Postpartum haemorrhage from ruptured pseudoaneurysm: efficacy of transcatheter arterial embolisation using N-butyl-2-cyanoacrylate

Transcatheter arterial embolization with N-butyl cyanoacrylate for postoperative hemorrhage treatment following pancreatoduodenectomy

PURPOSE

Postoperative hemorrhage (PPH) is a severe complication of pancreatoduodenectomy (PD) with a mortality rate of 5-20.2% and mortality due to hemorrhage of 11-58%. Transcatheter arterial embolization (TAE) has been widely recommended for PPH, however, TAE with N-butyl cyanoacrylate (NBCA) for PPH treatment has been reported rarely. Therefore, this study aimed to evaluate the safety and efficacy of TAE with NBCA for PPH treatment following PD.

METHODS

This retrospective study included 14 male patients (mean age, 60.93 ± 10.97 years) with postoperative hemorrhage following PD treated with TAE using NBCA as the main embolic agent from October 2019 to February 2022. The clinical data, technical and success rate, and complications were analyzed.

RESULTS

Among the 14 patients who underwent TAE, the technical and clinical success rates were 100 and 85.71%, respectively. Angiography revealed contrast extravasation in 12 cases and a pseudoaneurysm in 3 cases. One patient developed a serious infection and died 2 days after the TAE.

CONCLUSION

TAE with NBCA for PPH treatment following PD, especially for massive hemorrhage caused by a pancreatic fistula, biliary fistula, or inflammatory corrosion, can result in rapid and effective hemostasis with high safety.

Animal models of postpartum hemorrhage

Postpartum hemorrhage (PPH)-heavy bleeding following childbirth-is a leading cause of morbidity and mortality worldwide. PPH can affect individuals regardless of risks factors and its incidence has been increasing in high-income countries including the United States. The high incidence and severity of this childbirth complication has propelled research into advanced treatments and alternative solutions for patients facing PPH; however, the development of novel treatments is limited by the absence of a common, well-established and well-validated animal model of PPH. A variety of animals have been used for in vivo studies of novel therapeutic materials; however, each of these animals differs considerably from the anatomy and physiology of a postpartum woman, and the methods used for achieving a postpartum hemorrhagic condition vary widely. Here we critically evaluate the various animal models of PPH presented in the literature and propose additional and alternative methods for modeling PPH in in vivo studies. We highlight how current animal models successfully or unsuccessfully mimic the anatomy and physiology of a postpartum woman and how this may impact treatment development. We aim to equip researchers with the necessary background information to select appropriate animal models for their research related to PPH solutions, while supporting the goals of refinement, reduction and replacement (3Rs) in preclinical animal studies.

Usefulness of transcatheter arterial embolization for eighty-three patients with secondary postpartum hemorrhage: Focusing on difference in angiographic findings

BACKGROUND

Transcatheter arterial embolization (TAE) has been widely used as an effective and a safe treatment method and was often used as an alternative to the surgical management, but there are limited studies on the efficacy and the safety for patients undergoing their secondary postpartum hemorrhage (PPH).

AIM

To evaluate the usefulness of TAE for secondary PPH focusing on the angiographic findings.

METHODS

We conducted a research from January 2008 to July 2022 on all 83 patients (mean: 32 years, range: 24-43 years) presented with secondary PPH and they were treated with TAE in two university hospitals. The medical records and angiography were retrospective reviewed in order to evaluate the patients’ characteristics, delivery details, clinical status and peri-embolization management, angiography and embolization details, technical/clinical success and complications. The group with active bleeding sign and the group without it were also compared and analyzed.

RESULTS

On angiography, 46 (55.4%) patients showed active bleeding signs such as contrast extravasation (n = 37) or pseudoaneurysm (n = 8) or both (n = 1), and 37 (44.6%) patients showed non-active bleeding signs such as only spastic uterine artery (n = 2) or hyperemia (n = 35). In the active bleeding sign group there were more multiparous patients, low platelet count, prothrombin time prolongation, and high transfusion requirements. The technical success rates were 97.8% (45/46) in active bleeding sign group and 91.9% (34/37) in non-active bleeding sign group, and the overall clinical success rates were 95.7% (44/46) and 97.3% (36/37). An uterine rupture with peritonitis and abscess formation occurred to one patient after the embolization, therefore hysterostomy and retained placenta removal were performed which was a major complication.

CONCLUSION

TAE is an effective and a safe treatment method for controlling secondary PPH regardless of angiographic findings.

