{"paper_id":"07419730-aca4-4ba4-be34-576f088ef27d","body_text":"Vascular and Nonvascular Interventions in\nGynecology\nShowkat A. Banday 1 Kiran Gopinathan 2 Santhosh Poyyamoli 1 Bhawna Dev 2\n1 Department of Diagnostic and Interventional Radiology, Kovai\nMedical Center and Hospital, Coimbatore, Tamil Nadu, India\n2 Department of Radiology, Sri Ramachandra Institute of Higher\nE d u c a t i o na n dR e s e a r c h ,P o r u r ,T h i r u v a l l u r ,T a m i lN a d u ,I n d i a\nJ Gastrointestinal Abdominal Radiol ISGAR 2026;9:101 – 114.\nAddress for correspondence Kiran Gopinathan, DNB, Department of\nRadiology, Sri Ramachandra Institute of Higher Education and\nR e s e a r c h ,P o r u r ,T h i r u v a l l u r6 0 0 0 4 0 ,T a m i lN a d u ,I n d i a\n(e-mail: dr.kirangopinathan@gmail.com).\nIntroduction\nAdvancements in the field of radiology have revolutionized\nthe practice of medicine. In this era of technology, image-\nguided procedures are the standard of care wherever it is\nfeasible. It has the irrefutable advantage of being precise and\nminimally invasive while avoiding the morbidity and cost\nassociated with surgery, which is most often the alternative.\nIn gynecology, like elsewhere, image-guided interven-\ntions may be broadly classified into nonvascular and vascular\nKeywords\n► gynecology\n► interventional\nradiology\n► interventions\n► nonvascular\n► vascular\nAbstract Advancements in radiology have revolutionized medicine, making image-guided\nprocedures the standard of care due to their precision and minimally invasive nature.\nIn gynecology, these interventions are classi fied into nonvascular and vascular\nprocedures. Nonvascular interventions include diagnostic biopsies and therapeutic\nprocedures such as high-intensity focused u ltrasound, radiofrequency ablation (RFA),\nmicrowave ablation (MWA), cryoablation (CA), and sclerotherapy. Vascular interven-\ntions are primarily therapeutic, including uterine artery embolization (UAE), gonadal\nvein embolization (GVE), and iliac/renal vein stenting.\nNonvascular interventions can be performed via transabdominal, transvaginal, or\ntransrectal routes under ultrasound guidance, or transabdominal or transgluteal routes\nunder computed tomography guidance. Biop sies are used to evaluate complex adnexal\nmasses, while aspiration and drainage procedures manage ovarian cysts and pelvic\ncollections. Sclerotherapy is an alternative to laparoscopic cystectomy for ovarian\nendometriomas, and RFA, MWA, and CA are used for uterine fibroids and hepatic\nmetastasis in ovarian malignancies.\nVascular interventions, such as UAE, are effective for treating uterine fibroids and\nadenomyosis, offering a minimally invasive alternative to surgery. UAE reduces fibroid\nsize and alleviates symptoms, with a high success rate. UAE is moderately effective in\nproviding symptomatic relief in adenomyosis for patients who desire to preserve the\nuterus. Embolization is also used for managing bleeding in gynecological malignancies\nand treating pelvic venous disease (PeVD). GVE and pelvic varicosities sclerotherapy are\neffective for PeVD, while venous stenting addresses vein compression.\nImage-guided interventions provide safe and effective diagnostic and therapeutic\noptions for various gynecological conditi ons, improving patient outcomes and pre-\nserving fertility.\narticle published online\nDecember 3, 2025\nDOI https://doi.org/\n10.1055/s-0045-1813673.\nISSN 2581-9933.\n© 2025. The Author(s).\nThis is an open access article published by Thieme under the terms of the\nCreative Commons Attribution License, permitting unrestricted use,\ndistribution, and reproduction so long as the original work is properly cited.\n(https://creativecommons.org/licenses/by/4.0/)\nThieme Medical and Scienti fic Publishers Pvt. Ltd., A-12, 2nd Floor,\nSector 2, Noida-201301 UP , India\nTHIEME\nReview Article 101\nArticle published online: 2025-12-03\n\nprocedures. Nonvascular interventions can be further divid-\ned into diagnostic and therapeutic procedures. The former\nprimarily comprises biopsies, while therapeutic interven-\ntions include procedures such as high-intensity focused\nultrasound (HIFU), radiofrequency ablation (RFA), micro-\nwave ablation (MWA), cryoablation (CA), and sclerotherapy.\nAspiration/drainage procedures can serve both diagnostic\nand therapeutic purposes. Vascular interventions are essen-\ntially therapeutic in nature and include uterine artery em-\nbolization (UAE), gonadal vein embolization (GVE),\nsclerotherapy of pelvic varicosities, and iliac/renal vein\nstenting.