Super-selective embolisation for an intractable uterine pseudoaneurysm fed by the ovarian artery

Super-selective embolisation for an intractable uterine pseudoaneurysm fed by the ovarian artery | 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 Super-selective embolisation for an intractable uterine pseudoaneurysm fed by the ovarian artery Shunsuke Kamei, Yukihisa Ogawa, Takumi Takeuchi, Terumitsu Hasebe This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7495351/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background: Uterine artery pseudoaneurysm (UAP) is a rare but serious cause of delayed postpartum hemorrhage. While transcatheter arterial embolization (TAE) is generally effective for UAP, the use of permanent embolic agents for proximal embolization may result in residual blood flow via utero-ovarian anastomosis. In such a case, to preserve ovarian function, it is necessary to advance the catheter beyond these anastomoses. However, reports detailing embolization via the ovarian artery approach are scarce, and its technical feasibility and efficacy remain underexplored. Case Presentation: A woman in her 30s with a history of right salpingectomy developed an intractable UAP following miscarriage. Despite two sessions of bilateral uterine artery embolization at a previous hospital, the pseudoaneurysm recurred. The first TAE involved proximal coil embolization of the left uterine artery, which hindered subsequent attempts to access the bleeding point. Imaging revealed persistent blood flow via the left ovarian artery through the utero-ovarian anastomosis. Given the patient's desire to preserve fertility and the anatomical complexity, we performed super-selective embolization using a triaxial system, allowing navigation through the markedly tortuous ovarian artery and advancement beyond the ovarian branch. Glue embolization was successfully performed without complications. Post-procedural examinations confirmed complete occlusion of the UAP and preservation of ovarian function. The patient resumed menstruation and restarted fertility treatment. Conclusion: This case highlights the potential difficulty of re-intervention after proximal embolization and underscores the utility of the triaxial system in navigating challenging anatomy. Super-selective glue embolization via the ovarian artery may serve as a viable fertility-preserving treatment in cases of intractable UAP. uterine artery pseudoaneurysm ovarian artery embolization triaxial system Figures Figure 1 Figure 2 Figure 3 Figure 4 Background A uterine artery pseudoaneurysm (UAP) is characterized by a blood-filled cavity that communicates with the main vessel through a defect in the arterial wall [ 1 , 2 ]. UAP is associated with traumatic pregnancy or delivery and abortion, with occasional ruptures resulting in life-threatening bleeding [ 2 , 3 ]. It accounts for approximately 3% of postpartum haemorrhages (PPH) [ 4 ]. UAP can be diagnosed using colour Doppler ultrasonography (US), contrast-enhanced computed tomography (CECT), and angiography [ 2 , 5 ] Although many studies have demonstrated the successful treatment of UAP through transcatheter arterial embolisation (TAE) of both uterine arteries, occasional re-canalisation after TAE is observed due to potential anastomosis of the uterine artery with the vaginal and ovarian arteries [ 2 – 4 , 6 ]. The feasibility of preserving ovarian function through super-selective embolisation of the uterus via the ovarian artery beyond utero-ovarian anastomosis remains unclear. Case report An Asian woman in her 30s, gravida 4, para 0, with an intractable UAP was referred to the Vascular and Interventional Center of our hospital. The patient had undergone right salpingectomy for an ectopic pregnancy 3 years prior to presentation. In this case, pregnancy was achieved via frozen embryo transfer; however, miscarriage occurred at 9 weeks, and manual vacuum aspiration was performed. Three weeks later, colour Doppler US scan revealed a cavity with blood in the uterus, and the case was diagnosed as UAP. The patient was referred to a previous hospital, where she underwent repeated TAE for UAP. However, both uterine arteries re-canalised within a few weeks. In the first TAE, gelatin sponge particles (GS) and metallic coils were placed proximally to the left uterine artery, and GS was used for the right uterine artery. In the second TAE, the bilateral uterine arteries were embolised with GS; however, 1 month after TAE, UAP recurred, as observed on US and magnetic resonance imaging (MRI) scan. Subsequently, the patient was referred to our hospital for endovascular therapy to avoid hysterectomy. The patient was asymptomatic and non-anaemic. Gonadotropin releasing hormone (GnRH) antagonists were administered to induce a pseudomenopausal state for reducing the risk of UAP rupture during menstruation. Transvaginal US and MRI scans revealed a cavity with blood flow inside the uterus, without placental remnants. CECT revealed a pseudoaneurysm in the uterus (Fig. 1 A), and volume rendering images showed the left ovarian artery as a slightly