Kazuyuki Koyama

Diagnostic computed tomographic angiography and therapeutic emergency transcatheter arterial embolization for management of postoperative hemorrhage after gynecologic laparoscopic surgery.

STUDY OBJECTIVE To evaluate the diagnostic value of 3-dimensional computed tomographic (CT) angiography and treatment efficacy of emergency transcatheter arterial embolization (TAE) for early postoperative hemorrhage after gynecologic laparoscopic surgery. DESIGN Retrospective analysis (Canadian Task Force classification II-3). SETTING Department of gynecology at a general hospital. PATIENTS Nine patients with early postoperative hemorrhage after gynecologic laparoscopic surgery were treated by TAE between January 2004 and October 2007. Diagnostic 3-dimensional CT angiography was performed for identification of the bleeding artery before TAE in 5 of those patients. INTERVENTIONS Diagnostic 3-dimensional CT angiography and therapeutic emergency TAE. MEASUREMENTS AND MAIN RESULTS In all, 2952 patients (1165 laparoscopic-assisted vaginal hysterectomy [LAVH], 1086 adnexal surgery, 417 laparoscopic-assisted myomectomy [LAM], 222 ectopic pregnancy surgery, and 62 other) were treated by laparoscopic surgery between January 1994 and October 2007. Fourteen patients developed postoperative hemorrhagic shock (5 LAVH [0.43%], 1 adnexal surgery [0.09%], 7 LAM [1.68%], 1 ectopic pregnancy surgery [0.45%]). Since 2004, instead of second laparotomy or laparoscopy, TAE was primarily chosen to manage the postoperative hemorrhage for 3 cases after LAVH and 6 cases after LAM. In 5 cases experienced in the last 2 years, diagnostic 3-dimensional CT angiography was performed to identify the bleeding artery before TAE. Transfusion of preoperatively donated autologous blood and intraoperatively salvaged autologous blood was sufficient to maintain vital functions of the patients except in 1 case of LAM that required homologous blood transfusion before TAE as a result of significant delay in establishing the diagnosis. Postembolization course was uneventful except in 1 case of LAVH that developed vaginal stump abscess and required transvaginal drainage twice after readmission. CONCLUSION Emergency TAE is a safe and effective minimally invasive procedure for patients developing postoperative hemorrhage after gynecologic laparoscopic surgery. Diagnostic CT angiography could play a significant role in shortening the process of TAE by identifying the site of extravasation before TAE.

Early diagnosis and endovascular management of uterine artery pseudoaneurysm after laparoscopic-assisted myomectomy

OBJECTIVE To describe the diagnosis and management of uterine artery pseudoaneurysm after laparoscopic-assisted myomectomy. DESIGN Case reports. SETTING Departments of Obstetrics and Gynecology and Radiology at General Hospital. PATIENT(S) A 32-year-old woman and a 41-year-old woman each developed uterine artery pseudoaneurysm after laparoscopic-assisted myomectomy. INTERVENTION(S) Uterine artery pseudoaneurysm after laparoscopic-assisted myomectomy was diagnosed on ultrasonography, computerized tomographic angiography, and digital subtraction angiography, and treated by transcatheter arterial embolization. MAIN OUTCOME MEASURE(S) Uterine conservation. RESULT(S) Fertility preservation was achieved in both of these women who developed uterine artery pseudoaneurysm after laparoscopic-assisted myomectomy. CONCLUSION(S) Early diagnosis and endovascular management of uterine artery pseudoaneurysm after myomectomy are important to prevent life-threatening hemorrhage caused by pseudoaneurysmal rupture.

Diagnostic multimodal imaging and therapeutic transcatheter arterial chemoembolization for conservative management of hemorrhagic cesarean scar pregnancy.

