Case Report

The use of aortic occlusion balloon catheter withoutfluoroscopy for life-threatening post-partumhaemorrhage

E. Søvik1, P. Stokkeland

2, B. S. Storm3, P. Åsheim

3 and O. Bolås4

1Department of Radiology, St. Olavs University Hospital, Trondheim, Norway, 2Department of Radiology, Stavanger University Hospital,Stavanger, Norway, 3Department of Anesthesiology, St. Olavs University Hospital, Trondheim, Norway and 4Department of Gynecology andObstetrics, St. Olavs University Hospital, Trondheim, Norway

This article describes the use of a balloon catheter introduced viathe femoral artery into the abdominal aorta without the use offluoroscopy to stabilize six patients with life-threatening post-partum haemorrhage. The femoral artery was localized blindlyor with the use of ultrasound. Immediate control of the bleedingwas achieved in all patients, and the procedure was believed tobe life saving for some patients. One patient with a narrow andfragile aorta had an aortic rupture necessitating surgical repair,which may have been caused by the balloon. In these six cases,the procedures were carried out by interventional radiologists.

However, this procedure can also be performed by anaesthesi-ologists or surgeons who are trained in vascular accesstechniques.

Accepted for publication 4 November 2011

© 2012 The AuthorsActa Anaesthesiologica Scandinavica© 2012 The Acta Anaesthesiologica Scandinavica Foundation

Case report

Severe post-partum haemorrhage (PPH) occursin 1/1000 women giving birth.1 This condition is

often dramatic and may be life threatening.Treatments with intravenous fluids, volume

expanders and blood products and the use of ino-tropic agents have been the only options for anaes-thesiologists and obstetricians in cases with heavybleeding. For obstetricians, B-Lynch sutures and ahysterectomy may be the only solutions to haltbleeding, especially when the use of curettage,uterotonic drugs, manual compression and anintrauterine balloon has failed. Arterial emboliza-tion is also an option. However, this expertise is notalways readily available.2

There have been several reports describing theuse of aortic balloons to control bleeding in battlecasualties and in patients with aortic aneurysms oraortic damage.3–6 In recent years, there have alsobeen reports on the use of aortic occlusion cathetersto control exsanguination in patients with late sur-gical or obstetric bleeding in the abdomen or

pelvis.7–9 A common technique in these reports is theuse of fluoroscopy or computerized tomography(CT) in order to place the catheter in the correctposition in the aorta. Recently, there was a reportdescribing the use of intra-aortic balloon occlusion(IABO) without fluoroscopy to stop life-threateningbleeding in patients with pelvic fractures.10

In this report, we present six patients with severePPH treated with IABO without the use of fluoros-copy or CT. All patients were treated by a teamconsisting of an interventional radiologist (IR), ananaesthesiologist and an obstetrician. All patientsreceived misoprostol, oxytocin and a standardblood replacement treatment, including crystalloids,colloids, platelets, red blood cells (RBC) andinotropic drugs. All patients made uneventfulrecoveries.

Cases

Patient 1Labour was induced during week 37 of gestation ina 26-year-old primigravida woman due to severe

Acta Anaesthesiol Scand 2012; 56: 388–393Printed in Singapore. All rights reserved

© 2012 The AuthorsActa Anaesthesiologica Scandinavica

© 2012 The Acta Anaesthesiologica Scandinavica Foundation

ACTA ANAESTHESIOLOGICA SCANDINAVICA

doi: 10.1111/j.1399-6576.2011.02611.x

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pre-eclampsia. Due to PPH, atony of the uterus wassuspected. A curettage (revision treatment) was per-formed. Nevertheless, major bleeding through thecervical channel [haemoglobin (Hb) fell to 5 g/dl]was observed despite an injection of carboprostdirectly into the myometrium.

The IR was called and inserted an aortic balloonunder ultrasound (US) guidance. The blood pres-sure (BP) increased immediately, with systolicvalues rising from approximately 60 mmHg to110 mmHg, and the bleeding stopped. The balloonwas inflated for 40 min, which was only inter-rupted by two short deflations after 10 and 25 min.After 40 min, there was no bleeding when theballoon was deflated due to sufficient contractionof the uterus. Subsequently, the balloon wasremoved, but the introducer was left inside thefemoral artery for 4 h before it was removed. Alto-gether, the patient was given 9 units of RBC,8 units of concentrated platelets and 6 units ofhuman plasma solution. The total blood loss wasestimated to be 3500 ml.

