Selective Uterine Artery Embolization Research Articles

Embolization of Uterine Arteriovenous Malformations Associated with Cyanotic Congenital Heart Disease

Uterine arteriovenous malformation (AVM) is a rare cause of vaginal bleeding and miscarriage. We report two cases of uterine AVMs in patients with a history of complex congenital heart disease, an association that has not been previously described. Both patients were treated by selective uterine artery embolization, a minimally invasive therapy that has revolutionized the management of uterine AVMs, thus offering an alternative to conventional hysterectomy.

P46.01: A case report : The use of 3D power Doppler in the evaluation of intramural pregnancy with arteriovenous malformation treated by selective uterine artery embolization

P46.01: A case report : The use of 3D power Doppler in the evaluation of intramural pregnancy with arteriovenous malformation treated by selective uterine artery embolization

OP07.04: Three‐Dimensional Power Doppler Sonography in the diagnosis of Arteriovenous Malformations of the uterus and treated by selective uterine artery embolization

OP07.04: Three‐Dimensional Power Doppler Sonography in the diagnosis of Arteriovenous Malformations of the uterus and treated by selective uterine artery embolization

Angular ectopic pregnancy presenting as rupture of lateral wall of the uterus

This is a case report of a 32-year-old woman, being treated for secondary infertility, with history of previous ectopic pregnancy, who presented to the emergency obstetrical room in a state of hypovolemic shock. A diagnosis of ruptured ectopic pregnancy was confirmed in view of history of 14 weeks amenorrhea with a positive urine pregnancy test and positive colpopunture. She was immediately shifted for an emergency exploratory laparotomy. Intraoperatively, the authors were surprised to encounter a right lateral wall rupture uterus and ~14 weeks foetus with the placenta lying freely in the peritoneal cavity. That was suggestive of a right interstitial ectopic which had grown up to 14 weeks, invaded the uterine cavity thus forming an angular ectopic, which ended up as the catastrophic event. The authors here wish to highlight that angular pregnancy is rare but it has catastrophic consequences including maternal mortality. Had the patient presented early, in view of history of previous ectopic, an ultrasonography and color Doppler would have been useful in early detection. And a fertility conserving management in the form of Methotrexate therapy or Selective Uterine artery embolization could have been done.

Antenatally Ultrasound-impressed Placenta Percreta Complicated with Massive Hemorrhage Despite a Combinational Arterial Embolization and Two-stage Surgery

Morbidly adhered placentas include the spectrum of accreta, increta, and percreta. Abnormal placentation carries a significant risk of hemorrhage when late in gestation especially at peripartum. Many measures including extirpative surgery, selective arterial embolization, and methotrexate have been proposed either as a single method or in combination in the literature. We report a woman with placenta percreta who suffered from massive hemorrhage despite being treated with two-stage surgery plus intervening prophylactic uterine artery embolization. Classical incision at cesareans followed by selective uterine artery embolization and delayed hysterectomy still resulted in a failure to control bleeding. The patient survived after prolonged surgery and hospitalization in the intensive care unit. Treatment of placenta percreta needs to be considered on an individual basis and carries a significant risk of morbidity.

Conservative treatment of cervical pregnancy with selective unilateral uterine artery embolization

Cervical pregnancy is a rare form of ectopic pregnancy, and the most effective method of its treatment is still under investigation. We would like to call attention to selective uterine artery embolization as an effective modern treatment method. A patient with suspected cervical pregnancy and 7-week amenorrhea was admitted to the hospital after unsuccessful use of emergency contraception. Transvaginal ultrasound showed gestational sack located 11 mm from the external cervical os. Crown-rump length was 11.2 cm, and the fetal heartbeat was present. The level of serum chorionic gonadotropin was 31,930 U/L. Treatment with systemic methotrexate was unsuccessful, and unilateral uterine artery embolization was performed followed by dilatation and curettage of the cervical canal. Three days after the procedure, sonographic examination showed contracted cervical canal. After a period of two months, normal uterine artery flow was registered by Doppler ultrasonography on both sides. Uterine artery embolization in case of cervical pregnancy reduces the risk of bleeding and can be the method of choice when treatment with methotrexate fails. Unilateral embolization is effective when angiography shows unequal disposition of the arterial connections supplying the embryo.

