the management of PA is a safe and feasible technique with results that include mitigating blood loss during hysterectomy, decreasing transfusion requirements and potential ICU length of stay for patients.1,4


While studies such


as these provide us with valuable insight on UAE outcomes for PA, there is still insufficient literature at this time that compares hysterectomy to UAE overall as primary management of PA.9


Furthermore, in evaluating a patient for UAE treatment, it is also worth mentioning that, while a plethora of data exists in the domain of UAE for UFE, publications caution against extrapolating UFE techniques to UAE in the setting of PA.4


This is mainly


due to the timing of delivery, higher thrombotic state of pregnancy and the frequent additional targets of PA embolization.4


shunting, which may be present as a result of previous gynecological procedures, should also be assessed as this can also contribute to postpartum hemorrhage and has been show to safely respond to absorbable gelatin powder.12


In summary, while the use of UAE has proven effective in treatment of fibroids, AV uterine shunting and peri- and postpartum hemorrhage, its role in encouraging involution and preserving uterine reproduction remains an area of ongoing investigations.9,4,10,11


References For example, in a study


of prophylactic embolization of the uterine arteries in the peri-operative management of PA, 31 of 83 patients (37%) who underwent embolization required embolization of additional arteries other than the uterine vessels. These may include the vesical or vaginal arteries if these vessels provide significant uterine vascular supply pre-operatively.4


In UFE, there is


occasionally ovarian arterial supply to the uterus and fibroids; however, this occurs in roughly 5% of patients.2


Embolic agent choice in UAE arises as a central question in this particular case and for UAE in general. When analyzing UAE for fibroids, two of the typical embolic agents are polyvinyl alcohol (PVA) and microspheres.2 Absorbable gelatin powder particles dissolve 3–4 weeks after use and have been utilized as an embolic agent in the setting of uterine arterial hemorrhage.9,10


This agent


is ideal in its ability to temporarily interface with the uterine vascular bed with minimal complications while also maintaining uterine function,10 however there are no overt studies directly comparing the effects of embolics on reproductive outcomes.12 Postprocedure embolization complications may include fever, infection, transient foot or buttock ischemia, iliac thrombosis and uterine necrosis.11


Arteriovenous


1. Wang M, Ballah D, Wade A, Taylor AG, Rizzuto G, Li B, Lucero J, Chen LM, Kohi MP. Uterine artery embolization following cesarean delivery but prior to hysterectomy in the management of patients with invasive placenta. J Vasc Interv Radiol. 2019;30(5):687–691.


2. Spies J. Uterine Fibroid Embolization. Handbook of Interventional Radiologic Procedures, by Krishna Kandarpa et al., Lippincott Williams & Wilkins, 2016:475–482.


3. ACOG Practice Bulletin No. 96: Alternatives to hysterectomy in the management of leiomyomas. Obstetrics & Gynecology. 2008;112(2):387–400.


4. Izbizky G. Feasibility and safety of prophylactic uterine artery catheterization and embolization in the management of placenta accreta. J Vasc Interv Radiol. 2015;26(2):162–69.


5. Cheung CS, Chan BC. The sonographic appearance and obstetric management of placenta accreta. Int J Womens Health. 2012;4:587–594.


6. Steins Bisschop CN, Schaap TP, Vogelvang TE, Scholten PC. Invasive placentation and uterus preserving treatment modalities: A systematic review. Arch Gynecol Obstet. 2011;284(2):491–502


7. Cahill, AG. Placenta accreta spectrum. Am J Obstet Gynec. 2018;219(6)B2–16.


8. Sentilhes L, Ambroselli C, Kayem G, et al. Maternal outcome after conservative treatment of placenta accreta. Obstet Gynecol. 2010;115(3):526–534.


9. Noufaily A. Uterine artery embolization for management of placenta accreta, a single- center experience and literature review. The Arab J Interv Radiol. 2017;1(1):37.


10. Corr P. Arterial embolization for haemorrhage in the obstetric patient. Best Pract Res Clin Obstet Gynaecol. 2001;15(4):557–61.


11. Huang KL, Tsai CC, Fu HC, Cheng HH, Lai YJ, Hung HN, Tsang LLC, Hsu TY. Prophylactic transcatheter arterial embolization helps intraoperative hemorrhagic control for REMOVING invasive placenta. Journ Clin Med. 2018; 7(11):460.


12. Camacho A, Ahn EH, Appel E, et al. Uterine artery embolization with Gelfoam for acquired symptomatic uterine arteriovenous shunting. J Vasc Interv Radiol. 2019;30(11):1750–1758.


Disclaimer: This column represents the work and opinions of the contributing authors and do not necessarily reflect the views or policies of SIR. SIR assumes no liability, legal, financial or otherwise, for the accuracy of information in this article or the manner in which it is used. The statements made in the column are not intended to set a standard of care and should not be treated as medical advice nor as a substitute for independent, professional judgment.


sirweb.org/irq | 37


patients 45


treated with UAE demonstrated a secondary hysterectomy rate of 18%, menstruation rate of


62%, and subsequent pregnancy rate of 15% with full survival rate in all patients.5,6


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