Embolization of Complex Uterine Arteriovenous Malformation: Use All What You Have

Purpose: Uterine arteriovenous malformations (UAVMs) are rare entities that can be acquired after uterine trauma and instrumentation. They are often presented with bleeding that can be potentially life threatening. We present a case of complex UAVM that presented with pain and developed after minimally invasive cervical surgery. It was treated with embolization using different embolic agents.

Materials and Methods: A 48-year-old postmenopausal woman presented to the gynecology clinic with a 3-month complaint of intermittent pelvic pain that was responding to over-the-counter analgesia. However, the pain had increased in intensity recently. Her 3 history included delivery via cesarean section 24 years ago and transvaginal cervical polypectomy three months ago at an outside health care facility. Her physical examination was within normal limits except for the cesarean section scar. The cervix was healthy on speculum examination. Pelvic ultrasound with color Doppler showed multiple enlarged uterine and pelvic vessels with heterogenous flow signals. Contrast-enhanced magnetic resonance imaging was performed. It revealed multiple serpiginous flow-related signal voids within the uterus and pelvis. A presumptive diagnosis of the uterine arteriovenous malformation (AVM) was made, and the patient was referred to interventional radiology.

Results: The abdominal and pelvic aortogram showed a complex UAVM with an arterial supply not only from the uterine arteries but also from pelvic visceral and musculoskeletal arterial branches, including the ovarian, inferior mesenteric, vesical, inferior epigastric, and femoral circumflex arteries. Over two sessions with 1-week interval, each arterial branch was selectively catheterized and embolized starting with the large ones. Different embolic agents, including Onyx, polyvinyl alcohol particles, and gelatin sponge slurry, were injected as close as possible to the nidus depending on the branch size and locations. All arterial branches were selectively embolized. Final angiogram confirmed no opacification of the AVM or the early venous returns. At 1-month follow-up, the patient’s complaint had been relieved.

Conclusions: Our case has multiple peculiarities, including unusual symptoms and development of the large UAVM with complex anatomy after minimally invasive surgery of the cervix. Various embolic agents have been used for predictable and effective embolization of the arterial components of the lesion.