Comparison of n-butyl-2-cyanoacrylate and polyvinyl alcohol particles for bronchial artery embolisation in primary lung cancer: a retrospective cohort study

BACKGROUND

Bronchial artery embolisation (BAE) is an effective treatment option to control haemoptysis in primary lung cancer. However, no studies have investigated optimal embolisation material for BAE in lung cancer patients. Thus, this study aimed to compare the safety and efficacy of BAE performed using n-butyl-2-cyanoacrylate (NBCA) and polyvinyl alcohol (PVA) particles in primary lung cancer patients to determine which embolic material is better for patients with haemoptysis.

METHODS

This retrospective study was approved by the institutional review board, and consent was waived. The rates of hemostasis, complications, procedure time, dose-area product, and haemoptysis-free survival were retrospectively compared between primary lung cancer (non-small cell [n = 111] and small cell [n = 11]) patients who underwent BAE using NBCA (n = 58) or PVA particles (n = 64) between January 2004 and December 2019. Predictors of recurrent haemoptysis were analysed using the Cox proportional hazard regression model.

RESULTS

Among 122 patients (mean age, 66 ± 10 years; range 32-86 years; 103 men), more patients in the NBCA group (81.0%; 47 of 58) achieved complete hemostasis than did patients in the PVA group (53.1%; 34 of 64) (P = 0.002). No major complications were observed in either group. The procedure time (36.4 ± 21.6 vs. 56.3 ± 27.4 min, P < 0.001) was shorter, and the dose-area product (58.6 ± 64.0 vs. 233.5 ± 225.0 Gy*cm², P < 0.001) was smaller in the NBCA group than in the PVA group. The median haemoptysis-free survival was 173.0 in the NBCA group compared with 20.0 days in the PVA group (P < 0.001). The PVA use (P < 0.001) and coagulopathy (P = 0.014) were independent predictors of shortened haemoptysis-free survival.

CONCLUSION

BAE using NBCA showed significantly superior initial hemostasis with longer haemoptysis-free survival, shorter procedure time, and reduced radiation dose than BAE using PVA particles. The PVA use and coagulopathy were independent predictors of recurrent haemoptysis.

TRIAL REGISTRATION

Retrospectively registered.

Endovascular Embolisation Using N-Butyl-2-Cyanoacrylate: An Effective Treatment Option for Uterine Artery Pseudoaneurysm in Postpartum Hemorrhage

In this case series, we evaluated the efficacy and safety of uterine artery embolization (UAE) using N-butyl- 2-cyanoacrylate (NBCA)/glue for the treatment of uterine artery pseudoaneurysm (UAP). Here, we report 8 patients with uterine artery pseudoaneurysm, who underwent UAE using NBCA/glue. Angiograms and medical records were retrospectively analyzed to determine the technical success, clinical success, complications, average procedure time, the average duration of hospital stay after UAE. All patients were presented with secondary postpartum hemorrhage with hemodynamic instability. The technical and clinical success rates were 100%, respectively. The average procedure time was 21minutes and the average duration of hospital stay was 2.2 days. We did not encounter any major complications. Two patients following UAE were naturally conceived and delivered by repeat LSCS. UAE using NBCA/glue is a safe and effective treatment option for UAP in both hemodynamically stable and unstable patients.

Efficacy of superselective transcatheter arterial embolization for intractable postpartum hemorrhage due to genital tract trauma after vaginal delivery

Purpose

To evaluate the efficacy of superselective transcatheter arterial embolization (TAE) for intractable postpartum hemorrhage (PPH) due to genital tract trauma (GTT) after vaginal delivery.

Methods

We evaluated 27 patients who underwent TAE for intractable PPH due to GTT after vaginal delivery at our institution between January 2008 and December 2020. Patients were divided into two groups according to TAE procedure; TAE performed as close as possible to the bleeding point, at least more peripherally than the second branch of the anterior division of the internal iliac artery, was defined as superselective TAE (S-TAE). TAE performed from the proximal segment of the internal iliac artery was defined as proximal TAE (P-TAE). Patient characteristics, pre-procedural contrast-enhanced computed tomography (CE-CT), procedure details, technical/clinical success, and complications were evaluated separately for the S-TAE and P-TAE groups.

Results

The combined technical/clinical success rate was 92%. No major procedure-related complications were seen (mean follow-up: 6.12 ± 3.93 days). The combined technical/clinical success rate of S-TAE was 100% and of P-TAE was 67% (p = 0.04). S-TAE was performed more frequently in patients with pre-procedural CE-CT (p = 0.01) and use of permanent embolic materials (p = 0.003).

Conclusion

S-TAE is safe and effective for intractable PPH due to GTT. Pre-procedural CE-CT may be useful for detecting the culprit artery and be helpful in performing S-TAE.

