Gelfoam is feasible and safe for UAE uterine arteriovenous shunting

Uterine artery embolization (UAE) using gelfoam alone for symptomatic uterine arteriovenous shunting has a high technical and clinical success rate with few complications, according to radiologists at Beth Israel Deaconess Medical Center in Boston, who reported their study findings in the Aug. 10, 2019, online edition of the Journal of Vascular and Interventional Radiology.

Gelfoam is an absorbable, gelatin sponge used as a temporary embolization agent. Uterine arteriovenous malformation (AVM), characterized by a complex, tangled web of abnormal arteries and veins connected by one or more fistulas, is generally treated using permanent embolization agents, such as coils or glue.

“The treatment is very successful in stopping the vaginal bleeding,” principal investigator Olga R. Brook, MD, clinical director of computed tomography (CT), told Applied Radiology. “However due to permanent embolization agents, it may affect ability to become pregnant later or carry a fetus to term. In our practice, we have been using gelfoam with good success. Therefore, we decided to review our data to assess both technical and clinical success of the embolization, as well as long term fertility outcomes.”

The study focused on 18 patients, ranging in age from 21 to 45 years, who underwent 19 UAE procedures using gelfoam for arteriovenous shunting with associated uterine bleeding. The authors defined technical success as angiographic resolution of arteriovenous shunting at the end of the embolization procedure. Clinical success equated to cessation of symptomatic bleeding, minimal estimated blood loss on subsequent elective dilation and curettage (D&C) procedures, or resolution of findings on subsequent imaging studies.

An interventional radiologist performed bilateral UAE in all procedures using a gelfoam slurry consisting of gelfoam pledgets (Surgifoam, Ethicon, Somerville, MA) mixed with iodinated contrast and saline. One patient also needed embolization coals due to the large size of the shunt to prevent embolization of gelfoam in the central veins. Seven patients underwent D&C following UAE.

The clinical success rate was 94.1%. One patient required a repeat UAE, and subsequently suffered a pregnancy loss nearly 10 months following the second procedure. Two patients experienced complications: a pulmonary embolism diagnosed three days after UAE and a small-to-moderate-sized groin hematoma at the arterial access site.

Clinical follow-up averaged 19 months, with some patients followed for over four years. During this time, seven patients became pregnant. The authors stated that a longer follow-up would enable them to better assess the ability of women to become pregnant after having UAE with gelfoam.

“Gelfoam embolization has very good outcomes on patients who present with delayed post-partum hemorrhage, or who present with severe bleeding and delayed arteriovenous shunting on angiogram,” said Dr. Brook. “However, if a large proximal AV shunt is present in the injection of the uterine artery, we advise [using] adjunct coils for proximal embolization to prevent potential pulmonary emboli.”

REFERENCE

1. Camacho A, Ahn EH, Appel E, et al. Uterine artery embolization with gelfoam for acquired symptomatic uterine arteriovenous shunting. J Vasc Interv Radiol. Published online August 10, 2019. doi: 10.1016/j.jvir.2019.04.002.