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On Aug 2018




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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
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Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

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In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
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Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : December | Volume : 16 | Issue : 12 | Page : TC01 - TC04 Full Version

Role of Ovarian Artery to Uterine Artery Anastomosis in Uterine Artery Embolisation: A Retrospective Study


Published: December 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/57888.17308
Vasanthamani Palanisamy, Alamelu Mahalingam, Nachiappan Ramiah, Periyakaruppan Alagappan, Devimeenal Jagannathan

1. Dean, Government Kilpauk Medical College Hospital, Chennai, Tamil Nadu, India. 2. Postgraduate Student, Department of Radiology, Government Kilpauk Medical College Hospital, Chennai, Tamil Nadu, India. 3. Assistant Professor, Department of Biochemistry, Madras Medical College, Chennai, Tamil Nadu, India. 4. Consultant Interventional Radiologist, Department of Intervention Radiology, Government Omandurar Medical College, Chennai, Tamil Nadu, India. 5. Professor and Head, Department of Radiology, Government Kilpauk Medical College Hospital, Chennai, Tamil Nadu, India.

Correspondence Address :
Dr. Devimeenal Jagannathan,
No-10, Poonamalle High Road, Kilpauk, Chennai, Tamil Nadu, India.
E-mail: devinachi@gmail.com

Abstract

Introduction: Uterine Artery Embolisation (UAE) is now extensively recognised as a treatment for uterine fibroids, uterine artery pseudoaneurysms, and Uterine Arterio-Venous Malformations. The occurrence of collateral circulation from the ovarian artery to the uterine artery is one of the reasons for the failure of the process. The occurrence of ovarian failure and premature menopause after the UAE is high in patients with Utero-ovarian Artery (UOA) anastomosis.

Aim: To classify UOA as per Razavi MK et al., angiographic classification and to determine the presence of such anastomosis in UAE procedure failure cases.

Materials and Methods: A retrospective study was done for a period of two years from November 2017 to October 2019 in the Department of Radiodiagnosis, Government Kilpauk Medical College, Chennai, Tamil Nadu, India and Department of Interventional Radiology, Govt. Omandurar Multispeciality, Chennai, Tamil Nadu. UAE was performed with Poly Vinyl Alcohol (PVA) microparticles (300 to 500 μm in size) followed by capping with a gelatin sponge in all 25 cases and coils were used in three cases. The presence or absence of UOA and four different types as per Razavi MK et al., angiographic classification were noted.

Results: Among 25 cases who underwent UAE, 14 had UOA. The majority (six cases) were type Ib, five cases were type Ia, two cases were type II and one case was type III. The bilateral anastomosis was noted in one case with type Ia and Ib on either side. Eight cases with UOA had successful embolisation. The UAE was successful in 16 cases, and failed in nine cases. Among various causes for failure, six out of nine were due to UOA. Among six failure cases of UOA, two cases were Type Ia, two cases were Type Ib, one case was Type II and one case was Type III anastomosis.

Conclusion: The UOA is one of the major risk factors in the procedural failures of the UAE. Identification avoids non target ovarian embolisation.

Keywords

Failure of uterine artery embolisation, Ovarian embolisation, Polyvinyl alcohol microparticles, Utero ovarian collateral circulation

The UAE is an extensively known treatment for uterine fibroids, as an alternative to hysterectomy or myomectomy (1),(2),(3). The other indications of UAE procedure include abnormal uterine bleeding, uterine artery pseudoaneurysm, and Uterine Arterio-Venous Malformations (AVM). The UAE procedure was extensively studied for its safety and effectiveness and is now widely accepted as a treatment option for fibroids by the American Congress of Obstetricians and Gynaecologists (ACOG) (4). Preprocedural thorough evaluation includes menstrual and obstetric history, other medical histories, and physical examination. Most of the cases require bilateral uterine artery catheterisation and embolisation (5). Among numerous reasons for procedural failure, the occurrence of collateral circulation from the ovarian artery to the uterine artery has been concerned as one of them (6),(7). The occurrence of ovarian failure and premature menopause after the UAE procedure is high in patients with UOA anastomosis (6). Sheikh GT et al., analysed, postembolisation ovarian function and concluded that protective coiling can prevent ovarian failure (7). For this the abnormal anastomoses have to be reliably classified. Minimal data is available regarding the importance and frequency of such anastomoses and high failure rates. So, this study was conducted with an aim to classify ovarian artery to uterine artery anastomosis and compare the presence of such anastomosis with UAE procedure failure.

