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

Abstract

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.

Two Case Studies on Inferior Mesenteric Artery Embolization for Primary Postpartum Hemorrhage

“…In patients with PPH due to vaginal laceration, as in our case, the branches of the internal iliac arteries are first assumed to be the source of bleeding. The IMA is a very uncommon bleeding source of PPH [6]. The most probable mechanism for superior rectal artery bleeding is injury to the artery associated with birth canal expansion and lacera-tion and extravasation of blood through the torn lower uterine body, cervix, or vagina [4].…”

“…Various materials, including gelatin sponge particles (GSPs), material coils, and n-butyl cyanoacrylate (NBCA), are used in IMA embolization [6]. GSP is regarded as the embolic agent of choice for PPH.…”

Puerperal vulvovaginal hematoma with an uncommon feeding vessel from the inferior mesenteric artery: a case report

“…Cases of successful IMA embolization in patients exhibiting persistent bleeding after thorough embolism of the bilateral uterine arteries from the IIAs have been reported, and the possibility of substantial genital tract injury causing damage to the superior rectal artery has been discussed. 9,10) Reportedly, the IMA can be an unusual extrauterine source of post-partum hemorrhage, 10) although the frequency of postpartum hematoma due to damage to the IMA is unknown. In our patient, contrast-enhanced CT images before angiography revealed extravasation in the superior rectal artery branch, i.e., the peripheral artery of the IMA.…”

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

“…However, the relationship between the detailed embolization method, such as the position of the microcatheter at the start of the embolization and TAE results was not clarified. There have been other case reports and small case series of GTT requiring re-TAE due to persistent bleeding via anastomosis from the inferior mesenteric artery after embolization of the internal iliac artery [ 11 , 12 ]. Our findings indicated that S-TAE is effective with a high rate of complete hemostasis for intractable PPH due to GTT after vaginal delivery.…”

“…Several studies have demonstrated the high effectiveness of TAE for intractable PPH due to GTT [8][9][10]. However, some reports have suggested that the blood vessels that cause bleeding due to GTT are diverse, and there is a risk of re-bleeding from anastomotic branches [11,12]. In addition, other reports do not strictly distinguish between bleeding due to uterine atony and PPH due to GTT; thus, these conditions are often confused.…”