Uterine artery pseudoaneurysm in pregnant women with previous pelvic endometriosis

Uterine artery pseudoaneurysm (UAP) is a rare complication during pregnancy that can cause serious consequences in both the pregnant woman and the fetus. Herein, we have described the cases of two pregnant women with UAP. Both patients had a history of laparoscopy for management of endometrioid ovarian cysts. Neither patient was operated in the retroperitoneum or around the uterine vessels. UAP was diagnosed by Doppler ultrasonography and confirmed by magnetic resonance imaging. Due to exacerbation of hypogastric pain, the first patient was treated shortly after admission to the hospital at the 23rd week of gestation by endovascular intervention with occlusion of the UAP using microcoils. The patient's complaints resolved immediately, and a healthy baby was delivered via planned Cesarean section at the 38th gestational week. In the second case with twin pregnancy, angiography was performed at the 27th gestational week; however, the feeding vessel of the UAP could not be identified. The patient was followed up at weekly intervals, and due to increasing left hypogastric pain, cesarean section was performed at the 33rd gestational week. During surgery, the left internal iliac artery was ligated and the entire pseudoaneurysm was successfully removed. Both women gave birth to healthy neonates; however, the therapeutic approaches were distinct in both cases. As the previous laparoscopic surgeries in both patients were performed only in the adnexal area, and not around the uterine arteries in the parametria, the endometrial decidual reaction could have caused the UAPs in the described cases.

Transcatheter Arterial Embolization in the Management of Postpartum Hemorrhage due to Genital Tract Injury after Vaginal Delivery

PURPOSE

To evaluate efficacy and safety of transcatheter arterial embolization (TAE) in managing postpartum hemorrhage (PPH) due to genital tract injury after vaginal delivery and to investigate factors associated with outcome of TAE.

MATERIALS AND METHODS

A retrospective review of 43 women (mean age, 32.6 years) who underwent TAE to manage PPH secondary to genital tract injury after vaginal delivery was performed at a single institution between January 2007 and December 2018. Clinical data and outcomes were obtained. Patients were classified into clinical success (n = 39) and failure (n = 4) groups, and comparisons between the groups were performed.

RESULTS

The clinical success rate of TAE for PPH due to genital tract injury was 90.7%. In the clinical failure group, transfusion volumes were higher (failure vs success: packed red blood cells, 14 pt ± 3.37 vs 6.26 pt ± 4.52, P = .003; platelets, 10.33 pt ± 4.04 vs 2.92 pt ± 6.15, P = .036); hemoglobin levels before the procedure were lower (failure vs success: 7.3 g/dL vs 10.7, P = .016). Periprocedural complications included pulmonary edema (25.6%), fever (23.3%), and pain (9.3%). Twenty-four patients were either followed for > 6 months or answered a telephone survey; 23 (95.8%) recovered regular menstruation, and pregnancy was confirmed in 11 (45.8%). Regarding fertility desires, 7 women attempted to conceive, 6 of whom (85.7%) became pregnant.

CONCLUSIONS

TAE is an effective and safe method for managing PPH due to genital tract injury after vaginal delivery. Lower hemoglobin levels before the procedure and higher transfusion volumes were associated with clinical failure of TAE.

Pelvic arterial embolisation with cyanoacrylate during caesarean hysterectomy for placenta accreta

PURPOSE

To compare n-butyl cyanoacrylate (NBCA) and gelatine sponge (GS) as embolic materials for prophylactic pelvic arterial embolisation during caesarean hysterectomy for placenta accreta spectrum (PAS).

MATERIAL AND METHODS

This retrospective study comprised 12 women (age range, 23-42 years; mean, 34.1 years) who underwent caesarean hysterectomy for PAS. Following caesarean delivery, bilateral uterine and non-uterine parasitic arteries were embolized with GS in the first four cases (GS group) and primarily with NBCA mixed with iodized oil in the subsequent eight cases (NBCA group). Procedure time for embolisation and hysterectomy and total blood loss were compared between the two groups using Welch's t-test.

RESULTS

Although procedure time for embolisation tended to be longer in the NBCA group than in the GS group (111 ± 47 min versus 71 ± 32 min, p=.11), that for hysterectomy was significantly reduced in the NBCA group when compared to the GS group (158 ± 42 min versus 236 ± 39 min, p=.02). Total blood loss was significantly lower in the NBCA group than in the GS group (1375 ± 565 mL versus 2668 ± 587 mL, p=.01).

CONCLUSION

Procedure time for hysterectomy and total blood loss during caesarean hysterectomy can be reduced by using NBCA instead of GS in prophylactic pelvic arterial embolisation for PAS.