OBJECTIVE To evaluate the value of emergency transcatheter arterial chemoembolization (TACE) for initial conservative management of hemorrhagic cesarean scar pregnancy after multimodal image diagnosis. STUDY DESIGN Five consecutive cases of hemorrhagic cesarean scar pregnancy were diagnosed for precise localization of ectopic placentation site, depth of placental invasion and uteroplacental neovascularization by imaging studies including color Doppler ultrasonography, magnetic resonance imaging (MRI) and three-dimensional computerized tomographic angiography. Emergency TACE with dactinomycin was initially performed to achieve immediate hemostasis and cytotoxic effects on chorionic villous tissue. Then, the need for either expectant management or subsequent hysteroscopic resection was individually determined. Systemic methotrexate (MTX) administration was added when delayed decline of serum hCG value was noted. RESULTS On MRI, total placental invasion to the serosa of the anterior uterine wall was diagnosed in three cases, while the two remaining cases showed subtotal invasion to the anterior uterine wall. All cases were managed by emergency TACE as an initial conservative measure. Subsequently, spontaneous expulsion of gestational products occurred in one case of subtotal placental invasion. Additional MTX administration was required to achieve complete resorption of cesarean scar pregnancy in two cases of total placental invasion. In one case of subtotal placental invasion, successful hysteroscopic resection was performed under laparoscopic guidance, whereas, in one case of total placental invasion, hysteroscopic removal of gestational products was incomplete due to the risk of uterine perforation and additional systemic MTX administration was required for complete resolution. Uterine preservation was achieved in all cases without unfavorable effects of TACE or secondary hemorrhagic complications. CONCLUSIONS This small case series emphasizes that TACE is potentially useful as an initial emergency intervention for conservative management of hemorrhagic cesarean scar pregnancy to achieve immediate hemostasis and direct cytotoxic effects on chorionic villous tissue with minimal systemic side effects of chemotherapeutic agent.

Conservative management of placenta increta after first trimester abortion by transcatheter arterial chemoembolization: a case report and review of the literature

IntroductionPlacenta increta is a potentially life-threatening condition that may complicate a first trimester abortion in rare occasion. However, the therapeutic value of transcatheter arterial chemoembolization for the conservative management of this disorder is not described.Case reportA 27-year-old woman (gravida 3, para 1) with significant obstetric history for one previous lower segment cesarean section and one dilatation and curettage for missed abortion had uncomplicated dilatation and curettage for missed abortion. Eight weeks after curettage, the patient presented with increased amounts of vaginal bleeding. Image diagnostic modalities localized the heterogeneous mass within the myometrium in the fundal portion of the uterine corpus. Initially, arteriovenous fistula formation after abortion was suspected. However, an elevated serum hCG value indicated the presence of retained placental tissue and gave the diagnosis of persistent placenta increta after a first trimester abortion. Transcatheter arterial chemoembolization with dactinomycin was initiated to achieve immediate hemostasis and cytocidal effects on the placental tissue. The post-interventional course was uneventful. Twenty days after chemoembolization, the serum hCG value decreased to a normal level and the mass lesion disappeared on ultrasonography without secondary hemorrhagic complications.ConclusionsAfter precise diagnostic imaging, transcatheter arterial chemoembolization is a useful minimally invasive procedure to achieve uterine preservation in women with placenta increta masquerading as arteriovenous fistula after a first trimester abortion.

Placental polyp with prominent neovascularization

Placental polyp is a potentially life-threatening disorder that develops after abortion or parturition. Evaluation of neovascularization by multimodal imaging is potentially useful in management of placental polyp in a woman who wishes to preserve fertility.

Temporary endovascular balloon occlusion of the bilateral internal iliac arteries for control of hemorrhage during laparoscopic-assisted myomectomy in a nulligravida with a large cervical myoma

OBJECTIVE To describe the preoperative evaluation and minimally invasive management of a large cervical myoma in a nulligravida who wished to preserve fertility. DESIGN Case report. SETTING Departments of obstetrics and gynecology and radiology at a general hospital. PATIENT(S) A 33-year-old nulligravida with a large cervical myoma. INTERVENTION(S) A large cervical myoma was preoperatively diagnosed by ultrasonography, magnetic resonance imaging, and computed tomographic angiography and was successfully treated with minimal blood loss by laparoscopic-assisted myomectomy combined with prophylactic temporary endovascular balloon occlusion of the bilateral internal iliac arteries. MAIN OUTCOME MEASURE(S) Uterine conservation. RESULT(S) Fertility preservation was achieved with minimal blood loss in a nulligravida with a large cervical myoma. CONCLUSION(S) Laparoscopic-assisted myomectomy combined with prophylactic endovascular balloon occlusion of the bilateral internal iliac artery was an effective minimally invasive procedure to preserve fertility in a nulligravida with a large cervical myoma.

