Embolization of Spontaneous Rupture of an Aneurysm of the Ovarian Artery Supplying the Uterus with Fibroids

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1 Acta Radiologica ISSN: (Print) (Online) Journal homepage: Embolization of Spontaneous Rupture of an Aneurysm of the Ovarian Artery Supplying the Uterus with Fibroids M. Nakajo, K. Ohkubo, Y. Fukukura, T. Nandate & M. Nakajo To cite this article: M. Nakajo, K. Ohkubo, Y. Fukukura, T. Nandate & M. Nakajo (2005) Embolization of Spontaneous Rupture of an Aneurysm of the Ovarian Artery Supplying the Uterus with Fibroids, Acta Radiologica, 46:8, To link to this article: Published online: 09 Jul Submit your article to this journal Article views: 134 Full Terms & Conditions of access and use can be found at

2 CASE REPORT ACTA RADIOLOGICA Embolization of Spontaneous Rupture of an Aneurysm of the Ovarian Artery Supplying the Uterus with Fibroids M. NAKAJO, K.OHKUBO, Y.FUKUKURA, T.NANDATE &M.NAKAJO Department of Radiology, Imakiire General Hospital, Kagoshima, Japan; Department of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan Nakajo M, Ohkubo K, Fukukura Y, Nandate T, Nakajo M. Embolization of spontaneous rupture of an aneurysm of the ovarian artery supplying the uterus with fibroids. Acta Radiol 2005;46: We report a case of spontaneous retroperitoneal hemorrhage caused by rupture of an aneurysm of the right ovarian artery in a 55-year-old woman. Diagnosis was achieved by computed tomography and arteriography. The ruptured aneurysm was treated by transcatheter arterial embolization using microcoils and gelatin sponge particles. This is the first case of rupture of an aneurysm of the ovarian artery not related to pregnancy, and the third case of embolization of a ruptured ovarian artery aneurysm in the literature. We illustrate the usefulness of embolization in treatment of an ovarian artery aneurysm without surgery. Key words: Abdomen; aneurysms; angiography; computed tomography (CT); hemorrhage; ovaries Masayuki Nakajo, M.D., Ph.D., Department of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, Sakuragaoka, Kagoshima , Japan (fax , . nakajo@m.kufm.kagoshima-u.ac.jp) Spontaneous rupture of an ovarian artery aneurysm is rare, occurring most frequently in the early postpartum (, 4 days) (1, 2, 4, 6) and the late puerperium (5). We describe a case of embolization of spontaneous rupture of an aneurysm of the right ovarian artery supplying the uterus with fibroids. Case Report A 55-year-old post-menopausal female, Para II was admitted to our hospital with sudden onset of right flank pain on 27 April She had been in good health and had no history of trauma to the abdomen. Her first delivery was normal in 1975 and she received a cesarean section on the second delivery in Physical examination revealed right flank tenderness. She underwent a computed tomography (CT) examination immediately after admission. Unenhanced CT demonstrated a massive retroperitoneal hematoma ( cm) from the middle pole of the right kidney to the pelvic space. Contrast-enhanced dynamic CT showed a 565 mm enhancing oval structure in the hematoma in the arterial phase (Fig. 1A) and extravasation of contrast-medium in the hematoma in the venous phase (Fig. 1B), suggesting a retroperitoneal hematoma due to rupture of the aneurysm of an artery. There was no evidence of tumor involving the kidney or adrenal gland, but the uterus was swollen due to uterine fibroids (Fig. 1C), confirmed by MRI. A moderate anemia (RBC /ml, HB 11.1 g/dl) was noted 5 h after admission, but did not progress thereafter. The hematoma had decreased in size ( cm) without any sign of extravasation on a follow-up examination the next day. Surgical intervention was not therefore performed. On the 30th day after admission, a contrastenhanced dynamic CT examination demonstrated an enhancing oval structure in the inferior portion of the hematoma, which had increased in size (10610 mm) (Fig. 2), suggesting an impending re-rupture of the aneurysm. An abdominal aortography and selective arteriography of the celiac, superior mesenteric, inferior mesenteric, bilateral renal, and bilateral ovarian DOI / # 2005 Taylor & Francis

