Pelvic Arterial Embolization Research Articles

Impact of pelvic arterial embolization for intractable postpartum hemorrhage on fertility

Impact of pelvic arterial embolization for intractable postpartum hemorrhage on fertility

Fertility and pregnancy following pelvic arterial embolisation for postpartum haemorrhage

To determine and compare the fertility and pregnancy outcomes following embolisation with or without uterine-sparing surgery for postpartum haemorrhage, and to attempt to identify specific risk factors associated with an increased likelihood of intrauterine synechia. Retrospective study. University-affiliated tertiary referral centre. All consecutive women who had an embolisation with or without uterine-sparing surgery (vessel ligation and/or uterine compression) for postpartum haemorrhage between 1994 and 2007 were included. Data were retrieved from medical files and telephone interviews. Fertility and pregnancy outcomes, synechia. Data were available for 68 of the 85 women (80%) included in the study. Among the 15 women who complained of amenorrhoea or decreased flow of menstruation, synechia was found in all those who decided to undergo an ambulatory hysteroscopy (n = 8). Seventeen women had 26 pregnancies with 19 term deliveries, one ectopic pregnancy, two abortions and four miscarriages. The clinical courses of the 19 complete gestations were uneventful, but postpartum haemorrhage recurred in six women (31.6%) (caused by placenta accreta in two women). Fertility and pregnancy outcomes did not differ between women who had undergone embolisation versus both embolisation and a uterine-sparing surgical procedure. The occurrence of synechia was significantly associated with a higher rate of placenta accreta/percreta (P < 0.001) and postpartum fever above 38.5 degrees C (P = 0.04). Embolisation, whether or not associated with a uterine-sparing surgical procedure, for postpartum haemorrhage does not appear to compromise a woman's subsequent fertility and obstetric outcome. Nevertheless, these women should be considered at high risk for postpartum haemorrhage during future deliveries.

Fertility after pelvic arterial embolization, stepwise uterine devascularization, hypogastric artery ligation, and B-Lynch suture to control postpartum hemorrhage

0020-7292/$ – see front matter © 2009 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2009.10.003 A 28-year-old primiparous womanwas referred to our center with secondary postpartum hemorrhage (PPH). The patient had a previous history of two curettages. Secondary PPH occurred 10 days after an uneventful vaginal delivery of a healthy neonate. Ultrasound examination showed a poorly-defined, hyperechogenic intrauterine mass measuring 54 mm at its greatest diameter, which was consistent with a diagnosis of retained placenta. Emergency curettage performed under ultrasound guidance was not successful in removing the retained placenta or in stopping the hemorrhage. Sulprostone administrationwas started because of persistent bleeding unresponsive to oxytocics. Owing to stable hemodynamics the patient was transferred for pelvic arterial embolization that was performed successfully using pledgets of absorbable gelatin sponge and 900 to 1200-μm inert microparticles. PPH had stopped by completion of the procedure. However, recurrent bleeding occurred 3 hours later. Because the patient was primiparous and hemodynamically stable, subsequent uterine-sparing surgical procedures were undertaken according to our protocol for the management of PPH, as reported previously [1,2]. Our protocol outlines vessel ligation and B-Lynch suture as firstand second-line procedures, respectively, for the management of severe PPH [1,2] because there is no evidence to suggest that any one method is better than the other and because reassuring data regarding subsequent fertility are currently more numerous for vessel ligation than B-Lynch suture [3]. A stepwise uterine devascularization was performedfirst, without success. Therefore, hypogastric artery ligation was performed and, because the bleeding continued, a B-Lynch suture was placed prior to considering hysterectomy [1,2]. PPH stopped after B-Lynch suture. The postoperative period was uneventful. The patient had an unplanned pregnancy 4 months following the previous delivery. The pregnancy proceeded unremarkably. Labor was spontaneous at 41 weeks of pregnancy and a healthy female neonate weighing 3350 g was delivered vaginally. The third stage of labor was uneventful and no recurrent abnormal placentation was observed. Some authors have proposed that a second (or even a third) uterine-sparing procedure should be performed in case of a failed first (or second) procedure before considering peripartum hysterectomy in a hemodynamically stable patient with a desire for subsequent pregnancy [1–4]. Nevertheless, one can speculate that using multiple uterine-sparing procedures increases the risk of impairing the subsequent fertility and pregnancy outcomes, which would render this strategy unwarranted. The present case describes how 4 different uterine-sparing procedures to control PPH resulted in an uneventful postoperative period and a subsequent uncomplicated full-term pregnancy and vaginal delivery.

