DOI: 10.1148/rg.25si055510
Uterine Fibroid Vascularization and Clinical Relevance to Uterine Fibroid Embolization1
Jean-Pierre Pelage, MD, PhD,
Julien Cazejust, MD,
Etienne Pluot, MD,
Olivier Le Dref, MD,
Alexandre Laurent, MD, PhD,
James B. Spies, MD,
Sophie Chagnon, MD and
Pascal Lacombe, MD
1 From the Department of Radiology, Hôpital Ambroise Paré, 9 ave Charles-de-Gaulle, 92104 Boulogne Cedex, France (J.P.P., J.C., E.P., S.C., P.L.); Departments of Body and Vascular Imaging (O.L.D.) and Neuroradiology (A.L.), Hôpital Lariboisière, Paris, France; and Department of Radiology, Georgetown University Medical Center, Washington, DC (J.B.S.). Recipient of a Certificate of Merit award for an education exhibit at the 2004 RSNA Annual Meeting. Received February 15, 2005; revision requested March 25 and received June 7; accepted June 27. J.P.P. is a consultant with Biocompatibles, Biosphere Medical, and Boston Scientific, from which he has received research funding; J.B.S. is a consultant with Biosphere Medical and Boston Scientific, from which he has received research funding; and all remaining authors have no financial relationships to disclose.
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Figure 1. Digital subtraction angiogram (right anterior oblique projection) obtained with selective injection via the left internal iliac artery shows the division of the artery into two main stems (anterior stem, A; and posterior stem, P) and three branches (inferior gluteal artery, 1; uterine artery, 2; and superior gluteal artery, 3).
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Figure 2. Digital subtraction angiogram obtained with selective injection via the right common iliac artery shows the absence of the right internal iliac artery and the origin of all pelvic branches, including the uterine artery (UA), in the common iliac artery (arrow). (Courtesy of Jean-Louis Bertrand, MD, Centre Hospitalier de Perpignan, Perpignan, France.)
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Figure 3a. (a, b) Digital subtraction angiograms obtained with selective injection via the right internal iliac artery show, in left anterior oblique projection (a) and right (ipsilateral) oblique projection (b), the origin of the uterine artery (UA), which is best depicted in b (arrow) because of its location closer to the origin of the hypogastric artery. (c) Right anterior projection obtained with digital subtraction angiography shows superselective catheterization achieved by using a microcatheter and a guidewire with 90° angulation.
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Figure 3b. (a, b) Digital subtraction angiograms obtained with selective injection via the right internal iliac artery show, in left anterior oblique projection (a) and right (ipsilateral) oblique projection (b), the origin of the uterine artery (UA), which is best depicted in b (arrow) because of its location closer to the origin of the hypogastric artery. (c) Right anterior projection obtained with digital subtraction angiography shows superselective catheterization achieved by using a microcatheter and a guidewire with 90° angulation.
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Figure 3c. (a, b) Digital subtraction angiograms obtained with selective injection via the right internal iliac artery show, in left anterior oblique projection (a) and right (ipsilateral) oblique projection (b), the origin of the uterine artery (UA), which is best depicted in b (arrow) because of its location closer to the origin of the hypogastric artery. (c) Right anterior projection obtained with digital subtraction angiography shows superselective catheterization achieved by using a microcatheter and a guidewire with 90° angulation.
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Figure 4. Digital subtraction angiogram obtained with selective uterine artery injection shows the characteristic arterial course, with an initial descending segment (D), a transverse segment (T) from which the cervicovaginal artery (CV) originates, and an ascending segment (A). Numerous intramural arteries (arrows) also are visible.
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Figure 5. Digital subtraction angiogram obtained with selective injection via the right genitourinary artery trunk shows right cervicovaginal (CV), vesical (V), and uterine (UA) arteries that arise from the anterior division of the internal iliac artery via a common genitourinary artery trunk (GU).
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Figure 6. Flush pelvic aortogram shows replacement of both uterine arteries by multiple small arteries (arrows).
