A Systematic Review of Acquired Uterine Arteriovenous Malformations: Pathophysiology, Diagnosis, and Transcatheter Treatment

Abstract

Objective An acquired uterine arteriovenous malformation (AVM) is a rare cause of vaginal bleeding and, although hysterectomy is the definitive therapy, transcatheter embolization (TCE) provides an alternative treatment option. This systematic review presents the indications, technique, and outcomes for transcatheter treatment of the acquired uterine AVMs. Study Design Literature databases were searched from 2003 to 2013 for eligible clinical studies, including the patient characteristics, procedural indication, results, complications, as well as descriptions on laterality and embolic agents utilized. Results A total of 40 studies were included comprising of 54 patients (average age of 33.4 years). TCE had a primary success rate with symptomatic control of 61% (31 patients) and secondary success rate of 91% after repeated embolization. When combined with medical therapy, symptom resolution was noted in 48 (85%) patients without more invasive surgical procedures. Conclusion Low-level evidence supports the role of TCE, including in the event of persistent bleeding following initial embolization, for the treatment of acquired uterine AVMs. The variety of embolic agents and laterality of approach delineate the importance of refining procedural protocols in the treatment of the acquired uterine AVM. Condensation A review on the management of patients with acquired uterine AVMs.

Keywords: arteriovenous malformation; embolization; endovascular; postpartum hemorrhage; uterus.

Fig. 1

Unilateral Onyx (ev3 Endovascular Inc., Plymouth, MN) embolization, a type of nonadhesive liquid embolic agent, for an acquired uterine AVM. A 30-year-old G1P1001 presented with vaginal bleeding 9 days following D&C for retained products of conception. (A) Color Doppler ultrasound of the uterus in sagittal plane reveals a heterogeneous, hyperechoic region within the anterior fundal myometrium extending to the endometrium with an increased vascularity. (B) DSA of the aorta with contrast demonstrates increased vascularity arising from the left uterine artery and a normal appearing right uterine artery. (C) Selective catheter angiography of the left internal iliac artery with contrast confirms an acquired uterine AVM arising from the uterine artery with arteriovenous shunting. (D) Early venous filling is also noted on delayed imaging. (E) Post-Onyx embolization angiography reveals total occlusion of the AVM. (F) Representative coronal images from follow-up MRI showing preservation of uterine perfusion, absence of a vascular malformation, and associated artifact from the Onyx embolic agent. AVM, arteriovenous malformation; D&C, dilation and curettage; DSA, Digital subtraction angiography; MRI, magnetic resonance imaging.