Novel approach to uterine artery pseudoaneurysm embolization for delayed post‐partum hemorrhage

Abstract

Uterine artery pseudoaneurysms (UAP) are a rare cause of post-partum hemorrhage. Conservative management is discouraged due to the risk of spontaneous hemorrhage. Intra-arterial embolization is highly successful (>90%) and offers definitive treatment. We present the case of a 27-year-old woman with significant delayed post-partum hemorrhage after cesarean section who was found to have a UAP on imaging. Her tortuous vascular anatomy and spasmodic aneurysmal neck presented technical challenges to embolization with traditional material, such as gel foam and coils. Intra-arterial thrombin was then employed with good technical and clinical outcome. To our knowledge, this is the first case describing the use of intra-arterial thrombin in the treatment of UAP. Given its success in this case, we argue that intra-arterial thrombin should be considered a viable alternative for embolization of UAP when more traditional techniques fail.

Uterine artery pseudoaneurysm after treatment of cesarean scar pregnancy: a case report

“…In general, on grayscale ultrasonography, pseudoaneurysm has a characteristic sonographic appearance consisting of a pulsating anechoic or hypoechoic well defined cystic structure with or without associated pelvic hematoma or free fluid [ 6 ]. On color Doppler, the pseudoaneurysm systolic and diastolic flow creates a characteristic “to-and-fro” pattern, classically described as the “Yin-Yang” sign [ 7 ]; it is caused by changes of the pressure in the pseudoaneurysm and the blood vessel during the cardiac cycle. However, in practice, it is difficult to show the neck because the uterine artery is very small.…”

“…The treatment of UAP includes expectant management [ 10 , 11 ], selective UAE, ligation of the internal iliac artery or uterine artery and its branches [ 12 ], intra-arterial catheter-directed thrombin injection [ 7 ], or percutaneous or transvaginal UGTI [ 13 ]; selective UAE is the first-line treatment. UAE is a safe treatment method with a high success rate and few reports of complications [ 14 ].…”

Pseudo aneurysm of the uterine artery with arteriovenous fistula after cesarean section: A rare but sinister cause of delayed postpartum hemorrhage

“…Most uterine artery pseudoaneurysms are successfully treated with gel foam and/or metallic coils 2 . A case report in the literature describes intra‐arterial thrombin administration 5 . Eriksson et al followed up patients after interventional treatment of uterine artery pseudoaneurysm and observed no case of infertility after embolization 6 .…”

Novel approach to uterine artery pseudoaneurysm embolization for delayed post‐partum hemorrhage: Thrombin really necessary? Reply

“…We described our failed first attempts to access the pseudoaneurysm for coil embolization due to a tortuous and spasmotic uterine artery. 1 Although not specifically described in our article, the "various microcatheters" that failed did include the 2.4-Fr Progreat (Terumo, Tokyo, Japan). 1 While we respect the authors' rationale for considering gelatin sponge (Gelfoam: Pfizer, NY, USA) prior to other agents, we maintain our position for attempting thrombin for the following reasons.…”