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24 Inter ventions oftheMesenteric Arterial Circulation
295
development of these atherosclerotic changes is slow and
thus results in the development of signicant collateral circulation. Patients with good collaterals are asymptomatic. The
proximal portions of the mesenteric arteries are the most
commonly affected sites. Superadded acute thrombosis may
lead to acute presentation resembling acute mesenteric
ischemia.
24.3.2 Imaging
Imaging plays an important role in the diagnosis of mesenteric ischemia due to its nonspecic clinical features and
laboratory ndings. A normal serum lactate level does not
exclude mesenteric ischemia and thus should not be used to
exclude the need for further imaging. Doppler USG can be
used for the initial evaluation of chronic mesenteric ischemia. It is also a valuable tool for follow-up after endovascular interventions. Contrast-enhanced multiphase CT is the
primary imaging modality used in the evaluation of both
acute and chronic mesenteric ischemia. Technological
advancements like the development of multidetector CT
have enabled faster acquisition and improved reconstruction
for obtaining better quality images with relatively low radiation exposure. CT helps in the accurate diagnosis of the site,
level, and length of arterial occlusion. Additionally, it also
helps in evaluating the ischemic changes in the affected
bowel loops (bowel wall enhancement). The length and site
of bowel involvement and gangrene or impending gangrene
can be diagnosed with high accuracy on contrast-enhanced
CT.It also helps in depicting the collateral circulation and
provides a roadmap for planning endovascular interventions.
Post-processing techniques like multiplanar reconstruction
and maximum intensity projection have improved our ability
to precisely identify and calculate various measurements for
pre-procedural planning.
In the acute setting, CT is performed without administration of any oral contrast. Neutral contrast agents like oral
water or mannitol can be given in patients undergoing CT for
evaluation of chronic mesenteric ischemia. Multiphase CT
includes a noncontrast scan to look for bowel wall hemorrhage or preexisting hyperdensity within the bowel loops.
This is followed by acquisition of CT in the early arterial,
portal venous, and venous phases with an additional optional
delayed phase.
Emboli appear as lling defects within the arteries. The
mid-portion of the SMA just distal to the origin of the middle
colic artery is the most common site where emboli get
lodged. Acute thrombosis is usually secondary to preexisting
atherosclerotic disease with varying degrees of collateral formation. It is usually more extensive and extends across
branching points in a serpiginous manner unlike emboli.
Arterial dissection appears as a hypodense ap within the
lumen of the artery. Acute thrombosis secondary to a dissection can mask the existence of a ap on CT.Aortic dissection
with extension of ap into the mesenteric arteries can lead to
acute mesenteric ischemia. Isolated dissection of the mesenteric arteries is rare and can be seen in medium vessel vasculitis or segmental arterial mediolysis.
Acute arterial ischemia causes bowel wall thinning with
typical papery thin bowel walls on CT. Areas of complete
non-enhancement represent ischemia and impending gangrene. The presence of ascites or pneumoperitoneum in a
patient with arterial ischemia signies the development of
gangrene and focal perforation [1].
24.3.3 Treatment
Treatment options in acute mesenteric ischemia include medical management with systemic thrombolysis, endovascular
management, and surgery. Surgical treatment with exploratory
laparotomy, revascularization, and resection anastomosis of
infarcted segments was historically the primary modality of
treatment. However, endovascular treatment has been used
increasingly with favorable outcomes. It is recommended that
revascularization procedures are performed within the rst
12 hours for the best results. Endovascular options for the
treatment of acute mesenteric ischemia include mechanical
thrombectomy in patients with embolic mesenteric ischemia,
thrombectomy with or without catheter-directed thrombolysis,
and treatment of underlying stenosis with balloon angioplasty
or stenting in patients with thrombotic acute mesenteric ischemia. Balloon angioplasty with stenting of one of the affected
mesenteric arteries is commonly done in patients with chronic
mesenteric ischemia [2, 3].
Indications for endovascular treatment in acute mesenteric ischemia include
• Acute thromboembolism or dissection without signs of
irreversible intestinal ischemia on CT.
• Lack of improvement with conservative treatment.
• Presurgical treatment or hybrid procedures (thrombec-
tomy + bowel resection in the same intervention).
There are no absolute contraindications for endovascular
treatment.
24.3.3.1 Techniques ofEndovascular
Interventions
The initial steps are similar for all endovascular interventions and include establishing arterial access and performing
aortograms to assess the mesenteric vasculature and decide
on treatment planning.
