Pelvic Vascularization Research Articles

Pain syndromes in endometriosis: an integrated approach to the problem management

Background. Endometriosis affects 10 % of women of reproductive age. Endometriosis is often accompanied by the following symptoms: dyspareunia, pelvic pain, and dysmenorrhea. Pain is a leading symptom of endometriosis and often persists despite treatment.
 Objective. To elucidate the basics of pathogenesis and treatment of pain in endometriosis.
 Materials and methods. Analysis of literature data on this topic; own study involving 64 women with endometriosis. Group 1 was given dienogest (2 mg per day) for 3 months, and group 2 was given dienogest in combination with Tivortin (5 intravenous infusions of 100 ml each other day with the switch to Tivortin aspartate (“Yuria-Pharm”) orally).
 Results and discussion. Pain in endometriosis includes several pathophysiological mechanisms: increased nociception, inflammation, and changes in the recognition of pain in the nervous system. Significant pelvic vascularization promotes the rapid transmission of pain signals from this area to the brain. The severity of pain noted by women poorly correlates with the degree of disease detected during surgery. According to the recommendations of NICE (2017), one or more of the following symptoms are sufficient for suspected endometriosis: chronic pelvic pain (>6 months), dysmenorrhea, which adversely affects quality of life and daily activity, dyspareunia, gastrointestinal disorders and urinary system symptoms associated with menstruation, and infertility in combination with one or more of the above symptoms. Endometriosis requires flexible adaptation of management and the constant choice of treatment tactics depending on the symptoms and life situation of the patient. The basic goals of treatment inlude elimination of symptoms, restoration of quality of life and fertility, prevention of recurrences and repeated surgical intervention. Analgesics, neuromodulators and hormonal agents are used for pharmacological pain management. Additional and alternative methods include reflexology, manual therapy, osteopathy, exercise, dietary changes, and sleep hygiene. Elimination of the oxidation imbalance is one of the methods to treat pain in endometriosis. The uterus is a highly vascularized organ and its cells are constantly affected by high concentrations of oxygen. In settings of hypoxia, steroidogenesis, angiogenesis, inflammation and metabolic transition occur in endometrial cells. In women with endometriosis, there is an increase in markers of oxidative stress in the blood. Intrauterine oxidative stress can be eliminated with the powerful antioxidant L-arginine (Tivortin, “Yuria-Pharm”). In our own study, it was shown that the inclusion of Tivortin into the treatment allowed to decrease the intensity of intermenstrual endometriosis-associated pelvic pain more markedly than the standard treatment. The initial pain level was 61.32±3.2 according to the visual-analog scale in group 1 and 64.2±2.8 in group 2 (Tivortin). A month later, the indicators were 36.5±2.6 and 27.2±2.2, respectively. It should be noted that the effect of Tivortin is stable. In the standard treatment group, the intensity of pain increased again after the end of therapy, and in the Tivortin group remained at a low level. Evaluation of the McGill questionnaire results showed that in Tivortin group pain decreased not only due to the actual strength of the pain, but also due to a decrease in its sensory and emotional characteristics. After treatment, in group 1 the intensity of menstrual bleeding also increased more markedly.
 Conclusions. 1. The goals of endometriosis treatment are to eliminate symptoms, restore quality of life and fertility, prevent recurrence and repeated surgeries. 2. The effectiveness of L-arginine (Tivortin) in the treatment of endometriosis was ensured by normalizing vascular tone in the pelvic organs, reducing oxidative stress, psychostabilizing effect, increasing the antibacterial activity of neutrophils. 3. The use of Tivortin is a promising area for the treatment of endometriosis and prevention of its recurrence.

