Importance of timely diagnosis and intervention in uterine artery pseudoaneurysm caused by hysteroscopic surgery

Abstract

This manuscript explores the case on the occurrence of uterine artery pseudoaneurysm (UAP) during hysteroscopy endometrial polypectomy and the subsequent successful treatment via uterine artery embolization (UAE). Moreover, we focus on the management and treatment options for UAP in patients of advanced maternal age. A pseudoaneurysm is an extraluminal blood collection with a disrupted flow that communicates with the parent vessel via a defect in the arterial wall. The reported case involved a 48-year-old primiparous woman who developed a UAP after uterine polyp removal. The study enhances the understanding of UAP, a rare but potentially life-threatening condition, by providing a detailed and well-documented account of the comprehensive case presentation, effective use of medical imaging techniques for diagnosis, successful postoperative patient management following UAE, and practical clinical recommendations for clinicians managing similar cases. Overall, this study highlights the importance of considering UAP as a differential diagnosis in patients with abnormal vaginal bleeding following hysteroscopic surgery. Additionally, this manuscript recommends that clinicians with a high index of suspicion for UAP promptly request ultrasonography and computed tomography to facilitate early diagnosis. UAE is suggested as a primary treatment due to its effectiveness and safety, particularly in facilities capable of avoiding hysterectomy.

Key Words: Genital bleeding; Gynecologic surgery; Hemorrhagic complications; Transvaginal ultrasonography; Angiography; Uterine artery embolization

Core Tip: This manuscript emphasizes the critical role of early diagnosis and effective management of uterine artery pseudoaneurysm (UAP) during hysteroscopic endometrial polypectomy as described in the case report. Using advanced imaging techniques, transvaginal ultrasonography and pelvic contrast-enhanced computed tomography, the study accurately diagnosed UAP in a 48-year-old primigravid, primiparous woman. The successful treatment with uterine artery embolization (UAE) demonstrated its efficacy and safety, preventing life-threatening complications. This case highlights the importance of prompt intervention and suggests UAE as a primary treatment modality for UAP.

TO THE EDITOR

Uterine artery pseudoaneurysms (UAPs) are very rare, life-threatening causes of gynecological hemorrhage that can arise from complications following pelvic surgeries such as myomectomy, tubal ligation, or hysteroscopy[1]. It has also been associated with uncomplicated cases of spontaneous vaginal delivery, cesarean sections, manual removal of the placenta and instrumental deliveries using forceps or vacuum extraction[2-4]. Unlike a true aneurysm, which has a three-layer arterial wall, a pseudoaneurysm lacks this structure. Pseudoaneurysms start with an injury to the uterine artery wall during obstetric or gynecologic procedures. Subsequently, blood leaks into the periarterial tissue, forming a blood-filled cavity that remains connected to the original artery[5]. The clinical presentation may be asymptomatic (especially if unrupture), may thrombose or may occur with persistent vaginal bleeding. Pelvic pain, hypotension or tachycardia have been reported. Diagnosis is crucial due to the risk of rupture and lethal haemorrhage[5,6]. Transvaginal ultrasound, especially with colour Doppler, shows a pulsating structure connected to the parent artery. Magnetic resonance imaging reveals an enhanced pseudo aneurysmal sac within the uterus, however, this technique may not precisely identify the specific artery involved[7]. Angiography remains the gold standard for confirming uterine vascular lesions and planning treatment. The computed tomography (CT) angiography scan effectively confirms the presence of the pseudoaneurysm with a narrow connection to the parent artery; the uterine artery[8].

TREATMENT OPTIONS FOR UAPS

Treatment options vary based on the individual’s presentation and the available resources for treatment in the facility. Historically, uterine artery pseudoaneurysm (UAP) has been managed with an exploratory laparotomy, hysterectomy, or uterine/iliac artery ligation. Hysterectomy is particularly recommended for postmenopausal patients while laparoscopic methods have been rarely reported[9,10]. However, in recent years, treatment options have evolved to include transarterial embolization, which has been widely used in the management of UAP. Angiographic embolization is considered safe and effective for hemodynamically stable patients. Uterine artery embolization (UAE) offers a minimally invasive and uterine-preserving alternative while effectively controlling symptoms[8,11]. This procedure involves selective catheterization of uterine arteries and can use embolic agents such as stainless steel coils or gelatin sponges, which are absorbed after a few weeks[8,10,12]. Embolization should be considered before resorting to surgery in appropriate cases, as it can successfully obliterate the pseudoaneurysm[8,13]. Conservative management has also been documented for patients whose bleeding resolved spontaneously. Once the diagnosis of UAP was definitively confirmed via digital subtraction angiography, these cases were further managed conservatively with angiographic intervention[10,14].