296
N. Hemachandran and S. Gamanagatti
Preferred access: common femoral artery. Brachial artery
access is used in setting of signicant acute angulation of
mesenteric artery origins or aortoiliac occlusive disease.
Brachial artery access is associated with higher risk of complications like hematoma, pseudoaneurysm, or thrombosis,
and thus the smallest possible sheaths are used.
Once the access is obtained, long 7F sheath of sufcient
length is placed at D12 level (usually a 45cm sheath from
femoral access and 70 or 90cm sheath from brachial access).
This is followed by diagnostic angiograms in both anteroposterior and lateral projections. The anteroposterior angiogram provides an overview of the mesenteric circulation as
well as helps to identify distal arterial disease and the degree
of collateral development and inter-territorial ow. The lateral angiogram is better at identifying the level of origin and
the extent of ostial disease of the three mesenteric arteries as
they arise anteriorly from the aorta. This is followed by
selective cannulation and angiogram of the target vessel
(SMA most commonly) to identify the site and extent of
occlusion.
24.3.3.2 Intra-Arterial Thrombolysis
The commonly used thrombolytic agents are urokinase or
recombinant plasminogen activator (rt-PA—Alteplase).
After identifying the clot, a multiside hole straight thrombolysis catheter is introduced partially into the thrombus.
Then a bolus dose of thrombolytic agent is injected (either
slow or pulse spray technique). This is followed by infusion
of thrombolytic agent for 12–24hours.
Commonly used dosage of thrombolytic agent:
• Urokinase—50,000–250,000IU bolus followed by main-
tenance infusion of 50,000–100,000IU per hour.
• Recombinant plasminogen activator—5 mg bolus fol-
lowed by maintenance infusion of 0.5–1mg per hour.
• This is usually combined with a continuous heparin infu-
sion at 250–500IU/h.
Complications of thrombolytic therapy can range from
minor bleeding like oozing at arterial puncture or venipuncture sites to major intracranial hemorrhage or intramural or
mucosal hemorrhage of affected bowel segment.
Thrombolysis is stopped in case of a major bleeding event.
24.3.3.3 Mechanical Thrombectomy
This can be done either as a stand-alone procedure in case of
acute small focal emboli or after a course of thrombolytic
therapy (after the bolus dose in relatively acute clots or after
24hours infusion in more chronic clots). The selected aspiration catheter is impacted within the thrombus and connected
to an aspiration pump. Small fast to-and-fro movements of
the catheter aid in the fragmentation of thrombus and prevent
catheter obstruction. If there is residual thrombus even after
aspiration of ~500ml of blood, further aspiration is stopped
and catheter-directed perfusion thrombolysis is initiated.
Distal embolization can happen during thrombus fragmentation. However, a previous thrombolytic bolus dose would aid
in dissolution of the distal emboli [2].
24.3.3.4 Balloon Angioplasty andStenting
Balloon angioplasty and stenting are used to treat owlimiting stenosis and ow-limiting dissection aps involving the ostia or the proximal portions of the mesenteric
arteries (Fig.24.1). Balloon angioplasty alone is rarely used
in the mesenteric circulation and is usually combined with
stenting. Balloon expandable stents are used in patients with
short segment or ostial disease, and self-expandable metallic stents can be used in patients with dissection or a long
luminal abnormality. In patients with acute mesenteric ischemia, this is done if there is an underlying stenosis which is
unmasked after an initial thrombolysis or mechanical thrombectomy [2].
A oppy hydrophilic guidewire is used to cross the stenosis and is then exchanged with a stiff wire after conrming
the intraluminal position. The long sheath previously placed
in the aorta is pushed slowly across the stenotic segment to
enable easy placement of a stent across the stenosis. Predilation with a small caliber balloon (~4mm) may be needed
in patients with tight stenosis.
Intravenous/intra-arterial heparin is used throughout the
procedure in regular intervals to maintain an activated clotting time over 220s. A loading dose of aspirin (300mg) and
clopidogrel (300 mg) is given, followed by aspirin
75–150 mg and clopidogrel 75–150 mg once daily.
Follow-up Doppler USG is done to conrm vessel patency
at one week, one month, 3 months, 6 months, and yearly
thereafter.
cd
24 Inter ventions oftheMesenteric Arterial Circulation
297
Fig. 24.1 Short segment
SMA stenosis just distal to
the ostium. CT angio axial
image (a) shows small stump
at the ostium. Distal
reformation of SMA from
multiple small collaterals was
seen after approximately
2.2cm. SMA stent done using
6mm x 4cm balloon
mounted stent (b and c).
