Super-selective embolisation for an intractable uterine pseudoaneurysm fed by the ovarian artery

Background: Uterine artery pseudoaneurysm (UAP) is a rare but serious cause of delayed postpartum hemorrhage. While transcatheter arterial embolization (TAE) is generally effective for UAP, the use of permanent embolic agents for proximal embolization may result in residual blood flow via utero-ovarian anastomosis. In such a case, to preserve ovarian function, it is necessary to advance the catheter beyond these anastomoses. However, reports detailing embolization via the ovarian artery approach are scarce, and its technical feasibility and efficacy remain underexplored. Case Presentation: A woman in her 30s with a history of right salpingectomy developed an intractable UAP following miscarriage. Despite two sessions of bilateral uterine artery embolization at a previous hospital, the pseudoaneurysm recurred. The first TAE involved proximal coil embolization of the left uterine artery, which hindered subsequent attempts to access the bleeding point. Imaging revealed persistent blood flow via the left ovarian artery through the utero-ovarian anastomosis. Given the patient's desire to preserve fertility and the anatomical complexity, we performed super-selective embolization using a triaxial system, allowing navigation through the markedly tortuous ovarian artery and advancement beyond the ovarian branch. Glue embolization was successfully performed without complications. Post-procedural examinations confirmed complete occlusion of the UAP and preservation of ovarian function. The patient resumed menstruation and restarted fertility treatment. Conclusion: This case highlights the potential difficulty of re-intervention after proximal embolization and underscores the utility of the triaxial system in navigating challenging anatomy. Super-selective glue embolization via the ovarian artery may serve as a viable fertility-preserving treatment in cases of intractable UAP.