dilated tortuous vessel (Fig. 1 B). The patient and her partner expressed a desire to preserve her fertility. We provided comprehensive explanations of treatment options, including TAE, hysterectomy, and follow-up alone. We also explained that TAE might necessitate a hysterectomy due to potential necrosis of the uterus after treatment, which may not contribute to fertility preservation and pose a risk of complications in subsequent pregnancies [ 4 , 7 , 8 ]. Following our explanation, they confirmed their understanding of the associated risks and opted to undergo TAE. An epidural anaesthetic was administered in preparation for severe pain associated with uterine myometrial necrosis. Angiography was performed using Artis zee BA twin PURE (Siemens Healthineers, Erlangen, Germany). The bilateral femoral arteries were punctured under local anaesthesia, and introducer sheaths (4-F, 25 cm in the right femoral artery and 4-F, 16 cm in the left femoral artery) (Terumo Corporation, Tokyo, Japan) were placed. A pseudoaneurysm was observed at the centre of the pelvis on aortography (Fig. 2 A). Arteriography of the right uterine artery depicted enhancement of the myometrium and the absence of a pseudoaneurysm (Fig. 2 B). Arteriography of the left ovarian artery originating directly from the abdominal aorta (L2 vertebral level) revealed a dilated and tortuous vessel and UAP through the utero-ovarian anastomosis (Fig. 2 C). Although TAE of the left ovarian artery could effectively treat UAP, it was deemed unfavourable due to the risk of left ovarian necrosis, considering the patient’s history of right salpingectomy. After selecting the left ovarian artery using a 4-F Cobra-shaped catheter (Medikit, C2, Tokyo, Japan), we used a triple co-axial (triaxial) system with a combination of a 2.6-F Masters Parkway HF (Asahi Intech, Aichi, Japan), a 1.9-F Carry a Leon 2 marker catheter (UTM, Aichi, Japan), and a 0.016 inch Meister guidewire (Asahi Intecc). The smaller microcatheter was advanced beyond the ovarian branch, and TAE was performed using 0.4 mL of 33% n-butyl-2-cyanoacrylate (B. Braun, Melsungen, Germany) diluted with lipiodol (Guerbet, Villepinte, France) (Fig. 2 D). The procedure was successfully completed without complications. The patient experienced mild post-treatment pain, and the epidural anaesthesia catheter was removed a day after the treatment. No post-operative bleeding was noted, and the patient was discharged after 3 days of the treatment. One month later, CECT revealed the disappearance of the UAP without left ovary necrosis (Fig. 3 ). Subsequently, the GnRH antagonist was discontinued, and menstruation resumed. CECT at 3 months revealed the disappearance of the glue from the uterus. The blood levels of oestradiol and follicle-stimulating hormone were 142 pg/ml and 5.89 mIU/ml, respectively, indicating preserved ovarian function. Hysteroscopy revealed no endometrial abnormalities (Fig. 4 ). Despite the patient not achieving pregnancy at this point, she was able to resume assisted reproductive medicine 6 months after treatment. No recurrent pseudoaneurysm occurred during the 12-month follow-up. Discussion This case report has two important clinical implications. First, proximal embolisation with permanent embolic agents may lead to incomplete haemostasis and pose challenges with re-intervention. Second, the triaxial system plays an important role in navigating through the tortuous ovarian artery and reaching beyond the utero-ovarian anastomosis. Similar to PPH, TAE for UAP also yielded satisfactory outcomes. Duhan et al. reported successful treatment in 17 of 18 patients with a single TAE of the bilateral uterine arteries using GS and glue [ 4 ]. However, persistent bleeding from the ovarian artery after bilateral uterine artery embolisation for PPH has been documented [ 4 , 9 ]. In the present case, proximal embolisation of the left uterine artery with a permanent embolic agent during the first TAE may have contributed to this situation. After the first TAE, blood flow in the UAP persisted through the right uterine artery, and the utero-ovarian anastomosis was re-canalised by the left ovarian artery. During the second TAE, the bilateral uterine arteries were embolised using GS. However, the GS did not reach the UAP because of proximal coil embolisation of the left uterine artery, making the left ovarian artery the main feeding artery for the UAP. To the best of our knowledge, this is the first report demonstrating the preservation of ovarian function after embolisation via the left ovarian artery. Embolisation of the ovarian artery causes persistent bleeding after hysterectomy, embolisation of uterine fibroids, and rupture of ovarian artery aneurysms [ 10 – 12 ]. However, in all cases, embolisation was performed proximal to the ovarian artery, and no attempt was made to preserve ovarian function. Limited data are available regarding whether embolisation of the ovarian arteries affects ovarian function and fertility. However, it is well known that embolization for uterine fibroids may cause adverse effects on ovarian function [ 13 ]. In addition, protective coiling of the utero-ovarian anastomoses can prevent ovarian failure [ 14 ]. Based on these reports, it is reasonable to assume that embolisation of the ovarian arteries reduces ovarian function. Nevertheless, in cases where both ovaries are unaffected, unilateral ovarian artery embolisation may not lead to infertility, as is the case with unilateral oophorectomy. However, considering the patient had undergone right salpingectomy, preservation of the left ovary was preferred for fertility preservation. A triaxial system was introduced to advance through the left ovarian artery to the utero-ovarian anastomosis. Triaxial systems offer several advantages [ 15 ], making it valuable for complex embolisation procedures and better suited than the conventional co-axial system in these specific circumstances. The large microcatheter facilitated the advancement of the small microcatheter to tortuous and/or small target vessels by stabilising the position and preventing catheter kickback compared to the conventional co-axial system. The triaxial system is used in various situations such as type II endoleaks after endovascular aortic repair, gastrointestinal bleeding, and haemoptysis [ 16 , 17 ]. Advancing a microcatheter into a severely tortuous vessel is considerably challenging, often resulting in the deformation of the microwire tip and impaired controllability, particularly observed in highly bent vessels. In the present case, both the small microcatheter and microwires were irreversibly deformed. However, the triaxial system allowed for replacement of the damaged small microcatheter. Conclusion We presented a case of an intractable UAP in which the left uterine artery was the main feeding artery after proximal embolisation with coils/GS at another hospital. The triaxial system played an important role in advancing through the tortuous left ovarian artery. The UAP was treated using minimally invasive super-selective glue embolisation via the left ovarian artery, preserving ovarian function. Abbreviations UAP : Uterine artery pseudoaneurysm TAE : Transcatheter arterial embolization GS : Gelatin sponge CECT : Contrast-enhanced computed tomography US : Ultrasound PPH : Postpartum hemorrhage MRI : Magnetic resonance imaging Declarations Ethics Declarations Ethics approval and consent to participate The Ethics Committee of Tokai University School of Medicine determined that formal approval was not required for the case reports in accordance with institutional policies. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Competing interests The authors declare that they have no competing interests. Funding The authors received no specific funding for this work. Authors' contributions SK and TH performed the endovascular procedure. SK drafted the manuscript. TH and YO critically revised the manuscript. TT provided obstetric management and conducted post-treatment follow-up. All authors read and approved the final manuscript. Acknowledgements Not applicable. Availability of data and material Data sharing is not applicable to this article as no datasets were generated or analysed during the current study. References Butori N, Coulange L, Filipuzzi L et al (2009) Pseudoaneurysm of the uterine artery after cesarean delivery: management with superselective arterial embolization. Obstet Gynecol 113:540–543 Isono W, Tsutsumi R, Wada-Hiraike O et al (2010) Uterine Artery Pseudoaneurysm after Cesarean Section: Case Report and Literature Review. J Minim Invasive Gynecol 17(6):687–691 Zimon AE, Hwang JK, Principe DL et al (1999) Pseudoaneurysm of the uterine artery. Obstet Gynecol 94:827–830 Dohan A, Soyer P, Subhani A et al (2013) Postpartum Hemorrhage Resulting from Pelvic Pseudoaneurysm: A Retrospective Analysis of 588 Consecutive Cases Treated by Arterial Embolization. Cardiovasc Interv Radiol 36(5):1247–1255 Ludwin A, Martins WP, Ludwin I (2018) Managing uterine artery pseudoaneurysm after myomectomy. Ultrasound Obstet Gynecol 52(3):413–415 Wu CQ, Nayeemuddin M, Rattray D (2018) Uterine artery pseudoaneurysm with an anastomotic feeding vessel requiring repeat embolisation. BMJ Case Rep. ;2018 Cottier JP, Fignon A, Tranquart F et al (2002) Uterine necrosis after arterial embolization for postpartum hemorrhage. Obstet Gynecol 100:1074–1077 Matsuzaki S, Lee M, Nagase Y et al (2021) A systematic review and meta-analysis of obstetric and maternal outcomes after prior uterine artery embolization. Sci Rep. ;11(1) Lee CH, Yoon CJ, Lee JH et al (2022) Recurrent postpartum hemorrhage at subsequent pregnancy in patients with prior uterine artery embolization: angiographic findings and outcomes of repeat embolization. Br J Radiol 95(1136):20211355 Rathod KR, Deshmukh HL, Asrani A et al (2005) Successful Embolization of an Ovarian Artery Pseudoaneurysm Complicating Obstetric Hysterectomy. Cardiovasc Interv Radiol 28(1):113–116 Sakaguchi I, Ohba T, Ikeda O et al (2015) Embolization for post-partum rupture of ovarian artery aneurysm: Case report and review. J Obstet Gynecol Res 41(4):623–627 Ifergan H, Perus T, Janot K et al (2021) Ovarian