Severe primary postpartum hemorrhage due to genital tract laceration after operative vaginal delivery: successful treatment with transcatheter arterial embolization

The purpose of this study was to report our experience in the management of severe primary postpartum hemorrhage due to genital tract laceration following operative vaginal delivery with forceps using pelvic transcatheter arterial embolization (TAE). Ten women (mean age, 31.9 years) with severe primary postpartum hemorrhage due to genital tract laceration after operative delivery with forceps were treated with TAE. TAE was indicated because of intractable bleeding that could not be controlled with uterotonic drugs, blood transfusion, attempted suturing and packing in all patients. Postdelivery perineal examination showed cervical or vaginal tears in all women and associated paravaginal hematoma in four. Angiography revealed extravasation of contrast material in six patients. TAE performed with gelatin sponge allowed to control the bleeding in all patients. Cervical and vaginal suturing was made possible and successfully achieved in the six women who had failed suturing attempts before TAE. Paravaginal hematoma was successfully evacuated in four patients in whom it was present after TAE. No complications related to TAE were noted. We conclude that in women with severe primary postpartum hemorrhage due to genital tract laceration after operative delivery with forceps, TAE is effective and safe for stopping the bleeding and helps genital tract suturing and evacuation of hematoma.

Why stepwise uterine devascularization should be the first‐line conservative surgical treatment to control severe postpartum hemorrhage?

Sir, We thank Dr. Doumouchtsis and colleagues for their interest in our study, and for pursuing the debate regarding what to do when medical treatment fails 1. The main message of our work was that...

Impact of pelvic arterial embolization for intractable postpartum hemorrhage on fertility

This study was to determine the long-term outcomes of arterial pelvic embolization for intractable postpartum hemorrhage and particularly its effect on menses, fertility, and outcomes of subsequent pregnancies. Fifty-six consecutive patients who underwent emergency pelvic arterial embolization for severe postpartum hemorrhage between April 1995 and July 2005 were included in the study. Patients were contacted to obtain information about menses and fertility after pelvic arterial embolization. Thirty-four women (61.8%) were successfully contacted. One patient had a hysterectomy. Thirty women (91%) reported regular menses. Thirteen women (38.3%) had a total of 20 spontaneous pregnancies. Eight pregnancies ended during the first trimester. The 12 other pregnancies (60%) were all normal and all patients delivered vaginally healthy babies with normal weight for gestational age. The current study suggests that fertility is not adversely affected by arterial pelvic embolization for intractable postpartum hemorrhage and that women can conceive after the procedure with normal pregnancy outcomes.

Impact of pelvic arterial embolization for intractable postpartum hemorrhage on fertility

Impact of pelvic arterial embolization for intractable postpartum hemorrhage on fertility

Embolization as first‐line treatment in the management of puerperal hematoma in a case of congenital urogenital anomaly

This case report highlights the need for detailed consideration of a patient's entire medical history before complex surgical management. This is a complex case of congenital urogenital anomaly that had obstetric complications. Our patient had a pelvic hematoma following a home birth, which was treated with pelvic artery embolization. We are fortunate to have local expertise in pelvic artery embolization and demonstrate excellent multidisciplinary management of a complex case.

Transcatheter pelvic arterial embolisation for control of obstetric and gynaecological haemorrhage

SummaryWe present a 5-year experience of pelvic arterial embolisation at two centres in the UK, and emphasise the role of interventional radiology in the treatment of obstetric and gynaecological haemorrhage. A total of 31 women underwent pelvic embolization:19 patients had complete medical records, and of these, two women had antepartum haemorrhage, 12 women had primary postpartum haemorrhage (PPH), four women had secondary PPH and one woman had a haemorrhage following termination of pregnancy (TOP). The source of the haemorrhage was only identified in four women (21.1%). All patients underwent selective embolisation of the uterine artery or anterior divisional branch of the internal iliac artery with successful haemorrhage control in 17 patients (89.4%) and no immediate complications. Haemorrhage continued despite embolisation in two patients; both proceeded to surgery. Selective pelvic embolisation is a safe and effective treatment for acute obstetric or gynaecological haemorrhage and should be part of the management algorithm for PPH.

