- Email: [email protected]
Management of a ruptured pseudoaneurysm of the uterine artery using a modified percutaneous embolization technique
170
J.-S. Yuk et al. / International Journal of Gynecology and Obstetrics 129 (2015) 169–177
Previous studies have reported on experience with adnexal torsion at a single institution and not its incidence [1]. According to a previous study, adnexal torsion frequently occurs in women of childbearing age compared with premenarchal or postmenopausal women [5]. These results were consistent with the results of the present study (Fig. 1). Although the present study has limitations attributed to diagnosis coding errors, it provides valuable information regarding the use of HIRA-NIS, which includes a large population that is useful for studying the low incidence of adnexal torsion.
References [1] Hibbard LT. Adnexal torsion. Am J Obstet Gynecol 1985;152(4):456–61. [2] Oelsner G, Shashar D. Adnexal torsion. Clin Obstet Gynecol 2006;49(3):459–63. [3] Yuk J-S, Kim Y-J, Hur J-Y, Shin J-H. Incidence of Bartholin duct cysts and abscesses in the Republic of Korea. Int J Gynecol Obstet 2013;122(1):62–4. [4] World Health Organization. International Statistical Classification of Diseases and Related Health Problems. 10th Revision. http://apps.who.int/classifications/icd10/ browse/2015/en. [5] Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Ann Emerg Med 2001; 38(2):156–9.
Conflict of interest The authors have no conflicts of interest.
http://dx.doi.org/10.1016/j.ijgo.2014.11.027 0020-7292/© 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Management of a ruptured pseudoaneurysm of the uterine artery using a modified percutaneous embolization technique Manoj Kumar a,⁎, Sabuhi Quiresi b, Uma Singh b a b
Department of Radiodiagnosis, King George’s Medical University, Uttar Pradesh, Lucknow, India Department of Obstetrics and Gynecology, King George’s Medical University, Uttar Pradesh, Lucknow, India
a r t i c l e
i n f o
Article history: Received 25 July 2014 Received in revised form 18 November 2014 Accepted 22 January 2015 Keywords: Embolization India Low-resource setting Pseudoaneurysm Uterine artery
The aim of the present paper is to describe an indigenously modified, duplex ultrasound-guided, direct percutaneous embolization technique [1] performed to manage a ruptured pseudoaneurysm of a branch of the uterine artery. A forty-year-old woman (G4) was referred to Queen Mary Hospital (KGMU), Lucknow, in October 2013 following intractable secondary vaginal hemorrhage following abdominal hysterectomy for multiple uterine myomas. The surgery had been uneventful and the patient was discharged on the seventh postoperative day; however, she presented one week later with sudden onset of profuse vaginal bleeding and dizziness. After immediate hemodynamic stabilization via blood transfusion and intravenous colloids, hemostatic suturing of the vaginal vault was attempted but was ineffective. The patient was treated with vitamin K and procoagulants at the same remote hospital for a further
⁎ Corresponding author at: Department of Radiodiagnosis, King George’s Medical University, Uttar Pradesh, Lucknow, India PIN-226003. Tel.: +91 9935278765 (mobile); fax: +91 5222258713. E-mail address: [email protected] (M. Kumar).
six days before she was referred to King George’s Medical University in Lucknow. The patient presented with anemia, hypotension, early sepsis, coagulopathy, and electrolyte imbalance. On local examination, an organized hematoma was seen in the vaginal cavity with continuous oozing of bright red blood. After evacuating the hematoma, active bleeding was observed flowing from the right angle of the vaginal vault. The vaginal cavity was packed with roller gauze soaked in 5% povidone iodine solution. Bedside transabdominal and transvaginal ultrasound revealed an organized hematoma of approximately 60 x 70 mm in the pelvic cavity. The packing was removed 24 hours later but the bleeding restarted. Explorative laparotomy demonstrated no contamination. Anterior divisions of the bilateral anterior iliac arteries were ligated to control the ongoing vaginal bleeding. Vaginal packing was again removed 24 hours later, but bleeding continued. Duplex ultrasound with the Acuson X300 (Siemens, Munich, Germany) revealed the source of the bleeding to be a ruptured pseudoaneurysm arising from the branch of the right uterine artery located between the urinary bladder and rectum (Fig. 1A). Computerized tomography (CT) and CT angiography (Extended Brilliance Workspace, Philips Healthcare, Netherlands) of the abdomen revealed dilated and tortuous branches of the right uterine artery and a lobulated, ruptured pseudoaneurysmal sac measuring 23 x 15 mm. Owing to the patient’s poor general condition, sepsis, coagulopathy, history of multiple surgeries over a short time span, tissue edema, oozing and destroyed tissue planes, and an anticipated poor outcome, further surgical exploration was not contemplated. Written informed consent for the embolization procedure was obtained after detailed discussion of the possible complications and clinical outcome with the patient and her relatives. The patient was placed in a supine position and evaluated with duplex ultrasound imaging. Using a surgical blade, a Gelfoam pad (Pfizer Injectables, New York USA) was fragmented into 1−2-mm fine particles and mixed with sterile saline solution in a bowl to make a “slurry” and loaded into a 10 mL syringe. The procedure must be performed quickly
J.-S. Yuk et al. / International Journal of Gynecology and Obstetrics 129 (2015) 169–177
171
Fig. 1. (A) CT scan of the abdomen revealed dilated and tortuous branches of the right uterine artery (black arrow heads) and a lobulated pseudoaneurysmal sac (23 x 15 mm) of the branch of the right uterine artery (black arrow); (B) CT scan performed 48 hours after the procedure confirmed the thrombosis of the pseudoaneurysmal sac, offending branch (white arrow), and resolution of the dilated and tortuous branches of the right uterine artery (white arrow head).
