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Pictorial
Essay
Arterial
Anatomy
of the Female
Genital
and Relevance to Transcatheter
Embolization
Tract: Variations
of the Uterus
Jean-Pierre
Henri
Roland
Pelage12,
Olivier
ranscatheter
is
arterial
commonly
ing due
to various
causes,
disorders
[I,
arterial
2].
Recently,
uterine
arteries
of this technique
knowledge
necessitates
of the arterial
genital
tract
procedures
can
of
adjunct
anatomy
so that
safer
be performed
greater
of the fe-
of the internal
and
iliac
in uterine
Material
Jacob3,
untargetted
studies
of
artery,
the
especially
vascularization.
pictorial
study
essay
is based
on the
who
underwent
of 197 patients
embolization
between
Although
most
July
vascular
cervical
malignancies
Received
1994
and
retrospecuterine
Mourad
KardaChe1,
and
and abnormal
nal
iliac
artery
division
uterine
and
were
artery.
Tokyo,
philic
selective
performed
nonionic
in all
contrast
Dahan1,
Jean-Pierre
Lassau2,
iohexol
(Omnipaque
France).
In six patients,
(Tracker
18;
CA) was
terization.
needed
Target
Selective
the
ipsilateral
tive
study
internal
of the uterine
ity of iodinated
the
study
material
of branches
cathe-
stem
performed
Because
the potential
and radiation
of the
of
superselec-
then
in all patients.
regarding
contrast
Paris,
Fremont,
and
was
indications
for Uterine
Itely
Embolization
microcatheter
of the anterior
artery
to
of
Nycomed,
artery
was limited
in all patients.
ml of
superselective
iliac
arteries
us-
injection
Therapeutics,
study
arteries
and a hydroguidewire
a 3-French
to perform
anastomotic
Angiographic
and anatomic examinations
were
performed
by two observers
independently.
Of the
394 angiographic
studies (two each for 197 patients) that were available
for review.
19 angiograms
(5%) were excluded
because they did not
include
the internal iliac artery. Thus. 375 angio-
of the
of 10-15
300;
and other
the procedure-relevant
Terumo.
Each
consisted
artery
of the
(Radifocus:
197 patients.
media
internal
of
toxic-
exiliac
24, 1998.
Department
Iioth-
anterior
origin
0361-803X/99/1724-989
of the
the
catheterization
catheter
Institut
AJR 1999;172:989-994
and
cobra
(Radifocus)
posure,
study
to find
Superselective
uterine
and Gynecology,
or
young
healthy.
with normal
arterial
supply.
Indications
to perform
embolotherapy
were uterme myoma (n = 133); postpartum
(ii = 49), postabortion
(, = 5). and
postoperative
(n = 2)
hemorrhage:
and bleeding related to adenomyosis
(a = 3), malformation
(ii = 1 ), or cancer
(n = 4)
(Table I ). Angiography
of the contralateral
inter-
of Obstetrics
postpartum
are usually
dAnatomie
with
bleeding
erwise
ethical
November
malformations
have complex
women
broid-related
ing a 5-French
and Methods
This
1997.
Denis
contralateral
embolization
embolization
avoided.
Angiographic
provide
a comprehensive
assessment
anatomy
the
or as
leiomyoma
ceptance
trauma
embolization
to surgery
uterine
obstetric
pelvic
and
the
bleed-
including
as a preoperative
an alternative
tive
Soyer1,
vascularization,
in
of intractable
and gynecologic
male
Philippe
embolization
performed
management
ing
Le Dref1,
Rymer1
Cedex
correspondence
to J.-P. Pelage.
06, France.