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Figure 7a. (a) Flush pelvic aortogram shows no flow through the uterine arteries from the internal iliac artery, while both ovarian arteries, which arise from the infrarenal aorta, are visible (arrows). (b, c) Digital subtraction angiograms obtained with selective injection via the right (b) and left (c) ovarian arteries confirm ovarian arterial supply to the uterus.
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Figure 7b. (a) Flush pelvic aortogram shows no flow through the uterine arteries from the internal iliac artery, while both ovarian arteries, which arise from the infrarenal aorta, are visible (arrows). (b, c) Digital subtraction angiograms obtained with selective injection via the right (b) and left (c) ovarian arteries confirm ovarian arterial supply to the uterus.
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Figure 7c. (a) Flush pelvic aortogram shows no flow through the uterine arteries from the internal iliac artery, while both ovarian arteries, which arise from the infrarenal aorta, are visible (arrows). (b, c) Digital subtraction angiograms obtained with selective injection via the right (b) and left (c) ovarian arteries confirm ovarian arterial supply to the uterus.
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Figure 8. Anatomic variants. Flush pelvic aortogram depicts two moderately enlarged ovarian arteries (arrows): a left ovarian artery that arises from the aorta, and a right ovarian artery that arises from the right renal artery (*).
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Figure 9. Anatomic variants. Flush pelvic aortogram shows a right ovarian artery that arises from the right common iliac artery and supplies a large fundal fibroid tumor (F). (Courtesy of Gerald Zemel, MD, Miami Cardiac and Vascular Institute, Miami, Fla.)
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Figure 10. Digital subtraction angiogram obtained with selective injection via the left external iliac artery (*) shows a left round ligament artery (arrow) that arises from the inferior epigastric artery and supplies the left side of the uterus. (Reprinted, with permission, from reference 13.)
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Figure 11. Digital subtraction angiogram obtained with selective injection via the left uterine artery (LUA) shows transverse anastomosis (arrow) between that artery and the right uterine artery (RUA) and retrograde opacification of the left artery via a utero-ovarian anastomosis (OA).
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Figure 12. Digital subtraction angiogram obtained with selective injection via the left uterine artery (UA) depicts reflux into the ovarian artery (OA), a sign of anastomosis between the uterine and ovarian arteries.
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Figure 13. Digital subtraction angiogram obtained with selective injection via the right uterine artery shows reflux into the ovarian artery, with resultant opacification of the ovary (arrow). Ut = uterus.
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Figure 14. Anatomic drawing shows the arterial blood supply (short arrows) to the uterus and three fibroid tumors (F). The perifibroid plexus is composed of arteries with diameters of 500–1000 µm in most cases. The diameter of the utero-ovarian anastomosis (long arrow) is usually less than 500 µm. (Reprinted, with permission, from reference 7.)
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Figure 15. Photomicrograph (hematoxylin-safran-eosin stain; magnification, x200) of a specimen from the periphery of an intramural fibroid tumor (F), which was resected immediately after embolization, shows targeted occlusion of the perifibroid arterial plexus with 500–700-µm-diameter calibrated microspheres (arrows).
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Figure 16. Flush pelvic aortogram shows diffuse uterine hypervascularity in a woman with a uterus enlarged (volume, 800 mL) by multiple fibroid tumors.
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Figure 17. Late arterial phase flush pelvic aorto-gram in a woman with three intramural fibroid tumors shows three separate areas of localized hypervascularity with dimensions that correspond to those of the fibroid tumors.
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Figure 18. Flush pelvic aortogram in a patient with multiple fibroids depicts two enlarged ovarian arteries (arrows) that originate from the aorta.
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Figure 19. Digital subtraction angiogram obtained with selective injection via a left ovarian artery with origin in the aorta shows enlargement of the artery and a large hypervascular fundal fibroid tumor (F).
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Figure 20a. (a) Sagittal T2-weighted MR image shows a large fundal fibroid tumor (F) in a patient who previously underwent myomectomy. (b) Flush pelvic aortogram in the same patient depicts an enlarged right ovarian artery (OA) that originates from the aorta and supplies the fundal fibroid. Both uterine arteries (arrows) are also visible.
