vascular anatomy and dangerous anastomosis of the uterus ...€¦ · vascular anatomy and dangerous...
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Vascular Anatomy and DangerousAnastomosis of the Uterus and Ovary
Ricardo Garcia-Monaco MD, PhD
Hospital Italiano de Buenos Aires
Ricardo Garcia Monaco
• Speakers Bureau: Bard
• Consultant/Advisory Board: Sirtex, Celonova, BTG
Uterine Artery
1.-Descending (parietal seg)
2.-Transversal (ligament seg)
3.-Ascending (marginal seg)
• Uterine vascular supply
1.-Descending (parietal seg)
2.-Transversal (ligament seg)
3.-Ascending (marginal seg)
• Uterine vascular supply
• Extrauterine art supply
1
2
3
Uterine Artery
1.-Descending (parietal seg)
2.-Transversal (ligament seg)
3.-Ascending (marginal seg)
• Uterine vascular supply
• Extrauterine art supply
• Ovary
Uterine Artery
1.-Descending (parietal seg)
2.-Transversal (ligament seg)
3.-Ascending (marginal seg)
• Uterine vascular supply
• Extrauterine art supply
• Ovary
• Vagina
Uterine Artery
1.-Descending (parietal seg)
2.-Transversal (ligament seg)
3.-Ascending (marginal seg)
• Uterine vascular supply
• Extrauterine art supply
• Ovary
• Vagina
• Bladder
Uterine Artery
1.-Descending (parietal seg)
2.-Transversal (ligament seg)
3.-Ascending (marginal seg)
• Uterine vascular supply
• Extrauterine art supply
• Ovary
• Vagina
• Bladder
Uterine Artery
1.-Descending (parietal seg)
2.-Transversal (ligament seg)
3.-Ascending (marginal seg)
• Uterine vascular supply
• Extrauterine art supply
• Ovary
• Vagina Anastomoses
• Bladder
Uterine Artery
Dangerous anastomoses & risks
Uterine artery
Ovarian artery
Pelage JP et al. AJR 1999
Razavi M et al. Radiology 2002
Type 1 Type 3Type 2
Anastomoses Type 1
The OV connects the UT before fibroid supply through the T-O segment
Anastomoses Type 2
The ovarian artery supplies the fibroid directly
Anastomoses Type 3
The ovarian supply is from the UA with cephalic flow
Dangerous Anastomoses
• Non target embolization
- Complication: Ovarian ischemia after UAE
* Pelage JP et al. AJR 1999
* Razavi M et al. Radiology 2002
ovary ovary
Dangerous Anastomoses
• Non target embolization
- Complication: Ovarian ischemia after UAE
• Utero-ovarian anastomosis
- Upper Uterine Anastomoses
• Well known
• Well Described *
* Pelage JP et al. AJR 1999
* Razavi M et al. Radiology 2002
ovary ovary
Uterine vascular supply
Bladder Uterus
Ovary
Cadaveric specimen
Bladder Uterus
Ovary
Uterine vascular supply
Cadaveric specimen
Bladder Uterus
Ovary
Uterine vascular supply
Cadaveric specimen
Dangerous anastomoses & risks
Uterine artery
Vaginal & Vesical art
Pelage JP et al. AJR 1999
Palacio-Jaraquemada et al. Acta Obst Gyn 2007
Dangerous Anastomoses
• Utero-vesico-vaginal anastomosis
- Lower Uterine Anastomoses
• Less known
• Descriptions are scanty
Dangerous Anastomoses
• Utero-vesico-vaginal anastomosis
- Lower Uterine Anastomoses
• Less known
• Descriptions are scanty
• Non target embolization
- Complication: Vulvar/Vaginal/Bladder necrosis after UAE*
* Porcu et al. BJOG 2005
* El-Shalakany et al. BJOG 2003
Pedicle Artery trunk Origin Arterial
anastomoses
Region
Lower anastomoses
Upper Uterine HA 100%
Intramyometral
TMS interuterine
TMVI interuterine
Utero-pudendal
Uterus
Uterus
Uterus/bladder
Bladder/vagina/vulva
Middle Cervical
UA 67%
PIA 23%
LVA 10%
Cervico-pudendal
Cervico-vaginal
Bladder/vagina/vulva
Bladder/vagina/vulva
