Control of arterial hemorrhage using percutaneous arterial catheter techniques in patients with gynecologic malignancies

Transarterial embolisation for the treatment of acute gynecological cancer bleeding

PURPOSE

Acute bleeding in patients with gynecological cancer may result in serious life-threatening complications. In these situations, immediate diagnostic and appropriate treatment is a challenge for attending physicians. Accordingly, transarterial embolisation (TAE) has been described as an increasing and effective treatment alternative to surgery and radiotherapy.

METHODS

In the present retrospective study, 25 patients were included who underwent a TAE in the period from January 2006 to June 2013 due to acute gynecological cancer bleeding. The objective of this study was to assess the efficiency and outcome of TAE.

RESULTS

The primary technical success rate was 92.0% (n = 23). 21 patients were analyzed in the 30-day follow-up. The clinical success rate was achieved in 90.5% (n = 19). A clinical failure due to rebleeding was observed in 9.5% (n = 2). No associations were revealed between rebleeding and technical/clinical factors. Within 30 days after the last TAE, the complication and mortality rates were 0.0% and 5.0% (n = 1), respectively.

CONCLUSION

TAE was found as an effective and safe treatment in the clinical setting of acute gynecological cancer bleeding. An important component of efficient management is an early and interdisciplinary care. Optimal treatment can be achieved by close cooperation between gynecologists, radiotherapists and interventional radiologists.

N-butyl cyanoacrylate is very effective for massive haemorrhage during the perinatal period

Objective

The liquid embolic agent n-butyl cyanoacrylate (NBCA) is a tissue adhesive used as an immediate and permanent embolic agent when mixed with oil-based contrast medium. In this study, the preservation of fertility with TAE using NBCA for massive haemorrhage during pregnancy or the peripartum period and the utility of this therapy were investigated.

Methods

Cases from January 2005 to October 2010 in which TAE was performed for massive haemorrhage in pregnant women, particularly during the peripartum period, were investigated.

Results

TAE was performed in 27 pregnant women. The embolic agent used was GS only in five cases, NBCA only in 19 cases, and additional embolization with NBCA when the effect with GS was insufficient in three cases, one each of abruptio placentae, cervical pregnancy, and uterine atony.A comparison of mean blood loss when each embolic agent was used for haemostasis showed a significant difference between cases in which GS only was used and cases in which NBCA only was used. In a comparison of mean transfusion volume, a significant difference was seen between cases in which both GS and NBCA were used and cases in which NBCA only was used. In a postoperative follow-up survey, menses resumed in eight patients, including four patients who later became pregnant and three who delivered.

Conclusions

TAE with NBCA, which has an embolic effect unrelated to clotting dysfunction for massive haemorrhage during the peripartum period, is a minimally invasive and very effective treatment method for patients with severe DIC.

Transcatheter arterial embolotherapy: a therapeutic alternative in obstetrics and gynecologic emergencies

Transcatheter arterial embolization has become a major treatment modality in a variety of clinical applications, including management of bleeding related to a broad spectrum of obstetric and gynecologic disorders. Embolotherapy has a well-documented role in the management of pelvic and genital tract hemorrhage in the postpartum and postoperative/postcesarean setting. It is also an integral part in the treatment armamentarium of abdominal and cervical ectopic pregnancy, arteriovenous malformation, and gynecologic neoplasms, including more recently, uterine leiomyomata. Based on experiences accumulated over the past decades, embolotherapy has been proven to be highly effective with success rate in the 90 to 100% range in the appropriate clinical settings. It provides visualization of the bleeding site and enables targeted, minimally invasive therapy to achieve hemostasis, which allows preservation of the uterus and hence fertility. In hospitals where experienced personnel and technology is available, transcatheter arterial embolization should be considered in the emergent management of obstetric and gynecologic hemorrhage, particularly when local and conservative measures fail to attain hemostasis.

A case of pregnancy and childbirth after uterine artery embolization with a permanent embolic agent

OBJECTIVE

To report a case of full-term delivery after uterine artery embolization with N-butyl cyanoacrylate for abruptio placentae.

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

A 35-year old woman, gravida 2 para 0, at 32 weeks' and 4 days' gestation.