Uterine Artery Pseudoaneurysm: A Life-Threatening Cause of Vaginal Bleeding in the Emergency Department

BACKGROUND

Vaginal bleeding is a common presenting complaint in the emergency department (ED); life-threatening hemorrhage is rare. Uterine artery pseudoaneurysm (UAP) is an uncommon but potentially life-threatening cause of vaginal bleeding that is most likely to present primarily to EDs, given its delayed postpartum or postoperative presentation.

CASE REPORT

A 25-year-old female gravida two, para one, who was 19 days post dilation and evacuation for an elective termination of a pregnancy at 20 weeks, presented to the ED with profuse vaginal bleeding. She was hypotensive and tachycardic at presentation, requiring resuscitation with 0.9% normal saline and transfusions of packed red blood cells. Transvaginal ultrasound completed in the ED demonstrated a pulsatile mass in the cervix with internal "ying-yang" flow on Doppler images, suggestive of a uterine artery pseudoaneurysm within the cervix. The patient underwent emergent uterine artery embolization with resolution of bleeding and improvement in her hemodynamic status. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: UAP is an uncommon cause of vaginal bleeding, but UAP rupture can be life-threatening. UAP is an important differential diagnosis for vaginal bleeding, particularly in the postpartum or postoperative setting. Delaying diagnosis may worsen bleeding in the setting of a ruptured UAP if treatment is pursued for alternative diagnosis; for example, treating retained products of conception with a dilation and curettage. Being aware of UAP and how to diagnose it will allow early proper treatment and more favorable patient outcomes.

Postpartum hemorrhage from non-uterine arteries: clinical importance of their detection and the results of selective embolization

Background Identification of the source of postpartum hemorrhage (PPH) is important for embolization because PPH frequently originates from non-uterine arteries. Purpose To evaluate the clinical importance of identifying the non-uterine arteries causing the PPH and the results of their selective embolization. Material and Methods This retrospective study enrolled 59 patients who underwent embolization for PPH from June 2009 to July 2016. Angiographic findings and medical records were reviewed to determine whether non-uterine arteries contributed to PPH. Arteries showing extravasation or hypertrophy accompanying uterine hypervascular staining were regarded as sources of the PPH. The results of their embolization were analyzed. Results Of 59 patients, 19 (32.2%) underwent embolization of non-uterine arteries. These arteries were ovarian (n = 7), vaginal (n = 5), round ligament (n = 5), inferior epigastric (n = 3), cervical (n = 2), internal pudendal (n = 2), vesical (n = 1), and rectal (n = 1) arteries. The embolic materials used included n-butyl cyanoacrylate (n = 9), gelatin sponge particles (n = 8), gelatin sponge particles with microcoils (n = 1), and polyvinyl alcohol particles (n = 1). In 13 patients, bilateral uterine arterial embolization was performed. Re-embolization was performed in two patients with persistent bleeding. Hemostasis was achieved in 17 (89.5%) patients. Two patients underwent immediate hysterectomy due to persistent bleeding. One patient experienced a major complication due to pelvic organ ischemia. One patient underwent delayed hysterectomy for uterine infarction four months later. Conclusion Non-uterine arteries are major sources of PPH. Detection and selective embolization are important for successful hemostasis.

Clinical outcomes of 23 patients who had repeat pelvic arterial embolisation for uncontrolled post-partum haemorrhage at a single centre

AIM

To evaluate the safety and efficacy of repeated pelvic arterial embolisation (PAE) for uncontrolled postpartum haemorrhage (PPH) after a single session of PAE and to compare angiographic findings between the two sessions of PAE.

MATERIALS AND METHODS

A total of 23 consecutive patients (age range, 23-44 years) who underwent repeated PAE for uncontrolled PPH between March 2001 and January 2016 in Severance Hospital were reviewed. The interval times between the two sessions of PAE, the angiographic findings, embolic materials, arteries embolised during PAE, and the clinical outcomes were reviewed retrospectively.

RESULTS

Overall clinical success was achieved after repeated PAE in 21 of 23 patients (91.3%). There were no procedure-related, major complications. On angiography, active bleeding from the uterine collateral arteries was more frequently observed in the second session of PAE (p>0.05), and embolisation of the anterior division of the internal iliac artery was significantly higher during the second session of PAE. Use of permanent embolic materials was significantly higher during the second session of PAE. Recanalisation of a previously embolised artery was identified in 14 patients (60.9%) during the second session.

CONCLUSION

Repeated PAE is safe and effective for managing recurrent bleeding after a single session of PAE. Repeated PAE is related to a higher chance of embolisation of the anterior division of the internal iliac artery, with the use of permanent embolic materials. Recanalisation of a previously embolised artery seems to be a principal source of rebleeding during a repeated session of PAE.