Material and Methods

The present study was a retrospective cohort study done in the Department of Radiodiagnosis, Government Kilpauk Medical College, Chennai, Tamil Nadu, India and Department of Interventional Radiology, Govt. Omandurar Multispeciality, Chennai, Tamil Nadu, India for a period of two years from November 2017 to October 2019. The analysis of the data was done in April 2022. Institutional ethical clearance was obtained (42/2019 dated 10/12/2019).

The study included all cases done in the study period. It includes all 25 cases, amongst which 20 were cases of uterine fibroid and five were cases of Uterine Arterio-Venous malformation.

Inclusion criteria: For UAE, the inclusion criteria were patients presenting with hypermenorrhoea, symptomatic fibroid uterus, and Uterine AVM.

Exclusion criteria: Large leiomyoma (>10 cm) or multiple leiomyomas, malignant tumour in the uterus or adnexa, active pelvic inflammatory disease, pregnancy, allergy to iodine, and cases with renal failure were excluded from the study.

Pre-embolisation evaluation includes history to identify medical and gynaecological co-morbidities like anaphylactic reaction, coagulopathy, renal insufficiency, diabetes, hypertension, pelvic infection, previous surgeries, and a physical examination (Pulse, Blood Pressure (BP), abdominal examination, and Per vaginal examination). Radiological imaging includes Transabdominal and Transvaginal Ultrasound in conjunction with colour and pulsed Doppler ultrasound. Magnetic Resonance Imaging (MRI) was performed in all cases to assess the location of fibroid within the uterus, its number and size, the presence or absence of fibroid enhancement, associated adenomyosis, malignancies, and vascular malformations such as pseudoaneurysms and AVMs.

Embolisation

All patient access was through the right common femoral artery. In six cases pigtail aortogram was done to identify the ovarian artery. Bilateral uterine artery selective catheterisation was done using Roberts Uterine Curve Catheter 5Fr (Table/Fig 1)a in 19 cases. A 4-F Glide cobra catheter or a 5-F Cobra C2 catheter were alternative catheters used to selectively catheterise the anterior division of the internal iliac artery and into the uterine artery in six cases. Internal iliac arteriography (Table/Fig 1)b,c was done to localise the origin of the uterine arteries. Embolisation was performed with the catheter tip beyond the origin of the cervicovaginal branch in most cases, excluding it from the embolisation, to prevent the occurrence of dyspareunia.

Embolic materials used were PVA microparticles (Table/Fig 2)a 300 to 500 μm in size followed by scrapings with a gel foam (Table/Fig 2)b of 6-25 mL depending upon the size of the fibroid and vascularity in all the cases and coils were used in three cases (Table/Fig 2)c. In cases of catheter induced vasospasm, a microcatheter (4-5 F) was used.

Embolisation Endpoint

The endpoint of UAE (Table/Fig 3)a-c was to have a still column of contrast in the uterine artery, with only a stump of the uterine artery being filled with contrast, when the internal iliac artery was injected. The gel foam scrapings aid to cause complete occlusion of the uterine artery. It also stops the PVA particles from being drawn out of the uterine artery, and thereby non target embolisation.

Postembolisation

Postembolisation follow-up was done in all the study cases at 1 day, 3 days, 7 days 1, 3, 6, 12 months and 18 months. They were asked to report back immediately if any adverse events occurred. Follow-up was done to assess the efficacy and long-term effects of UAE. The procedure was considered successful if the woman was free of heavy bleeding. The presence or absence of UOA was noted, classified as per Razavi MK et al., angiographic classification (6).