arteries embolization in women with persistent symptoms following uterine arteries embolization for uterus fibroids. Abdom Radiol 46(12):5707–5714 McLucas B, Voorhees Iii WD, Elliott S (2016) Fertility after uterine artery embolization: a review. Minim Invasive Therapy Allied Technol 25(1):1–7 Sheikh GT, Najafi A, Cunier M et al (2020) Angiographic Detection of Utero-Ovarian Anastomosis and Influence on Ovarian Function After Uterine Artery Embolization. Cardiovasc Interv Radiol 43(2):231–237 Shimohira M, Ogino H, Kawai T et al (1987) Clinical usefulness of the triaxial system in super-selective transcatheter arterial chemoembolization for hepatocellular carcinoma. Acta radiologica (Stockholm, Sweden: 2012;53(8):857 – 61 Shimohira M, Ohta K, Suzuki K et al (2018) Newly developed triaxial microcatheter for complicated interventions. Minim Invasive Therapy Allied Technol 27(1):11–16 Nakashima M, Shimohira M, Nagai K et al (2022) Embolization for acute arterial bleeding: use of the triaxial system and N-butyl-2-cyanoacrylate. Minim Invasive Therapy Allied Technol 31(3):389–395 Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 20 Sep, 2025 Reviewers invited by journal 17 Sep, 2025 Editor assigned by journal 08 Sep, 2025 First submitted to journal 04 Sep, 2025 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-7495351","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":516288037,"identity":"197f2b49-8482-43f2-ae0d-839c8408bc37","order_by":0,"name":"Shunsuke 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06:59:35","extension":"html","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":47027,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7495351/v1/547eb7418789b1185933f114.html"},{"id":92233598,"identity":"5cc1621f-6ee7-4ea5-b2c6-8706f98396eb","added_by":"auto","created_at":"2025-09-26 06:59:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1612907,"visible":true,"origin":"","legend":"\u003cp\u003eContrast-enhanced computed tomography images before treatment. (a) Early arterial phase showing a pseudoaneurysm in the uterus (arrow). (b) Three-dimensional volume rendering images show a pseudoaneurysm in the uterus (purple vessel), both uterine arteries (green and blue vessels), and a slightly dilated left ovarian artery (red vessel)\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7495351/v1/90ec88cadeead1eedc0fffb4.png"},{"id":92233606,"identity":"06c1770f-f3e2-4810-a506-c96a9b815691","added_by":"auto","created_at":"2025-09-26 06:59:36","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":23561346,"visible":true,"origin":"","legend":"\u003cp\u003eArteriography for uterine artery pseudoaneurysm (UAP). (a) Aortography showing UAP on the right side of the metal coil and dilated left ovarian artery (arrowhead). (b) Arteriography of the right uterine artery showing enhancement of the myometrium and lack of UAP. (c) Left ovarian arteriography showing the entire pseudoaneurysm (circle) and major branch of the ovary (arrow). (d) Triaxial system catheters(arrow, the tip of the small microcatheter) are inserted peripherally beyond the major branch of the ovary, and glue embolisation is performed.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-7495351/v1/ccb8d13650260d48860f899d.png"},{"id":92233599,"identity":"03e033ca-350b-419c-a24e-4bff960befe5","added_by":"auto","created_at":"2025-09-26 06:59:35","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1473709,"visible":true,"origin":"","legend":"\u003cp\u003ePost-operative contrast-enhanced computed tomography (CECT) obtained 1 month later. (a) Arterial phase showing lipiodol deposits(arrow) and no residual pseudoaneurysm or extravasation in the uterus. (b) CECT showing no necrosis of the left ovary (arrow).\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7495351/v1/ce0a73d8c785daa6ceac48a3.png"},{"id":92234498,"identity":"79811aa0-d5ce-41e3-a870-88858ef92c53","added_by":"auto","created_at":"2025-09-26 07:07:35","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":2533807,"visible":true,"origin":"","legend":"\u003cp\u003eHysteroscopic image of the uterine cavity shows a normal appearance of the endometrium without any defects or retained products of pregnancy.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-7495351/v1/05393ce0f2631bd1b757f8bb.png"},{"id":92235387,"identity":"0caed9d1-73ec-4df3-96c7-faedf03020b9","added_by":"auto","created_at":"2025-09-26 07:16:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":31596308,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7495351/v1/a8dd9bc1-cc11-41f9-819a-46a469aeed82.pdf"}],"financialInterests":"","formattedTitle":"Super-selective embolisation for an intractable uterine pseudoaneurysm fed by the ovarian artery","fulltext":[{"header":"Background","content":"\u003cp\u003eA uterine artery pseudoaneurysm (UAP) is characterized by a blood-filled cavity that communicates with the main vessel through a defect in the arterial wall [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. UAP is associated with traumatic pregnancy or delivery and abortion, with occasional ruptures resulting in