Post-procedure run showed
good distal ow (d)
a
b
24.4 Gastrointestinal Hemorrhage
late, a new terminology, mid-gastrointestinal bleeding
(MGIB), is used for small bowel bleeding occurring in
24.4.1 Clinical Features
between the duodenal papilla and the ileocecal valve. UGIB
is far more common in comparison to LGIB or
Gastrointestinal bleed can range from mild blood-tinged
vomitus to life-threatening hemorrhage. Without appropriate and timely treatment, it carries a high risk of mortality.
It is traditionally classied based on the site of hemorrhage
into upper gastrointestinal bleed (UGIB) and lower gastrointestinal bleed (LGIB), with the ligament of Treitz being
the anatomical landmark of division between the two. Of
MGIB.Patients with UGIB present with frank blood in the
vomitus, blood mixed contents in the nasogastric tube, or
melena, while patients with MGIB or LGIB present with
melena, fresh bleed per rectum, or anemia with occult
blood in the stools. Evaluation of the small bowel needs
additional measures like dual lumen enteroscopy and capsule endoscopy.
298
N. Hemachandran and S. Gamanagatti
24.4.2 Endoscopy
Endoscopic evaluation with upper gastrointestinal endoscopy and colonoscopy remains the initial diagnostic procedure for UGIB and LGIB respectively. It is helpful in
determining the cause of bleeding and can also be used for
therapeutic measures in the same sitting. It can also help
determine the nature of bleed (arterial versus venous), so as
to help determine the further course of management. In
patients in whom therapeutic interventions are not feasible
by endoscopic route, metal clips can be placed close to the
site of the bleed during endoscopy to facilitate easy identication of the site during angiography or surgery.
24.4.3 Imaging
Radiology plays an important role in the diagnosis and management of gastrointestinal bleed which is resistant to medical and endoscopic treatment. The location and severity of
the bleed and the patient’s hemodynamic status determine
the further treatment approach. Hemodynamically unstable
patients with acute severe bleed and known expected source
(either by endoscopy or previous history) can be taken up
directly for diagnostic subtraction angiography and embolization. However, in hemodynamically stable patients, in
patients with chronic gastrointestinal bleed, and in patients
in whom endoscopy could not be done or could not nd a
source of bleed, multiphase contrast-enhanced CT is done
for further assessment and treatment planning.
In the acute setting, CT is performed without administration of any oral contrast. Neutral contrast agents like oral
water or mannitol can be given in patients undergoing CT for
evaluation of chronic gastrointestinal bleed. Multiphase CT
includes a noncontrast scan to look for preexisting hyperdensity (sentinel clots) within the bowel loops that could be
secondary to recent hemorrhage. This is followed by acquisition of CT in the early arterial, portal venous, and venous
phases with a delayed phase to look for active extravasation
of contrast. CT can detect active bleeding even occurring at a
rate as low as 0.3mL/min. It also has high specicity for
identifying the etiology of gastrointestinal bleed. The sensitivity of CT for the detection of the bleed varies with the rate
of active bleeding, the hemodynamic status of the patient, as
well as the rate and volume of contrast administered.
Radionuclide scans are also used for the evaluation of
gastrointestinal bleed. It is particularly useful in patients
with intermittent bleeding. 99 m-Technetium-labeled red
blood cells are the commonly used agent. It can be imaged
up to 24hours from the time of injection enabling the identication of intermittent or low rates of bleed (as low as
0.1–0.35 mL/min). However, these radionucleotide studies
are not useful in the setting of active or massive gastrointestinal hemorrhage.
Digital subtraction angiography (DSA) can be used to
identify the source of bleeding as well as for selective embolization of the affected vessel. It is rarely used as a standalone diagnostic modality nowadays. Contrast-enhanced CT
angiography provides a roadmap for DSA and subsequent
embolization whenever available. In patients who are being
taken up for DSA directly due to hemodynamic instability,
sequential angiograms of all three mesenteric vessels are
done with the order and need for selective and super- selective
angiograms dictated by the clinical scenario and the suspected site of bleed. For example, in a patient with UGIB,
celiac angiogram is performed rst followed by selective
angiograms of the gastroduodenal artery and left gastric
artery. Splenic artery angiogram is also done in patients with
pancreatitis. If negative, SMA and IMA angiograms are performed. Similarly, in a patient with LGIB, IMA angiogram is
performed rst if the source of bleed is suspected to be in the
descending colon and SMA is performed if the source of
bleed is suspected to be from in the small bowel or proximal
colon. If no source is identied on SMA and IMA angiograms, bilateral internal iliac artery angiograms are performed to evaluate the bilateral middle and inferior rectal
arteries [4, 5].