In Type I UOA-The ovarian artery is a major source of ovarian blood supply in the fibroids by means of direct anastomosis with the intramural uterine artery.

Type Ia UOA-No evidence of retrograde reflux in the direction of the ovary on selective uterine angiograms.

Type Ib UOA-Reflux is seen on pre-embolisation selective uterine angiograms (Table/Fig 4).

Type II UOA-Fibroids are directly supplied by the ovarian artery (Table/Fig 5).

Type III UOA-Selective uterine angiograms show tubal artery flow is towards the ovary (Table/Fig 6).

Statistical Analysis
The collected data were analysed using Statistical Package for the Social Sciences (SPSS) version 20.0 software. Descriptive statistics were used.

Results

The mean age was 34.36±13.97 years. Most of the patients 13 (52%) were in the age group of 21-30 years (Table/Fig 7).

The presenting symptoms were pressure symptoms such as increased frequency of micturition in four patients, pelvic pain in 10 patients and menorrhagia in 18 patients. Among 25 cases who underwent UAE, 14 cases had uterine artery to ovarian artery anastomosis. Majority (six cases) were type Ib, five cases were type Ia, two cases were type II and one case was type III. Bilateral anastomosis was noted in one case with type Ia and Ib on either side.

Eight cases with UOA had successful embolisation. The procedure of UAE was successful in 16 cases, and failed in nine cases. Among various causes for procedural failure, six out of nine were due to UOA anastomosis. Among six cases of UOA anastomosis failure, two cases were Type Ia, two cases were Type Ib, one case was Type II and one case was Type III anastomosis (Table/Fig 8). Among three other causes of failure, there were two cases of adenomyoma and the cause was not known in one. The complications noted were: One patient had internal iliac artery dissection during the procedure and one patient had fibroid passage. Fifteen patients had pelvic pain and low-grade fever which was managed with analgesics and antipyretic.

Discussion

Many women had significant reduction in pain after UAE. Significant decrease was noted in bulk symptoms like abdominal wall distortion and pressure symptoms. Appreciable improvement was seen with menorrhagia (8),(9). Uterine embolisation is one of the uterine-sparing options (10). UAE can be done preoperatively to reduce the bleeding complications perioperatively (11). Goodwin SC et al., assessed the outcomes in long-term after UAE in a large cohort and states that UAE helps in durable improvement in the quality of life in symptomatic fibroids (12).

With the increasing use of calibrated microsphere embolic agents, embolisation procedure has become technically more easier (13), since it provides a predictable level of embolisation and minimises the incidence of clogging of both standard and microcatheters, which is a common problem with standard PVA preparations.

The causes of clinical failure of UAE have not been well studied and are multifactorial. Among various collaterals supplying uterus, ovarian artery is the major source of collateral blood vessel supply to uterine fibroids (14). If not addressed appropriately, will cause postprocedural complications and failure. In 40% of cases, ovarian arteries supply the ovaries, 56% by both ovarian and uterine arteries, and 4% by uterine arteries alone (15),(16). Among various aetiologies posed for the presence of uteroovarian anastomosis, the dependence of the ovary on the uterine artery may be due to congenital absence of the ovarian artery. The occlusive lesions affecting the ovarian artery or the aorta, or ovarian abnormalities such as tumour or inflammatory conditions cause the recruitment of additional blood supply from the uterine artery (16). Non visualisation of an ovarian artery-to-uterine artery anastomosis at selective angiography does not indicate the absence of such a connection.

In present study, of 14 cases with uterine ovarian anastomosis, five cases with type Ia, six cases with type Ib, two cases with type II and one case with type III anastomosis. In a similar study by Razavi MK et al., (6), 33 cases had type I anastomosis, six type II and 10 type III anastomosis, out of 76 consecutive cases undergoing UAE. The incidence of type I anastomosis was higher in this study, similar to present. Kim HS et al., assessed the long-term outcomes (more than three years period) in young patients (less than 40 years old) who underwent UAE with and without UOA. He concluded that there is a significant improvement in symptoms related to fibroids. There was 27.5% chance of repeat interventions being needed if UOA was found in young women (17).