as the Gelfoam absorbs water and the particles swell, which makes it more difficult to push the slurry through a 16-gauge spinal needle. A16-gauge spinal needle was directly advanced via the percutaneous transvesical route to puncture the pseudoaneurysmal sac under ultrasound guidance. The needle tip was positioned so that the bevel edge of the needle was directed toward the neck of the pseudoaneurysm and the lumen of the offending branch of the uterine artery. The slurry was then injected into the sac and offending branch to achieve thrombosis. Without dislodging the spinal needle, the syringe was disconnected and 0.5 mL isoamyl 2-cyanoacrylate glue (Amcrylate; Concord Drugs Ltd, India) was injected. The needle was kept in the same position for 60 seconds to allow time for polymerization of the glue, stabilization, and to strengthen the “clot-slurry-glue” complex to prevent subsequent dislodgement. The needle was removed after cessation of bleeding through the needle hub. Complete thrombosis of the pseudoaneurysm and offending branch of the uterine artery was confirmed using duplex ultrasound imaging. CT of the pelvis and CT angiography of the abdomen performed 48 hours after the procedure confirmed thrombosis of the
pseudoaneurysm and offending branch, and resolution of the dilated and tortuous branches of the right uterine artery (Fig. 1B). With supportive management, the patient had a rapid recovery and was discharged after two weeks. The patient was well at follow-up 14 months later. This feasible, safe, quick, cost-effective, and lifesaving modified embolization technique proved to be an alternative to surgery and transarterial embolization in a resource-limited setting. Conflict of interest The authors have no conflicts of interest to declare. Reference [1] Kumar M, Goel P, Rawat JD, Kumari S, Shankhwar SN, Kureel SN. Percutaneous transhepatic gelfoam-cyanoacrylate glue embolization for ruptured post-traumatic hepatic artery pseudo-aneurysm in a limited-resource scenario. Pediatr Surg Int 2013;29(5): 465–9.
http://dx.doi.org/10.1016/j.ijgo.2014.11.020 0020-7292/© 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
J.-S. Yuk et al. / International Journal of Gynecology and Obstetrics 129 (2015) 169–177
Previous studies have reported on experience with adnexal torsion at a single institution and not its incidence [1]. According to a previous study, adnexal torsion frequently occurs in women of childbearing age compared with premenarchal or postmenopausal women [5]. These results were consistent with the results of the present study (Fig. 1). Although the present study has limitations attributed to diagnosis coding errors, it provides valuable information regarding the use of HIRA-NIS, which includes a large population that is useful for studying the low incidence of adnexal torsion.
References [1] Hibbard LT. Adnexal torsion. Am J Obstet Gynecol 1985;152(4):456–61. [2] Oelsner G, Shashar D. Adnexal torsion. Clin Obstet Gynecol 2006;49(3):459–63. [3] Yuk J-S, Kim Y-J, Hur J-Y, Shin J-H. Incidence of Bartholin duct cysts and abscesses in the Republic of Korea. Int J Gynecol Obstet 2013;122(1):62–4. [4] World Health Organization. International Statistical Classification of Diseases and Related Health Problems. 10th Revision. http://apps.who.int/classifications/icd10/ browse/2015/en. [5] Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Ann Emerg Med 2001; 38(2):156–9.
Conflict of interest The authors have no conflicts of interest.
http://dx.doi.org/10.1016/j.ijgo.2014.11.027 0020-7292/© 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Management of a ruptured pseudoaneurysm of the uterine artery using a modified percutaneous embolization technique Manoj Kumar a,⁎, Sabuhi Quiresi b, Uma Singh b a b
Department of Radiodiagnosis, King George’s Medical University, Uttar Pradesh, Lucknow, India Department of Obstetrics and Gynecology, King George’s Medical University, Uttar Pradesh, Lucknow, India
a r t i c l e
i n f o
Article history: Received 25 July 2014 Received in revised form 18 November 2014 Accepted 22 January 2015 Keywords: Embolization India Low-resource setting Pseudoaneurysm Uterine artery
The aim of the present paper is to describe an indigenously modified, duplex ultrasound-guided, direct percutaneous embolization technique [1] performed to manage a ruptured pseudoaneurysm of a branch of the uterine artery. A forty-year-old woman (G4) was referred to Queen Mary Hospital (KGMU), Lucknow, in October 2013 following intractable secondary vaginal hemorrhage following abdominal hysterectomy for multiple uterine myomas. The surgery had been uneventful and the patient was discharged on the seventh postoperative day; however, she presented one week later with sudden onset of profuse vaginal bleeding and dizziness. After immediate hemodynamic stabilization via blood transfusion and intravenous colloids, hemostatic suturing of the vaginal vault was attempted but was ineffective. The patient was treated with vitamin K and procoagulants at the same remote hospital for a further
⁎ Corresponding author at: Department of Radiodiagnosis, King George’s Medical University, Uttar Pradesh, Lucknow, India PIN-226003. Tel.: +91 9935278765 (mobile); fax: +91 5222258713. E-mail address: [email protected] (M. Kumar).
