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Applications of IR inObstetrics and Gynecology                            Grand Rounds               Obstetrics and Gyneco...
Stephen Kee, MD    Christopher Loh, MD      Cheryl Hoffman, MD  Section Chief      Director, Santa Monica   Director, Manh...
Manhattan Beach    - UCLA
   Part I – Hemorrhage     Obstetric hemorrhage     Gynecologic hemorrhage   Part II – Thrombosis     Deep vein throm...
Obstetric Hemorrhage
Obstetric                                         hemorrhage   Obstetric hemorrhage is the single    most important cause...
Obstetric                                  hemorrhage   >500 cc (vaginal delivery)   >1000 cc (Cesarean section)   Post-...
Obstetric                                  hemorrhage   Conservative management is    usually sufficient                 ...
Obstetric                                    hemorrhage   Surgery can be performed when    conservative modes fail       ...
Obstetric                                            hemorrhage   Uterine artery embolization is a    minimally invasive ...
LR
Obstetric                                             hemorrhage   Distal occlusion prevents    arterial reconstitution f...
Obstetric                                       hemorrhage   Success rates in controlling PPH    (hysterectomy avoided): ...
Obstetric                                      hemorrhage   Normal menstruation usually    resumes in 3-6 months         ...
Obstetric                                                    hemorrhage   Fertility is usually preserved    ◦ Picone 2003...
Obstetric                                        hemorrhage   Advantages over surgical    ligation or hysterectomy       ...
Obstetric                                          hemorrhage   Embolization can be successful    even after all surgical...
Obstetric                                              hemorrhage   Conclusion    ◦ Embolotherapy is a first-line        ...
ObstetrichemorrhageInvasive placenta Background
Obstetric                                           hemorrhage   Defect in decidua basalis    resulting in abnormal    im...
Obstetric                                       hemorrhage   Cesarean delivery and    hysterectomy is the traditional    ...
Obstetric                                        hemorrhage   How can we help?    ◦ Pre-operative occlusion balloon      ...
Obstetric                                              hemorrhage   Balloon occlusion technique:    ◦ Bilateral femoral o...
Obstetric    hemorrhage     Invasive placenta       IR assistanceSalazar 2009
Obstetric                                         hemorrhage   Aortic occlusion balloon    ◦ Paull 1995: 600 cc blood los...
Obstetric                                         hemorrhage   Comparative studies are    contradictory    ◦ Levine 1999:...
Obstetric                                                   hemorrhage   Uterine-sparing treatment may be    achievable w...
ObstetrichemorrhageInvasive placenta IR assistanceBanovac 2007
Obstetric                                         hemorrhage   Interventional radiology can    have several roles in mana...
Obstetric                                   hemorrhage   Cervical ectopic: ~1/5,000    pregnancies   Abdominal ectopic: ...
Obstetric                                           hemorrhage   Overall very limited role of IR    in ectopic pregnancy ...
Obstetric                                             hemorrhage   11 reports of arterial    embolization for abdominal a...
Obstetric                                           hemorrhage   Post-partum hemorrhage can be    effectively and safely ...
Gynecologic hemorrhage
Gynecologic                                   hemorrhage   Gynecologic causes of pelvic    hemorrhage are much less      ...
Gynecologic                                          hemorrhage   Causative tumors    ◦ Cervical CA    ◦ Endometrial CA  ...
Gynecologic                                         hemorrhage   Subselective angiography and    embolization            ...
GynecologichemorrhagePelvic malignancyBanovac 2007
Gynecologic                                            hemorrhage   Results of UAE in tumor-related    bleeding    ◦ Lang...
GynecologichemorrhageUterine AVMs  BackgroundKwon 2002
Gynecologic                                               hemorrhage   Uncommon vascular lesions with    direct communica...
Gynecologic   Ultrasound:         hemorrhage    Hypoechoic cystic    or tubular-like    structures   Doppler: Low-      ...
Gynecologic                                                  hemorrhage   Congenital AVMs    ◦ Difficult to treat    ◦ Su...
Gynecologic                                                   hemorrhage   Acquired AVMs    ◦ Can usually be treated with...
Gynecologic                                        hemorrhage   More than 70 cases of acquired    uterine AVM embolizatio...
Gynecologic                                      hemorrhage   Gynecologic hemorrhage (usually    from tumor bleeding) can...
Thrombosis
Thrombosis   Pulmonary thromboembolism    (PE), arising from deep vein        Introduction    thrombosis (DVT), is the #1...
Thrombosis   DVT in pregnancy    ◦ 90% left-sided                        Deep venous                                     ...
Thrombosis   Unilateral (usually left-sided)    leg pain and swelling                                      Deep venous  ...
Thrombosis   Medical therapy    ◦ Warfarin is teratogenic and must be      avoided during pregnancy                      ...
Thrombosis   IVC filter    ◦ Percutaneously placed device to                                              Deep venous    ...
Thrombosis                                                 Deep venous                                                 thr...
Thrombosis   Technique    ◦ Right IJ access                       Deep venous                                            ...
Thrombosis   IVC filters are safe and effective in    pregnancy                                              Deep venous ...
Thrombosis   Retrievable IVC filters    ◦ Can be removed within 1-12                                           Deep venou...