H#{227}pital
Lariboisi#{232}re,
75475 Paris Cedex 10, France.
American
Roentgen
Ray Society
989
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Pelage
grams of the internal iliac artery were available for
review. During the review, special attention
was
given to trunk formation and the sequence of main
branches from the internal iliac artery. The origin,
width, course, and branches of the uterine artery
were noted. Anastomoses
were searched
for. Arteries that mimicked
the uterine
artery and other
arteries selectively studied were analyzed.
three
panietal
branches
(obturator,
inferior
gluteal, and internal pudendal)
and three visceral vessels
dle rectal)
Origin
ofthe
of the uterine
(Figs.
division
Artery
of the uterine
oblique
the uterine
ofthe
artery
internal
artery
was usually
10 cases of life-threatening
iliac
nal
procedure
Internal
The
hemorrhage,
of the anterior
to great
on successful
in free-flow
in 191
cobra catheter
5-French
patients
the width
2). When
arteries
(26%)
used to prevent
of the uterine
(Fig.
and in-
(97%)
(1 French
the anterior
Evaluation
variation:
catheterization
tween
from
or
6).
with
artery
was
was noticed
Va.sodilators
or treat uterine
bein 97
were
artery
0.33 mm).
not
spasm.
em-
of the inter-
division
was subject
artery
Thus,
one, three,
from
Contralat-
originated
views.
artery
jection
on anteroposterior
anterior
when
catheterization
Uterine
The origin
not visible
Superselective
uterovaginal,
(vesical,
were identified
the uterine
was based
end
Results
et al.
to shorten
exposure.
the
IliacArtery
internal
iliac
artery
terminated
into
and
main
one
stem
in 4%
of cases
4). No systematization
was possible
in
2% of cases.
In all cases, the posterior
trunk
gave rise to the iliolumbar,
the lateral sacral,
(Fig.
branch.
as well defined
anterior
as the posterior
division
3). The
the terwas
not
stem: Usually
Fig. 2.-28-year-old
woman with primary postpartum
hemorrhage. Digital subtraction angiogram of right internal iliac artery in left anterior oblique projection
(contralateral oblique) shows division into two main
stems. Note anteriortrunk (arrow) and posterior trunk
(arrowhead).
1 = enlarged uterine artery, 2 = umbilical
artery, 3 = vaginal artery, 4 = inferior gluteal artery, 5 =
obturator artery, 6 = pudendal artery.
990
Fig. 1.-Anatomic
drawing shows lateral view of division offemale internal iliac artery into two main stems. Note
that uterine artery is branch of anterior division of internal iliac artery. Piriformis muscle (orange), sacrospinal
ligament (light green), and sacrotuberal ligament (dark green) are also portrayed.
Fig. 3.-39-year-old
woman with uterine fibroids. Digital subtraction angiogram of left internal iliac artery in
right anterior oblique projection (contralateral
oblique) shows division into two main stems. Note postenor branches: 1 = iliolumbar artery, 2 = superior sacral
artery, 3 = inferior sacral artery, 4 = superior gluteal artery. Uterine artery is indicated by arrow.
Fig. 4-41-year-old
Digital
subtraction
woman
angiogram
iliac arposterior
internal puden-
Arterial
Course ofthe
We
Uterine
identified
Artery
the
characteristic
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downward
and medially
141, which
segment
(Fig.
U-shaped
consists
running
7). a transversal
Anatomy
of the
ligament
segment
me arch
part,
segment
running
[4] (Fig.
8).
the artery
At
Female
coursing
and
Tract
the uter-
and divided
branches-tubal
or ascending
and ovarian-creating
anastomoses
the side
of the uterus
ovarian
[4, 5] (Figs.
angle
of the uterus,
the superior
penetrated
medially,
the marginal
along
Genital
into
the broad
ligament
branches
artery
Branches ofthe
Uterine
Most branches
with
the
9 and 10).
Artery
of the uterine
artery
were iden-
When
originated
covaginal
branch
small
was not
size. Intramural
the utetine
iliac artery,
seen
branches
because
arising
artery
along
the
branches
ofthe
arcuate
arteries
were anastomosed
contralateral
side
ofthe ovarian
(Fig.
Artery
Identification
anterolaterally
from
the abdominal
sinuous
tomosed
woman with uterine fibroids. Digital subtraction
angiograms
of left internal iliac artery in
right anterior oblique projection
(contralateral)
300 oblique (A) and left anterior (homolateral)
30#{176}
oblique (B). Origin of uterine artery (arrow, A and B) is well identified on homolateral
oblique because of its upper origin.
