Managing uterine artery pseudoaneurysm after myomectomy

A pseudoaneurysm is a blood-filled cavity communicating with the lumen of an artery, and the surrounding perivascular tissue creates the pseudoaneurysmal wall. Uterine artery pseudoaneurysm (UAP) may occur after surgical procedures such as Cesarean section1. UAP after myomectomy is considered a rare and potentially life-threatening event2. A 41-year-old woman with primary infertility, presenting with a single leiomyoma (8-cm diameter) on the right uterine wall and an endometrioma on the left ovary, underwent abdominal myomectomy and endometrioma resection in March 2017. Postoperative gonadotropin-releasing hormone agonist was used to avoid recurrence of endometriosis. At the routine follow-up visit 1 month after surgery, the patient was asymptomatic but transvaginal ultrasound revealed a pulsatile hypoechoic structure with a diameter of nearly 20 mm on the right myometrial wall. Pulsed-wave Doppler and bidirectional power Doppler (high-definition flow Doppler) confirmed UAP with turbulent arterial flow within the anechoic area. Three-dimensional ultrasound combined with high-definition flow enabled detailed morphologic characterization of the UAP. It was located on the right uterine isthmus with a reasonable margin of myometrium (> 10 mm) and hemoglobin was 12.6 g/dL; it was also possible to identify the ‘yin-yang sign’ (Figure 1, Videoclip S1). After discussing possible interventions, including uterine artery embolization, the patient opted for expectant management, with the recommendation to avoid heavy physical activity and sexual intercourse3. Ultrasound examination performed 1 week later showed partial thrombosis within the UAP; total resolution of the UAP was observed 1 month after diagnosis (Figure 2). Women diagnosed with UAP generally undergo uterine artery embolization, even when asymptomatic1; however, our case suggests that conservative management may be an option. Although UAP following myomectomy seems exceptionally rare based on case reports, a retrospective analysis showed that it might be much more common, affecting up to 1% of women undergoing myomectomy1, and the prevalence might be similar after other gynecological and obstetric interventions4. It is possible that the majority of cases of UAP resolve spontaneously, without ever being diagnosed. One of the problems with early diagnosis of UAP is the method used for diagnosis. Angiography (conventional or computerized tomography) is the preferred method, however, it requires ionizing radiation, involves a risk of a serious allergic reaction and is more expensive and less available than is ultrasound. We believe that systematic use of transvaginal ultrasound is pivotal for assessing the true prevalence of UAP, the rate of spontaneous resolution and complications, and also whether ultrasound can be used to predict massive bleeding. Suggestions of how to use different ultrasound modalities for the diagnosis and follow-up of UAP are described in Table 1. In addition to estimation of the true prevalence of UAP and the rate of spontaneous resolution, studies assessing the effectiveness and safety of conservative interventions, such as gonadotropin-releasing hormone agonists and transvaginal ultrasound-guided thrombin injection5, are important, particularly for women who wish to get pregnant. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.