Internal Pudendal Artery Research Articles

ANALYSIS OF THE CAUSES OF SEXUAL DISORDERS IN PATIENTS WITH PROSTATE CANCER AFTER SURGICAL AND COMPLEX TREATMENT

Objective: Analysis of the causes of sexual disorders in patients with prostate cancer after combination therapy. Material and Methods: 30 patients with prostate cancer were examined after 1-2 years of antitumor treatment including radical prostatectomy and/or radiation and glandular therapy. The comparative group consisted of 15 healthy men. Immuneenzyme analysis was used for detection of sexual hormone status; ultrasound and dopplergraphic methods as well as radiation method were conducted for angiographic study of pool vessels of the inner pudendal artery. Denervation disturbances in the pool of the inner sexual artery were diagnosed by the conduction of the applicative electroneuromyographic studies of the penis. Results: According to research conducted in 100% of cases within patients with prostate cancer erectile and sexual dysfunction were detected after combination therapy, which was not detected before therapy. Sporadic usage of the Vth type of phosphodiesterase inhibitors by patients with erectile dysfunction of severe form did not lead to improvement of potency. The main cause of erectile and sexual dysfunction in patients with prostate cancer was an aggressive antitumor therapy, which led to the development of stenosis in 100% of cases, occlusion in the pool of internal pudendal artery and in 100% cases to sensory-motor disorders of innervation of the penis. Maximum androgen blockade aggravated sexual dysfunctions within the patients with prostate cancer. Conclusion: Denervation and hemodynamically significant perfusion disturbances in the pool of the inner pudendal artery within the patients with prostate cancer after surgical and combination therapy lead to erectile and sexual dysfunction. The only possible mean of sexual rehabilitation of patients with prostate cancer after antitumor treatment is the endoprosthesis of penis.

Anatomical Variation of Arterial Supply to the Prostate in a Cadaver Population

For men in the United States, aside from the skin, the prostate is the most common cancer site. Roughly 1 of 7 males will be diagnosed with prostate cancer. This does not include the numerous undocumented signs of prostate cancer identified postmortem. In 2015, it was estimated that in 2016 there would be180,890 new cases of prostate cancer and the disease would cause 26,120 deaths. The vasculature of the prostate differs among individuals, and is not completely understood. Typically, the prostate is supplied by arteries arising from the internal pudendal artery, however there are many undefined variations. The position of the prostate makes it difficult to study during standard gross anatomy course dissection. This study involved development of a protocol for isolation and examination of cadaveric prostates.It was found that observation of the prostate gland was enhanced by isolating the pelvic region. This involved careful removal of the sigmoid colon followed by cuts through both thighs including the femur just inferior to the inguinal region ligament. The vertebral column was detached from the sacrum by cutting through the intervertebral disc between L5 and the sacrum. Once the pelvis was isolated it could be positioned to allow access to the internal iliac artery. The branches of internal iliac were then identified. This was then followed by a midsaggital cut through the entire pelvis enabling greater access to the prostate gland. This also allowed for confirmation of the targets of the branches of the internal iliac and for further dissection revealing how those branches continued into the prostate. Future studies will involve examination of the arterial supply of the prostates of 12 male cadavers. Further understanding of the prostate arterial supply may lead to innovation regarding treatment of prostate cancer.Support or Funding InformationWork supported by the Department of Biology and Mathematics, D'Youville College.

