Uterine Artery Embolization of Uterine Arteriovenous Malformation: A Systematic Review of Success Rate, Complications, and Posterior Pregnancy Outcomes

Abstract

Uterine Arteriovenous Malformation (UAVM) is a rare but life-threating cause of uterine bleeding. The clinical management of this condition is challenging, and there is a need to describe the most adequate approach for these patients. Uterine artery embolization (UAE) is the most widely-published treatment in the literature in recent years, although there is a need to update the evidence on this treatment and to compare it with other available therapies. Thus, the objective of this systematic review is to quantify the efficacy of UAE of UAVM. In addition, we evaluated the clinical context of the patients included, the treatment complications, and the pregnancy outcomes after UAE. With this goal in mind, we finally included 371 patients spread over all continents who were included in 95 studies. Our results show that, similar to other medical therapies, the global success rate after embolization treatment was 88.4%, presenting a low risk of adverse outcomes (1.8%), even in women with later pregnancy (77% had no complications). To date, this is the largest systematic review conducted in this field, although there are still some points to address in future studies. The results obtained in our study should be outlined in UAE protocols and guidelines to aid in clinical decision-making in patients with UAVM.

Uterine Vascular Anomalies: Management and Treatment Overview

“…UVAs are rare, although the precise incidence is unknown due to heterogeneity in definitions and reporting bias in the literature, with the most recent systemic review by Ruiz Labarta et al identifying 371 cases of DSA-confirmed UVAs reported in the literature from 2000 to 2021. 1 2 3…”

“…UVAs can be categorized by general etiology of congenital versus acquired, with literature almost exclusively discussing the latter. 1 4 In practice and in the literature, there has been conflicting terminology, with “uterine arteriovenous malformation (AVM)” the prevailing, albeit technically inaccurate, term to describe all types of UVAs. 2 5 6 For this review, the term UVA is used to collectively describe hypervascular myometrial abnormalities, including true uterine AVMs, arteriovenous fistulas (AVFs), and non-AVM vascular anomalies, which Timmerman et al described as low-flow lesions without early filling of a draining vein.…”

“…1 3 8 13 The median reported time from the event to presentation is approximately 6 weeks, although can range from less than 1 day to years. 1 UVAs have varying presentations, from asymptomatic to mild pelvic pain and abnormal uterine bleeding to life-threatening hemorrhage. 8 Bleeding may have a gradual or sudden onset and may require a blood transfusion in up to 30 to 50% of cases.…”

“…The recommended laboratory values to obtain are complete blood count, including hemoglobin/hematocrit and platelets (prior to an invasive procedure), coagulation panel, and serum beta human chorionic gonadotropin (b-hCG), which can suggest retained products of conception (RPOCs) or trophoblastic disease if persistently elevated. 1 8 11…”

“…Limited high-level evidence and no definitive guidelines for UVA management exist. 1 16 Thus, treatment decisions for UVAs are generally based on clinical presentation, including volume of bleeding and hemodynamic status, and patient preference, supplemented by laboratory and imaging findings 1 19 25 ( Fig. 5 ).…”