Patient 2A 38-year-old woman was admitted at term for hersecond childbirth. Soon after delivery, increasingvaginal bleeding was observed, and post-partumatony was suspected. Due to uncontrollable bleed-ing, she was admitted to the operation theatre withan Hb level of 4.7 g/dl. Gynaecological inspectionrevealed several vaginal tears and an atonic uterus.Carboprost was given intramyometrically.

An IABO catheter was inserted without the useof US. An initial increase in systolic BP from40 mmHg to 80 mmHg was achieved after treat-ment with intravenous volume expanders. Thesystolic BP increased further from 80 mmHg to130 mmHg as the balloon was inflated, and partialhaemostasis simplified the suturing of the vaginaltears. After 30 min, the balloon was deflated, whichwas accompanied by a fall in systolic BP to60 mmHg. Subsequently bleeding was attributed tobe mainly caused by atony of the uterus. After-wards, a hysterectomy was performed; however,vaginal bleeding was observed. Therefore, thepatient was taken to the angiography laboratory forembolization, with the balloon still inflated. Afterdeflation of the balloon, no bleeding was observedand embolization was not performed. The balloonwas then removed, and the arterial introducer wasleft in place until the next day. The total estimatedblood loss was 10 l.

Patient 3After delivery of a healthy baby, a 30-year-oldprimigravida woman developed a profound vaginalbleeding. The patient presented with pre-shocksymptoms and was taken to the operating theatre.Under general anaesthesia, an IABO catheter wasrapidly inserted under US guidance into theabdominal aorta. An immediate increase in BP frombelow 70 mmHg to over 90 mmHg was noted. Theballoon was partly deflated after 1 min and retractedto the aortic bifurcation where it was reinflated andleft for 10 min before the second deflation. Novaginal bleeding or cervical tears were seen, but pla-cental material was evacuated by curettage. Theballoon was inflated for a third time for 13 minbefore deflation. Meanwhile, carboprost was givenintramyometrically. After these procedures, theuterus was well contracted, and the bleeding gradu-ally stopped. The total blood loss was estimated tobe 2300 ml. (Fig. 1)

The femoral introducer was left in place until thenext day. (Fig. 2)

Patient 4Planned labour was induced with misoprostol dueto gestational impaired glucose tolerance in a44-year-old woman at term.

After delivery, PPH was observed, with bloodloss increasing after 1 h to 1700 ml as the patientdeveloped atony of the uterus. Curettage was per-formed, and minimal residual placenta wasremoved. An intrauterine balloon and B-Lynchsutures were used without effect. A hysterectomy

Fig. 1. Picture of the NuMED PTX-S 25 ¥ 30 mm balloon used inpatient 3.

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and US-guided insertion of an IABO catheter wereperformed simultaneously. The balloon was inflated,and the BP immediately rose from 70 mmHg to110 mmHg, and haemostasis was achieved. Theballoon was deflated after 15 min. Some bleedingwas still observed in the operating field, but after afew additional minutes with the balloon reinflated,the balloon was removed without further bleeding.The estimated total blood loss was 9 l. The intro-ducer was left in place. During the next day, thepatient was stable but had minor ongoing bleedingthat required transfusion. Embolization of theuterine artery was performed, which resulted in apermanent haemostasis.

Patient 5A 30-year-old woman was admitted for her thirdchildbirth. The patient had gestational diabetesduring this third pregnancy. After delivery, thepatient had a retained placenta, and manual extrac-tion and revision were performed. The patient hadongoing bleeding due to atony despite intravenousmedication and intramyometrial prostaglandinadministration. She was given 21 units of RBC, 6units of human plasma solution and 8 IU of plate-lets. An intrauterine balloon was unsuccessful, andHg fell to 3.5 g/dl. An aortic balloon was insertedunder US guidance, which caused the bleeding tostop immediately, with a rise in the systolic BP from85 mmHg to 115 mmHg. A hysterectomy was per-formed without further complications. The intro-ducer was removed the following day, and the

patient made an uneventful recovery. The totalblood loss was estimated to be 7 l.