Thrombosis   Retrievable IVC filters                              Deep venous                              thrombosis    ...
Thrombosis   Massive PE in pregnancy is rare    but life-threatening   Treatment options:                               ...
Thrombosis   Thrombolysis can be considered    when the patient has life-    threatening PE   Systemic lysis: 13 cases r...
Thrombosis   DVT is common in the    puerperial period   IVC filters are useful and safe in    select patients, and can ...
Elective procedures
Elective                                           procedures   Interventional radiology can offer    minimally invasive,...
ElectiveproceduresUterine fibroidembolization Background
Elective                                         procedures   20-40% of women over 35 have    symptomatic uterine fibroid...
ElectiveproceduresUterine fibroidembolization Background
Elective                                                 procedures   Usual candidates for UFE    ◦ Pre- and peri-menopau...
Elective                                             procedures   Contraindications    ◦ Pregnancy                       ...
Elective                                              procedures   Technique:        Common femoral artery access       ...
Elective                                                procedures   Complications of UFE    ◦ Data varies, 1-5%.        ...
UFE Symptom ImprovementStudy         # patients   Mean F/U   Menorrhagia   Bulk sx         Fibroid                        ...
Elective                                                     procedures   Summary of published results    ◦ Improvement i...
Elective                                                   procedures   EMMY Results-Randomized Clinical    EMbolization ...
Elective                                                   procedures   UFE and future pregnancy    ◦ Only small studies ...
Elective                                           procedures   With appropriate patient    selection, UFE is a proven ef...
ElectiveproceduresPelvic congestionsyndrome  BackgroundLiddle 2007
Elective                                                  procedures   Chronic pelvic pain is a common and    distressing...
Elective                                             procedures   Clinical features    ◦ Premenopausal woman    ◦ Usually...
Elective                                                     procedures   Gynecologic exam is often normal    ◦ Ovarian p...
ElectiveproceduresPelvic congestionsyndrome Diagnosis
Elective          Dynamic contrast-enhanced MRI          procedures                                                 Pelvic...
Elective                                        procedures   Medical therapy (chemical    menopause) is effective but oft...
Elective                                        procedures   Ovarian vein embolization is a    minimally invasive alterna...
ElectiveproceduresPelvic congestionsyndrome Treatment
ElectiveproceduresPelvic congestionsyndrome Treatment
Elective                                                  procedures   Prospective study compared ovarian    vein emboliz...
ElectiveproceduresFallopian tuberecanalization  Backgroundcourtesy of C. Hoffman, MD
Elective                                             procedures   Tubal abnormalities account for a    significant propor...
Elective                                                      procedures   Catheter placed transcervically into    tubal ...
ElectiveproceduresFallopian tuberecanalization  Techniquecourtesy of C. Hoffman, MD
Elective                                           procedures   RCT showed diagnostic accuracy was    comparable to lapar...
Elective                                                     procedures   Can (should?) be used as initial tubal    asses...
Elective                                                 procedures   Endorsed by American Fertility Society    and Royal...
Elective                                                procedures   UFE is an effective and minimally    invasive altern...
Radiation and contrast
Radiation                                           and contrast   Radiographic examinations in    obstetric patients cau...
Radiation                                       and contrast   Potential effects of in utero    radiation exposure    ◦  ...
Radiation                                           and contrast   Prenatal death    ◦ Most sensitive time: 0-8 days     ...
Radiation                                           and contrast   Growth retardation    ◦ Most sensitive time: 1 week-2 ...
Radiation                                         and contrast   Organ malformation    ◦ Most sensitive time: 2 weeks – 2...
Radiation                                              and contrast   Mental retardation/reduced IQ    ◦ Most sensitive t...
Radiation                                        and contrast   Childhood cancer    ◦ Most sensitive time: 0-3 months   R...
Radiation                                                             and contrastDose to fetus   No             No childh...
Radiation                                                       and contrast   ACOG policy statement    ◦ “Women should b...
Radiation                                      and contrast   Iodinated contrast media is    required in many radiologic ...
Radiation                                          and contrast   There is no evidence of mutagenic    or teratogenic eff...
Radiation                                                             and contrast   Depression of thyroid function is th...
Radiation                                                          and contrast   Contrast media in lactating mothers    ...
Radiation                                                   and contrast   The increased risk of fetal abnormalities    o...
Final                                            thoughts   Interventional radiology can offer    several minimally invas...
