Acquired uterine vascular malformations: radiological and clinical outcome after transcatheter embolotherapy

Abstract

The purpose of this retrospective study is to assess the radiological and clinical outcome of transcatheter embolization of acquired uterine vascular malformations in patients presenting with secondary postpartum or postabortion vaginal hemorrhage. In a cohort of 17 patients (mean age: 29.7 years; standard deviation: 4.23; range: 25-38 years) 18 embolization procedures were performed. Angiography demonstrated a uterine parenchymal hyperemia with normal drainage into the large pelvic veins ("low-flow uterine vascular malformation") in 83% (n=15) or a direct arteriovenous fistula ("high-flow uterine vascular malformation") in 17% (n=3). Clinically, in all patients the bleeding stopped after embolization but in 1 patient early recurrence of hemorrhage occurred and was treated by hysterectomy. Pathological analysis revealed a choriocarcinoma. During follow-up (mean time period: 18.8 months; range: 1-36 months) 6 patients became pregnant and delivered a healthy child. Transcatheter embolization of the uterine arteries, using microparticles, is safe and highly effective in the treatment of a bleeding acquired uterine vascular malformation. In case of clinical failure, an underlying neoplastic disease should be considered. Future pregnancy is still possible after embolization.

Postabortion Doppler Evaluation of the Uterus

“…9,12,13 In our study, the causes of myometrial hypervascularity on postabortion day 10 were pathologically proven RPOC in 61.5% of cases and hydatidiform moles in 15.4%. There was no case of a uterine AVM, and hypervascular uterine lesions completely disappeared in all cases at an average of 16.54 ± 11.06 days (range, 7-48 days) after the second D&C. In the previously reported studies 1,3,4,11,12,14,15 and case reports, 5-7,9,10,16 nearly all AVMs and vascular malformations of the uterus were diagnosed within a few days to several weeks after term delivery, molar pregnancy, or induced or spontaneous abortion. Three large studies 1,3,4 reported that 23.4% to 63% of patients having Doppler findings of a uterine vascular malformation also had sonographic evidence of RPOC, which was pathologically confirmed to be trophoblastic tissue or molar pregnancy in almost all of those who underwent curettage.…”

“…1,3 In a study of 17 women with uterine vascular malformations treated with embolization of the uterine arteries, hysteroscopic resection of residual trophoblastic tissue was performed in 6 cases within 1 to 2 weeks after the embolization procedure. 14 In almost all patients with CDS characteristics of a uterine AVM in the literature who had expectant management without uterine artery embolization because of the absence of heavy vaginal bleeding or molar pregnancy, spontaneous resolution of the lesion occurred within short periods, with mean times for resolution being 69.5 days (range, 40-112 days) in a study by Wiebe and Switzer, 16 5.3 weeks (range, 1 week-6 months) in a study by Timmerman et al, 1 and 6 weeks (range, 2-8 weeks) in another study by Timmerman et al 15 However, the term "malformation" describes defects in the structure of an organ resulting from an intrinsically abnormal process of development; therefore, spontaneous resolution of a malformation in a short period is unlikely. 17 In 2 recent studies of uterine artery embolization performed in patients with color Doppler findings suggesting a uterine AVM and heavy vaginal bleeding, a true AVM was detected on angiography in only 3 of 8 cases in the study by Timmerman et al 1 and in 3 of 18 cases (17%) in a study by Maleux et al 14 Kido et al 9 reported a patient in whom CDS, magnetic resonance imaging, and magnetic resonance angiography all suggested a uterine AVM, but pathologic examination after hysterectomy revealed only RPOC.…”

“…[1][2][3][4]9 Angiographic findings in patients with a true uterine AVM include bilateral hypertrophy of uterine arteries feeding a tortuous hypervascular uterine mass with large accessory feeding vessels and early drainage into the enlarged veins. 1,11,14,17 Enlargement and hypertrophy in the pelvic vasculature supplying the uterus result from increased uterine blood flow due to direct arteriovenous communications within the malformation. Although angiography has been considered the reference standard for the diagnosis of uterine AVMs, there is some evidence that some pregnancy-related conditions with arteriovenous shunting such as RPOC, missed abortion, and gestational trophoblastic disease might mimic a uterine AVM on angiography.…”

Uterine vascular lesions: a rare cause of abnormal uterine bleeding, reporting of two cases

“…Uterine trauma is one of the leading causes for development of uterine artery vascular lesions in the form of acquired Arteriovenous Malformation (AVM) or pseudo aneurysm. [1][2][3][4][5] So far nearly 100 cases of uterine AVM and very few cases of pseudo aneurysm have been reported. Trauma, resulting from prior dilation and curettage (D&C), therapeutic abortion, uterine surgery, or direct uterine trauma may lead to development of acquired uterine AVMs.…”

Three-dimensional rotational angiography is preferable to conventional two-dimensional techniques for uterine artery embolization

“…terine artery embolization (UAE) has shown to be a valuable, minimally invasive alternative for the treatment of women with symptomatic leiomyomas, uterine vascular malformations, and postpartum hemorrhage (1)(2)(3)(4)(5)(6)(7)(8)(9). The procedure is performed with angiographic and fluoroscopic guidance.…”