Surgical internal iliac artery preservation associated with endovascular repair of infrarenal aortoiliac aneurysms to avoid buttock claudication and distal type I endoleaks

ObjectiveThe objective of this study was to assess outcomes of a hybrid technique for treatment of abdominal aortic aneurysm (AAA) associated with iliac aneurysm without distal neck by combining an AAA endovascular repair approach with open surgery for preservation of the internal iliac artery (IIA). MethodsThe files of 51 patients operated on between 1998 and 2017 in a single vascular surgery department were retrospectively analyzed. Inclusion criteria were patients with AAA associated with uni-iliac or bi-iliac aneurysm without suitable distal sealing zone. Surgery consisted of deployment of an aortouni-iliac stent graft combined with an extra-anatomic crossover prosthetic bypass. With use of a limited retroperitoneal approach, the contralateral proximal common iliac aneurysm was surgically excluded and the IIA revascularized by direct ilioiliac anastomosis or terminal common iliac suture, preserving the iliac bifurcation. ResultsThe patients' mean age was 74 years (58-88 years), and 92% were men. The mean follow-up was 5.8 years (0.1-18 years). Twenty-nine patients (57%) had one or more high-risk criteria for open surgery. Nineteen patients (37.3%) had aortouni-iliac aneurysms, 19 (37.3%) aortobi-iliac aneurysms, 5 (10%) isolated iliac aneurysms, and 8 (15.7%) bi-iliac aneurysms without aortic location. Four patients (7.8%) also had IIA aneurysms. Surgery was successful in all cases. Two patients (4%) died during the 30 days after surgery. One surgically preserved IIA occluded within the first month, resulting in buttock claudication. The 5-year IIA primary patency rate was 96%. Type I proximal endoleaks occurred in two patients, requiring additional surgery 3 years and 13 years after the initial surgery, respectively. ConclusionsThis hybrid technique, consisting of AAA endovascular exclusion combined with open IIA revascularization, is safe and effective for preservation of pelvic vascularization. It is associated with long-term patency and low morbidity rates. We have been using this technique since before the advent of branched dedicated devices, allowing preservation of the IIA with good results. This technique should continue to be proposed, especially in patients not eligible for endovascular iliac branch repair because of anatomic contraindications, to avoid pelvic ischemia if the IIA has to be sacrificed.

Fetal median sacral artery anatomy study by micro-CT imaging.

The median sacral artery (MSA) is the termination of the dorsal aorta, which undergoes a complex regression and remodeling process during embryo and fetal development. The MSA contributes to the pelvic vascularization and may be injured during pelvic surgery. The embryological steps of MSA development, anastomosis formation and anatomical variations are linked, but not fully understood. The pelvic vascularization and more precisely the MSA of a human fetus at 22 weeks of gestation (GW) were studied using micro-CT imaging. Image treatment included arterial segmentations and 3D visualization. At 22GW, the MSA was a well-developed straight artery in front of the sacrum and was longer than the abdominal aorta. Anastomoses between the MSA and the internal pudendal arteries and the superior rectal artery were detected. No evidence was found for the existence of a coccygeal glomus with arteriovenous anastomosis. Micro-CT imaging and 3D visualization helped us understand the MSA central role in pelvic vascularization through the ilio-aortic anastomotic system. It is essential to know this anastomotic network to treat pathological conditions, such as sacrococcygeal teratomas and parasitic ischiopagus twins (for instance, fetus in fetu and twin-reversed arterial perfusion sequence).

Anatomical study of the inferior vesical artery: is it specific to the male sex?

The aim of our study was to clarify the origin of the inferior vesical artery and determine its existence in women. This descriptive study is based on 25 dissections (6 male and 19 female cadavers). We dissected the internal iliac artery and its branches from the iliac bifurcation, bilaterally and comparatively. Each arterial branch supplying the bladder was identified and dissected as far as the bladder. In total, 50 topographies of the bladder vascularization were visualised. The inferior vesical artery was observed in 92% of the male subjects and in 47.4% of the female subjects. In the male cadavers, it arose from the internal iliac artery in 72.7% of cases and from the umbilical artery in 27.3% of cases. In the female cadavers, it arose from a common trunk with the umbilical artery and the uterine artery in 33.3% of cases and directly from the umbilical artery in 33.3% with one terminal branch supplying the upper part of the vagina. In two female subjects, the inferior vesical artery arose from the first segment of the uterine artery (22.2%), and in one subject from the obturator artery (11.1%). The inferior vesical artery is not specific to the male sex. The contradictions found in the literature of this artery are due to the variations observed in pelvic vascularization and to the close connections between vaginal and bladder vascularisation in women. However, surgeons should consider these variations, to prevent bladder devascularization by non-selective ligation.