\nNonvascular Interventions\nGynecological interventions can be done via transabdominal,\ntransvaginal, or transrectal route under ultrasound (US)\nguidance and via transabdominal or transgluteal route under\ncomputed tomography (CT) guidance. Local anesthesia is\nsufficient for most cases, using 2% lignocaine injection (or 2%\nlignocaine gel in case of transvaginal/transrectal route).\nIn deep-seated lesions where a safe window between\nbowel loops might be dif ficult to obtain on transabdominal\nUS, transvaginal/transrectal approach or CT guidance is\nrequired.\nBiopsies\nImage-guided biopsies in gynecology are primarily used in\nevaluating complex adnexal masses with documented spread\nsuch as malignant ascites, peritoneal deposits, or distant\nmetastases (\n►Fig. 1 ). This is due to the dreaded possibility\nof causing dissemination in an otherwise localized malignant\ntumor, especially in cystic neoplasms. Though this is sup-\nported only by anecdotal evidence in literature with more\nrecent studies deeming the risk to be theoretical,\n1,2 it is\nadvisable to avoid performing such procedures unless left\nwith no feasible alternative. Ovarian tumors without perito-\nneal spread can be biopsied if local invasiveness precludes\nsurgery and tissue diagnosis is required to initiate chemother-\napy. Image-guided biopsies are also very useful in the evalua-\ntion of omental and peritoneal deposits to confirm metastatic\ndisease.\nFig. 1 (A) Axial section of contrast-enhanced CT showing a large, complex abdominopelvic mass. ( B) Transabdominal US-guided biopsy done\nfrom the solid portion of the complex mass seen in ( A). (C) Axial T2-weighted MRI showing a left adnexal mass. ( D) Transvaginal US-guided biopsy\nd o n ef r o mt h em a s sl e s i o ns e e ni n(C) with the arrow pointing to the biopsy needle. CT, computed tomography; MRI, magnetic resonance\nimaging; US, ultrasound.\nJournal of Gastrointestinal and Abdominal Radio logy ISGAR Vol. 9 No. 1/2026 © 2025. The Author(s).\nInterventional Radiology in Gynecology Banday et al.102\n\n\nBiopsies can be performed using semiautomatic or auto-\nmatic devices (►Fig. 2 ). We prefer semiautomatic biopsy guns\n(18/20G /C2 16 cm) for transabdominal/transgluteal biopsies\nand automatic devices (18/20G /C2 25 cm) for transvaginal/\ntransrectal biopsies. Longer needles are required for endolu-\nminal procedures (along with a needle guide) to match the\nlength of the endoluminal probe.\nPercutaneous biopsies can be done in the in-plane or out-\nof-plane technique (\n►Fig. 3 ), though the former is preferred\nwherever possible as the entire length of the needle can be\nvisualized in a single frame.\nAspiration\nRadiological imaging plays a major role in the evaluation and\nmonitoring of ovarian cystic lesions, with guidelines in place\nproviding a detailed roadmap.\n3 Beyond diagnosis, the man-\nagement of these lesions has also come under the purview of\nradiology. Image-guided ovarian cyst aspiration is an estab-\nlished treatment of choice in pre- and perimenopausal\nwomen with persistent, symptomatic cysts that have no\nUS features of malignancy. In postmenopausal women, how-\never, cyst aspiration is not recommended, with the disease\nbest treated surgically, where possible, irrespective of US\nFig. 3 Graphic representation of ( A) in-plane technique and ( B) out-of-plane technique with the positioning of the needle relative to the\nultrasound probe shown above and the corresponding appearance on the ultrasound image shown below.\nFig. 2 (A) Semiautomatic biopsy gun kit (20G /C2 16 cm) and ( B)a u t o m a t i cb i o p s yg u n( 1 8 G/C2 25 cm) with an endoluminal ultrasound probe,\nneedle guide, and probe cover.\nJournal of Gastrointestinal and Abdominal Radi ology ISGAR Vol. 9 No. 1/2026 © 2025. The Author(s).\nInterventional Radiology in Gynecology Banday et al. 103\n\n\nappearance.4 Benign features on US include simple cysts,\ncysts with few thin ( <3 mm) smooth septations, diffuse low-\nlevel internal echoes, and absent internal vascularity. 3 Aspi-\nration should be avoided in complex/multilocular cysts and\ncysts with typical features of mature cystic teratoma. Endo-\nmetriotic cyst aspiration is controversial and percutaneous\npuncture should be avoided in the initial stages due to the\nrisk of pelvic adhesions. It can be attempted, preferably via\ntransvaginal approach, in patients with chronic pain who\nwish to retain their reproductive potential.\nTechnique is the same as in biopsies, with the choice of\napproach determined by the route, which gives the best\nvisibility of the cyst. We prefer the use of a spinal needle\n(18/20G, 9 cm) for transabdominal approach and Chiba\nneedle (18/20G, 20 cm) for transvaginal/transrectal aspira-\ntions (\n►Figs. 4 and 5).