Round Ligament Arteries Research Articles

Collateral Round Ligament Arterial Supply of Placenta Accreta Spectrum and Considerations for Prophylactic Balloon Occlusion Catheter Placement

Internal iliac artery (IIA) balloon occlusion catheters have been commonly inserted to decrease the risk of postpartum hemorrhage in placenta accreta spectrum disorders; however, there has been mixed success in clinical studies. Placement of an infrarenal aortic balloon has shown more consistent effectiveness in recent studies. A possible reason for this is collateral arterial supply to the placenta from external iliac artery branches. Retrospective chart review was conducted of angiography images during prophylactic IIA balloon occlusion catheter insertion over a 7-year period. Sixty-two individual cases were identified. Digital subtraction angiography (DSA) was performed in 32 (52%) cases, and 20 (62%) showed collateral blood supply from branches of the external iliac arteries, namely the round ligament artery. In conclusion, a high proportion of placenta accreta spectrum cases have arterial blood supply from branches of the external iliac artery, which may explain the discrepancy in effectiveness seen between IIA and infrarenal aortic sites of balloon occlusion catheter placement.

1812 Excision of Ovarian Remnant

Video Objective Dissection techniques for removal of ovarian remnant. Setting Patients with persistent ovarian tissue and persistent pelvic pain after Oophorectomy. Interventions Excision of persistent ovarian tissue. Conclusion Ovarian remnant is a challenging problem as it is seen in patient whose primary surgery was complicated due to excessive adhesions or severe endometriosis. If the initial dissection was incomplete, a portion of ovarian tissue may remain adhered and continue to cause pelvic pain. This surgery requires dissection of pelvic side wall where remnant is most commonly isolated. Complete ureterolysis, separation of sigmoid colon from pelvic side wall and vagina, isolation of round ligament, IP ligament and uterine artery are the key steps while excising the ovarian residual tissue. This video demonstrates these key steps of dissection. Such patients will often be referred to a minimally invasive gynecologic surgeon who are trained in dissection of pelvic side wall with knowledge of retroperitoneal anatomy and can safely perform this complex dissection.

Collateral Uterine Arterial Supply in the Setting of Various Uterine Pathologies

AbstractIn most patients, bilateral uterine arteries supply the uterus exclusively. However, collateral arterial supply to the uterus has been described, predominantly in the context of uterine artery embolization (UAE) for fibroid treatment. This may lead to incomplete embolization, which can impact clinical outcomes. Therefore, identification of potential collateral supply to the uterus is essential for achieving optimal clinical results. The authors report three cases of collateral uterine arterial supply from the ovarian and round ligament arteries in the setting of uterine arteriovenous fistula (uAVF), postpartum hemorrhage (PPH), and symptomatic fibroids. Aortography from the level of the renal arteries was performed for initial evaluation of uterine arterial supply in all patients and identified hypertrophied, tortuous ovarian artery collaterals. Selective angiography of the external iliac artery was required to identify round ligament collateral uterine supply. Three-dimensional cone beam computed tomography (CT) was also used to visualize vascular distribution of bilateral uterine arteries and an ovarian collateral feeding a uAVF. In regard to outcomes, identification of collateral uterine arterial supply allowed for single-session complete embolization in fibroid patients with collateralized round ligament or ovarian arteries and in the PPH patient in disseminated intravascular coagulation with predominantly ovarian artery supply to the uterus. Identification of collateral uterine arterial supply facilitated technical success in all patients. In the setting of various uterine pathologies, identification of collateral uterine arterial supply is essential to optimize clinical success of UAE.

Epiphyseal Arterial Network and Inferior Retinacular Artery Seem Critical to Femoral Head Perfusion in Adults With Femoral Neck Fractures.

