Uterine Artery Embolization Failure Secondary to Collateral Parasitization from Celiac and Superior Mesenteric Arterial Branches: A Case Report and Literature Review

Uterine Artery Embolization Failure Secondary to Collateral Parasitization from Celiac and Superior Mesenteric Arterial Branches: A Case Report and Literature Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Uterine Artery Embolization Failure Secondary to Collateral Parasitization from Celiac and Superior Mesenteric Arterial Branches: A Case Report and Literature Review Haidara A. Almansour, Mohammadhossein Ghasempourabadi, Darren Klass This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7172065/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: To present a rare case of uterine artery embolization (UAE) failure due to collateral arterial supply from the celiac axis and superior mesenteric artery (SMA), and to review the diagnostic and interventional considerations in such presentations. Case Presentation: A 41-year-old woman with symptomatic fibroids underwent bilateral UAE. Follow-up imaging showed persistent vascularity of a dominant 20 cm fibroid due to collateral supply from the celiac axis and SMA. As surgery was contraindicated, GnRH agonist therapy was used for symptom management, resulting in partial fibroid shrinkage. Conclusion: Persistent fibroid vascularization after UAE may result from unrecognized extra-uterine arterial supply. Recognition of atypical collateral pathways through cross-sectional angiography is essential for optimizing management and preventing treatment failure. Uterine artery embolization Fibroid Parasitic arterial supply Collateral circulation Multimodality imaging Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Uterine fibroid embolization (UFE) is a well-established, uterus-preserving treatment for symptomatic leiomyomas, with high technical success and sustained clinical outcomes [ 1 , 2 ]. Despite this, up to 10–20% of patients experience persistent or recurrent symptoms, frequently due to incomplete fibroid infarction [ 3 , 4 ]. Collateral arterial supply, most commonly from the ovarian arteries, is a recognized contributor to UFE failure [ 5 ]. More rarely, parasitic vascularization may originate from branches of the inferior mesenteric artery (IMA), celiac axis, or superior mesenteric artery (SMA), which can maintain fibroid perfusion despite technically adequate embolization [ 6 – 8 ]. Cross-sectional imaging, particularly contrast-enhanced MRI and CT angiography, plays a key role in detecting these atypical feeders and guiding re-intervention [ 9 ]. Awareness of these rare vascular patterns is essential to optimize patient outcomes, especially in the context of large or persistent fibroids [ 10 ]. This case describes UFE failure due to parasitic arterial supply from the SMA and celiac axis, highlighting the diagnostic and therapeutic challenges posed by extra-uterine collaterals. Literature Review Uterine fibroid embolization (UFE) is a widely accepted, minimally invasive treatment for symptomatic leiomyomas, with clinical success rates exceeding 80% and relatively low complication rates [ 1 , 2 ]. However, treatment failure occurs in up to 20% of cases, often due to incomplete infarction from unrecognized collateral arterial supply [ 3 ]. While the ovarian arteries are the most commonly implicated extra-uterine feeders, studies have identified rare parasitic supplies from the inferior mesenteric artery (IMA), celiac axis, and superior mesenteric artery (SMA) [ 4 – 6 ]. In such cases, embolization of the uterine arteries alone is insufficient, and persistent perfusion may lead to clinical failure. Chang et al. reported that IMA collaterals were present in 1.3% of cases and were associated with larger uterine volumes and adenomyosis [ 6 ]. Similarly, Song et al. described fibroid vascularization via SMA branches, which required selective embolization for complete devascularization [ 7 ]. Imaging plays a critical role in identifying these atypical feeders. Lee et al. demonstrated that contrast-enhanced MR angiography could predict the need for ovarian or alternative artery embolization based on uterine artery size and ovarian artery enlargement [ 8 ]. When persistent symptoms follow technically successful UFE, cross-sectional angiography or CTA should be considered to assess for collateral pathways. Table 1 Case Reports on Aberrant Arterial Supply in UFE Failures Year Citation Study Objective Type of Collateral Circulation Imaging Modality & Diagnostic Role Clinical Relevance & Implications Key Findings 2014 Song et al. Case report: SMA parasitic supply to fibroids SMA CT angiography and angiography Illustrates rare SMA parasitic supply; underscores need for full vascular assessment post-UFE failure. SMA branches can sustain fibroid perfusion; selective embolization required. 2013 Salazar et al. Impact of embolizing UOAs on symptoms and amenorrhea Utero-ovarian anastomoses Angiographic UOA identification Supports embolization of UOAs to reduce recurrence; reassures on amenorrhea risk. OAE reduces recurrence when UOAs present; no amenorrhea risk. 2013 Chang et al. Prevalence and risk of IMA collaterals in UFE IMA MRA + angiography to detect IMA Warns about IMA collaterals in large uteri or adenomyosis; advocates comprehensive angiography. IMA collaterals present in 1.3%; associated with larger uterus and adenomyosis. 