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

PURPOSE: To evaluate the feasibility and efficacy of embolization of the round ligament arteries in the management of postpartum hemorrhage. MATERIALS AND METHODS: Eleven women (mean age, 31 y) underwent round ligament artery because of persistent or recurrent hemorrhage after initial uterine or internal iliac artery embolization. RESULTS: A 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. CONCLUSIONS: Selective 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.

Diffusion-weighted MR imaging of uterine leiomyomas following uterine artery embolization.

PURPOSE: To test whether variations in apparent diffusion coefficient (ADC) values of uterine leiomyomas after uterine artery embolization (UAE) may correlate with outcome and assess the effects of UAE on leiomyomas and normal myometrium with magnetic resonance imaging (MRI). METHODS: Data of 49 women who underwent pelvic MRI before and after UAE were retrospectively reviewed. Uterine and leiomyoma volumes, ADC values of leiomyomas, and normal myometrium were calculated before and after UAE. RESULTS: By comparison with baseline ADC values, a significant drop in leiomyoma ADC was found at 6-month post-UAE (1.096 × 10(-3) mm(2)/s vs. 0.712 × 10(-3) mm(2)/s, respectively; p < 0.0001), but not at 48-h post-UAE. Leiomyoma devascularization was complete in 40/49 women (82 %) at 48 h and in 37/49 women (76 %) at 6 months. Volume reduction and leiomyoma ADC values at 6 months correlated with the degree of devascularization. There was a significant drop in myometrium ADC after UAE. Perfusion defect of the myometrium was observed at 48 h in 14/49 women (28.5 %) in association with higher degrees of leiomyoma devascularization. CONCLUSION: Six months after UAE, drop in leiomyoma ADC values and volume reduction correlate with the degree of leiomyoma devascularization. UAE affects the myometrium as evidenced by a drop in ADC values and initial myometrial perfusion defect. KEY POINTS: • A drop in leiomyoma ADC values is observed 6 months after UAE. • Drop in leiomyoma ADC value is associated with leiomyoma devascularizarion after UAE. • MR 48 h post-UAE allows assessing leiomyoma devascularization. • Myometrium perfusion defect occurs more often in women with a smaller uterus.

Role and Effectiveness of Percutaneous Arterial Embolization in Hemodynamically Unstable Patients with Ruptured Splanchnic Artery Pseudoaneurysms.

PURPOSE: To assess the role and effectiveness of percutaneous arterial embolization (TAE) in patients with hemodynamic instability due to hypovolemic shock secondary to ruptured splanchnic artery pseudoaneurysms (SAPA). MATERIALS AND METHODS: Seventeen patients (11 men, 6 women; mean age, 53 years) with hemodynamic instability (systolic blood pressure <90 mmHg) due to hypovolemic shock secondary to ruptured SAPA were treated by TAE. Clinical files, multidetector row computed tomography angiography, and angiographic examinations along with procedure details were reviewed. RESULTS: Seventeen SAPAs were present, predominantly located on gastroduodenal or pancreatic arteries (9/17; 53%). Angiography showed extravasation of contrast medium from SAPA in 15/17 patients (88%). Technical success rate of TAE was 100%. TAE was performed using metallic coils in all patients (100%), in association with gelatin sponge in 5/17 patients (29%). TAE allowed controlling the bleeding and returning to normal hemodynamic status in 16/17 patients (94%). In 1/17 patient (6%), surgery was needed to definitively control the bleeding. The mortality and morbidity rate of TAE at 30 days were 0 and 12%, respectively. Morbidity consisted in coil migration in 1/17 patient (6%) and transient serum liver enzyme elevation in 1/17 patient (6%). CONCLUSION: TAE is an effective and safe treatment option for ruptured SAPA in hemodynamically unstable patients, with a success rate of 94%. Our results suggest that TAE should be the favored option in patients with hemodynamic instability due to ruptured SAPA.