3 888 M. Nakajo et al. A B C Figure 1. A C. Arterial (A) and venous (B) phase contrast-enhanced CT images obtained at onset. An enhancing oval structure (arrowhead) can be seen in the retroperitoneal hematoma (arrow) (A). There is extravasation of contrast medium (arrow) in the hematoma (B). The uterus is swollen and lobulated (C). The highly attenuated spot in B is the right ureter (arrowhead). arteries were thereafter performed to identify the artery with an aneurysm. Abdominal aortograms demonstrated both ovarian arteries originating from the aorta. The other arteries had no relationship to the hematoma. Selective right ovarian arteriography showed a characteristic tortuous course of the enlarged ovarian artery with fine branches surrounding the hematoma. The right ovarian artery also supplied the uterus with fibroids. The aneurysm was observed at the middle third of the artery (Fig. 3A). A microcatheter (Renegade; Boston Scientific, Natick, Mass., USA) was introduced into a diagnostic 5-Fr cobra catheter (Hanako Medical, Tokyo, Japan) for treatment of the aneurysm (Fig. 3B). We were unable to introduce the microcatheter into the artery distal to the aneurysm because of tortuousness of the ovarian artery and a risk of rupturing the aneurysm during the procedure., Three microcoils (Trufill; Cordis, Miami, Fl., USA) were therefore placed in the artery proximal to the aneurysm, followed by injection of gelatin sponge particles (Gelfoam; Pfizer, Kalamazoo, Mich., USA). The aneurysm was successfully embolized in this way (Fig. 4). Although selective arteriography of the uterine arteries on both sides was not performed, they were not enlarged on abdominal aortography. The angiographic and therapeutic procedures took a total of 3 h and 100 ml of contrast medium [Iopamilon 300 (Iopamidol); Schering, Osaka, Japan] was used without sedatives. Pelvic MRI 4 months after embolization showed two intramural fibroids within the uterine fundus. Contrast-enhanced dynamic CT 7 months after embolization demonstrated a small hematoma (26161 cm) in the retroperitoneal space, and disappearance of the aneurysm.

4 Discussion Spontaneous Retroperitoneal Hemorrhage 889 Fig. 2. Arterial phase contrast-enhancement CT image obtained after 30 days from onset. The retroperitoneal hematoma has lessened in size from that at onset, but the enhancing oval structure (arrow) has increased in size. Most of the reported cases of rupture of an ovarian artery aneurysm have been related to pregnancy (1, 2, 4 6). The pregnancy-related mechanisms that may lead to aneurysmal formation and rupture are not fully understood, but are thought to include both hemodynamic and hormonal changes (1, 2, 6). In the present case, selective right ovarian arteriography revealed that the enlarged ovarian artery supplied the uterus. The uterine arteries on both sides were not enlarged on abdominal aortography. PELAGE et al. (7) reported embolization of the ovarian artery in the management of uterine fibroids. They considered that a large ovarian artery extending to the pelvis with a significant flow to the uterus was likely to be an additional arterial supply to the fibroids, and the fibroids might be supplied by the ovarian arteries, especially in women with prior pelvic surgery or large fundal fibroids. A B Fig. 3. A, B. Right ovarian artery angiograms show that the right enlarged tortuous ovarian artery with an aneurysm (arrowheads) supplies the uterine fibroids (arrow).

5 890 M. Nakajo et al. Embolization of a ruptured aneurysm of the ovarian artery with coils has been reported in 2 cases (4, 6). In the present case, we considered it reasonable to place microcoils in both sides distal and proximal to the aneurysmal neck for prevention of recanalization of the aneurysm through collateral circulation (3, 8), because the ovarian artery anastomoses with the uterine artery (7). However, we were unable to introduce the microcatheter into the artery distal to the aneurysm because of the risk of rupture of the aneurysm during the procedure. The aneurysm was therefore embolized with microcoils and gelatin sponge particles proximal to it. Follow-up CT 7 months after embolization showed the occluded aneurysm without retrograde perfusion. Further follow-up studies are necessary to reveal if the occluded aneurysm will be recanalized. References Fig. 4. Right ovarian artery angiogram obtained after embolization reveals successful embolization of the ovarian artery and disappearance of the aneurysm. Our case had had prior pelvic surgery with cesarean section and the enlarged right ovarian artery was found to supply the uterus with fibroids. We believe that this significant variation in the distribution of blood flow may induce structural changes in the artery, thereby predisposing formation of an aneurysm. 1. Blachar A, Bloom AI, Golan G, Venturero M, Bar-ziv J. Spiral CT imaging of a ruptured post-partum ovarian artery aneurysm. Clin Radiol 2000;55: Burnett RA, Carfrae DC. Spontaneous rupture of ovarian artery aneurysm in the puerperium: two case reports and a review of the literature. Br J Obstet Gynaecol 1976;83: Gabelmann A, Gorich J, Merkle EM. Endvascular treatment of visceral artery aneurysms. J Endovasc Ther 2002;9: Guillem P, Bondue X, Chambon JP, Lemaitre L, Bounoua F. Spontaneous retroperitoneal hematoma from rupture of an aneurysm of the ovarian artery following delivery. Ann Vasc Surg 1999;13: Jafari K, Saleh I. Postpartum spontaneous rupture of ovarian artery aneurysm. Obstet Gynecol 1977;49: King WLM. Ruptured ovarian artery aneurysm: a case report. J Vasc Surg 1990;12: Pelage JP, Walker WJ, Dref OL, Rymer R. Ovarian artery: angiographic appearance, embolization and relevance to uterine fibroid embolization. Cardiovasc Intervent Radiol 2003;26: Rundback JH, Chughtai S, Rozenblit G, Panageas E, Poplausky M. Traumatic ilecolic pseudoaneurysm: diagnosis and transcatheter treatment. Cathet Cardiovasc Intervent 1999;48: