Uterine artery embolization (UAE) is a minimally invasive interventional radiological procedure to occlude the arterial supply to the uterus. UAE has been very useful for controlling hemorrhage following delivery/abortion, in ectopic or cervical pregnancy, gestational trophoblastic disease or carcinoma cervix. Currently it is being mostly used for treating uterine fibroids. It requires a shorter Hospital stay with early resumption to normal activity. This review briefly summarizes the role of this relatively new technique in gynecologic practice.

1. The
role of uterine artery embolizati
on in gynecology practice

2. Apollo Medicine 2012 September
Volume 9, Number 3; pp. 206e211 Review Article
The role of uterine artery embolization in gynecology practice
S. Kheda Amitha Vikramaa,*, Ramamurthy Chitrab
ABSTRACT
Uterine artery embolization (UAE) is a minimally invasive interventional radiological procedure to occlude the arterial
supply to the uterus. UAE has been very useful for controlling hemorrhage following delivery/abortion, in ectopic or
cervical pregnancy, gestational trophoblastic disease or carcinoma cervix. Currently it is being mostly used for
treating uterine fibroids. It requires a shorter hospital stay with early resumption to normal activity. This review briefly
summarizes the role of this relatively new technique in gynecologic practice.
Copyright © 2012, Indraprastha Medical Corporation Ltd. All rights reserved.
Keyword: Uterine artery embolization, Hemorrhage, Interventional Radiology
INTRODUCTION
Uterine artery embolization (UAE) is a relatively new, mini-mally
invasive interventional radiological technique to
occlude the arterial supply to the uterus. UAE has been prac-ticed
over more than 20 years for controlling hemorrhage
following delivery/abortion, in ectopic or cervical preg-nancy,
gestational trophoblastic disease or carcinoma cervix.
Currently, UAE is being used mostly for treating uterine
fibroids. UAE is recommended to women with symptom-atic
fibroids who wish to retain their uteruses and avoid
surgery. It selectively blocks the feeding arteries that supply
blood to the fibroids and causes ischemic necrosis and
subsequent absorption or expulsion of leiomyoma.1
Worldwide technical success rates reported for UAE are
98%e100%.2e4 The decrease in fibroid and uterine size is
around 50% by the end of the first year post procedure. The
majority of patients have reported significant symptom
improvement and improvement in the overall quality of
life following UAE. Pregnancies have been reported after
the procedure. However, pregnancy outcome was worse
when compared with that of the general population. Miscar-riage
rates are higher; the risk for abnormal placentation is
increased; and an increased incidence of preterm delivery
and postpartum hemorrhage has been reported.
HISTORICAL ASPECTS
UAE was first reported in 1995, by Ravina et al.5 They
noted that several women with symptomatic leiomyomata
who underwent UAE as a pre-hysterectomy treatment had
significant clinical improvement to an extent that hysterec-tomy
was no longer required.
SURGERY VERSUS EMBOLIZATION
Few randomized controlled trials have compared UAE with
surgical management. The EMMY trial (EMbolization
versus hysterectoMY) reported similar symptom improve-ment
rates between the two groups, and 76.5% of patients
randomized to UAE were able to avoid surgery.6 The trial
by Mara and colleagues compared myomectomy with
UAE. Although symptom improvement was similar
between the two approaches, reproductive outcome was
superior in the myomectomy group.7
Uterine fibroid embolization has several advantages over
conventional hormone suppression (progestogens andGnRH
analogs) and surgical procedures (myomectomy, hysterec-tomy),
including avoidance of the side effects of drug therapy
and postoperative complications resulting from surgery.8
aConsultant Vascular and Interventional Radiology, bSenior consultant, Department of Obstetrics and Gynaecology, Apollo Hospitals, Banner-ghatta
Road, Bangalore 560076, India.
* Corresponding author. email: amithavikrama@gmail.com
Received:30.3.2012; Accepted: 29.6.2012; Available online: 5.7.2012
Copyright 2012, Indraprastha Medical Corporation Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.apme.2012.06.008

