The uterine artery is usually a branch off the internal iliac artery (anterior division), and can be recognized by its characteristic location and its strikingly serpiginous distribution. It frequently anastomoses with the nearby ipsilateral ovarian artery (which originates more distantly from the aorta, just below the renal arteries (or occasionally from the renal arteries). This anastomosis can become significant in embolization procedures. Occasionally, the ovarian artery may supply a large portion of the uterus, leading to incomplete embolization. Nontarget embolization from the uterine artery to the ovary, leading to premature ovarian failure is also an important consideration.
The arterial anastomoses between the uterine artery and ovarian artery has been shown to be less than 500 microns normally, and use of embolization particles larger than this may help prevent nontarget embolization of the ipislateral ovary.
|Selective arteriogram of the right uterine artery in preparation for embolization of adenomyosis|
What is a good catheter approach for the uterine artery embolization (or other branches of the internal iliac artery)? One can approach it ipsilaterally or contralaterally to try to maneuver the catheter into the internal iliac artery orifice, and then subselectively approach the uterine artery.
- catheter: 4Fr Cobra-1 catheter (some have described using up to 6Fr), with coaxial 3Fr microcatheter approach for embolization
- guidewire: 70 degree gold-tip 0.018" glidewire
- injection rate/volume: 3-5 ml/sec, total 6-10 ml
- filming: 8 @ 1 fps, AP and 30 degree oblique
The microcatheter is advanced into the transverse or horizontal position of the uterine artery several cm beyond the uterine artery origin, distal to cervicovaginal branches.
A flush abdominal aortogram after the embolization procedure is not necessary on a routine basis, but occasionally can reveal significant ovarian artery contributions to a fibroid uterus, and can be pursued if there is suspicion on the subselective uterine artery arteriograms
|Waltman loop (ref 4)|
In 1% of women, the uterine artery anatomy is nonstandard, and in this group, it often originates from the ipsilateral ovarian artery.
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2. "Diagnostic Angiography" Kadir S. (1986)
3. Gonsalves, C. "Uterine Artery Embolization for Treatment of Symptomatic Fibroids" Seminars in Interventional Radiology. Vol 25:4 (2008)
4. Worthington-Kirsch RL, Andrews RT, Siskin GP, "II. Uterine fibroid embolization: Technical Aspects" Techniques in Vascular and Interventional Radiology Volume 5, Issue 1, March 2002, Pages 17–345. Schirf BE, Vogelzang RL, Chrisman HB. "Complications of Uterine Fibroid Embolization" Seminars in Interventional Radiology. Vol 25:4 (2008).
6. Katz MD, Sugay SB, Walker DK, et al. "Beyond Hemostasis: Spectrum of Gynecologic and Obstetric Indications for Transcatheter Embolization" RadioGraphics. (2012) 32:1713-1731.