An unusual arterial supply to the uterus. A case report and review of anatomy-implications for uterine artery embolization

Update on Endovascular Therapy for Fibroids and Adenomyosis

Uterine fibroids and adenomyosis are prevalent benign neoplasms that can lead to serious deleterious health effects including life-threatening anemia, prolonged menses, and pelvic pain; however, up to 40% of women remain undiagnosed. Traditional treatment options such as myomectomy or hysterectomy can effectively manage symptoms but may entail longer hospital stays and hinder future fertility. Endovascular treatment, such as uterine artery embolization (UAE), is a minimally invasive procedure that has emerged as a well-validated alternative to surgical options while preserving the uterus and offering shorter hospital stays. Careful patient selection and appropriate techniques are crucial to achieving optimal outcomes. There have been advancements in recent times that encompass pre- and postprocedural care aimed at enhancing results and alleviating discomfort prior to, during, and after UAE. Furthermore, success and reintervention rates may also depend on the size and location of the fibroids. This article reviews the current state of endovascular treatments of uterine fibroids and adenomyosis.

From Where Does the Uterine Artery Originate? A Prospective, Observational Laparoscopic Anatomic Study

STUDY OBJECTIVE

To determine and categorize the anatomic variations of the uterine artery (UA) as observed during laparoscopic hysterectomy with retroperitoneal dissection for benign conditions.

DESIGN

A prospective, observational study.

SETTING

A hospital department of obstetrics and gynecology, Uludag University Hospital, Bursa, Turkey.

PATIENTS

A total of 378 female patients who presented with indications for laparoscopic hysterectomy for benign disease.

INTERVENTIONS

Laparoscopic hysterectomy with retroperitoneal dissection was performed bilaterally in all patients between March 2014 and October 2018. The vascular anatomy beginning at the bifurcation of the common iliac artery down to the crossing of the UA with the ureter was exposed and subsequently studied. The UA was identified, and its variable branching patterns were recorded. The patterns were then categorized into groups adapted from classic vascular anatomy studies.

MEASUREMENTS AND MAIN RESULTS

Retroperitoneal dissections of 756 UAs were performed in 378 female patients. The UA was the first anterior branch of the internal iliac artery in 80.9% of the cases (Model 1; Main Model). Three additional models adequately described other variations of the UA as follows: Model 2 (Cross Model), 3.7%; Model 3 (Trifurcation Model), 3.1%; and Model 4 (Inverted-Y Model), 7.4%. The origin of the UA could not be determined in 7.4% of the cases.

CONCLUSION

The UA is the first anterior branch of the internal iliac artery in more than 80% of females. Surgeons should be aware of the anatomic variations of the UA to perform safe and efficient procedures.

Inferior mesenteric artery embolization for persistent postpartum hemorrhage after sufficient bilateral iliac arteries embolization: safety and efficacy in eight patients

OBJECTIVE

To assess the safety and efficacy of transcatheter arterial embolization (TAE) of the inferior mesenteric artery (IMA) for the management of post-partum hemorrhage (PPH).

METHODS

A retrospective analysis was performed regarding eight patients (mean age, 34.4 y; age range, 31 - 40 y) who underwent TAE of the IMA for PPH between March 2001 and September 2018. Obstetric records, including maternal characteristics, clinical manifestations, complications, and clinical outcomes, as well as TAE details were obtained.

RESULTS

All eight patients had primary PPH and the vaginal delivery mode. CT scans of two patients showed active bleeding from the lower uterus or hematoma and with the origin of contrast extravasation abutting the adjacent rectum. In seven patients, an aortogram or IMA arteriogram following persistent vaginal bleeding after sufficient embolization of the bleeding focus from the bilateral iliac arteries, found the bleeding focus of the IMA, while in one patient, the IMA bleeding focus was found at the second session 4 h after the first session. TAE of the IMA was technically successful in all eight patients and cessation of bleeding without repeated TAE or additional hemostatic surgery was achieved in all patients after TAE of the IMA. There were neither procedure-related complications nor bowel ischemia during follow-up.

CONCLUSION

TAE of the IMA for PPH was safe and effective with successful hemostasis. Bleeding from the IMA should be suspected when there is persistent vaginal bleeding after sufficient embolization of bleeders from the bilateral iliac arteries.

ADVANCES IN KNOWLEDGE

Bleeding from the IMA should be suspected when there is persistent vaginal bleeding after sufficient embolization of bleeders from the bilateral iliac arteries.

Adrenal artery embolization: anatomy, indications, and technical considerations

OBJECTIVE

The purpose of this review is to describe adrenal arterial anatomy and to discuss the indications, outcomes, and technical considerations of adrenal artery embolization.

CONCLUSION

Adrenal artery embolization can be used for management of adrenal tumors (palliative for pain relief, debulking, or hormone suppression) and treatment of acute bleeding from ruptured adrenal tumors, traumatic adrenal injury, and aneurysms. Variant arterial supplies, options for embolic agents, and potential complications are important considerations.

Aberrant ovarian artery arising from the common iliac artery: case report

A 46-year-old Vietnamese woman received embolization therapy in order to control postpartum hemorrhage. Angiography revealed an aberrant ovarian artery arising from the right common iliac artery. Superselective catheterization and subsequent embolization of the aberrant ovarian artery and bilateral uterine arteries were performed. Precise knowledge of the anatomic variations of the ovarian artery is important for successful embolization.

Successful fibroid embolization of pelvic and inferior mesenteric artery collaterals after previous uterine artery embolization

A 47-year-old woman with a history of myomectomies and uterine artery embolization 15 years previously presented with increasing menorrhagia and dysmenorrhea. Magnetic resonance imaging (MRI) demonstrated multiple enhancing fibroids, extensive uterine supply from what appeared to be patent uterine arteries, and significant supply from what appeared to be the left ovarian artery. Aortography demonstrated no ovarian supply, but extensive collateral supply from distal branches of the inferior mesenteric artery (IMA), with further collateral supply from the anterior division of both internal iliac arteries. There was no filling of the uterine arteries distal to the coils. Embolization was performed with technical and clinical success. This case highlights the potential for recruitment of collateral vessels following coil embolization and is the first reported case of successful fibroid embolization from distal IMA branches.

Role of prophylactic uterine artery balloon catheters in the management of women with suspected placenta accreta

BACKGROUND

Placenta praevia and accreta are leading causes of major obstetric haemorrhage and peripartum hysterectomy. Detection is largely based on a high index of clinical suspicion, though the diagnostic accuracy of radiological imaging is improving. Interventional radiological techniques can reduce blood loss and the incidence of hysterectomy.

METHODS

We have reviewed our experience with bilateral prophylactic uterine artery balloon occlusion in the management of women with suspected placenta accreta. Thirteen women at high risk of major haemorrhage due to placenta praevia or suspected placenta accreta were retrospectively studied. Uterine artery balloons were placed prophylactically under neuraxial anaesthesia in the angiography suite followed by caesarean delivery in the obstetric operating theatre.

RESULTS

Intraoperative blood loss and transfusion requirements were low in our case series. There were no hysterectomies or admissions to the intensive care unit. Fetal bradycardia necessitating immediate caesarean delivery occurred in two women (15.4%).

CONCLUSION

In our case series in women with suspected placenta accreta, prophylactic use of uterine artery balloons was associated with a low requirement for blood transfusion but with possible increased risk of fetal compromise. Performing the interventional procedure at a different site from the operative room complicated management.