\nFig. 6 Axial ( A)a n ds a g i t t a l(B) sections of contrast-enhanced CT delayed phase showing a pelvic collection with an air fluid level in the\nrectouterine space with the bladder (white arrow) compressed anteri o r l y .An a r r o ww i n d o wi ss e e nb e t w e e nt h eb l a d d e ra n da d j a c e n tb o w e l\nloops through which a p igtail catheter ( C) was inserted under CT guidance. CT, computed tomography.\nFig. 4 (A) Chiba needle of 20/18 gauge and length 20 cm used for transvaginal/transrectal aspiration and ( B) 18G spinal needle used for\ntransabdominal aspiration.\nFig. 5 Transvaginal US images ( A)a n d( B) showing needle aspiration of an adnexal cyst with complete collapse of the cyst in ( C). US, ultrasound.\nJournal of Gastrointestinal and Abdominal Radio logy ISGAR Vol. 9 No. 1/2026 © 2025. The Author(s).\nInterventional Radiology in Gynecology Banday et al.104\n\n\nDrainage Procedures\nComplex pelvic collections such as abscesses with dense inter-\nnal echoes/debris have a high chance of recurrence/incomplete\ndrainage after simple needle aspiration. Image-guided place-\nment of drainage catheters is preferable in such collections 5\n(►Fig. 6). Prior to catheter placement, needle aspiration can be\ndone to confirm the presence of pus or to obtain samples for\ndiagnostic tests.\nPigtail catheters are widely used for drainage procedures.\nThey are available in two kits, one with a guidewire and serial\ndilator set and another with a metal trocar ( ►Fig. 7 ). The\nformer is introduced using the Seldinger technique, whereas\nthe latter is inserted via direct puncture.\nSclerotherapy\nSclerotherapy has emerged over the years as a promising\nalternative to laparoscopic cystectomy for the management\nof ovarian endometriomas due to concern over the risk of\nreduction in ovarian reserve associated with surgery. 6 It can\nalso be used to treat recurrent pelvic collections such as\nlymphoceles/seromas. Needle aspiration of endometriomas\nhas a high recurrence rate, and repeated aspirations increase\nthe risk of the development of pelvic adhesions.\nCatheter-directed sclerotherapy is preferred over direct\nneedle injection due to the risk of needle displacement and\nperitoneal spillage of the sclerosant. Similar to drainage cathe-\nter placement, an 8Fr pigtail catheter is inserted into the\nendometrioma either via Seldinger technique (using Chiba\nneedle, guidewire, and serial dilator) or direct puncture (using\ntrocar). The cyst contents are aspirated, and a cystogram (by\ninjecting radiopaque contrast material) is performed to confirm\nthe absence of peritoneal leak. Ninety- five percent ethanol is\nthen infused into the cyst at a volume of 25% of the aspirate\n(maximum dose of 100 mL).\n7 The patient is then made to\nchange positions intermittently, ensuring a 360-degree rota-\ntion, thereby allowing the sclerosant to mix well with any\nresidual contents and coat the cyst wall epithelium entirely.\nAfter 20 minutes, the injected ethanol is completely reaspi-\nrated, and the catheter is removed.\nRadiofrequency Ablation\nRFA is a minimally invasive, uterus-preserving procedure\nfor the treatment of symptomatic uterine leiomyomas. 8–10\nIt involves the placement of a specialized electrode under\nUS or CT guidance into the lesion, through which high-\nfrequency alternating current is passed, that causes agita-\ntion of surrounding molecules (\n►Fig. 8 ). This results in the\nproduction of heat, which at temperatures above 60°C\ncauses coagulative necrosis. A grounding pad is required\nfor the completion of the circuit. The volume of ablated\ntissue is dependent on the electrode design, the amount of\npower supplied, and its duration. The uniformity of ablation\ncan be limited by charring of tissue and proximity to vessels,\nthe so-called heat-sink effect. RFA may be preferred over\nuterine fibroid embolization (UFE) in cases where the\nfibroids are smaller and limited in number, and when\npreservation of fertility is of paramount importance, as\nevidenced by multiple documented healthy pregnancies\nin post-RFA patients.\n8 The requirement of an expensive\ncath-lab setup also limits the availability of UFE as a\ntreatment option. RFA has also been found to be of use in\nthe local control of hepatic metastasis in ovarian\nmalignancies.\n11\nMicrowave Ablation\nSimilar to RFA, MWA is a minimally invasive technique\nof thermal ablation. It uses microwave energy to generate\nheat that results in a much more rapid and homogeneous\nablative zone (\n►Fig. 8 ). The indications, technique of\nantenna placement, and safety pro file are similar to\nRFA.12– 14 However, unlike RFA, the thermal ef ficiency of\nMWA is less susceptible to the heat-sink effect and tissue\nimpedance due to charring. The use of grounding pads is\nnot required, thereby avoiding the risk of skin burns.