Recent Update of Embolization of Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is a life-threatening condition and remains a leading cause of maternal mortality. Transcatheter arterial embolization (TAE) is an effective therapeutic strategy for PPH with the advantages of fast speed, repeatability, and the possibility of fertility preservation. We reviewed the vascular anatomy relevant to PPH, the practical details of TAE emphasizing the timing of embolization, and various clinical conditions of PPH according to a recent literature review.

Long-term uterine balloon tamponade for treatment and obliteration of ruptured uterine pseudoaneurysm

OBJECTIVE

Rupture of uterine artery pseudoaneurysm (UAP) is a life-threatening event after childbirth. Hysterectomy or uterine arterial embolization was often needed for hemostasis. However, such procedures may cause severe morbidities for these women. To estimate the efficacy of uterine balloon tamponade (UBT) for controlling ruptured UAP bleeding, a retrospective analysis in a single teaching hospital was performed.

MATERIALS AND METHODS

We reviewed the medical record of Juntendo University Hospital in 2015. All the women diagnosed with UAP were recruited to this study and management for UAP was investigated.

RESULTS

Three women were treated with UBT for ruptured UAP. All cases achieved hemostasis. One case had recurrent UAP after 24 h of UBT, and was retreated with UBT for a longer duration. The UAP was obliterated after more than 2 days of UBT in all cases.

CONCLUSION

UBT has potential as a therapeutic technique not only for treatment of a ruptured UAP but also for obliteration of a UAP.

Postpartum haemorrhage due to genital tract injury after vaginal delivery: safety and efficacy of transcatheter arterial embolisation

OBJECTIVES

To evaluate the safety and efficacy of transcatheter arterial embolisation (TAE) managing postpartum haemorrhage associated with genital tract injury (PPH-GTI) and to determine the factors associated with clinical outcomes.

METHODS

From 2002 to 2017, a retrospective analysis was performed in 60 patients (mean 31.5 years) undergoing TAE for PPH-GTI. Information regarding clinical data, angiography and embolisation details, and clinical outcomes was obtained. Univariate analyses were performed to determine the factors related to clinical outcomes.

RESULTS

Technical and clinical success was achieved in 98% and 88%, respectively. Bleeding foci were observed on angiography in 56 patients (93%). The major bleeding artery was the vaginal artery (32%, 24/74), followed by the uterine artery (cervicovaginal branch) (n = 18), internal pudendal artery (n = 13), cervical artery (n = 9), inferior mesenteric artery (n = 4) and external pudendal artery (n = 3). Embolic agents were gelatin sponge particles (n = 23), gelatin sponge with permanent embolic agents (microcoils, n-butyl cyanoacrylate) (n = 34) and permanent embolic agents only (n = 3). In seven patients, bleeding control failed and was managed by repeat TAE (n = 5) or surgery (n = 2) and with eventual bleeding control in all of these patients. Univariate analysis showed that paravaginal haematoma, massive transfusion and long hospital stay were related to clinical failure. During the mean follow-up period of 33.1 months, regular menstruation resumed in 95.2% (40/42) and 14 of them became pregnant.

CONCLUSIONS

TAE is safe and effective for treating PPH-GTI. Massive transfusion, paravaginal haematoma and long hospital stay were related to the failure of bleeding control.

KEY POINTS

• PPH-GTI had a high detection rate of active bleeding foci on angiography. • Besides vaginal artery, inferior mesenteric and external pudendal arteries were notable bleeding foci. • Permanent embolic agents were used more than only gelatin sponge particles. • Paravaginal haematoma and massive transfusion were related to clinical failure. • TAE for PPH-GTI was safe and effective with preservation of menstrual cycles.

Delayed hemorrhage as a result of ruptured uterine artery pseudoaneurysm after transmyometrial oocyte retrieval: Management by transcatheter arterial embolization using N-butyl-2-cyanoacrylate

Uterine artery pseudoaneurysm is a rare but potentially life-threatening complication that can occur after various uterine manipulations. A 34-year-old nulliparous patient with a previous history of four consecutive miscarriages with unknown etiologies underwent transmyometrial oocyte retrieval as a result of malpositioning of the right ovary. Six days later, she experienced massive vaginal bleeding after a day of intermittent bleeding and was transferred to our hospital. At triage, continuous bleeding from the cervical canal was observed. Color Doppler ultrasonography and three-dimensional computerized tomographic angiography revealed a ruptured pseudoaneurysm originating from the peripheral branch of the right uterine artery in the lower uterine segment. It was successfully treated by transcatheter arterial embolization with N-butyl-2-cyanoacrylate. Transcatheter arterial embolization with N-butyl-2-cyanoacrylate is a feasible option for uterus-preserving management of late massive hemorrhage resulting from a ruptured uterine artery pseudoaneurysm after transmyometrial oocyte retrieval.