Postpartum hemorrhage resulting from pelvic pseudoaneurysm: a retrospective analysis of 588 consecutive cases treated by arterial embolization.

OBJECTIVE: This study was designed to determine the incidence of arterial pseudoaneurysm in patients presenting with postpartum hemorrhage (PPH), to analyze the angiographic characteristics of pseudoaneurysms that cause PPH, and to evaluate the effectiveness of pelvic arterial embolization for the treatment of this condition. STUDY DESIGN: Eighteen women with pelvic arterial pseudoaneurysm were retrieved from a series of 588 consecutive patients with PPH treated by arterial embolization. Clinical files, angiographic examinations, and procedure details were reviewed. RESULTS: The incidence of pseudoaneurysm was 3.06 % (18/588; 95 % confidence interval (CI): 1.82-4.8 %). A total of 20 pseudoaneurysms were found; 15/20 (75 %) were located on the uterine arteries. Angiography revealed extravasation of contrast material from pseudoaneurysm indicating rupture in 9 of 18 (50 %) patients. Arterial embolization was performed using gelatin sponge alone in 12 of 18 (67 %) patients or in association with metallic coils in 5 of 18 (28 %) patients or n-butyl-2-cyanoacrylate in 1 of 18 (6 %) patients. Arterial embolization allowed controlling the bleeding in all patients after one or two embolization sessions in 17 of 18 (94 %) and 1 of 18 patients (6 %) respectively, without complications, obviating the need for further surgery. CONCLUSIONS: Pseudoaneurysm is rarely associated with PPH. Arterial embolization is an effective and safe procedure for the treatment of PPH due to uterine or vaginal artery pseudoaneurysm. Our results suggest that gelatin sponge is effective for the treatment of ruptured pseudoaneurysms, although we agree that our series does not contain sufficient material to allow drawing definitive conclusions with respect to the most effective embolic material.

Placental vascularity and resorption delay after conservative management of invasive placenta: MR imaging evaluation.

OBJECTIVES: To assess the potential of magnetic resonance (MR) imaging in evaluating placental vascularity and predicting placental resorption delay after conservative management of invasive placenta. METHODS: MR examinations of 23 women with conservative management of invasive placenta were reviewed. Twelve women had pelvic embolisation because of postpartum haemorrhage (Group 1) and 11 had no embolisation (Group 2). Comparisons between the two groups were made with respect to the delay for complete placental resorption at follow-up MR imaging and degree of placental vascularity 24 h after delivery on early (30s) and late (180 s) phase of dynamic gadolinium chelate-enhanced MR imaging. RESULTS: The median delay for complete placental resorption in the cohort study was 21.1 weeks (range, 1-111 weeks). In Group 1, the median delay for complete placental resorption was shorter than in Group 2 (17 vs 32 weeks) (P = 0.036). Decreased placental vascularity on the early phase was observed in Group 1 by comparison with Group 2 (P = 0.003). Significant correlation was found between the degree of vascularity on early phase of dynamic MR imaging and the delay for complete placental resorption (r = 0.693; P < 0.001). CONCLUSIONS: MR imaging provides useful information after conservative management of invasive placenta and may help predict delay for complete placental resorption.

Evaluation of symptomatic uterine fibroids in candidates for uterine artery embolization: comparison between ultrasonographic and MR imaging findings in 68 consecutive patients.

Ultrasonographic and magnetic resonance (MR) imaging examinations of 68 women with uterine fibroids were reviewed to determine whether MR imaging may alter the therapeutic approach based on ultrasonography alone before uterine embolization. Therapeutic decisions based on ultrasonography alone were compared to those obtained after MR imaging. Discordant findings between both examinations involved 51 women (75%), and 19 (28%) had their therapeutic approaches based on ultrasonography alone altered by MR imaging. Ultrasonography and MR imaging showed concordant findings in 17 women (25%) for whom no changes in therapeutic option were made. MR imaging alters the therapeutic approach based on ultrasonography alone in 28% of candidates for uterine artery embolization.