A better understanding of the blood supply of the femoral head is essential to guide therapeutic strategies for patients with femoral neck fractures. However, because of the limitations of conventional techniques, the precise distribution and characteristics of intraosseous arteries of the femoral head are not well displayed. To explore the characteristics and interconnections of the intraosseous vessel system between different areas of the femoral head and the possible blood supply compensatory mechanism after femoral neck fracture. The three-dimensional (3-D) structures of the intraosseous blood supply in 30 uninjured normal human femoral heads were reconstructed using angiography methods and microCT scans. The data were imported in the AMIRA® and MIMICS® software programs to reconstruct and quantify the extra- and intraosseous arteries (diameter, length). In a separate experiment, we evaluated the residual blood supply of femoral heads in 27 patients with femoral neck fractures before surgery by analyzing digital subtraction angiography data; during the study period, this was performed on all patients in whom hip-preserving surgery was planned, rather than arthroplasty. The number of affected and unaffected subjects included in the three groups (superior, inferior, and anterior retinacular arteries) with different types of fractures (Garden Types I-IV) were recorded and analyzed (Fisher's exact test) to reflect the affected degrees of these three groups of retinacular arteries in patients after femoral neck fractures. The main results of our cadaver study were: (1) the main blood supply sources of the femoral head were connected by three main network structures as a whole, and the epiphyseal arterial network is the most widely distributed and the primary network structure in the femoral head; (2) the main stems of the epiphyseal arteries which were located on the periphery of the intraosseous vascular system have fewer anastomoses than the network located in the central region; (3) compared with the round ligament artery and anterior retinacular artery, the inferior retinacular artery has a relatively large caliber. Digital subtraction angiography of the 27 patients with hip fractures indicated that the inferior retinacular arterial system had a high likelihood of being unaffected after femoral neck fracture (100% [14 of 14] in nondisplaced fractures and 60% [six of 10] in Garden Type III fractures). The epiphyseal arterial network and inferior retinacular arterial system appear to be two important structures for maintaining the femoral head blood supply after femoral neck fracture. Increased efforts to protect these key structures during surgery, such as drilling and placing internal implants closer to the central region of the femoral head, might be helpful to reduce the effect of iatrogenic injury of the intraosseous vascular system. 3-D anatomic evidence of intraosseous arterial distribution of the femoral head and the high frequency with which the inferior retinacular arteries remained patent after femoral neck fracture lead us to consider the necessity of drilling and placing internal implants closer to the central region of the femoral head during surgery. Future controlled studies might evaluate this proposition.

Value of Round Ligament Artery Embolization in the Management of Postpartum Hemorrhage

PurposeTo evaluate the feasibility and efficacy of embolization of the round ligament arteries in the management of postpartum hemorrhage. Materials and MethodsEleven women (mean age, 31 y) underwent round ligament artery because of persistent or recurrent hemorrhage after initial uterine or internal iliac artery embolization. ResultsA total of 16 round ligament arteries were embolized. The round ligament artery arose from the inferior epigastric artery in 11 cases (69%) and directly from the external iliac artery in 5 (31%). Embolization was performed with calibrated microspheres in 7 women (63%) and gelatin sponge pledgets in 4 (37%). Coils were used in addition to gelatin sponge pledgets in 3 patients. Hemostasis was achieved in 10 patients (91%), and 1 required additional conservative surgery. The mean hemoglobin level before embolization was 7.2 g/dL ± 1 and increased significantly on day 1 after embolization (10.3 g/dL ± 1.0; P < .05). No procedure-related complication was reported. The mean hospital stay was 5.6 days ± 2. Two patients had further pregnancies 13 and 14 months after embolization. ConclusionsSelective embolization of the round ligament artery is a safe and effective treatment for obstetric hemorrhage. It should be considered in cases of persistent or recurrent bleeding after initial uterine or internal iliac artery embolization.

Spatial anatomy of the round ligament, gallbladder, and intrahepatic vessels in patients with right-sided round ligament of the liver.

To analyze the vascular structure of the liver in patients with a right-sided round ligament. We reviewed 16 patients with a right-sided round ligament and 3 polysplenia and situs inversus patients with a left-sided round ligament who underwent multidetector row CT with contrast media. The patient population consisted of 13 men and 6 women (mean 62years). We analyzed the axial and volume-rendered images for the location of the round ligament, gallbladder, portal veins, hepatic veins, and hepatic artery. The following imaging findings for the patients with polysplenia and situs inversus were horizontally reversed. The prevalence of a right-sided round ligament with and without polysplenia was 75 and 0.11%, respectively. The gallbladder was located to the right, below, and left of the round ligament in 27.7, 38.8 and 33.3%, respectively. Independent branching of the right posterior portal vein was noted in 57.8%. PV4 was difficult to identify in 36.8%. The middle hepatic vein was located to the left of the round ligament. Two branching patterns for the lateral and medial branches of the right anterior hepatic artery were noted: the common (44.4%) and separated types (55.5%). Both of the right anterior hepatic artery and portal vein ramified into two segments; the lateral segment with many branches and the medial segment with a few branches. The right-sided round ligament divided the right anterior section into the lateral and medial segments based on the portal vein and hepatic artery anatomy.

