What is the treatment approach for arteriovenous (AV) malformations in the uterus?

Treatment Approach for Arteriovenous Malformations in the Uterus

Uterine arteriovenous malformations (AVMs) should be treated primarily with uterine artery embolization as the first-line therapy for symptomatic cases, especially in women of reproductive age who desire future fertility. 1, 2, 3

Diagnosis and Assessment

• Transvaginal color-Doppler ultrasound is the initial diagnostic technique for uterine AVMs, revealing tubular and tortuous structures with mixed arterial and venous flows 2
• For more detailed assessment, contrast-enhanced magnetic resonance imaging (MRI) or computed tomography (CT) can be used to determine the extent, feeding vessels, and drainage patterns 2, 3
• Digital subtraction angiography remains the gold standard for pre-treatment assessment, providing superior visualization of angioarchitectural features 4

Treatment Algorithm

First-line Treatment:

• Uterine artery embolization (UAE) is the treatment of choice for symptomatic uterine AVMs, especially in women of reproductive age who desire future fertility 1, 2, 3
• Clinical and technical success rates of UAE are high, up to 90%, with preservation of childbearing capacity 2
• Multiple embolizing agents can be used, with liquid embolic agents (especially dimethyl-sulfoxide family) offering technical advantages 2

Conservative Management:

• For asymptomatic or mildly symptomatic cases, conservative management can be considered as many uterine AVMs tend to resolve spontaneously 5
• Long-term follow-up has shown sonographic resolution of uterine AVMs in patients managed conservatively 5

Surgical Options:

• For cases where embolization fails or is not feasible:
  • Selective ligation of vessels supplying the malformation can be performed when uterine preservation is desired 6
  • Hysterectomy remains the definitive surgical treatment when fertility preservation is not a concern or when other approaches fail 5, 2

Special Considerations

• Management should be guided primarily by clinical presentation rather than sonographic findings alone 5
• For extensive lesions affecting the whole myometrium, UAE can still be successful even in cases with hemodynamic instability 3
• Measurement of uterine O₂ saturation and perfusion index can be effective in the intraoperative assessment of uterine viability during surgical procedures 6

Pitfalls and Caveats

• Complete obliteration of the AVM is essential as subtotal treatment does not provide protection from future complications 4
• Post-treatment angiography is recommended to confirm complete obliteration 4
• Long-term follow-up imaging is essential to detect potential recurrence 4
• Patients should be counseled about the risk of recurrent bleeding and the potential need for multiple embolization procedures 2
• In cases of acquired AVMs (often following D&C, pregnancy complications, or uterine surgery), addressing the underlying cause is important for preventing recurrence 1, 2