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PurposeThe purpose of our study was to evaluate the outcome of selective pelvic arterial embolisation (PAE) in women with severe postpartum hemorrhage (PPH).MethodsWe performed a retrospective, controlled, single-center cohort study. A total of 16 consecutive women with PPH who underwent therapeutic PAE were included. As historical control group, we included 22 women with similar severity of PPH who were managed without PAE. Outcome measures included necessity of surgical interventions such as postpartum hysterectomy and laparotomy after vaginal delivery, the amount of red blood cell transfusions, and hematologic findings after the procedure.ResultsPAE was successful in stopping PPH and preserving the uterus in all 16 women in the study group. No woman in the PAE group required a postpartum hysterectomy, whereas postpartum hysterectomy was unavoidable in two women in the control group. Laparotomy after vaginal delivery was necessary in two women of the group without embolisation. Hematologic parameters after the treatment were better in the PAE group than in the control group, although these differences were only in part statistically significant. There were no unwarranted effects of PAE identifiable in the study group.ConclusionThis is the first controlled study assessing the efficacy of PAE for the treatment of PPH. Our data suggest that PAE is effective for the treatment of severe PPH. In view of the lack of complications and unwarranted effects, clinical use of PAE in severe PPH seems justified, particularly in view of the life-threatening condition and the potential to preserve fertility in affected patients. Further evidence from well-designed prospective randomized-controlled trials would be nevertheless desirable in the future.

Objective To evaluate the beneficial effects of Implanon on pelvic pain in women with pelvic congestion syndrome (PCS). The efficacy of pain control, amount and frequency of menstrual loss, degree of patient’s satisfaction and objective pelvic venography scores were investigated. Methods In a prospective open-labelled study, 25 consecutive women complaining of chronic pelvic pain were recruited. Pretreatment objective peruterine venography and diagnostic laparoscopy of pure PCS together with subjective pelvic pain scores, prefilled questionnaire of Hospital Anxiety and Depression Scale (HADS), visual analogue scale (VAS), verbal rating scale (VRS) and quantified menstrual loss using the pictorial blood loss chart were documented in all cases. After identification, 23 subjects with pure PCS were randomly assigned to have either Implanon inserted subcutaneously (12 cases) or no treatment (11 cases). Patients were followed up at 1, 3, 6, 9 and 12 months. A symptom diary for side effects, VAS, VRS and menstrual scores were used to assess the subjective response to treatment. At the end of the study, all patients underwent repeat venography to assess the long-term objective response. After 12 months, subjects having Implanon inserted were requested to rate their overall degree of satisfaction with therapy. Results All 25 women recruited in the study completed follow-up. Two cases were excluded from the study and referred to the psychiatry department after a negative evaluation for disease and HADS scores relevant for depression. An improvement in symptoms was observed throughout the 12 months amongst the Implanon group versus no treatment. The greatest changes in pain assessed using either the VAS or VRS were between the pretreatment scores and those after 6 months (7.7 ± 1.3 vs. 4.6 ± 3.0 for VAS, P  < 0.001; and 25 ± 13.8 vs. 19 ± 18.9 for VRS, P  < 0.002). The monthly quantified blood loss fell from 204 (196) pretreatment to 90 (157) at 6 months ( P  < 0.001) and then to 64 (32) at 9 months ( P  < 0.002). Objective repeat venography score was reduced significantly at 1 year after treatment compared with the baseline evaluation as well as with the control group (4.5 ± 1.2 vs. 8.6 ± 0.5; P  = 0.001 and 4.2 ± 0.9 vs. 8.5 ± 0.6; P  = 0.0002, respectively). At final satisfaction assessment, 2 (17%) women were very satisfied 8 (66%) were satisfied, and 2 (17%) were uncertain. The implant was retained by all women at the end of the study. Conclusion Implanon seems to be an effective hormonal alternative for long-term treatment of properly selected patients with pure PCS-related pelvic pain.

Key Points Venous thromboembolism (VTE) occurs as often as stroke, and recurs frequently, with around 30% of patients with VTE experiencing recurrence within 10 years Occurrence of VTE, especially pulmonary embolism (PE), is associated with reduction in survival, and PE is an independent predictor of reduced survival for up to 3 months VTE is associated with high health-care costs and increased disability-adjusted life-years Despite identification of VTE risk factors, development of new prophylaxis regimens, and improved uptake of VTE prophylaxis, the occurrence of VTE is increasing Venous thromboembolism, including deep-vein thrombosis and pulmonary embolism, is a common, often-recurring condition that is occurring with increasing frequency, despite the availability of prophylactic treatments. The epidemiology of VTE involves interactions between predispositions to thrombosis and a range of risk factors, including hospitalization, cancer, and pregnancy. Thrombosis can affect any venous circulation. Venous thromboembolism (VTE) includes deep-vein thrombosis of the leg or pelvis, and its complication, pulmonary embolism. VTE is a fairly common disease, particularly in older age, and is associated with reduced survival, substantial health-care costs, and a high rate of recurrence. VTE is a complex (multifactorial) disease, involving interactions between acquired or inherited predispositions to thrombosis and various risk factors. Major risk factors for incident VTE include hospitalization for surgery or acute illness, active cancer, neurological disease with leg paresis, nursing-home confinement, trauma or fracture, superficial vein thrombosis, and—in women—pregnancy and puerperium, oral contraception, and hormone therapy. Although independent risk factors for incident VTE and predictors of VTE recurrence have been identified, and effective primary and secondary prophylaxis is available, the occurrence of VTE seems to be fairly constant, or even increasing.

