Uterine artery

Uterine leiomyomas, or fibroids, are the most common type of solid tumors in adult women, clinically apparent in at least 25% of those of reproductive age [24-26]. Abnormal menstrual bleeding, pelvic pain, and infertility are the most commonly experienced symptoms in these women. Uterine fibroids are the leading cause of hysterectomies performed in the United States, accounting for over 200,000 of these procedures each year. Other invasive surgical interventions for the treatment of uterine fibroids include myomectomy and uterine artery embolization. Leiomyomas are estrogen-responsive tumors that can be treated... 

Zhang L, Dyer DC. (1993). Lysergic acid diethylamide is a partial agonist at 5-HT2 receptors in ovine uterine artery of late pregnancy. EurJ Pharmacol. 230(1) 115-17. 

The blood supply to the vagina is through the uterine arteries and the internal iliac artery. Blood returns to the venous system through veins that empty into the internal iliac vein. Lymphatic drainage is through the external and internal iliac lymph nodes and superficial inguinal lymph nodes. 

Morgadinho MT, Fontes Ribeiro CA, Macedo TR (1999) Presynaptic dopamine receptors involved in the inhibition of noradrenaline and dopamine release in the human gastric and uterine arteries. Fundam Clin Pharmacol 13 662-70... 

Cicinelli, E., Cignarelli, M., Sabatelli, S., Romano, F., Schonauer, L. M., Padovano, R., and Einer-Jensen, N. (1998), Plasma concentrations of progesterone are higher in the uterine artery than in the radial artery after vaginal administration of micronized progesterone in an oil-based solution to postmenopausal women, Fertil. Steril., 69, 471—473. 

The subtype of muscarinic receptor in the smooth muscle has been characterized as M3 by use of selective anticholinergics and different smooth muscle preparations from different species. These smooth muscle tissues include (l)trachea (22), ileum (23, 24), uterine artery (25), and submucosal arterioles of guinea pig (26) (2) aorta (27) and coronary artery of rabbit (28) and (3) trachea (29), aorta (30), and iris (3 l)of rat. Human uterine arteries (32), airways (33), and ciliary muscles (34) have also been shovm to contain the M3 type of muscarinic receptors. 

Hovsepian DM, Siskin GP, Bonn J, et al. (2004) Quality improvement guidelines for uterine artery embolization for symptomatic leiomyomata [see comment]. Cardiovasc Intervent Radiol 27 307-313... 

Chua GC, Wilsher M, Young MP, Manyonda I, Morgan R, Belli AM (2005) Comparison of particle penetration with non-spherical polyvinyl alcohol versus trisacryl gelatin microspheres in women undergoing premyomectomy uterine artery embolization. Clin Radiol 60 116-122... 

Spies JB, Allison S, Flick P, et al. (2004) Polyvinyl alcohol particles and tris-acryl gelatin microspheres for uterine artery embolization for leiomyomas results of a randomized comparative study. J Vase Interv Radiol 15 793-800... 

There have been complications reported in association with the use of trisacryl gelatin microspheres. De Blok et al. reported a case of fatal sepsis after uterine artery embolization performed with this agent. In this case, diffuse necrosis of the vaginal wall and cervix was found, attributed to distal penetration of spheres measuring 500-700 p in diameter... 

Goodwin S, McLucas B, Lee M, et al. (1999) Uterine artery embolization for the treatment of uterine leiomyomata midterm results. J Vase Interv Radiol 10 1159-1165... 

Spies JB, Ascher SA, Roth AR, et al. (2001) Uterine artery embolization for leiomyomata. Obstet Gynecol 98 29-34... 

Walker WJ, Pelage JP (2002) Uterine artery embolisation for symptomatic fibroids clinical results in 400 women with imaging follow-up. BJOG 109 1262-1272... 

Aziz A, Petrucco OM, Mikinoda S, et al. (1998) Transarterial embolization of the uterine arteries patient reactions and effects on uterine vasculature. Acta Ohstet Gynecol Scand 77 334-340... 

Pelage JP, LeDref O, Beregi JP,et al. (2003) Limited uterine artery embolization with tris-acryl gelatin microspheres for uterine fibroids. J Vase Interv Radiol 14 15-20... 

Spies JB, Benenati JF, Worthington-Kirsch RL,et al. (2001) Initial experience with the use of trisacryl gelatin microspheres for uterine artery embolization for leiomyomata. J Vase Interv Radiol 12 1059-1063... 

Pelage JP, Laurent A, WassefM,et al. (2002) Uterine artery embolization in sheep comparison of acute effects with polyvinyl alcohol particles and calibrated microspheres. Radiology 224 436-444... 

Richard HM, Siskin GP, Stainken BF (2004) Endometritis after uterine artery embolization with gold-colored gelatin microspheres. J Vase Interv Radiol 15 406-407... 

