Subscribe to RSS
DOI: 10.1055/s-0043-1770714
Uterine Vascular Anomalies: Management and Treatment Overview
Abstract
Uterine vascular anomalies (UVAs), while rare, can result in severe, life-threatening hemorrhage. An understanding of the presentation and management options for UVAs is important for interventional radiologists to appropriately evaluate and care for these patients. The authors propose a standardized terminology for UVAs to avoid confusion and conflating congenital from acquired vascular lesions, which have a different pathophysiology. Limited high-level evidence and no definitive guidelines for UVA management exist, although endovascular treatment with uterine artery embolization has generally become the first-line approach for symptomatic or persistent UVAs with high technical and clinical success rates. There is also no consensus on the optimal embolization technique; the authors propose an initial approach to first embolize the dominant uterine artery supplying the UVA with gelatin sponge, with the option to embolize the contralateral side at the time of initial embolization if there is persistent supply (avoiding bilateral empiric embolization). Repeat embolization is feasible and recommended in the setting of recurrence, and both clinical and imaging follow-up is important. Ultimately, a multidisciplinary approach with individualized patient management is needed, particularly in the face of a lack of consensus guidelines for the management of symptomatic UVAs.
Keywords
uterine arteriovenous anomaly - uterine arteriovenous fistula - uterine vascular malformation - uterine artery embolization - interventional radiologyDisclosures
M.M.M. has no disclosures. T.M.C. serves as medical director of Varian Interventional Solutions.
Publication History
Article published online:
10 August 2023
© 2023. Thieme. All rights reserved.
Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
-
References
- 1 Ruiz Labarta FJ, Pintado Recarte MP, González Leyte M. et al. Uterine artery embolization of uterine arteriovenous malformation: a systematic review of success rate, complications, and posterior pregnancy outcomes. J Pers Med 2022; 12 (07) 1098
- 2 Müngen E. Vascular abnormalities of the uterus: have we recently over-diagnosed them?. Ultrasound Obstet Gynecol 2003; 21 (06) 529-531
- 3 Peitsidis P, Manolakos E, Tsekoura V, Kreienberg R, Schwentner L. Uterine arteriovenous malformations induced after diagnostic curettage: a systematic review. Arch Gynecol Obstet 2011; 284 (05) 1137-1151
- 4 Timor-Tritsch IE, Haynes MC, Monteagudo A, Khatib N, Kovács S. Ultrasound diagnosis and management of acquired uterine enhanced myometrial vascularity/arteriovenous malformations. Am J Obstet Gynecol 2016; 214 (06) 731.e1-731.e10
- 5 Polat P, Suma S, Kantarcý M, Alper F, Levent A. Color Doppler US in the evaluation of uterine vascular abnormalities. Radiographics 2002; 22 (01) 47-53
- 6 Timmerman D, Wauters J, Van Calenbergh S. et al. Color Doppler imaging is a valuable tool for the diagnosis and management of uterine vascular malformations. Ultrasound Obstet Gynecol 2003; 21 (06) 570-577
- 7 Lowe LH, Marchant TC, Rivard DC, Scherbel AJ. Vascular malformations: classification and terminology the radiologist needs to know. Semin Roentgenol 2012; 47 (02) 106-117
- 8 Yoon DJ, Jones M, Taani JA, Buhimschi C, Dowell JD. A systematic review of acquired uterine arteriovenous malformations: pathophysiology, diagnosis, and transcatheter treatment. AJP Rep 2016; 6 (01) e6-e14
- 9 Molvi SNM, Dash K, Rastogi H, Khanna SB. Transcatheter embolization of uterine arteriovenous malformation: report of 2 cases and review of literature. J Minim Invasive Gynecol 2011; 18 (06) 812-819
- 10 Iraha Y, Okada M, Iraha R. et al. CT and MR imaging of gynecologic emergencies. Radiographics 2017; 37 (05) 1569-1586
- 11 Giurazza F, Corvino F, Silvestre M. et al. Uterine arteriovenous malformations. Semin Ultrasound CT MR 2021; 42 (01) 37-45
- 12 Grewal K, Al-Memar M, Fourie H, Stalder C, Timmerman D, Bourne T. Natural history of pregnancy-related enhanced myometrial vascularity following miscarriage. Ultrasound Obstet Gynecol 2020; 55 (05) 676-682
- 13 Lee TY, Kim SH, Lee HJ. et al. Ultrasonographic indications for conservative treatment in pregnancy-related uterine arteriovenous malformations. Acta Radiol 2014; 55 (09) 1145-1152
- 14 Abdullah HMA, Oliver T, Lamfers R, Narayana Gowda S. High output heart failure in a young woman secondary to massive arteriovenous malformations from a uterine tumor. BMJ Case Rep 2020; 13 (02) e233887
- 15 Yazawa H, Soeda S, Hiraiwa T. et al. Prospective evaluation of the incidence of uterine vascular malformations developing after abortion or delivery. J Minim Invasive Gynecol 2013; 20 (03) 360-367
- 16 O'Rourke-Suchoff D, Benitez S, Higgins MCCS, Stier EA. Diagnosis and treatment of women with radiologic findings suspicious for uterine arteriovenous malformations. J Obstet Gynaecol 2021; 41 (05) 769-773
