studies assessing EBL and hysterectomies performed following IR arterial occlusion in PAS patients, yielding 16 results. Studies were analyzed together and later split into groups dependent on the artery occluded. The results of these were then inputted into forest plots to identify their overall estimated effect with confidence intervals.


      Prophylactic IR arterial occlusion was proven to reduce both EBL and hysterectomies. When separated by artery, IIA achieved the worst outcomes with no proven effect on EBL and a minimal reduction in hysterectomies. UA scored in the middle with a modest reduction in both outcomes, whilst AA occlusion had the most significant reduction in both EBL and hysterectomies.


      Prophylactic IR arterial occlusion should be routinely considered in PAS patients to reduce both EBL and rates of hysterectomies. Current literature promotes the use of IIA occlusion; however the findings of this analysis propose that AA and UA occlusion should be favoured

      Key Words

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        • Cahill AG
        • et al.
        Society of gynecologic oncology; American College of Obstetricians and gynecologists and the society for maternal–fetal medicine.
        Am J Obstet Gynecol. 2018; 219: B2-B16
        • Fitzpatrick KE
        • Sellers S
        • Spark P
        • et al.
        The management and outcomes of placenta accreta, increta, and percreta in the UK: a population-based descriptive study.
        BJOG. 2014; 121: 62-71
        • Piñas Carrillo A
        • Chandraharan E
        Placenta accreta spectrum: risk factors, diagnosis and management with special reference to the Triple P procedure.
        Womens Health (Lond). 2019; 151745506519878081.
        • Carusi DA.
        The placenta accreta spectrum: epidemiology and risk factors.
        Clin Obstet Gynecol. 2018; 61: 733-742
        • Morlando M
        • Collins S.
        Placenta accreta spectrum disorders: challenges, risks, and management strategies.
        Int J Womens Health. 2020; 12: 1033-1045
        • Zhang J
        • Xu H
        • Xin Y
        • et al.
        Assessment of the massive hemorrhage in placenta accreta spectrum with magnetic resonance imaging.
        Exp Ther Med. 2020; 19: 2367-2376
        • Palacios-Jaraquemada JM
        • Fiorillo A
        • Hamer J
        • et al.
        Placenta accreta spectrum: a hysterectomy can be prevented in almost 80% of cases using a resective-reconstructive technique.
        J Matern Fetal Neonatal Med. 2022; 35: 275-282
        • Clarke-Pearson DL
        • Geller EJ.
        Complications of hysterectomy.
        Obstet Gynecol. 2013; 121: 654-673
        • Makary M
        • Chowdary P
        • Westgate JA.
        Vascular balloon occlusion and planned caesarean hysterectomy for morbidly adherent placenta: asystematic review.
        Aust N Z J Obstet Gynaecol. 2019; 59: 608-615
        • Lindquist JD
        • Vogelzang RL.
        Pelvic Artery Embolization for treatment of postpartum hemorrhage.
        Semin Intervent Radiol. 2018; 35: 41-47
        • Selçuk İ
        • Uzuner B
        • Boduç E
        • et al.
        Step-by-step ligation of the internal iliac artery.
        J Turk Ger Gynecol Assoc. 2019; 20: 123-128
        • Xie L
        • Wang Y
        • Luo FY
        • et al.
        Prophylactic use of an infrarenal abdominal aorta balloon catheter in pregnancies complicated by placenta accreta.
        J Obstet Gynaecol. 2017; 37: 557-561
        • Sugai S.
        • Nonaka T.
        • Tamegai K.
        • et al.
        Successful repeated uterine artery embolization in postpartum hemorrhage with disseminated intravascular coagulation: a case report and literature review.
        BMC Pregnancy Childbirth. 2021; 21: 710
        • Liu J
        • Zhang J
        • Xie S
        • et al.
        The effects of increasing aortic occlusion times at the level of the highest renal artery (zone II) in the normovolemic rabbit model.
        Acad Radiol. 2022; 29: 986-993
      1. Medians and interquartile ranges. 2022 <>[Accessed 3 August 2022].

      2. Cochrane handbook for systematic reviews of interventions. 2022; (Accessed August 3, 2022)
      3. Tools to assess risk of bias in case control studies (2022). Retrieved 4 August 2022, from Accessed4 August 2022,