2012 Dixon et al. Case report: IMA collaterals post-UFE IMA Angiography Emphasizes need for follow-up imaging; reintervention is common post-UFE. Successful embolization of IMA collaterals after previous UFE failure. 2010 Horton et al. Anatomical variant: ovarian artery supplying uterus/adrenal Ovarian (variant anatomy) Angiography discovery Alerts to rare ovarian artery variants; reinforces need for detailed angiographic review. Unusual ovarian artery anatomy supplying both uterus and adrenal gland. Case Presentation A 41-year-old premenopausal woman with a history of hypertension, morbid obesity, endometriosis, and prior CSF leak repair presented with menorrhagia and pelvic pressure unresponsive to medical therapy. MRI revealed a dominant 18.9 cm FIGO type 7 pedunculated fibroid with multiple smaller fibroids. She underwent bilateral UAE using 500–900 µm Embospheres, with post-embolization angiography showing stasis and no visible ovarian collaterals. At 3-month follow-up, symptoms persisted. MRI demonstrated infarction of smaller fibroids but continued enhancement of the dominant lesion. CT angiography identified parasitic vascularization from the gastroduodenal and SMA branches. Owing to elevated surgical risk after a recent pulmonary embolism, the patient opted for GnRH agonist therapy for symptom management. This resulted in partial fibroid shrinkage and clinical improvement. Surgical options are under reassessment. 5. Clinical and Diagnostic Assessment Clinical Course: The patient exhibited refractory menorrhagia and bulk symptoms despite technically successful bilateral UAE. Comorbidities included prior pulmonary embolism, raising perioperative risk. Symptoms persisted post-embolization with no clinical improvement. Imaging Findings: Initial MRI identified a large pedunculated fibroid with vascular enhancement and cystic degeneration. Smaller fibroids demonstrated infarction on post-UAE imaging, whereas the dominant lesion remained perfused. CT angiography identified aberrant supply from celiac and SMA branches. Repeat CT following GnRH therapy showed interval reduction in fibroid volume but persistent parasitic vascularity. Discussion Uterine fibroid embolization (UFE) is widely accepted as a safe and effective alternative to surgery for symptomatic fibroids, with clinical success rates approaching 90% in appropriately selected patients. However, failure of symptom resolution following technically successful embolization raises concern for incomplete fibroid infarction, often due to collateral blood supply. While the ovarian arteries are the most frequently identified source of extra-uterine perfusion, less common contributors include branches of the inferior mesenteric artery (IMA), celiac trunk, and superior mesenteric artery (SMA) [ 3 , 6 – 8 ]. This case illustrates a rare instance of failed embolization due to parasitic vascularization from both the celiac and SMA arteries. As seen in other isolated reports, these aberrant feeders may be recruited by large or pedunculated fibroids, particularly when peripheral fibroid regions extend beyond the uterine arterial territory [ 7 , 8 ]. In such cases, the uterine arteries may not provide the dominant vascular supply, and embolization limited to them can result in persistent viability of the fibroid. Cross-sectional vascular imaging, particularly contrast-enhanced CT angiography or MR angiography, is crucial in assessing treatment failure. In this patient, these modalities revealed continued perfusion from gastroduodenal and jejunal branches—findings not apparent during the initial embolization. Identification of such feeders is essential to guide further intervention, whether through targeted embolization or surgical planning. This case underscores the need for heightened vigilance in post-UFE follow-up, especially in patients with persistent symptoms and large fibroids. Conclusion This case highlights a rare cause of uterine fibroid embolization (UFE) failure due to parasitic arterial supply from the celiac and superior mesenteric arteries. It underscores the importance of considering atypical collateral pathways in patients with persistent symptoms following technically successful embolization. Cross-sectional angiographic imaging plays a critical role in identifying extra-uterine feeders and guiding further management. Multidisciplinary evaluation remains essential to tailor treatment strategies in complex cases involving aberrant vascular anatomy and elevated surgical risk. Declarations Conflict of Interest Statement: The authors declare no conflicts of interest related to this manuscript. Funding Statement: No external funding was received for this study. Ethical Approval: Not applicable. Patient consent was obtained for publication of this case report and accompanying images. Ethics approval and consent to participate Not applicable. Written informed consent to participate was obtained from the patient. Consent for publication Written informed consent for publication of this case report and the accompanying