24.4.4 Technique ofEndovascular
Embolization (Figs.24.2, 24.3, and24.4)
Common femoral artery is the preferred access. A short
length 5 F/ 6 F arterial sheath is used initially. The short
sheath can be exchanged for a long curved sheath or guiding
catheter after cannulation of the selected mesenteric vessel in
patients with tortuous target vessels. The mesenteric arteries
are cannulated using smooth curved catheters like the cobra
or Rosch celiac. In patients with acute angulations of the
mesenteric vessel, a double-curve catheter with the primary
and secondary curves oriented in different directions like the
Simmons catheter can be used. This is followed by selective
diagnostic angiograms of the mesenteric vessels in the order
described above. A ow rate of 5–7 ml/s is used for celiac
and SMA angiograms, and a ow rate of 2–3ml/s is used for
IMA angiograms. This is followed by selective cannulation
of the target vessel (based on angiographic ndings or the
suspected source based on CT/clinical scenario) and performing selective angiograms to identify the site and extent
of occlusion. A microcatheter is then used to super- selectively
cannulate the source of bleed [4, 5].
Anti-peristaltic agents like intravenous hyoscine butylbromide (Buscopan) or glucagon can be used when bowel
motion causes signicant artifacts impairing the interpreta-
ab
cd
24 Inter ventions oftheMesenteric Arterial Circulation
Fig. 24.2 CT scan (a)
showing focal active
extravasation in the lumen of
distal ileal loop and arising
from one of the ileal branches
of ileocolic artery (SMA).
DSA runs conrmed the
ndings (b), and using
microcatheter, two coils
(18-2-2 coils and 18-3-2
coils) were deployed distal
and proximal to the site of
extravasation (c and d)
299
abc
Fig. 24.3 CT angiography scan (a) shows focal hyperdensity in the
lumen of the distal ileal loop. Selective run of ileocolic branch of SMA
shows active extravasation (b). Two coils, 18-3-3, were placed across
tion of the images. In patients with negative angiograms, a
provocative angiogram is done by using intravenous heparin
(2000–6000 U) or intra-arterial vasodilator therapy with
the site of extravasation. Post-procedure run showed no active extravasation of contrast (c)
nitroglycerin (100–300μg), tolazoline (10–30mg), or papaverine (1 mg) in the suspected artery to help visualize the
source of bleed. However, such provocative measures should
300
ab
cd
N. Hemachandran and S. Gamanagatti
Fig. 24.4 CT angiography scan (a) shows GDA—superior pancreati-
coduodenal artery appearing irregular in contour with fuzzy margin.
DSA run (b) showed the suspected artery in spasm. Warm saline was
be used with utmost care as they can lead to catastrophic
bleeding [6].
used to relieve spasms. An attempt to cannulate with microcatheter was
done. Post-cannulation run showed active extravasation (c). Fifty percent glue was injected, which stopped the extravasation (d)
Anatomical factors: The territories in the upper GI tract
supplied by the celiac axis and the SMA signicantly overlap with each other. This reduces the chance of ischemia post
24.4.4.1 Principles ofEmbolization
Embolizing agents: A wide range of embolization agents like
coils, particulate agents like polyvinyl alcohol (PVA), liquid
agents like n-butyl cyanoacrylate (NBCA) glue, and temporary agents like gel foam can be used based on various factors like the site of bleed, the microcatheter position relative
to the site of bleed, collateral supply, and logistical issues
like availability and cost. Coils and NBCA glue are the most
commonly used agents. Coils provide greater control during
deployment with good visualization on uoroscopy. NBCA
glue can be effectively used in experienced hands. However,
the learning curve for using glue is long, and various complications can occur due to nonselective or nontarget
embolization.
embolization and necessitates the use of a sandwich technique by embolizing both the front door and the back door.
For example, embolization of proximal portion of gastroduodenal artery alone would lead to persistent bleeding due to
collateral supply from the SMA through the pancreaticoduodenal arcade. On the other hand, the vasa recta supplying the
lower GI tract are terminal vessels with no signicant collateralization. This increases the chance of ischemia post
embolization and necessitates super-selective cannulation
before embolization.