Use of uterine artery embolization to prevent peripartum hemorrhage of placental abruption with fetal demise & severe DIC

Uterine artery embolization (UAE) is typically not indicated in the pre-operative management of pregnancies with a live fetus, because risk of fetal death from reduced uteroplacental blood flow. However, pre-operative UAE in pregnancies with a fetal demise poses no fetal risk, and may offer maternal benefits. Patients with placental abruption resulting in fetal demise are at high-risk for developing disseminated intravascular coagulation (DIC), which could have devastating complications such as peri-operative hemorrhage and death. This case report describes the first successful execution of a pre-operative UAE that effectively prevented antepartum and postpartum hemorrhage in a patient with DIC secondary to a placental abruption and recent fetal demise.

Uterine artery pseudoaneurysm: its occurrence after non-traumatic events, and possibility of "without embolization" strategy

OBJECTIVES

Uterine artery pseudoaneurysm (UAP) has been considered to occur very rarely after traumatic delivery/abortion, and is usually detected after its rupture, yielding massive bleeding. Our hypothesis is: some UAP may be undetected without massive bleeding and may spontaneously resolve, and, thus, may not require transarterial embolization (TAE). We attempted: (1) to detect both ruptured and non-ruptured UAP, thereby characterizing candidates of spontaneously resolving UAP, and (2) to confirm that UAP is not rare and not always associated with traumatic events.

STUDY DESIGN

This was a retrospective observational study of 50 women with angiographically confirmed UAP and treated by TAE. Angiograms and medical charts were retrieved to examine the associations among symptoms, ultrasound findings, and extravasation. Gray-scale ultrasound was performed for all women after delivery or abortion as our routine practice.

RESULTS

UAP occurred in 3-6/1000 deliveries and 40% occurred after non-traumatic deliveries/abortion. While 36% had active vaginal bleeding at admission, 64% did not. While 100% of patients with current active bleeding showed extravasation from the pseudoaneurysmal sac, patients without it showed a varied incidence of extravasation depending on the bleeding pattern/history and ultrasound findings. Interestingly, all patients with current bleeding (-), bleeding history (+), and ultrasound-discernable-intrauterine low echoic mass (-) were devoid of extravasation, suggesting that UAP may show progression to thrombosis and, thus, resolve spontaneously.

CONCLUSIONS

UAP may not be so rare and not associated with traumatic delivery/abortion. Some UAP may resolve, and, thus, may not require TAE, at least immediately.

Outcomes of pelvic arterial embolization in the management of postpartum haemorrhage: a case series study and systematic review

BACKGROUND

Postpartum haemorrhage (PPH) is an unpredictable obstetric emergency that requires a multidisciplinary approach. Pelvic arterial embolization (PAE) is considered as a second-line treatment, although the published results have not been reviewed systematically since 2007.

OBJECTIVES

To evaluate success and complication rates of PAE to treat PPH in the study hospital between 2009 and 2015, and to perform a systematic review of the literature on the reported efficacy and safety of PAE for the management of PPH.

SEARCH STRATEGY

A systematic review of articles on PAE in English or Spanish was conducted using Medline and the Cochrane Library.

SELECTION CRITERIA

All published articles assessing success and complication rates of PAE in cases of PPH. The search was restricted to articles published in English or Spanish between 2000 and 2015, with at least 25 cases.

DATA COLLECTION AND ANALYSIS

Obstetric variables, maternal haemodynamic state, pre-/postembolization management, technique-related variables, post-PAE evolution and complications were recorded in the case series study. Study characteristics, success rates and PAE-related complication rates were recorded in the systematic review.

MAIN RESULTS

The case series included 29 patients. The majority of these patients were primiparous, with singleton term pregnancies and spontaneous labour. Caesarean section was performed in 62.1% of patients undergoing PAE for PPH. PAE was successful in 89.6% [95% confidence interval (CI) 78.3-100] of cases. Twenty studies were included in the systematic review, providing data from 1739 patients. PAE was successful in 89.4% (95% CI 87.9-90.9) of cases. The mortality rate was 0.9%, and other major complications were uncommon (1.8%).

CONCLUSIONS

PAE was found to be a minimally invasive, highly successful and safe technique for the management of PPH. It should be considered in PPH refractory to initial treatment.

