Ultrasound Imaging of Acquired Myometrial Pseudoaneurysm: The Role of Manipulators as an Unusual Cause during Laparoscopic Surgery

Abstract

An acquired uterine artery myometrial pseudoaneurysm can occur due to inflammation, trauma, or iatrogenic causes, such as surgical procedures, and can lead to profuse bleeding. The efficacy of uterine manipulators in gynecological surgery, particularly as a cause of a pseudoaneurysm, has been poorly discussed in the literature. In this paper, we discuss a case of a 39-year-old woman with profuse uterine bleeding that occurred seven days after operative laparoscopic surgery for endometriosis. The color Doppler ultrasound better evoked the arterial-like turbulent blood flow inside this cavity. These sonographic features were highly suggestive of uterine artery pseudoaneurysm, presumably related to a secondary trauma caused by the manipulator. The diagnosis was subsequently re-confirmed by angiography, and the patient was treated conservatively with uterine artery embolization. Ultrasound has been shown to be a valuable and safe tool for imaging pseudoaneurysm and guiding subsequent interventional procedures. Accordingly, we briefly review the most suitable manipulators used in benign gynecological surgeries to verify if the different types in use can guide the surgeon towards the correct choice according to surgical needs and thus prevent potentially dangerous trauma.

Keywords: computed tomography; dimension; magnetic resonance; ultrasound; uterine artery pseudoaneurysm.

Figure 1

(A) Preoperative ultrasonography of the pelvis (the blue square denotes the area of interest). (B) Postoperative ultrasonography of the pelvis.

Figure 2

Acquired pseudoaneurysm from the ascending branch of the left uterine artery. Note the to-and-fro sign and the yin-yang image.

Figure 3

(A) Selective angiography of the left internal iliac artery before embolization: the contrast media injection shows an abnormal dilatation with contrast media extravasation (indicated by the arrow) out of the distal branch of the left uterine artery. (B) Angiography after embolization with embolic particles; the lesion is no longer visible.

Figure 4

(A) 3D-HD flow color Doppler rendering image showing turbulent arterial flow into the anechoic area deriving from the right uterine artery vessel. (B) 3D-HD flow rendering image after the first embolization procedure showing the persistence of the flow deriving from a collateral branch of the left uterine artery vessel.