Uterine artery embolization for the treatment of uterine leiomyomata midterm results

Fibroid embolization

The most common surgical treatment for fibroids is hysterectomy and approximately 30,000 are carried out annually in the UK for this condition. The operation, however, carries a significant complication rate. Since the first case was carried out in 1989 there has been increasing interest in the interventional radiological procedure called fibroid embolization where angiographic techniques are used to occlude the vascular supply of fibroids. This article is a review of the world experience of fibroid embolization, its development, techniques, indications, results and complications. So far evidence indicates very promising mid-term results but more long-term comprehensive data is needed from large trials.

II. Uterine fibroid embolization: technical aspects

Successful superselective catheterization of the uterine artery requires familiarity with female pelvic arterial anatomy, knowledge of effective catheter and guidewire combinations, and a few tricks. A learning curve can be expected for each of these elements, although it is assumed that the operator will already have experience in basic catheter techniques. Safe transcatheter delivery, understanding of embolization end points, and avoidance of nontarget embolization are essential. Equally important are knowledge of the properties of the embolic agents currently available and their indications for use. Uterine fibroid embolization unavoidably results in radiation exposure to the uterus and ovaries, and adherence to meticulous fluoroscopic technique is crucial to keep the absorbed dose as low as possible.

I. Uterine fibroid embolization: preprocedure assessment

Increasing clinical experience with uterine fibroid embolization (UFE) has improved the ability of interventionalist radiologists to discern who is and who is not an appropriate candidate for this procedure. Initial evaluation should be directed at obtaining answers to the following key questions: (1) Does the patient have uterine fibroids that account for her symptoms and are they severe enough to require invasive treatment? (2) Does she desire future childbearing? (3) Are there any clinical indications or imaging signs of uterine malignancy? (4) Are there any medical or anatomic features that would favor a particular therapeutic modality? (5) What are her own preferences regarding treatment? Ultrasound and magnetic resonance imaging are vital elements to the assessment and planning of the appropriate course of action. Given the lack of prospective comparative trials between UFE and surgical treatment, recommendations are often highly influenced by patient preference.

IV. Uterine fibroid embolization: follow-up

Patients generally notice some relief of both menorrhagia and mass-effect symptoms during the first few weeks after uterine fibroid embolization (UFE). Shrinkage of the fibroids continues to take place over several months, peaking somewhere between 3 and 6 months, with measurable shrinkage sometimes noted for up to 1 year. The timing of follow-up visits is intended to coincide with the time course of improvement so that diagnostic imaging and intervention can be performed if symptoms worsen or relief does not appear to be on schedule. The amount of shrinkage of fibroids correlates neither with the intensity of immediate postprocedure symptoms or the degree of symptom relief. Affected fibroids undergo hyaline degeneration, a process in which the hard, cellular tumor is replaced by softer, acellular material. A nationwide registry has been constructed for the accumulation of procedural and follow-up data so that success and complication rates can be accurately determined and long-term issues about the durability of UFE and possible side effects can be addressed.

V. Uterine fibroid embolization: management of complications

Fortunately, the number of complications reported after uterine fibroid embolization (UFE) is extremely low. Angiographic mishap or drug reaction are probably more common than purely UFE-related complications. However, the possibility of infection or necrosis of the uterus, with their significant attendant morbidity, is a sobering reminder that embolotherapy can have a powerful impact on the target organ(s). Knowledge of the expected time course for symptom resolution and the often confusing imaging findings shortly after UFE are critical for avoiding unnecessary delay in surgical intervention or, perhaps more important, an inappropriate rush to surgery when antibiotics alone will suffice. Other complications include alteration of uterine physiology, which may disrupt sexual function, and menstrual irregularity and even premature menopause.

III. Uterine fibroid embolization: pain management

Conscious sedation and analgesia are integral components of successful uterine fibroid embolization (UFE), both in providing comfort to the anxious patient undergoing an elective procedure and for providing relief of the severe pelvic pain, cramps, and nausea that may result from acute uterine ischemia and the postembolization syndrome that may follow. The agents used are typically those with which interventional radiologists already have extensive experience in the performance of a variety of invasive procedures. Immediate postprocedure care benefits greatly from the use of narcotic delivered via PCA (patient-controlled analgesia) pump. Nonsteroidal anti-inflammatory drugs (NSAIDs) are also particularly useful for treating the pain and cramping caused by UFE and help reduce the amount of narcotic necessary for pain relief during the recovery period. Detailed instructions for the first week of convalescence are necessary to insure comfort and avoid complications.