life-threatening bleeding [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. It accounts for approximately 3% of postpartum haemorrhages (PPH) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. UAP can be diagnosed using colour Doppler ultrasonography (US), contrast-enhanced computed tomography (CECT), and angiography [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eAlthough many studies have demonstrated the successful treatment of UAP through transcatheter arterial embolisation (TAE) of both uterine arteries, occasional re-canalisation after TAE is observed due to potential anastomosis of the uterine artery with the vaginal and ovarian arteries [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The feasibility of preserving ovarian function through super-selective embolisation of the uterus via the ovarian artery beyond utero-ovarian anastomosis remains unclear.\u003c/p\u003e"},{"header":"Case report","content":"\u003cp\u003eAn Asian woman in her 30s, gravida 4, para 0, with an intractable UAP was referred to the Vascular and Interventional Center of our hospital. The patient had undergone right salpingectomy for an ectopic pregnancy 3 years prior to presentation. In this case, pregnancy was achieved via frozen embryo transfer; however, miscarriage occurred at 9 weeks, and manual vacuum aspiration was performed. Three weeks later, colour Doppler US scan revealed a cavity with blood in the uterus, and the case was diagnosed as UAP. The patient was referred to a previous hospital, where she underwent repeated TAE for UAP. However, both uterine arteries re-canalised within a few weeks. In the first TAE, gelatin sponge particles (GS) and metallic coils were placed proximally to the left uterine artery, and GS was used for the right uterine artery. In the second TAE, the bilateral uterine arteries were embolised with GS; however, 1 month after TAE, UAP recurred, as observed on US and magnetic resonance imaging (MRI) scan. Subsequently, the patient was referred to our hospital for endovascular therapy to avoid hysterectomy.\u003c/p\u003e\u003cp\u003eThe patient was asymptomatic and non-anaemic. Gonadotropin releasing hormone (GnRH) antagonists were administered to induce a pseudomenopausal state for reducing the risk of UAP rupture during menstruation. Transvaginal US and MRI scans revealed a cavity with blood flow inside the uterus, without placental remnants. CECT revealed a pseudoaneurysm in the uterus (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA), and volume rendering images showed the left ovarian artery as a slightly dilated tortuous vessel (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe patient and her partner expressed a desire to preserve her fertility. We provided comprehensive explanations of treatment options, including TAE, hysterectomy, and follow-up alone. We also explained that TAE might necessitate a hysterectomy due to potential necrosis of the uterus after treatment, which may not contribute to fertility preservation and pose a risk of complications in subsequent pregnancies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Following our explanation, they confirmed their understanding of the associated risks and opted to undergo TAE.\u003c/p\u003e\u003cp\u003eAn epidural anaesthetic was administered in preparation for severe pain associated with uterine myometrial necrosis. Angiography was performed using Artis zee BA twin PURE (Siemens Healthineers, Erlangen, Germany). The bilateral femoral arteries were punctured under local anaesthesia, and introducer sheaths (4-F, 25 cm in the right femoral artery and 4-F, 16 cm in the left femoral artery) (Terumo Corporation, Tokyo, Japan) were placed. A pseudoaneurysm was observed at the centre of the pelvis on aortography (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). Arteriography of the right uterine artery depicted enhancement of the myometrium and the absence of a pseudoaneurysm (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). Arteriography of the left ovarian artery originating directly from the abdominal aorta (L2 vertebral level) revealed a dilated and tortuous vessel and UAP through the utero-ovarian anastomosis (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC). Although TAE of the left ovarian artery could effectively treat UAP, it was deemed unfavourable due to the risk of left ovarian necrosis, considering the patient\u0026rsquo;s history of right salpingectomy.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAfter selecting the left ovarian artery using a 4-F Cobra-shaped catheter (Medikit, C2, Tokyo, Japan), we used a triple co-axial (triaxial) system with a combination of a 2.6-F Masters Parkway HF (Asahi Intech, Aichi, Japan), a 1.9-F Carry a Leon 2 marker catheter (UTM, Aichi, Japan), and a 0.016 inch Meister guidewire (Asahi Intecc). The smaller microcatheter was advanced beyond the ovarian branch, and TAE was performed using 0.4 mL of 33% n-butyl-2-cyanoacrylate (B. Braun, Melsungen, Germany) diluted with lipiodol (Guerbet, Villepinte, France) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD). The procedure was successfully completed without complications.