Anaesthetic strategies for managing placenta accreta spectrum with REBOA Insights from an international multicentre retrospective study

BACKGROUND Placenta accreta spectrum (PAS) with resuscitative endovascular balloon occlusion of the aorta (REBOA) presents unique anaesthetic challenges, yet optimal management strategies remain undefined. OBJECTIVE To provide a real-world description of anaesthetic practices, REBOA management, and surgical outcomes in patients undergoing caesarean delivery with REBOA for PAS across four international centres. DESIGN International multicentre retrospective cohort study. SETTING Four tertiary care centres across Israel and Spain between January 2019 and December 2023. PATIENTS A total of 47 patients diagnosed with PAS who underwent caesarean delivery with REBOA placement. INTERVENTION None. MAIN OUTCOME MEASURES The primary outcome was to evaluate the anaesthetic management and outcomes of PAS patients undergoing caesarean delivery with REBOA. Secondary outcomes included assessment of REBOA utilisation patterns, blood loss management strategies and maternal and neonatal outcomes. RESULTS Initial anaesthesia was predominantly neuraxial (85.1%), with combined spinal-epidural being the most common (46.8%). Conversion to general anaesthesia occurred in 52.5% of neuraxial cases, primarily due to pain (52.4%) and surgeon requests (42.9%). REBOA was placed in all cases but inflated in only 76.6%, mainly under ultrasound guidance (57.4%), with significantly shorter anaesthesia-to-delivery intervals than fluoroscopy (60.0 vs. 111.0 min, P ¼ 0.003). Median estimated blood loss was 1.5 l [0.9 to 2.5]. Hysterectomy was performed in 57.4% of cases. REBOA-related complications were minimal (4.3%), and maternal outcomes were generally favourable, with 31.9% requiring intensive care admission. Neonatal outcomes were good, with median Apgar scores of 9.0 at both one and five minutes. CONCLUSIONS Although REBOA shows promise in PAS management, the high neuraxial-to-general anaesthesia conversion rate suggests the need for refined anaesthetic protocols. Combined spinal-epidural with readiness to convert to general anaesthesia may offer the optimal approach. Ultrasound-guided REBOA placement appears to significantly reduce procedural time. Success depends on thorough preparation, clear communication and adaptability to rapidly changing clinical situations.