The use of 3D rendering, VCI‐C, 3D power Doppler and B‐flow in the evaluation of interstitial pregnancy with arteriovenous malformation treated by selective uterine artery embolization

Cornual pregnancy is a rare form of ectopic pregnancy. We describe a case of cornual pregnancy suspected by two-dimensional ultrasonography (2DUS) and confirmed by three-dimensional volume contrast imaging in the C-plane. Three-dimensional power Doppler showed a particularly rich blood supply and two-dimensional color Doppler mapping demonstrated arteriovenous malformation (AVM). The feeding vessel originating from the right uterine artery and AVM were demonstrated with B-flow spatio-temporal image correlation (STIC) modality. Conservative management was chosen to preserve the uterus. Angiography confirmed the diagnosis of AVM; embolization with polyvinyl alcohol particles and embolization coils was performed through the right uterine artery until occlusion of the AVM and feeding vessels had occurred. Postprocedure color Doppler mapping and B-flow STIC modalities demonstrated absence of flow in the AVM. Serum human chorionic gonadotropin (hCG) levels gradually fell to non-pregnant levels during the ensuing 5 weeks. To the best of our knowledge this is the first report of cornual pregnancy with AVM. We demonstrate here the value of new three-dimensional ultrasound modalities in the diagnosis of cornual pregnancy and the use of embolization as an effective therapeutic option when conservative treatment with uterine preservation is desired.

Selective Uterine Artery Embolization for Management of Interstitial Ectopic Pregnancy

Interstitial ectopic pregnancy is a rare condition of pregnancy and may be very dangerous if not identified and treated urgently. We report a case of successful treatment of an interstitial pregnancy using selective uterine artery embolization. A 27-year-old woman with interstitial pregnancy was treated by uterine artery embolization after failure of systemic methotrexate treatment. Her serum beta-human chorionic gonadotropin (β-hCG) was undetectable one month after the therapeutic embolization and transvaginal sonography 31 days after embolization showed normal endometrium and cornu. The patient achieved a normal pregnancy eight months after embolization.

帝王切開創部妊娠が疑われ，選択的子宮動脈塞栓術を行い，保存的治療が可能であった臨床経験

帝王切開創部妊娠が疑われ，選択的子宮動脈塞栓術を行い，保存的治療が可能であった臨床経験

Conservative management of placenta increta with selective arterial embolization preserves future fertility and results in a favorable outcome in subsequent pregnancies

To present a case of selective arterial embolization for the treatment of placenta increta in a patient with subsequent pregnancy. Case report and literature review. Community-based hospital. A 31-year-old G2P1 woman with placenta increta presenting with delayed postpartum hemorrhage. Selective uterine artery embolization. Cessation of uterine hemorrhage, future pregnancy. The patient's uterine bleeding immediately resolved. She subsequently delivered a healthy neonate at term without recurrence of abnormal placentation. Arterial embolization is effective for treating placenta increta in women who wish to preserve fertility. A review of the literature demonstrates a 76.9% success rate and an 11% complication rate.

A reply

We would like to thank Dr Duffy for the interest shown in our article. We would like to point out that the aim of our article was not to review management of intractable obstetric haemorrhage, but to raise awareness about the technique of selective uterine artery embolisation as an invaluable strategy in controlling obstetric bleeding and preserving the uterus. We concede that selective uterine embolisation may not be available in every hospital and that transfer of an unstable bleeding postpartum patient is often fraught with risks. We have no experience with the use of recombinant factor VIIa in our institution. We are fortunate in having an excellent interventional radiology team offering a 24 h per day, 7 days per week service. Despite numerous reports about the success of recombinant factor VIIa in bleeding patients, there are a number of unanswered questions regarding the minimum effective dose, the optimal timing of administration, the amount of platelets and other coagulation factors that need to be given simultaneously for desired effect and the best tests to assess response [1-3]. Even in the case series by Ahonen and Jokela [4], four of the 12 patients had to undergo subsequent embolisation and five patients had hysterectomies. It would appear logical to perform a randomised placebo-controlled trial looking at the efficacy and safety of recombinant factor VIIa before wholeheartedly accepting it as an integral component of major bleeding protocols. However, such a trial is unlikely to be performed because of the difficulty in obtaining informed consent and the positive bias of published articles. The successful management of obstetric haemorrhage relies on a co-ordinated multidisciplinary effort to identify high risk cases, recognise ongoing bleeding unresponsive to conventional techniques, control the bleeding surgically or radiologically and replace red cells and clotting factors. We do not think that at the present time denying a bleeding postpartum patient recombinant factor VIIa could be considered negligent; however, it is a promising adjunct to intractable bleeding even in the absence of coagulopathy.

