uterine artery embolization, interventional radiology, coils

1. UTERINE ARTERY
EMBOLIZATION FOR
FIBROIDS
Waqar Shah, MD
DuBois Regional Medical Center

2. UTERINE LEIOMYOMAS
(FIBROIDS)
Definition- benign tumor of uterine smooth
muscle
 Most common benign tumors of the female
genital tract
- prevalence: 20-40% (=millions)
- 75% asymptomatic
- 25% symptomatic
 Most frequent between the ages of 30s & 40s

3. ETIOLOGY OF FIBROIDS
 Exact etiology unknown
 Strong relationship with estrogen
 Genetic factors
 Various growth factors

4. TYPES OF FIBROIDS
 Submucosal- 5%
 Intramural-60%
 Subserosal-35%

5. SYMPTOMS OF FIBROIDS
 Abnormal Uterine Bleeding- most common
symptom i.e. menorrhagia
 Pain
 Pressure effects- constipation and urinary
frequency
 Low back pain
 Infertility- depending on location
 Dyspareunia

6. DIAGNOSIS
 Clinical History and Physical Exam
 Pelvic Ultrasound (US)
 Magnetic Resonance Imaging (MRI)
 Laparoscopy or Hysteroscopy

7. CURRENT TREAMENT OF
FIBROIDS
 Small & No symptoms- follow with US and Pelvic exam
 Mild Symptoms- OTC meds, OCP
 Moderate Symptoms- Lupron- GnRH agonist (recurrence)
 Severe Symptoms-
1)surgical-a) Hysterectomy
-curative, but irreversible
b) Myomectomy
- higher morbidity, significant blood loss
- may not treat culprit fibroid
2) UTERINE FIBROID EBOLIZATION (UFE)

8. HISTORY OF EMBOLIZATION
 1970’s- pelvic trauma, post partum hemorrhage,
post surgical hemorrhage etc.
 1995- Ravina et al (France) – first successful
treatment of fibroids by UFE
 1997- Report of first U S experience by
Goodwin
 1998- Hundreds of procedures

9. HOW DOES UTERINE FIBROID
EMBOLIZATION WORK?
 Definition: therapeutic introduction of foreign material
in the vascular system to occlude blood vessels
supplying anatomical sites. i.e. fibroids
 What Happens?
- Immediate ischemia and Infarction
- Hyaline sclerosis (Coagulative necrosis)
- Moderate Inflammation( PES)
- Progressive dehydration and retraction
- Occasional sloughing

10. VASCULAR ANATOMY

11. INSTRUMENTS USED FOR UFE

12. MATERIALS USED FOR
EMBOLIZATION
TRUE EMBOLIZATION- “ NOT TO PROXIMAL NOT TO
DISTAL”
1)PVA (Polyvinyl Alcohol) 0.3-0.7mm
- most commonly used “plastic particles”
- good proximal emobilization
- aggregation-clogs small catheters
2)Gelfoam .04-.06mm
- not the method of choice
- distal embolization-ischemia
3)Emobospheres- acrylic polymer impregnated with porcine gelatin
- spheres precisely calibrated
- no aggregation
-less pain

14. THE PROCEDURE
I Vascular Access- Femoral Artery approach
II Pelvic Arteriogram
III Selection of the Uterine Artery
IV Embolization
V Post Operative Care

15. VASCULAR ACCESS

16. PELVIC ARTERIOGRAM
EXT ILIAC
INT ILIAC

17. UFE

18. PRE AND POST EMBOLIZATION
OF LEFT UTERINE ARTERY
 Injection of Left Uterine
Artery
 Tortuous Arteries
 Cessation of blood flow

19. RIGHT UTERINE ARTERY PRE
AND POST
EMBOLIZATION
 Right Uterine Artery  Post Embolization

20. MRI PELVIS PRE AND 6
MONTHS POST
EMBOLIZATION

21. MRI OF THE PELVIS PRE AND
POST EMBOLIZATION

22. Immediate:
• Overnight stay
15% of early d/c will need
readmission
• Morphine PCA
significant pelvic pain in 100%
• Anti-inflammatory medication
Ibuprofen 400 mg po qid
• Fever control
Tylenol 2 tabs po qid
JVIR 1997;8:517-526
Curr Opin Obstet Gynecol
1998;10:315-320
POST PROCEDURE CARE