Selective vs super-selective embolization: Embolization
is ideally performed as selective as possible to avoid
nontarget embolization. However, it may not always be possible to reach the exact site of bleed due to tortuous vessel
24 Inter ventions oftheMesenteric Arterial Circulation
301
anatomy or associated signicant vasospasm. In such cases,
embolization can be attempted from a more proximal
location if the bleeding is from the upper GI tract. However,
nonselective embolization of the lower GI tract can lead to
signicant bowel ischemia. Unlike coils, NBCA glue is
prone to backow and nontarget embolization in inexperienced hands even after selective cannulation. As a
thumb rule, not more than three contiguous vasa recta in the
superior mesenteric circulation and not more than ve contiguous vasa recta in the inferior mesenteric circulation are to
be embolized when using particulate or liquid agents to
avoid signicant bowel ischemia.
24.4.4.2 Complications
Rebleeding due to signicant collateral supply can happen
in a signicant number of individuals if sandwich technique
is not used in the upper GI tract. Nontarget embolization can
lead to complications like splenic infarct. Bowel infarction
leading to peritonitis can develop, especially in patients
with lower GI bleed due to nonselective embolization.
Laparotomy and resection of the affected segment and reanastomosis of the adjacent viable bowel loops may be
needed in such cases.
Initial reports showed left gastric artery embolization to
be a promising well-tolerated percutaneous technique resulting in clinically signicant weight loss. Expected reported
weight loss was 5–10%. A systematic review and metaanalysis by Hafezi-Nejad etal. in 2019 concluded that there
was statistically signicant weight loss during short-term
follow-up after left gastric artery embolization [8]. However,
later reports showed that the decrease in the ghrelin levels
and the resultant weight loss were not sustained and ghrelin
levels returned to near-normal levels after 1year.
Pirlet et al. reported long-term follow-up in their study
group (n=7) and concluded that left gastric artery embolization can induce weight loss, which appears to be sustained
for up to 2years [9]. The reported weight loss is lower than
that with bariatric surgery. Thus, gastric artery embolization
could be considered for achieving weight loss prior to major
surgery and in patients who are deemed to be too high risk
for bariatric surgery. A systematic review and meta-analysis
by Mizandari etal., in 2023, concluded that ghrelin levels in
humans had not been affected by bariatric left gastric artery
embolization, although it might signicantly improve body
mass index and weight [10].
24.5 Bariatric Embolization
Bariatric embolization is a relatively new technique for
inducing weight loss in patients with morbid obesity by
embolizing one or more gastric arteries (most commonly
the left gastric artery) with particulate embolic agents. It is
based on the hypothesis that most of the ghrelin-secreting
cells are located in the fundus of the stomach and the
decreased circulating ghrelin levels could lead to weight
loss. The rst report of invivo left gastric artery embolization for weight loss in human subjects was published by
Kipshidze etal. in 2015 [7].
24.5.1 Technique
Femoral access was used in the initial reports. However,
radial access reduces the risk of puncture site complications
in morbidly obese patients. Celiac angiogram is performed
to ascertain the origin of left gastric artery. The left gastric
artery is selectively cannulated and an angiogram is performed. Care is to be taken to look for anatomical variants
like replaced left hepatic artery arising from the left gastric
artery. This is followed by embolization of the left gastric
artery using particulate agents like PVA, especially of
300–500 microns size. Transient supercial mucosal ulcers
are common after left gastric artery embolization. Major
complications are rare and include gastric perforation, pancreatitis, and splenic infarction.
References
1. Olson MC, Fletcher JG, Nagpal P, Froemming AT, Khandelwal
A. Mesenteric ischemia: what the radiologist needs to know.
Cardiovasc Diagn Ther. 2019;9(Suppl 1):S74–87.
2. Ierardi AM, Tsetis D, Sbaraini S, Angileri SA, Galanakis N, Petrillo
M, Patella F, Panella S, Balestra F, Lucchina N, Carraello G.The
role of endovascular therapy in acute mesenteric ischemia. Ann
Gastroenterol. 2017;30(5):526–33.
3. Sakamoto T, Kubota T, Funakoshi H, Lefor AK.Multidisciplinary
management of acute mesenteric ischemia: surgery and endovascular intervention. World J Gastrointest Surg. 2021;13(8):806–13.