P.7.b.014 - The association between early childhood onset epilepsy and comorbid autism-ADHD: a prospective study of 3032 children with autism spectrum disorders

Forty percent of the abdominal aortic aneurysms present an extension to the iliac axes. The access to a distal neck requiring an embolization of the internal iliac artery (IIA) may cause buttock claudication, colic ischemia, perineal necrosis, erectile dysfunction, and spinal cord ischemia. The aim of the branched iliac stent grafts is to preserve pelvic vascularization while adapting to the constraints of arterial tortuosity which generate type Ib endoleaks, plications, and limb thromboses. The objective was to analyze and compare the in vivo anatomical conformability of the Gore Excluder® Iliac Branch Endoprosthesis (IBE) and the Zenith Bifurcated Iliac Side® (ZBIS) Cook Iliac Endovascular Device branched stent grafts.This was a monocentric retrospective therapeutic study including 13 IBE and 9 ZBIS stent grafts. Three indices of tortuosity were measured with EndoSize: common iliac artery, pelvic artery index (PAI), and the double iliac sign (DIS). The centerline lengths of the iliac axes and the iliac axis and the IIA were measured by 2 different operators as a blind fashion.The interoperator correlation of the measurements was r = 0.841 (P < 0.0001). Twenty-two patients had a high iliac tortuosity: PAI ≥ 1.14 (mean PAI 1.43 [1.16–2.09]). The IBE stent graft modified neither the ipsilateral length nor tortuosity of the common iliac axis or the PAI (P ≤ 0.17, P ≤ 0.16, and P ≤ 0.23, respectively). The ZBIS stent graft significantly modified (P ≤ 0.02) the length and the tortuosity measured by the PAI compared with the IBE group (P ≤ 0.02). The use of IBE or ZBIS did not modify the postoperative length of the IIA (P ≤ 0.34). Three patients of the IBE group presented one DIS. Postoperatively, they did not present any DIS without significant modification of the postoperative PAI (P ≤ 0.07).In patients with a severe iliac tortuosity, the IBE Gore branched iliac stent graft is more conformable than the ZBIS Cook. IBE, more conformable with the anatomy of the patient, could thus make it possible to decrease the incidence of distal endoleaks without increasing the risk of limb thrombosis related to the anatomical constraints.

Conformability of GORE Excluder Iliac Branch Endoprosthesis and COOK Zenith Bifurcated Iliac Side Branched Iliac Stent Grafts

Forty percent of the abdominal aortic aneurysms present an extension to the iliac axes. The access to a distal neck requiring an embolization of the internal iliac artery (IIA) may cause buttock claudication, colic ischemia, perineal necrosis, erectile dysfunction, and spinal cord ischemia. The aim of the branched iliac stent grafts is to preserve pelvic vascularization while adapting to the constraints of arterial tortuosity which generate type Ib endoleaks, plications, and limb thromboses. The objective was to analyze and compare the invivo anatomical conformability of the Gore Excluder® Iliac Branch Endoprosthesis (IBE) and the Zenith Bifurcated Iliac Side® (ZBIS) Cook Iliac Endovascular Device branched stent grafts. This was a monocentric retrospective therapeutic study including 13 IBE and 9 ZBIS stent grafts. Three indices of tortuosity were measured with EndoSize: common iliac artery, pelvic artery index (PAI), and the double iliac sign (DIS). The centerline lengths of the iliac axes and the iliac axis and the IIA were measured by 2 different operators as a blind fashion. The interoperator correlation of the measurements was r=0.841 (P<0.0001). Twenty-two patients had a high iliac tortuosity: PAI ≥ 1.14 (mean PAI 1.43 [1.16-2.09]). The IBE stent graft modified neither the ipsilateral length nor tortuosity of the common iliac axis or the PAI (P ≤ 0.17, P ≤ 0.16, and P ≤ 0.23, respectively). The ZBIS stent graft significantly modified (P ≤ 0.02) the length and the tortuosity measured by the PAI compared with the IBE group (P ≤ 0.02). The use of IBE or ZBIS did not modify the postoperative length of the IIA (P ≤ 0.34). Three patients of the IBE group presented one DIS. Postoperatively, they did not present any DIS without significant modification of the postoperative PAI (P ≤ 0.07). In patients with a severe iliac tortuosity, the IBE Gore branched iliac stent graft is more conformable than the ZBIS Cook. IBE, more conformable with the anatomy of the patient, could thus make it possible to decrease the incidence of distal endoleaks without increasing the risk of limb thrombosis related to the anatomical constraints.