069 NO-independent and Purinergic-dependent NANC-mediated Relaxation in the Proximal vs Distal Internal Pudendal Artery

069 NO-independent and Purinergic-dependent NANC-mediated Relaxation in the Proximal vs Distal Internal Pudendal Artery

ERECTILE DYSFUNCTION WITHIN THE PATIENTS WITH AUTONOMIC DIABETIC NEUROPATHY

Erectile disorders in men with diabetes mellitus (DM) in combination with autonomic neuropathy are diagnosed and rehabilitation methods of patients with erectile dysfunction (ED) are detected. Thirty patients with DM were examined (15 patients with diabetes mellitus type 1 and 15 patients with diabetes mellitus type 2 respectively). Patients with DM had ED mainly of severe form (IIEF-5 from 6 to 16 points). According to the examination results, the patients were assigned conservative therapy, including phosphodiesterase inhibitors of type V, anticholinesterase drugs, thioctic acid drugs. Conservative therapy was combined with shock wave therapy in the area of the penis. The comparison group consisted of 15 healthy men (volunteers) without ED signs (IIEF-5 21–22 points). The immune-enzyme analysis was used for detection of sex hormone status. Ultrasound, dopplergraphic and X-ray methods were used for conduction of angiography of pool vessels of internal pudendal artery (IPA). Electroneuromyography of penis nerves was made. According to the obtained results, patients with DM were diagnosed with cavernous fibrosis, angiosclerosis of IPA and penis vessels in 100% of cases. Axonopathy of motor and sensory penis nerves was detected in 100 % of cases; stenosis and occlusion changes in IPA were detected in 42.9 % of cases causing disorder and insufficiency in arterial perfusion in the IPA pool. Denervation changes in sensory and motor penis nerves and hemodynamicly significant perfusion disorders in the IPA pool were the principal pathogenetic ED factors in patients with DM. A decrease of the IPA reaction to the pharmological stimulation was noted in patients with DM, which was caused by angiosclerosis and arterial wall elasticity loss. The inefficiency of conservative therapy in patients with DM and severe ED was revealed.

Hematospermia: An Unusual Cause of Urology Emergency

Hematospermia is a distressing disorder in sexually active men resulting in great concern to the patient. We report an unusual case of hematospermia with an atypical presentation, involving a 54-year-old man presented with acute urinary retention after sexual intercourse. Although the causes are widely known, arteriovenous malformation as the cause of this disorder has not much been reported in the literature. Transcatheter embolization of internal pudendal artery is a promising option for hematospermia caused by arterial fistula or bleeding.

AB278. SPR-05 Purinergic regulation of nitric oxide mediated vasodilation in rat internal pudendal arteries

ObjectiveInternal pudendal arteries (IPA) provide 70% of total blood blow resistance to penile arteries and have been shown to undergo significant vascular remodeling due to aging, diabetes, chronic kidney disease, and cardiovascular disease. Balloon angioplasty and stent placement is a common treatment option to restore blood flow within IPAs; however, stent failure is disproportionately higher than coronary artery stents despite similar stents and placement techniques suggesting a unique IPA physiology. Non-adrenergic non-cholinergic (NANC) mediated vasodilation is well characterized in the penis, but IPA neurotransmitter release has yet to be characterized. The objective of this study is to characterize electric field stimulated (EFS) mediated neurotransmitter release in rat IPA and address the novel role of ATP as a neurotransmitter.MethodsProximal (internal iliac to gluteal artery) and distal (gluteal artery to penis) IPA segments excised from male Sprague-Dawley rats (350–475 g) were mounted into myographs. NANC vasodilation was assessed in precontracted IPAs following incubation with inhibitors of norepinephrine release (guanethidine; 10-6 M) and cholinergic receptors (atropine, 10-5 M) to assess neuronal nitric oxide (NO) release. This procedure was repeated with additional incubation of a NO synthase (NOS) inhibitor (L-NAME; 10-6 M), selective P2X1 inhibitor (NF-449; 10-5 M), or selective P2Y1 inhibitor (MRS 2500; 10-6 M). EFS relaxation parameters used were 5 ms delay, 0.3 ms duration at 20V and 0.5–32 Hz. Concentration response curves to assess ADP, a P2Y1 receptor agonist, relaxation and α,β-MetATP, a stable P2X1 receptor agonist, contraction were also performed.ResultsNANC stimulation lead to greater relaxation in distal IPA (30% vs. 15%, P<0.05). Additional inhibition of NOS completely eliminated NANC relaxation in distal IPA; however, did not reduce proximal IPA relaxation. P2X1 or P2Y1 inhibition caused further distal IPA relaxation, but combined P2X1 and P2Y1 inhibition increased distal IPA relaxation from 30% to 53% without affecting proximal IPA relaxation. No significant differences were noted to α,β-MetATP mediated contractions via the P2X1 receptor. ADP mediated relaxation was markedly increased in proximal IPA (16%) compared to distal IPA (6%).ConclusionsFunctional physiological differences exist within the proximal and distal segments of the IPA. NANC-mediated relaxation in the distal IPA is greater than the proximal IPA and is mediated by NO-dependent mechanisms. Furthermore, the distal IPA undergoes additional purinergic regulation which is NO-independent. Understanding the physiology of this critical feeder blood vessel to the penis is crucial when developing novel treatments that target the vasculature to recover erectile function.Funding Source(s)None

