AJR 2000; 175:1273-1278
© American Roentgen Ray Society
Role of the Interventional Radiologist in Treating Obstetric—Gynecologic Pathology
Thomas E. Velling1,
Frank J. Brennan1,
Lee D. Hall1 and
John T. Watabe2
1
Department of Radiology and Clinical Investigation, Naval Medical Center San
Diego, c/o Clinical Investigation Department-KCA, 34800 Bob Wilson Dr., Ste.
5, San Diego, CA 92134-1005.
2
Department of Radiology, Tripler Army Medical Center, 1 Jarret White Rd.,
Honolulu, HI 96859-5000.
Received March 20, 2000;
accepted after revision May 2, 2000.
The views expressed in this article are those of the authors and do not
reflect the official policy or position of the Department of the Navy,
Department of Defense, or the United States government.
Address correspondence to T. E. Velling.
Introduction
In recent years, the transcatheter and percutaneous techniques of
interventional radiology have been applied to the diseases of various organ
systems, including the female pelvis. Through development of new procedures
and refinement of standard techniques, the interventional radiologist can now
offer many services to the obstetrician—gynecologist. These include
assistance in the treatment of vascular and nonvascular diseases.
From a vascular standpoint, substantial attention has been given recently
to the nonsurgical treatment of uterine fibroids by uterine artery
embolization and, to a lesser extent, to treating "pelvic congestion
syndrome" by ovarian vein embolization. Embolization was also used for
many years to treat persistent postpartum hemorrhage and bleeding
complications after surgery.
On the side of nonvascular interventions, fallopian tube recanalization and
transvaginal drainage and biopsy are well-established procedures. More
recently, percutaneous treatment of tuboovarian abscesses and uterine fluid
collections has received some attention in the literature, in addition to
stent placement for malignant cervical strictures
[1,2,3].
Uterine Artery Embolization
Since Ravina et al. [4]
reported their results in 1995, uterine artery embolization has received
widespread attention as a nonsurgical alternative in the treatment of
symptomatic uterine fibroids. The procedure involves selective catheterization
of both uterine arteries, which are branches of the anterior division of the
internal iliac artery, and embolization with a permanent agent, usually
polyvinyl alcohol particles (Fig.
1A,1B).
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Fig. 1A. —43-year-old woman with menorrhagia caused by large uterine
fibroids. Selective angiogram of right uterine artery before embolization
shows typical appearance of tortuous vessels (arrows) supplying
uterus enlarged by fibroids.
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Fig. 1B. —43-year-old woman with menorrhagia caused by large uterine
fibroids. Angiogram obtained after embolization shows nonfilling of distal
uterine artery branches. Arrow indicates long reversecurved catheter coming
from right femoral access. Patient's abnormal bleeding decreased within 1
month after procedure.
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A more recent study by Goodwin et al.
[5] described a clinical
success rate of 81%, with a low complication rate. Clinical success was
defined as decrease in abnormal uterine bleeding or pelvic pain. Although
successful pregnancies after the procedure have been reported anecdotally, the
effect of embolization on fertility has yet to be studied.
Ovarian Vein Embolization
Pelvic congestion syndrome is a poorly understood condition in which
incompetent valves in the ovarian veins result in pelvic varicosities.
Symptoms include dyspareunia, pelvic pain, and fullness or heaviness that may
be exacerbated in the upright position or by pregnancy. Since 1994, there have
been reports of radiologists successfully treating this condition with
embolization of the ovarian veins
[6]. This treatment is
accomplished with selective catheterization and coil embolization (Fig.
2A,2B).
Technical success rates range from 88.9%
[7] to 96.7%
[8]. Clinical success rates
vary. Capasso et al. [7]
reported variable symptomatic relief in 73.7% and complete response in 57.9%,
with an average follow-up of 15.4 months. Cordts et al.
[8] reported immediate relief
in 88.9% of patients and 40-100% relief at 13.4-month mean follow-up in 82% of
patients.
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Fig. 2B. —45-year-old woman with clinical symptoms of pelvic congestion
syndrome, manifested by chronic pelvic pain and fullness. Venogram obtained
after coil embolization shows nonfilling of ovarian vein.