Lower Vaginal
PIA 71%
UA 18%
HA 11%
Cervico-vaginal
TMVI interuterine
Azygos VA
Cervix/bladder/uterus
Uterus
Uterus
Dangerous Anastomoses
HA= hypogastric artery; UA= uterine artery; PIA=
pudendal internal artery; LVA=lower vaginal Artery; TMS=
transmedial segmental; TMVI= transmedial vesical
intramural;VA=vaginal artery
Lower uterine artery anastomosis
Uterus
Catheter
Pudendal artery
Vagina Vagina
Uterus
Lower uterine artery anastomosis
Dangerous Anastomoses
Utero-vaginal anastomosis Int Pudendal art cathCadaveric specimen
Uterus
Catheter
Pudendal artery
Vagina Vagina
Uterus
Lower uterine artery anastomosis
Dangerous Anastomoses
Utero-vaginal anastomosis Int Pudendal art cathCadaveric specimen
Uterus
Catheter
Pudendal artery
Vagina Vagina
Uterus
Lower uterine artery anastomosis
Dangerous Anastomoses
Utero-vaginal anastomosis Int Pudendal art cathCadaveric specimen
Uterus
Catheter
Pudendal artery
Vagina Vagina
Uterus
Lower uterine artery anastomosis
Dangerous Anastomoses
Utero-vaginal anastomosis Cadaveric specimen Int Pudendal art cath
Dangerous AnastomosesLower uterine artery anastomosis
Vesical art cathUtero-vesical anastomosis
Dangerous AnastomosesLower uterine artery anastomosis
Vesical art cathUtero-vesical anastomosis
Lower uterine artery anastomosis
Dangerous Anastomoses
Uterine art cathUtero-pudendal anastomosis
Lower uterine artery anastomosis
Dangerous Anastomoses
Utero-pudendal anastomosis
*UFE= uterine fibroids embolization
*PPB= post partum bleeding
Obst Gyn 2002
BJOG 2005
JVIR 2003
BJOG 2003
UAE Complications : Non Target Embo
“…arterial retrograde reflux of the embolic agents
into the internal pudendal artery might have
caused the complications…”
“ … however reflux was not observed by any
interventional radiologist during the procedures ”
UAE Complications : Non Target Embo
Obst Gyn 2002
BJOG 2005
JVIR 2003
BJOG 2003
*UFE= uterine fibroids embolization
*PPB= post partum bleeding
Obst Gyn 2002
BJOG 2005
JVIR 2003
BJOG 2003Undesired passage of embo throughthe Lower Uterine Anastomoses !!
UAE Complications : Non Target Embo
• Uterine arteries but also…”dangerous anastomoses”
- Utero-ovarian (Upper Anastomosis)
- Utero-vesico-vaginal (Lower Anastomosis)
UAE Anatomy: Conclusions
• Uterine arteries but also…”dangerous anastomoses”
- Utero-ovarian (Upper Anastomosis)
- Utero-vesico-vaginal (Lower Anastomosis)
• Anastomosis are hard to observe normally
UAE Anatomy: Conclusions
But there are always present !!
• Uterine arteries but also…”dangerous anastomoses”
- Utero-ovarian (Upper Anastomosis)
- Utero-vesico-vaginal (Lower Anastomosis)
• Anastomosis are hard to observe normally
• May be angiographically evident• Wedge cath position
• Forcefull injection
• Hypervascular conditions
• Anatomic Variants
But there are always present !!
UAE Anatomy: Conclusions
• Though frequently invisible, the anastomoses are constant
• Represent a risk for non target embolization
- Ovarian ischemia
- Bladder necrosis
- Vaginal / Labial necrosis
• Technical challenge
- Free flow embolization
- Avoid overembolization
- Avoid or be cautious with small size embolic agents
Anastomosis = Risks
Conclusion
• Knowledge of Functional Vascular Anatomy
is essential for the Interventional Radiologist
• Obtain good clinical results
• Avoid predictable complications
Ricardo Garcia-Monaco MD, PhD
Hospital Italiano de Buenos Aires
Thank you !!