Aesthetic Penoscrotal Resurfacing: Creating Propeller Flaps from Gluteal Folds

BackgroundReconstruction of extensive penoscrotal defects is a surgical challenge. Resurfacing defects in highly complex three-dimensional structures and restoring their function are an essential part of the reconstruction of penoscrotal regions. ObjectiveWe describe a technique using internal pudendal artery perforator (IPAP) pedicled propeller flaps created from the gluteal fold. This could be a reliable surgical option that maintains a natural looking scrotal pouch with minimal donor site morbidity and optimal sexual activity. Design, setting, and participantsWe retrospectively reviewed data for 10 consecutive patients who had undergone penoscrotal reconstruction using IPAP pedicled propeller flaps between January 2011 and March 2015. Surgical procedureThe IPAP was identified using a hand-held Doppler ultrasound device. This was the pivot around which the flap was internally rotated more than 90° in a tension-free manner. The long axis of the flap was centred on the gluteal fold to provide a better-orientated donor site scar. MeasurementsComplications and patient satisfaction with respect to size, colour match, scar appearance, and sexual activity were evaluated. Results and limitationsAnatomic and aesthetic penoscrotal reconstruction was performed without any major complications in the follow-up period (mean, 19.7 mo). The mean width of the IPAP pedicled propeller flaps was 6.7cm, and the mean length was 11.7cm. Partial distal flap necrosis occurred in only one case, and healed spontaneously. All of the patients were satisfied with the cosmetic and functional results. ConclusionsOn the basis of reliable perforators, donor site morbidity, flap thickness, and a better orientated scar, our technique using IPAP pedicled propeller flaps created from the gluteal fold could be a reasonable surgical option for extensive penoscrotal reconstruction. Patient summaryThe creation of pedicled propeller flaps using an internal pudendal artery perforator could be a reliable surgical option for reconstruction of extensive penoscrotal defects. The approach yields functional and aesthetically acceptable surgical results.

Study of variations in the origin of obturator artery

Introduction: Obturator artery is the branch of anterior division of internal iliac artery. Variations in its origin are quite common and are very important from surgical point of view. Methods: To study the variations in the origin of the obturator artery 35 dissected vessels were studied. Results: Commonest variation of its origin from the posterior division of internal iliac artery was found in five cases. Other variations like its origin from internal pudendal artery or from inferior gluteal artery were also found, which are also discussed along with its embryological basis and clinical significance. Conclusions: Knowledge of anomalous origin of obturator artery from posterior division is helpful to vascular surgeons while planning endovascular treatment.

Reconstruction of Large Defects in the Perineal Area Using Multiple Perforator Flaps.

BackgroundPerineal defects are commonly encountered during the treatment of conditions such as malignancy, infectious disease, and trauma. Covering large defects in the perineal area is challenging due to its complicated anatomy and the need for functional preservation.MethodsFourteen patients who underwent reconstructive surgery with multiple perforator flaps for defects >100 cm2 in the perineal area were included in this retrospective cohort study. Characteristics of the perforator flap operation and postoperative outcomes were reviewed.ResultsReconstruction was performed using 2 perforator flaps for 13 patients and 3 perforator flaps for 1 patient. Internal pudendal artery perforator flaps were mainly used for covering the defects. The average defect size was 176.3±61.8 cm2 and the average size of each flap was 95.7±31.9 cm2. Six patients had minor complications, such as wound dehiscence and partial necrosis of the flap margin, which were corrected with simple revision procedures.ConclusionsMultiple perforator flaps can be used to achieve successful reconstructions of large perineal defects that are difficult to reconstruct with other coverage methods.

