Keywords
uterine artery embolization - transfemoral approach - 5F-Picard catheter - 0.035 curved-tipped hydrophilic guidewire - reverse loop
Introduction
Uterine artery embolization (UAE) through unilateral transfemoral approach (TFA) in absence of commercially available reverse loop catheter (Roberts uterine catheter [RUC]) is challenging. We did UAE by unilateral TFA using simple gentle curve catheter (Picard) in 12 patients with 100% technical success and comparable fluoroscopic times. This article describes this technique in details where a reverse curve loop was made to cannulate uterine arteries (UAs).
Technique Description
Step1: Right transfemoral puncture followed by 5F arterial sheath placement in right common femoral artery. Insertion of 5F-Picard catheter with 0.035 curved-tip hydrophilic guidewire in abdominal aorta followed by crossing over to opposite common iliac artery (CIA) ([Fig. 1A and B]).
Fig. 1 (A, B) Fluoroscopic image (A) shows 5F-Picard catheter with 0.035 curved-tipped hydrophilic guidewire (arrow) after crossing the aortic bifurcation through 5F arterial sheath placement in the right common femoral artery through right transfemoral puncture. Note 0.035 curved-tipped hydrophilic guidewire in opposite common iliac artery. Fluoroscopic image (B) shows position of catheter-guidewire (arrow) assembly in distal left common iliac artery (CIA).
Step 2: Placement of guidewire in contralateral superficial femoral artery (SFA) followed by advancement of catheter tip till SFA origin or hip joint level. Removal of guidewire ([Fig. 2]).
Fig. 2 Fluoroscopic image shows catheter tip at level of origin of left (contralateral) superficial femoral artery (SFA) (arrow). Guidewire is withdrawn after desired position is achieved.
Step 3: Insertion of guidewire with hard end tip till aortic bifurcation ([Fig. 3A]) and gentle push upwards of both guidewire and catheter ([Fig. 3B]) together till catheter forms “inverted-U loop” in abdominal aorta ([Fig. 3C]). Tip of catheter during this maneuver retracts proximally from contralateral femoral artery to lie within external iliac or CIA ([Fig. 3B]). Now, with this maneuver catheter forms a shape akin to RUC and behaves similarly while maneuvering within the pelvic vessels.
Fig. 3 (A–C) Fluoroscopic image (A–C) show insertion of guidewire with hard end till aortic bifurcation (thick arrow in A) and gentle push upwards (thin arrow in A and B) till the catheter forms an “inverted-U loop” in abdominal/lower thoracic aorta (arrows in C). The tip of the catheter during this maneuver will be retracted proximally from the contralateral femoral artery to lie within the contralateral external iliac artery or common iliac artery (thick arrow in B). Now, with this maneuver the catheter forms a loop like Waltman's loop/Simmons' reverse curve shape akin to Roberts uterine curve catheter and behaves in a similar fashion.
Step 4: Gently pull catheter, to advance catheter tip in contralateral left CIA ([Fig. 4A]). Catheter tip can then be easily maneuvered into internal iliac artery (IIA) followed by selective cannulation of UA (Fig. 4B). Guidewire can be used as and when desired.
Fig. 4 (A, B) Angiographic images (A and B) show catheter (thick arrow in A) in anterior division of contralateral left internal iliac artery after pulling the catheter (thin long arrow). With further maneuvering (long arrow in B) cannulation of uterine artery can be done (thick arrow in B).
Step 5: After embolization of contralateral UA gently keep pushing catheter till catheter tip lies at aortic bifurcation ([Fig. 5A]). Now pull catheter with tip directed to same side of femoral puncture ([Fig. 5B]). Further pulling out catheter will bring its tip down distally into ipsilateral CIA ([Fig. 5C]). Then, cannulation of IIA and UA ([Fig. 5D]) can be done easily.
Fig. 5 (A–D) Fluoroscopic images (A and B). After embolization of contralateral uterine artery (left side here) gentle pushing (thin long arrow in A) of the catheter will take the catheter tip to lie at aortic bifurcation (thick arrow in A). After pulling the catheter (thin long arrow in B) with the tip directed to the same side of femoral puncture (right side here) will bring the catheter to the ipsilateral common iliac artery (thick arrow in B). Angiographic images (C and D). Further pulling out the catheter at desired site will bring its tip down distally into the ipsilateral internal iliac artery (C) and ipsilateral uterine artery (D).
Step 6: Following embolization of ipsilateral UA, push catheter till its tip lies in lower abdominal aorta ([Fig. 6A]). Pass guidewire and place again in contralateral SFA ([Fig. 6B]) and roll over catheter over it and remove the assembly ([Fig. 6C]).
