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Fatal Nontarget Embolization via an Intrafibroid Arterial Venous Fistula during Uterine Fibroid Embolization
Letters to the Editor
Fatal Nontarget Embolization via an Intrafibroid Arterial Venous Fistula during Uterine Fibroid Embolization Editors Note: The following letter reviews complications in a 39-year-old woman referred for routine uterine fibroid embolization. Nontarget embolization resulted in fatal systemic and pulmonary embolism. The authors have noted that, by court order, the institution at which the event occurred must remain anonymous, and the authors have also requested anonymity. The authors provide cautionary advice to interventional specialists performing this procedure. Institutional review board waivers were sought and obtained from both the institution at which the procedure was performed and the authors’ institution. As the Editor, I feel that anonymous publication is warranted because of the important cautionary lesson provided by the report. From: Anonymous Editor: A 39-year-old woman with menorrhagia believed to be related to a uterine fibroid was evaluated for fibroid embolization. Her preprocedure evaluation included an ultrasonographic (US) examination that was consistent with the presence of a 10-cm uterine fibroid. She was scheduled to undergo a routine uterine fibroid embolization. Preparation for embolization was uneventful. The initial flush angiogram demonstrated symmetric flow to the left and right uterine arteries (Fig 1). Review of the selective left uterine artery angiogram demonstrated a dilated vascular space in the early capillary phase (Fig 2). A selective left uterine angiogram was obtained, and selective embolization was initiated. A total of 22 syringes of embolization microparticles were opened for the procedure, including 13 500 –700-m and five 700 –900-m Embosphere microsphere syringes (Biosphere Medical, Rockland, Massachusetts) and four 500 –700-m Contour SE microparticle syringes (Boston Scientific, Natick, Massachusetts). The patient’s oxygen saturation dropped precipitously, and she suffered respiratory arrest. No final postembolization digital subtraction angiogram was obtained. The patient was intubated and admitted to the intensive care unit. Electrocardiography was suggestive of myocardial infarction. Cardiac catheterization demonstrated normal coronary arteries. Computed tomography (CT) of the brain demonstrated global ischemic changes consistent with watershed infarcts. The patient developed multisystem organ failure and was pronounced brain dead 2 days later. The autopsy report stated that: “The uterus is 710.0 gm. There is an anterior 8.5-cm well-circumscribed tumor of bulging, dark purple tissue. Near the center of this is a 1.9-cm aggregate of blood-filled spaces.” Such an aggregate of blood-filled spaces is most consistent with an arteriovenous vascular malformation within the leiomyoma. A patent foramen ovale was also identified. Microspheres were identified in the lungs, heart, and kidneys. Foci of acute central nervous system watershed infarction and
Figure 1. Flush pelvic angiogram demonstrates roughly equal flow to the left and right uterine arteries.
Figure 2. Selective left uterine angiogram shows early filling of the dilated vascular space (arrow).
10.1016/j.jvir.2008.12.412
419
420
•
March 2009
Letters to the Editor
widespread ischemia of the central nervous system with herniation were noted. Uterine fibroid embolization is an increasingly common treatment for menorrhagia related to uterine fibroid disease. Research on complications from uterine fibroid embolization is typically based on studies of long-term success (1). Fatal complications after uterine artery embolization are unusual. Deaths related to infection and pulmonary embolism have been reported (2,3). Nevertheless, it remains important to be aware of potentially serious risks and ways to avoid them. Nontarget embolization to the lungs can result in fatal pulmonary embolization (4). Arterial venous connections sufficiently large to allow passage of Embospheres are not commonly seen in uterine fibroid tumors. Most uterine fibroids have a vascular plexus that is 500 –700 m in diameter and can be safely embolized with particles in the 500 – 700-m range. Although arterial venous communications may be diagnosed at color Doppler US or pelvic magnetic resonance (MR) imaging, neither study was performed in this case (5). Arterial venous communications may also be diagnosed at angiography, but the dilated vascular spaces are often subtle and were not appreciated in this case. Although no agreed-upon preprocedural imaging guidelines are available, pre-embolization