Selective uterine artery embolization: A new therapeutic approach in a patient with low-risk gestational trophoblastic disease

We report a case of persistent gestational trophoblastic disease (GTD) in which a selective uterine artery embolization instead of invasive surgery achieved both the control of pelvic hemorrhage and of disease.

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.

Management of Interstitial Pregnancy Using Selective Uterine Artery Embolization

Clinique d’Obstétrique, Centre Hospitalier Régional et Universitaire, 59037 Lille Cedex, France Editor’s Note: Obstetrics & Gynecology welcomes letters as written or e-mail correspondence. Send e-mail addressed to [email protected]

Management of Interstitial Pregnancy Using Selective Uterine Artery Embolization

Interstitial pregnancy is a rare and dangerous form of ectopic pregnancy which is treated by surgery, medical treatment, or both. Management options are not standardized. Currently, conservative nonsurgical treatment seems to be an alternative method in case of interstitial pregnancy. A right interstitial pregnancy was diagnosed in a 28-year-old woman. She was successfully treated by 2 courses of systemic methotrexate (1 mg/kg) 24 hours apart followed by selective uterine artery embolization. The postembolization course was uneventful, and no rupture occurred. Ten weeks after embolization, human chorionic gonadotropin level was negative. Uterine embolization associated with methotrexate can be used successfully in treating selected cases of early interstitial pregnancy. We hypothesize that this procedure combined with methotrexate could reduce hemorrhagic risk.

Uterine Fibroid Vascularization and Clinical Relevance to Uterine Fibroid Embolization

Embolization has become a first-line treatment for symptomatic uterine fibroid tumors. Selective catheterization and embolization of both uterine arteries, which are the predominant source of blood flow to fibroid tumors in most cases, is the cornerstone of treatment. Although embolization for treatment of uterine fibroid tumors is widely accepted, great familiarity with the normal and variant pelvic arterial anatomy is needed to ensure the safety and success of the procedure. The uterine artery classically arises as a first or second branch of the anterior division of the internal iliac artery and is usually dilated in the presence of a uterine fibroid tumor. Angiography is used for comprehensive pretreatment assessment of the pelvic arterial anatomy; for noninvasive evaluation, Doppler ultrasonography, contrast material-enhanced magnetic resonance (MR) imaging, and MR angiography also may be used. After the uterine artery is identified, selective catheterization should be performed distal to its cervicovaginal branch. For targeted embolization of the perifibroid arterial plexus, injection of particles with diameters larger than 500 mum is generally recommended. Excessive embolization may injure normal myometrium, ovaries, or fallopian tubes and lead to uterine necrosis or infection or to ovarian failure. Incomplete treatment or additional blood supply to the tumor (eg, via an ovarian artery) may result in clinical failure. The common postembolization angiographic end point is occlusion of the uterine arterial branches to the fibroid tumor while antegrade flow is maintained in the main uterine artery.

Amenorrhea due to partial uterine necrosis after uterine artery embolization for control of refractory postpartum hemorrhage

We report a case of a woman in whom selective embolization of both uterine arteries was performed using gelatin sponge for control of refractary postpartum hemorrhage. Ten months after delivery, the women had not resumed noticeable menstruation. Examination and investigation were consistent with partial uterine necrosis and complete obliteration of the cavity.

Malformation artérioveineuse utérine. Une cause rare de métrorragies récidivantes

Uterine arteriovenous malformation is a rare condition. We report a case with acquired arteriovenous malformation arising from the left uterine artery. She was diagnosed by color Doppler ultrasound and treated with a selective uterine artery embolization.