Three-Directional Reconstruction of a Massive Perineal Defect after Wide Local Excision of Extramammary Paget's Disease

Extramammary Paget's disease (EMPD) is a rare, slow-growing intraepithelial malignancy that mainly involves the genital region, including the vulva, penis, scrotum, perianal, and periurethral areas. Although several treatment options exist, wide local excision with a safe margin is considered the treatment of choice. After resection of the lesion, it is often challenging to reconstruct the defect because defects in the perineal region require adequate volume for protection and are susceptible to infections, which is a particularly significant risk for large defects. We report a case of perivulvar EMPD that was reconstructed with three-directional local flaps after wide excision of the tumor. We covered the defect sequentially using the following 3 flaps: a gracilis myocutaneous flap from the left thigh, a bipedicled V-Y advancement flap from the lower abdomen, and an internal pudendal artery perforator-based island flap from the right buttock. To the best of our knowledge, this report is the first to describe a three-directional approach to extensive perivulvar reconstruction.

Internal Pudental Artery Dysfunction in Diabetes Mellitus Is Mediated by NOX1-Derived ROS-, Nrf2-, and Rho Kinase-Dependent Mechanisms.

Oxidative stress plays an important role in diabetes mellitus (DM)-associated vascular injury. DM is an important risk factor for erectile dysfunction. Functional and structural changes in internal pudendal arteries (IPA) can lead to erectile dysfunction. We hypothesized that downregulation of nuclear factor E2-related factor 2 (Nrf2), consequent to increased nicotinamide adenine dinucleotide phosphate oxidase 1 (NOX1)-derived reactive oxygen species (ROS), impairs IPA function in DM. IPA and vascular smooth muscle cells from C57BL/6 (control) and NOX1 knockout mice were used. DM was induced by streptozotocin in C57BL/6 mice. Functional properties of IPA were assessed using a myograph, protein expression and peroxiredoxin oxidation by Western blot, RNA expression by polymerase chain reaction, carbonylation by oxyblot assay, ROS generation by lucigenin, nitrotyrosine, and amplex red, and Rho kinase activity and nuclear accumulation of Nrf2 by ELISA. IPA from diabetic mice displayed increased contractions to phenylephrine (control 138.5±9.5 versus DM 191.8±15.5). ROS scavenger, Nrf2 activator, NOX1 and Rho kinase inhibitors normalized vascular function. High glucose increased ROS generation in IPA vascular smooth muscle cell. This effect was abrogated by Nrf2 activation and not observed in NOX1 knockout vascular smooth muscle cell. High glucose also increased levels of nitrotyrosine, protein oxidation/carbonylation, and Rho kinase activity, but reduced Nrf2 activity and expression of Nrf2-regulated genes (catalase [25.6±0.05%], heme oxygenase-1 [21±0.1%], and quinone oxidoreductase 1 [22±0.1%]) and hydrogen peroxide levels. These effects were not observed in vascular smooth muscle cell from NOX1 knockout mice. In these cells, high glucose increased hydrogen peroxide levels. In conclusion, Rho kinase activation, via NOX1-derived ROS and downregulation of Nrf2 system, impairs IPA function in DM. These data suggest that Nrf2 is vasoprotective in DM-associated erectile dysfunction.

Cadaveric and radiologic study of the anatomical variations of the prostatic arteries: A review of the literature and a new classification proposal with application to prostatectomy.