Gonadotropin-releasing hormone agonist and depot medroxyprogesterone acetate following uterine artery embolization in the management of uterine arteriovenous malformation

A young woman presenting with recurrent episodes of uterine bleeding due to an extensive uterine arteriovenous malformation was treated with two sessions of uterine artery embolization. Further bleeding was managed with a combination of gonadotropin-releasing hormone and depot medroxyprogesterone acetate. The patient remains asymptomatic with a significant decrease in uterine and pelvic vascularity at one year follow-up. These drugs may decrease the need for repeat embolization.

Hypogastric artery bypass in open repair of abdominal aortoiliac aneurysm: a safe procedure

The aim of this study is to assess the immediate and mid-term results of hypogastric artery bypass (HAB) in open repair of abdominal aortic aneurysm (AAA). The clinical data of 24 patients with an average age of 70.4 years [standard deviation (S.D.)+/-8.1 years] with AAA treated between January 2005 and December 2008 with HAB during open repair of aortoiliac aneurysm were reviewed. Eighteen patients received unilateral and six bilateral hypogastric bypasses, using a segment of Dacron graft prosthesis. Concomitant hypogastric eversion endarterectomy was associated in six cases (25%). Follow-up was complete in all the 24 patients and averaged 16.2 months (range 1-35). Postoperative imaging protocol involved a conventional Echocolordoppler and CT-scan. With respect to the operating time, the blood loss, the intensive care unit (ICU) and the length of ward admission (LWA) stay, we compared the 24 patients who underwent hypogastric bypass (group A) with the 50 patients who had bifurcated graft without hypogastric bypass (group B). Between the two groups, statistically different results were demonstrated only with respect to the duration of operation (h) (group A 5.19+/-1.38 vs. group B 4.39+/-1.32, P=0.0195). No statistical differences were noted for ICU stay (h) (group A median 21.50 vs. group B median 21.3, range 1 degrees -3 degrees quartile 19.75-23.50) and LWA stay (days) (group A median 8.50, range 1 degrees -3 degrees quartile 7.00-11.50 vs. group B median 8.0, range 1 degrees -3 degrees quartile 7.00-9.00). There were no operative deaths, bowel or intestinal ischemia in the early postoperative period between the two groups. In group A, one patient had transient renal failure and one patient had an acute coronary syndrome. In group B, one patient had a peripheral ischemia who required tibioperoneal embolectomy. The patency of the hypogastric grafts was demonstrated in all cases. In our experience, direct revascularization of the hypogastric artery to ensure pelvic vascularization in aortoiliac surgery appears a safe procedure.