- 17 Salmeri N, Papale M, Montresor C, Candiani M, Garavaglia E. Uterine arteriovenous malformation (UAVM) as a rare cause of postpartum hemorrhage (PPH): a literature review. Arch Gynecol Obstet 2022; 306 (06) 1873-1884
- 18 Taneja A, Chopra I, Kaur H. et al. Successful management of abnormal uterine bleeding from uterine arteriovenous malformations with progesterone in postabortal patients. J Obstet Gynaecol Res 2019; 45 (06) 1114-1117
- 19 Gao F, Ma X, Xu Y, Fu L, Guo X. Management of acquired uterine arteriovenous malformations associated with retained products of conception. J Vasc Interv Radiol 2022; 33 (05) 547-553
- 20 Camacho A, Ahn EH, Appel E. et al. Uterine artery embolization with Gelfoam for acquired symptomatic uterine arteriovenous shunting. J Vasc Interv Radiol 2019; 30 (11) 1750-1758
- 21 Delplanque S, Le Lous M, Proisy M. et al. Fertility, pregnancy, and clinical outcomes after uterine arteriovenous malformation management. J Minim Invasive Gynecol 2019; 26 (01) 153-161
- 22 Grill N, Struebing F, Krebs L, Sadick M. Diagnostic radiology findings and spectrum of therapeutic interventions in gynaecological and urogenital vascular anomalies. Br J Radiol 2021; 94 (1124): 20210246-20210246
- 23 Groszmann YS, Healy Murphy AL, Benacerraf BR. Diagnosis and management of patients with enhanced myometrial vascularity associated with retained products of conception. Ultrasound Obstet Gynecol 2018; 52 (03) 396-399
- 24 Chen HZ, Zhao FM, Liu LJ. et al. Accuracy of flow-void diameters on MR images in diagnosing uterine arteriovenous malformations in patients with pregnancy-related diseases. Sci Rep 2021; 11 (01) 19806
- 25 Ghanaati H, Firouznia K, Moradi B, Behestani S. Fertility outcomes after uterine artery embolization for symptomatic uterine arteriovenous malformations: a single-center retrospective study in 33 women. Cardiovasc Intervent Radiol 2022; 45 (07) 983-991
- 26 ISSVA classification for vascular anomalies.. International Society for the Study of Vascular Anomalies. Accessed March 13, 2023 at: https://www.issva.org/classification
- 27 Rosen A, Chan WV, Matelski J, Walsh C, Murji A. Medical treatment of uterine arteriovenous malformation: a systematic review and meta-analysis. Fertil Steril 2021; 116 (04) 1107-1116
- 28 Andrews RT, Spies JB, Sacks D. et al; Task Force on Uterine Artery Embolization and the Standards Division of the Society of Interventional Radiology. Patient care and uterine artery embolization for leiomyomata. J Vasc Interv Radiol 2009; 20 (07) S307-S311
- 29 Patel IJ, Rahim S, Davidson JC. et al. Society of Interventional Radiology Consensus Guidelines for the periprocedural management of thrombotic and bleeding risk in patients undergoing percutaneous image-guided interventions - Part II: recommendations: endorsed by the Canadian Association for Interventional Radiology and the Cardiovascular and Interventional Radiological Society of Europe. J Vasc Interv Radiol 2019; 30 (08) 1168-1184.e1
- 30 Picel AC, Koo SJ, Roberts AC. Transcatheter arterial embolization with n-butyl cyanoacrylate for the treatment of acquired uterine vascular malformations. Cardiovasc Intervent Radiol 2016; 39 (08) 1170-1176
- 31 Castillo MS, Borge MA, Pierce KL. Embolization of a traumatic uterine arteriovenous malformation. Semin Intervent Radiol 2007; 24 (03) 296-299
- 32 Wu R, Peters GL, Charles H, Kokabi N, Bercu ZL, Majdalany BS. Transradial uterine artery embolization complicated by stroke. Semin Intervent Radiol 2022; 39 (06) 591-595
- 33 Kishino M, Miyasaka N, Takeguchi Y, Ohashi I. Retrograde transvenous obliteration for uterine arteriovenous malformation. Obstet Gynecol 2014; 123 (2, Pt 2, Suppl 2): 427-430
- 34 Morita R, Abo D, Kinota N. et al. Successful transvenous embolization for type II uterine arteriovenous malformation: a case report. Radiol Case Rep 2021; 16 (08) 2007-2011
- 35 Kuc N, Gans JH, Wattamwar K, Hirschl D, Golowa Y, Cynamon J. Direct percutaneous embolization of uterine arteriovenous malformations. J Vasc Interv Radiol 2022; 33 (05) 607-609
- 36 Lehrman ED, Heller M, Poder L, Kerlan R, Huddleston HG, Kohi MP. Transvaginal obliteration of a complex uterine arteriovenous fistula using ethylene vinyl alcohol copolymer. J Vasc Interv Radiol 2017; 28 (06) 842-843
- 37 Yan X, Zhao C, Tian C, Wen S, He X, Zhou Y. Ultrasound-guided high-intensity focused ultrasound ablation for treating uterine arteriovenous malformation. BJOG 2017; 124 (Suppl. 03) 93-96
- 38 Chen H, Tan X, Xiong W, Wang X. High-intensity-focused ultrasound for uterine arteriovenous malformation associated with retained products of conception: a case report. Asian J Surg 2023; 46 (01) 653-654
- 39 Liu L, Wang T, Lei B. High-intensity focused ultrasound (HIFU) ablation versus surgical interventions for the treatment of symptomatic uterine fibroids: a meta-analysis. Eur Radiol 2022; 32 (02) 1195-1204
- 40 Izadifar Z, Izadifar Z, Chapman D, Babyn P. An introduction to high intensity focused ultrasound: systematic review on principles, devices, and clinical applications. J Clin Med 2020; 9 (02) 460