\nMWA has also been found to produce larger ablation\nvolumes and less periprocedural pain.\n14 It is safe to use\nin patients with metallic devices such as pacemakers and\nsurgical clips, which are absolute contraindications for\nRFA.\nFig. 7 Pigtail drainage catheters ( A) with guidewire and serial dilator set and ( B)w i t ht r o c a r .\nJournal of Gastrointestinal and Abdominal Radi ology ISGAR Vol. 9 No. 1/2026 © 2025. The Author(s).\nInterventional Radiology in Gynecology Banday et al. 105\n\n\nHigh-Intensity Focused Ultrasound\nHIFU is a completely noninvasive method of thermal ablation\nwhere US energy is focused in short or continuous pulses\nover a target area, resulting in the production of heat and\ncoagulative necrosis. It is used to treat symptomatic uterine\nfibroids as an alternative to myomectomy or hysterectomy.\n15\nHIFU systems can be either US-guided (USgFUS) or MRI-\nguided (MRgFUS). MRgFUS systems are more expensive but\nprovide higher spatial and tissue contrast resolution for\ntreatment planning and proton resonance frequency shift\nthermometry for intraprocedural monitoring (\n►Fig. 9 ). HIFU\nhas been found to result in shorter hospital stays, lower\ncomplication rates, and higher postprocedural pregnancy\nrates compared with UAE, while producing symptom reduc -\ntion comparable to surgery.\n16\nCryoablation\nCA is another uterine-sparing ablation technique which,\ncontrary to RFA and MWA, utilizes the effect of rapid cooling\n(up to /C0 40°C) to destroy tissue. It works on the principle of the\nJoule–Thomson effect, which refers to the drop in temperature\nattained when pressurized gas is forced through a valve, result-\ning in rapid expansion. Cryoprobes typically employ the use of\nargon and helium gases with a standard procedure requiring\nmultiple freeze-thaw cycles that can be time consuming. It has\nbeen found to be as safe and effective as microwave and RFA\nwith the added advantage of the ability to visualize the ablation\nzone in real time in the form of an ice-ball formation.\n17 This is\nvery helpful, both in planning further cycles to overcome\nunderablation of the lesion and in stopping the procedure if\nthe ablation zone has reached too close to a vital structure. Like\nin RFA, proximity to vessels can result in a “cold-sink effect.”\n17\nCA has been associated with less intraprocedural pain than\nMWA.18 It has been found to be effective in the treatment of\nsubserosalfibroids, which are resistant to UAE.19 Similar to RFA\nand MWA, it can be used to treat limited hepatic metastasis in\novarian cancers.20\nVascular Interventions\nPercutaneous vascular embolization is a highly effective ther-\napeutic approach for treating various gynecological condi-\ntions. This minimally invasive technique eliminates the need\nfor surgery and extended hospital stays, thereby reducing\nmorbidity and overall cost while preserving the patient ’s\npotential for future fertility.\nFig. 8 (A) Multipronged RFA electrode, ( B) microwave antenna with port for cold saline infus ion (black arrow), transabdominal US images ( C)\nand ( D) showing RFA electrode tip within a fibroid ( C)p r e -a n d( D) postablation. Multiple hyperchoic foci with postacoustic dirty shadowing\n(white arrow) noted within the fibroid in image ( D), suggestive of gas bubbles formed during the ablation process. RFA, radiofrequency\nablation; US, ultrasound.\nJournal of Gastrointestinal and Abdominal Radio logy ISGAR Vol. 9 No. 1/2026 © 2025. The Author(s).\nInterventional Radiology in Gynecology Banday et al.106\n\n\nA comprehensive understanding of pelvic vascular anatomy\nis crucial for optimizing outcomes in transcatheter emboliza-\ntion procedures, especially in gynecologic interventions.\nTranscatheter embolization is utilized both for emergent\ncontrol of pelvic and vaginal hemorrhages, as well as elective\ntreatment of uterine fibroids and pelvic congestion syndrome.\nThis technique is effective in managing bleeding complications\nresulting from various gynecological conditions, including\nbenign conditions, advanced-stage cancer, and complications\nfrom gynecologic -obstetric surgeries.\n21\nTranscatheter embolization is performed in an angiogra-\nphy suite with digital subtraction angiography capabilities or\nin an operating room equipped with similar angiographic\ntechnology. To manage pain and reduce anxiety, moderate\nsedation is administered intravenously using short-acting\nnarcotics and benzodiazepines. After sterile preparation of\nthe planned puncture site, the common femoral artery or\nradial artery is accessed utilizing a single-wall puncture\ntechnique. A 4- or 5-French short sheath is then introduced\nto maintain the access (\n►Fig. 10 ).