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 Fig. 1. Aortogram with a pigtail catheter clearly displays the enlarged left ovarian and right uterine arteries supplying the uterine AVM. |
 Fig. 2. The enlarged left ovarian artery, feeding the AVM, is visualized along with an early draining vein. |
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A 29-year-old female with a history of prior molar pregnancy presented with heavy menstrual bleeding. Hysteroscopy revealed a pulsatile lesion, and the patient underwent a transvaginal ultrasound. Ultrasound demonstrated a 1.4 x 1.6 x 1.4 cm arteriovenous malformation (AVM) in the anterior fundus, which appeared to be supplied by bilateral uterine arteries with a left-sided predominance. Pelvic angiograpy did not display a defined AVM; a suggestion of a small tangle of vessels and an early draining right-sided ovarian vein were observed. Given positive ultrasound and hysteroscopy results, empirical embolization of bilateral uterine arteries was performed, using 750 micron PVA particles, until approximately 80% stasis of flow was achieved. A follow-up transvaginal ultrasound performed a month later showed a small persistent AVM. The patient underwent another selective embolization of bilateral uterine arteries with 500-700 micron PVA particles to stasis. The patient’s uterine bleeding persisted and a selective internal iliac arteriogram was performed a month later. This study demonstrated occlusion of both uterine arteries from previous embolization procedures and a persistent uterine AVM deriving blood supply from the right ovarian artery which could not be selectively catheterized. An attempt at percutaneous puncture and embolization of the AVM under ultrasound-guidance was unsuccessful. Eight months later, a pelvic MRA with gadolinium demonstrated the lower uterine AVM. Angiographic re-evaluation of the AVM was performed recently (Fig. 1); showing an enlarged left ovarian artery feeding the AVM (Fig. 2). The right ovarian artery supplies small tortuous collaterals to the AVM as well (Fig. 3). Both uterine arteries have recanalized, right more so than the left, and still feed the AVM (Figs. 4 and 5). The treatment plan in consideration is to re-embolize bilateral uterine arteries. The enlarged left ovarian artery may allow catheterization and selective embolization of its collateral supply to the AVM past the ovary. Given the small lumen of the right ovarian artery and the tortuosity of its collateral supply to the AVM, the right ovary and its artery would be sacrificed. The patient is a young woman and wants to conceive. Embolization of bilateral ovarian arteries could induce early menopause and infertility, negating the reason the patient wants treatment for the AVM. |
 Fig. 3. Selective arteriogram with a rim catheter shows the right ovarian artery and its tortuous collaterals supplying the AVM. |
 Fig. 4. The recanalized right uterine artery provides a tangle of feeding vessels to the uterine AVM. |
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 Fig. 5. Contralateral catheterization of the left uterine artery clearly demonstrates its recanalization and persistent supply to the uterine AVM. |
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Questions:
1) Do you think embolization of the left ovarian artery past the take off of the left ovary is possible in order to preserve fertility? 2) Should one consider another attempt at direct puncture with a catheter in the artery to aid in opacification and an occlusion balloon in the right gonadal vein to reduce flow? 3) Any other suggestions for treating this patient’s AVM while maintaining her fertility? Related cases: |
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