Patient 6A 26-year-old woman collapsed during labour witha loss of consciousness and a fall in systolic BP ini-tially to below 90 mmHg, which was followed by adrop in the heart rate of the baby. An acute Caesar-ean section was successfully performed. However,the mother’s BP rapidly fell below 60 mmHg, whichoccured simultaneously with a massive vaginalbleeding. The blood loss was estimated to be 3 l in10 min. An aortic occlusion balloon was insertedwith US guidance and was inflated with approxi-mately 10 ml saline. An immediate increase in BP toabove 90 mmHg was noted, but heavy vaginal bleed-ing was still reported. Doppler examination of theleft femoral artery revealed both a venous pulse anda pulse in the femoral artery. A small hole in theballoon or an underinflated balloon was suspected;therefore, and additional 3–4 ml of saline wasinjected into the balloon. The bleeding graduallystopped, and the BP stabilized between 90 and100 mmHg.

After 15 and 30 min, the balloon was slightlydeflated, which resulted in an immediate fall in BPto below 60 mmHg. A hysterectomy was then per-formed, which was followed by a new dramatic fallin BP immediately after deflation of the balloon.Damage to the aorta was suspected, and the vascularsurgeons were called. The balloon was rapidlychanged, and the new balloon was inserted 40 cmfrom the insertion point in the right groin in order tostop the suspected bleeding. Again, the BP increasedslowly to 85 mmHg as the patient was given massivetransfusions. Surgical examination revealed agracile infrarenal aorta that was found to have adiameter of only 1.2 cm, measured after suturing ofthe vessel wall and with the circulation restored inthe vessel.

Total blood loss was estimated to be at least 15 l,and the patient was given 39 units of RBC, 27 unitsof human plasma solution, 36 IU of platelets and 3doses of recombinant activated factor VII. She wasreoperated 4 h later due to ongoing bleeding fromthe upper portion of the vagina. After 4 days in theintensive care unit, she made a full recovery. (Fig. 3)

MethodologyIn 2008, we assembled an ‘aortic occlusion kit’ thatconsisted of two NuMED PTX-S [NuMED CanadaInc., Cornwall, ON, Canada (25 ¥ 30 mm)] paediatric

Fig. 2. Patient 3 with an 8 French introducer left in the commonright femoral artery after removal of the aortic balloon. The intro-ducer was removed the following day.

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sizing balloons, two pairs of sterile gloves, twofemoral insertion needles, two 8 French introducers,sterile dressings and two J-curved 150 cm 0.35guidewires. This kit was placed near the operatingroom at the Department of Gynaecology and Obstet-rics in the two hospitals. We also added the use of anaortic occlusion balloon to the procedure list for theobstetrician. The on-call IR was to be contacted witha response time less than 30 min in these situations.

All patients had weak or no palpable pulses in theright femoral artery due to hypotension. Underaseptic conditions, the needle was inserted underUS guidance in five of the six patients. The IABOcatheter was introduced through the right commonfemoral artery in all patients.

The J-curved guide wire was inserted smoothly atapproximately 50 cm. If any resistance was felt, thewire was retracted and inserted a second time underUS guidance to assure an intraluminal position.However, this was not a problem in any patients. An8 French introducer was introduced through thefemoral artery before the balloon was placedapproximately 30 cm from the puncture site into the

abdominal aorta by the Seldinger technique. Theballoon was inflated with isotonic saline until aslight resistance was felt, which was usually after theinjection of approximately 10 ml. In three of the sixcases, the balloon was deflated approximately 50%after a short time and then retracted until a slightresistance was felt. At this point, it was believed theballoon had entered the proximal part of thecommon iliac artery. The balloon was then reinflateduntil the bleeding stopped.

The occlusion balloon was inserted via thecommon femoral artery only by palpation of thefemoral pulse in one case and with US guidance infive cases. After inserting the guidewire of approxi-mately 50 cm, the wire was believed to be situated inthe lower descending thoracic aorta. Using an 8French introducer, a NuMED PTX-S (NuMEDCanada Inc., Cornwall, ON, Canada) 25–30 mmballoon catheter was inserted approximately 30 cminto the abdominal aorta.

