Repair of Isthmocele Following Embolization of Uterine Arteriovenous Malformation

Objective: To present a case of concurrent uterine arteriovenous malformation (AVM) and isthmocele, treated with ethylene vinyl alcohol copolymer (EVAC) embolization of the AVM followed by robotic isthmocele repair.

Design: A stepwise video demonstration with narration.

Setting: A tertiary care academic hospital. Patient is a 37-year-old with one previous cesarean section who presented with persistent heavy vaginal bleeding after a dilation and evacuation procedure. Imaging showed evidence of an isthmocele and an iatrogenic uterine AVM secondary to the dilation and evacuation procedure. Both entities are morbid conditions associated with significant operative blood loss. Embolization of the acquired AVM was first performed to stabilize bleeding. In addition, owing to the extensive uterine defect and history of infertility, surgical repair of the isthmocele was recommended.

Interventions: A multidisciplinary approach combining interventional radiology and gynecologic surgery expertise, implementing several strategies to minimize blood loss: 1. Image-guided uterine AVM embolization with EVAC [1] 2. Hysteroscopic identification of isthmocele and residual EVAC in the cavity, with fluorescence transillumination to clearly delineate isthmocele borders 3. Robot-assisted laparoscopic approach for bladder flap creation, as well as retroperitoneal space dissection to skeletonize uterine arteries 4. Transient occlusion of uterine arteries using vascular clamps to minimize operative blood loss given the isthmocele size and its proximity to the left uterine artery 5. Resection of the isthmocele and removal of residual intracavitary EVAC 6. Multilayer, bidirectional hysterotomy closure and vascular clamp removal to restore uterine blood supply CONCLUSIONS: Successful multidisciplinary treatment of concurrent uterine AVM and isthmocele. Cesarean delivery at 36 to 37 weeks' gestational age was recommended for future deliveries.