The Role of Radical Surgery in the Management of Acquired Uterine Arteriovenous Malformation

Abstract

Background: Acquired arteriovenous malformations (AVMs) can develop after uterine instrumentation. The increased risks of vascular changes, including abnormal placentation, after repeated cesarean sections are well studied. Herein, we describe a patient with delayed hemorrhage from a uterine AVM, following dilation and curettage for a cesarean scar pregnancy. Case: A 32-year-old G3P2 presented with a cesarean scar ectopic pregnancy managed with dilation and curettage, which incurred a 1,500-ml blood loss. Within 6 weeks, she returned with 2 episodes of vaginal bleeding. Initial angiography demonstrated a high-flow arteriovenous fistula, which was coiled. Vaginal hemorrhage recurred; repeat angiography demonstrated a large AVM. Gelfoam embolization of the bilateral internal iliac arteries reduced the vascularity of the AVM. The AVM's location, starting at the left lateral apex of the cesarean scar and extending into the parametrium, necessitated a radical hysterectomy. Pathologic examination revealed a placenta percreta extending into the parametrium. Conclusion: The prevalence of uterine AVMs has increased with the rise in surgical obstetrics. In patients with a failed prior interventional procedure, surgical management is necessary to prevent life-threatening hemorrhage. The location of the AVM within the abnormal uterine scar tissue requires familiarity with radical pelvic surgical techniques that are normally used in cancer surgery in order to definitively treat this delayed obstetrical complication.

A Systematic Review of Acquired Uterine Arteriovenous Malformations: Pathophysiology, Diagnosis, and Transcatheter Treatment

“… 60 Given the acuity of clinical situations that necessitate surgical intervention and the distorted uterine tissue and anatomy created by an AVM, hysterectomy should be performed by those skilled in radical pelvic surgical techniques. 60 61 …”

Temporary balloon occlusion of the uterine arteries to control hemorrhage during hysterectomy in a case of uterine arteriovenous fistula

“…Even today, hysterectomy is the first choice for management of UAVF, especially for cases where women do not need to preserve reproductive function, because single uterine artery embolization is not always successful and failure of embolization may result in repetitive bleeding that requires repeated embolizations or a hysterectomy . Hysterectomy, however, can lead to massive blood loss, and may require invasive surgeries such as radical hysterectomy . In the present case, hysterectomy was chosen over embolization because the patient had no need of uterine preservation, and a single uterine artery embolization was considered to be ineffective due to the large diameter and the high velocity of blood flow at the lesion.…”

An Unusual Case of Acquired Uterine Arteriovenous Malformation With Persistent Scar Ectopic Pregnancy Successfully Managed With Uterine Artery Embolization

“…Abnormal implantation in the cesarean scar bed accounts for 6% of ectopic pregnancies in multiparous women. More than half of these women have had one previous cesarean delivery [11,12]. AVMs have been confirmed as arising from a prior cesarean scar ectopic implantation site [11].…”