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Embolization for Postpartum and Postsurgical Bleeding
Diagnostic angiography with transcatheter embolotherapy has become a vital
tool in treating postpartum hemorrhage and persistent bleeding after
gynecologic surgery. Since the late 1970s, arterial embolization for
postpartum hemorrhage was reported in numerous small series. In a review of
the literature, Vedantham et al.
[9] reported a 97% success rate
with a 6-7% complication rate. This rate included 16 of 18 successful
embolizations after cesarean delivery. The same researchers also reported
excellent results in 19 patients who underwent transcatheter arterial
embolization for persistent bleeding after gynecologic surgery.
The technique is basically the same as with other embolization procedures.
Diagnostic angiography is initially performed with follow-up embolization of
abnormal arteries that may show extravasation (Fig.
3A,3B,3C),
abnormal arteriovenous communication (Fig.
4A,4B,4C),
truncation, or spasm.
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Fig. 3A. —62-year-old woman with persistently dropping hematocrit level
after gynecologic surgery for urinary stress incontinence. Late phase pelvic
angiogram shows active contrast extravasation (arrow) from arterial
branch of left internal iliac artery (arrowhead), indicative of
active bleeding.
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Fig. 3B. —62-year-old woman with persistently dropping hematocrit level
after gynecologic surgery for urinary stress incontinence. Selective angiogram
proximal to injured artery shows catheter tip at bifurcation of left internal
iliac artery (arrow). Note contrast extravasation from injured vessel
(arrowhead).
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Fig. 3C. —62-year-old woman with persistently dropping hematocrit level
after gynecologic surgery for urinary stress incontinence. Angiogram after
coil embolization shows occlusion of injured artery and no further
extravasation (straight arrow). Catheter (curved arrow) is
from left femoral access.
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Fig. 4A. —43-year-old woman 2 days after cesarean delivery who, because
of religious beliefs, refused blood transfusion. Her hematocrit level dropped
rapidly. CT scan shows uterine dehiscence (arrow) and free fluid in
pelvis.
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Fig. 4B. —43-year-old woman 2 days after cesarean delivery who, because
of religious beliefs, refused blood transfusion. Her hematocrit level dropped
rapidly. Late arterial phase pelvic angiogram shows early draining vein
(straight arrow), consistent with abnormal arteriovenous
communication. Catheter (curved arrows) is coming from right femoral
access.
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Fig. 4C. —43-year-old woman 2 days after cesarean delivery who, because
of religious beliefs, refused blood transfusion. Her hematocrit level dropped
rapidly. Left internal iliac angiogram shows good result after Gelfoam
(Upjohn, Kalamazoo, MI) embolization. Note truncated internal iliac artery
(arrow). Patient's hematocrit level stabilized.
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Fallopian Tube Recanalization
Well-described in the radiology literature, fallopian tube recanalization
has become an accepted technique in treating infertile women with proximal
tubal obstruction [7].
Techniques vary, but most involve hysterosalpingography followed by selective
salpingography. If this treatment fails to open the tube, guidewires or
microcatheters are passed into the tube in an attempt to recanalize the
occlusion (Fig.
5A,5B,5C).
Pregnancy rates are difficult to determine given the multifactorial causes of
infertility but are reported to be in the 30% range
[1].
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Fig. 5B. —31-year-old infertile woman with no prior history of pelvic
inflammatory disease. Hysterosalpingogram shows hydrophilic wire
(arrow) advanced beyond obstruction on right side without
difficulty.
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Fig. 5C. —31-year-old infertile woman with no prior history of pelvic
inflammatory disease. Selective salpingogram now shows normal filling of right
fallopian tube (arrow) and free peritoneal spillage of contrast
material (arrowhead). Left side was recanalized in similar
fashion.
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Transvaginal Biopsy or Drainage Procedures
The transvaginal route, in conjunction with sonographic guidance, provides
a safe and effective means of draining fluid collections in the deep pelvis
and of sampling solid masses for diagnosis. High success rates and low
complication rates have been reported for transvaginal drainage procedures
[10]. The procedure is usually
performed with an endovaginal sonography transducer to guide initial needle
placement. Both Seldinger and trocar techniques have been used, in conjunction
with fluoroscopy, to guide catheter placement.