Delayed spontaneous expulsion of a cervical ectopic pregnancy: A case report

Cervical ectopic pregnancy is an uncommon event. Modern diagnostic and treatment options provide an opportunity for conservative treatment of this condition. A case of a profuse hemorrhage associated with delayed spontaneous expulsion of a cervical ectopic pregnancy is described, and the management is discussed. In this patient, the cervical ectopic pregnancy was treated successfully using systemic methotrexate and selective uterine artery embolization. The patient returned 1 week later with spontaneous expulsion of the ectopic pregnancy associated with profuse hemorrhage. The bleeding subsided following tamponade using a transcervical Foley catheter. We conclude that conservative treatment of cervical ectopic pregnancy is feasible, with careful posttreatment surveillance.

Uterine artery embolization to control bleeding after myomectomy

Selective uterine artery embolization is being performed as an emergency procedure to control uterine bleeding. In this procedure, a small angiographic catheter is guided into the uterine arteries and a stream of tiny particles such as polyvinyl alcohol is injected to decrease blood flow to the uterus. It is now considered a safe and highly effective nonsurgical treatment of women with symptomatic uterine fibroid tumors. A 27-year-old woman, gravida 3, para 1, D & C 2, was admitted to our hospital with vaginal bleeding after myomectomy for her giant leiomyoma. Her history revealed heavy menstrual and intermenstrual bleeding. She had been on oral contraceptive pills before. She had no other operations or medical disease in her past history, other than the myomectomy 7 days ago, in which the giant fibroid complex of 12 cm diameter consisting of leiomyomas with intramural and subserous components and touching the endometrium was extirpated. The operation was uneventful. However, she suffered from a sort of vaginal bleeding that was in time considered normal and expected to cease. On the postoperative seventh day, she referred to our clinic with heavier vaginal bleeding exceeding 100 ml/day. On ultrasonographic examination, an aberrant vessel at the myoma bed with Doppler flow was detected (Fig. 1). On angiographic examination, the diameters of the uterine arteries were found to be increased and collaterals more prominent (Fig. 2). On the left side, where the myoma was taken out, dispersion of distal parts of arteries was complex and in anarchy. The patient was consulted and the management options were discussed, and it was decided to perform bilateral uterine artery embolization (Fig. 3). Prophylactic antibiotics were administered. Immediately after polyvinyl alcohol injection, the prominent vasculature disappeared. The patient was hospitalized for further complications. A transvaginal ultrasound was performed on the second day to check whether the previous findings exist. Fortunately, no flow was detected at the myoma bed, and the patient was discharged on the second day. She is now doing well. Pulse-wave doppler sonographic image depicting high blood flow at the myoma bed. Angiographic picture of the left uterine artery prior to embolization. Angiographic picture after embolization. Because of the risk of postoperative bleeding, every patient undergoing a gynecologic operation is monitored carefully during the first 24 hr after the operation. However, there are rare occasions of later bleeding problems, where conservative options to control bleeding are more favorable. Examples to conservative procedures are uterine artery embolization and very recently described transvaginal ligation of uterine arteries (1). In the transvaginal uterine artery ligation technique, a circumferential incision is performed outside the transformation zone from anterior to the posterior cervix. The uterosacral ligaments are ligated with 0 Vicryl sutures; after that the cardinal ligaments in order to include the uterine arteries are ligated. Later, the cervical incision is approximated. The cessation of blood flow from the uterine arteries is demonstrated by the loss of Doppler waveforms. This technique can be applied as an outpatient procedure and seems to be a promising approach (1,2). Embolization procedures for postsurgical hemorrhage have high success rates. Embolization has been used to treat obstetric hemorrhage, severe bleeding after hysterectomy, bleeding in gynecologic cancers, and symptomatic leiomyomata. It is preferred to hypogastric artery ligation in many cases. It may be considered an alternative to hysterectomy, or myomectomy, in well-selected cases, especially if the patient has no desire of future fertility (3,4). In uterine fibroid tumors, besides being an alternative to surgery, embolization can be performed in cases of ongoing heavy bleeding despite myomectomy. Although promising results have been achieved in terms of successful pregnancies after uterine artery embolization, at the present time, however, it is not routinely recommended for women who desire future fertility (5,6). The authors thank Ozgur H. Harmanli, MD, Department of Obstetrics and Gynecology, Temple University School of Medicine, for his invaluable support in the preparation of this manuscript.