Applications of ir in obstetrics and gynecology2
Applications of ir in obstetrics and gynecology2
Applications of ir in obstetrics and gynecology2
Applications of ir in obstetrics and gynecology2
Applications of ir in obstetrics and gynecology2
Applications of ir in obstetrics and gynecology2
Applications of ir in obstetrics and gynecology2
Applications of ir in obstetrics and gynecology2
Applications of ir in obstetrics and gynecology2
Applications of ir in obstetrics and gynecology2
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Applications of ir in obstetrics and gynecology2

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Applications of ir in obstetrics and gynecology2

  1. 1. Applications of IR inObstetrics and Gynecology Grand Rounds Obstetrics and Gynecology 1/29/2010 Justin McWilliams, MD Assistant Professor UCLA Interventional Radiology
  2. 2. Stephen Kee, MD Christopher Loh, MD Cheryl Hoffman, MD Section Chief Director, Santa Monica Director, Manhattan Beach Justin McWilliams, MD Michael Kuo, MD Antoinette Gomes, MD Susie Muir, MDUCLA Interventional Radiology
  3. 3. Manhattan Beach - UCLA
  4. 4.  Part I – Hemorrhage  Obstetric hemorrhage  Gynecologic hemorrhage Part II – Thrombosis  Deep vein thrombosis  Pulmonary embolism Part III – Elective procedures  Uterine fibroid embolization  Pelvic congestion syndrome  Fallopian tube recanalization Part IV – Radiation and contrastOutline of Discussion
  5. 5. Obstetric Hemorrhage
  6. 6. Obstetric hemorrhage Obstetric hemorrhage is the single most important cause of maternal Introduction mortality worldwide ◦ 3rd leading cause of maternal mortality in the USA Complicates ~5% of deliveries
  7. 7. Obstetric hemorrhage >500 cc (vaginal delivery) >1000 cc (Cesarean section) Post-partum hemorrhage Causes: The 4 “T’s” Definition ◦ Tone  Uterine atony ◦ Tissue  Retained placenta ◦ Trauma  Lacerations  Uterine rupture ◦ Thrombosis disorders  Coagulopathy
  8. 8. Obstetric hemorrhage Conservative management is usually sufficient Post-partum ◦ Hemodynamic resuscitation hemorrhage ◦ Uterotonic infusion Conservative therapy ◦ Bimanual or abdominal massage ◦ Laceration repair ◦ Uterine packing Mousa 2003
  9. 9. Obstetric hemorrhage Surgery can be performed when conservative modes fail Post-partum ◦ Hysterectomy hemorrhage ◦ Surgical arterial ligation ◦ Uterine suturing techniques Surgical therapy
  10. 10. Obstetric hemorrhage Uterine artery embolization is a minimally invasive alternative Post-partum hemorrhage ◦ Performed under conscious sedation ◦ Technique Embolotherapy  Common femoral artery access  Pelvic aortogram  Selective angiography of internal iliac arteries  Gelfoam embolization of uterine arteries +/- others
  11. 11. LR
  12. 12. Obstetric hemorrhage Distal occlusion prevents arterial reconstitution from collaterals Post-partum hemorrhage Temporary occlusive effect (usually 10-30 days) Embolotherapy Rapid (similar to trauma) ◦ Available at all times ◦ Procedure time usually less than one hour
  13. 13. Obstetric hemorrhage Success rates in controlling PPH (hysterectomy avoided): ◦ Greenwood 1987: 8/8 Post-partum hemorrhage ◦ Gilbert 1992: 10/10 ◦ Mitty 1993: 17/18 ◦ Yamashita 1994: 15/15 ◦ Merland 1996: 15/16 ◦ Pelage 1998: 34/35 Embolotherapy ◦ Deux 2001: 24/25 ◦ Borgatta 2001: 10/11 ◦ Chung 2003: 31/33 ◦ Tourne 2003: 11/12 Overall success rate of 90-95%
  14. 14. Obstetric hemorrhage Normal menstruation usually resumes in 3-6 months Post-partum hemorrhage Complications are uncommon (3-7%) and much lower than laparotomy ◦ Post-embolization syndrome Embolotherapy ◦ Access site hematoma ◦ Infection ◦ Rare ischemic complications (bladder or uterine necrosis, nerve paresis) Vedantham 1997
  15. 15. Obstetric hemorrhage Fertility is usually preserved ◦ Picone 2003: Ultrasound showed normal Post-partum fetal growth and Doppler findings in 8/8 hemorrhage ◦ Oman 2003: 28 patients post- embolotherapy were followed for ~12 years  6/6 who desired pregnancy were successful  All pregnancies and deliveries were Embolotherapy uncomplicated ◦ Delotte 2009: Review of all reported cases of pregnancy following UAE for PPH  “Fertility appears greatly preserved”  18% miscarriage rate (similar to general population)  Recurrent PPH can occur (19%)
  16. 16. Obstetric hemorrhage Advantages over surgical ligation or hysterectomy Post-partum hemorrhage ◦ Less invasive/morbid ◦ Unanticipated (non-uterine) bleeding sources can be identified and treated Embolotherapy ◦ Immediate angiographic confirmation of success ◦ No adverse impact on subsequent arterial ligation if necessary
  17. 17. Obstetric hemorrhage Embolization can be successful even after all surgical options have failed Post-partum hemorrhage ◦ Arterial embolization successful in 10/11 cases of failed surgical ligation for PPH Embolotherapy ◦ More technically difficult Sentilhes 2009