Computed tomographic angiography in diagnosis and management of placental polyp with neovascularization

ObjectiveTo evaluate the neovascularization in placental polyp tissue by computed tomographic angiography and to determine the need for uterine artery embolization before hysteroscopic resection.Study designSeventeen consecutive women with suspected placental polyp were enrolled in this retrospective study. Neovascularization in placental polyp tissue was assessed by computed tomographic angiography. Cases with neovascularization were treated by hysteroscopic resection with preoperative uterine artery embolization, while cases without neovascularization were treated by hysteroscopic resection alone.ResultsOf 17 patients with suspected placental polyp after abortion or parturition, nine patients were diagnosed to have placental polyp with prominent neovascularization by computed tomographic angiography, and were treated by uterine artery embolization followed by hysteroscopic resection. Two patients subsequently conceived after conservative management.ConclusionsAfter precise evaluation of neovascularization by computed tomographic angiography, hysteroscopic resection with preoperative uterine artery embolization is an effective minimally invasive procedure to conservatively treat placental polyp with prominent neovascularization.

Temporary endovascular balloon occlusion of the bilateral internal iliac arteries to control hemorrhage during laparoscopic-assisted vaginal hysterectomy for cervical myoma

OBJECTIVE To report our initial experience with temporary endovascular balloon occlusion of the bilateral internal iliac arteries to control hemorrhage during laparoscopic-assisted vaginal hysterectomy (LAVH) for cervical myoma. STUDY DESIGN Thirteen patients with cervical myoma were treated by LAVH combined with temporary endovascular balloon occlusion of the bilateral internal iliac arteries from September 2008 to October 2010. Preoperative evaluation of cervical myoma was made by ultrasonography, magnetic resonance imaging and three-dimensional computerized tomographic angiography, and curative management was made by LAVH combined with temporary endovascular balloon occlusion of the bilateral internal iliac arteries. RESULTS Nine patients with extracervical myoma and 4 patients with intracervical myoma were successfully managed by LAVH combined with temporary endovascular balloon occlusion of the bilateral internal iliac arteries. For extracervical myomas, the median extirpated uterine weight was 591 g (range 360-1010 g). Median duration required for placement of balloon occlusion catheter was 60 min (range 47-69 min). Median surgical duration was 98.5 min (range 77-149 min). Median duration of endovascular balloon occlusion of the bilateral internal iliac arteries was 66 min (range 42-98 min). The median estimated blood loss was 355 mL (range 50-1950 mL). For intracervical myomas, the median extirpated uterine weight was 513 g (range 302-710 g). Median duration required for placement of balloon occlusion catheter was 63 min (range 42-76 min). Median surgical duration was 96.5 min (range 92-100 min). Median duration of endovascular balloon occlusion of the bilateral internal iliac arteries was 49 min (range 44-60 min). The median estimated blood loss was 210 mL (range 150-650 mL). Transfusion of preoperatively donated autologous blood negated the need for bank blood. There were no major interventional radiological and surgical complications in the present case series. CONCLUSIONS Temporary endovascular balloon occlusion of the bilateral internal iliac arteries is a feasible minimally invasive alternative to control hemorrhage during LAVH for cervical myoma.

Late occurrence of severe hyponatremia followed by extrapontine osmotic demyelination syndrome after successful conservative management of postpartum hemorrhage due to placenta accreta by uterine artery embolization

Development of severe hyponatremia followed by extrapontine osmotic demyelination syndrome was reported as a significant late complication after successful conservative management of postpartum hemorrhage due to placenta accreta by uterine artery embolization.