4. Loffroy RF, Abualsaud BA, Lin MD, Rao PP. Recent advances
in endovascular techniques for management of acute nonvariceal upper gastrointestinal bleeding. World J Gastrointest Surg.
2011;3(7):89–100.
5. Shin JH. Recent update of embolization of upper gastrointestinal
tract bleeding. Korean J Radiol. 2012;13(Suppl 1):S31–9.
6. Hegde S, Sutphin PD, Zurkiya O, et al. Provocative mesenteric
angiography for occult gastrointestinal bleeding: a systematic
review. CVIR Endovasc. 2023;6:42.
7. Kipshidze N, Archvadze A, Bertog S, Leon MB, Sievert
H. Endovascular bariatrics: rst in humans study of gastric
artery embolization for weight loss. JACC Cardiovasc Interv.
2015;8(12):1641–4.
8. Hafezi-Nejad N, Bailey CR, Gunn AJ, Weiss CR.Weight loss after
left gastric artery embolization: a systematic review and metaanalysis. J Vasc Interv Radiol. 2019;30(10):1593–1603.e3.
9. Pirlet C, Ruzsa Z, Costerousse O, Nemes B, Merkely B, Poirier
P, Bertrand OF. Transradial left gastric artery embolization to
treat severe obesity: a pilot study. Catheter Cardiovasc Interv.
2019;93(3):365–70.
10. Mizandari M, Keshavarz P, Azrumelashvili T, Yazdanpanah F,
Lorzadeh E, Hosseinpour H, Bazyar A, Nejati SF, Ebrahimian
SF.Left gastric artery embolization for obesity treatment: a systematic review and meta-analysis of human and animal studies. Abdom
Radiol (NY). 2021;46(9):4440–51.
Interventions ofthePelvic Vessels
VijayKubihal, S.H.Chandrashekhara, andG.S.Triveni
25
Key Messages
1. Knowledge of pelvic vascular anatomy, and its variations, is crucial for successful pelvic vascular interventions, and to prevent possible complications.
2. Uterine artery embolization (UAE) is useful in the management of a variety of gynecological and obstetric conditions including broid uterus, adenomyosis, uterine
arteriovenous malformation, postpartum hemorrhage,
and abnormal placentation.
3. The choice of embolic agent depends on the indication
for UAE, severity of bleeding, number of vessels to be
embolized, ow dynamics of vascular lesion, and presence of collaterals.
4. BPH is common in elderly men, with up to 80% of men
above 70years of age having lower urinary tract symptoms secondary to BPH; prostatic artery embolization
offers a minimally invasive alternative to surgery in
patients with BPH, when medical management fails or is
contraindicated.
5. A 10-step PERFECTED technique of PAE is associated
with better clinical outcome, and lower rate of recurrence, where steps 1 to 7 involve proximal embolization,
and steps 8 to 10 describe distal embolization.
6. Polyvinyl alcohol particles and microspheres are the
common embolic agents used for PAE.
7. Varicocele may be associated with infertility, scrotal
pain, or discomfort; percutaneous varicocele embolization is a minimally invasive alternative to surgery in
patients with symptomatic varicocele or infertility.
V. Kubihal
Interventional Radiology, Department of Radiodiagnosis, K S
Hegde Medical Academy, Mangalore, India
S. H. Chandrashekhara (
Department of Radiodiagnosis and Interventional Radiology,
IRCH, All India Institute of Medical Sciences, Delhi, India
G. S. Triveni
Department of Obstetrics and Gynecology, Vardhman Mahavir
Medical College and Safdarjung Hospital, Delhi, India
*)
8. Up to 10% of women can have pelvic varicosities, of
which, only up to 40% will have chronic pelvic pain/
pelvic congestion syndrome; embolization of pelvic varicosities is the preferred curative treatment for patients
with pelvic congestion syndrome.
9. Liquid embolization agents with or without metallic coils
are most commonly used in percutaneous varicocele
embolization and embolization of pelvic varicosities.
10. Penile vascular interventions are useful in the treatment
of high ow or non-ischemic priapism, and vasculogenic
erectile dysfunction from insufcient penile arterial ow.
25.1 Introduction
Pelvic anatomy, and pelvic pathology differs signicantly
between men and women. Knowledge of pelvic vascular
anatomy, and its variations, is crucial for successful pelvic
vascular interventions, and to reduce possible complications.