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Figure 20b. (a) Sagittal T2-weighted MR image shows a large fundal fibroid tumor (F) in a patient who previously underwent myomectomy. (b) Flush pelvic aortogram in the same patient depicts an enlarged right ovarian artery (OA) that originates from the aorta and supplies the fundal fibroid. Both uterine arteries (arrows) are also visible.
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Figure 21. Flush pelvic aortogram in a patient with a pedunculated subserosal fibroid tumor shows a large left lumbar artery that supplies the fibroid (*). (Courtesy of Woodruff Walker, MBBS, FRCR, Royal Surrey Hospital, Guildford, England.)
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Figure 22a. (a) Contrast-enhanced sagittal MR image in a patient with a left-sided pedunculated subserosal fibroid tumor (F) shows the arterial pedicle (arrow). (b) Digital subtraction angiogram obtained with selective injection via the left uterine artery in the same patient depicts the same arterial pedicle (arrow) and tumor (F).
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Figure 22b. (a) Contrast-enhanced sagittal MR image in a patient with a left-sided pedunculated subserosal fibroid tumor (F) shows the arterial pedicle (arrow). (b) Digital subtraction angiogram obtained with selective injection via the left uterine artery in the same patient depicts the same arterial pedicle (arrow) and tumor (F).
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Figure 23a. (a) Axial T2-weighted image shows a bicornate uterus with a single intramural fibroid tumor (F) on the left side. (b) Early arterial phase flush pelvic aorto-gram in the same patient shows exclusive supply to the fibroid tumor from the left uterine artery (arrow) and a small right uterine artery. (c) Late phase digital subtraction angiogram depicts hypervascularity of the fibroid (F). (Courtesy of Woodruff Walker, MBBS, FRCR, Royal Surrey Hospital, Guildford, England.)
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Figure 23b. (a) Axial T2-weighted image shows a bicornate uterus with a single intramural fibroid tumor (F) on the left side. (b) Early arterial phase flush pelvic aorto-gram in the same patient shows exclusive supply to the fibroid tumor from the left uterine artery (arrow) and a small right uterine artery. (c) Late phase digital subtraction angiogram depicts hypervascularity of the fibroid (F). (Courtesy of Woodruff Walker, MBBS, FRCR, Royal Surrey Hospital, Guildford, England.)
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Figure 23c. (a) Axial T2-weighted image shows a bicornate uterus with a single intramural fibroid tumor (F) on the left side. (b) Early arterial phase flush pelvic aorto-gram in the same patient shows exclusive supply to the fibroid tumor from the left uterine artery (arrow) and a small right uterine artery. (c) Late phase digital subtraction angiogram depicts hypervascularity of the fibroid (F). (Courtesy of Woodruff Walker, MBBS, FRCR, Royal Surrey Hospital, Guildford, England.)
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Figure 24a. (a) Power Doppler US image in a patient with a 5-cm-diameter intramural fibroid tumor shows characteristic peripheral arterial flow that corresponds to the perifibroid plexus (arrows). (b) Pulsed Doppler US image in the same patient shows a low resistance index (0.50) in the periphery of the fibroid tumor.
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Figure 24b. (a) Power Doppler US image in a patient with a 5-cm-diameter intramural fibroid tumor shows characteristic peripheral arterial flow that corresponds to the perifibroid plexus (arrows). (b) Pulsed Doppler US image in the same patient shows a low resistance index (0.50) in the periphery of the fibroid tumor.
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Figure 25a. (a) Color Doppler US image in a woman with diffuse adenomyosis shows dense intramural vascularity. (b) Flush pelvic aortogram shows multiple small abnormal intramural arteries and patchy uterine vascularization, findings that are consistent with adenomyosis.
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Figure 25b. (a) Color Doppler US image in a woman with diffuse adenomyosis shows dense intramural vascularity. (b) Flush pelvic aortogram shows multiple small abnormal intramural arteries and patchy uterine vascularization, findings that are consistent with adenomyosis.