DISCUSSION

Pseudoaneurysms result from traumatic lacerations of an artery. In the case report by Kakinuma et al[15], the pseudoaneurysm likely resulted from inadequate hemostasis following hysteroscopic endometrial polypectomy, with probable accidental puncture of the right uterine artery during the procedure[15]. Cases of UAP following traumatic pelvic surgery have previously been reported, most commonly after cesarean sections and other indications, including laparoscopic myomectomy, dilatation and curettage, and cervical conisation, with the major presentation being vaginal bleeding[3,13].

Several factors must be considered before initiating the treatment of UAP, including the patient's hemodynamic stability, the events surrounding the peripartum or postpartum period, the desire for future fertility, and the availability of specialized expertise and equipment. Treatment is particularly critical if the pseudoaneurysm exceeds 2 cm in diameter in women of childbearing age or when surgical assessment of the artery is challenging[7]. Embolization and conservative management have been the most commonly applied treatments, with quite successful outcomes and follow-up periods[14].

The case reported by Kakinuma et al[15] involves a woman of advanced maternal age or an elderly primiparous woman, defined as having a first pregnancy at age 35 years or older. Managing UAPs in this high-risk group may merit additional investigation. Pregnancies at advanced maternal age have been associated with increased cases of premature delivery, uterine polyps, and uterine fibromata. With advancing maternal age, there is a distinct increase in the number of surgical deliveries[16,17]. Dystocia, assisted vaginal delivery, and caesarean section are frequent, along with postpartum hemorrhage from lacerations and uterine atony, which increase the risk of developing UAPs. When a UAP is associated with hemodynamic shock, it may be necessary to perform an emergency exploratory laparotomy to control significant bleeding from the uterine artery by means of surgical ligation[18]. In cases of spontaneous thrombosis of the UAP, a conservative management approach with close monitoring can be proposed, with patients being informed about the risk of rupture. Due to the relative scarcity of formal guidelines for the surveillance and treatment of asymptomatic UAPs, current treatment is usually based on retrospective data.

In the context of this study the importance of prompt diagnosis and management of UAP in preventing potentially life-threatening hemorrhagic complications is discussed in detail. The patient was diagnosed using transvaginal ultrasonography and pelvic contrast-enhanced CT, which revealed a hypoechoic mass with turbulent blood flow, confirming the presence of a UAP. UAE was then performed, involving coil embolization of the feeder artery to stop the blood flow to the pseudoaneurysm. The use of these advanced imaging techniques for early diagnosis is commendable. The prompt intervention with UAE highlights the importance of swift and appropriate management in preventing life-threatening complications. The study emphasizes the role of dynamic CT and color Doppler ultrasonography in diagnosing UAP. These imaging modalities not only confirm the presence of UAP but also help in planning the treatment strategy by visualizing the feeder vessels and the extent of the aneurysm. In this case study, the UAE treatment was successful, with the patient experiencing an uneventful postoperative course and no recurrence of the UAP at follow-up six months post-procedure. The positive outcome adds to the growing body of evidence supporting UAE as a reliable treatment for UAP.

FUTURE DIRECTIONS AND CLINICAL RECOMMENDATIONS

To minimize the risk of UAP, careful attention should be paid to the techniques used during hysteroscopic procedures. This includes selecting appropriate instruments for cervical dilation and managing intrauterine pressure during surgery. Moreover, educating clinicians about the potential complications and their management can improve patient outcomes. The authors recommend that clinicians maintain a high index of suspicion for UAP in cases of unexplained genital bleeding post-surgery. Prompt use of ultrasonography and CT can facilitate early diagnosis. UAE should be considered a primary treatment modality due to its efficacy and relative safety. Future research should focus on developing standardized protocols for the early detection and management of UAP, particularly in advanced maternal age. Investigations into the optimal use of imaging modalities and the long-term outcomes of UAE are also warranted. Additionally, exploring less invasive methods for cervical dilation and hysteroscopy may help reduce the incidence of UAP.

CONCLUSION

The case report by Kakinuma et al[15] contributes significantly to understanding UAP management which includes the successful diagnosis and treatment using UAE in a 48-year-old primigravid, primiparous patient. It emphasizes the importance of prompt intervention and use of advanced imaging techniques. Future recommendations include developing standardized protocols for early UAP detection, focusing on advanced maternal age cases, and exploring less invasive surgical techniques to reduce UAP incidence. These efforts can significantly improve patient care and outcomes in gynecological practice.