This review article focuses on the advancements in non-contrast magnetic resonance angiography (NC-MRA) and its increasing importance in body imaging, especially for patients with renal complications, pregnant women, and children. It highlights the relevance of NC-MRA in chest, abdominal, and pelvis imaging and details various bright-blood NC-MRA techniques like cardiac-gated 3D Fast Spin Echo (FSE), balanced Steady-State Free Precession (bSSFP), Arterial Spin Labeling (ASL), and 4D flow methods. The article explains the operational principles of these techniques, their clinical applications, and their advantages over traditional contrast-enhanced methods. Special attention is given to the utility of these techniques in diverse imaging scenarios, including liver, renal, and pelvic imaging. The article underscores the growing importance of NC-MRA in medical diagnostics, offering insights into current practices and potential future developments. This comprehensive review is a valuable resource for radiologists and clinicians, emphasizing NC-MRA’s role in enhancing patient care and diagnostic accuracy across various medical conditions.

Introduction and Hypothesis The internal iliac artery stands as the main blood supplier of the pelvis, serving as the primary source of blood for the pelvic viscera while also nourishing the musculoskeletal framework within. The arterial anatomy of the pelvis exhibits a vast array of variations, especially regarding the branching pattern of the internal iliac arteries. The posterior division of the internal iliac artery (PDIIA) may also have variable topography, especially regarding the location of its origin in the pelvic region. Methods A retrospective study was carried out to determine the anatomical variations, prevalence, and morphometric data of the PDIIA and its branches. A total of 75 computed tomography angiographies were analyzed. Results The most prevalent branch of the PDIIA was the superior gluteal artery, as it was present in 114 of the studied cases (77.03%). The median diameter of the PDIIA at its origin was 6.66 mm. The median cross-sectional area of the PDIIA at its origin was set to be 34.59 mm 2 . Conclusion Our study highlights the critical significance of understanding the PDIIA and its branches in surgical interventions aimed at managing pelvic hemorrhage. The present study provides valuable insights into the precise localization and characteristics of the PDIIA and its branches, which are essential for surgical procedures targeting specific vessels to control bleeding effectively. Owing to the high level of variability of the branching pattern of the PDIIA, a novel classification system consisting of six types was created.

Pelvic congestion syndrome is defined as chronic pelvic pain due to incompetent (dilated and refluxing) pelvic veins. The aim of this study was to investigate the prevalence of this condition by examining the prevalence of dilated ovarian and para-uterine veins in pre- and postmenopausal female patients, irrespective of their symptoms. We subsequently investigated how many women with dilated veins suffered from chronic pelvic pain. Additionally, we attempted to define diagnostic criteria that may allow for early identification of affected patients. We reassessed 2384 abdomino-pelvic computed tomography scans performed on women at our institution. The maximal diameters of the ovarian and para-uterine veins were measured. Patients with a pathological process in the abdomen or pelvis affecting the veins were excluded. We considered ovarian vein dilation to be 6 mm or more in the axial plane. For patients that met these criteria, we performed a retrospective chart review to evaluate the clinical presentation and/or symptoms of these patients. Dilated pelvic veins were present in 293/2384 (12%) patients, 118/559 premenopausal (21%) and 175/1825 postmenopausal (10%). Chronic pelvic pain of unclear etiology had been documented prior to the CT in 54/293 (18%) women with dilated veins-2% of the whole study collective (54/2384); 8% of all premenopausal (44/559) and 0.5% of all postmenopausal (10/1825). It was often accompanied by urological symptoms such as hematuria, dysuria, and urinary frequency, in the absence of infection (p<0.05). We identified a strong correlation between the presence of dilated ovarian veins and chronic pelvic pain in premenopausal parous patients with hematuria. Pelvic congestion syndrome appears to be an underdiagnosed and undertreated disease. In our study, 8% of all premenopausal women had documented chronic pelvic pain of unclear etiology and dilated ovarian and pelvic veins on cross-sectional imaging studies. The features we identified in this study as most relevant should enable a faster identification of patients who could benefit from a specific treatment regimen for this condition.