  18. 18. Obstetric hemorrhage Conclusion ◦ Embolotherapy is a first-line Post-partum hemorrhage treatment for PPH refractory to local measures ◦ Surgical options are always available for embolization failures Embolotherapy ◦ Close collaboration between obstetrics and IR should result in a low rate of hysterectomy or exsanguination in patients with PPH
  19. 19. ObstetrichemorrhageInvasive placenta Background
  20. 20. Obstetric hemorrhage Defect in decidua basalis resulting in abnormal implantation of the placenta Incidence has markedly increased in recent years Invasive placenta ◦ 1930s: 1/30,000 ◦ 1980s: 1/2,500 Background ◦ 2006: 1/540 May result in massive hemorrhage at delivery Historically high mortality rate ◦ 25% with conservative measures ◦ 6% with hysterectomy ◦ 90% will require blood transfusion Fox 1972
  21. 21. Obstetric hemorrhage Cesarean delivery and hysterectomy is the traditional management Invasive placenta Estimated blood loss among 62 patients with placenta accreta Conventional therapy undergoing Cesarean hysterectomy ◦ >2 L in 41 patients ◦ >5 L in 9 patients ◦ >10 L in 4 patients ◦ >20 L in 2 patients Miller 1997
  22. 22. Obstetric hemorrhage How can we help? ◦ Pre-operative occlusion balloon placement in aorta or bilateral internal iliac arteries Invasive placenta ◦ Post-delivery uterine artery embolization (with or without pre-operative catheter placement) IR assistance ◦ May also aid conservative (uterine-sparing) treatment by performing UAE to reduce bleeding and shrink the placental remnant
  23. 23. Obstetric hemorrhage Balloon occlusion technique: ◦ Bilateral femoral or axillary artery access Invasive placenta ◦ Bilateral occlusion balloons are placed IR assistance ◦ Balloons inflated in operating room after delivery  Decreases uterine and pelvic blood flow  Increases time for surgical control of hemorrhage  Embolization can be performed if necessary
  24. 24. Obstetric hemorrhage Invasive placenta IR assistanceSalazar 2009
  25. 25. Obstetric hemorrhage Aortic occlusion balloon ◦ Paull 1995: 600 cc blood loss (n=1) ◦ Masamoto 2009: 3200 cc blood loss (n=1) Invasive placenta Bilateral internal iliac occlusion balloons IR assistance ◦ Dubois 1997: 1500-2000 cc blood loss (n=2) ◦ Weeks : 1500 cc blood loss (n=1) ◦ Kidney: 1100-4000 cc blood loss (n=5)
  26. 26. Obstetric hemorrhage Comparative studies are contradictory ◦ Levine 1999: No difference in estimated blood loss (~5000 cc) Invasive placenta ◦ Tan 2007: Lower blood loss (2000 cc) with balloon occlusion IR assistance than control group (3300 cc) ◦ Shrivastava 2007: No difference in estimated blood loss (~3000 cc) Study bias?
  27. 27. Obstetric hemorrhage Uterine-sparing treatment may be achievable with embolotherapy ◦ Bilateral uterine artery embolization with gelfoam Invasive placenta ◦ Catheters can be placed prior to delivery to facilitate rapid embolization IR assistance Currently there are 35 case reports or case series of UAE for placenta accreta (n=73) ◦ Success rate 77% Alanis 2006
  28. 28. ObstetrichemorrhageInvasive placenta IR assistanceBanovac 2007
  29. 29. Obstetric hemorrhage Interventional radiology can have several roles in managing invasive placenta Invasive placenta ◦ Balloon occlusion ◦ Pre-operative or intra-operative embolization to limit blood loss Conclusions of caesarian hysterectomy or other surgical procedures ◦ Uterine-sparing treatment with uterine artery embolization
  30. 30. Obstetric hemorrhage Cervical ectopic: ~1/5,000 pregnancies Abdominal ectopic: ~1/10,000 pregnancies Ectopic pregnancy
  31. 31. Obstetric hemorrhage Overall very limited role of IR in ectopic pregnancy ◦ Prompt medical or operative treatment is usually adequate Embolization can be used to limit blood loss in select cases Ectopic pregnancy ◦ Cervical ectopic pregnancies  Uterine cervix contains only 20% smooth muscle tissue  Limited response to uterotonics ◦ Abdominal ectopic pregnancies
  32. 32. Obstetric hemorrhage 11 reports of arterial embolization for abdominal and cervical pregnancies ◦ Total patients = 22 ◦ 100% success rate in controlling Ectopic pregnancy hemorrhage Badawy 2001
  33. 33. Obstetric hemorrhage Post-partum hemorrhage can be effectively and safely controlled by UAE, with success rates of 90-95% ◦ Fertility maintained ◦ Low radiation dose ◦ Fast and readily available Balloon occlusion or UAE can be Conclusions considered for patients with invasive placenta to reduce blood loss ◦ Anecdotal effectiveness ◦ Data not yet mature
  34. 34. Gynecologic hemorrhage
  35. 35. Gynecologic hemorrhage Gynecologic causes of pelvic hemorrhage are much less Introduction common than obstetric causes ◦ Pelvic malignancy ◦ Uterine AVMs
  36. 36. Gynecologic hemorrhage Causative tumors ◦ Cervical CA ◦ Endometrial CA ◦ Choriocarcinoma Pelvic malignancy Bleeding is usually slow, but persistent and poorly responsive to surgical and radiation therapy
  37. 37. Gynecologic hemorrhage Subselective angiography and embolization Pelvic malignancy ◦ Permanent occlusion is desirable  Particles  Coils ◦ Gelfoam can be used if rapid cessation of bleeding is necessary
