Management of Intrauterine Arteriovenous Malformation (AVM) in 14 Patients by Sonographically Guided Tisseel Application

Abstract

Abstract Purpose AVMs are rare tumorous vascular lesions derived from placental tissue that may present with massive post-partum hemorrhage (PPH) causing potentially life-threatening anemic shock. Current treatment options include the embolization of uterine arteries and emergency postpartum hysterectomy. We present a new form of minimally invasive, highly specific sonographically guided treatment in the form of the application of a human fibrin sealant leading to the instant cease of blood loss. Materials and Methods A management protocol was established and a case series of 14 patients is presented. Diagnosis by endovaginal color Doppler sonography is followed by the sonographically guided application of biological glue (TISSEEL®), thus allowing for super-selective occlusion of the feeding vessels. Results The procedure was technically successful in all 14 patients, 3 of whom (21 %) had a repeated procedure after 4 – 7 days. The mean age (yrs.) of the patients was 31 (25 – 40), the gravity was median 2 (1 – 5) and the parity was median 1 (0 – 4), the lowest Hb value was on average 9.35 ± 2.25 (5.2 – 14.2) g/dl, the lowest Ht was on average 30.82 ± 6.02 (18 – 41 %). Spectral Doppler analysis revealed an average of 80.71 ± 11.2 (66 – 115) cm/sec for the maximal detectable PSV. In the period of 4 – 55 months after treatment, 7 patients (50 %) had 8 successful pregnancies and 2 miscarriages. Conclusion In PPH there is vital interest in timely diagnosis of the underlying cause, thus allowing fertility-sparing, minimally invasive and super-selective emergency treatment. In AVMs causing PPH, a positive impact on perinatal morbidity and mortality may be achieved by sonographically guided application of this biological glue.