232: Avoiding cesarean hysterectomy in women with placenta accreta by prophylactic pelvic artery catheterization and embolization

232: Avoiding cesarean hysterectomy in women with placenta accreta by prophylactic pelvic artery catheterization and embolization

Use of the 4F Rösch Inferior Mesenteric Catheter in Embolization Procedures in the Pelvis: A Review of 300 Cases

The aim of this study is to evaluate the use of a 4F Rösch inferior mesenteric (RIM) catheter for pelvic embolization procedures. Between October 2000 and January 2006, 364 patients (357 female, 7 male; age: 23-67 years) underwent embolization of various pathologies [uterine fibroids (n = 324), pure adenomyosis of the uterus (n = 19), postpartum hemorrhage (n =1), traumatic or postoperative hemorrhage (n = 9), bleeding related to cervical cancer (n =7), AV malformation of the uterus (n = 2) and high-flow priapism (n = 2)] at a single institution. In all cases, bilateral catheterization was primarily attempted with the use of a 4F hook-shaped braided endhole catheter (Rösch-Inferior-Mesenteric, RIM-Catheter, Cordis, Miami, FL). Frequency of initial failure to catheterize the vascular territory of interest and carry out the embolization were recorded and the types of difficulty encountered were noted. Catheterization of the main stem of the vessel territory of interest with the use of a unilateral femoral approach and the 4F RIM catheter was successful in 334/364 (91.8%) the embolization cases. Bilateral catheterization of the internal iliac arteries using a single common femoral artery access and the 4F RIM catheter was achieved in 322/364 (88.5%) patients. In 12/364 (3.3%) patients, a contralateral puncture was performed and the same 4F catheter was used. In 28/364 (7.7%) cases the 4F RIM catheter was exchanged for a catheter with a cobra-shaped or sidewinder configuration. The 4F RIM catheter is a simple and valuable alternative to catheters and techniques commonly employed for pelvic artery embolization.

Selective pelvic arterial embolization in the management of obstetric hemorrhage

Selective pelvic arterial embolization in the management of obstetric hemorrhage

Pelvic arterial embolization in the setting of acute hemorrhage as a result of the anterior Prolift® procedure

Acute hemorrhage following pelvic reconstructive surgery is a complication requiring immediate evaluation and treatment. Therapeutic options include fluid resuscitation, tamponade techniques, exploratory surgical intervention, and, more recently, pelvic vessel embolization. New approaches to pelvic organ prolapse have been evolving rapidly with little reported on safety and efficacy. We present a 77-year-old female who had a life-threatening acute pelvic hemorrhage from an anterior Prolift procedure successfully treated with pelvic artery embolization.

Selective pelvic arterial embolization in the management of obstetric hemorrhage

Objective Retrospective evaluation of pelvic arterial embolization for the treatment of severe post-partum hemorrhage. Methods Data were collected, from our departmental clinical records, on all patients with life-threatening post-partum hemorrhage managed with arterial embolization between January 2001 and December 2003. Results During the period analyzed, there were 29,119 deliveries in our institution. Of these, 27 patients underwent pelvic arterial embolization to control severe hemorrhaging despite conservative management. Of the 27 patients, 22 (81.5%) had a vaginal delivery and 5 had a caesarean section. The major indication for embolization was uterine atony (15 women). Disseminated intravascular coagulation developed in 20 cases (74.1%). There were eight cases (29.6%) who underwent hysterectomy, seven of them pre-embolization. The most frequent vessel embolized was the uterine artery (13 cases; 38.3%). One patient (3.7%) presented complications related to the procedure. The success rate was 96.3%. Conclusion Pelvic arterial embolization is a good therapeutic choice for severe post-partum hemorrhage refractory to conservative treatment measures.

Bilateral persistent sciatic artery: a potential risk in pelvic arterial embolization for primary postpartum hemorrhage

Bilateral persistent sciatic artery: a potential risk in pelvic arterial embolization for primary postpartum hemorrhage

Gestación tras embolización bilateral de arterias uterinas por hemorragia obstétrica

We report a case of normal pregnancy and delivery after bilateral embolization of uterine arteries due to postpartum hemorrhage in a previous pregnancy. The introduction of pelvic arterial embolization in the management of postpartum hemorrhage refractory to medical treatment avoids emergency obstetric hysterectomy, which used to be required in most cases, with the possibility of preserving fertility. Nevertheless, there are still only a few published cases of pregnancies after embolization of both uterine arteries for an obstetric cause.

