Three-Dimensional Rotational Angiography in Uterine Fibroid Embolization: Redefining Care with Enhanced Visualization and Accuracy
Dr. Sandeep Burathoki, DM, Interventional Radiologist
Ajeesha Isha, Cardiovascular Technician Supervisor
Aster Hospital, Dubai, UAE

Uterine Fibroid Embolization is an established, non-surgical treatment option for symptomatic uterine fibroids. Safe delivery of embolic agent requires distal catheterization of both uterine arteries, avoiding non-target embolization. There are frequent anatomical variations of pelvic artery anatomy. Sometimes it is difficult to visualize the origin of uterine artery.

In this case report, we demonstrated feasibility of using three-dimensional rotational angiography (Dyna3D) to guide distal uterine artery (UA) catheterization and enable the reduction of radiation dose.

38-year-old female presented with:

• Heavy menstrual bleeding
• Severe pelvic cramps
• Lethargic and easy fatigability
• Severe Anemia
• Lower back pain

On physical examination

• Non-tender, firm lump at infra-umbilical region arising from pelvis corresponding to 20 weeks uterus.

MR imaging

• MRI Pelvis with contrast showed large intramural-subserosal  fibroid (8.7 cm x 6.0 cm) at fundal region.

Materials and Methods

Under local anesthesia via right femoral route, 6F short sheath placed at right femoral artery. Under fluoroscopy guidance,5F Cobra glide catheter (Terumo) was navigated to left internal iliac artery (IIA). Initial left IIA injections in standard AP and contralateral oblique (right anterior oblique) were obtained. However, origin of left uterine artery was seen overlapping with other pelvic branches of left IIA.

Three-dimensional rotational angiography of left IIA performed using 3-DSA Body protocol on Siemens Healthineers ARTIS Q with PURE. Total 24 ml of contrast volume was used at flow rate of 3 ml/s. 

RA depict the anterior origin of uterine artery from anterior division of left IIA. Smart roadmap was obtained in that projection and distal catheterization of left uterine artery done using 2.7 Progreat microcatheter. 

Abnormal peri-fibroid vascular plexus were embolized using 3 vials of Embosoft particles (500-700 mic).

Then, we catheterize ipsilateral (right) IIA anterior trunk using 5 F Cobra catheter and after standard AP projection, we obtained Dyna3D. On the right side too, anterior origin of Uterine artery nicely demonstrated on Dyna3D and working projection was chosen accordingly. Similarly, super selective catheterization of right uterine artery obtained using road map fluoroscopy and embolization performed.

Successful Uterine Fibroid Embolization requires distal catheterization of each uterine artery, placing micro-catheter tip at horizontal segment of uterine artery, distal to cervico-vaginal artery, to avoid non-target embolization of vaginal artery.

Uterine Arteries most frequently arise from anterior division of left internal iliac artery. There is wide variation in pelvic artery anatomy and variability in the site of origin of uterine artery. Most commonly, uterine artery arises as first branch of inferior gluteal artery (46%). In others, it arises as second or third branch of inferior gluteal artery (6%), as trifurcation off the internal artery (43%) or as first branch of internal iliac artery (6%). 

Three-dimensional rotational angiography performed on the ARTIS Q system helped to achieve the best working position. 

Frequently, 20–30-degree contralateral obliques demonstrate the uterine artery origin. Sometimes, it’s difficult to visualize the origin of uterine artery on conventional two-dimensional images, especially if there is anterior origin of uterine artery from anterior division of IIA. Also, vessels overlapping or foreshortening, loop or kink at proximal descending segment uterine artery could be responsible for sub-optimal visualization and difficult catheterization. This would increase duration of procedure and radiation exposure to ovaries.

We demonstrated that three-dimensional rotational angiography (Dyna3D) is very helpful in obtaining optimal working position, guiding distal uterine artery (UA) catheterization and reducing the working time.

Conclusion

Three-dimensional rotational angiography facilitates UA catheterization and should be incorporated in uterine fibroid Embolization procedure as standard of practice.