  38. 38. GynecologichemorrhagePelvic malignancyBanovac 2007
  39. 39. Gynecologic hemorrhage Results of UAE in tumor-related bleeding ◦ Lang 1981: 23/23 cessation Pelvic malignancy ◦ Pisco 1989: 74/108 complete cessation; 23/108 partial cessation ◦ Yamashita 1993: 17/17 cessation for cervical cancer; 3 required re- embo Also evidence that survival is prolonged in patients with advanced malignancy ◦ Median survival extended 4-6 months Banovac 2007
  40. 40. GynecologichemorrhageUterine AVMs BackgroundKwon 2002
  41. 41. Gynecologic hemorrhage Uncommon vascular lesions with direct communication between arteries and veins Uterine AVMs Congenital AVM Background ◦ Often extend beyond uterus ◦ Central nidus with multiple arterial feeders and draining veins Acquired AVM ◦ Confined to endometrium/myometrium ◦ No nidus ◦ Caused by endometrial curettage, pelvic surgery, gestational trophoblastic disease Cura 2009
  42. 42. Gynecologic Ultrasound: hemorrhage Hypoechoic cystic or tubular-like structures Doppler: Low- Uterine AVMs resistance high- velocity blood flow Diagnosis Beta-HCG helps distinguish from RPOC and GTD Cura 2009
  43. 43. Gynecologic hemorrhage Congenital AVMs ◦ Difficult to treat ◦ Surgical ligation leads to rapid Uterine AVMs recruitment of collateral vessels ◦ If AVM is limited to uterus, then pre- operative embolization followed by excision can be curative Treatment ◦ If AVM extends to pelvic organs, it is usually unresectable  Repeated percutaneous embolization  Palliative rather than curative in most instances Calligaro 1992
  44. 44. Gynecologic hemorrhage Acquired AVMs ◦ Can usually be treated with embolotherapy alone ◦ Subselective angiography is followed by Uterine AVMs permanent embolization (particles or glue) Treatment Banovac 2007, Salazar 2009
  45. 45. Gynecologic hemorrhage More than 70 cases of acquired uterine AVM embolization have been reported ◦ Control of bleeding in 96% Uterine AVMs ◦ Complication rate of 4% ◦ Restoration of normal menstruation and fertility have Treatment been reported Banovac 2007
  46. 46. Gynecologic hemorrhage Gynecologic hemorrhage (usually from tumor bleeding) can be effectively controlled with UAE ◦ Similar success rates to PPH Most uterine AVMs can be effectively treated with Conclusions embolization Banovac 2007
  47. 47. Thrombosis
  48. 48. Thrombosis Pulmonary thromboembolism (PE), arising from deep vein Introduction thrombosis (DVT), is the #1 cause of maternal mortality in the USA Late pregnancy and puerperial period are major risk factors ◦ 5-20x relative risk Banovac 2007
  49. 49. Thrombosis DVT in pregnancy ◦ 90% left-sided Deep venous thrombosis ◦ 70% are iliofemoral (more likely to Background embolize than femoropopliteal) Banovac 2007
  50. 50. Thrombosis Unilateral (usually left-sided) leg pain and swelling Deep venous Ultrasound confirms diagnosis thrombosis Diagnosis
  51. 51. Thrombosis Medical therapy ◦ Warfarin is teratogenic and must be avoided during pregnancy Deep venous thrombosis ◦ LMWH is the medical treatment of choice, but is not a perfect solution  Some patients are not candidates for anticoagulation  Increased bleeding risk  5% risk of breakthrough PE Treatment  Heparin-induced thrombocytopenia Decousus 1998
  52. 52. Thrombosis IVC filter ◦ Percutaneously placed device to Deep venous prevent venous thrombi from thrombosis embolizing to the lungs ◦ Absolute indications are DVT or PE with: Treatment  Failure of anticoagulation  Contraindication to anticoagulation  Complication of anticoagulation ◦ May also be considered for:  Free-floating iliocaval thrombus  Iliofemoral DVT close to labor Banovac 2007
  53. 53. Thrombosis Deep venous thrombosis Optease (21 days) G2 Recovery (1 year) TreatmentGunther Tulip (1 month) Option (6 months)
  54. 54. Thrombosis Technique ◦ Right IJ access Deep venous thrombosis ◦ Cavogram to locate renal veins ◦ Suprarenal IVC filter deployment Treatment  Avoids contact with gravid uterus  Protects against emboli from ovarian veins Very safe (major complication rate 0.3%) Aburahma 2001
  55. 55. Thrombosis IVC filters are safe and effective in pregnancy Deep venous ◦ IVC filter placed in 18 pregnant thrombosis patients with DVT ◦ Mean fluoro time <2 minutes Treatment ◦ No fetal or maternal morbidity or mortality ◦ No PE or filter-related complications with 6.5 year follow-up Aburahma 2001
  56. 56. Thrombosis Retrievable IVC filters ◦ Can be removed within 1-12 Deep venous months after placement thrombosis depending on design ◦ Prevents potential (though rare) long-term complications of filters Treatment  Caval occlusion  Delayed migration  Caval penetration ◦ Retrieval success rates are high (>90%) Athanasoulis 2000
  57. 57. Thrombosis Retrievable IVC filters Deep venous thrombosis Treatment
  58. 58. Thrombosis Massive PE in pregnancy is rare but life-threatening Treatment options: Pulmonary embolism ◦ Surgical embolectomy ◦ Systemic (IV) thrombolysis ◦ Localized (catheter-directed) thrombolysis
