Yonsei Med J.  2014 Mar;55(2):367-373.

Management of Bleeding Uterine Arteriovenous Malformation with Bilateral Uterine Artery Embolization

• Kim T
• Shin JH
• Kim J
• Yoon HK
• Ko GY
• Gwon DI
• Yang H
• Sung KB

Abstract

PURPOSE
To evaluate the technical feasibility and clinical outcome of bilateral uterine artery embolization (UAE) as a first-line therapeutic option for bleeding uterine arteriovenous malformation (AVM).
MATERIALS AND METHODS
Between 2002 and 2012, 19 patients were diagnosed with acquired uterine AVM clinically and through imaging studies. The clinical characteristics, angiographic features, technical success rate of embolization, procedure-related complications, imaging, and clinical follow-up data were assessed. Clinical success was defined as immediate symptomatic resolution with disappearance of vascular abnormality on subsequent imaging studies.
RESULTS
A total of 20 bilateral UAE, with or without embolization of extra-uterine feeders, were performed as the first-line treatment. Technical and clinical success rate was 90.0% (18/20) and 89.5% (17/19), respectively. Embolization was incomplete in two patients who had residual extra-uterine fine feeders to the AVM or a procedure-related complication (ruptured uterine artery); the former showed slow regression of the vascular malformation during the observation period, while the latter underwent a successful second bilateral UAE. Immediate clinical success was achieved in the remaining 17 patients after a single session and no recurrence of bleeding was found. Recovery to normal menstrual cycle was seen in all 17 patients with clinical success within one or two months, two of whom subsequently had uneventful intrauterine pregnancies carried to term.
CONCLUSION
Bilateral UAE is a safe and effective first-line therapeutic option for the management of bleeding uterine AVMs. However, incomplete embolization due to unembolizable feeders or difficult access into the uterine artery may lead to suboptimal treatment.

Keyword

Uterine arteriovenous malformation; embolization

MeSH Terms

Arteriovenous Malformations*
Female
Follow-Up Studies
Hemorrhage*
Humans
Menstrual Cycle
Methods
Pregnancy
Recurrence
Uterine Artery Embolization*
Uterine Artery*
Vascular Malformations

Figure

• 

  Fig. 1 A 26-year-old patient (No. 4) presenting with progressive vaginal bleeding. The axial enhanced CT scan (A) and CT angiography (B) show focal a hypervascular lesion (arrows) with feeders from the right uterine artery. (C and D) Right internal iliac arteriograms show the AVM along with the early opacification of the right ovarian vein. (E) Left internal iliac arteriogram does not show much blood supply to the AVM. Bilateral uterine arteries were embolized with gelfoam pledgets (not shown). At one-month follow-up, transvaginal ultrasound (not shown) showed resolution of the AVM together with clinical improvement. AVM, arteriovenous malformation.

• 

  Fig. 2 A 21-year-old patient (No. 10) presenting with progressive vaginal bleeding. (A) The enhanced coronal MR image shows tortuosity of the right uterine artery with a large pseudoaneurysm (arrows) at the uterine fundus. (B and C) Aortograms show tortuosity of bilateral (the right side being dominant) uterine arteries, a pseudoaneurysm (arrows), and early drainage into the right ovarian vein (arrowheads). The right uterine artery was ruptured during guide wire manipulation. The right ovarian vein and ruptured right uterine artery were embolized using coils. (D) The angiogram obtained upon completion shows the remaining pseudoaneurysm. (E) Selective angiograms of the right uterine artery angiogram of the left uterine artery obtained eight months after the first embolization procedure show the residual AVMs with opacification of the pseudoaneurysm. (F) The selective angiogram of the inferior mesenteric artery angiogram shows the AVM with a pseudoaneurysm. All feeding arteries were completely embolized using polyvinyl alcohol particles and gelfoam pledgets (not shown). AVM, arteriovenous malformation.

• 

  Fig. 3 Results of bilateral UAE for uterine AVMs. UAE, uterine artery embolization; AVM, arteriovenous malformation; UA, uterine artery; IMA, inferior mesenteric artery.

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