images was obtained from the patient. Availability of data and material All data generated or analyzed during this study are included in this published article. Competing interests The authors declare that they have no competing interests. Funding No external funding was received for this study. Authors’ contributions HA collected clinical data and drafted the case description. MG conducted the literature review, drafted the manuscript, and coordinated revisions. DK supervised the project, provided critical revisions, and approved the final version. All authors read and approved the final manuscript. Acknowledgements Not applicable. Authors’ information (optional) Haidara A. Almansour, MD – Interventional Radiology Fellow, University of British Columbia, Vancouver, Canada. Mohammadhossein Ghasempourabadi, PhD – Medical Student, School of Medicine, Laval University, Quebec City, Canada. Darren Klass, MD – Clinical Professor of Radiology, University of British Columbia, Vancouver, Canada. Corresponding Author: Dr. Mohammadhossein Ghasempourabadi, PhD School of Medicine Laval University 1015-7615 Rue des Métis Québec, QC G2K 2J6, Canada Email: [email protected] Cell: +1 (437) 375-5177 13/07/2023 Editor-in-Chief CVIR Endovascular References Kohi MP, Spies JB. Updates on uterine artery embolization. Seminars in Interventional Radiology. 2018;35(1):48–55. https://doi.org/10.1055/s-0038-1636521 Toor SS, Jaberi A, Macdonald DB, McInnes MDF, Schweitzer ME, Rasuli P. Complication rates and effectiveness of uterine artery embolization in the treatment of symptomatic leiomyomas: a systematic review and meta-analysis. AJR American Journal of Roentgenology. 2012;199(5):1153–1163. https://doi.org/10.2214/AJR.11.8362 D’hoore T, Timmerman D, Laenen A, Maleux G. Long-term outcome and pre-interventional predictors for late intervention after uterine fibroid embolization. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2020;247:149–155. https://doi.org/10.1016/j.ejogrb.2020.02.019 Salazar GM, Walker TG, Conway RF, et al. Embolization of angiographically visible type I and II utero-ovarian anastomoses during uterine artery embolization for fibroid tumors: impact on symptom recurrence and permanent amenorrhea. Journal of Vascular and Interventional Radiology. 2013;24(9):1347–1352. https://doi.org/10.1016/j.jvir.2013.05.043 Scheurig-Muenkler C, Poellinger A, Wagner M, Hamm B, Kroencke TJ. Ovarian artery embolization in patients with collateral supply to symptomatic uterine leiomyomata. CardioVascular and Interventional Radiology. 2011;34(6):1199–1207. https://doi.org/10.1007/s00270-010-9991-y Chang S, Lee MS, Kim MD, et al. Inferior mesenteric artery collaterals to the uterus during uterine artery embolization: prevalence, risk factors, and clinical outcomes. Journal of Vascular and Interventional Radiology. 2013;24(9):1353–1360. https://doi.org/10.1016/j.jvir.2013.05.049 Dixon S, Tapping CR, Chuah PS, Bratby M, Uberoi R, Anthony S. Successful fibroid embolization of pelvic and inferior mesenteric artery collaterals after previous uterine artery embolization. Acta Radiologica. 2012;53(3):292–295. https://doi.org/10.1258/ar.2011.110518 Song CI, Kim YJ, Kim HC, et al. Aberrant arterial supply to uterine fibroids from branches of the superior mesenteric artery. CardioVascular and Interventional Radiology. 2014;37(5):1434–1438. https://doi.org/10.1007/s00270-014-0858-5 Lee MS, Kim MD, Lee M, et al. Contrast-enhanced MR angiography of uterine arteries for the prediction of ovarian artery embolization in 349 patients. Journal of Vascular and Interventional Radiology. 2012;23(9):1174–1179. https://doi.org/10.1016/j.jvir.2012.06.015 Horton AW, Patel U, Belli AM. An unusual arterial supply to the uterus: a case report and review of anatomy—implications for uterine artery embolization. Clinical Radiology. 2010;65(12):1038–1042. https://doi.org/10.1016/j.crad.2010.07.007 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7172065","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":506208431,"identity":"7415fc8e-95fc-4948-8bc5-37bc03ffc61f","order_by":0,"name":"Haidara A. 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No definite ovarian arterial supply is identified.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7172065/v1/840d7d82a6924e3b82cb0d65.png"},{"id":90544308,"identity":"0b21ec58-5d5c-4f8f-be83-1b0455b2c944","added_by":"auto","created_at":"2025-09-04 00:17:48","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":368569,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIntraprocedural digital subtraction angiography (DSA) images of the right and left uterine arteries before (A, B) and after (C, D) embolization. Pre-embolization images (A, B) demonstrate hypertrophied uterine arteries with prominent vascular supply to the fibroid. Post-embolization images (C, D) show successful devascularization with markedly reduced arterial flow to the fibroid.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7172065/v1/fb0fef7530ba2b127b6e0069.png"},{"id":90545041,"identity":"8bf98e90-acc8-483f-85cb-4c566ae833a6","added_by":"auto","created_at":"2025-09-04 00:25:47","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":166238,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eT1-weighted post-gadolinium MR image in the sagittal plane demonstrating multiple intramural and submucosal uterine fibroids that have been successfully devascularized. In contrast, the dominant 20 cm pedunculated fibroid remains largely vascularized.