LETTER TO THE EDITOR

Transvaginal 3D HD-flow in diagnosis of uterine arteriovenousmalformation

Kenji Kanenishi • Masato Mashima •

Hirokazu Tanaka • Hisako Nagasaka •

Yoshihiro Toyama • Toshiyuki Hata

Received: 22 January 2012 / Accepted: 23 February 2012 / Published online: 6 March 2012

� Springer-Verlag 2012

To the Editor,

‘‘Uterine arteriovenous malformation (AVM) is a rare

lesion with a considerable risk potential. The clinical pre-

sentation varies from no signs, to various degrees of

menorrhagia, to massive life-threatening vaginal bleeding;

Clinical suspicion is essential for a prompt diagnosis and

treatment’’ [1]. Conventional two-dimensional (2D) color/

power Doppler sonography is a valuable and noninvasive

modality for the definitive diagnosis of pelvic AVM in

clinical practice [2, 3]. Moreover, three-dimensional (3D)

color/power Doppler sonography has the potential to pro-

vide an improved visualization and recognition of pelvic

AVM [4–6].

‘‘High definition-flow (HD-flow) is a bi-directional

power Doppler technique that delivers high-definition axial

resolution and increased sensitivity for imaging small

vessels. In addition, it reduces the spatial overlap of tissue

signals by the application of small sample volumes, and

provides optimal clutter elimination with adaptive wall

filtering. 3D HD-flow is unique for 3D reconstruction of

fetal vascularities in the whole body’’ [7]. We present our

experience of uterine AVM with heavy vaginal bleeding

following uterine curettage, diagnosed by employing

transvaginal 3D HD-flow with multiplanar and angio-

graphic displays.

A 25-year-old Japanese woman, gravida 5, para 0, was

referred to our university hospital because of an episode of

sudden episodic profuse vaginal bleeding following her

menses. She had undergone dilatation and curettage due to

first-trimester missed abortion 6 weeks previously.

Urine hCG was negative on the visit. Transvaginal 2D

sonography depicted an ill-defined, inhomogeneous lesion

involving the endometrial and subendometrial tissues with

variously sized hypoechoic cysts (Fig. 1). Transvaginal 2D

HD-flow revealed a hypervascular lesion in the myome-

trium involving the endometrial and subendometrial tissues

Fig. 1 Transvaginal two-dimensional sonographic sagittal view of

the uterus. An ill-defined inhomogeneous lesion involving the

endometrial and subendometrial tissues with variously sized hypo-

echoic cysts (arrow) is noted

K. Kanenishi � M. Mashima � H. Tanaka � T. Hata (&)

Department of Perinatology and Gynecology, Kagawa

University School of Medicine, 1750-1 Ikenobe, Miki,

Kagawa 761-0793, Japan

e-mail: toshi28@med.kagawa-u.ac.jp

H. Nagasaka

Department of Obstetrics and Gynecology, Yashima General

Hospital, 1857-1 Yashimanishi-machi, Takamatsu,

Kagawa 761-0113, Japan

Y. Toyama

Department of Radiology, Kagawa University School of

Medicine, 1750-1 Ikenobe, Miki, Kagawa 761-0793, Japan

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Arch Gynecol Obstet (2012) 286:541–544

DOI 10.1007/s00404-012-2284-8

(Fig. 2). Transvaginal 3D HD-flow in multiplanar mode

revealed the exact site, extent, and size of this hypervas-

cular lesion (Fig. 3). 3D HD-flow angiography showed

uterine AVM including its feeding and draining vessels

(Fig. 4). Contrast CT, 3D CT, MRI and angiography

(Fig. 5) confirmed the diagnosis of uterine AVM. The

selective embolization of bilateral uterine arteries was

carried out, resulting in hemostasis. Transvaginal 2D/3D

HD-flow examinations showed no vascular lakes in the

uterus after this procedure (Fig. 6), and the patient has been

doing well.

There have been numerous reports of uterine AVM

acquired following uterine curettage [8–10]. The time

between uterine curettage and the diagnosis was 2–8 weeks

[10]. In the present case, it was 6 weeks. The most

important issue is to differentiate it from diagnoses of

retained products of conception and gestational tropho-

blastic disease. However, those conditions are readily dis-

tinguished by increased levels of hCG, while uterine AVM

is associated with undetectable or low hCG levels. In our

case, urine hCG was negative at the time of the diagnosis

before treatment. The differential diagnosis among these

three entities is crucial because the treatment modalities are

Fig. 2 Transvaginal two-dimensional HD-flow feature of uterine

arteriovenous malformation

Fig. 4 Transvaginal three-dimensional HD-flow angiographic dis-

play of uterine arteriovenous malformation (*). DV draining vessel,

FV feeding vessel

Fig. 3 Transvaginal three-dimensional HD-flow multiplanar view of uterine arteriovenous malformation (AVM). The exact site, extent, and size

of the AVM in the uterus are clearly identified

542 Arch Gynecol Obstet (2012) 286:541–544

123

completely different: uterine curettage for retained con-

ceptional products, chemotherapy for gestational tropho-

blastic disease, and selective uterine embolization for

uterine AVM [10]. ‘‘Moreover, uterine curettage is con-

traindicated in uterine AVM’’ [10].

Based on our search of the literature, we identified

three investigations that described the use of 3D color/

power Doppler sonography for the visualization of uterine

AVM [4–6]. ‘‘The advantage of 3D reconstruction of

color/power Doppler sonographic images is that this can

enable us to understand the spatial relationships of vessels

in areas where complex structures are present’’ [4].

Moreover, 3D color/power Doppler sonography can pro-

vide additional information useful to the clinician, such as

identification of the vascular connections including its

feeding and draining vessels [5]. In the present report,

transvaginal scanning was used, and very clear 3D

HD-flow images could be obtained for a better under-

standing of uterine AVM. Especially, the power of

transvaginal 3D HD-flow to identify the exact site, extent,

and size of uterine AVM was marked. The site and size

of uterine AVM are clinically important in considering

the treatment modalities [1]. The role of 3D HD-flow is

more to assist the treatment of choice rather than altering

the diagnosis in the pre-treatment period.

Conflict of interest The authors declare no conflict of interest.

Fig. 6 Transvaginal three-dimensional HD-flow multiplanar view of the uterus 4 days after uterine artery embolization. Uterine arteriovenous

malformation has almost disappeared

Fig. 5 Right uterine arteriographic image of uterine arteriovenous

malformation (arrow)

Arch Gynecol Obstet (2012) 286:541–544 543

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