\u003c/p\u003e\u003cp\u003eThe patient experienced mild post-treatment pain, and the epidural anaesthesia catheter was removed a day after the treatment. No post-operative bleeding was noted, and the patient was discharged after 3 days of the treatment. One month later, CECT revealed the disappearance of the UAP without left ovary necrosis (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Subsequently, the GnRH antagonist was discontinued, and menstruation resumed. CECT at 3 months revealed the disappearance of the glue from the uterus. The blood levels of oestradiol and follicle-stimulating hormone were 142 pg/ml and 5.89 mIU/ml, respectively, indicating preserved ovarian function. Hysteroscopy revealed no endometrial abnormalities (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Despite the patient not achieving pregnancy at this point, she was able to resume assisted reproductive medicine 6 months after treatment. No recurrent pseudoaneurysm occurred during the 12-month follow-up.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case report has two important clinical implications. First, proximal embolisation with permanent embolic agents may lead to incomplete haemostasis and pose challenges with re-intervention. Second, the triaxial system plays an important role in navigating through the tortuous ovarian artery and reaching beyond the utero-ovarian anastomosis.\u003c/p\u003e\u003cp\u003eSimilar to PPH, TAE for UAP also yielded satisfactory outcomes. Duhan et al. reported successful treatment in 17 of 18 patients with a single TAE of the bilateral uterine arteries using GS and glue [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, persistent bleeding from the ovarian artery after bilateral uterine artery embolisation for PPH has been documented [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In the present case, proximal embolisation of the left uterine artery with a permanent embolic agent during the first TAE may have contributed to this situation. After the first TAE, blood flow in the UAP persisted through the right uterine artery, and the utero-ovarian anastomosis was re-canalised by the left ovarian artery. During the second TAE, the bilateral uterine arteries were embolised using GS. However, the GS did not reach the UAP because of proximal coil embolisation of the left uterine artery, making the left ovarian artery the main feeding artery for the UAP.\u003c/p\u003e\u003cp\u003eTo the best of our knowledge, this is the first report demonstrating the preservation of ovarian function after embolisation via the left ovarian artery. Embolisation of the ovarian artery causes persistent bleeding after hysterectomy, embolisation of uterine fibroids, and rupture of ovarian artery aneurysms [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, in all cases, embolisation was performed proximal to the ovarian artery, and no attempt was made to preserve ovarian function.\u003c/p\u003e\u003cp\u003eLimited data are available regarding whether embolisation of the ovarian arteries affects ovarian function and fertility. However, it is well known that embolization for uterine fibroids may cause adverse effects on ovarian function [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In addition, protective coiling of the utero-ovarian anastomoses can prevent ovarian failure [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Based on these reports, it is reasonable to assume that embolisation of the ovarian arteries reduces ovarian function. Nevertheless, in cases where both ovaries are unaffected, unilateral ovarian artery embolisation may not lead to infertility, as is the case with unilateral oophorectomy. However, considering the patient had undergone right salpingectomy, preservation of the left ovary was preferred for fertility preservation.\u003c/p\u003e\u003cp\u003eA triaxial system was introduced to advance through the left ovarian artery to the utero-ovarian anastomosis. Triaxial systems offer several advantages [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], making it valuable for complex embolisation procedures and better suited than the conventional co-axial system in these specific circumstances. The large microcatheter facilitated the advancement of the small microcatheter to tortuous and/or small target vessels by stabilising the position and preventing catheter kickback compared to the conventional co-axial system. The triaxial system is used in various situations such as type II endoleaks after endovascular aortic repair, gastrointestinal bleeding, and haemoptysis [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Advancing a microcatheter into a severely tortuous vessel is considerably challenging, often resulting in the deformation of the microwire tip and impaired controllability, particularly observed in highly bent vessels. In the present case, both the small microcatheter and microwires were irreversibly deformed. However, the triaxial system allowed for replacement of the damaged small microcatheter.