Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3726_Библиотеки_им_академика_М_И_Перельмана.pdf
202
5 Pelvic Vascular Emergencies
a
c
b
d
Fig. 5.9 Details from the embolization. (a–d) selective
catheterization of the right uterine artery and embolization
of the artery with micro-coils; arrows indicate the pseu-
doaneurysm. (d, e) embolization of the left uterine artery
with micro-coils (f)
5.4 Uterine Artery Bleeding-II
ef
Fig. 5.9 (continued)
203
5.3.4 Outcome
The patient was discharged the next day without
any complications. There were no new bleeding
episodes or complaints in the follow-up period
and control MR scanning showed restored uterus
morphology (Fig. 5.10).
5.4 Uterine Artery Bleeding-II
Key Points
• Uterine artery pseudoaneurysms with
arteriovenous stulae are very easily
treated with micro-coil embolization.
• In a majority of cases, both uterine
arteries usually need to be occluded,
but sometimes it is possible to perform
embolization on only one side.
• The intervention is well-tolerated.
• Microspheres should never be used for
such patients.
5.4.1 Aetiology andClinical
Presentation
A 34-year-old patient underwent a medical abortion 2 months prior. The patient was haemodynamically stable with recurrent metrorrhagia.
There were no other complaints. Doppler ultrasound revealed a hypervascular uterine lesion.
5.4.2 Pre-interventional Diagnosis
Contrast-enhanced CT showed a hypervascular
arterial lesion/pseudoaneurysm on the right side
and a hypervascular region in the uterus suspected of early venous lling (Fig.5.11).
5.4.3 Endovascular Intervention
Selective angiography of both uterine arteries
revealed a pseudoaneurysm of the right uterine
artery and early venous lling with a traumatic
arteriovenous stula (Fig.5.12). Embolization
was performed with micro-coils delivered
204
Fig. 5.10 Control T1- and T2-weighted MR sequences 3months after the embolization showing a normal uterus
morphology and no new signal changes
5 Pelvic Vascular Emergencies
through a microcatheter with a good outcome.
In such cases, microspheres are contraindicated
due to the presence of the stula to the venous
system. Mechanical micro-coils are a very safe
and relatively simple intervention (Fig.5.13).
5.4.4 Outcome
The patient was discharged the next day without
any complications. There were no new bleeding
episodes or complaints in the follow-up period.
5.5 Uterine Artery Bleeding-III
Key Points
• Uterine artery pseudoaneurysms with
arteriovenous stulas are very easily
treated with micro-coil embolization.
• In a majority of cases, both uterine arteries usually need to be occluded, but
sometimes it is possible to perform
embolization on only one side.
• The intervention is well-tolerated.
• Microspheres should never be used for
such patients.
5.5.1 Aetiology andClinical
Presentation
A 26-year-old patient underwent acute sectioning
complicated with bleeding and underwent reoperation 2 times thereafter. After the second
operation, the bleeding persisted, and the patient
received 18 portions of SAG-M blood. Abdominal
packing was performed, and acute CT scanning
was ordered.
bc
5.5 Uterine Artery Bleeding-III
a
205
Fig. 5.11 Contrast-enhanced CT showing a right uterine artery pseudoaneurysm (blue arrows) and a hyperdense
region suspected of being an arteriovenous stula
206
cd
5 Pelvic Vascular Emergencies
a
b
Fig. 5.12 Selective angiography of the right uterine
artery showing a pseudoaneurysm (blue arrow) (a). Late
phase image showing a stula to the venous system (green
arrows) (b–d). A microcatheter was advanced, and embo-
lization with micro-coils (orange arrows) was performed
(e–h). Selective angiography of the left uterine artery
shows venous lling via the left uterine artery, and microcoil embolization was performed (orange arrows) (f–h)
5.5 Uterine Artery Bleeding-III
ef
207
g
Fig. 5.12 (continued)
h
208
Fig. 5.13 Control T2-weighted axial and sagittal magnetic resonance imaging scans showing remodelling of the uterine cavity and no signal changes or vascular pathology
5 Pelvic Vascular Emergencies
5.5.2 Pre-interventional Diagnosis
Contrast-enhanced CT showed bleeding from the
internal iliac branch on the right side (Fig.5.14).
An enlarged uterus, a retroperitoneal haematoma
and the abdominal packing can be seen on CT.
5.5.3 Endovascular Intervention
Selective catheterization of the right internal
iliac artery was performed percutaneously
through the left femoral artery, and the bleeding
site from the right uterine artery was conrmed
(Fig. 5.15). Then, super-selective catheterization was performed with a microcatheter
advanced into the bleeding uterine artery.
Micro-coils 3 mm in diameter were used for
embolization and bleeding arrest. There was no
problem with the left uterine artery, which was
thus not occluded.
5.5.4 Outcome
The patient recovered gradually no new bleeding
complications. Control CT 3 months after the
embolization showed almost complete haematoma resorption (Fig.5.16).
5.6 Arterio-Enteric Fistula Bleeding-I
Key Points
• Arterio-enteric stulas are a severe
complication with high mortality and
morbidity.
• Usually, arterio-enteric stulas occur a
few years after the surgery but can occur
earlier as well.
• In cases of gastrointestinal bleeding after
surgery, arterio-enteric stula should be
considered.
• Stent graft deployment can serve as a
temporary or denitive treatment in some
cases.
5.6.1 Aetiology andClinical
Presentation
A 67-year-old patient underwent open surgery 4
years prior due to an abdominal aortic aneurysm.
There were no other signicant comorbidities.
The patient was admitted with massive gastrointestinal bleeding and responded to initial resuscitation. The gastroscopy was inconclusive. An
emergency CT scan was performed.
bc
5.6 Arterio-Enteric Fistula Bleeding-I
a
209
Fig. 5.14 Contrast-enhanced CT showing active bleeding from the right uterine artery (blue arrows). The uterus was
enlarged (orange arrow)
210
ab
cd
5 Pelvic Vascular Emergencies
Fig. 5.15 Crossover technique. (a and b) selective angiography of the right internal iliac artery and right uterine artery
show extravasation (blue arrows). (c and d) control images after micro-coil embolization with bleeding arrest
5.6 Arterio-Enteric Fistula Bleeding-I
a
211
b
c
Fig. 5.16 Control CT 3months after the procedure showed a satisfactory result. Arrows indicate the micro-coils