Conservative two-step procedure including uterine artery embolization with embosphere and surgical myomectomy for the treatment of multiple fibroids: preliminary experience.

OBJECTIVE: To evaluate the feasibility and safety of combined uterine artery embolization (UAE) using embosphere and surgical myomectomy as an alternative to radical hysterectomy in premenopausal women with multiple fibroids. MATERIALS AND METHODS: Mid-term clinical outcome (mean, 25 months) of 12 premenopausal women (mean age, 38 years) with multiple and large symptomatic fibroids who desired to retain their uterus and who were treated using combined UAE and surgical myomectomy were retrospectively analyzed. In all women, UAE alone was contraindicated because of large (>10 cm) or subserosal or submucosal fibroids and myomectomy alone was contraindicated because of too many (>10) fibroids. RESULTS: UAE and surgical myomectomy were successfully performed in all women. Myomectomy was performed using laparoscopy (n=6), open laparotomy (n=3), hysteroscopy (n=2), or laparoscopy and hysteroscopy (n=1). Mean serum hemoglobin level drop was 0.97 g/dL and no blood transfusion was needed. No immediate complications were observed and all women reported resumption of normal menses. During a mean follow-up period of 25 months (range, 14-37 months), complete resolution of initial symptoms along with decrease in uterine volume (mean, 48%) was observed in all women. No further hysterectomy was required in any woman. CONCLUSION: In premenopausal women with multiple fibroids, the two-step procedure is safe and effective alternative to radical hysterectomy, which allows preserving the uterus. Further prospective studies, however, should be done to determine the actual benefit of this combined approach on the incidence of subsequent pregnancies.

Value of pelvic embolization in the management of severe postpartum hemorrhage due to placenta accreta, increta or percreta.

OBJECTIVES: To evaluate the role, efficacy and safety of pelvic embolization in the management of severe postpartum hemorrhage in women with placenta accreta, increta or percreta. METHODS: The clinical files and angiographic examinations of 12 consecutive women with placenta accreta (n=4), increta (n=2) or percreta (n=6) who were treated with pelvic embolization because of severe primary (n=10) or secondary (n=2) postpartum hemorrhage were reviewed. Before embolization, four women had complete placental conservation, four had partial placental conservation, three had an extirpative approach and one had hysterectomy after failed partial conservative approach. RESULTS: In 10 women, pelvic embolization was successful and stopped the bleeding, after one (n=7) or two sessions (n=3). Emergency hysterectomy was needed in two women with persistent bleeding after embolization, both with placenta percreta and bladder involvement first treated by extirpation. One case of regressive hematoma at the puncture site was the single complication of embolization. CONCLUSIONS: In women with severe postpartum hemorrhage due to placenta accreta, increta or percreta, pelvic embolization is effective for stopping the bleeding in most cases, thus allowing uterine conservation and future fertility. Further studies, however, should be done to evaluate the potential of pelvic embolization in women with placenta percreta with bladder involvement.

Persistent postpartum haemorrhage after failed arterial ligation: value of pelvic embolisation.

OBJECTIVES: To evaluate the role and efficacy of pelvic embolisation in the treatment of persistent postpartum haemorrhage after failed arterial ligation and to identify the complications of this procedure in this specific population. METHODS: The clinical files and angiographic examinations of 12 consecutive women (mean age 32 years) who were treated with pelvic embolisation because of persistent, severe postpartum haemorrhage after failed arterial ligation were reviewed. RESULTS: Angiography revealed that persistent bleeding was due to incomplete arterial ligation (n = 4) or the presence of newly developed anastomotic routes (n = 8). In 11 women, pelvic embolisation stopped the bleeding. Hysterectomy was needed in one woman with retained placenta. Two complications due to pelvic embolisation, including leg ischaemia and transient sciatic nerve ischaemia, were identified, both after internal iliac artery ligation. CONCLUSIONS: In women with persistent postpartum haemorrhage after failed arterial ligation, pelvic embolisation is an effective treatment in most cases. However, embolisation of the anastomotic routes that contribute to persistent bleeding may result in ischaemic complications. These potential complications reaffirm that arterial ligation should not be the favoured option for postpartum haemorrhage and that special care must be given during pelvic embolisation after failed arterial ligation.