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe presented a case of an intractable UAP in which the left uterine artery was the main feeding artery after proximal embolisation with coils/GS at another hospital. The triaxial system played an important role in advancing through the tortuous left ovarian artery. The UAP was treated using minimally invasive super-selective glue embolisation via the left ovarian artery, preserving ovarian function.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eUAP\u003c/strong\u003e: Uterine artery pseudoaneurysm\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTAE\u003c/strong\u003e: Transcatheter arterial embolization\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGS\u003c/strong\u003e: Gelatin sponge\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCECT\u003c/strong\u003e: Contrast-enhanced computed tomography\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUS\u003c/strong\u003e: Ultrasound\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePPH\u003c/strong\u003e: Postpartum hemorrhage\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMRI\u003c/strong\u003e: Magnetic resonance imaging\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics Declarations\u003c/b\u003e\u003c/h2\u003e\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003eThe Ethics Committee of Tokai University School of Medicine determined that formal approval was not required for the case reports in accordance with institutional policies.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003e Written informed consent was obtained from the patient for publication of this case report and any accompanying images.\u003c/p\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThe authors received no specific funding for this work.\u003c/p\u003e\u003ch2\u003eAuthors' contributions\u003c/h2\u003e\u003cp\u003eSK and TH performed the endovascular procedure. SK drafted the manuscript. TH and YO critically revised the manuscript. TT provided obstetric management and conducted post-treatment follow-up. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eAvailability of data and material\u003c/h2\u003e\u003cp\u003eData sharing is not applicable to this article as no datasets were generated or analysed during the current study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eButori N, Coulange L, Filipuzzi L et al (2009) Pseudoaneurysm of the uterine artery after cesarean delivery: management with superselective arterial embolization. Obstet Gynecol 113:540\u0026ndash;543\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIsono W, Tsutsumi R, Wada-Hiraike O et al (2010) Uterine Artery Pseudoaneurysm after Cesarean Section: Case Report and Literature Review. J Minim Invasive Gynecol 17(6):687\u0026ndash;691\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZimon AE, Hwang JK, Principe DL et al (1999) Pseudoaneurysm of the uterine artery. Obstet Gynecol 94:827\u0026ndash;830\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDohan A, Soyer P, Subhani A et al (2013) Postpartum Hemorrhage Resulting from Pelvic Pseudoaneurysm: A Retrospective Analysis of 588 Consecutive Cases Treated by Arterial Embolization. Cardiovasc Interv Radiol 36(5):1247\u0026ndash;1255\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLudwin A, Martins WP, Ludwin I (2018) Managing uterine artery pseudoaneurysm after myomectomy. Ultrasound Obstet Gynecol 52(3):413\u0026ndash;415\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWu CQ, Nayeemuddin M, Rattray D (2018) Uterine artery pseudoaneurysm with an anastomotic feeding vessel requiring repeat embolisation. BMJ Case Rep. ;2018\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCottier JP, Fignon A, Tranquart F et al (2002) Uterine necrosis after arterial embolization for postpartum hemorrhage. Obstet Gynecol 100:1074\u0026ndash;1077\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMatsuzaki S, Lee M, Nagase Y et al (2021) A systematic review and meta-analysis of obstetric and maternal outcomes after prior uterine artery embolization. Sci Rep. ;11(1)\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee CH, Yoon CJ, Lee JH et al (2022) Recurrent postpartum hemorrhage at subsequent pregnancy in patients with prior uterine artery embolization: angiographic findings and outcomes of repeat embolization. Br J Radiol 95(1136):20211355\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRathod KR, Deshmukh HL, Asrani A et al (2005) Successful Embolization of an Ovarian Artery Pseudoaneurysm Complicating Obstetric Hysterectomy. Cardiovasc Interv Radiol 28(1):113\u0026ndash;116\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSakaguchi I, Ohba T, Ikeda O et al (2015) Embolization for post-partum rupture of ovarian artery aneurysm: Case report and review. J Obstet Gynecol Res 41(4):623\u0026ndash;627\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIfergan H, Perus T, Janot K et al (2021) Ovarian arteries embolization in women with persistent symptoms following uterine arteries embolization for uterus fibroids. Abdom Radiol 46(12):5707\u0026ndash;5714\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcLucas