PMC5735662_01
MR ((a) and (b)) and CT ((c) and (d)) before the embolization. (a) T2-weighted MR in axial plane; (b) contrast-enhanced T1-weighted MR in axial plane; arterious contrast-enhanced CT with maximum intensity projection in axial (c) and coronal planes (d). Multiple ectatic and serpiginous anomalous vessels adjacent to the uterine wall bilaterally are appreciable at MR and CT imaging; these are indicated by white arrows in (a) and (b) and black arrows in (c) and (d). In (d), uterine arteries, indicated by black asterisks, are in direct connection with the anomalous vessels of the uterine wall.
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During the hospital stay, she underwent a suprapubic ultrasound (US) examination revealing a high flow vascular lesion involving the uterine wall; a contrast-enhanced Magnetic Resonance (MR) (Figures 1(a) and 1(b)) showed multiple ectatic and serpiginous anomalous vessels adjacent to the uterine wall bilaterally. Vessels enhancement is appreciable after contrast injection in Figure 1(b); a contrast-enhanced Computed Tomography (CT) (Figures 1(c) and 1(d)) showed an abnormal arterious vascular network involving the uterus with concomitant pelvic varicocele; both uterine arteries supplied the lesion with aberrant venous outflow.
Procedural imaging and digital subtraction angiography. (a) Pelvic angiogram after 5Fr pigtail catheter positioning in abdominal aorta showing the vascular lesion in arterious phase injection. (b) Selective left uterine arteriography by 5Fr Cobra catheterization positioned crossing the aortic carrefour (white arrow): ectatic and aberrant arterious vessels with concomitant ectatic and serpiginous direct venous outflow, confirming the AVF diagnosis. (c) Selective right uterine arteriography by 5Fr Robert Uterine Curve catheterization (white arrow): involvement of the right uterine artery in terms of inflow to the AVF. ((d) and (e)) Left and right postembolization hypogastric artery angiography, respectively: complete occlusion of the uterine arteries after Onyx-18 injection and preservation of the other hypogastric branches; the Onyx-18 cast is indicated by the black arrows. (f) Final pelvic angiogram: the AVF is no more appreciable after embolization with Onyx-18 (black arrows indicate the casts).
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The patient underwent a bilateral superselective UAE (Figure 2); the procedure was performed with a monolateral access by positioning a 5Fr sheath into the right common femoral artery. AVF, excluding the involvement of arteries originating from body districts other than the hypogastric trunk (Figure 2(a)). A selective hypogastric arteriogram was obtained bilaterally, using a 5Fr Cobra curve for the (left) contralateral artery (Figure 2(b)) and a 5Fr Robert Uterine Catheter Curve for the (right) homolateral artery (Figure 2(c)): these demonstrated that both uterine arteries refurnished the fistula, with a major component from the left side; no other vessels were involved, confirming the findings of CT and MR.
Postoperative MR 30 days after the embolization. (a) T2-weighted MR in sagittal plane: uterine wall preservation with serpiginous Onyx-18 cast (white arrow) into the left uterine artery. ((b) and (c)) Contrast-enhanced T1-weighted MR, sagittal and axial planes, respectively: preserved uterine wall perfusion (black arrow in (b)) without enhancement of the uterine arteries because of the Onyx-18 embolization (white arrows in (b) and (c)).
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