Uterine Arteriovenous Fistula with Concomitant Pelvic Varicocele: Endovascular Embolization with Onyx-18®

Abstract

Uterine arteriovenous fistulas are rare and acquired causes of life-threatening vaginal bleeding. They usually present with intermittent menometrorrhagia in young patients in childbearing age with history of gynecological procedures on uterus. Traditional management is hysterectomy; endovascular embolization represents nowadays an alternative strategy for patients wishing to preserve fertility. Here, the endovascular approach to a 29-year-old woman affected by severe menometrorrhagia caused by a uterine arteriovenous fistula with a concomitant pelvic varicocele is reported; a bilateral uterine arteries embolization with Onyx-18 (ev3, Irvine, CA, USA) has successfully resolved the fistula with clinical success.

Figure 1

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.

Figure 2

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).

Figure 3

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)).