B, Voorhees Iii WD, Elliott S (2016) Fertility after uterine artery embolization: a review. Minim Invasive Therapy Allied Technol 25(1):1\u0026ndash;7\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSheikh GT, Najafi A, Cunier M et al (2020) Angiographic Detection of Utero-Ovarian Anastomosis and Influence on Ovarian Function After Uterine Artery Embolization. Cardiovasc Interv Radiol 43(2):231\u0026ndash;237\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShimohira M, Ogino H, Kawai T et al (1987) Clinical usefulness of the triaxial system in super-selective transcatheter arterial chemoembolization for hepatocellular carcinoma. Acta radiologica (Stockholm, Sweden: 2012;53(8):857\u0026thinsp;\u0026ndash;\u0026thinsp;61\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShimohira M, Ohta K, Suzuki K et al (2018) Newly developed triaxial microcatheter for complicated interventions. Minim Invasive Therapy Allied Technol 27(1):11\u0026ndash;16\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNakashima M, Shimohira M, Nagai K et al (2022) Embolization for acute arterial bleeding: use of the triaxial system and N-butyl-2-cyanoacrylate. Minim Invasive Therapy Allied Technol 31(3):389\u0026ndash;395\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"cvir-endovascular","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cire","sideBox":"Learn more about [CVIR Endovascular](https://www.springer.com/journal/42155)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/cire/default.aspx","title":"CVIR Endovascular","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"uterine artery pseudoaneurysm, ovarian artery embolization, triaxial system","lastPublishedDoi":"10.21203/rs.3.rs-7495351/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7495351/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Uterine artery pseudoaneurysm (UAP) is a rare but serious cause of delayed postpartum hemorrhage. While transcatheter arterial embolization (TAE) is generally effective for UAP, the use of permanent embolic agents for proximal embolization may result in residual blood flow via utero-ovarian anastomosis. In such a case, to preserve ovarian function, it is necessary to advance the catheter beyond these anastomoses. However, reports detailing embolization via the ovarian artery approach are scarce, and its technical feasibility and efficacy remain underexplored.\u003c/p\u003e\n\u003cp\u003eCase Presentation: A woman in her 30s with a history of right salpingectomy developed an intractable UAP following miscarriage. Despite two sessions of bilateral uterine artery embolization at a previous hospital, the pseudoaneurysm recurred. The first TAE involved proximal coil embolization of the left uterine artery, which hindered subsequent attempts to access the bleeding point. Imaging revealed persistent blood flow via the left ovarian artery through the utero-ovarian anastomosis. Given the patient's desire to preserve fertility and the anatomical complexity, we performed super-selective embolization using a triaxial system, allowing navigation through the markedly tortuous ovarian artery and advancement beyond the ovarian branch. Glue embolization was successfully performed without complications. Post-procedural examinations confirmed complete occlusion of the UAP and preservation of ovarian function. The patient resumed menstruation and restarted fertility treatment.\u003c/p\u003e\n\u003cp\u003eConclusion: This case highlights the potential difficulty of re-intervention after proximal embolization and underscores the utility of the triaxial system in navigating challenging anatomy. Super-selective glue embolization via the ovarian artery may serve as a viable fertility-preserving treatment in cases of intractable UAP.\u003c/p\u003e","manuscriptTitle":"Super-selective embolisation for an intractable uterine pseudoaneurysm fed by the ovarian artery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-26 06:59:31","doi":"10.21203/rs.3.rs-7495351/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2025-09-20T08:02:16+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-17T05:59:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-08T06:02:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"CVIR Endovascular","date":"2025-09-04T07:05:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"cvir-endovascular","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cire","sideBox":"Learn more about [CVIR Endovascular](https://www.springer.com/journal/42155)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/cire/default.aspx","title":"CVIR Endovascular","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"501febe2-1d74-4674-82f7-d7bf51985f78","owner":[],"postedDate":"September 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-26T06:59:31+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-26 06:59:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7495351","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7495351","identity":"rs-7495351","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}