(Fig.
14). This
artery
in
at
body (Fig.
its characartery
anas-
Arteria!Anastomoses
Fig. 5.-42-year-old
course
aorta below
on aortography
was positioned
12).
Fig. 1.-40-year-old
subtraction
angiogram
injection
Three
Transversal
types
of anastomoses
were
anastomoses
between
identified.
right and
Fig. 8.-29-year-old
woman with primary postpartum
hemorrhage related to uterine atony. Digital subtraction
angiogram
of superselective
injection
tery shows ascending segment (1) and numerous intramural branches (2).
991
Fig. 9.-Anatomic
drawing of normal
vascularization
of uterus and adnexa shows internal iliac artery (IIA);
ovarian artery (0) originating from
left uterine
tween
the uterine
abdominal
aorta (not shown);
uterme artery (UA); uterus (U); intramural branches (IM); bladder (B); and
were
visible
in
right,
nine;
both
ment
artery
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ble in
arteries
epigastric
(10%).
Anastomoses
and ovarian
22
arteries
( 1 1%)
patients
sides,
artery
A round
seven).
embolized
be-
(Fig. 10)
(left, six;
liga-
of the proximal
was an anastomosic
to a previously
supplier
artery
uterine
in one
16).
patient(Fig.
Other
(Figs.
19 patients
Procedure-Relevant
The vaginal
of the
division
Pelvic Vessels
artery
from
arising
internal
iliac
the anterior
artery
just
below
artery
from
artery.
ing
division
usually
identified
in 345 (92%)
trunk
the vaginal
trunk
The vesical
iac artery
mon
(9%),
a common
above
formed
artery,
the uterine
artery
il-
artery,
of 375 cases.
anis-
of the internal
was
A com-
was found
in
and gave
which
were
easily
was
full (Fig.
off three
terminal
identified
when
the
branches,
bladder
l7B).
Discussion
Several
anatomy
been
have
of analysis
methods
the arterial
used
knowledge,
of variations
of the female
in previous
of cadavers
tract
To our
studies.
dissections
gained
or during
in
genital
surgical
from
proce-
dures has been the basis of the most comprehensive accounts in the literature
[6). Angiography
has
Fig. 10-37-year-old
woman with uterine fibroids. Digital
subtraction angiogram of superselective injection of 10 ml of
iodinated-contrast
material into left uterine artery before
embolization shows anastomosis between tubal part of left
uterine artery (1) and uterine part of left ovarian artery (2).
Fig. 11.-31-year-old woman with delayed postpartum bleeding. Digital subtraction angiogram of
superselective injection into left uterine artery
shows left cervicovaginal artery (1) arising from
arch part of uterine artery (2).
been
used
formation
the origin
In our
occasionally
to
establish
trunk
series,
the relative
ofthe
ofdivision
of modes
frequencies
internal
was
study
which
than
was
division
found
the 60%
into
in 77%
two
main
stems,
of all arteries,
more
reported
[4].
one
anterior
and
one
posterior,
in most
iliac artery
of the internal
rior division
of the internal
to numerous
variations.
cedures,
identification
the parietal
especially
landmarks
are
catheterization
iliac artery
During
of these anterior
ones,
is facilitated
established
performed.
is subject
pro-
angiographic
and
branches,
if bony
superselective
try ofthe branching pattern ofthe internal iliac antery was observed in 91% of patients.
Fig. 12.-35-year-old
enlarged
artery
992
left uterine
artery
(not shown).
injection shows
The
division
uterine
artery
of the internal
arises
from
iliac
artery.
the
anterior
We describe
Arterial
a simple
and
useful
technique
and catheterization
using
Anatomy
of the
Female
Genital
Tract
of identification
oblique
incidence:
In
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practical
terms. if the internal iliac artery is divided into two main trunks, the best projection
to identify
the origin
contralateral
anterior
inclination.