        • Cho SB
        • Hong SJ
        • Lee S
        • et al.
        Preoperative prophylactic balloon-assisted occlusion of the internal iliac arteries in the management of placenta increta/percreta.
        Medicina (Kaunas). 2020; 56: 368
        • Peng Y
        • Jiang L
        • Peng C
        • et al.
        The application of prophylactic balloon occlusion of the internal iliac artery for the treatment of placenta accreta spectrum with placenta previa: a retrospective case-control study.
        BMC Pregnancy Childbirth. 2020; 20: 349
        • Chen M
        • Liu X
        • You Y
        • et al.
        Internal liac artery balloon occlusion for placenta previa and suspected placenta accreta: a randomized controlled trial.
        Obstet Gynecol. 2020; 135: 1112-1119
        • Zhou-Xin E.
        • et al.
        The effectiveness of prophylactic internal iliac artery balloon occlusion in the treatment of patients with pernicious placenta previa coexisting with placenta accreta.
        J Mat-Fetal Neonatal Med. 2021; 34: 93-98
        • Li K.
        • Zou Y.
        • Sun J.
        • et al.
        Prophylactic balloon occlusion of internal iliac arteries, common iliac arteries and infrarenal abdominal aorta in pregnancies complicated by placenta accreta: a retrospective cohort study.
        Eur Radiol. 2018; 28: 4959-4967
        • Gulino F.A.
        • Guardo F.D.
        • Zambrotta E.
        • et al.
        Placenta accreta and balloon catheterization: the experience of a single center and an update of latest evidence of literature.
        Arch Gynecol Obstet. 2018; 298: 83-88
        • Fan Y
        • Gong X
        • Wang N
        • et al.
        A prospective observational study evaluating the efficacy of prophylactic internal iliac artery balloon catheterization in the management of placenta previa-accreta: aSTROBE compliant article.
        Medicine (Baltimore). 2017; 96: e8276
        • Feng S
        • Liao Z
        • Huang H.
        Effect of prophylactic placement of internal iliac artery balloon catheters on outcomes of women with placenta accreta: an impact study.
        Anaesthesia. 2017; 72: 853-858
        • Omar HR
        • Sprenker C
        • Alvey E
        The value of occlusive balloons in the management of abnormal placentation: aretrospective study.
        J Obstet Gynaecol. 2016; 36: 333-336
        • Salim R
        • Chulski A
        • Romano S
        • et al.
        Precesarean prophylactic balloon catheters for suspected placenta accreta: a randomized controlled trial.
        Obstet Gynecol. 2015; 126 (PMID: 26444128): 1022-1028
        • Darwish H.
        • Zaytoun H.
        • Kamel H.
        • et al.
        (2014). Prophylactic preoperative balloon occlusion of hypogastric arteries in abnormal placentation; 5years experience.
        The Egyptian Journal Of Radiology And Nuclear Medicine. 2014; 45: 751-759
        • Tan CH
        • Tay KH
        • Sheah K
        • et al.
        Perioperative endovascular internal iliac artery occlusion balloon placement in management of placenta accreta.
        AJR Am J Roentgenol. 2007; 189: 1158-1163
        • Zheng W
        • Dou R
        • Yan J
        • et al.
        Intra-abdominal aortic balloon occlusion in the management of placenta percreta.
        Chin Med J. 2022; 135: 441-446
        • Cui S
        • Zhi Y
        • Cheng G
        • et al.
        Retrospective analysis of placenta previa with abnormal placentation with and without prophylactic use of abdominal aorta balloon occlusion.
        Int J Gynaecol Obstet. 2017; 137: 265-270
        • Zeng C
        • Yang M
        • Ding Y
        Preoperative infrarenal abdominal aorta balloon catheter occlusion combined with Bakri tamponade reduced maternal morbidity of placenta increta/percreta.
        Medicine (Baltimore). 2017; 96: e8114
        • 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: 1573-1579
        • Panici P.B
        • Anceschi M
        • Borgia M.L
        • et al.
        Intraoperative aorta balloon occlusion: fertility preservation in patients with placenta previa accreta/increta.
        J Matern-Fetal Neonatal Med. 2012; 25: 2512-2516
        • Yuan Q
        • Jin Y
        • Chen L
        • et al.
        Prophylactic uterine artery embolization during cesarean delivery for placenta previa complicated by placenta accreta.
        Int J Gynaecol Obstet. 2020; 149 (Epub 2019 Dec 20. PMID: 31778209): 43-47
        • Huang KL
        • Tsai CC
        • Fu HC
        Prophylactic transcatheter arterial embolization helps intraoperative emorrhagic control for REMOVING invasive placenta.
        J Clin Med. 2018; 7 (PMID: 30469429; PMCID: PMC6262565): 460
        • Pan Y
        • Zhou X
        • Yang Z
        • et al.
        Retrospective cohort study of prophylactic intraoperative uterine artery embolization for abnormally invasive placenta.
        Int J Gynaecol Obstet. 2017; 137: 45-50
        • Nankali A
        • Salari N
        • Kazeminia M
        • et al.
        The effect prophylactic internal iliac artery balloon occlusion in patients with placenta previa or placental accreta spectrum: a systematic review and meta-analysis.
        Reprod Biol Endocrinol. 2021; 19 (Published 2021 Mar 4): 40
        • Dai M
        • Zhang F
        • Li K
        • et al.
        The effect of prophylactic balloon occlusion in patients with placenta accreta spectrum: a Bayesian network meta-analysis.
        Eur Radiol. 2022; 32: 3297-3308
        • Liang D
        • Zhao H
        • Liu D
        • et al.
        Internal iliac artery balloon occlusion in the management of placenta accreta: asystematic review and meta-analysis.
        Eur J Radiol. 2021; 139109711.
        • Chen L
        • Wang X
        • Wang H
        • et al.
        Clinical evaluation of prophylactic abdominal aortic balloon occlusion in patients with placenta accreta: a systematic review and meta-analysis.
        BMC Pregnancy Childbirth. 2019; 19 (Published 2019 Jan 15): 30
        • Knuttinen MG
        • Jani A
        • Gaba RC
        • et al.
        Balloon occlusion of the hypogastric arteries in the management of placenta accreta: a case report and review of the literature.
        Semin Intervent Radiol. 2012; 29161168.
        • Sousa LHD
        • Baptista-Silva JC
        • Vasconcelos V
        • et al.
        Internal iliac artery revascularisation versus internal iliac artery occlusion for endovascular treatment of aorto-iliac aneurysms.
        Cochrane Database Syst Rev. 2020; 7 (CD013168. Published 2020 Jul 21)
        • Liapis K
        • Tasis N
        • Tsouknidas I
        • et al.
        Anatomic variations of the uterine artery. review of the literature and their clinical significance.
        Turk J Obstet Gynecol. 2020; 17: 58-62