Bilateral persistent sciatic artery: a potential risk in pelvic arterial embolization for primary postpartum hemorrhage

Emergency transcatheter embolization of the uterine arteries is an effective method to control primary postpartum hemorrhage (1,2). Persistence of the sciatic artery is a rare congenital abnormality in which this artery originates from the anterior division of the internal iliac artery and provides the major part of the arterial blood flow to the ipsilateral inferior limb (3,4). Therefore, correct identification of this rare abnormality is crucial to prevent irreversible ischemic damage of the lower limbs in case of embolization of the uterine arteries for postpartum hemorrhage. We report a case of bilateral persistent sciatic arteries detected before attempted uterine artery embolization for postpartum hemorrhage. A 19-year-old woman was referred to our Institution because of uncontrollable primary postpartum hemorrhage after cesarean section with a hemoglobin level of 6.1 g/dL and an estimated blood loss of 2000 mL. Manual exploration of the uterus did not reveal any retained portion of the placenta. Disseminated intravascular coagulopathy was confirmed in the presence of thrombocytopenia (platelet count 39 000 × 109/L), elevated prothrombin time and hypofibrinogenemia (fibrinogen level 0.45 g/L). The patient had had a blood transfusion (5 units) and received fresh-frozen plasma. Uterine atony was treated with intravenous prostaglandin-E2 analog (sulprostone, Nalador®, Laboratoire Schering, Lys-lez-Lannoy, France) at a dose of 1000 µg and manual external uterine massage. Because of persistent bleeding, the decision to perform embolization was made in consensus by the obstetrician, the anesthetist and the interventional radiologist. Digital subtraction angiography of the pelvis showed a high aortic bifurcation with bilateral short common iliac arteries and almost immediate bifurcation into small-caliber external iliac arteries and large-caliber internal iliac arteries. Selective angiography of the anterior division of the left iliac artery was then performed to localize the origin of the left uterine artery (2). The left internal iliac artery was large and continued into the left lower limb as a persistent sciatic artery (Fig. 1). The left uterine artery originated at the anterior aspect of the internal iliac artery, below the origin of the superior gluteal artery (Fig. 2). The left uterine artery was tiny and tortuous and despite several attempts could not be selectively catheterized, even with the use of a 3-F microcatheter. The same anatomy and catheterization problems were found on the right side. Further angiographic analysis showed that both sciatic arteries coursed through the posterior aspect of the thighs and continued as the popliteal arteries. Because of persisting bleeding and the presence of sciatic arteries preventing embolization of the anterior division of the internal iliac artery, hysterectomy was subsequently performed. After hysterectomy, the patient was referred to the intensive care unit and discharged at postoperative day 14. Digital subtraction angiogram over the left hip shows enlarged left internal iliac artery and persistent sciatic artery (arrow) and hypoplastic left external iliac artery (arrowhead). Digital subtraction angiogram obtained during selective catheterization of the left internal iliac artery shows tiny uterine artery (arrowheads) originating 1 cm below the origin of the superior gluteal artery. Persistent sciatic artery is clearly seen (arrow). Selective arterial embolization is widely considered as the treatment of choice for severe postpartum hemorrhage in case of failure with conservative therapy. This technique has a high success rate with minimal morbidity (1). Although no complications were encountered in our experience involving more than 150 cases so far, arterial embolization may not be free of side-effects. The location of the injection, the particle size, and the amount of the material used for proper embolization may influence the safety of the procedure (1). When superselective catheterization of the uterine artery is not feasible because of spasm or a too small caliber, it is possible to embolize more proximally in the anterior division of the internal iliac artery (5). We found this situation in about 20% of our cases and this was not correlated with higher degrees of morbidity (1,2). Conversely, in our current case with persisting sciatic artery in which the uterine artery could not be catheterized, the embolization of the anterior division of the internal iliac artery was not attempted because of the high potential risk of irreversible ischemic damage of the lower limbs. To our knowledge, this condition as a cause of failure of uterine embolization has never been reported so far. In conclusion, persistent sciatic artery is rare. However, because of the widespread use of pelvic embolization to treat a variety of diseases, such as postpartum hemorrhage, uterine leiomyomata and bleeding from pelvic tumors, the correct identification of this uncommon vessel in due time is crucial. This case highlights the importance of understanding the arterial anatomy of the pelvis, its potential variations and their potential impact on the outcome of the procedure.