Endovascular Management of Intractable Postpartum Hemorrhage Caused by Vaginal Laceration

PURPOSE

We evaluated the management of transcatheter arterial embolization for postpartum hemorrhage caused by vaginal laceration.

MATERIALS AND METHODS

We reviewed seven cases of patients (mean age 30.9 years; range 27-35) with intractable hemorrhages and pelvic hematomas caused by vaginal lacerations, who underwent superselective transcatheter arterial embolization from January 2008 to July 2014. Postpartum hemorrhage was evaluated by angiographic vascular mapping to determine the vaginal artery's architecture, technical and clinical success rates, and complications.

RESULTS

The vaginal artery was confirmed as the source of bleeding in all cases. The artery was found to originate from the uterine artery in three cases, the uterine and obturator arteries in two, or the internal pudendal artery in two. After vaginal artery embolization, persistent contrast extravasation from the inferior mesenteric artery as an anastomotic branch was noted in one patient. Nontarget vessels (the inferior vesical artery and nonbleeding vaginal arterial branches) were embolized in one patient. Effective control of hemostasis and no post-procedural complications were confirmed for all cases.

CONCLUSION

Postpartum hemorrhages caused by vaginal lacerations involve the vaginal artery arising from the anterior trunk of the internal iliac artery with various branching patterns. Superselective vaginal artery embolization is clinically acceptable for the successful treatment of vaginal laceration hemorrhages, with no complications. After vaginal artery embolization, it is suggested to check for the presence of other possible bleeding vessels by pelvic aortography with a catheter tip at the L3 vertebral level, and to perform a follow-up assessment.

Post-partum hemoperitoneum: Do not miss false aneurysm as a cause of bleeding

A 27-year-old woman underwent a first vaginal delivery at our institution. She returned four days after delivery, presenting with abdominal pain and an unexplained drop in her hemoglobin value, without external bleeding. The initial computed tomography abdominal scan revealed an isolated diffuse hemoperitoneum. A laparoscopy did not find the cause of bleeding. A second computed tomography scan, performed 15 days later, revealed hemoperitoneum associated with a false aneurysm of the right uterine artery. Treatment consisted of embolization of the uterine arteries, with clinical success. False aneurysms are a rare cause of intra-abdominal non-exteriorized bleeding in late post-partum hemorrhage.

Transcatheter Arterial Embolization of Ruptured Inferior Phrenic Artery Pseudoaneurysm Following Completion Gastrectomy

A 56-year-old man underwent completion gastrectomy and regional lymphadenectomy for adenocarcinoma of the remnant stomach. Postoperatively, he developed an esophagojejunal anastomotic insufficiency associated with leakage of activated pancreatic juice, resulting in pseudoaneurysm arising from the inferior phrenic artery (IPA) with massive bleeding. Emergency angiography was performed, and the artery was successfully embolized using N-butyl cyanoacrylate. Pseudoaneurysm of the IPA is an extremely rare entity, and transcatheter arterial embolization is an effective treatment method because of its advantages over surgery.

Clinical efficacy of transcatheter embolization of visceral artery pseudoaneurysms using N-butyl cyanoacrylate (NBCA)

PURPOSE

Transcatheter endovascular embolization within a reasonable time before rupture or deterioration of a patient's general condition is an important procedure for managing visceral pseudoaneurysms. N-butyl 2-cyanoacrylate (NBCA, enbucrilate) is an embolic material used in the blockade of visceral pseudoaneurysms. This study evaluated the clinical efficacy of transcatheter embolization of visceral artery pseudoaneurysms using NBCA.

PATIENTS AND METHODS

Between June 2004 and February 2014, 13 patients (9 males and 4 females; age range, 26-80years; mean, 57.9years) with 14 pseudoaneurysms were treated by transcatheter embolization using NBCA. NBCA was mixed with iodized oil at a 1:3 ratio to control its polymerization time and to render it radiopaque. Pseudoaneurysms were located on the gastroduodenal artery (n=1), pancreaticoduodenal artery (n=2), dorsal pancreatic artery (n=1), proximal jejunal artery (n=1), colic artery (n=1), splenic artery (n=3), renal artery (n=4; two in one patient), and hepatic artery (n=1).

RESULTS

All patients recovered immediately following the embolization procedure, and two patients showed minor complications that required only medical observation.

CONCLUSIONS

Transcatheter embolization using NBCA for the treatment of visceral pseudoaneurysms is a safe, effective, and low-cost treatment method with a high success rate.