Inferior Mesenteric Artery Collaterals to the Uterus during Uterine Artery Embolization: Prevalence, Risk Factors, and Clinical Outcomes

PurposeTo evaluate the prevalence of inferior mesenteric artery (IMA) collaterals to the uterus found during uterine artery embolization (UAE), associated risk factors, and clinical outcomes. Materials and MethodsThe records of 559 women who underwent UAE during the period 2008–2011 for uterine fibroids or adenomyosis found on magnetic resonance imaging were retrospectively analyzed. If IMA collaterals to the uterus were suspected on aortography performed after embolization, selective angiography was performed. Risk factors for IMA collaterals to the uterus were analyzed, including the presence of adenomyosis, baseline uterine volume, or prior pelvic surgery. ResultsCollaterals to the uterus were found from the ovarian artery (n = 21; 3.8%), IMA (n = 7; 1.3%), round ligament artery (n = 1; 0.2%), and internal pudendal artery (n = 1; 0.2%). IMA collaterals were found in seven patients. Of 185 patients, 6 (3.2%) had adenomyosis, with or without fibroids, which was significantly more frequent than the 1 (0.27%) of 374 patients who had fibroids only (P = .006). On multiple logistic regression analysis, the presence of adenomyosis (odds ratio, 19.556; P = .0168) and uterine volume (odds ratio, 1.003; P = .0069) were independent factors for the presence of IMA collaterals. Of the seven patients with IMA collaterals, embolization was not attempted in six, resulting in clinical failure in four. One patient who underwent IMA embolization with coils experienced clinical improvement. ConclusionsThe IMA was the second most common (1.3%) source of collaterals to the uterus. IMA collaterals were more frequent in patients with adenomyosis than in patients with fibroids only, resulting in high frequency of treatment failure.

Importance of Angiographic Visualization of Round Ligament Arteries in Women Evaluated for Intractable Vaginal Bleeding after Uterine Artery Embolization

To determine the incidence of angiographic visualization and the clinical significance of round ligament arteries in patients who present with intractable vaginal bleeding. A review of 113 patients (age range, 20-67 years) who underwent pelvic angiography for intractable vaginal bleeding between June 1992 and May 2008 was retrospectively performed. It was recorded whether round ligament artery was visualized on pelvic aortography after uterine artery embolization (UAE). The medical records of the patients were reviewed to analyze the final clinical outcome. The Fisher exact test was used to correlate persistent vaginal bleeding after UAE with visualization of round ligament arteries. Of 111 patients who underwent UAE, 42 patients (postpartum bleeding, n = 40; postabortion bleeding, n = 2) had at least one visible round ligament artery on postembolization pelvic aortography. Ten patients received round ligament artery embolization. Persistent vaginal bleeding after adequate UAE was observed more commonly in patients whose round ligament artery was seen on postembolization pelvic aortography (P = .007). Round ligament arteries are commonly visualized in patients who present with postpartum bleeding and should be investigated when there is persistent bleeding, even after adequate UAE.

Abstract No. 312 EE: The Prevalence and Significance of Round Ligament Arteries in Patients with Vaginal Bleeding

Abstract No. 312 EE: The Prevalence and Significance of Round Ligament Arteries in Patients with Vaginal Bleeding

Embolization in Post-Partal Bleeding

Post partal hemorrhage remains a leading cause of maternal mortality throughout the world. Uterine atony, lower genital tract lacerations and abnormal placentation account for the majority of cases. Atonic uterus is usually controlled satisfactorily using oxytocin drugs and prostaglandin analogues. Specific surgical repair is effective to treat cervical tears and curettage may be sufficient to remove retained placental tissue. For patients whose clinical condition continues to deteriorate, ligation of the hypogastric artery or even hysterectomy is often the favored treatment. The successful use of arterial embolization was first reported in 1979. Since then many reports have emphasized the advantages of embolization over surgery in the management of severe postpartal hemorrhage. The main blood supply to the uterus is provided by the uterine arteries. However, additional blood supply from the ovarian or round ligament arteries may account for technical failure or recurrence of bleeding. The overall success rates of embolization using mainly gelatin sponge pledgets range between 80 and 95% to treat bleeding following cesarean section and in case of uterine atony respectively. Pluridisciplinary management for these patients should be realized in highly specialized centers open 24 hours a day only.