\nTranscatheter embolization procedures are either per-\nformed via a transarterial route, such as UFE, or a transvenous\nroute, such as gonadal vein (GV) and pelvic vein embolization\nin pelvic venous disorders (PeVDs).\n21\nThe procedure is usually preceded by cross-sectional imag-\ning, which helps assess the vascular pathology and anatomy to\nFig. 9 HIFU procedure. ( A) Pretreatment sagittal T2-weighted image with arrows pointing to subserosal and submucosal uterine fibroids. ( B)\nPretreatment contrast-enhanced T1 fat-saturated image showing homogeneous enhancement within the submucosal fibroid. ( C)T r e a t m e n t\nplanning ( D) postprocedure contrast-enhanced T1 fat-saturated image showing nonenhancement of the submucosal fibroid. HIFU, high-\nintensity focused ultrasound.\nJournal of Gastrointestinal and Abdominal Radi ology ISGAR Vol. 9 No. 1/2026 © 2025. The Author(s).\nInterventional Radiology in Gynecology Banday et al. 107\n\n\nplan the procedure. Typically, a 4- or 5-French selective angio-\ngraphic catheter is used to access the internal iliac arteries, while\na 2- or 3-French microcatheter and microwire may be employed\nfor selective catheterization of smaller branches ( ►Fig. 10 ).\nOnce extravasation or another pathological condition is identi-\nfied, the catheter is optimally positioned for embolization. The\nchoice of embolic material depends on the indication. Transient\nbut urgent pathologies such as postpartum hemorrhage will\nneed swift, nonselective embolization using a nonpermanent\nagent (Gelfoam). At the same time, elective pathologies such as\nfibroid or adenomyosis require permanent particulate embolic\nagents (polyvinyl alcohol [PVA] or Embospheres). Focal pathol-\nogies such as pseudoaneurysms, require liquid (N-butyl cyano-\nacrylate) or mechanical agents (coils) (\n►Fig. 11 ). These agents\nand sclerosants (sodium tetradecyl sulfate) are used during GVE\nfor pelvic venous disease (PeVD).\n21,22\nIdentification of the uterine artery, which is one of the\ninitial branches of the anterior division of the internal iliac\nartery, is relatively easy due to its typical morphology.\nFrom lateral to medial, there are three portions: the\ndescending, transverse, and ascending portions. The as-\ncending segment, which courses along the body of the\nuterus, has a typical corkscrew appearance, which, when\nhypertrophied, becomes quite evident on the angiograms.\nThe origin is pro filed in the ipsilateral oblique projections\n(\n►Fig. 12 ). Due to the abundant collateral supply of the\nuterus, uterine necrosis from UAE is uncommon. 15 Trans-\nradial access is gaining traction worldwide as a favored\nroute in view of patient comfort, early mobilization, re-\nduced complications, and potentially reduced costs.\nTransarterial Procedures\nUterine Fibroid Embolization\nUterine fibroids are the most prevalent benign tumors of the\npelvis, affecting approximately 20 to 40% of women of\nreproductive age. 23 These fibroids can be asymptomatic\nand may be discovered incidentally during routine pelvic\nUSs.23 However, they can also lead to a range of symptoms,\nwith the most common being menorrhagia or dysmenor-\nrhea. Other possible symptoms include urinary urgency,\nconstipation, infertility, and pain, all of which necessitate\ntreatment.\nUFE is a minimally invasive treatment option, an alternative\nto surgical options such as myomectomy and hysterectomy,\nparticularly for patients who prefer to preserve their uterus.\n24\nUterine fibroids are commonly initially detected on trans-\nvaginal or transabdominal pelvic US. Contrast-enhanced mag-\nnetic resonance imaging (CE MRI) helps determine the exact\nsize, location, and number of fibroids and their enhancement\npatterns (\n►Fig. 13A –C). It also rules out other potential causes\nof a patient’s symptoms.\nA higher T2 signal intensity and greater postcontrast\nenhancement correlate with improved success rates follow-\ning UFE. 25 Additionally, the type of fibroid can signi ficantly\nimpact clinical outcomes. For example, pedunculated and\nsubserosal fibroids are linked to higher rates of complica-\ntions such as expulsion of submucosal fibroids and necrosis\nor detachment of pedunculated subserosal fibroids. Under-\nstanding these factors is vital for optimizing patient care and\nimproving treatment outcomes. 15\nFig. 10 Photograph shows standard hardware used for transfemoral uterine artery embolization. ( A) A 5-French femoral access short sheath,\n(B) 5-French Roberts uterine artery catheter, ( C) angled hydrophilic guide wire, and ( D)m i c r o c a t h e t e r .