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7172065/v1/46804c15b2498f5c08e27b35.png"},{"id":90543180,"identity":"7f23b792-448e-4958-92b3-1c2d03249ff1","added_by":"auto","created_at":"2025-09-04 00:09:48","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":366460,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e3D volume-rendered CT angiography image illustrating aberrant arterial supply to the fibroid. Branches from the celiac axis and gastroduodenal artery (GDA) primarily supply the right/anterior portion, while branches from the superior mesenteric artery (SMA) supply the left side of the fibroid.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7172065/v1/8b004b0fac1658ae9e330ad5.png"},{"id":90542197,"identity":"8fd57847-ee0e-4d54-9cce-88f04946f2aa","added_by":"auto","created_at":"2025-09-04 00:01:48","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":232937,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFollow-up contrast-enhanced CT sagittal image demonstrating interval reduction in size of a 15 cm pedunculated uterine fibroid following GnRH agonist therapy.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7172065/v1/4a07f4c878ea4473f279c5dc.png"},{"id":91627896,"identity":"33962c02-b2ca-4281-9726-7b6735220c02","added_by":"auto","created_at":"2025-09-18 12:26:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2430042,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7172065/v1/c7ab1269-82c7-455a-8743-31c8ace19c30.pdf"}],"financialInterests":"","formattedTitle":"Uterine Artery Embolization Failure Secondary to Collateral Parasitization from Celiac and Superior Mesenteric Arterial Branches: A Case Report and Literature Review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUterine fibroid embolization (UFE) is a well-established, uterus-preserving treatment for symptomatic leiomyomas, with high technical success and sustained clinical outcomes [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Despite this, up to 10\u0026ndash;20% of patients experience persistent or recurrent symptoms, frequently due to incomplete fibroid infarction [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCollateral arterial supply, most commonly from the ovarian arteries, is a recognized contributor to UFE failure [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. More rarely, parasitic vascularization may originate from branches of the inferior mesenteric artery (IMA), celiac axis, or superior mesenteric artery (SMA), which can maintain fibroid perfusion despite technically adequate embolization [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCross-sectional imaging, particularly contrast-enhanced MRI and CT angiography, plays a key role in detecting these atypical feeders and guiding re-intervention [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Awareness of these rare vascular patterns is essential to optimize patient outcomes, especially in the context of large or persistent fibroids [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis case describes UFE failure due to parasitic arterial supply from the SMA and celiac axis, highlighting the diagnostic and therapeutic challenges posed by extra-uterine collaterals.\u003c/p\u003e"},{"header":"Literature Review","content":"\u003cp\u003eUterine fibroid embolization (UFE) is a widely accepted, minimally invasive treatment for symptomatic leiomyomas, with clinical success rates exceeding 80% and relatively low complication rates [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, treatment failure occurs in up to 20% of cases, often due to incomplete infarction from unrecognized collateral arterial supply [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile the ovarian arteries are the most commonly implicated extra-uterine feeders, studies have identified rare parasitic supplies from the inferior mesenteric artery (IMA), celiac axis, and superior mesenteric artery (SMA) [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In such cases, embolization of the uterine arteries alone is insufficient, and persistent perfusion may lead to clinical failure. Chang et al. reported that IMA collaterals were present in 1.3% of cases and were associated with larger uterine volumes and adenomyosis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Similarly, Song et al. described fibroid vascularization via SMA branches, which required selective embolization for complete devascularization [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eImaging plays a critical role in identifying these atypical feeders. Lee et al. demonstrated that contrast-enhanced MR angiography could predict the need for ovarian or alternative artery embolization based on uterine artery size and ovarian artery enlargement [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. When persistent symptoms follow technically successful UFE, cross-sectional angiography or CTA should be considered to assess for collateral pathways.