Fig. 6 (A–C) Fluoroscopic images (A–C). After embolization of ipsilateral uterine artery push the catheter (thin long arrows in A) till its tip lies in lower abdominal aorta and tip of catheter directed toward contralateral common iliac artery (thick arrow A). Once that position is achieved pass on the guidewire with floppy end (0.035 curved-tipped hydrophilic guidewire) and place again in contralateral superficial femoral artery (SFA) (thick arrow in B) and roll over catheter over it (thick arrow in C) and pull the assembly (long arrow in C).
Discussion
UAE is an established technique for many gynecological and obstetrical problems.[1]
[2]
[3]
[4]
[5]
[6]
Usually preferred approach is TFA which can be unilateral or bilateral with equivalent technical success; however, unilateral TFA puncture is preferred due to lesser chances of puncture-related complications as compared to bilateral puncture.[7]
[8]
Previously, UAE, through unilateral TFA was possible with formation of Waltman's loop using a simple curve catheter where reverse loop was made by immersing catheter with reshaping wire in boiling water.[9] Other techniques used in the past were creation of Simmons' reverse curve (akin to Waltman's loop) using 5F cobra-shaped catheter (Cobra; Terumo, Tokyo, Japan) and hydrophilic polymer-coated 0.032-inch guidewire (Radifocus; Terumo)[10]
[11] or using an especially designed catheter with a suture.[12] Few authors have also used 4F Rosch inferior mesenteric catheter (Cordis, Miami, Florida, United States) with acceptable technical success up to 79.2[13] and 91.8%.[14] In both these series either bilateral TFA or additional hardware (catheters or microcatheters) were used.[13]
[14]
With availability of reverse catheters like Gandras or RUC, UAE by unilateral TFA became popular with RUC being the catheter of choice.[6]
[14]
[15]
[16] However, lately RUC had been retracted from markets because of unknown reasons, forcing the interventional radiologists to use bilateral TFA or unilateral TFA with catheters and techniques used in the past.
At our institution we performed UAE through right TFA approach using 5F-Picard angiographic catheter with 100% technical success with acceptable procedure (25–50 minutes) and fluoroscopic time (15–25 minutes). The technique is simple and can be performed in any interventional angiographic suite without any requirement of additional hardware. The key point was to make simple catheter a reverse-curve catheter (like Simmons' reverse loop) akin to RUC that cannulates all desired branches of IIA on both the sides easily. This was achieved by first placing the catheter tip in contralateral SFA and then passing stiff (hard) end of 0.035 hydrophilic guidewire in proximal ipsilateral CIA near aortic bifurcation and then gently pushing upwards the guidewire with catheter assembly till it forms an inverted loop in abdominal aorta ([Figs. 1],[2],[3]). Once the catheter forms the desired loop in the abdominal aorta, the guidewire is withdrawn and subsequently the catheter tip can easily be maneuvered to cannulate contralateral IIA and UA using floppy end of the guidewire ([Fig. 4]). Once embolization is done on the contralateral side, the catheter is pushed till the tip lies at aortic bifurcation and then maneuvered so that the tip lies in ipsilateral CIA, gently pulling the catheter and guidewire assemble together ([Fig. 5]) places the catheter in IIA and then UA can be cannulated by maneuvering. The technique thus allows selective cannulation of UAs without requirement of additional hardware, further if so desired a microcatheter can be easily passed through the catheter for superselective cannulation of branches of UAs as the bend that forms is gentle without acute angulations.
Once the embolization is done on both sides the catheter is pushed back in aorta with the tip directed toward contralateral CIA and guidewire passed with floppy end and the catheter passed over it till the loop vanishes and the tip of the catheter lies in SFA. Subsequently, the assembly is withdrawn ([Fig. 6]).
A technique similar to our technique has been described in literature by Pelage et al and Costantino et al.[10]
[11] Pelage et al[10] cannulated contralateral UA without formation of reverse loop and ipsilateral UA was cannulated with formation of Simmons' reverse loop. Reverse loop was formed by keeping the catheter tip of 5F cobra-shaped catheter (Cobra; Terumo) in contralateral UA and after placement of 0.032-inch hydrophilic polymer-coated guidewire a strong torque was applied to make an inverted loop in aorta and the catheter pulled to cannulate the ipsilateral UA. Costantino et al[11] in their article describe cannulation of contralateral UA using microcatheter after placing hydrophilic 5F cobra-shaped catheters (Glidecath; Terumo, Somerset, New Jersey, United States) in IIA; however, the ipsilateral UA was cannulated similar to our technique by forming reverse loop. Our technique vis-à-vis previously described techniques is simpler, safe, and does not require any additional hardware like microcatheters as used by Costantino et al and not associated with any inadvertent complications like arterial injury or dissection which may arise due to strong applied torque (though not reported by Pelage et al). Also, withdrawal of catheter assembly postprocedure by our technique is easy without any chance of knotting of catheter.
Conclusion
Technique described by us for bilateral UA access for UAE by unilateral TFA approach is simple, easy, and cost effective with 100% technical success and does not require any additional hardware. Procedure and fluoroscopic time remain the same as with RUC catheter.
