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We report 2 patients for whom anesthetic management using aortic occlusion balloon catheter (AOBC) was performed thrice. A 14-year-old boy and a 43-year-old man with sacral giant cell tumor underwent tumor resection. In both patients, transcatheter arterial embolization (TAE) was performed several times before the operation. Before the surgery, an AOBC was inserted via the right femoral artery. For tumor resection, the AOBC was inflated, and a slight decrease in hemorrhage was observed. The occlusion was maintained for 40-55 min, with a loss of 1,400-3,700 ml of blood. In case 1, moderate bleeding from the epidural venous plexus was observed. In case 2, packed red blood cell transfusion was needed, and the patient returned to surgery for hemostasis. Because the AOBC could not decrease the severity of venous hemorrhage, we expected increased hemorrhage with an increase in the extent of surgery. In addition, preoperative multiple TAE might lead to the development of collateral circulation around the sacrum and augment the amount of blood loss in that region. Although the AOBC could reduce intraoperative hemorrhage, uncontrollable bleeding may occur if the sacral giant cell tumor shows extensive dissemination.

A 37-year-old multigravida presented at 37 weeks of gestation with low-lying placenta and highly suspected placenta accreta. The placenta adhered widely to the anterior wall of the uterus. Therefore, a longitudinal incision of the uterine corpus at the thinnest part of the placenta was made during surgery. Concurrent with the incision, rapid and massive hemorrhage occurred. After the delivery of the baby and confirmation of the placental adhesion, the hysterectomy was started promptly. The bladder adhered strongly to the uterus, and was injured during the dissection. The total volume of hemorrhage was estimated to be 24,480 ml (including amniotic fluid and urine). No arterial clamp for hemostasis was used during the procedure. The patient was discharged on the 12th postoperative day with no sequela. The pathological diagnosis was placenta percreta. Placenta accreta is a rare disease with a high mortality rate. The hemorrhage becomes difficult to control in case of injury of placenta accreta. The hysterectomy following cesarean section also becomes complicated. Bladder injury is one of the complications of the cesarean hysterectomy which makes the hemorrhage greader. In conclusion, when placenta accreta is suspected a strategy to minimize blood loss during surgery should be discussed by a multidisciplinary team.