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCase Reports on Aberrant Arterial Supply in UFE Failures\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYear\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCitation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStudy Objective\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eType of Collateral Circulation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eImaging Modality \u0026amp; Diagnostic Role\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eClinical Relevance \u0026amp; Implications\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eKey Findings\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2014\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSong et al.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCase report: SMA parasitic supply to fibroids\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSMA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCT angiography and angiography\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eIllustrates rare SMA parasitic supply; underscores need for full vascular assessment post-UFE failure.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSMA branches can sustain fibroid perfusion; selective embolization required.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2013\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSalazar et al.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eImpact of embolizing UOAs on symptoms and amenorrhea\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eUtero-ovarian anastomoses\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAngiographic UOA identification\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSupports embolization of UOAs to reduce recurrence; reassures on amenorrhea risk.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eOAE reduces recurrence when UOAs present; no amenorrhea risk.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2013\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eChang et al.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePrevalence and risk of IMA collaterals in UFE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIMA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMRA\u0026thinsp;+\u0026thinsp;angiography to detect IMA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eWarns about IMA collaterals in large uteri or adenomyosis; advocates comprehensive angiography.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eIMA collaterals present in 1.3%; associated with larger uterus and adenomyosis.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2012\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDixon et al.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCase report: IMA collaterals post-UFE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIMA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAngiography\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eEmphasizes need for follow-up imaging; reintervention is common post-UFE.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSuccessful embolization of IMA collaterals after previous UFE failure.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2010\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHorton et al.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAnatomical variant: ovarian artery supplying uterus/adrenal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOvarian (variant anatomy)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eAngiography discovery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAlerts to rare ovarian artery variants; reinforces need for detailed angiographic review.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eUnusual ovarian artery anatomy supplying both uterus and adrenal gland.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 41-year-old premenopausal woman with a history of hypertension, morbid obesity, endometriosis, and prior CSF leak repair presented with menorrhagia and pelvic pressure unresponsive to medical therapy. MRI revealed a dominant 18.9 cm FIGO type 7 pedunculated fibroid with multiple smaller fibroids. She underwent bilateral UAE using 500\u0026ndash;900 \u0026micro;m Embospheres, with post-embolization angiography showing stasis and no visible ovarian collaterals.\u003c/p\u003e\n\u003cp\u003eAt 3-month follow-up, symptoms persisted. MRI demonstrated infarction of smaller fibroids but continued enhancement of the dominant lesion. CT angiography identified parasitic vascularization from the gastroduodenal and SMA branches. Owing to elevated surgical risk after a recent pulmonary embolism, the patient opted for GnRH agonist therapy for symptom management. This resulted in partial fibroid shrinkage and clinical improvement. Surgical options are under reassessment.\u003c/p\u003e\n\u003ch3\u003e5. Clinical and Diagnostic Assessment\u003c/h3\u003e\n\u003cp\u003eClinical Course:\u003c/p\u003e\n\u003cp\u003eThe patient exhibited refractory menorrhagia and bulk symptoms despite technically successful bilateral UAE. Comorbidities included prior pulmonary embolism, raising perioperative risk. Symptoms persisted post-embolization with no clinical improvement.