DiscussionClamping of the aorta has been performed since thebeginning of aortic surgery. However, the use ofaortic balloons is also well known. These balloonsare not only used in aortic surgery or during theremodelling of stent grafts but also in situationswith heavy bleeding from the pelvis.10 IABO hasalso been used electively on patients undergoing aCaesarean section due to placenta previa percreta.6

However, fluoroscopy or CT has been regarded asnecessary in the insertion of an occlusive ballooninto the aorta from the femoral artery. In addition,most balloons demand introducers with diameterslarger than 8 French. By using NuMED sizing bal-loons with diameters 25 mm or less, an 8 Frenchintroducer was sufficient to access the artery. A safeand easy sealing of the artery after removal of theintroducers was also made possible by using the 8French Angio-Seal (Minnetonka, MN, USA) device.

In one patient, the balloon inflation resulted in atear of the wall of a very gracile aorta.

In five of these cases, the balloon was deflatedafter 10–15 min for a short time period to evaluatethe status of the bleeding. In addition, balloon defla-tion allowed reperfusion of the occluded organs andthe lower limbs to prevent formation of thrombusand reduce the risk of distal embolization, becausethe patients were not heparinized. In addition, wewanted to avoid further hypotension because reper-fusion and flushing of ischaemic metabolites fromthe pelvis and the lower extremities may contribute

Fig. 3. X-ray picture from an embolization procedure of theuterine arteries after a Caesarean section. This patient is notreferred to in this article; however, this image illustrates the posi-tion of an aortic occlusion balloon inflated in the distal abdominalaorta.

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to this condition. The formation of a thrombus ordistal embolization was not observed in any of thesix patients; however, the sample size was toosmall to assess complications related to distalembolization.

In some patients, a temporary occlusion of thevisceral arteries and the renal arteries might havetaken place. However, this possibility was regardedas a minor problem relative to the ongoing andpotentially life-threatening exsanguination. In threepatients, partial deflation and retraction of thecatheter to the aortic bifurcation was performedwithin 10 min of the primary balloon inflation.Nevertheless, the kidneys can withstand ap-proximately 40 min of warm ischaemia withoutdamage.11

In addition to the circulatory benefits achievedwith this technique, both inspection and surgicalmanagement of the vaginal tears were easier due toa better overview of the operating field. An occludedaorta also gave the obstetricians time to do a thor-ough examination and to wait for the effects ofdrugs that were provided to induce contraction inthe atonic uterus. If the patient was still bleedingafter approximately 30 min, a hysterectomy orembolization was performed.

The use of expensive blood products may also bereduced by this method, especially if the method isused during an early phase of PPH. Nevertheless,we cannot rule out the probability that these patientscould have been managed with traditional methods.However, we think this method is of value early inthe process because of its relative simplicity and thefact that one can limit the use of blood products andthe development of the deadly triad of hypother-mia, acidosis and coagulopathy.

Stabilization of any patient with heavy bleeding inthe abdomen, pelvis or the lower extremities withIABO may give doctors the additional time neededto perform a primary surgery or prepare an alterna-tive treatment, such as embolization or a more con-trolled surgery. This may also be a good method fortreating multitraumatized patients or for patientsundergoing extensive surgeries, where heavy bleed-ing might be expected.

Due to the complications noted in case 6, theballoon was changed to a smaller 20 ¥ 30 mmNuMED PTX-S (NuMED Canada Inc., Cornwall,ON, Canada) catheter. The diameter of the infrar-enal aorta in young women seldom exceeds 20 mm.In addition, we set a maximum limit of 8 ml of salinethat can be pumped into the balloon. We also rec-ommend the use of a 20 ml syringe instead of a

smaller syringe, which makes it easier for the inter-ventionalist to feel the resistance as the balloon hitsthe aortic wall during inflation. Successful use of thissmaller balloon has been performed recently but isnot referred to in this article.

With the method described in this article, six IRswere able to place an aortic occlusion catheter intothe abdominal aorta without the use of fluoroscopyin six patients with life-threatening PPH. In hospi-tals without IRs on-call, we believe that anaesthesi-ologists can also perform this procedure if they aretrained in US-guided access to the common femoralartery.

ConclusionThis article describes the use of IABO withoutthe use of fluoroscopy to halt potentially life-threatening PPH in six patients. The proceduresresulted in reduced bleeding and acted as a bridgeintervention that allowed for the eventual deliveryof definitive treatment. We believe this method willcontribute to a reduced mortality among patientswith severe PPH.

Conflict of interest: There is no known conflict ofinterest.

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Address:Edmund SøvikDepartment of RadiologySt. Olavs University Hospital7006 TrondheimNorwaye-mail: edmund.sovik@stolav.no

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