Severe pelvic hemorrhage significantly contributes to mortality in trauma patients, yet the most effective treatment for severe pelvic injuries remains unclear. This systematic review evaluates the mortality and morbidity associated with bilateral internal iliac artery ligation (BIIAL) in patients experiencing severe hemorrhage from traumatic pelvic fractures. Comprehensive searches were conducted in MEDLINE PubMed, EMBASE, and Cochrane databases until February 7, 2024, to identify relevant articles. The risk of bias in observational studies was assessed using the ROBINS-I tool, which evaluates bias risk in nonrandomized intervention studies. The primary outcome was mortality following BIIAL, with the secondary outcome being complications related to the procedure. The review included eight studies, all observational. The overall mortality rate after BIIAL ranged from 45.0% to 76.9%. Ischemic complications from BIIAL were infrequent. A high and unclear risk of bias due to confounding and participant selection was noted across the studies. Four studies highlighted distinct indications for BIIAL compared to angioembolization. BIIAL was employed for patients with severe hemodynamic instability or when angiography was not available. Due to geographical limitations and significant heterogeneity among the studies reviewed, the true effect size of BIIAL remains indeterminate. Nevertheless, further prospective studies with robust designs are necessary. BIIAL holds potential as a viable option when angioembolization is not accessible or in cases of critical patient instability.

Introduction and Hypothesis The obturator artery (ObA) is described as a branch of the anterior division of the internal iliac artery. It arises close to the origin of the umbilical artery, where it is crossed by the ureter. The main goal of the present study was to create an anatomical map of the ObA demonstrating the most frequent locations of the vessel’s origin and course. Methods In May 2022, an evaluation of the findings from 75 consecutive patients who underwent computed tomography angiography studies of the abdomen and pelvis was performed. Results The presented results are based on a total of 138 arteries. Mostly, ObA originated from the anterior trunk of the internal iliac artery (79 out of 138; 57.2%). The median ObA diameter at its origin was found to be 3.34 mm (lower quartile [LQ] = 3.00; upper quartile [UQ] = 3.87). The median cross-sectional area of the ObA at its origin was found to be 6.31 mm 2 (LQ = 5.43; UQ = 7.32). Conclusions Our study developed a unique arterial anatomical map of the ObA, showcasing its origin and course. Moreover, we have provided more data for straightforward intraoperative identification of the corona mortis through simple anatomical landmarks, including the pubic symphysis. Interestingly, a statistically significant difference ( p  < 0.05) between the morphometric properties of the aberrant ObAs and the “normal” ObAs originating from the internal iliac artery was found. It is hoped that our study may aid in reducing the risk of serious hemorrhagic complications during various surgical procedures in the pelvic region.

To analyze CT angiographic images to provide comprehensive data on the corona mortis (CMOR) and propose a new classification method for venous corona mortis (VCMOR). This retrospective study included 719 patients (378 males, mean age 55 years) who underwent CT-enhanced examination of the whole abdomen or pelvis. Patient demographics, variation incidence, vessel diameter and location, anatomical configuration, and acetabular distance were evaluated. 73.44% of patients had at least one arterial or venous CMOR, with bilateral occurrences being more common ( P  < 0.001). The incidence of arterial corona mortis (ACMOR) was 23.92%, and it could be categorized into four types. The mean distance from ACMOR to the pubic symphysis was 56.6 mm, with a greater distance in females (62.2 mm) compared to males (50.4 mm) ( P  < 0.001). The incidence of VCMOR was 68.43%, with a higher bilateral occurrence ( P  < 0.001). Fourteen anatomical configurations of the VCMOR were identified and classified into two types and five subtypes. The mean interacetabular distance was 200.5 mm. The origin and branching variation of CMOR vary considerably, especially the venous type, which is characterized by diversity and complexity and needs to be recognized before pelvic operation.

Purpose To describe and categorize the angiographic findings regarding prostatic vascularization, propose an anatomic classification, and discuss its implications for the PAE procedure. Methods Angiographic findings from 143 PAE procedures were reviewed retrospectively, and the origin of the inferior vesical artery (IVA) was classified into five subtypes as follows: type I: IVA originating from the anterior division of the internal iliac artery (IIA), from a common trunk with the superior vesical artery (SVA); type II: IVA originating from the anterior division of the IIA, inferior to the SVA origin; type III: IVA originating from the obturator artery; type IV: IVA originating from the internal pudendal artery; and type V: less common origins of the IVA. Incidences were calculated by percentage. Results Two hundred eighty-six pelvic sides ( n  = 286) were analyzed, and 267 (93.3 %) were classified into I–IV types. Among them, the most common origin was type IV ( n  = 89, 31.1 %), followed by type I ( n  = 82, 28.7 %), type III ( n  = 54, 18.9 %), and type II ( n  = 42, 14.7 %). Type V anatomy was seen in 16 cases (5.6 %). Double vascularization, defined as two independent prostatic branches in one pelvic side, was seen in 23 cases (8.0 %). Conclusions Despite the large number of possible anatomical variations of male pelvis, four main patterns corresponded to almost 95 % of the cases. Evaluation of anatomy in a systematic fashion, following a standard classification, will make PAE a faster, safer, and more effective procedure.