Technical results and clinical outcome of transcatheter embolization for severe post-hysterectomy intra-abdominal hemorrhage

Abstract

Purpose

To assess the technical and clinical outcome of catheter-directed embolization for severe, post-hysterectomy hemorrhage associated with intra-abdominal hematoma.

Materials and Methods

Retrospective analysis of consecutive patients presenting with severe post-hysterectomy hemorrhage and treated with catheter-directed embolization at the authors’ clinic. Preoperative and follow-up clinical, laboratory, and imaging data were collected from the patients’ electronic medical records.

Results

7 patients (mean age 41 years) were included in the study. Indications for hysterectomy were uncontrollable postpartum hemorrhage (n=4), uterine fibroids (n=2), and cervical cancer (n=1). The mean interval between surgery and embolization was 4.7 days. The mean hemoglobin level before embolization was 8.1 g/dL after administration of a mean of 9.6 units of packed cells. The mean volume of the post-hysterectomy abdominal hematoma was 761 ml and angiography revealed a mean number of 2 bleeding arteries per patient. No embolization-related complications were found. Overall, technical and clinical success rates were 85% and 71%, respectively. All patients survived and were discharged after a mean hospital stay of 18 days (range: 4–39 days).

Conclusion

Severe, post-hysterectomy hemorrhage associated with large, intra-abdominal hematoma can be safely and effectively managed with catheter-directed embolization. Two or more bleeding arteries may be identified during therapeutic angiography.

Key Points

• TAE for severe post-hysterectomy bleeding is safe and efficient

• Two or more bleeding arteries may be identified on imaging studies

• The uterine artery stump is extravasating in the majority of cases

• Various non-uterine arteries may also be injured

Citation Format

• Gigi A, Vanslembrouck R, Bonne L et al. Technical results and clinical outcome of transcatheter embolization for severe post-hysterectomy intra-abdominal hemorrhage. Rofo 2025; DOI 10.1055/a-2661-4822

 

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Zusammenfassung

Zweck

Beurteilung des technischen und klinischen Ergebnisses der Katheter-gestützten Embolisation bei schweren Blutungen nach Hysterektomie in Verbindung mit intraabdominalem Hämatom.

Material und Methoden

Retrospektive Analyse aufeinanderfolgender Patientinnen mit schweren Blutungen nach Hysterektomie, die in der Klinik der Autoren mit einer Katheter-gestützten Embolisation behandelt wurden. Perioperative klinische, Labor- und Bildgebungsdaten wurden aus den elektronischen Patientenakten der Patientinnen erhoben.

Ergebnisse

Sieben Patientinnen (Durchschnittsalter 41 Jahre) wurden in die Studie eingeschlossen. Indikationen für die Hysterektomie waren unkontrollierbare postpartale Blutungen (n = 4), Uterusmyome (n = 2) und Gebärmutterhalskrebs (n = 1); das mediane Intervall zwischen Operation und Embolisation betrug 4,7 Tage. Der mediane Hämoglobinwert vor der Embolisation betrug 8,1 g/dl nach Gabe von durchschnittlich 9,6 Erythrocytenkonzentraten. Das mediane Volumen des abdominalen Hämatoms nach Hysterektomie betrug 761 ml und die Angiografie zeigte durchschnittlich zwei blutende Arterien pro Patientin. Es traten keine embolisationsbedingten Komplikationen auf. Der technische und klinische Gesamterfolg lag bei 85% bzw. 71%. Alle Patientinnen überlebten und wurden nach einem medianen Krankenhausaufenthalt von 18 Tagen (4–39 Tage) entlassen.

Schlussfolgerung

Schwere Blutungen nach Hysterektomie, die mit einem großen intraabdominalen Hämatom einhergehen, können mit einer Katheter-gestützten Embolisation sicher und effektiv behandelt werden. Im Rahmen der therapeutischen Angiografie können zwei oder mehr Blutungsquellen identifiziert werden.

Kernaussagen

• TAE bei schwerer posthysterektomiebedingter Blutung ist sicher und effektiv.

• In der Bildgebung können zwei oder mehr blutende Arterien identifiziert werden.

• Meistens befindet sich die Extravasation im Stumpfes der A. uterina.

• Verschiedene, nicht- uterine Arterien können ebenfalls verletzt sein.