Life-threatening intra-abdominal hemorrhage from left superior colonic artery pseudoaneurysm after percutaneous renal biopsy: successful treatment with superselective arterial embolization.

Life-threatening intra-abdominal hemorrhage following ultrasonographically guided percutaneous renal biopsy is extremely rare and, most of the time, is due to renal vascular injury. Injury of other abdominal arteries during percutaneous renal biopsy is exceedingly rare. We report herein a case of left superior colonic artery injury during ultrasonographically guided percutaneous renal biopsy, which was responsible for pseudoaneurysm formation and subsequent intra-abdominal hemorrhage and gastrointestinal bleeding. Arterial pseudoaneurysm was rapidly and successfully treated with minimally invasive endovascular treatment using microcoils. Superselective embolization stopped the bleeding and preserved colonic vascularization, thus preventing ischemia of the involved colonic segment.

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.

Severe postpartum haemorrhage from ruptured pseudoaneurysm: successful treatment with transcatheter arterial embolization.

The purpose of this retrospective study was to evaluate the role of transcatheter arterial embolization in the management of severe postpartum haemorrhage due to a ruptured pseudoaneurysm and to analyse the clinical symptoms that may suggest a pseudoaneurysm as a cause of postpartum haemorrhage. A retrospective search of our database disclosed seven women with severe postpartum haemorrhage in whom angiography revealed the presence of a uterine or vaginal artery pseudoaneurysm and who were treated using transcatheter arterial embolization. Clinical files were reviewed for possible clinical findings that could suggest pseudoaneurysm as a cause of bleeding. Angiography revealed extravasation of contrast material in five out of seven patients. Transcatheter arterial embolization allowed to control the bleeding in all patients and subsequently achieve vaginal suture in four patients with vaginal laceration. No complications related to transcatheter arterial embolization were noted. Only two patients had uterine atony, and inefficiency of sulprostone was observed in all patients. Transcatheter arterial embolization is an effective and secure technique for the treatment of severe postpartum haemorrhage due to uterine or vaginal artery pseudoaneurysm. Ineffectiveness of suprostone and absence of uterine atony should raise the possibility of a ruptured pseudoaneurysm.

Multicenter safety and efficacy analysis of assisted closure after antegrade arterial punctures using the StarClose device.

PURPOSE: To evaluate the safety and efficacy of the StarClose device for closure of antegrade punctures following infrainguinal endovascular interventions. METHODS: A retrospective review was conducted of 221 consecutive patients treated with the StarClose device in a 12-month period at 5 centers (4 French and 1 British). Of these, 107 patients (69 men; median age 75 years, range 44-93) were from the UK cohort (111 closures), and 94 patients (75 men; median age 67 years, range 32-95) were from the French cohort (111 closures). Technical success, complication rates, demographic data, medical history, and procedural details were gathered for all patients. Residual bleeding and the requirement for additional manual compression were recorded when the device failed. Clinical evaluation was performed at discharge; color-coded duplex ultrasonography was done in a subset of French patients. RESULTS: The overall technical success rate was 94.6% (210/222; 95% CI 3.1%-9.2%). The results were similar in the 2 cohorts: 95.5% (106/111; 95% CI 1.9%-10.1%) in the UK and 93.7% (104/111; 95% CI 3.1%-12.4%) in France. The 12 failures (5 UK and 7 France) were due to several mechanisms: device failure (n=5), obesity (n=1), groin scarring (n=2), and unexplained (n=4). In 2 failed cases, open surgical closure of the arteriotomy was performed because pressure hemostasis failed. Two pseudoaneurysms were observed: one after immediate failure was successfully treated by prolonged pressure; the other, after apparent success of the device, required surgical therapy. The incidence of serious vascular complication was 1.8% (4/222; 95% CI 0.7%-4.5%); 2 patients from each cohort. CONCLUSION: The StarClose device safely and effectively closes antegrade punctures after infrainguinal endovascular intervention, even in patients who would be considered to be at high risk for puncture-site bleeding. However, a randomized trial would be required to support any definitive recommendations.