Development of prostatic arterial embolization (PAE) to treat benign prostatic hyperplasia (BPH) has raised interest in the variations of the prostatic arteries (PA). The aim of this study is to identify these vascular variations, to compare them with previous data, and to propose a simple classification. Ten adult male pelvis sides from embalmed cadavers were dissected, ages 69 to 92 years, and 10 PA were examined. In a retrospective analysis of 34 DSA pelvic angiographies on 28 patients aged 50 to 90 years, 48 PA were identified. A total of 58 PA were therefore analyzed. Six types are defined. Type I: PA originates from the anterior division (AD) of the internal iliac artery (IIA), 20.7%; Type II: PA emerges from the obturator artery (OA), 5.2%; type III: PA arises from the gluteal-pudendal trunk (GPT), 27.5%; Type IV: PA originates from the internal pudendal artery (IPA), 29.3%; Type V: PA comes from the middle rectal artery (MRA), 15.5%. Other origins, not observed in our sample but described in the literature, were amalgamated under Type VI. The AD/GPT/IPA stem is the main source of the PA. Analysis of the definitions of IIA branches and the associated terminology is necessary for interpreting the results reported by several authors on different samples, but in general the results fit the meta-analysis well. A new, simple, and complete classification for vascular variations of the PA is proposed. Clin. Anat. 30:71-80, 2017. © 2016 Wiley Periodicals, Inc.

New laparoscopic approach to the pudendal nerve for neuromodulation based on an anatomic study.

The aim was to develop a new laparoscopic technique for placement of a pudendal lead. Development of a direct, feasible and reliable minimal-invasive laparoscopic approach to the pudendal nerve (PN). Thirty-one embalmed human specimens were dissected for the relevant anatomic structures of the pelvis. Step-by-step documentation and analysis of the laparoscopic approach in order to locate the PN directly in its course around the medial part of the sacrospinous ligament and test this approach for feasibility. Landmarks for intraoperative navigation towards the PN as well as the possible position of an lead were selected and demonstrated. The visible medial umbilical fold, the intrapelvine part of the internal pudendal artery, the coccygeus muscle and the sacrospinous ligament are the main landmarks. The PN traverses the medial part of the sacrospinous ligament dorsally, medially to the internal pudendal artery. The medial part of the sacrospinous ligament has to be exposed in order to display the nerve. An lead can be placed ventrally on the nerve or around it, depending on the lead type or shape. A precise and reliable identification of the PN by means of laparoscopy is feasible with an easy four-step approach: (1) identification of the medial umbilical fold; (2) identification of the internal iliac artery; (3) identification of the internal pudendal artery and incision of the coccygeus muscle ('white line', arcuated line); and (4) exposition of the medial part of the sacrospinous ligament to display the PN.

Internal Pudendal Artery Perforator Island Flap for Management of Recurrent Benign Rectovaginal Fistula.

The management of recurrent rectovaginal fistula after obstetric injury and cryptoglandular sepsis is considered a major surgical challenge. The fistula poses a significant negative psychosocial and sexual morbidity. In addition, the poor quality of local tissues due to previous attempts at surgical repair adds to this challenge. There are few data regarding the management of persistent or recurrent fistula in the literature; however, several studies reported high failure rates after 2 or more procedures. We present 4 cases managed successfully in a multidisciplinary approach involving fistulectomy and immediate reconstruction with an internal pudendal artery perforator island flap.

Benign Prostatic Hyperplasia: Cone-Beam CT in Conjunction with DSA for Identifying Prostatic Arterial Anatomy

Purpose To describe findings in prostatic arteries (PAs) at digital subtraction angiography (DSA) and cone-beam computed tomography (CT) that allow identification of benign prostatic hyperplasia and to determine the value added with the use of cone-beam CT. Materials and Methods This retrospective single-institution study was approved by the institutional review board, and the requirement for written informed consent was waived. From February 2009 to December 2014, a total of 148 patients (mean age ± standard deviation, 70.5 years ± 14.5) underwent DSA of the internal iliac arteries and cone-beam CT with a flat-detector angiographic system before they underwent prostate artery embolization. Both the DSA and cone-beam CT images were evaluated by two interventional radiologists to determine the number of independent PAs and their origins and anastomoses with adjacent arteries. The exact McNemar test was used to compare the detection rate of the PAs and the anastomoses with DSA and with cone-beam CT. Results The PA anatomy was evaluated successfully by means of cone-beam CT in conjunction with DSA in all patients. Of the 296 pelvic sides, 274 (92.6%) had only one PA. The most frequent PA origin was the common gluteal-pudendal trunk with the superior vesicular artery in 118 (37.1%), followed by the anterior division of the internal iliac artery in 99 (31.1%), and the internal pudendal artery in 77 (24.2%) pelvic sides. In 67 (22.6%) pelvic sides, anastomoses to adjacent arteries were documented. The numbers of PA origins and anastomoses, respectively, that could be identified were significantly higher with cone-beam CT (301 of 318 [94.7%] and 65 of 67 [97.0%]) than with DSA (237 [74.5%] and 39 [58.2%], P < .05). Cone-beam CT provided essential information that was not available with DSA in 90 of 148 (60.8%) patients. Conclusion Cone-beam CT is a useful adjunctive technique to DSA for identification of the PA anatomy and provides information to help treatment planning during prostatic arterial embolization. © RSNA, 2016.