In Goodwin SC et al., study type Ia anastomosis was unlikely to be a source of procedural failure. Type II anastomosis- can be a cause of clinical failure due to incomplete fibroid embolisation (12). In the present study, the failure rate of the procedure is less with type I anastomosis. In a study by Lanciego C et al., among 202 cases who underwent UAE, 104 cases were with UOA, amongst them, 38 anastomoses were bilateral, and 66 were unilateral. The most common was type III (66 cases) anastomosis followed by (22 cases) of type Ia and (18 cases) of type Ib. No type II was reported in this study. Twenty-seven women (14%) had amenorrhoea during a 5-year follow-up after UAE (3% of women were <45 years old). There were 10 cases of clinical failure with a median follow-up of >4 years (18).

Kim HS et al., demonstrated the correlation between utero-ovarian anastomosis at angiography with its histologic effect on patients who underwent UAE with or without Ovarian Artery Embolisation (OAE) for symptomatic uterine leiomyomata. In patients without utero-ovarian anastomosis angiography do not show particles in the ovary (19). Another Kim HS et al., study on effects of utero-ovarian anastomoses on clinical outcomes, shows incidence of anastomoses on angiography was 40.3%. Although the overall repeat intervention rate after initial UAE is only 5.6%, higher incidence of repeat intervention rates after UAE were noted only in cases with UOA (20).

When the ovarian artery gives away collateral vessels to the uterus, it is important for the interventional radiologist to ensure that sufficient embolic material gets to the uterine fundus, beyond the point of ovarian artery inflow. Careful monitoring of the injection pressure during embolisation is mandatory, so that only minimal reflux occurs across the anastomosis and that embolic material does get beyond the anastomosis. A small amount of reflux is allowed and then the refluxed material gets washed back into the uterus. Embolic material is taken back to the fundus by the ovarian artery inflow. The ovary escapes embolisation, it is found few centimeters proximal to the utero-ovarian anastomosis.

Embolisation using large gelatine sponge pledgets of the proximal ovarian artery has shown to decrease the filling pressure into the uterus, enough to provide a good clinical result without endangering the ovaries (21),(22). Embolisation of the ovarian artery collateral supply with relatively large gel foam particles (more than 500 to 600 μ μm) is also considered to be effective since these particles are too large to enter the ovarian vascular bed and hence will bypass the ovary and go into the uterine vascular bed (23). A branch inferior epigastric artery-anatomically artery of the round ligament, may also supply the uterus. This vessel can very well be embolised with no or little fear of complications (24).

Ovarian failure is not the only reason for amenorrhoea, ischaemic endometrial damage from UAE is also a known cause (25). Many authors have suggested routine pre-embolisation aortography to assess the ovarian arteries status and their branches to uterus, so that proper preprocedural planning can be done and adequate embolisation of supplying collaterals is ensured (9).

Limitation(s)

Limited sample size, retrospective nature of the study, selection bias since, the cases were taken from a tertiary centre and no attempt was done to correlate the occurrence of these anastomoses to other anatomic or physiologic factors.

Conclusion

The UOA is considered one of the major risk factors in procedural failures of UAE. A routine abdominopelvic angiogram before and immediately after embolisation is recommended. The success of the UAE lies in the identification of the normal anatomical course of the uterine artery and the main variations in the arterial course. Identification of UOA anastomosis is helpful to avoid non target embolisation of ovarian artery.

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DOI and Others

DOI: 10.7860/JCDR/2022/57888.17308

Date of Submission: May 23, 2022
Date of Peer Review: Jul 28, 2022
Date of Acceptance: Oct 17, 2022
Date of Publishing: Dec 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jun 11, 2022
• Manual Googling: Sep 24, 2022
• iThenticate Software: Oct 11, 2022 (25%)

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