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.

Midterm results of uterine artery embolization for symptomatic adenomyosis: initial experience.

PURPOSE: To prospectively evaluate the midterm results of uterine artery embolization for symptomatic adenomyosis. MATERIALS AND METHODS: The study protocol was approved by the institutional review board, and all participants gave written informed consent. Eighteen women (mean age, 44.3 years) with symptomatic adenomyosis were treated with bilateral embolization of the uterine arteries. The diagnosis of diffuse adenomyosis was based on heterogeneous abnormal myometrial echogenicity with myometrial cysts at ultrasonography (US) or on enlarged junctional zone and myometrial cysts at magnetic resonance (MR) imaging. Focal adenomyosis was diagnosed if there was a circumscribed nodular lesion mimicking intramural fibroid. All patients with associated uterine fibroids were excluded. Embolization was offered as an alternative to hysterectomy in all women. Clinical evaluation was made at regular intervals to assess patient outcome. Follow-up US or MR imaging was performed 6 months after embolization to assess uterine volume reduction. RESULTS: Bilateral uterine artery embolization was achieved in all but one woman by using polyvinyl alcohol particles or trisacryl microspheres. All women resumed normal menstruation after the procedure. After 6 months, 15 (94%) of 16 women reported improvement in menorrhagia. Follow-up images at 6 months depicted a slight decrease (mean, 15%) in uterine volume in 17 (94%) of 18 women. After 1 year, 11 (73%) of 15 women had improvement in menorrhagia, and eight (53%) of 15, complete resolution. After 2 years, five (56%) of nine women had complete resolution of menorrhagia. Eight (44%) of 18 women required additional treatment during follow-up for failure or recurrence; five women (28%) underwent hysterectomy. CONCLUSION: Even if short-term results of uterine artery embolization to treat adenomyosis appear encouraging, midterm results are disappointing, with only 55% of treated patients showing clinical improvement after 2 years.

Limited uterine artery embolization with tris-acryl gelatin microspheres for uterine fibroids.

PURPOSE: To evaluate the midterm results of limited embolization of the uterine arteries in the management of symptomatic uterine fibroids and to evaluate the efficacy and safety of limited uterine artery embolization (UAE) with use of calibrated tris-acryl gelatin microspheres in the management of symptomatic uterine fibroids. MATERIALS AND METHODS: Twenty women (mean age, 43 years) with symptomatic uterine fibroids underwent bilateral embolization of the uterine arteries with use of calibrated microspheres. Devascularization of the fibroids was achieved and the main uterine artery was left patent in all women. Embolization was offered as an alternative to surgery in all women who had been treated unsuccessfully with medical therapy. RESULTS: All procedures were technically successful. Microspheres 700-900 micro m in diameter were used in 14 women (70%). After a mean follow-up duration of 30.2 months (range, 24-48 mo), all women reported improvement in their symptoms, with 85% reporting complete resolution of menorrhagia at the most recent follow-up. One woman with multiple fibroids required a second embolization procedure because of persisting symptoms at 6 months. She is currently symptom-free after 48 months. In two women with submucosal fibroids, expulsion of necrotic fibroids occurred 2 and 7 months after the procedure, respectively. All women resumed normal menstruation after the procedure. One woman had a successful full-term pregnancy after embolization. CONCLUSION: Early experience with UAE with use of calibrated tris-acryl gelatin microspheres indicates that it is safe and efficacious in controlling menorrhagia.