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Uterine Arteries: Bilateral Catheterization with a Single Femoral Approach and a Single 5-F Catheter— Technical Note

¹ Department of Body and Vascular Imaging, Hôpital Lariboisière, AP-HP, 2 rue Ambroise Paré, 75475 Paris 10, France.

	Abstract

TOP Abstract Introduction Materials and Methods Results Discussion References

 
In 197 patients, uterine embolization with a single femoral approach and a single 5-F cobra catheter was successful in 362 of 394 (92%) uterine arteries. In six patients (12 arteries), distal embolization with a coaxial 3-F microcatheter was safer. In 10 patients with a life-threatening condition, embolization was performed at the anterior division of both internal iliac arteries. Bilateral selective embolization of the uterine arteries can be performed with a single catheter.

Index terms: Arteries, therapeutic blockade, 986.1264 • Arteries, uterine, 986.1264 • Interventional procedures, technology, 986.715, 986.716 • Uterine neoplasms, 986.715, 986.716

	Introduction

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Transcatheter embolization of the uterine arteries has recently emerged as a highly effective technique to control genital hemorrhage. In most published reports, bilateral selective embolization of the uterine arteries was performed with use of various catheters, wires, or arterial accesses (1,2). We are not aware of any study that reported the use of a unilateral femoral approach with a single 5-F catheter; therefore, we performed this study.

	Materials and Methods

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From July 1994 through November 1997, in 197 consecutive women (age range, 28–79 years; mean age, 38.3 years), selective angiography and bilateral embolization of the uterine arteries was performed in our institution. Indications for treating the patients were uterine leiomyoma (n = 133); adenomyosis (n = 3); postpartum (n = 49), postabortum (n = 5), or postoperative (n = 2) hemorrhage; and bleeding related to pelvic tumors (n = 4) or vascular malformations (n = 1). The potential risks and benefits of the procedure were explained, and informed consent was obtained in all cases from the patient or her family. All angiographic studies were performed with a unilateral femoral approach (right side, n = 189 [96%]; left side, n = 8 [4%]).

Internal iliac artery angiography and selective study of the anterior division were performed to localize the origin of the contralateral uterine artery. Catheterization was facilitated by means of digital road mapping. Superselective catheterization of the contralateral uterine artery was then attempted by using a 5-F cobra-shaped catheter (Cobra; Terumo, Tokyo, Japan) and a hydrophilic polymer-coated 0.032-inch guide wire (Radifocus; Terumo). When occlusion of the contralateral uterine artery was confirmed fluoroscopically, the guide wire was advanced through the catheter at the level of the aortic bifurcation to rigidify the proximal part of the catheter (Figure, part a). The catheter was then slowly advanced with fluoroscopic guidance, and a strong torque movement was applied to give it a Simmons reverse curve (Figure, part b). The catheter was then pulled out into the aorta (Figure, part c) and placed into the ipsilateral common iliac artery and then into the internal iliac artery (Figure, part d). Selective study of the anterior division and superselective catheterization of the uterine artery were then performed with the same catheter (Figure, part e).

View larger version (190K): [in this window] [in a new window]   Figure 1a. Fluoroscopic images obtained in one patient during bilateral selective embolization of the uterine arteries with a unilateral femoral approach and use of a single 5-F catheter. (a) The 5-F catheter is in the left internal iliac artery (arrowhead). The guide wire is carefully advanced inside the catheter at the level of the aortic bifurcation (arrow). (b) After a torque movement, the catheter and guide wire have a Simmons reverse curve (arrow). (c) The catheter has been pulled out into the aorta. (d) Catheterization of the right internal iliac artery (arrow) is achieved. (e) Selective catheterization of the anterior division (arrowheads) of the right internal iliac artery is achieved. The arrow indicates the uterine artery.

View larger version (207K): [in this window] [in a new window]   Figure 1b. Fluoroscopic images obtained in one patient during bilateral selective embolization of the uterine arteries with a unilateral femoral approach and use of a single 5-F catheter. (a) The 5-F catheter is in the left internal iliac artery (arrowhead). The guide wire is carefully advanced inside the catheter at the level of the aortic bifurcation (arrow). (b) After a torque movement, the catheter and guide wire have a Simmons reverse curve (arrow). (c) The catheter has been pulled out into the aorta. (d) Catheterization of the right internal iliac artery (arrow) is achieved. (e) Selective catheterization of the anterior division (arrowheads) of the right internal iliac artery is achieved. The arrow indicates the uterine artery.

View larger version (164K): [in this window] [in a new window]   Figure 1c. Fluoroscopic images obtained in one patient during bilateral selective embolization of the uterine arteries with a unilateral femoral approach and use of a single 5-F catheter. (a) The 5-F catheter is in the left internal iliac artery (arrowhead). The guide wire is carefully advanced inside the catheter at the level of the aortic bifurcation (arrow). (b) After a torque movement, the catheter and guide wire have a Simmons reverse curve (arrow). (c) The catheter has been pulled out into the aorta. (d) Catheterization of the right internal iliac artery (arrow) is achieved. (e) Selective catheterization of the anterior division (arrowheads) of the right internal iliac artery is achieved. The arrow indicates the uterine artery.