MR imaging has been shown to change treatment planning in a variety of scenarios (6). When embolizing vascular tumors, it is incumbent on the operator to ensure that no arterial venous communications exist. This is classically done with selective flush angiography. When this test is performed with imaging into the venous phase, early venous filling should alert the operator to the possibility of an arterial venous communication. When the vascular bed requires vastly more embolic agent than usual, this should also alert the operator to an unexpected arterial venous communication. A possible clue to the underlying abnormality in this case is the large amount of embolic material required. It would be distinctly uncommon for a single 10-cm uterine fibroid tumor to require the amount of embolic material used in this case. When the operator has used more particles than usual, he or she should consider the possibility of an unexpected arterial venous communication that could lead to a disastrous nontarget embolization. References 1. Kitamura Y, Ascher SM, Cooper C, et al. Imaging manifestations of complications associated with uterine artery embolization. RadioGraphics 2005; 25(suppl 1):S119 –S132. 2. Vashisht A, Studd J, Carey A, Burn PF. Fatal septicaemia after fibroid embolisation. Lancet 199; 354:307–308. 3. Czeyda-Pommersheim F, Magee ST, Cooper C, Hahn WY, Spies JB. Venous thromboembolism after uterine fibroid embolization. Cardiovasc Intervent Radiol 2006; 29:1136 –1140. 4. Brown KT. Fatal pulmonary complications after arterial embolization with 40 –120-micro m tris-acryl gelatin microspheres. J Vasc Interv Radiol 2004; 15:197–200. 5. Huang MW, Muradali D, Thurston WA, Burns PN, Wilson SR. Uterine arteriovenous malformations: gray-scale and Doppler US features with MRI imaging correlation. Radiology 1998; 206:115– 123. 6. Omary RA, Vasireddy S, Chrisman HB, et al. The effect of pelvic MR imaging on the diagnosis and treatment of women with presumed symptomatic uterine fibroids. J Vasc Interv Radiol 2002; 13:1149 –1153.
JVIR
Migration of an Ingested Foreign Body into the Right External Iliac Vein From: Yu-Dong Chen, MD, Hsiou-Shan Tseng, MD, Rheun-Chuan Lee, MD, Yi-You Chiou, MD, Jen-Huey Chiang, MD, and Cheng-Yen Chang, MD Department of Radiology Taipei Veterans General Hospital 201 Sect 2 Shih-Pai Rd Peitou Taipei 11217 Taiwan Republic of China National Yang Ming University School of Medicine Taipei, Taiwan Republic of China Research supported wholly by the research program of the Taipei Veterans General Hospital, Taipei, Taiwan Editor: One of the least common complications of foreign body ingestion is penetration and migration, which may lead to serious morbidity or even death. Following the ingestion of a metallic body, its subsequent migration from the small intestine into a blood vessel is a rare presentation. A percutaneous technique for the extraction of the metallic foreign body can spare patients from surgery to remove the foreign body. No institutional review board approval is required at our institution for the publication of case reports such as this. Informed consent was obtained before computed tomography (CT) and interventional management. A 54-year-old man had a painful gross hematuria and right flank pain for 4 days. He had a history of bilateral renal stones and had undergone extracorporeal shockwave lithotripsy 3 years earlier. Upon arrival at our emergency department, his body temperature was 36.3°C, his pulse rate was 74 beats per minute, and his respiratory rate was 20 breaths per minute. His blood pressure was 150/78 mm Hg. Physical examination revealed a right costovertebral angle knocking pain. The white blood cell count was 8,200 cells per cubic millimeter (8.2 ⫻ 109/L), and the hemoglobin level was 14.3 g/dL (143 g/L). The serum blood urea nitrogen level was 18 mg/dL (6.42 mmol/L) and the creatinine level 1.1 mg/dL (97 mol/L). Urine sedimentation revealed a substantial amount of red blood cells. CT of the abdomen revealed a tiny right upper third ureteral stone without hydronephrosis or hydroureter. A 2-cm-long needlelike object was trapped in the distal ileum, partially penetrating beyond the bowel wall (Figure, part a). Due to increasing abdominal pain, another abdominal CT examination was performed 2 days later, and the previously noted linear high attenuation material had migrated into the right external iliac vein and was partially in the lumen (Figure, part b). Standard angiographic interventional techniques were used to place an inflated 12 ⫻ 40-mm Wanda angioplasty balloon catheter (Boston Scientific, Natick, Massachusetts) in the right common iliac vein, by using a left femoral vein approach, to prevent central migration of the foreign body
