isation coils (William Cook Europe, Bjaeverskov, Den- mark) (Fig. 2(a)) which obliterated flow in the A-V fistula. The patient was discharged uneventfully, had a.
EJVES Extra 6, 49–51 (2003) doi: 10.1016/S1533-3167(03)00074-8, available online at http://www.sciencedirect.com on
SHORT REPORT
Endovascular Therapy for Arteriovenous Pseudoaneurysm of the Uterine Vessels D. J. Ferguson1*, G. E. Morris1, A. Odurny2, J. L. Ferguson2 and M. J. Phillips1 Departments of 1Vascular Surgery, and 2Radiology, Southampton University Hospitals Trust, Southampton, UK Key Words: Arterio-venous pseudoaneurysm; Embolisation.
Introduction Arteriovenous (A-V) pseudoaneurysms subsequent to fistulae of the uterine vessels are rare.1 Those reported in the literature following hysterectomy number less than 20. They are a diagnostic and therapeutic problem due to the variety and occasional absence of symptoms, along with the serious potential sequelae posed by the lesion itself and resulting from its treatment.2 This case report describes successful endovascular treatment of an A-V pseudoaneurysm of the uterine artery and reviews the literature pertaining to this rare condition.
Case Report A patient underwent X-ray examinations of her hip following 3 months of hip pain. She previously had undergone a vaginal hysterectomy and coronary artery bypass grafting. Co-morbidities were mild angina and hyperlipidaemia, with no other risk factors for vascular disease. The X-ray reported unusual calcification within the pelvis, consistent with an ovarian lesion. A Duplex ultrasound showed calcification within a pulsatile mass. Computed tomography (CT) showed a pseudoaneurysm of a branch of the internal iliac artery (Fig. 1(a)). *Corresponding author. Mr Douglas J. Ferguson, 14 Beach Avenue, Barton-On-Sea, Hampshire BH25 7EJ, UK.
Subsequent contrast angiography (Fig. 1(b)) demonstrated an A-V pseudoaneurysm of the uterine artery. This was embolized using six M_Reye embolisation coils (William Cook Europe, Bjaeverskov, Denmark) (Fig. 2(a)) which obliterated flow in the A-V fistula. The patient was discharged uneventfully, had a normal follow up CT scan (Fig. 2(b)) and has remained well since.
Discussion A-V fistulae may develop spontaneously from atheroma, congenitally, or following vessel trauma.3 The likely cause of the A-V pseudoaneurysm in this patient is an iatrogenic post hysterectomy A-V fistula. Suture transfixion of the vascular pedicle during hysterectomy can create a fistulous connection in one of two ways; directly from the needle puncture of the artery and vein, or from pressure necrosis eroding the vessels’ walls due to the ligature itself allowing development of a continuous connection between the two vessels. Pseudoaneurysms may develop after several years from this.3 Presenting features vary and are sometimes absent, but pain, a pulsatile mass, and claudication may be noted.4 Hypovolaemia can occur following pseudoaneurysmal rupture and elective intervention is advisable.1,4 The diagnosis is made on clinical suspicion with the aid of CT, Duplex ultrasonography and angiography. Conventionally, treatment has been surgical with
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Fig. 1. (a) Diagnostic CT angiography. (b) Pre-embolisation angiograms.
ligation of the feeding vessels and resection of the fistula favoured.4 Surgical treatment carries significant morbidity. Dissection, vascular control and access are difficult.2,5 Surgical manipulation can release paradoxical emboli.5 It may also induce cardiovascular decompensation, by abruptly changing after-load and venous return on vessel clamping.5 Ghosh6 first described the use of percutaneous embolisation, in two patients with menorrhagia, in EJVES Extra, 2003
whom it was used to treat uterine AV fistulae. In only one patient, using Gelfoam, was this technically successful with the patient surviving. The patient, however, suffered many severe complications as a result. Since then, percutaneous embolisation has been proposed by others1 as an alternative to open surgery. This report demonstrates that percutaneous embolisation is a safe and durable modality in excluding a uterine artery A-V pseudoaneurysm. Embolisation is a relatively minor and minimally invasive procedure
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and should be considered as a first line treatment for this rare condition.
References 1 Langer JE, Cope C. Ultrasonographic diagnosis of uterine artery pseudoaneurysm after hysterectomy. J ultrasound Med 1999; 18: 711 –714. 2 Lee WK, Roche CJ, Duddalwar VA, Buckley AR, Morris DC. Pseudoaneurysm of the uterine artery after abdominal hysterectomy: radiological diagnosis and management. Am J Obstet Gynecol 2001; 185(5): 1269–1272. 3 Fulmer GT, Mayberger HW, Sheehy TJ et al. Arterio venous fistula of the uterine artery. Angiology 1970; 11: 647– 653. 4 Perdue GD, Mittenthal MJ, Smith RB et al. Aneurysms of the internal iliac artery. Surgery 1993; 93(2): 243–246. 5 Gilling-Smith GL, Mansfield AO. Spontaneous abdominal arteriovenous fistulae and a review of the literature. Br J Surg 1991; 78(4): 421 –426. 6 Ghosh TK. Arteriovenous malformations of the uterus and pelvis. Obstet and Gynae 1986; 68(53): 405 –435. Accepted 30 September 2003
Fig. 2. (a) Post coil embolisation. (b) Follow-up CT.
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