Management of Suspected Uterine Arteriovenous Malformation or Fistula in the Postprocedural Setting

Purpose: To identify key variables that can help guide the management of suspected uterine arteriovenous malformations (AVMs) and arteriovenous fistulas (AVFs) in the postprocedural setting.

Materials and Methods: A single institution search for ultrasound and angiographic findings suspicious for uterine AVMs and AVFs between September 2012 and September 2021 was performed. Patients were filtered for acute vaginal bleeding with a history of gynecologic procedure. Patients were included if initial ultrasound imaging was either suggestive or equivocal for uterine AVM or AVF or if emergent angiography revealed uterine AVM or AVF. Patients were divided into immediate intervention, failed medical management, and successful medical management groups. Several key variables were then documented, and a descriptive analysis was performed.

Results: A total of 36 patients were identified with either suspected uterine AVM or AVF on preliminary ultrasonography or on emergent angiography. Immediate intervention was performed in 7 patients (19.4%), and medical management was attempted in 29 patients (80.5%). Among patients in whom medical management was attempted, 17 subsequently required endovascular intervention (58.6%), and 12 patients continued with medical management alone (41.4%). For patients who underwent immediate endovascular intervention, the average age was 44 years, hematocrit was 28.95%, units transfused were 2 units, and 42.9% were hemodynamically unstable. For patients who failed medical management, the average age was 31.5 years, hematocrit was 31.7%, units transfused were 0.63, and 10.3% of patients became hemodynamically unstable. Ultrasonography was suggestive of AVM or AVF in 37.5% of patients and equivocal in 62.5%, and the average lesion size was 3.05 cm. For patients with successful medical management, the average age was 29.4 years, hematocrit was 35.7%, and units transfused were 0.19. Ultrasonography was suggestive of AVM or AVF in 8.3% of patients and equivocal in 91.7%, and the average lesion size was 2.5 cm. In total, 66.7% of patients underwent embolization. Gelfoam was most commonly used, including in 50% of immediate interventions and 70.6% of delayed interventions. Glue and coils were used in 50% of immediate interventions. The technical success rate was 100%. Cessation of bleeding occurred in 83.3% of patients after one intervention and 100% after one or more interventions. No major complications occurred.

Conclusions: Evaluation of age, hematocrit, transfusion requirements, hemodynamics, sonographic findings, and lesion size can help manage patients with suspected uterine AVM or AVF.