Few common pelvic pathologies in females, where interventional radiology has signicant role in their management
include uterine broid, adenomyosis, uterine arteriovenous
malformation, post-partum hemorrhage, abnormal placentation, and pelvic congestion syndrome. And in males, common indications include benign prostatic hyperplasia,
varicocele, high ow priapism, and erectile dysfunction. In
our review, we have briey described some of the common
pelvic interventions that include uterine artery embolization,
prostatic artery embolization, varicocele embolization,
embolization of pelvic varicosities, and penile angiographic
interventions.
25.2 Uterine Artery Embolization (UAE)
Uterine artery embolization (UAE) is useful in the management
of a variety of gynecological and obstetric conditions including
broid uterus, adenomyosis, uterine arteriovenous malformation, postpartum hemorrhage, and abnormal placentation
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
S. H. Chandrashekhara (ed.), Textbook of Interventional Radiology, https://doi.org/10.1007/978-981-97-9601-4_25
303
304
V. Kubihal et al.
25.2.2 Contraindications [1, 2]
No absolute contraindications in patients where UAE is
planned for life-threatening hemorrhage. Contraindications
to elective UAE are listed below.
• Active pelvic infection.
• Intrauterine pregnancy with normal placentation.
• Uncorrectable coagulopathy.
• Renal impairment.
• Prior severe allergy to intravenous contrast media.
• Prior pelvic radiation therapy.
• Use of gonadotrophin-releasing hormone, and its ana-
logues, which may cause vasoconstriction of uterine
arteries.
• In patients where UAE is planned for symptomatic uter-
ine broid, UAE is not indicated if a broid is <1cm,
pedunculated, infarcted (on contrast-enhanced MRI), or
located in the uterine cervix.
25.2.3 Relevant Vascular Anatomy [2]
Fig. 25.1 Schematic diagram of uterine artery balloon occlusion for
the prevention of PPH
(Fig. 25.1). It is a safe and effective alternative to surgery in
patients who are poor candidates for surgery, or in patients who
opt for minimally invasive and uterine-sparing treatment [1].
25.2.1 Indications [1, 2]
Obstetric indications
• Post-partum hemorrhage that is refractory to standard
obstetric management, in hemodynamically stable
patients with ongoing bleeding, usually in patients who
desire to retain fertility.
• Abnormal placentation—Planned delivery at 34weeks,
with peripartum UAE, is preferred in patients where preservation of the uterus is desired.
• Cervical ectopic pregnancy.
Non-obstetric indications
• Symptomatic uterine broid.
• Symptomatic uterine adenomyosis.
• Uterine arteriovenous malformation.
• Gynecological malignancy—intractable bleeding in inoperable gynecological malignancy including endometrial
cancer, cervical cancer, and gestation trophoblastic disease or for preoperative embolization.
The uterine artery arises from an anterior division of the
internal iliac artery. An internal iliac artery has two divisions,
namely, anterior and posterior division. The anterior division
of the internal iliac artery gives rise to multiple branches
(uterine artery, superior vesical artery, vaginal artery, obturator artery, middle rectal artery, internal pudendal artery, and
inferior gluteal artery). The uterine artery is the rst or second branch of the anterior division of the internal iliac artery
in more than 50% of cases. A uterine artery has three segments. Descending segment courses along the pelvic side
wall. No side branches arise from descending segment.
Transverse segment courses horizontally toward the uterus.
Ascending segment courses along the lateral wall of the
uterus. The cervicovaginal branch can often arise from a mid
or distal transverse segment, but can also arise from ascending segment. Ascending segment supplies the uterus.
Anastomosis between uterine artery and ovarian artery is
seen in nearly 50% females at autopsy, and 10% females on
angiography.
25.2.4 Preprocedural Evaluation
Patients are evaluated by experienced gynecologist and interventional radiologist. Detailed clinical evaluation is necessary to rule out other causes. Complete hemogram,
coagulation prole, and renal function test can be obtained
before the procedure. Reproductive hormonal status assessment is not routinely indicated. Beta-HCG can be done to
exclude pregnancy. Ultrasound is often the rst line of imaging and has the advantage of lower cost, easy availability,
25 Interventions ofthePelvic Vessels
305
and rapid evaluation. However, ultrasound is a less sensitive
investigation for broid mapping and evaluation of coexistent pathology. MRI is the preferred imaging modality
for preprocedural evaluation of patients and post-procedural
follow-up. MRI has excellent soft tissue resolution, and MR
angiography can be used to delineate pelvic vascular anatomy [1–3].