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Figure 26a. (a) MR angiogram before uterine fibroid embolization nicely depicts trifurcation of the right internal iliac artery and a kink at the origin of the uterine artery (UA). (b) Digital subtraction angiogram obtained with selective injection via the right internal iliac artery in the same patient demonstrates good correlation between MR angiography and digital subtraction angiography.
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Figure 26b. (a) MR angiogram before uterine fibroid embolization nicely depicts trifurcation of the right internal iliac artery and a kink at the origin of the uterine artery (UA). (b) Digital subtraction angiogram obtained with selective injection via the right internal iliac artery in the same patient demonstrates good correlation between MR angiography and digital subtraction angiography.
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Figure 27. MR angiogram in a patient with multiple uterine fibroid tumors shows two uterine arteries and two enlarged ovarian arteries.
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Figure 28. Sagittal contrast-enhanced MR image in a patient with multiple fibroid tumors shows intense enhancement of intramural fibroid tumors (F).
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Figure 29a. (a, b) Digital subtraction angiograms obtained with injections in the right (a) and left (b) uterine arteries after embolization with 355–500-µm-diameter nonspherical polyvinyl alcohol particles show an area of stasis and myometrial devascularization (arrow). (c) Postembolization contrast-enhanced MR image shows the same area of devascularization (arrows) and helps confirm the infarction of all fibroids (F).
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Figure 29b. (a, b) Digital subtraction angiograms obtained with injections in the right (a) and left (b) uterine arteries after embolization with 355–500-µm-diameter nonspherical polyvinyl alcohol particles show an area of stasis and myometrial devascularization (arrow). (c) Postembolization contrast-enhanced MR image shows the same area of devascularization (arrows) and helps confirm the infarction of all fibroids (F).
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Figure 29c. (a, b) Digital subtraction angiograms obtained with injections in the right (a) and left (b) uterine arteries after embolization with 355–500-µm-diameter nonspherical polyvinyl alcohol particles show an area of stasis and myometrial devascularization (arrow). (c) Postembolization contrast-enhanced MR image shows the same area of devascularization (arrows) and helps confirm the infarction of all fibroids (F).
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Figure 30a. (a, b) Digital subtraction angiograms obtained with selective injection via the left uterine artery before (a) and after (b) limited embolization with 500–700-µm-diameter tris-acryl microspheres. The postembolization image shows patency of the main uterine artery (arrow) and cervicovaginal branches (CV). (c, d) Contrast-enhanced sagittal MR images obtained before (c) and 24 hours after (d) embolization. The postembolization image shows normal perfusion of the myometrium and infarction of the three fibroid tumors (F).
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Figure 30b. (a, b) Digital subtraction angiograms obtained with selective injection via the left uterine artery before (a) and after (b) limited embolization with 500–700-µm-diameter tris-acryl microspheres. The postembolization image shows patency of the main uterine artery (arrow) and cervicovaginal branches (CV). (c, d) Contrast-enhanced sagittal MR images obtained before (c) and 24 hours after (d) embolization. The postembolization image shows normal perfusion of the myometrium and infarction of the three fibroid tumors (F).
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Figure 30c. (a, b) Digital subtraction angiograms obtained with selective injection via the left uterine artery before (a) and after (b) limited embolization with 500–700-µm-diameter tris-acryl microspheres. The postembolization image shows patency of the main uterine artery (arrow) and cervicovaginal branches (CV). (c, d) Contrast-enhanced sagittal MR images obtained before (c) and 24 hours after (d) embolization. The postembolization image shows normal perfusion of the myometrium and infarction of the three fibroid tumors (F).
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Figure 30d. (a, b) Digital subtraction angiograms obtained with selective injection via the left uterine artery before (a) and after (b) limited embolization with 500–700-µm-diameter tris-acryl microspheres. The postembolization image shows patency of the main uterine artery (arrow) and cervicovaginal branches (CV). (c, d) Contrast-enhanced sagittal MR images obtained before (c) and 24 hours after (d) embolization. The postembolization image shows normal perfusion of the myometrium and infarction of the three fibroid tumors (F).