Three-dimensional visualization of pelvic vascularity

The aim of this study was to establish a 3D digitized model of pelvic vasculature for anatomic study, preoperative planning, and virtual reality. Three adult fresh cadavers were perfused with carboxymethyl cellulose/lead oxide mixture to mark blood vessels, and subjected to multilayer spiral computed tomography scanning to obtain a series of thin sections. Then, the 2D images of the pelvis and pelvic blood vessels were transformed into 3D digitized models using Mimics 11.0. The 2D images of carboxymethyl cellulose/lead oxide filled arteries had the features of entire outline and few constructed defects. The 3D digitized models of the pelvis and pelvic artery system displayed spatial location and the adjacent relationship of arteries with the pelvis. Not only the well-known arteries but also the tiny blood vessels in the reconstructed structures were well demonstrated and observed interactively. The reconstructed tissue flaps, including a lobulated skin flap with the pedicle of superficial epigastric artery, and an iliac flap with the pedicle of deep iliac circumflex artery, demonstrated their blood supply area. This indicated that the modified technique of vascular perfusion with carboxymethyl cellulose/lead oxide and reconstitution with Mimics 11.0 software contributed to 3D digitized model of pelvic vasculature.

Color Doppler Angiography and Color Doppler Frequency Use in Obstetrics and Gynecology

Neoangiogenesis is an important event that may signal the healthy development of normal processes such as folliculogenesis, ovulation, and implantation, or it may indicate the development of abnormal conditions such as carcinogenesis, infection, and certain types of infertility. The development of transducers capable of monitoring uterine, ovarian, and pelvic vascularization has allowed study of normal flow in the pelvic organs and the association of certain flow abnormalities with anovulation, defects of the corpus luteum, implantation failure, and neoplasia. The authors describe on the advantages and disadvantages of the use of color Doppler frequency and color Doppler angiography for the evaluation of uterine and ovarian abnormalities in adult women. (J GYNECOL SURG 15:27, 1999)