23. First Week:
• Abdominal pain slowly tapers off
- continue Ibuprofen for 5-7 days
- narcotic prn, e.g., Hydromorphone 1-2 q 4-6
• Fever control
- continue Tylenol for 5-7 days, when not taking pain
medication that already contains it
- don’t let temp increase raise a red flag, unless
associated with discharge or increasing pain
POST PROCEDURE CARE
JVIR 1997;8:517-526
Curr Opin Obstet Gynecol 1998;10:315-320

24. Follow-up:
• Office visit or phone call at 1 week
• If fever or Sx, may need
readmission
– bleeding may persist for several
weeks
– patient may pass submucosal
fibroids
• Exam and ultrasound at 3 and 6
months
– document size and number of
fibroids
– check on symptom relief
POST PROCEDURE CARE

25. Embolization-related:
• Non-target embolization
- cause of premature ovarian failure in 1-2%
• No allergic or adverse reaction to PVA or
gelfoam
- over 20 years of experience
Infectious:
• Hysterectomy in fewer than 1% in most
series
• Overall rate for pelvic embolization: 4%
COMPLICATIONS
Am J Obstet Gynecol 1997;176:938-948

26. Radiation-related:
• Worldwide experience shows no increase
in...
- pelvic tumors
- congenital birth defects
Fertility-related:
• Several pelvic embolization series have
found no impact
- pregnancies reported in all UAE series
- premature menopause 1-2%
COMPLICATIONS
Am J Obstet Gynecol 1997;176:938-948
Contemp Review Obstet Gynecol 1998;Sept:217-221

27. COMPLICATIONS OF UFE

28. RESULTS OF UFE

29. • Are the fibroids causing the patient’s
symptoms?
• Is future childbearing an issue?
- if yes, myomectomy is the treatment of choice if it is
surgically feasible
• Are there any contraindications?
- chronic endometritis, pelvic irradiation, renal failure,
malignancy
• What are the patient’s wishes?
PATIENT SELECTION

30. • Thorough history and physical
- all patients seen by experienced OB/Gyn
• Endometrial biopsy
- rule out other pathology:
endometrial CA, adenomyosis, infection
• Exclude pregnancy
• Labs
- creatiine, BUN, PT/PTT, Chem 7
PRE PROCEDURE EVALUATION
Curr Opin Obstet Gynecol 1998;10:315-320

31. ADVANTAGES OF UFE
 Treats all fibroids simultaneously
 Minimally invasive
 Shorter recovery period
 No adhesion formation
 Minimal blood loss, no transfusion
 No general anesthesia

32. DISADVANTAGES OF UFE
 10-15% do not respond despite technical
success
 Post embolization syndrome
 No tissue obtained
 Long term results unknown

33. • Hundreds treated in U.S.
• Technical success rates = average
98% !!!!!!!!!!!!!!!!
• High rate of clinical success
- > 90% require no further treatment
- > 85% significant decrease bleeding
- > 90% decrease mass-effect
• Average volume reduction
- uterus 35-40%
- fibroids 40-50%
>Recently approved by Medicare
IN CONCLUSION
Am J Obstet Gynecol 1997;176:938-948
Radiology 1998;208:625-629

34. CREDITS
 JVIR 1997;8:517-526
 Curr Opin Obstet Gynecol 1998;10:315-320
 Am J Obstet Gynecol 1997;176:938-948
 Radiology 1998;208:625-629
 Curr Opin Obstet Gynecol 1998;10:315-320
 Gynecol Am J Obstet Gynecol 1997;176:938-948
 Contemp Review Obstet 1998;Sept:217-221
 JVIR 1997;8:517-526
 Curr Opin Obstet Gynecol 1998;10:315-320