3. The role of uterine artery embolization Review Article 207
The advantages of UAE compared with hysterectomy
include avoidance of surgical risks, shorter hospitalization,
and the potential for maintaining fertility. However, one
must remember that, unlike hysterectomy, UAE is palliative
rather than curative.
UAE patients can expect excellent short-term and mid-term
results with regards to menorrhagia, pelvic pain,
bulk-related symptoms, and reductions in uterine volume.
Longer term results are not known.
Recovery is shorter than recovery from hysterectomy or
open myomectomy (7e10 days versus 6 weeks).3,9
INDICATIONS
Symptomatic fibroids, dysfunctional uterine bleeding,
adenomyosis; excessive bleeding due to uterine artery pseu-doaneurysm,
arterio-venous malformations, trauma and
post curettage.
EMBOLIZATION IN POSTPARTUM
HEMORRHAGE
Postpartum hemorrhage remains a major cause of maternal
mortality throughout the world.10 Rapid identification of
the source and control of bleeding are necessary because
the situation is potentially life threatening. In most cases,
primary postpartum hemorrhage can be managed with
conservative treatment involving vaginal packing and admin-istration
of uterotonic drugs. With persistent bleeding,
vascular ligation or hysterectomy may be needed.11 Surgical
treatment, however, sometimes may be technically difficult
to perform and may fail to control hemorrhage. For these
reasons, transcatheter embolization of the uterine arteries
may represent an interesting alternate technique in the treat-ment
of intractable bleeding, preserving future fertility.
Major causes of bleeding include uterine atony, lower
genital tract lacerations or hematoma, retained placental
tissue, placenta accreta or percreta, rupture or inversion of
the uterus and coagulopathy. Secondary postpartum hemor-rhage
occurring more than 24 h after delivery is mainly
related to retained gestational products. In a study involving
27 cases of primary postpartum hemorrhage, Pelage et al12
reported that selective arterial embolization was successful
in 25 cases after failure of medical management. Emboliza-tion
failed in one of the patients with palcenta accreta who
later underwent hysterectomy.
Placenta accreta is one of the major causes of hysterec-tomy
after embolization because of persistent bleeding.13
Failures are also likely to occur with unilateral treatment
and in patients who have undergone bilateral ligation of
the hypogastric artery before embolization.
CONTRAINDICATIONS
Absolute contraindications include active infection and
pregnancy. Relative contraindications include coagulop-athy,
severe allergy to iodinated contrast, renal insuffi-ciency,
prior pelvic irradiation and prior bilateral ligation
of iliac arteries. It is also not advisable in women desirous
of future pregnancy.
PRE-PROCEDURE EVALUATION
A complete history and physical examination is necessary,
as well as ultrasonographic or magnetic resonance imaging
(MRI) of pelvis to allow proper treatment. Uterine and
fibroid volume measurements provide a baseline for deter-mining
the degree of postprocedural reduction in fibroid
and uterine volume.
In a preliminary report, Jha et al attached prognostic
significance to both the location and vascularity of fibroids
on MR imaging.14 Mizukami et al also have reported
a possible prognostic value for preprocedural MRI by
demonstrating better response to embolization in patients
with intermediate or high-signal intensity within their
fibroids on T2-weighted images (Fig. 7).15
Laboratory studies include hematocrit, coagulation
profile and serum creatinine.
Withhold GnRH agonist therapy at least 12 weeks prior to
the procedure. Premedication is usually with prophylactic
antibiotics, corticosteroids, antiemetics, and analgesics.
UAE is usually performed under conscious sedation. Corti-costeroids
are well documented to reduce the incidence of
postembolization syndrome after embolization of solid
tumors. John J. Bissler et al16 reported that the use of
a short-term tapering dose of corticosteroid was successful
in reducing postembolization syndrome as compared with
the reported literature and also improved patient comfort.
PROCEDURE
The procedure time is 45e135 min with 90% of the proce-dures
lasting from 50 to 75 min. There is an average proce-dural
exposure of 20 rad to the ovaries. Most patients are
discharged within 24 h; however, hospitalization for up to
48 h is sometimes required for the management of postop-erative
pain. The majority of patients return to normal activ-ities
within 1 week.17
Common femoral artery is punctured using an 18G
puncture needle and access secured by a 5F sheath. Usually
the right common femoral artery is punctured and rarely
bilateral punctures may be required. A pigtail catheter is
positioned at the lower abdominal aorta and a flush