  59. 59. Thrombosis Thrombolysis can be considered when the patient has life- threatening PE Systemic lysis: 13 cases reported ◦ No maternal deaths Pulmonary ◦ 4 major maternal bleeds embolism ◦ 2 fetal deaths ◦ 5 preterm deliveries Catheter-directed lysis: 4 cases reported ◦ No maternal deaths ◦ 1 fetal death ◦ 1 preterm delivery te Raa 2009
  60. 60. Thrombosis DVT is common in the puerperial period IVC filters are useful and safe in select patients, and can be retrieved after delivery Conclusions Though data is limited, lysis should not be withheld from pregnant women in cases of life-threatening PE
  61. 61. Elective procedures
  62. 62. Elective procedures Interventional radiology can offer minimally invasive, well tolerated Introduction treatments for select patients with: ◦ Uterine fibroids ◦ Pelvic pain of unknown cause (or known pelvic congestion) ◦ Tubal infertility
  63. 63. ElectiveproceduresUterine fibroidembolization Background
  64. 64. Elective procedures 20-40% of women over 35 have symptomatic uterine fibroids Uterine fibroid 200,000 of the 600,000 embolization hysterectomies per year are for Background fibroids 2002 FDA cleared particulate embolic agents for use in treating fibroids in women Approximately 22,000 UFE procedures are currently performed yearly courtesy of C. Hoffman, MD
  65. 65. ElectiveproceduresUterine fibroidembolization Background
  66. 66. Elective procedures Usual candidates for UFE ◦ Pre- and peri-menopausal women with symptomatic fibroids (age 35-55) Uterine fibroid embolization ◦ Women who have had their children or do not want to have children Background ◦ Women who want to keep their uterus ◦ Women who do not want surgery ◦ Women who have failed myomectomy ◦ Women who want a short hospital stay and as little time off work as possible. courtesy of C. Hoffman, MD
  67. 67. Elective procedures Contraindications ◦ Pregnancy Uterine fibroid ◦ Suspicion of cancer - embolization uterine, ovarian, cervical Background ◦ Infarcted fibroids Relative contraindications ◦ Pedunculated fibroid ◦ Intracavitary fibroid (>4cm), due to expulsion/infection risk ◦ Extremely large fibroids (bulk symptoms may persist post UFE)
  68. 68. Elective procedures Technique:  Common femoral artery access Uterine fibroid embolization  Select both uterine arteries using Background coaxial (microcatheter) technique  Embolize using 500-700 micron particles (PVA or tris-acryl microspheres)
  69. 69. Elective procedures Complications of UFE ◦ Data varies, 1-5%. Uterine fibroid embolization ◦ Fibroid registry complication data Treatment  1700 patients with 1-year follow-up  No deaths  4% major events (most common readmission for pain)  1% readmission for D&C (fibroid being expelled)  0.1% had hysterectomy within 30 days courtesy of C. Hoffman, MD
  70. 70. UFE Symptom ImprovementStudy # patients Mean F/U Menorrhagia Bulk sx Fibroid sx improved improved volume reductionHutchins 305 1 yr 92% 92% -1999Ravina 188 29 mo 90% - 87% @ 6 mo1999Mclucas 167 6 mo 82% 69% 49% 6 mo2001 52% 1 yrSpies 200 21 mo 90% 1 yr 91% 1yr 60% 1yr2001Walker 2002 400 16.7 mo 84% 79% 73% @ 9.7 moPron 2003 550 8.9 mo 83% 77% 42%@3mo (median)Spies 2004 102 1 yr 83%@ 6mo 84% @1 yr 54%@6moSpies 2005 200 1yr 90% 91% 57% 5yr <------73% --------- courtesy of C. Hoffman, MD
  71. 71. Elective procedures Summary of published results ◦ Improvement in menorrhagia in ~90% Uterine fibroid  Usually within 2 cycles embolization ◦ Improvement in bulk symptoms in ~80%  Takes at least 3 months Results ◦ Uterine volume reduction is ~50% at 1 year ◦ Technical success of UFE procedure is 98% ◦ Clinical failure can occur due to collateral supply from ovarian arteries (~10%)
  72. 72. Elective procedures EMMY Results-Randomized Clinical EMbolization vs HysterectoMY (n=177, 88 UFE & 89 Hysterectomy) Uterine fibroid ◦ 6 weeks after treatment, UFE patients embolization were more satisfied than the hysterectomy pts. ◦ 2 years post UFE, 90% satisfied with their procedure (same for hysterectomy) Results “The 24 month cumulative cost of UAE is lower than that of hysterectomy. From a societal economic perspective, UAE is the superior treatment strategy in women with symptomatic uterine fibroids.” JVIR 2008
  73. 73. Elective procedures UFE and future pregnancy ◦ Only small studies on UFE and future pregnancy are available. Uterine fibroid embolization ◦ Myomectomy is preferred-there is less risk of amenorrhea ◦ Consider UFE if the patient has failed Results medical therapy and the only options are extensive myomectomy or hysterectomy ◦ 2005 data…there is no increased risk with pregnancy following UFE… Only an increase in C-section rate. courtesy of C. Hoffman, MD
  74. 74. Elective procedures With appropriate patient selection, UFE is a proven effective and safe minimally invasive Uterine fibroid therapy for the treatment of embolization uterine fibroids Further education of the public and collaborative efforts between IR Results and OB/Gyn are needed.
