vascular anatomy and dangerous anastomosis of the uterus ...€¦ · vascular anatomy and dangerous...

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 !!