\nJournal of Gastrointestinal and Abdominal Radio logy ISGAR Vol. 9 No. 1/2026 © 2025. The Author(s).\nInterventional Radiology in Gynecology Banday et al.108\n\n\nContraindications to UFE include viable pregnancy, active\npelvic infections, gynecologic malignancy, severe renal dys-\nfunction, and uncorrectable coagulopathy. Additionally, sub-\nmucosal and pedunculated subserosalfibroids are considered\nrelative contraindications.\nUFE is typically performed via the common femoral artery\nutilizing a 5-French short sheath (\n►Fig. 10A ). Selective\ncannulation of the common iliac and internal iliac arteries\nis achieved using a dedicated Roberts uterine artery catheter.\nAfter successfully cannulating the uterine artery, a micro-\ncatheter may be advanced past the cervicovaginal branch of\nthe uterine artery, and UFE is performed using PVA particles\n(500–700 µm) until stasis, indicated by stasis in 5 to 10\ncardiac cycles. The ipsilateral iliac arteries are accessed by\ncreating a Waltman ’s loop, and embolization is performed\nsimilarly to the contralateral side\n25 (►Fig. 13 ).\nPostprocedure management after UFE is an important\npart of patient care; it focuses on controlling symptoms\nrelated to acute ischemia of the uterus and fibroids and\naddressing postembolization syndrome. Patients may expe-\nrience abdominal cramps, nausea, and pain, which can start\nimmediately after the procedure and persist during recovery.\nA multimodal regimen of acetaminophen, nonsteroidal anti-\ninflammatory drugs, and opioids is utilized for effective pain\nmanagement following the procedure. Additionally, adju-\nvant techniques such as hypogastric nerve blocks and intra-\narterial lidocaine administered during embolization may\nenhance pain control. Antiemetics are also used to address\nFig. 11 Embolic agents commonly used in gynecological conditions. ( A) Absorbable gelatin sponge packet (Gelfoam). ( B)0 . 0 1 8″ pushable\nfibered coil. ( C) n-Butyl cyanoacrylate glue (1 mL) and lipiodol vial. ( D) Polyvinyl alcohol particles (500 – 710 µm) vial.\nFig. 12 Ipsilateral oblique image from selective right internal iliac artery\ndigital subtraction angiography shows characteristic “U”-shaped course\nof uterine artery consisting of descending segment (thin arrow),\ntransverse segment (arrowhead), and distal ascending segment\n(thick arrow), which has a typical corkscrew appearance.\nJournal of Gastrointestinal and Abdominal Radi ology ISGAR Vol. 9 No. 1/2026 © 2025. The Author(s).\nInterventional Radiology in Gynecology Banday et al. 109\n\n\nnausea and vomiting as part of postembolization syndrome\nmanagement.25,26\nUAE has shown promising results for women with uter-\nine fibroids. Patients experience a signi ficant reduction in\nfibroid size, typically between 50 to 60%. Additionally,\naround 88 to 92% of women report relief from bulk symp-\ntoms, and more than 90% eliminate uterine bleeding. Over-\nall, about 75% of patients see an improvement in their\nsymptoms.\n27\nComplications associated include prolonged vaginal dis-\ncharge (2 –17%), fibroid expulsion (3 –15%), or, in rare cases,\nsepticemia (1–3%). In patients desiring preservation of fertility,\nmyomectomy is preferred over UFE due to a perceived fear of\ninfertility after the latter procedure, although no robust data\nare available.\n28,29\nRecent studies and trials have provided insights into the\nefficacy and safety of UAE compared with other treatments\nsuch as myomectomy. The FEMME study, a randomized\ntrial, compared UAE and myomectomy, finding that both\ntreatments resulted in similar quality of life improvements.\nHowever, myomectomy had a slight edge in fibroid-related\nquality of life at 2-year follow-up, whereas UAE was associ-\nated with fewer complications, shorter hospital stays, and\nquicker return to work. There was no signi ficant difference\nin the pregnancy rates or outcomes between UAE and\nmyomectomy.\n30\nThe EMMY trial, with a 10-year follow-up, showed that\nUAE and hysterectomy had similar health-related quality of\nlife outcomes. However, 35% of UAE patients eventually\nrequired a hysterectomy due to persistent symptoms. 31\nUAE is also effective for treating pedunculated fibroids\ndespite initial concerns about complications such as fibroid\ntorsion. Studies have shown that UAE can safely treat these\nfibroids, with a high symptom resolution rate and low\ncomplication rates. 21\nOverall, the UAE is a valuable option for women seeking\nuterine preservation, offering a minimally invasive alterna-\ntive with comparable outcomes to surgical options.