25.2.5 Technique
Although antibiotic prophylaxis is commonly given, there
are no studies that show a reduction of post-procedure infection risk with antibiotic prophylaxis. Catheterization of urinary bladder is recommended as it helps to empty the bladder,
and prevent obscuration by excreted contrast with in the
bladder.
Depending on the indication, UAE can be performed in
angiographic suite, or hybrid operating room. Moderate conscious sedation is often used, while some prefer spinal or
epidural anesthesia. General anesthesia is rarely required.
Groin area is cleaned and draped prior to the procedure.
Common femoral artery access is most commonly used.
Most interventional radiologists prefer unilateral femoral
access, while some use bilateral femoral access. Transradial
access can be used, and has the advantage of early ambulation. A diagnostic angiogram is obtained to evaluate vascular
anatomy following selective and super-selective catheterization of iliac arteries and uterine arteries. 4 or 5F catheter is
used to cannulate internal iliac artery and 2 or 3F microcatheter is used to cannulate uterine artery and its branches.
Robert’s uterine catheter can be used to catheterize bilateral
uterine arteries with unilateral femoral access. Waltman loop
technique is often used to catheterize ipsilateral uterine
artery. Uterine artery is the rst or second branch of anterior
division of internal iliac artery in more than 50% of cases,
and is better visualized on contralateral oblique view. After
super-selective catheterization of uterine artery with microcatheter, angiogram is obtained to look for collateral supply
to ovary, vagina, and bladder, which can affect the choice of
embolizing agent.
Choice of embolic agent depends on indication for UAE,
severity of bleeding, number of vessels to be embolized, ow
dynamics of vascular lesion, and presence of collaterals. In
patients with uterine broid, adenomyosis, and gynecological malignancy, permanent distal embolizing agent such as
PVA particles are preferred. PVA particles of size >500
micrometers are used, which are mixed with intravenous
contrast for better angiographic visualization. Although a
variety of embolizing agents, either alone or in combination,
can be used for uterine arteriovenous malformation, embolization of nidus with glue is the preferred method. Glue is
mixed with lipiodol for better angiographic visualization.
5% dextrose solution is used to ush the catheter before and
after glue embolization to prevent clogging of catheter. In
patients with postpartum hemorrhage, gel foam and PVA
particles are commonly used embolic agents. In patients with
proximal injury to larger arteries, both proximal and distal
embolization is done in view of rich network of collaterals.
Metallic coils or vascular plugs can be used. If catheter cannot be negotiated beyond the injury, distal embolization can
be achieved using glue. In patients with abnormal placentation, bilateral uterine artery angiographic balloons are placed
using bilateral femoral approach, prior to caesarean delivery,
which are inated in immediate postpartum period to control
the bleeding. In patients with persistent bleeding, embolization with gel foam or coils can be done. End point for distal
embolization can be contrast stasis in uterine artery for
5–10seconds, pruned appearance of uterine artery, or contrast reux proximally [1–4].
25.2.6 Post-Procedural Care
UAE is often associated with pain that can last for several
hours, and can sometimes be severe. Opioid analgesics or
NSAIDs can be used for pain management. Alternatively,
epidural analgesia or superior hypogastric nerve block can
be considered. Nausea is a common post-embolization side
effect, can be treated with prophylactic antiemetic in postembolization period, or treated as needed. Patients are discharged with instructions for pain and nausea control.
Patients can be advised to follow up at outpatient clinic, at 1
to 3weeks following the procedure, when puncture site healing and any possible complications are to be looked for.
Follow-up (MRI or USG) imaging is advised at 3 to 6months
after UAE [1–3].
25.2.7 Complications
Uterine artery embolization is a relatively safe procedure,
with overall complication rate ranging between 6 and 9%.
Complications can be classied as those associated with
angiographic technique, and those that are specic for uterine artery embolization. Complications associated with angiographic technique include puncture site hematoma/
pseudoaneurysm, arterial dissection, contrast allergy, and
contrast-induced nephropathy. Post-embolization syndrome
is seen in nearly 50% of cases, and is characterized by pain,
nausea, vomiting, fever, and leukocytosis. It can last for several days and is often treated with analgesics and antiinammatory drugs. Other rare but serious complications
include arterial perforation requiring surgery (2 to 3in 100
patients), sepsis, and abscess formation (1in 100 patients),
and uterine necrosis or rupture. Non-target embolization is
rare and can cause bladder or rectal infarction. Ovarian failure can occur secondary to embolization of ovarian–uterine