Prise en charge des hémorragies graves du post-partum: indications et techniques de l’embolisation artérielle

Pluridisciplinary management of women with postpartum hemorrhage is mandatory in order to precisely assess initial seriousness, to maintain hemodynamic parameters and to confirm the cause of bleeding. Embolization should be offered only after exploration of the uterine cavity, inspection of the vagina, cervix and perineum and failure of uterotonic drugs. Embolization should be carried out in an angiography suite under constant monitoring of the patient by the anesthesiologist. Indications to perform arterial embolization include uterine atony particularly following a vaginal delivery, cervico-uterine hemorrhage, cervicovaginal lacerations (previously repaired or if surgical repair has failed) and vaginal thrombus, particularly in case of associated coagulopathy. Arterial embolization is effective in about 85% of cases. Placenta acccreta can also be successfully managed with arterial embolization as an alternative to hysterectomy. Unilateral femoral approach allows selective study of both internal iliac arteries and branches. Selective embolization of both uterine arteries should be ideally performed. In case of spasm or difficult catheterization, embolization of the anterior division of both internal iliac arteries should be considered. In case of bleeding from the cervico-vaginal region, selective evaluation and embolization of cervicovaginal branches should be performed. In case of failure or recurrence of bleeding, ovarian and round ligament arteries should be evaluated. In most cases, resorbable gelatin sponge pledgets should be used to perform embolization. The use of microcatheters and non resorbable embolization agents should be considered by trained interventional radiologists in case of placenta accreta or vascular lesions. After embolization, the patient should be transferred to the intensive care unit for further observation in order to offer emergent surgical procedure or another session of embolization in case of recurrence of bleeding.

Uterine Artery Replacement by the Round Ligament Artery: An Anatomic Variant Discovered during Uterine Artery Embolization for Leiomyomata

The authors report a case of an unusual anatomic variation encountered during uterine embolization, that of absence of a uterine artery, with replacement by an enlarged round ligament artery. This case highlights the importance of understanding the arterial anatomy of the uterus and its potential variations and their potential impact on the outcome of the procedure.

Uterine and ovarian artery blood flow in the rhesus monkey near term

Uterine and ovarian artery blood flow (UABF and OABF) were measured in six pregnant monkeys near tem by means of the electromagnetic flowmeter. The average UABF was 21.4 ml/min and OABF was 1.9 ml/min. Complete aortic occlusion reduced UABF from 21.4 to 2.4 ml/min, while OABF increased from 1.9 to only 2.1 ml/min. In six pregnant monkeys near term, chronic partial constriction of the abdominal aorta for an average of 10 days produced a parallel reduction in UABF but no increased circulation through the ovarian or round ligament arteries. The ovarian arteries were not visualized on angiography in these pregnant monkeys even when the abdominal aorta was acutely or chronically constricted; the uterine arteries were readily seen. The authors concluded that acute or chronic aortic constriction in the pregnant monkey at term results in a noncompensated uterine blood flow (UBF) reduction. The possible implications in pregnant women are discussed.

Aortocaval compression by the uterus in late human pregnancy: IV. Circulatory homeostasis by preferential perfusion of the placenta

Circulatory adjustments to pregnancy have been studied by serial angiography in 70 pregnant supine women and in 30 nonpregnant controls. In nonpregnant women only uterine arteries were found to supply the uterus. During pregnancy uterine arteries dilate and are joined by widened ovarian arteries, as well as by canalized round ligament arteries. Thus a virtual arterial circle is formed. Arcuate and spiral arteries increase their width and tortuosity as they converge toward the placenta. Extraplacental vessels remain narrow. Unlike conditions seen in angiograms from nonpregnant women, dye clears twice as quickly in pregnancy through uterine arteries toward the placenta as through gluteal or femoral arteries. The pelvic and lower extremity circuits are blocked because compression occludes the return through the inferior vena cava. The placenta offers less resistance because its vascular bed dilates and drains freely through ovarian plexuses, bypassing the vena caval obstruction. The opening of this essentially new visceral circuit compensates for the aortocaval compression, providing for favorable perfusion of the placenta and for an adequate venous return to the right heart. Failure of these compensatory adjustments has been observed in both hypertensive and hypotensive disorders of pregnancy.