  75. 75. ElectiveproceduresPelvic congestionsyndrome BackgroundLiddle 2007
  76. 76. Elective procedures Chronic pelvic pain is a common and distressing complaint among women of childbearing age ◦ No diagnosis is made in more than half of cases ◦ Historically, was often attributed to Pelvic congestion syndrome psychogenic causes ◦ Beard 1984: 91% of women with chronic Background pelvic pain have pelvic varices Pelvic congestion syndrome refers to the presence of pelvic varices, which lead to venous stasis and congestion of the pelvic organs, and chronic pelvic pain ◦ Hormonal and anatomic factors Liddle 2007
  77. 77. Elective procedures Clinical features ◦ Premenopausal woman ◦ Usually have had children Pelvic congestion syndrome ◦ Dull ache similar to the pain of varicose veins of the legs; Diagnosis predominantly unilateral ◦ Exacerbated by standing, lifting, pregnancy, coitus ◦ Regresses completely after menopause
  78. 78. Elective procedures Gynecologic exam is often normal ◦ Ovarian point tenderness may be present Routine imaging and laparoscopy may not detect ovarian varicosities ◦ Supine position collapses varices Pelvic congestion ◦ Dynamic MRI is gaining favor syndrome Ovarian venography using a tilting table Diagnosis is gold standard for diagnosis ◦ Abnormal dilation of ovarian veins >10 mm ◦ Ovarian vein reflux ◦ Uterine venous engorgement ◦ Filling of pelvic veins across the midline
  79. 79. ElectiveproceduresPelvic congestionsyndrome Diagnosis
  80. 80. Elective Dynamic contrast-enhanced MRI procedures Pelvic congestion syndrome DiagnosisEarly arterial Late arterial Early venous
  81. 81. Elective procedures Medical therapy (chemical menopause) is effective but often unacceptable to patients Surgery (hysterectomy +/- Pelvic congestion oophorectomy) was traditionally syndrome considered for medical failures Treatment Chung 2003, Cordts 1998
  82. 82. Elective procedures Ovarian vein embolization is a minimally invasive alternative ◦ Outpatient procedure Pelvic congestion ◦ Coils or sclerosing agent syndrome administered to ovarian veins ◦ Technical success 89-97% Treatment◦ Clinical success rates are 74-89% over follow-up to 15 months Chung 2003, Cordts 1998
  83. 83. ElectiveproceduresPelvic congestionsyndrome Treatment
  84. 84. ElectiveproceduresPelvic congestionsyndrome Treatment
  85. 85. Elective procedures Prospective study compared ovarian vein embolization to hysterectomy (with unilateral or bilateral oophorectomy) for chronic pelvic pain Pelvic congestion ◦ 106 patients syndrome ◦ All had failed medical treatment ◦ After follow-up out to 32 months, ovarian Treatment vein embolization was significantly more effective at reducing pelvic pain ◦ Treatment was safe and well-tolerated Chung 2003
  86. 86. ElectiveproceduresFallopian tuberecanalization Backgroundcourtesy of C. Hoffman, MD
  87. 87. Elective procedures Tubal abnormalities account for a significant proportion of female infertility ◦ Often due to plugs of amorphous material in an otherwise normal tube Selective salpingography can Fallopian tube diagnose true obstruction, and recanalization subsequent recanalization may aid Background fertility Chung 2003
  88. 88. Elective procedures Catheter placed transcervically into tubal ostium Contrast media injected directly into fallopian tube ◦ Evaluate tube patency and peritoneal spillage ◦ Differentiate spasm from true obstruction Fallopian tube recanalization If proximal tubal occlusion is seen, recanalization can be attempted Technique using a microcatheter and guidewire Ovarian radiation exposure is low (1 rad) Chung 2003
  89. 89. ElectiveproceduresFallopian tuberecanalization Techniquecourtesy of C. Hoffman, MD
  90. 90. Elective procedures RCT showed diagnostic accuracy was comparable to laparoscopy and dye test (and less invasive) Pregnancy rates after the procedure are difficult to compare due to multifactorial causes of infertility Fallopian tube ◦ Range 9-56% recanalization ◦ Average 30% Complications are rare ◦ Tubal perforation (2%) Results ◦ Pelvic infection (1%) Chung 2003
  91. 91. Elective procedures Can (should?) be used as initial tubal assessment test ◦ Largest series (n=110) published in 2003 ◦ Selective salpingography possible in 92% ◦ Proximal tubal blockage (unilateral or bilateral) detected in about 1/3 of patients ◦ Spontaneous conception at least once in Fallopian tube 22% of women (no other interventions) recanalization Recanalization and flushing of the tubes may maximize unassisted fertility Results Papaioannou 2003
  92. 92. Elective procedures Endorsed by American Fertility Society and Royal College of Obstetricians and Gynaecologists for at least the last 10 years, but rarely used Comparable fertility results to more expensive and invasive treatments Fallopian tube ◦ In vitro fertilization / embryo transfer recanalization ◦ Microsurgical proximal tube repair Wider role has been advocated recently ◦ Simple Results ◦ Inexpensive ◦ Appears effective Chung 2003