to great
The
of the uterine
oblique
width
variation;
artery
with
of the artery
enlargement
is the
20-30#{176}of
is subject
is common
in
pregnant
patients
and those with leiomyoma
[5]. In the midline,
the terminal
parts of arcuate branches of the uterine
with those of the contralateral
The
paired
ovarian
anterolateral
arteries
vides
the
dominant
ovarian
with
the uterine
blood
artery
which
arises
artery
tery,
be responsible
after
The
division
from
artery
pro-
uterus,
either
or from
in
[7].
anastomoses
branches
plays
conditions
epigastric
ing
artery
in physiologic
may
the
the renal
to the
terminal
flow
usually
the corresponding
role
from
artery
is frequently
involved
hypervascularized
processes
the ovarian
pathologic
Each
arise
aorta below
abdominal
[7]. Although
arteries
artery anastomose
side [5].
from
of
a minor
[8].
the
This
inferior
the external
iliac arfor persistent
bleedFig. 13-27-year-old
hysterectomy.
vesical
artery
of the internal
a common
trunk
arises
from
iliac artery,
with
the anterior
sometimes
the uterine
artery,
tum hemorrhage.
pigtail catheter
teries
shows
with
5-French
enlarged
plying uterus.
Fig. 15-39-year-old
woman with polymyomatous
uterus. Gross specimen obtained after hysterectomy.
Red dye injection into left uterine artery (arrows) and blue dye injection into right uterine artery (arrowhead).
Anastomoses between both sides identified
in myometrium.
obtained
Fig. 14-28-year-old
woman with numerous uterine fibroids. Digital subtraction
angiogram
of superselective
catheterization ofrightovarian
artery providing uterine vasculanzation to posterolateral intramural myoma (arrow)
993
Pelage
et al.
use of a hydrophilic
polymer-coated
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In this study
supply
edge
ofthe
0.032-inch
can prevent
guidewire
artery.
of pelvic
angiograms,
uterus is discussed.
of the normal
and variant
the blood
Precise knowlanatomy
of the
of embolization
of the uterus.
References
1. Ring EJ. Athanasoulis
MN.
Baum
hemorrhage
1973;
S. Arteriographic
following
management
pelvic fracture.
of
Radiology
109:65-70
2. Greenwood
LH,
Glickman
MG,
Schwartz
PE,
Fig. 17.-41-year-old woman with uterine fibroids. Digital subtraction angiogram ofselective injection into right internal iliac artery before embolization
shows right vesical artery mimicking
course of uterine artery.
A, Selective injection into internal iliac artery shows common trunk of vesical artery (1) with uterine artery (2).
B, Superselective catheterization of vesical artery shows characteristic terminal branches (arrowheads)
allowing vesical and uterine arteries to be identified.
1995:346:671-672
4. Merland
JJ. Chiras
Merland
pelvis:
branches
of our patients.
that supply
to the bladder.
during
uterine
der necrosis,
untargeued
994
care
should
flow
be taken
to avoid
reported
bladafter
[9].
of all branches
is necessary
vesical
of the blood
embolotherapy
which has been
embolization
Identification
iliac artery
bolization
Special
It has three
80%
of the internal
to avoid untargetted
em[2, 9]. Anatomic
variants may inter-
of the procedure,
high degree
to the uterus
against
offlow
unexpected
reflux
even if the
tends to protect
of the embolic
descending
segment of the uterine artery. Similarly, failure of superselective
catheterization
of
the uterine artery
lization
embo-
J. Normal
and
N, et
Lancet
angiography.
Arteriographv
therapeutic
artery
Br Corn.rnrnonw
B. A composite
In:
of the
procedures.
1970;77:%7-975
study of the hypoga.stric
Ann Surg
1918;67:584-608
PJ. Percutaneous
em-
mate-
rial. To perform
safer embolization
in free-flow,
the catheter should be carefully
placed into the
to treat myomata.
Berlin: Springer-Verlag,
1981:5-68
5. Farrer-Brown
0. Beilby JO, Tarbit MH. The blood
supply to the uterus: arterial vasculature. J Obstet
Gynaecol
6. Lipshutz
as in three
D, Ciraru-Vigneron
of
of
WW.
hypogastric
Gangrene
artery
of bladder:
com-
embolization.
1977;9:670-671