 

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Keywords

post-hysterectomy hemorrhage - intra-abdominal hematoma - selective angiography - clinical outcome - bleeding arteries - embolization

Introduction

Hysterectomy is one of the most common, gynecological surgical procedures with approximately 600000 procedures performed per year in the United States [1]. Different surgical techniques are used, depending on the medical indication, patient’s characteristics, surgeon’s preference, and expertise or locally available operative technology. Typical surgical approaches include open abdominal, vaginal, laparoscopic, laparoscopic-assisted vaginal, and robotic-assisted hysterectomy [2]. Despite high technical expertise in many centers, hysterectomy is not free of complications. Common postoperative complications, including infection, hemorrhage, venous thromboembolism as well as more specific, hysterectomy-related complications, including genitourinary, gastrointestinal or nerve injury and vaginal cuff dehiscence might occur in a limited number of cases [1] [2] [3] [4] [5]. Post-hysterectomy hemorrhage is a life-threatening complication with an incidence of 0.2% to 2% [3]. The hemorrhage can be related to improper vessel ligation and missed bleeding vessels and might be associated with low intraoperative blood pressure, intraoperative administration of vasopressin drugs, and subacute infection or bleeding disorders [4].

Redo surgery is the first line management of early, postoperative bleeding. However, this can be challenging in hemodynamically unstable patients with a large, intra-abdominal hematoma. Transcatheter embolization is a valuable and alternative treatment for postoperative bleeding with a high success rate as demonstrated for various other bleeding indications over the last decades [6] [7] [8]. However, data on the safety and efficacy of embolization for post-hysterectomy hemorrhage are limited [9] [10] and mainly focus on post-myomectomy bleeding [11].

Therefore, we conducted a retrospective study to investigate the safety and efficacy of catheter-directed embolization for early, post-hysterectomy bleeding in the authors’ institution.

 

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Materials and Methods

Patients and study design

Consecutive patients who underwent transcatheter arterial embolization (TAE) for post-hysterectomy hemorrhage between August 2008 and October 2021 in the authors’ institution were collected from the institutional interventional radiology database and approval was obtained from the institutional ethics committee (MP023472). The patients’ medical history, presenting symptoms, and laboratory data were gathered from the patients’ electronic medical records. Imaging data were collected from the institutional Picture Archiving and Communicating System (PACS, Enterprise Agfa Gevaert, Mortsel, Belgium).

 

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Preinterventional imaging

After resuscitation and fluid and blood product administration, bedside transabdominal and/or transvaginal ultrasound was performed as a screening tool to identify a pelvic/ abdominal fluid collection and triphasic contrast-enhanced computed tomography (CE-CT) was performed in order to confirm the abdominal hematoma and to identify one or more bleeding arteries. CT was performed before and after intravenous injection of 100 ml non-ionic iodized contrast medium at an injection rate of 3 ml/sec. CT scans in both the arterial phase, 10 seconds after reaching the threshold of 100 Hounsfield units (HU) with trigger in the abdominal aorta, and in the portal venous phase, 90 seconds after reaching the HU threshold, were obtained. Axial, coronal, and sagittal images were reconstructed. The volume of the postoperative hematoma was measured after segmentation of the hematoma on serial 3 mm axial CT slices by an experienced abdominal radiologist (RV).

 

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Angiographic embolization technique

After obtaining the patient’s informed consent, it was decided to perform TAE under local or general anesthesia, depending on the patient’s general and hemodynamic condition.

Vascular access was made through percutaneous puncture of the right common femoral artery and placement of a 4 French (F) sheath. Based on the information from the CE-CT examination, selective catheterization of the internal iliac or other arteries was performed with use of a 4F Cobra or Simmons I catheter (Glidecath, Terumo Europe, Leuven, Belgium). Once the bleeding artery was identified, superselective catheterization of the bleeding artery was performed with use of a microcatheter (Progreat 2.4, Terumo Europe, Leuven, Belgium or Cantata 2.5, Cook Medical, Bloomington, IN, USA or Maestro 2.4, Merit Medical, South Jordan, UT, USA) and embolization was performed with various types of embolic agents, including calibrated microspheres (Embosphere, Merit Medical, South Jordan, UT, USA), glue as a mixture of Lipiodol (Guerbet, Villepinte, France) and n-butyl-cyano-acrylate (Histo-acryl, B. Braun, Melsungen, Germany), although off-label for catheter-directed embolization procedures and microcoils (Target microcoils, Boston Scientific, Natick, MA, USA or Microtornado, Cook Medical, Bloomington, IN, USA) at the discretion of the attending interventional radiologist. After the embolization procedure, the vascular sheath was left in place for 24 hours, in order to further monitor the arterial pressure and to have access if re-intervention for potentially persistent bleeding should be needed.