Functional and structural changes in internal pudendal arteries underlie erectile dysfunction induced by androgen deprivation.

Androgen deficiency is strongly associated with erectile dysfunction (ED). Inadequate penile arterial blood flow is one of the major causes of ED. The blood flow to the corpus cavernosum is mainly derived from the internal pudendal arteries (IPAs); however, no study has evaluated the effects of androgen deprivation on IPA's function. We hypothesized that castration impairs IPAs reactivity and structure, contributing to ED. In our study, Wistar male rats, 8-week-old, were castrated and studied 30 days after orchiectomy. Functional and structural properties of rat IPAs were determined using wire and pressure myograph systems, respectively. Protein expression was determined by Western blot and immunohistochemistry. Plasma testosterone levels were determined using the IMMULITE 1000 Immunoassay System. Castrated rats exhibited impaired erectile function, represented by decreased intracavernosal pressure/mean arterial pressure ratio. IPAs from castrated rats exhibited decreased phenylephrine- and electrical field stimulation (EFS)-induced contraction and decreased acetylcholine- and EFS-induced vasodilatation. IPAs from castrated rats exhibited decreased internal diameter, external diameter, thickness of the arterial wall, and cross-sectional area. Castration decreased nNOS and α-actin expression and increased collagen expression, p38 (Thr180/Tyr182) phosphorylation, as well as caspase 3 cleavage. In conclusion, androgen deficiency is associated with impairment of IPA reactivity and structure and increased apoptosis signaling markers. Our findings suggest that androgen deficiency-induced vascular dysfunction is an event involving hypotrophic vascular remodeling of IPAs.

Ethylene-vinyl alcohol copolymer (Onyx®) transarterial embolization for post-traumatic high-flow priapism

We report a case of high-flow priapism treated successfully with superselective embolization of the cavernous artery. A 16-year-old male developed post-traumatic priapism subsequent to a fall causing blunt perineal trauma. He presented to our hospital four days after trauma. Immediately after the injury, he suffered painless sustained incomplete erection. High-flow priapism was diagnosed on the basis of color doppler ultrasonography findings. Computed tomography scan showed a high-flow arterio-venous fistula with feeders from branches of the right internal iliac artery. Selective arteriography of the right internal pudendal artery demonstrated an arterio-cavernous fistula. The fistula was superselectively embolized with ethylene-vinyl alcohol copolymer (Onyx(®)) liquid agent and disappeared completely. Improvement was noted, with significant detumescence on table. This was later confirmed on repeat color Doppler imaging. At follow-up 3 months later, he had normal erectile function. To our knowledge, transarterial embolization of high-flow priapism with Onyx(®) has never been reported and appears to be a safe and effective treatment for managing patients with such a condition.

Endovascular Management of Intractable Postpartum Hemorrhage Caused by Vaginal Laceration.

