Preservation of Fertility by Direct Puncture Embolization of Acquired Uterine Arteriovenous Fistulae in Women of Childbearing Age with Life-Threatening Hemorrhage

Abstract

Purpose: To determine the safety and effectiveness of ultrasound (US)-guided direct puncture and embolization of acquired uterine arteriovenous fistulae (UAVFs) with ethylene vinyl alcohol copolymer (EVOH) and to determine its impact on subsequent fertility.

Materials and methods: A retrospective review of consecutive patients treated for UAVFs with life-threatening hemorrhage from July 2015 to April 2022 was performed. Patient demographics, imaging studies, procedural reports and follow-up clinic notes were reviewed. A total of 7 patients were included; median age was 32 years (range, 22-38 years). All patients had a history of uterine instrumentation and presented with vaginal bleeding and presumed UAVF, confirmed by US or magnetic resonance (MR) imaging. Two (29%) had previously undergone proximal transarterial uterine artery embolization but had recurrent bleeding. US-guided direct UAVF puncture was performed by a transabdominal (n = 2) or transvaginal (n = 5) approach with injection of EVOH in all patients. Technical success was defined as resolution of UAVF on intraprocedural angiography and US and follow-up MR imaging. Clinical success was defined as resolution of the bleeding without recurrence or need for subsequent embolization or hysterectomy.

Results: Median follow-up duration was 158 days (range, 7-2,061 days). Technical success was 100%. Clinical success was 100% with resolution of bleeding in all patients. No adverse events related to the embolization procedure were noted. One patient was lost to follow-up within a month of the procedure and, therefore, excluded from clinical analysis. Of the remaining 6 patients, 3 had successful childbirths after the embolization procedure, and 1 was pregnant at the time of data collection. One patient had an ectopic pregnancy after the procedure.

Conclusions: US-guided direct puncture and EVOH embolization appears to be a safe and effective option for management of acquired UAVFs in a small cohort of patients, avoiding hysterectomy and preserving the option of fertility in young women.