 

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Clinical follow-up

Patients were followed-up clinically by the attending intensive care physician and gynecologist. If persistent bleeding was observed, re-intervention or additional surgery was performed after multidisciplinary discussion between the attending intensive care physician, gynecologist, and interventional radiologist.

 

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Definitions

Technical success was defined as the absence of contrast extravasation on completion angiography after TAE. Clinical success was defined as no need for further endovascular or surgical intervention to definitively stop the bleeding.

 

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Results

Patient characteristics

Seven consecutive patients with a mean age of 41 years (range: 33–51 years) were included in the study and 6 out of 7 patients underwent initial hysterectomy in a community hospital and were urgently transferred to the authors’ academic, tertiary care center for obstetrics and gynecology for the management of persistent, severe post-hysterectomy bleeding. In the same study period, no embolization for post-hysterectomy vaginal bleeding without intra-abdominal hemorrhage was performed. The indications for hysterectomy were uncontrollable postpartum hemorrhage (n=4), uterine fibroids (n=2), and cervical cancer (n=1). The mean level of preinterventional hemoglobin was 8.1 g/dL (range: 5.5 g/dL – 11 g/dL) after administration of a mean of 4 units (range: 0–18 units) of fresh frozen plasma and a mean of 9.6 units of packed cells (0–18 units) as summarized in [Table 1]. The mean time interval between hysterectomy and TAE was 4.7 days (1–18 days).

Table 1 Patient and operative characteristics.

Patient	Age (y)	Parity	Transferred/inpatient	Relevant medical condition	Indication of hysterectomy	Type of hysterectomy	Perioperative complications	Excised uterine weight (g)
y=years, g=gram, G=Gravida, A=Abortus, P=Para, HIV=Human Immunodeficiency Virus, Pap smear=Papanicolaou test, DIC=Disseminated Intravascular Coagulation, CIN=Cervical Intraepithelial Neoplasia, LAVH=Laparoscopic Assisted Vaginal Hysterectomy, USO=Unilateral Salpingo-Oophorectomy.
1	41	G4A1P3	Transferred	None	Painful intramural fibroid High colpocele posterior fornix Abnormal Pap smears	LAVH without adnexectomy	None	82
2	51	G6A3P3	Transferred	Pregnancy, Insulin-dependent, pregnancy diabetes	Postpartum bleeding with placenta accreta and amniotic fluid embolism with secondary DIC	Abdominal hysterectomy	Amniotic fluid embolism with secondary DIC	755
3	33	G2AOP2	Transferred	Pregnancy	Postpartum bleeding and atonic uterus	Abdominal hysterectomy	Additional intra-abdominal bleeding related to ruptured splenic aneurysm	Unknown
4	41	G0A0P0	Transferred	Fechtner syndrome	Painful exophytic fibroid	LAVH without adnexectomy	None	186
5	38	G3AOP3	Inpatient	Pregnancy, HIV-1 long-term non-progressor undetectable load, defected 12 years ago, prior infection of hepatitis A and B, Asherman syndrome with hysteroscopic resection of synechiae	Postpartum bleeding due to uterus rupture, abruptio placentae, uterus inversion	Abdominal hysterectomy with USO	None	950
6	34	G4A1P3	Transferred	Pregnancy, obesity	Postpartum bleeding with hypovolemic shock	Abdominal subtotal hysterectomy	Resuscitation with heat massage	1100
7	50	G2AOP2	Transferred	None	CIN II Menorrhagia	Vaginal hysterectomy	None	Unknown

 

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Imaging and angiographic embolization results

The mean volume of the abdominal hematoma on CE-CT was 761 ml (range: 76–1677 ml). A mean of 2 foci of contrast extravasation on preinterventional CTA was identified as summarized in [Table 2]. In n=6 (86%) patients, one or more bleeding arteries were found on selective angiography ([Fig. 1]), with contrast extravasation at the uterine artery stump being most frequently identified ([Fig. 2]). In the majority of patients (n=6), microspheres were used to occlude one or more bleeding arteries. Also, other embolic agents, alone or in combination with microspheres, were also used as summarized in [Table 2]. Technical success after TAE was achieved in 15 out of 16 bleeding arteries (94%), in 6 out of 7 patients (85%), as summarized in [Table 2]. In patient 2, an additional blush of contrast extravasation in the right flank was identified on CE-CT. However, no corresponding contrast extravasation could be identified on selective angiography of the right ovarian artery or right lumbar arteries or on flush angiography of the abdominal aorta.

Table 2 Postoperative clinical course and TEA characteristics.

Patient	Time interval surgery – bleeding symptoms	Time interval surgery – embolization	Lowest Hb before TAE (g/dL)	Number of transfusions before TAE	Volume of hematoma on CTA (ml)	Number of foci of contrast extravasation on CTA	Bleeding arteries on angiography	Embolic agents and place of embolization	TAE related complications/residual bleeding	Outcome (days of discharge after TAE)
h=hours, d=day, g/d=grams per deciliter, TAE=Transarterial Embolization, CTA=Computed Tomography Angiography, U=units, PC=Packed Cells, FFP=Fresh Frozen Plasma, BPL=blood.
1	< 24h	1 day	8.9	0	659.98	1	No active bleeding found	Microspheres 700–900 µm in the anterior division of right internal iliac artery	None	8 days
2	< 24h	< 24h	6.9	8 U PC 5 U FFP 1 U BPL	1677.10	1	Medial branch of right inferior epigastric profunda artery Right epigastric artery, right and left uterine artery Right ligamentum rotundum	Histoacryl/ lipiodol ½ in the medial branch of the right deep inferior epigastric artery Microspheres 300–500 µm in the right epigastric artery, microspheres 300–500 µm + histoacryl/ lipiodol ½ in the right uterine artery, microspheres 300–500 µm in the left uterine artery Microspheres 300–500 µm in the artery supplying the right ligamentum rotundum	Residual bleeding on DSA untreatable by endovascular treatment due to spasms and absence of antegrade flow in right L1 lumbar artery branch going to lower abdomen after selective catheterization. It required abdominal surgery.	15 days after last TAE
3	1 day	1 day	9.2	18 U PC 9 U FFP 3 U BPL	917.58	1	Right uterine artery	Histoacryl/ lipiodol 1/6 in the right uterine artery	Relook on day 1 showed diffuse oozing requiring packing. Relook on day 2 showed subcapsular liver hematoma, posterior ruptured requiring new packing.	38 days
4	18 days	18 days	6.9	5 U PC 3 U FFP 1 U BPL	76.46	2	Left uterine artery stump Terminal branch of the vaginal artery	Microcoils + histoacryl/lipiodol 1/5 in the left uterine artery Microspheres 300–500 µm in the collateral terminal branches of the anterior division of right internal iliac artery	None	6 days
5	< 24h	1 day	8.4	16 U PC 11 U FFP 3 U BPL	477.57	4	Left anterior division collateral Right uterine artery stump	Microcoils 5/5 + Microspheres 500–700 µm in the anterior division of the left internal iliac artery Microspheres 500–700 µm in the right uterine artery	None	15 days
6	1 day	1 day	5.5	14 U PC FFP, U unknown BPL, U unknown	Unknown		Left uterine artery stump Right anterior division branches	Microspheres 500–700 µm + microcoils + histoacryl/lipiodol 1/1 in the left uterine artery Microspheres 500–700 µm + 2 microcoils in the right internal iliac branches	None	39 days
7	3 days: vague abdominal pain, vaginal blood loss	11 days	11	9 U PC 2 U FFP	Unknown		Left vaginal artery stump Right vaginal artery stump	Microspheres 500–700 µm in the left vaginal artery terminal branches Microspheres 500–700 µm in the right vaginal artery terminal branches	None	4 days

Fig. 1 a Post-hysterectomy contrast-enhanced computed tomography in patient 3 reveals a large pelvic hematoma in the resection area with clear contrast extravasation (arrows). b Selective right internal iliac artery angiography shows the contrast extravasation (arrows) at the stump of the ligated right uterine artery. c Completion selective angiography of the right internal iliac artery shows the cast of the glue (arrowheads) completely occluding the uterine artery stump.

Fig. 2 a Contrast-enhanced computed tomography in patient 2 reveals contrast extravasation (arrows) in a large post-hysterectomy hematoma (arrowheads). b Corresponding superselective angiography of the right round ligament artery demonstrates contrast extravasation (arrows) from the distal branches. c Selective angiography after glue embolization demonstrates no more contrast extravasation; note the cast of glue in both branches of the round ligament artery (arrows) and also in the right peri-uterine collateral branches associated with the placenta accreta (arrowheads) previously embolized in the same session. d Selective right inferior epigastric artery angiography shows another point of contrast extravasation (arrow). e Completion selective angiography of the right common femoral artery after glue (arrowheads) embolization shows absence of contrast extravasation.

 

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Clinical follow-up results

In n=2 patients, additional surgical intervention was required, including relook operation with packing for persistent diffuse abdominal oozing, for an additional subcapsular liver hematoma, and for surgical management of right flank bleeding after failed identification of the bleeding point during therapeutic angiography.