Postpartum hemorrhage from extravasation or pseudoaneurysm: efficacy of transcatheter arterial embolization using N-butyl cyanoacrylate and comparison with gelatin sponge particle

PURPOSE

To evaluate the safety and effectiveness of transcatheter arterial embolization (TAE) using N-butyl cyanoacrylate (NBCA) for the treatment of active postpartum hemorrhage (PPH) and compare the efficacy of NBCA with gelatin sponge particles.

MATERIALS AND METHODS

From January 2004 to September 2013, 26 patients with PPH underwent TAE using NBCA as the primary embolic material. All patients were actively bleeding, and 12 (46.2%) had coagulopathy. TAE was performed using 1:2-1:4 mixtures of NBCA and ethiodized oil with or without use of a coil or gelatin sponge. To compare the efficacy of NBCA with conventional embolic material, 50 patients with active bleeding who underwent TAE using gelatin sponge were also analyzed.

RESULTS

Angiograms demonstrated pseudoaneurysm or extravasation or both. The technical and clinical success rates were 100% and 92.3% (24 of 26 patients), respectively, for NBCA and 98% and 86.0% (43 of 50 patients), respectively, for gelatin sponge. In the NBCA group, one patient recovered with conservative management, and the other patient died because of multiorgan dysfunction. There were no major or minor procedure-related complications.

CONCLUSIONS

TAE using NBCA as the primary embolic agent is an effective method for treating PPH with extravasation or pseudoaneurysm; NBCA is comparable to gelatin sponge particles. TAE using NBCA seems to fill pseudoaneurysms and make devascularization more effective than using gelatin sponge.

Transcatheter arterial embolization for secondary postpartum hemorrhage: outcome in 52 patients at a single tertiary referral center

PURPOSE

To assess the safety and efficacy of transcatheter arterial embolization (TAE) for the management of secondary postpartum hemorrhage (PPH) and to determine the factors associated with the clinical outcomes.

MATERIALS AND METHODS

A retrospective analysis of 52 patients (mean age, 31.6 y; range, 25-40 y) undergoing TAE for secondary PPH was performed. Clinical data, including maternal characteristics, delivery details, embolization details, and transfusion requirements, were obtained. Univariate analyses were performed to determine the factors related to clinical outcomes.

RESULTS

The major cause of bleeding was retained placental tissue (44.2%; 23 of 52). Actively bleeding foci were observed in 25 (48.1%) patients. Technical and clinical successes were achieved in 100% and 90.4% (47 of 52) of patients, respectively. Gelatin sponge particles with (n = 10) or without (n = 38) permanent embolic materials, such as microcoils or N-butyl cyanoacrylate, were most commonly used (92.3%; 48 of 52), whereas permanent embolic materials alone were used in 7.7% (4 of 52) of patients. In five patients, embolization failed, and these patients were managed by hysterectomy (n = 3), repeat TAE (n = 1), or conservative management (n = 1). Bleeding control was eventually achieved in all five patients. No maternal risk factors were related to clinical results. The median and mean follow-up periods were 3 months and 12.6 months (range, 1-62 mo). Regular menstruation resumed in all 44 patients with available follow-up, and 5 of the patients became pregnant.

CONCLUSIONS

TAE for secondary PPH is safe and effective and showed technical and clinical success in 100% and 90.4% of patients, respectively. Approximately half of these patients showed a positive bleeding focus, and the use of permanent embolic materials was also common.

Post-operative hemorrhage after myomectomy: safety and efficacy of transcatheter uterine artery embolization

Objective

To evaluate the safety and clinical efficacy of transcatheter uterine artery embolization (UAE) for post-myomectomy hemorrhage.

Materials and Methods

We identified eight female patients (age ranged from 29 to 51 years and with a median age of 37) in two regional hospitals who suffered from post-myomectomy hemorrhage requiring UAE during the time period from 2004 to 2012. A retrospective review of the patients' clinical data, uterine artery angiographic findings, embolization details, and clinical outcomes was conducted.

Results

The pelvic angiography findings were as follows: hypervascular staining without bleeding focus (n = 5); active contrast extravasation from the uterine artery (n = 2); and pseudoaneurysm in the uterus (n = 1). Gelatin sponge particle was used in bilateral uterine arteries of all eight patients, acting as an empirical or therapeutic embolization agent for the various angiographic findings. N-butyl-2-cyanoacrylate was administered to the target bleeding uterine arteries in the two patients with active contrast extravasation. Technical and clinical success were achieved in all patients (100%) with bleeding cessation and no further related surgical intervention or embolization procedure was required for hemorrhage control. Uterine artery dissection occurred in one patient as a minor complication. Normal menstrual cycles were restored in all patients.

Conclusion

Uterine artery embolization is a safe, minimally invasive, and effective management option for controlling post-myomectomy hemorrhage without the need for hysterectomy.