We evaluated the management of transcatheter arterial embolization for postpartum hemorrhage caused by vaginal laceration. We reviewed seven cases of patients (mean age 30.9years; range 27-35) with intractable hemorrhages and pelvic hematomas caused by vaginal lacerations, who underwent superselective transcatheter arterial embolization from January 2008 to July 2014. Postpartum hemorrhage was evaluated by angiographic vascular mapping to determine the vaginal artery's architecture, technical and clinical success rates, and complications. The vaginal artery was confirmed as the source of bleeding in all cases. The artery was found to originate from the uterine artery in three cases, the uterine and obturator arteries in two, or the internal pudendal artery in two. After vaginal artery embolization, persistent contrast extravasation from the inferior mesenteric artery as an anastomotic branch was noted in one patient. Nontarget vessels (the inferior vesical artery and nonbleeding vaginal arterial branches) were embolized in one patient. Effective control of hemostasis and no post-procedural complications were confirmed for all cases. Postpartum hemorrhages caused by vaginal lacerations involve the vaginal artery arising from the anterior trunk of the internal iliac artery with various branching patterns. Superselective vaginal artery embolization is clinically acceptable for the successful treatment of vaginal laceration hemorrhages, with no complications. After vaginal artery embolization, it is suggested to check for the presence of other possible bleeding vessels by pelvic aortography with a catheter tip at the L3 vertebral level, and to perform a follow-up assessment.

Evaluation of efficacy and safety of pelvic arterial embolization in women with primary postpartum hemorrhage

To evaluate the efficacy and safety of pelvic arterial embolization (PAE) in women with intractable primary postpartum hemorrhage (PPH). Clinical data of 36 cases were analyzed retrospectively in which women underwent PAE for intractable primary PPH in Peking Union Medical College Hospital between Jan 2006 and Jan 2015. The success rate of PAE were measured and possible predictive risk factors associated with treatment failure were analyzed. The complications secondary to PAE were also recorded. (1) The etiology of PPH. Among the 36 cases, 21 patients delivered viginally (Group VD) and 15 received cesarean section (Group CS). The most frequent cause of PPH was uterine atony (72%, 26/36). The less common causes were placental problems (28%, 10/36), genital tract trauma (6%, 2/36) and coagulation defects (3%, 1/36) in turn. Three patients (8%, 3/36) had combined causes. (2) Interventions before PAE. Uterotonic medications were used in all patients. 31 patients received carboprost methylate suppositorites, 27 received carbetocin and 31 received carboprost tromethamine. Besides, 20 patients received one or more surgical interventions before PAE. PAE was performed when these interventions failed. (3) Characteristics of PAE. Altogether 78 arteries were embolized in 36 cases. Embolization of bilateral uterine arteries was performed in 31 cases, right internal iliac artery and bilateral inferior epigastric arteries were embolized in one case. Right internal pudendal artery, bilateral uterine arteries and bilateral internal iliac arteries were embolized in one case. And bilateral uterine arteries, bilateral internal iliac arteries were embolized in one case. In the other 2 cases, bilateral internal iliac arteries were embolized. (4) Efficacy of PAE. The overall technical success rate of PAE was 100%(36/36), while the clinical success rate was 94%(34/36). All patients survived. (5) Complications of PAE. 15 patients were transferred to ICU after PAE for 1 to 7 days. Except self-limited fever, no puncture site hematoma, buttock necrosis or vessel rupture was observed. The effect on menstrual cycle and fertility were followed in 25 patients. 17 (68%, 17/25) reported resumption of normal menses and 8 (32%, 8/25) reported amenorrhea. Three pregnancies after PAE were observed. PAE is a safe and effective treatment for intractable primary PPH which can prevent hysterectomy and preserve fertility of patients.

Spontaneous Bleeding from Internal Pudendal Artery associated with Abciximab after Primary Percutaneous Coronary Intervention: Successful Treatment with Percutaneous Gel-Foam Embolization

We describe a case of spontaneous bleeding from a branch of the right internal pudendal artery that resulted in massive scrotal swelling in a patient who had underwent primary percutaneous coronary intervention with the use of abciximab concurrent with conventional anticoagulation and dual antiplatelet therapies for the treatment of acute ST-segment elevation myocardial infarction. This unusual complication was promptly identified by percutaneous peripheral arteriography and successfully treated with gel-foam embolization.