Pelvic Embolization for Intractable Postpartum Hemorrhage

In Brief OBJECTIVE To determine the long-term sequelae of pelvic embolization for postpartum hemorrhage and to study the effect on fertility and menses. METHODS Twenty-eight consecutive patients who underwent pelvic embolization for postpartum hemorrhage between the years 1977 and 2002 were included in the study. Chart review and telephone interviews were conducted to gather data regarding the type of delivery, causative factors of the bleeding, preembolization treatments, total blood loss, length of time between delivery and embolization, complications, long-term side effects, and subsequent pregnancies. RESULTS The average (± standard deviation) time to follow-up was 11.7 ± 6.9 years. The most common causes of hemorrhage were vaginal/cervical laceration, placenta accreta, and placenta previa. In only one case was the embolization unsuccessful, during which there was an accidental perforation of an internal iliac artery resulting in a retroperitoneal hematoma and subsequent total abdominal hysterectomy. All of the interviewed patients that desired to get pregnant after embolization were able to do so. Six patients reported a total of six uncomplicated pregnancies and deliveries in the years after their embolization. Of the remaining patients interviewed, none made subsequent attempts to get pregnant. The most commonly reported long-term side effects were transient buttock numbness (n = 2) and urinary frequency (n = 2). In no patients were the side effects severe enough to seek further medical attention. CONCLUSION Pelvic arterial embolization is a safe and effective procedure and offers patients a fertility-preserving alternative to hysterectomy for treatment of intractable postpartum hemorrhage. Pelvic arterial embolization offers women a safe, effective, fertility-preserving alternative to hysterectomy for treatment of intractable postpartum hemorrhage.

Efficacy of Embolization in Traumatic Uterine Vascular Malformations

To evaluate the efficacy of embolotherapy in patients with bleeding traumatic uterine arteriovenous malformations (AVMs). A retrospective review of all patients who underwent pelvic arterial embolization at our institution between July 1992 and September 2002 was performed. Fifteen patients were diagnosed with a uterine vascular malformation on duplex ultrasonography and correlative MR imaging. Serial beta-human chorionic gonadotropin levels were measured to exclude gestational trophoblastic neoplasia. All patients underwent transcatheter embolization of the uterine arteries. Embolizations were performed with use of standard 4-5-F catheters and microcatheters when necessary. Embolic agents in the 25 procedures included glue only (n = 13), polyvinyl alcohol (PVA) particles and glue (n = 4), PVA particles (n = 2), Gelfoam (n = 2), coils (n = 1), PVA particles and coils (n = 1), glue and Gelfoam (n = 1), and glue and coils (n = 1). PVA particle size ranged from 350 to 1,000 micro m. Outcomes assessed were cessation of bleeding, persistence or resolution of the AVM, complications, and pregnancy after embolization. These were assessed by chart, laboratory, and imaging reviews. A total of 25 embolization procedures were performed in 15 patients. Six patients required repeat embolization (one patient underwent embolization on six occasions; five patients had two embolization procedures each) for recurrence of bleeding. Sixteen procedures were performed on an elective basis and nine were performed on an emergent basis. The technical success rate of embolization was 100%. The clinical success rate was 93%: bleeding was controlled in 14 of 15 patients and one patient underwent a hysterectomy. Four of the 15 patients subsequently had a total of five uneventful intrauterine pregnancies carried to term. The 14 patients who underwent successful embolization had no recurrence of bleeding at a median follow-up of 53 months (range, 3-124 months) after treatment. Three patients were eventually lost to follow-up. One minor complication (0.4%) of non-flow-limiting dissection of the internal iliac artery occurred. Percutaneous embolotherapy is a safe and effective treatment for traumatic AVMs. This procedure allows for preservation of uterine function with the possibility of future pregnancy and should be considered as a primary treatment option.

Pelvic artery ligation or embolization and fertility and pregnancy

Pelvic artery ligation or embolization and fertility and pregnancy