View larger version (186K): [in this window] [in a new window]   Figure 1d. Fluoroscopic images obtained in one patient during bilateral selective embolization of the uterine arteries with a unilateral femoral approach and use of a single 5-F catheter. (a) The 5-F catheter is in the left internal iliac artery (arrowhead). The guide wire is carefully advanced inside the catheter at the level of the aortic bifurcation (arrow). (b) After a torque movement, the catheter and guide wire have a Simmons reverse curve (arrow). (c) The catheter has been pulled out into the aorta. (d) Catheterization of the right internal iliac artery (arrow) is achieved. (e) Selective catheterization of the anterior division (arrowheads) of the right internal iliac artery is achieved. The arrow indicates the uterine artery.

View larger version (183K): [in this window] [in a new window]   Figure 1e. Fluoroscopic images obtained in one patient during bilateral selective embolization of the uterine arteries with a unilateral femoral approach and use of a single 5-F catheter. (a) The 5-F catheter is in the left internal iliac artery (arrowhead). The guide wire is carefully advanced inside the catheter at the level of the aortic bifurcation (arrow). (b) After a torque movement, the catheter and guide wire have a Simmons reverse curve (arrow). (c) The catheter has been pulled out into the aorta. (d) Catheterization of the right internal iliac artery (arrow) is achieved. (e) Selective catheterization of the anterior division (arrowheads) of the right internal iliac artery is achieved. The arrow indicates the uterine artery.

	Results

TOP Abstract Introduction Materials and Methods Results Discussion References

	Discussion

TOP Abstract Introduction Materials and Methods Results Discussion References

 
Transcatheter arterial uterine embolization is commonly used in the management of intractable tumoral (3), postoperative (4), and postpartum (5) hemorrhage. Recently, bilateral arterial embolization of the uterine arteries has been used in our institution as a preoperative adjunct or as an alternative to surgery in the treatment of uterine leiomyoma (6). The widespread use of this technique makes it necessary to reassess the importance of angiographic manipulations with the appropriate catheter and guide wire to perform safer embolization.

In the literature, two different catheters were often used to perform successive catheterization of contralateral and ipsilateral uterine arteries (1). Our procedure with a single catheter, therefore, costs less than embolization with multiple catheters. In addition, unilateral arterial access decreases the risk of arterial dissection and hematoma at the puncture site. Also, various types of long reverse-curve catheters were used, and bilateral femoral approach (1,2) or axillary access are often recommended (2,7). The advantage of the femoral approach over axillary access is the ability to leave the introducer sheath in place in case of emergent embolization associated with coagulopathy or failure of the first session. In addition, the axillary approach is not free of side effects. The ability of the same cobra catheter to be used to perform ipsilateral catheterization was proved in all cases in our study. In our series, spasm of visceral branches of the internal iliac artery including the uterine artery was encountered in 25% of cases, precluding superselective catheterization in only 3% of the patients, which is a lower rate than that reported previously (8). Spasm is a common problem in superselective catheterization of small arteries in young patients. In cases of hemostatic embolization of the uterine arteries, spasm is related to various factors including hypovolemic shock or use of adrenergic and uterotonic drugs. If these drugs can be stopped at least 30 minutes before the procedure, superselective catheterization is often possible. Vasodilation would be risky because genital hemorrhage could be increased. Conversely, in case of persistent vasospasm, embolization of the anterior division of the internal iliac artery should be the favored option to shorten the procedure in a life-threatening situation. During embolization of the uterine arteries to treat leiomyomata, vasospasm has a mainly iatrogenic origin related to the use of analogues of gonadotropin releasing hormone, or Gn-RH, and luteinizing–hormone releasing hormone, or LHRH. Therefore, medical treatment should be stopped 1 or 2 weeks before the procedure. Three of our patients experienced severe vasospasm that precluded superselective catheterization. A second session of embolization was the preferred option. Of interest in our experience, the use of a 0.032-inch hydrophilic guide wire was helpful in all these situations.

In conclusion, our experience supports the use of a single catheter to perform bilateral selective embolization of the uterine arteries, thus avoiding bilateral puncture and use of multiple catheters.

	Footnotes

 
Address reprint requests to J.P.P.

Author contributions: Guarantors of integrity of entire study, J.P.P., R.R.; study concepts, J.P.P., O.L.D.; study design, J.P.P., P.S.; definition of intellectual content, J.P.P., O.L.D., R.R.; literature research, J.P.P., O.L.D.; clinical studies, J.P.P., O.L.D., P.S., M.K., H.D., J.C.; data acquisition, J.P.P., O.L.D., P.S., M.K., H.D., J.C.; data analysis, J.P.P., O.L.D.; manuscript preparation, J.P.P.; manuscript editing and review, J.P.P., P.S.

Received March 26, 1998; revision requested June 24, 1998; revision received July 15, 1998; accepted September 8, 1998.

	References

TOP Abstract Introduction Materials and Methods Results Discussion References

 

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