six days before she was referred to King George’s Medical University in Lucknow. The patient presented with anemia, hypotension, early sepsis, coagulopathy, and electrolyte imbalance. On local examination, an organized hematoma was seen in the vaginal cavity with continuous oozing of bright red blood. After evacuating the hematoma, active bleeding was observed flowing from the right angle of the vaginal vault. The vaginal cavity was packed with roller gauze soaked in 5% povidone iodine solution. Bedside transabdominal and transvaginal ultrasound revealed an organized hematoma of approximately 60 x 70 mm in the pelvic cavity. The packing was removed 24 hours later but the bleeding restarted. Explorative laparotomy demonstrated no contamination. Anterior divisions of the bilateral anterior iliac arteries were ligated to control the ongoing vaginal bleeding. Vaginal packing was again removed 24 hours later, but bleeding continued. Duplex ultrasound with the Acuson X300 (Siemens, Munich, Germany) revealed the source of the bleeding to be a ruptured pseudoaneurysm arising from the branch of the right uterine artery located between the urinary bladder and rectum (Fig. 1A). Computerized tomography (CT) and CT angiography (Extended Brilliance Workspace, Philips Healthcare, Netherlands) of the abdomen revealed dilated and tortuous branches of the right uterine artery and a lobulated, ruptured pseudoaneurysmal sac measuring 23 x 15 mm. Owing to the patient’s poor general condition, sepsis, coagulopathy, history of multiple surgeries over a short time span, tissue edema, oozing and destroyed tissue planes, and an anticipated poor outcome, further surgical exploration was not contemplated. Written informed consent for the embolization procedure was obtained after detailed discussion of the possible complications and clinical outcome with the patient and her relatives. The patient was placed in a supine position and evaluated with duplex ultrasound imaging. Using a surgical blade, a Gelfoam pad (Pfizer Injectables, New York USA) was fragmented into 1−2-mm fine particles and mixed with sterile saline solution in a bowl to make a “slurry” and loaded into a 10 mL syringe. The procedure must be performed quickly
J.-S. Yuk et al. / International Journal of Gynecology and Obstetrics 129 (2015) 169–177
171
Fig. 1. (A) CT scan of the abdomen revealed dilated and tortuous branches of the right uterine artery (black arrow heads) and a lobulated pseudoaneurysmal sac (23 x 15 mm) of the branch of the right uterine artery (black arrow); (B) CT scan performed 48 hours after the procedure confirmed the thrombosis of the pseudoaneurysmal sac, offending branch (white arrow), and resolution of the dilated and tortuous branches of the right uterine artery (white arrow head).
as the Gelfoam absorbs water and the particles swell, which makes it more difficult to push the slurry through a 16-gauge spinal needle. A16-gauge spinal needle was directly advanced via the percutaneous transvesical route to puncture the pseudoaneurysmal sac under ultrasound guidance. The needle tip was positioned so that the bevel edge of the needle was directed toward the neck of the pseudoaneurysm and the lumen of the offending branch of the uterine artery. The slurry was then injected into the sac and offending branch to achieve thrombosis. Without dislodging the spinal needle, the syringe was disconnected and 0.5 mL isoamyl 2-cyanoacrylate glue (Amcrylate; Concord Drugs Ltd, India) was injected. The needle was kept in the same position for 60 seconds to allow time for polymerization of the glue, stabilization, and to strengthen the “clot-slurry-glue” complex to prevent subsequent dislodgement. The needle was removed after cessation of bleeding through the needle hub. Complete thrombosis of the pseudoaneurysm and offending branch of the uterine artery was confirmed using duplex ultrasound imaging. CT of the pelvis and CT angiography of the abdomen performed 48 hours after the procedure confirmed thrombosis of the
pseudoaneurysm and offending branch, and resolution of the dilated and tortuous branches of the right uterine artery (Fig. 1B). With supportive management, the patient had a rapid recovery and was discharged after two weeks. The patient was well at follow-up 14 months later. This feasible, safe, quick, cost-effective, and lifesaving modified embolization technique proved to be an alternative to surgery and transarterial embolization in a resource-limited setting. Conflict of interest The authors have no conflicts of interest to declare. Reference [1] Kumar M, Goel P, Rawat JD, Kumari S, Shankhwar SN, Kureel SN. Percutaneous transhepatic gelfoam-cyanoacrylate glue embolization for ruptured post-traumatic hepatic artery pseudo-aneurysm in a limited-resource scenario. Pediatr Surg Int 2013;29(5): 465–9.
http://dx.doi.org/10.1016/j.ijgo.2014.11.020 0020-7292/© 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.