All patients survived and were discharged after a mean hospital stay of 18 days (range: 4–39 days) as summarized in [Table 2].

 

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Discussion

This study confirms the high efficacy of TAE for severe post-hysterectomy hemorrhage. It was technically feasible to occlude 15 out of 16 bleeding arteries (94%), identified on selective angiography examinations, in 6 out of 7 patients (85%), which is in line with other reports on embolization of post-hysterectomy bleeding [9]. In addition, this report also demonstrates that TAE might be a valuable alternative to repeated surgery even if the bleeding occurs within 1 day after the index hysterectomy. In line with the report of Kart et al., TAE can also be performed later after the index surgery in the case of delayed onset of hemorrhage [12]. Lee et al. found a median time interval between hysterectomy and secondary hemorrhage of 28.4 days (16–52 days), which is in contrast to and much longer than the presented study (mean interval of 4.7 days) with 5 out of 7 patients (71%) being embolized within 24 hours after the index hysterectomy [9].

In this study, patients were referred to an urgent angiographic embolization procedure if the CT scan was positive for contrast extravasation, which is in line with the findings of Takeda et al. demonstrating the added value of pre-embolization CT to shorten the process of TAE by identifying the site of extravasation before TAE [13]. Interestingly, the number of foci of contrast extravasation on CTA was not always the same as the number of bleeding arteries identified on selective angiography. Although vaginal bleeding seems to be the most common post-hysterectomy bleeding complication as reported by other authors [3] [4] [9] [11], this study demonstrates that a large intra-abdominal hematoma may develop as a serious hemorrhagic complication after hysterectomy. In 5 out of 7 patients, a large, postoperative abdominal hematoma with a mean volume of 761 cc (76–1677cc) was found on pre-TAE CT. In these patients with persistent bleeding and a large hematoma in-situ 1 day post-hysterectomy, a repeated surgery may be hazardous with a serious risk for failure to identify the bleeding arteries and stopping the hemorrhage. In these situations, an angiographic approach may be more effective to identify and definitively manage the postoperative hemorrhage.

Several studies reporting on a laparoscopic, open surgical, or transarterial approach to manage post-hysterectomy bleeding did not mention the number of bleeding arteries in the abdomen [1] [2] [3] [4]. In the presented study, in 5 out of 7 patients (71%), two or more bleeding arteries were identified on selective angiographic evaluation. This finding underlines the need to look for other bleeding arteries once an area of contrast extravasation is identified on both CT and selective angiography in order to avoid persistent hemorrhage after occluding 1 target, extravasating artery. Although the stump of the ligated uterine artery was targeted in the majority of patients, other arteries might also be injured during hysterectomy, including the epigastric and round ligament artery or other small collaterals originating from other internal iliac artery branches.

The type of embolic agent used in this case series was variable and mainly depended on the angiographic presentation of the contrast extravasation; if small, distal branches were bleeding, microparticles were used in the majority of cases; if large, proximal arteries presented with contrast extravasation, glue or microcoils were used to occlude the injured artery. However, independent of the type of embolic used, no procedure-related complications were noted, highlighting the safety of TAE in these post-hysterectomy embolization procedures.

This study has some limitations. First, the retrospective design of the study might bias some outcome results. Second, the indication to refer the patient to interventional radiology rather than performing a repeated surgery was mainly based on the intuitive decision of the attending gynecologist and not on an institutional protocol based on clinical, hemodynamic, or imaging findings. Last, the embolic agent was selected at the discretion of the attending interventional radiologist. However, we did not find real differences in clinical outcome or in complication rate based on the embolic used. Prospective, multicenter registries might give a definitive answer to these limitations. However, the very low incidence of severe, post-hysterectomy hemorrhage might make the performance of these studies unlikely.

 

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Conclusion

This report demonstrates the clinical efficacy of TAE for severe, post-hysterectomy bleeding using various types of embolic agents. In addition, two or more bleeding arteries were identified on selective angiography in the majority of included patients. Finally, no complications related to the embolization procedure were reported.

 

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Clinical relevance of the study

Transcatheter embolization is safe and efficient for the treatment of severe, post-hysterectomy bleeding. Various types of embolic agents can be used. Two or more bleeding arteries can be identified on selective angiography in the majority of included patients. The uterine artery stump is extravasating in the majority of cases and, various, non-uterine arteries may also be injured during hysterectomy.

 

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Conflict of Interest

The authors declare that they have no conflict of interest.

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Publication History

Received: 14 February 2025

Accepted after revision: 11 July 2025

Article published online:
19 August 2025