\nUterine Artery Embolization in Adenomyosis\nAdenomyosis is the abnormal presence of endometrial tissue\nwithin the uterine myometrium with associated hypertro-\nphy and hyperplasia of the stromal myometrium. This con-\ndition predominantly affects women aged 41 to 45 years,\nwith an incidence rate of 1% and a prevalence of 0.8%.\nAdenomyosis can present as either focal or diffuse, and it\nis typically diagnosed using US and MRI. US findings often\ninclude a thickened endometrium, disruption of the endo-\nmetrial–myometrial interface, and the presence of cysts\nwithin the myometrium. A thickened junctional zone ex-\nceeding 12 mm on MRI is a key diagnostic criterion for\nadenomyosis on MRI.\nFig. 13 UFE performed using a transfemoral approach in a 43-year-old woman with menorrhagia due to a uterine fibroid. ( A–C)P e l v i cc o n t r a s t -\nenhanced MRI showing enhancing intramural posterolateral wall uterine fibroid (thin arrows). Selective DSA of left ( D)a n dr i g h t(F)\nuterine arteries performed using 5-French RUC showing hypertrop hied tortuous uterine arteries (arrow heads). Bilateral uterine fibroid\nembolization was performed using 500 to 700 µm PVA particles, and ( E, G ) post-UFE angiogram images show stasis in uterine arteries\n(thick arrows). DSA, digital subtraction angiography; MRI, magnetic resonance imaging; RUC, uterine artery catheter; PVA, polyvinyl alcohol;\nUFE, uterine fibroid embolization.\nJournal of Gastrointestinal and Abdominal Radio logy ISGAR Vol. 9 No. 1/2026 © 2025. The Author(s).\nInterventional Radiology in Gynecology Banday et al.110\n\n\nIf the patient has menorrhagia or dysmenorrhea, which is\nmedication resistant, invasive treatment options have to be\nconsidered. Hysterectomy remains the primary treatment\noption for de finitive management, while UAE serves as an\nalternative strategy for patients wishing to preserve their\nuterus. However, UAE for adenomyosis has demonstrated\nlower ef ficacy than UFE. Recent studies indicate that the\nUAE’s success and satisfaction rates for treating adenomyosis\nrange from 60 to 70% and 72 to 94.3%, respectively. 28\nThe technique of UAE is similar to UFE, except that emboli-\nzation is started with smaller particles with progressively\nincreased particle size using the 1-2-3 protocol (150 –250,\n250–355, and 355 –500 µm PVA) ( ►Fig. 14 ). This protocol\naims to embolize the distal vessels and induce necrosis in\nthe abnormal endometrial tissue.32\nEmbolization in Gynecological Malignancies\nEmbolization may be appropriate in patients with locally\nadvanced uterine malignancies with intractable bleeding\nwhen conservative local treatments are ineffective (\n►Fig. 15 ).\nBleeding control within 24 hours occurs in 95% of patients after\na pelvic vessel or UAE.33,34 Permanent embolic agents such as\ncoils and liquid agents are preferred due to their durable\nembolic effect and ability to prevent the recurrence of bleeding.\nPelvic Venous Disease\nPeVD is a spectrum of symptoms and signs arising from\ndysfunction in the pelvic veins and their drainage pathways.\nPeVD is characterized by noncyclic pelvic pain, dyspareunia,\ndysmenorrhea, and extrapelvic symptoms due to venous\nreflux, varices, or obstruction.\n22\nThe pelvic venous system includes the uterine, ovarian,\nand internal iliac veins (IIVs), which drain blood from the\nuterus and surrounding structures into the inferior vena cava\n(IVC). The left GV drains into the left renal vein, and the right\nGV drains into the IVC. Venous incompetence, often due to\nvalve dysfunction or compression, leads to retrograde flow in\nthe veins, which in turn causes venous hypertension and\nvariceal formation in venous reservoirs. The PeVD primarily\nresults from three pathophysiological mechanisms: ovarian\nvein reflux, compression of the left iliac vein (May –Thurner’s\nsyndrome), and the left renal vein (nutcracker syndrome).\n35\nPeVD symptoms include noncyclic chronic pelvic pain,\npostcoital pain, and vulvar or lower extremity varices. The\nsymptoms are aggravated by standing and become more\nsevere by the end of the day. Transvaginal and transabdo-\nminal US and time-resolved magnetic resonance venography\nare key for diagnosing PeVDs and ruling out other pelvic\npathologies. Key findings on US are dilated GVs (size > 6m m )\nFig. 14 Uterine artery embolization for adenomyosis in a 38-year-old woman with menorrhagia, dysmenorrhea, and anemia not responding to\nmedical management. ( A, B ) Pelvic MRI T2 sagittal and axial images show adenomyosis i n the posterior uterine wall (thin arrow). Selective left\n(C)a n dr i g h t(D) uterine artery DSA images show hypertrop hied tortuous uterine arteries. Bilateral uterine artery embolization was done\nusing 300- to 500-µm PVA particles. A microcatheter was used on the ri ght side (arrow). The DSA image after embolization shows stasis in the\nright uterine artery ( E, thick arrow). On 1-year follow-up, the patient had symptomatic improvement with a reduction in the uterus size\non transvaginal sonography ( F). DSA, digital subtraction angiography; MRI, magnetic resonance imaging; PVA, polyvinyl alcohol.