\u003c/p\u003e\n\u003cp\u003eImaging Findings:\u003c/p\u003e\n\u003cp\u003eInitial MRI identified a large pedunculated fibroid with vascular enhancement and cystic degeneration. Smaller fibroids demonstrated infarction on post-UAE imaging, whereas the dominant lesion remained perfused. CT angiography identified aberrant supply from celiac and SMA branches. Repeat CT following GnRH therapy showed interval reduction in fibroid volume but persistent parasitic vascularity.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eUterine fibroid embolization (UFE) is widely accepted as a safe and effective alternative to surgery for symptomatic fibroids, with clinical success rates approaching 90% in appropriately selected patients. However, failure of symptom resolution following technically successful embolization raises concern for incomplete fibroid infarction, often due to collateral blood supply. While the ovarian arteries are the most frequently identified source of extra-uterine perfusion, less common contributors include branches of the inferior mesenteric artery (IMA), celiac trunk, and superior mesenteric artery (SMA) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis case illustrates a rare instance of failed embolization due to parasitic vascularization from both the celiac and SMA arteries. As seen in other isolated reports, these aberrant feeders may be recruited by large or pedunculated fibroids, particularly when peripheral fibroid regions extend beyond the uterine arterial territory [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In such cases, the uterine arteries may not provide the dominant vascular supply, and embolization limited to them can result in persistent viability of the fibroid.\u003c/p\u003e\u003cp\u003eCross-sectional vascular imaging, particularly contrast-enhanced CT angiography or MR angiography, is crucial in assessing treatment failure. In this patient, these modalities revealed continued perfusion from gastroduodenal and jejunal branches\u0026mdash;findings not apparent during the initial embolization. Identification of such feeders is essential to guide further intervention, whether through targeted embolization or surgical planning. This case underscores the need for heightened vigilance in post-UFE follow-up, especially in patients with persistent symptoms and large fibroids.\u003c/p\u003e"},{"header":" Conclusion","content":"\u003cp\u003eThis case highlights a rare cause of uterine fibroid embolization (UFE) failure due to parasitic arterial supply from the celiac and superior mesenteric arteries. It underscores the importance of considering atypical collateral pathways in patients with persistent symptoms following technically successful embolization. Cross-sectional angiographic imaging plays a critical role in identifying extra-uterine feeders and guiding further management. Multidisciplinary evaluation remains essential to tailor treatment strategies in complex cases involving aberrant vascular anatomy and elevated surgical risk.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare no conflicts of interest related to this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;No external funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable. Patient consent was obtained for publication of this case report and accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable. Written informed consent to participate was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Written informed consent for publication of this case report and the accompanying images was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;All data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;No external funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;HA collected clinical data and drafted the case description. MG conducted the literature review, drafted the manuscript, and coordinated revisions. DK supervised the project, provided critical revisions, and approved the final version. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ information\u003c/strong\u003e (optional)\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eHaidara A. Almansour, MD\u003c/strong\u003e – Interventional Radiology Fellow, University of British Columbia, Vancouver, Canada.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMohammadhossein Ghasempourabadi, PhD\u003c/strong\u003e – Medical Student, School of Medicine, Laval University, Quebec City, Canada.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eDarren Klass, MD\u003c/strong\u003e – Clinical Professor of Radiology, University of British Columbia, Vancouver, Canada.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eCorresponding Author:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDr. Mohammadhossein Ghasempourabadi, PhD\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;School of Medicine\u003cbr\u003e\u0026nbsp;Laval University\u003cbr\u003e\u0026nbsp;1015-7615 Rue des Métis\u003cbr\u003e\u0026nbsp;Québec, QC G2K 2J6, Canada\u003cbr\u003e\u0026nbsp;Email: [email protected]\u003cbr\u003e\u0026nbsp;Cell: +1 (437) 375-5177\u003c/p\u003e\n\u003cp\u003e13/07/2023\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEditor-in-Chief\u003c/strong\u003e\u003cbr\u003e\u003cem\u003eCVIR Endovascular\u003c/em\u003e\u003cbr\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eKohi MP, Spies JB. Updates on uterine artery embolization. Seminars in Interventional Radiology. 