10.1016/j.jvir.2008.11.028
Fatal Nontarget Embolization via an Intrafibroid Arterial Venous Fistula during Uterine Fibroid Embolization Editors Note: The following letter reviews complications in a 39-year-old woman referred for routine uterine fibroid embolization. Nontarget embolization resulted in fatal systemic and pulmonary embolism. The authors have noted that, by court order, the institution at which the event occurred must remain anonymous, and the authors have also requested anonymity. The authors provide cautionary advice to interventional specialists performing this procedure. Institutional review board waivers were sought and obtained from both the institution at which the procedure was performed and the authors’ institution. As the Editor, I feel that anonymous publication is warranted because of the important cautionary lesson provided by the report. From: Anonymous Editor: A 39-year-old woman with menorrhagia believed to be related to a uterine fibroid was evaluated for fibroid embolization. Her preprocedure evaluation included an ultrasonographic (US) examination that was consistent with the presence of a 10-cm uterine fibroid. She was scheduled to undergo a routine uterine fibroid embolization. Preparation for embolization was uneventful. The initial flush angiogram demonstrated symmetric flow to the left and right uterine arteries (Fig 1). Review of the selective left uterine artery angiogram demonstrated a dilated vascular space in the early capillary phase (Fig 2). A selective left uterine angiogram was obtained, and selective embolization was initiated. A total of 22 syringes of embolization microparticles were opened for the procedure, including 13 500 –700-m and five 700 –900-m Embosphere microsphere syringes (Biosphere Medical, Rockland, Massachusetts) and four 500 –700-m Contour SE microparticle syringes (Boston Scientific, Natick, Massachusetts). The patient’s oxygen saturation dropped precipitously, and she suffered respiratory arrest. No final postembolization digital subtraction angiogram was obtained. The patient was intubated and admitted to the intensive care unit. Electrocardiography was suggestive of myocardial infarction. Cardiac catheterization demonstrated normal coronary arteries. Computed tomography (CT) of the brain demonstrated global ischemic changes consistent with watershed infarcts. The patient developed multisystem organ failure and was pronounced brain dead 2 days later. The autopsy report stated that: “The uterus is 710.0 gm. There is an anterior 8.5-cm well-circumscribed tumor of bulging, dark purple tissue. Near the center of this is a 1.9-cm aggregate of blood-filled spaces.” Such an aggregate of blood-filled spaces is most consistent with an arteriovenous vascular malformation within the leiomyoma. A patent foramen ovale was also identified. Microspheres were identified in the lungs, heart, and kidneys. Foci of acute central nervous system watershed infarction and
Figure 1. Flush pelvic angiogram demonstrates roughly equal flow to the left and right uterine arteries.
Figure 2. Selective left uterine angiogram shows early filling of the dilated vascular space (arrow).
10.1016/j.jvir.2008.12.412
419
420
•
March 2009
Letters to the Editor
widespread ischemia of the central nervous system with herniation were noted. Uterine fibroid embolization is an increasingly common treatment for menorrhagia related to uterine fibroid disease. Research on complications from uterine fibroid embolization is typically based on studies of long-term success (1). Fatal complications after uterine artery embolization are unusual. Deaths related to infection and pulmonary embolism have been reported (2,3). Nevertheless, it remains important to be aware of potentially serious risks and ways to avoid them. Nontarget embolization to the lungs can result in fatal pulmonary embolization (4). Arterial venous connections sufficiently large to allow passage of Embospheres are not commonly seen in uterine fibroid tumors. Most uterine fibroids have a vascular plexus that is 500 –700 m in diameter and can be safely embolized with particles in the 500 – 700-m range. Although arterial venous communications may be diagnosed at color Doppler US or pelvic magnetic resonance (MR) imaging, neither study was performed in this case (5). Arterial venous communications may also be diagnosed at angiography, but the dilated vascular spaces are often subtle and were not appreciated in this case. Although no agreed-upon preprocedural imaging guidelines are available, pre-embolization MR imaging has been shown to change treatment planning in a variety of scenarios (6). When embolizing vascular tumors, it is incumbent on the operator to ensure that no arterial venous communications exist. This is classically done with selective flush angiography. When this test is performed with imaging into the venous phase, early venous filling should alert the operator to the possibility of an arterial venous communication. When the vascular bed requires vastly more embolic agent than usual, this should also alert the operator to an unexpected arterial venous communication. A possible clue to the underlying abnormality in this case is the large amount of embolic material required. It would be distinctly uncommon for a single 10-cm uterine fibroid tumor to require the amount of embolic material used in this case. When the operator has used more particles than usual, he or she should consider the possibility of an unexpected arterial venous communication that could lead to a disastrous nontarget embolization. References 1. Kitamura Y, Ascher SM, Cooper C, et al. Imaging manifestations of complications associated with uterine artery embolization. RadioGraphics 2005; 25(suppl 1):S119 –S132. 2. Vashisht A, Studd J, Carey A, Burn PF. Fatal septicaemia after fibroid embolisation. Lancet 199; 354:307–308. 3. Czeyda-Pommersheim F, Magee ST, Cooper C, Hahn WY, Spies JB. Venous thromboembolism after uterine fibroid embolization. Cardiovasc Intervent Radiol 2006; 29:1136 –1140. 4. Brown KT. Fatal pulmonary complications after arterial embolization with 40 –120-micro m tris-acryl gelatin microspheres. J Vasc Interv Radiol 2004; 15:197–200. 5. Huang MW, Muradali D, Thurston WA, Burns PN, Wilson SR. Uterine arteriovenous malformations: gray-scale and Doppler US features with MRI imaging correlation. Radiology 1998; 206:115– 123. 6. Omary RA, Vasireddy S, Chrisman HB, et al. The effect of pelvic MR imaging on the diagnosis and treatment of women with presumed symptomatic uterine fibroids. J Vasc Interv Radiol 2002; 13:1149 –1153.
JVIR
Migration of an Ingested Foreign Body into the Right External Iliac Vein From: Yu-Dong Chen, MD, Hsiou-Shan Tseng, MD, Rheun-Chuan Lee, MD, Yi-You Chiou, MD, Jen-Huey Chiang, MD, and Cheng-Yen Chang, MD Department of Radiology Taipei Veterans General Hospital 201 Sect 2 Shih-Pai Rd Peitou Taipei 11217 Taiwan Republic of China National Yang Ming University School of Medicine Taipei, Taiwan Republic of China Research supported wholly by the research program of the Taipei Veterans General Hospital, Taipei, Taiwan Editor: One of the least common complications of foreign body ingestion is penetration and migration, which may lead to serious morbidity or even death. Following the ingestion of a metallic body, its subsequent migration from the small intestine into a blood vessel is a rare presentation. A percutaneous technique for the extraction of the metallic foreign body can spare patients from surgery to remove the foreign body. No institutional review board approval is required at our institution for the publication of case reports such as this. Informed consent was obtained before computed tomography (CT) and interventional management. A 54-year-old man had a painful gross hematuria and right flank pain for 4 days. He had a history of bilateral renal stones and had undergone extracorporeal shockwave lithotripsy 3 years earlier. Upon arrival at our emergency department, his body temperature was 36.3°C, his pulse rate was 74 beats per minute, and his respiratory rate was 20 breaths per minute. His blood pressure was 150/78 mm Hg. Physical examination revealed a right costovertebral angle knocking pain. The white blood cell count was 8,200 cells per cubic millimeter (8.2 ⫻ 109/L), and the hemoglobin level was 14.3 g/dL (143 g/L). The serum blood urea nitrogen level was 18 mg/dL (6.42 mmol/L) and the creatinine level 1.1 mg/dL (97 mol/L). Urine sedimentation revealed a substantial amount of red blood cells. CT of the abdomen revealed a tiny right upper third ureteral stone without hydronephrosis or hydroureter. A 2-cm-long needlelike object was trapped in the distal ileum, partially penetrating beyond the bowel wall (Figure, part a). Due to increasing abdominal pain, another abdominal CT examination was performed 2 days later, and the previously noted linear high attenuation material had migrated into the right external iliac vein and was partially in the lumen (Figure, part b). Standard angiographic interventional techniques were used to place an inflated 12 ⫻ 40-mm Wanda angioplasty balloon catheter (Boston Scientific, Natick, Massachusetts) in the right common iliac vein, by using a left femoral vein approach, to prevent central migration of the foreign body
10.1016/j.jvir.2008.11.028