INTERVENTION(S)

Transcatheter arterial embolization with N-butyl cyanoacrylate (NBCA).

RESULT(S)

An emergency cesarean section was performed for abruptio placentae. The neonate died on day 0. After the cesarean section, a hematoma was found at the uterine incision that continued to increase. Therefore, pelvic angiography was performed, and extravasation was observed from the uterine arteries. NBCA was used for embolization, and the extravasation stopped rapidly. Total transfusion volume was 10,190 mL. Nine months after the cesarean section, the patient became pregnant naturally and delivered a boy by elective cesarean section.

CONCLUSION(S)

For treatment of shock caused by perinatal hemorrhage, which is a major cause of perinatal mortality, even if clotting abnormalities are present, transcatheter arterial embolization using NBCA can provide effective hemostasis. Moreover, in patients who would otherwise require a hysterectomy, fertility can be preserved.

Pelvic embolization for treatment of hemorrhage related to spontaneous and induced abortion

OBJECTIVE

Presentation of outcomes of pelvic arterial embolization for hemorrhage after spontaneous or induced abortion.

STUDY DESIGN

We collected case reports of embolization after spontaneous or induced abortion from oral presentations and from members of the National Abortion Federation.

RESULTS

Pelvic arterial embolization was performed for 11 women who had hemorrhage after spontaneous or induced abortion, and it was initially successful for all women. One woman ultimately required a hysterectomy after unsuccessful repeated embolization. Prophylactic embolization was done for 8 women who were at risk for hemorrhage from placenta accreta; 4 of these women had subsequent hysterectomies.

CONCLUSIONS

Selective pelvic arterial embolization may be a successful treatment for hemorrhage associated with spontaneous and induced abortion. Embolization can be considered before hysterectomy is undertaken for control of hemorrhage. There may be a role for prophylactic catheterization or embolization when there is a risk of severe hemorrhage.

Embolic management of rare hemorrhagic gynecologic and obstetrical conditions

Severe life-threatening hemorrhage was controlled by angiographic management in 3 patients with bleeding due to unusual gynecological abnormalities and in 1 patient with a rare obstetrically related hemorrhage. Successful management of such rare causes of bleeding emphasizes that early angiographic intervention can, in selected patients, reduce the need for an immediate or subsequent surgical procedure and allow conservative management followed by disease-specific therapy.

Angiographic arterial embolization in the management of postoperative vaginal hemorrhage

Recently great success was achieved at the Toronto General Hospital in treating patients with postoperative vaginal hemorrhage by angiographic methods. A retrospective review was performed from 1975 to 1984 on eight patients treated by this technique for nine separate episodes of hemorrhage with a mean estimated blood loss in excess of 5000 ml. Success was achieved in seven episodes despite failure of various vaginal and abdominal approaches. One of the failures was due to previous bilateral hypogastric artery ligation that made the bleeding branch inaccessible to the angiography catheter. The other patient developed bleeding following cesarean section which did not respond to angiographic embolization due to faulty technique. Both of these patients were eventually cured by abdominal surgery. We feel that angiographic embolization is the procedure of choice in the management of postoperative vaginal hemorrhage when conservative management has failed or is inappropriate; it can be lifesaving when all other attempts to stop the hemorrhage have failed.

Transcatheter hemostasis in the genitourinary tract

Transcatheter hemostasis is applicable in a large variety of causes of genitourinary hemorrhage. The method is particularly useful in the management of trauma since temporary occlusion of the bleeding vessel usually produces cessation of hemorrhage without significant sacrifice of additional parenchyma. Control of arteriovenous fistulas requires an assessment of flow characteristics and careful tailoring of catheter and embolization technique; large emboli or glue is frequently required for occlusion of large fistulas, whereas small ones can be treated with Ivalon. Hemorrhage from renal or pelvic neoplasm is also effectively managed by transcatheter therapy.

Direct intralumen balloon tamponade: a technic for the control of massive retroperitoneal hemorrhage

Control of massive retroperitoneal hemorrhage by the direct insertion of a Fogarty, catheter into the lumen of the vessel and inflation of the balloon is described. The applicability of this new technic for the control of hemorrhage from inaccessible vessels is discussed.