4. 208 Apollo Medicine 2012 September; Vol. 9, No. 3 Amitha Vikrama and Chitra
angiogram is obtained to identify the right and left uterine
arteries; ovarian, lumbar, or other collateral parasitic
supplies to a large myomatous uterus may be seen. Uterine
arteries are the predominant feeders in most of the cases
(Figs. 1, 3 and 5). They are selectively cannulated using
a 5F catheter or a microcatheter and embolized using
300e500 or 500e700 micron poly-vinyl-alcohol (PVA)
particles, sparing the cervico-vaginal branch (Figs. 2, 4
and 6).
Histologically, PVA particles adhere to the vessel wall,
causing slow flow within that vessel. The result is intralu-minal
thrombus formation, inflammatory reaction,
foreign-body reaction, and focal angionecrosis of the vessel
wall. The foreign-body reaction induced by PVA is re-ported
to persist up to 28 months after embolization.
RECOVERY
Most patients will have postembolization syndrome which
is similar to solid tumor postembolization syndrome and
typically lasts a week. Signs and symptoms may include
pelvic pain, cramping, nausea, vomiting, low-grade fever
and general malaise.
Postembolization pain is controlled by oral, IV, epidural,
and/or patient-controlled analgesia in both an inpatient and
outpatient setting. Opioid, Nonsteroidal anti-inflammatory
drugs and antinausea medications are routinely used.
Fig. 1 Right uterine artery angiogram showing tortuous spiral
arteries supplying the fibroid.
Fig. 2 Postembolization check angiogram showing non-opa-cification
of the uterine artery and opacification of the cervico-vaginal
branch which is not embolized.
Fig. 3 Left uterine artery angiogram showing tortuous spiral
arteries supplying the fibroid.

5. The role of uterine artery embolization Review Article 209
Fig. 4 Postembolization check angiogram showing non-opa-cification
of the distal left uterine artery and contrast stasis
proximally.
COMPLICATIONS
Infection (pyometrium with acute endometritis), pervaginal
expulsion of pedunculated submucosal fibroids, premature
ovarian failure and pulmonary embolism.
Complications due to inadvertent embolization of non-target
arteries include sexual dysfunction due to emboliza-tion
of the cervical vaginal branch, damage to the rectum,
bladder, buttocks, and sciatic nerve.
Technical failure in UAE can be defined as an inability
to successfully catheterize and embolize both the right and
the left uterine arteries.
Two deaths have been reportededue to sepsis and multi-organ
failure and pulmonary embolism.18,19
Finally, complications related to angiography are rare
and include 0.2% hematoma, 0.2%e0.4% arterial throm-bosis,
and 0.05% false aneurysm.5
Fig. 5 Left uterine angiogram showing hypertrophied and
tortuous vessels supplying the uterine arterio-venous
malformation.
Fig. 6 Postembolization check angiogram in uterine AVM
showing non-opacification of the left uterine artery and opa-cification
of the other internal iliac branches.

6. 210 Apollo Medicine 2012 September; Vol. 9, No. 3 Amitha Vikrama and Chitra
FERTILITY FOLLOWING EMBOLIZATION
Although there is growing literature demonstrating that preg-nancy
after UAE is possible, there is not sufficient evidence
that this treatment modality offers advantages over the
conventional treatments. Whether UAE is safe for patients
who wish to retain future fertility is controversial. In fact,
ACOG Committee Opinion from 2004 states: “.There is
insufficient evidence to ensure its (UAE) safety in women
desiring to retain their fertility, and pregnancy-related
outcomes remain understudied. The ACOG considers this
procedure investigational or relatively contra-indicated in
women wishing to retain fertility.”. Myomectomy remains
the standard of care in patients who wish to retain their
fertility. UAE’s effect on fertility and pregnancy needs to
be studied further. Meanwhile, this technique should only
be used in patients desiring to remain fertile for whom there
are no other feasible options.20
Several pregnancy complications have been reported
after UAE. In one survey involving 50 published articles
on successful pregnancies following UAE, these complica-tions
were reported; malpresentations (17%), SGA (7%),
cesarean section (56%), preterm delivery (28%), and post-partum
hemorrhage (13%).21 The rates of abortions,
preterm delivery, malpresentations and postpartum
hemorrhage are significantly higher in patients treated
with UAE compared to myomectomy group.22
SUMMARY
Uterine artery embolization is a safe and effective treatment
for haemorrhagic uterine disorders including fibroid
disease. It requires a shorter hospital stay with early
resumption of normal activities. However, unlike hysterec-tomy,
UAE is palliative rather than curative.
CONFLICTS OF INTEREST
All authors have none to declare.
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