Zanetta et al. [11] studied
101 transvaginal sonographically guided punctures for diagnoses. This study
included 46 cytologic aspirates and 55 biopsies. The researchers found neither
moderate nor severe complications, and the specificity rate was 100% (Fig.
6A,6B,6C).
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Fig. 6B. —41-year-old woman with history of ovarian carcinoma. Coronal
transvaginal sonogram reveals mass (arrow). Note loop of bowel
posterior to mass (arrowhead) and posterior acoustic enhancement
indicating cystic nature of mass.
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Drainage of Tuboovarian Abscess
The standard treatment for tuboovarian abscess is antibiotic therapy and
surgery in patients resistant to antibiotic treatment. Ample literature
supports percutaneous drainage a an alternative to surgery or in patients not
responding to more conservative measures
[3] (Fig.
7A,7B).
Casola et al. [2] found good
clinical responses in 94% of patients, 81% of whom avoided surgery because
they were treated percutaneously. The procedure may be performed from a
transvaginal, transgluteal, or transabdominal approach depending on patient
and operator preference and the safest access route to the abscess.
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Fig. 7A. —28-year-old infertile woman who developed fever and pelvic
pain after hysterosalpingography with oily contrast material. Pelvic CT scan
12 days after hysterosalpingography shows multiloculated fluid collection in
pelvis consistent with tuboovarian abscess (arrowhead). Note
high-attenuation foci consistent with oily contrast material (straight
arrow). Bladder is anterior (curved arrow).
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Fig. 7B. —28-year-old infertile woman who developed fever and pelvic
pain after hysterosalpingography with oily contrast material. Pelvic CT scan 2
weeks after transgluteal drainage shows good result with resolution of
abscess. Pigtail catheter tip is anterior to rectum (arrow). This
approach was chosen because of operator preference. Drain was pulled after
CT.
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Percutaneous Drainage of Uterine Collections, With or Without
Cervical Stent Placement
Percutaneous drainage of uterine fluid collections can be a useful and
effective procedure in appropriate clinical situations (Fig.
8A,8B,8C).
Occasionally, drainage may need to be supplemented by cervical stent
placement. This procedure was recently reported in the literature by Gooding
et al. [3] in select patients
with malignant cervical strictures and proved to be effective in providing
symptomatic relief and improving quality of life. The technique involves
placement of self-expanding metallic stents after percutaneous uterine
drainage (Fig.
9A,9B,9C,9D).
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Fig. 8A. —12-year-old girl with history of vaginal atresia had
breakthrough menstrual pain despite hormonal suppression. Sagittal T2-weighted
MR image shows blood products in uterus and cervix consistent with
hematometra.
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Fig. 8B. —12-year-old girl with history of vaginal atresia had
breakthrough menstrual pain despite hormonal suppression. Sagittal
transabdominal sonogram shows marked enlargement of uterus (solid
arrow) and cervix (open arrow) with echogenic material in both,
consistent with hematometra. CT-guided transabdominal drainage (not shown) was
subsequently performed and confirmed hematometra.
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Fig. 8C. —12-year-old girl with history of vaginal atresia had
breakthrough menstrual pain despite hormonal suppression. Hysterogram obtained
through percutaneously placed drain shows unicornuate uterus, now
decompressed, and nonvisualization of vagina. Patient underwent successful
vaginal reconstruction after drain removal.
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Fig. 9B. —54-year-old woman with sepsis and history of both cervical
and ovarian carcinoma. CT scan with oral contrast agent shows percutaneous
catheter placement. Cultures from intrauterine collection grew out
Enterococcus faecalis organisms.
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Fig. 9D. —54-year-old woman with sepsis and history of both cervical
and ovarian carcinoma. Hysterogram obtained after placement of 10 mm diameter
by 60 mm long self-expanding stent shows free flow of contrast material
through cervix. Percutaneous drain was subsequently removed leaving patient
catheter-free.
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Conclusion
As shown in our study, the interventional radiologist can provide many
valuable services to the obstetrician—gynecologist in both vascular and
nonvascular interventional procedures.
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Introduction
Uterine Artery Embolization