2018;35(1):48\u0026ndash;55. https://doi.org/10.1055/s-0038-1636521\u003c/li\u003e\n \u003cli\u003eToor SS, Jaberi A, Macdonald DB, McInnes MDF, Schweitzer ME, Rasuli P. Complication rates and effectiveness of uterine artery embolization in the treatment of symptomatic leiomyomas: a systematic review and meta-analysis. AJR American Journal of Roentgenology. 2012;199(5):1153\u0026ndash;1163. https://doi.org/10.2214/AJR.11.8362\u003c/li\u003e\n \u003cli\u003eD\u0026rsquo;hoore T, Timmerman D, Laenen A, Maleux G. Long-term outcome and pre-interventional predictors for late intervention after uterine fibroid embolization. European Journal of Obstetrics \u0026amp; Gynecology and Reproductive Biology. 2020;247:149\u0026ndash;155. https://doi.org/10.1016/j.ejogrb.2020.02.019\u003c/li\u003e\n \u003cli\u003eSalazar GM, Walker TG, Conway RF, et al. Embolization of angiographically visible type I and II utero-ovarian anastomoses during uterine artery embolization for fibroid tumors: impact on symptom recurrence and permanent amenorrhea. Journal of Vascular and Interventional Radiology. 2013;24(9):1347\u0026ndash;1352. https://doi.org/10.1016/j.jvir.2013.05.043\u003c/li\u003e\n \u003cli\u003eScheurig-Muenkler C, Poellinger A, Wagner M, Hamm B, Kroencke TJ. Ovarian artery embolization in patients with collateral supply to symptomatic uterine leiomyomata. CardioVascular and Interventional Radiology. 2011;34(6):1199\u0026ndash;1207. https://doi.org/10.1007/s00270-010-9991-y\u003c/li\u003e\n \u003cli\u003eChang S, Lee MS, Kim MD, et al. Inferior mesenteric artery collaterals to the uterus during uterine artery embolization: prevalence, risk factors, and clinical outcomes. Journal of Vascular and Interventional Radiology. 2013;24(9):1353\u0026ndash;1360. https://doi.org/10.1016/j.jvir.2013.05.049\u003c/li\u003e\n \u003cli\u003eDixon S, Tapping CR, Chuah PS, Bratby M, Uberoi R, Anthony S. Successful fibroid embolization of pelvic and inferior mesenteric artery collaterals after previous uterine artery embolization. Acta Radiologica. 2012;53(3):292\u0026ndash;295. https://doi.org/10.1258/ar.2011.110518\u003c/li\u003e\n \u003cli\u003eSong CI, Kim YJ, Kim HC, et al. Aberrant arterial supply to uterine fibroids from branches of the superior mesenteric artery. CardioVascular and Interventional Radiology. 2014;37(5):1434\u0026ndash;1438. https://doi.org/10.1007/s00270-014-0858-5\u003c/li\u003e\n \u003cli\u003eLee MS, Kim MD, Lee M, et al. Contrast-enhanced MR angiography of uterine arteries for the prediction of ovarian artery embolization in 349 patients. Journal of Vascular and Interventional Radiology. 2012;23(9):1174\u0026ndash;1179. https://doi.org/10.1016/j.jvir.2012.06.015\u003c/li\u003e\n \u003cli\u003eHorton AW, Patel U, Belli AM. An unusual arterial supply to the uterus: a case report and review of anatomy\u0026mdash;implications for uterine artery embolization. Clinical Radiology. 2010;65(12):1038\u0026ndash;1042. https://doi.org/10.1016/j.crad.2010.07.007\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Uterine artery embolization, Fibroid, Parasitic arterial supply, Collateral circulation, Multimodality imaging","lastPublishedDoi":"10.21203/rs.3.rs-7172065/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7172065/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo present a rare case of uterine artery embolization (UAE) failure due to collateral arterial supply from the celiac axis and superior mesenteric artery (SMA), and to review the diagnostic and interventional considerations in such presentations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 41-year-old woman with symptomatic fibroids underwent bilateral UAE. Follow-up imaging showed persistent vascularity of a dominant 20 cm fibroid due to collateral supply from the celiac axis and SMA. As surgery was contraindicated, GnRH agonist therapy was used for symptom management, resulting in partial fibroid shrinkage.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePersistent fibroid vascularization after UAE may result from unrecognized extra-uterine arterial supply. Recognition of atypical collateral pathways through cross-sectional angiography is essential for optimizing management and preventing treatment failure.\u003c/p\u003e","manuscriptTitle":"Uterine Artery Embolization Failure Secondary to Collateral Parasitization from Celiac and Superior Mesenteric Arterial Branches: A Case Report and Literature Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-04 00:01:43","doi":"10.21203/rs.3.rs-7172065/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cf34a4f1-f817-4d4f-87ce-c9c7c018fccc","owner":[],"postedDate":"September 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-18T12:17:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-04 00:01:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7172065","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7172065","identity":"rs-7172065","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}