  93. 93. Elective procedures UFE is an effective and minimally invasive alternative to surgical fibroid treatments ◦ Patient awareness is important Pelvic congestion syndrome should be considered in patients with chronic pelvic pain without discernible cause ◦ MRI or venography to diagnose Conclusions ◦ Ovarian vein embolization is safe and effective Fallopian tube recanalization can aid fertility in patients with proximal tubal obstruction
  94. 94. Radiation and contrast
  95. 95. Radiation and contrast Radiographic examinations in obstetric patients cause significant Introduction anxiety ◦ To the mother ◦ To the referring physician Potentially harmful effects to the fetus are often misunderstood
  96. 96. Radiation and contrast Potential effects of in utero radiation exposure ◦ Prenatal death Radiation ◦ IUGR ◦ Mental retardation ◦ Organ malformation ◦ Childhood cancer Risk of each effect depends on gestational age and magnitude of dose McCollough 2007
  97. 97. Radiation and contrast Prenatal death ◦ Most sensitive time: 0-8 days Radiation ◦ Threshold dose: 10-25 rads (animal studies) ◦ If embryo survives, no radiation effects are likely McCollough 2007
  98. 98. Radiation and contrast Growth retardation ◦ Most sensitive time: 1 week-2 Radiation months ◦ Threshold dose: 20 rads ◦ Atomic bomb survivors receiving >20 rads were ~1 inch shorter than controls McCollough 2007
  99. 99. Radiation and contrast Organ malformation ◦ Most sensitive time: 2 weeks – 2 Radiation months ◦ Threshold dose: 25 rads McCollough 2007
  100. 100. Radiation and contrast Mental retardation/reduced IQ ◦ Most sensitive time: 2-4 months Radiation ◦ Threshold dose: 10 rads ◦ IQ reduction is about 0.25 points per rad McCollough 2007
  101. 101. Radiation and contrast Childhood cancer ◦ Most sensitive time: 0-3 months Radiation ◦ Threshold dose: None ◦ Leukemia is most common McCollough 2007
  102. 102. Radiation and contrastDose to fetus No No childhood No malformation cancer malformation and no Radiation childhood cancer0 96% 99.93% 95.93%1 rad 95.98% 99.84% 95.83%10 rads 95.8% 99.07% 94.91% McCollough 2007
  103. 103. Radiation and contrast ACOG policy statement ◦ “Women should be counseled that x-ray exposure from a single diagnostic procedure does not result in harmful fetal Radiation effects. Specifically, exposure to less than 5 rad [50 mGy] has not been associated with an increase in fetal anomalies or pregnancy loss.” Even with 10 rad dose, increase over background incidence for organ malformation and childhood cancer combined is only ~1% McCollough 2007
  104. 104. Radiation and contrast Iodinated contrast media is required in many radiologic studies Contrast Anxiety occurs regarding safety for the fetus and with breast- feeding
  105. 105. Radiation and contrast There is no evidence of mutagenic or teratogenic effects of iodinated contrast Contrast ◦ In vitro testing ◦ In vivo animal testing Some IV contrast does traverse the placenta into the fetus Webb 2005
  106. 106. Radiation and contrast Depression of thyroid function is the main concern ◦ Fetal thyroid function is important for CNS development Contrast ◦ Excessive iodide uptake by the fetal thyroid can cause fetal hypothyroidism ◦ Only the free iodide portion is potentially harmful; 99.9% of iodine in contrast media is bound ◦ Likely that the free iodide diffuses out of the placenta rapidly and fetus is only exposed for a short time, but there are no experimental data ◦ Hypothyroid screening should be performed during the 1st week of life Webb 2005
  107. 107. Radiation and contrast Contrast media in lactating mothers ◦ Very low levels of IV contrast agent are excreted into the milk (about 0.4% of the dose) Contrast ◦ Very small amounts of the contrast agent that is ingested by the baby will be absorbed (about 0.8%) ◦ These amounts are orders of magnitude less than what would be used for typical radiographic exams in infants (pediatric urography, etc) Likelihood of direct toxicity or allergic reaction are extremely low Webb 2005
  108. 108. Radiation and contrast The increased risk of fetal abnormalities or childhood cancer from radiation is quite small ◦ Negligible for fetal exposure <5 rads ◦ ~1% increased incidence (from 4% to 5%) for 10 rads Radiographic procedures should be performed when essential Conclusions The use of IV contrast should be minimized in pregnancy due to lack of experimental data ◦ Potential thyroid effects (likely minimal) Breast-feeding can continue normally after IV contrast administration Webb 2005
  109. 109. Final thoughts Interventional radiology can offer several minimally invasive procedures to save or improve the lives of women ◦ Excessive bleeding ◦ DVT/PE ◦ Fibroids ◦ Pelvic pain ◦ Infertility Awareness is crucial! A close relationship between our departments can benefit your patients

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