\nJournal of Gastrointestinal and Abdominal Radi ology ISGAR Vol. 9 No. 1/2026 © 2025. The Author(s).\nInterventional Radiology in Gynecology Banday et al. 111\n\n\nFig. 16 Left gonadal vein embolization in a 39-year-old multiparous woman wi th noncyclic chronic pelvic pain worsening on standing for 1 year.\n(A) TVS shows dilated parametrial veins with re flux on Valsalva (thin arrow). ( B) Venous phase contrast CT pelvis image shows bilateral dilated\ntortuous parametrial veins (thin arrows). ( C) A transjugular venographic image shows selecti ve catheterization of the left ovarian vein with\nreflux in the vein and pelvic varicosities (thick arrows). ( D, E ) Glue embolization of pelvic varicosities and coil þ glue embolization of the left\ngonadal vein (arrowhead) were performed. ( F) Subtracted venographic image of left ovarian vein following embolization shows complete\nocclusion and absence of re flux (thin black arrow).\nFig. 15 Embolization of the uterine artery for massive vaginal bleeding in a 54-year-old woman with advanced-stage inoperable cervical cancer.\n(A) Aortic bifurcation angiogram shows active contrast extravasation from the right uterine artery (arrow). ( B) Postembolization angiogram\nshows occlusion of the right uterine artery (arrowhead).\nJournal of Gastrointestinal and Abdominal Radio logy ISGAR Vol. 9 No. 1/2026 © 2025. The Author(s).\nInterventional Radiology in Gynecology Banday et al.112\n\n\nwith retrograde flow on Valsalva, pelvic varices, and venous\nstenosis.35,36\nCatheter-directed venography is a de finitive diagnostic\ntool for PeVDs. Characteristic findings include an ovarian\nvein diameter >6 mm, contrast retention >20 seconds, pelvic\nvenous plexus congestion, opaci fication of the ipsilateral or\ncontralateral internal iliac vein, and/or filling of vulvovaginal\nor thigh varices. 35\nTranscatheter embolization is an effective treatment op-\ntion for PeVD. Its success rate is 98 to 100%, and symptom\nimprovement is 80 to 93% in patients at 5 years. The\ncomplication and recurrence rates are low.\n1. Gonadal vein embolization (GVE) ( ►Fig. 16 ):\nGVE is indicated in patients with gonadal venous re flux\nand is performed through a transjugular or transfemoral\napproach using coils, sclerosants, or both, with technical\nsuccess of 96.7 to 100% and clinical success of 90 to\n100%.\n37\nGVE is a safe procedure. Rare adverse events include\npulmonary embolism or coil migration. Recurrence of\nsymptoms (15%), however, is not uncommon.\n2. Pelvic varicosities sclerotherapy ( ►Fig. 16D ):\nGV re flux is associated with pelvic varicosities and is\ntreated with sclerotherapy using sclerosant foam (3%\nsodium tetradecyl sulfate). Coils are avoided because of\nthe risk of coil migration.\n37\n3. Venous stenting ( ►Fig. 17 ):\nFor patients with a suspected primary cause of PeVD due\nto compression of either the iliac or renal veins, stenting of\nthe stenosed or compressed vein, preferably by a dedicat-\ned venous stent, is the treatment option with a technical\nsuccess rate of 94 to 100%. Intravascular US is superior to\nvenography for grading stenosis severity, determining the\nexact site of stenosis, and guiding the sizing of the stent.\nComplications such as bleeding, stent migration, and\nthrombosis can occur. Venous stenting is effective for\nstenosis-related symptoms; however, the long-term out-\ncome is less studied.\n38\nConclusion\nImage-guided interventions provide a minimally invasive\ndiagnostic and therapeutic option for various gynecological\nconditions, as outlined earlier. Drainage catheters can be safely\nplaced into deep-seated pelvic collections under image guid-\nance. The solid viable portion of complex adnexal masses can\nbe accurately targeted during biopsies, thereby signi ficantly\nimproving diagnostic yield. Embolization of the uterine artery\nand image-guided ablation procedures have been proven to be\nas effective as surgery for uterine fibroids and adenomyosis.\nGVE with or without iliac vein stenting is safe and effective for\nthe spectrum of PeVD.\nConflict of Interest\nNone declared.\nReferences\n1 Griffin N, Grant LA, Freeman SJ, et al. Image-guided biopsy in\npatients with suspected ovarian carcinoma: a safe and effective\ntechnique? 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