Puberty and Age-intensity Profiles in Schistosome Infections: Another Hypothesis

In an excellent focus article on puberty and age-related changes in susceptibility to schistosome infection, Fulford et al.[1xFulford, A.J.C. et al. Parasitol. Today. 1998; 14: 23–26Abstract | Full Text | Full Text PDF | PubMed | Scopus (91)See all References[1]provide a new explanation for the characteristic age-intensity profile in areas where schistosomiasis is endemic. An age-dependent host factor seems to override—at least during adolescence—the variation in intensity of infection expected both from the variability of exposure with changing age and from the dynamics of acquired immunity. Fulford and colleagues put forward the hypothesis that physiological changes in the production of sex hormones could be one explanation. The authors explore how sex hormones might exert a regulatory effect on the immune system, eventually leading to an increased resistance to infection. Other modes of action by which sex hormones, particularly in females, may influence parasites are only mentioned briefly, but not commented on.Pelvic vascularization alters when girls enter puberty, resulting in multiple anastomoses between the rectal and the vesical plexus, and between the plexus of external and internal genital organs[2xSee all References, 3xSee all References]. These adaptive changes are accentuated during pregnancy. As adult worms tend to migrate, the adaptive changes in pelvic vascularization add to the chance that parasites reach the adjacent vascular beds, thereby increasing the probability of a settlement in female genital organs. In fact, at least in Schistosoma haematobium infection, involvement of external and internal genital organs is extremely common. Of women infected with this parasite species 40–80% are considered to have manifestations in the lower reproductive tract[4xFeldmeier, H. et al. Trop. Geogr. Med. 1995; 47: 1–15See all References, 5xKjetland, E. et al. Acta Trop. 1996; 62: 239–255Crossref | PubMed | Scopus (65)See all References, 6xLeutscher, P. et al. Acta Trop. 1997; 66: 27–34Crossref | PubMed | Scopus (27)See all References]. How many women also have worms located in the internal genital organs is unknown; post-mortem studies in female schistosomiasis patients, however, show that the ovaries, the fallopian tubes and the uterus are affected in 10–80% of cases[7xEdington, G.M. et al. Trans. R. Soc. Trop. Med. Hyg. 1971; 20: 846–849See all References, 8xGelfand, M. and Ross, W. Trans. R. Soc. Trop. Med. Hyg. 1953; 47: 218–220PubMed | Scopus (17)See all References, 9xYoussef, A.F. et al. J. Obstet. Gynaecol. Br. Commonw. 1970; 77: 847–851Crossref | PubMedSee all References].A shift of adult worms to topographic sites from which eggs cannot reach the lumen of the bladder, and thus are not excreted, obviously has an important consequence on age-intensity profiles: even if reinfection rates remain unchanged, egg excretion in urine will diminish and thus create the impression that there is an age-associated decrease of intensity of infection with onset of puberty.Two lines of evidence support this assumption. First, according to the literature, female genital schistosomiasis (FGS) occurs mainly after girls have reached sexual maturity[4xFeldmeier, H. et al. Trop. Geogr. Med. 1995; 47: 1–15See all References[4], ie. at an age when intensity of infection—as measured by egg excretion—decreases. Recently, these clinical observations were supported by data from a community-based study in Tanzania; the existence of FGS as measured by the presence of eggs in cervical biopsies and the prevalence/intensity of egg excretion in urine were inversely correlated during adolescence (Poggensee et al., unpublished).Second, if with the beginning of puberty a topographic shift of adult worms, rather than a diminished worm burden, is responsible for a decrease of egg excretion in urine, then the simultaneous measurement of egg excretion and circulating antigens should provide an important clue. Agnew et al.[10xAgnew, A. et al. Am. J. Trop. Med. Hyg. 1996; 55: 338–343PubMedSee all References[10]examined S. haematobium- or S. mansoni-infected populations for egg excretion as well as circulating anodic antigen (CAA). Schistosoma haematobium egg output relative to serum CAA was significantly reduced with onset of puberty. Nothing like that was observed in patients infected with S. mansoni, a parasite less commonly affecting the genital tract[4xFeldmeier, H. et al. Trop. Geogr. Med. 1995; 47: 1–15See all References[4]. Moreover, the effect observed by Agnew et al.[10xAgnew, A. et al. Am. J. Trop. Med. Hyg. 1996; 55: 338–343PubMedSee all References[10]was highly significant in women, but not in men, whose genitals are less frequently affected by ectopic schistosomiasis.Taken together, these circumstantial facts favour the hypothesis that in S. haematobium infection in women yet another mechanism may explain the familar age-intensity profile with the typical decline of the curve after onset of puberty. Whether vascular changes induced by sex hormones during puberty and pregnancy and subsequent anatomical compartmentalization of adult worms also have a regulatory effect on protective immune mechanisms is another intriguing question. The dynamics of schistosomiasis are probably much more complex than we still know. Why should it not be different between women and men?

Aortic False Aneurysms After Prosthetic Reconstruction of the Infrarenal Aorta

False aneurysm of the infrarenal aorta was found at the site of proximal anastomosis in 13 patients after vascular reconstruction for lower limb arterial disease. The grafts involved were aortoprosthetic in one patient, aortobiiliac in two patients, and aortobifemoral in 10 patients. They had been implanted eight years prior to reoperation on the average (range six months to 15 years). False aneurysm was diagnosed because of abdominal pain in four cases, embolism in two cases, intestinal hemorrhage in one case, and during routine sonographic or computed tomographic (CT) scan surveillance in the six other cases. Femoral false aneurysm was associated in eight of 10 cases with femoral anastomoses. Aortic false aneurysms were repaired by interposition of a prosthetic tube between the infrarenal aorta and the original prosthetic graft in 11 cases and by changing the aortobifemoral graft in two cases. In one further case, repair was accomplished by implanting an aortobifemoral prosthetic graft laterally on a prosthetic tube interposed between the infrarenal aorta and the body of the original prosthetic graft, which continued to irrigate the internal iliac arteries. There was no mortality. Thrombosis of a prosthetic branch occurred in one case and was treated by thrombectomy. One patient underwent reoperation for intestinal obstruction. Two others had distal embolism responsible for toe necrosis. Anastomotic false aneurysms should be looked for routinely during the surveillance of prosthetic grafts implanted on the infrarenal aorta, especially when femoral false aneurysm is found. Preservation of pelvic vascularization must be an integral part of management.