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Figure 31a. (a) Flush pelvic aortogram obtained after bilateral uterine artery embolization in a woman with a large fundal fibroid shows additional supply to the uterus via an ovarian artery (arrow). Embolization of the ovarian artery was not performed because specific informed consent had not been obtained from the patient. (b) Postembolization contrast-enhanced MR image shows persistent perfusion (arrow) of the right inferior portion of the fibroid tumor. (c) Digital subtraction angiogram obtained with selective injection via the ovarian artery because of clinical recurrence 1 year later shows additional arterial supply to the fibroid. Embolization was performed by using 500–700-µm-diameter tris-acryl microspheres. (d) Postembolization contrast-enhanced MR image shows complete infarction of the fibroid and normal perfusion of the surrounding myometrium.
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Figure 31b. (a) Flush pelvic aortogram obtained after bilateral uterine artery embolization in a woman with a large fundal fibroid shows additional supply to the uterus via an ovarian artery (arrow). Embolization of the ovarian artery was not performed because specific informed consent had not been obtained from the patient. (b) Postembolization contrast-enhanced MR image shows persistent perfusion (arrow) of the right inferior portion of the fibroid tumor. (c) Digital subtraction angiogram obtained with selective injection via the ovarian artery because of clinical recurrence 1 year later shows additional arterial supply to the fibroid. Embolization was performed by using 500–700-µm-diameter tris-acryl microspheres. (d) Postembolization contrast-enhanced MR image shows complete infarction of the fibroid and normal perfusion of the surrounding myometrium.
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Figure 31c. (a) Flush pelvic aortogram obtained after bilateral uterine artery embolization in a woman with a large fundal fibroid shows additional supply to the uterus via an ovarian artery (arrow). Embolization of the ovarian artery was not performed because specific informed consent had not been obtained from the patient. (b) Postembolization contrast-enhanced MR image shows persistent perfusion (arrow) of the right inferior portion of the fibroid tumor. (c) Digital subtraction angiogram obtained with selective injection via the ovarian artery because of clinical recurrence 1 year later shows additional arterial supply to the fibroid. Embolization was performed by using 500–700-µm-diameter tris-acryl microspheres. (d) Postembolization contrast-enhanced MR image shows complete infarction of the fibroid and normal perfusion of the surrounding myometrium.
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Figure 31d. (a) Flush pelvic aortogram obtained after bilateral uterine artery embolization in a woman with a large fundal fibroid shows additional supply to the uterus via an ovarian artery (arrow). Embolization of the ovarian artery was not performed because specific informed consent had not been obtained from the patient. (b) Postembolization contrast-enhanced MR image shows persistent perfusion (arrow) of the right inferior portion of the fibroid tumor. (c) Digital subtraction angiogram obtained with selective injection via the ovarian artery because of clinical recurrence 1 year later shows additional arterial supply to the fibroid. Embolization was performed by using 500–700-µm-diameter tris-acryl microspheres. (d) Postembolization contrast-enhanced MR image shows complete infarction of the fibroid and normal perfusion of the surrounding myometrium.
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Figure 32. Photomicrograph (hematoxylin-safran-eosin stain; magnification, x4) of a resected fallopian tube 6 months after embolization of a uterine fibroid tumor with 300–500-µm-diameter tris-acryl microspheres shows nontarget embolization of a tubal branch by a microsphere (arrow).
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Figure 33a. (a) Digital subtraction angiogram obtained with selective injection via the left uterine artery during embolization shows a large collateral artery that supplies the ovary (arrow) and patency of some arterial branches in the fibroid tumor. (b) After embolization of the utero-ovarian anastomosis with a 2 x 20-mm coil (arrow) to protect the ovary, uterine artery embolization was safely completed.
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Figure 33b. (a) Digital subtraction angiogram obtained with selective injection via the left uterine artery during embolization shows a large collateral artery that supplies the ovary (arrow) and patency of some arterial branches in the fibroid tumor. (b) After embolization of the utero-ovarian anastomosis with a 2 x 20-mm coil (arrow) to protect the ovary, uterine artery embolization was safely completed.
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Copyright © 2005 by the Radiological Society of North America.