Katz RN, Mitty HA, Stancato-Pasik A, et al. (1998) Comparison of uterine artery embolization for fibroids using gelatin sponge-pledgets and polyvinyl alcohol [abstract]. J Vase Interv Radiol 9 194... 

Sterling KM, Siskin GP, Ponturo MM, et al. (2002) A multicenter study evaluating the use of Gelfoam only for uterine artery emholization for symptomatic leiomyomata [abstract]. J Vase Interv Radiol 13(2, Part 2) S19... 

McIvor J, Cameron EW (1996) Pregnancy after uterine artery emholization to control hemorrhage from gestational trophoblastic tumour. Br J Radiol 69 624-629... 

Vedantham S, Goodwin SC, McLucas B, et al. (1997) Uterine artery embolization an underused method of controlling pelvic hemorrhage. Am J Ohstet Gynecol 176 938-948... 

Spies JB, Pelage JP (eds) (2004) Uterine artery embolization and gynecologic embolotherapy. Lippencott, USA Wilkins RA, Viamonte M (eds) (1982) Interventional radiology. Blackwell, Oxford... 

Fig. 9.1. Angiogram of the right uterine artery demonstrating Fig. 9.2. Selective angiogram of right ovarian artery feeding...

Apart from the classic pattern in which the uterine artery arises from the medial aspect of llA, there are many other variants that have been identified (please see Chap. 10.3). It may also arise from its anterior or lateral aspect of the IIA [18]. The origin of the uterine artery from the main IIA itself or from the aorta has also been described [18]. A common trunk between the uterine artery and vesical artery is another important variant that might lead to inadvertent vesical ischemia in cases of non-tar-geted embolization [19]. The uterine artery may also duplicate as illustrated by Redlich et al. [20]. The ovarian artery represents the second main vessel for PPH [21, 22]. The ovarian artery that participates in uterine blood supply could represent the major feeding vessel to the uterus as demonstrated in UFE literature [23] (Fig. 9.2). Recently, Saraiya et al. illustrated uterine artery replacement by the round ligament artery during embolization for leio-... 

Fig.9.3a,b. Right iliac angiogram showed collateral pathways from the artery supplying the round ligament after embolization of both right internal iliac and uterine arteries... 

Catheterization of bilateral uterine arteries is mandatory. A cobra-shaped catheter is the best catheter to use for easy insertion into uterine arteries. The cobra catheter is available in three different types, each according to the degree of opening of the curve. The medium sized catheter (C2) is the one most commonly used. When using a 4-F catheter, one should make sure that the lumen of the catheter is able to accept 0.038-in. guidewire for possible microcatheter use. The contralateral internal iliac artery is catheterized first and can be reached by pushing the cobra. In some difficult cases, a curved catheter, such as SOS or sidewinder, could be handy to cross the aortic bifurcation. 

The ipsilateral uterine artery access is obtained using the Waltman loop. When the angle of aortic bifurcation is too tight, again the use of a sidewinder allows for easy catheterization. 

Angiography can detect contrast medium extravasation however, this is not seen in the majority of cases. Contrast media extravasations were observed in 18% of patients in a recent study [33]. Even without extravasation, bilateral uterine artery embolization needs to be performed. 

Fig. 9.5. Final aortogram showed complete occlusion of uterine arteries. The patent ovarian arteries were demonstrated...

For this reason, when an embolotherapy is planned we recommend immediate cessation of prostaglandin Ej agonist infusion. In case of arterial spasm at the ostium of the uterine artery, the use of a coaxial system with a microcatheter is then required. It is possible to successfully catheterize the distal part of the uterine artery in most cases. In these circumstances, the preferred embolic agent is the one that can be easily delivered through a microcatheter, such as PVA (Polyvinyl alcohol) or Embospheres. We prefer to use particles with larger diameters, such as Embospheres 700-900 mg. Even if these particles are used for the above-mentioned reasons, additional Gelfoam embolization of internal iliac arteries is performed because of the extensive collateral pathways of the female pelvis. 

Fig.9.6a-c. Spasm of uterine artery involving proximal segment (a), and distal segments (b,c). Spasm induced a complete occlusion of the distal artery in (c) (arrows)... 

Fig. 9.8. Angiogram of left uterine artery contrast media extravasation from a vaginal laceration (arrows)...

Fig. 9.9. Angiogram of right uterine artery showing contrast media extravasation (arrows)...

Finally, fetal growth retardation (FGR) is reported to occur in patients after uterine artery embolization this was reported in one case by Cordonnier etal. [50]. 

Fig.9.10a,b. Late phase uterine artery angiograms shows contrast media extravasations (arrows)... 

Worthington-Kirsch RL (2000) Anatomy of the uterine artery. AJR Am J Roentgenol 174 258... 

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