Rare case of pseudoaneurysm of uterine artery

A 32 year old female presented with two days history of acute abdominal pain. The pain was localized in right iliac fossa and pelvic region. On examination, moderate abdominal tenderness was also present, along with abdominal distention. She had a history of hysterectomy performed about one month ago for symptomatic uterine fibroids. An urgent ultrasonography of abdomen was performed which revealed gross amount of echogenic fluid in pelvic cavity. Thick mobile echoes suggested a possibility of hemoperitoneum.

The diagnosis was supported by initial hemodynamic shock and anemia. The BP at presentation was 90/60 mm Hg, with tachycardia [heart rate: 120 bpm], and a hemoglobin (Hb) value of 8.3 gm/dL. Her previously recorded Hb was 12.7 gm/dL which suggested a rapid onset bleeding. After initial resuscitation with intravenous fluids and blood transfusion, she got stabilized. She was further investigated with CECT abdomen with angiography protocol. The CT scan confirmed a pelvic collection causing compression over right ureter and causing right moderate hydronephrosis [Fig.1]. Her right iliac fossa and flank pain could be explained by this finding. However, the CT angiogram images did not reveal any significant ooze, active leak or pseudoaneursym arising from any pelvic artery [Fig.2].

A decision to surgically evacuate this hematoma was not appreciable due to the risk of loss of the “tamponade” effect of hematoma over bleeding vessel. Hence, it was decided to take the patient for conventional catheter-based digital subtraction angiography [DSA], and look for any culprit artery. Two days after the initial presentation, the patient underwent DSA. A right femoral artery access was taken with a 6F sheath. Using 0.035” angled-tip glidewire [Terumo] and 5F pigtail catheter, aortogram was performed for a general pelvic vasculature assessment, and also to opacify the ovarian arteries [Fig.3]. Further, catheterization of each of the uterine arteries was done with a 5F Robert’s uterine catheter [RUC] and hydrophilic guide wire. Selective angiograms of both uterine arteries were performed which revealed diffusely increased vascular “blush”, tortuosity of arterial branches and overall hypervascularity [Fig.4]. A 2.7 French microcatheter and microguidwire combination [Progreat, Terumo] was used to superselectively catheterize each uterine artery. The tip of the catheter was placed distal to the origin of cervico-vaginal artery, to prevent inadvertent vaginal ischemia and future possibility of vaginal parasthesia. 500-700 micron-sized polyvinyl alcohol [PVA] particles were used to embolize this hypervascularity from both sides. The PVA was injected with gentle, repeated push of the syringe, and continued till stasis in the main artery was achieved.

To our surprise, a post-embolization check angiogram revealed opacification of a pseudoaneurym arising from main trunk of right uterine artery [Fig.5]. Hence, a decision of coil embolization was taken. A 5 cm long, 5 mm diameter coil [35-5-5; MReye, Cook] was used to coil the right uterine artery [Fig.6]. As there was possibility of retrograde filling of the pseudoaneurysm from the opposite side, the anterior division of left internal iliac artery was also embolized using 7 cm long, 6 mm diameter coil [35-7-6; MReye, Cook]. Post-embolization final angiogram revealed non-opacification and exclusion of pseudoaneurysm from circulation [Fig.7].

The patient was then shifted to ICU for next two days, and then shifted to ward. Owing to rapid decrease in abdominal distention and pain, and a stable hematocrit, she was discharged from hospital five days after the embolization procedure.