Early pregnancy uninterrupted by laparoscopic bipolar coagulation of uterine vessels

Laparoscopic bipolar coagulation of uterine vessels (LBCUV) is reported to treat clinically symptomatic myomas that caused severe menorrhagia, but the viability of pregnancy after operation is unknown. A woman with clinically diagnosed uterine myomas, possibly with adenomyosis, had unexpected early pregnancy diagnosed at the time of LBCUV. The procedure resulted in improvement of menorrhagia to normal menstruation and reductions in the volume of both uterus and myomas. The intrauterine pregnancy was terminated at the woman's request. Pregnancy may be possible after LBCUV, although none has been reported.

Role of uterine artery Doppler flow in fibroid embolization

OBJECTIVE

To determine whether Doppler flow measurements are useful in predicting variables associated with uterine fibroid embolization, including shrinkage of the uterus and myomas, adenomyosis, and uterine fibroid embolization failure.

METHODS

A group of 227 patients with menorrhagia or postmenopausal bleeding secondary to uterine myomas were evaluated with uterine artery Doppler flow sonography before uterine fibroid embolization. Doppler flow measurements were repeated 6 months after uterine fibroid embolization for 188 of the patients. Data were analyzed for correlations between peak systolic velocity and uterine fibroid embolization patient data, including size and shrinkage of the uterus and myomas, embolization particle size, adenomyosis, and uterine fibroid embolization failure.

RESULTS

Initial peak systolic velocity was positively correlated with the size and shrinkage of myomas and uterine volume. Peak systolic velocity was positively correlated with the size and load of embolization particles and was significantly lower (mean, 33.2 cm/s) in patients with adenomyosis than those without adenomyosis (mean, 39.3 cm/s). High peak systolic velocity (>64 cm/s) was a significant predictor of failure. Postembolization peak systolic velocity (mean, 21.85 cm/s) was significantly lower than preembolization peak systolic velocity (mean, 40.33 cm/s) and was not correlated with uterine fibroid embolization variables.

CONCLUSIONS

Doppler flow measurements can aid in predicting adenomyosis and uterine fibroid embolization failure. Postembolization peak systolic velocity did not show value.

Uterine arterial embolization for leiomyomas: perfusion and volume changes at MR imaging and relation to clinical outcome

PURPOSE

To monitor changes in perfusion and volume of uterus and leiomyomas after bilateral uterine artery embolization (UAE) and to correlate immediate perfusion changes with subsequent reduction in leiomyoma volume and clinical outcome.

MATERIALS AND METHODS

Eleven consecutive women underwent magnetic resonance (MR) imaging before UAE, immediately after, and at 1 and 4 months. Reduction in maximal enhancement above baseline at 90 seconds (ME(90)) after injection of the dominant leiomyoma immediately after embolization was correlated with its volume reduction at 4 months and with clinical response at 12 months.

RESULTS

Forty-five leiomyomas were noted (mean, four per patient). Myometrium enhanced briskly (ME(90) of 110%), with a reduction in ME(90) to 26% immediately after embolization. Initial leiomyoma ME(90) was lower (P <.001), but it suppressed to baseline levels immediately after embolization. At 1 and 4 months, myometrial perfusion returned to normal, but leiomyoma perfusion remained suppressed (P <.001). Immediate reduction in leiomyoma ME(90) correlated with clinical response (Spearman rho = 0.64). Leiomyomas initially high in SI on T2-weighted images showed significantly greater volume reduction than those low in SI (P =.006). Well-perfused leiomyomas did not show greater volume reduction than those that were poorly perfused. Volume reduction did not correlate with improvement in clinical symptom score.

CONCLUSION

Immediate reduction in leiomyoma perfusion after bilateral UAE correlates with clinical response, whereas leiomyomas initially high in SI on T2-weighted images indicate a likely greater volume reduction.

Three-dimensional color Doppler sonography and uterine artery arteriography of fibroids: assessment of changes in vascularity before and after embolization

OBJECTIVE

To assess the accuracy of three-dimensional color Doppler sonography and uterine artery arteriography in depicting changes in fibroid vascularity before and after embolization.

METHODS

Preembolization and postembolization three-dimensional color Doppler sonography and selective uterine artery arteriography were retrospectively compared in 15 patients who underwent uterine artery embolization for treatment of symptomatic fibroids. Three-dimensional color Doppler sonography was performed by using a scanner with color power angiographic imaging capability. Vascularity was quantified by using an estimation of power-weighted pixel density as described by our group in previously published studies. Uterine artery arteriography was performed by using a standard selective microcatheter embolization technique. For purposes of comparison, fibroids were classified as either hypervascular or hypovascular relative to myometrial vascularity before and minutes to several hours after uterine artery embolization. Changes in fibroid vascularity (i.e., from hypervascular to hypovascular) as depicted by three-dimensional color Doppler sonography were compared with those shown on uterine artery arteriography and classified as being in agreement or disagreement.

RESULTS

In 13 (87%) of 15 patients there was agreement; in 2 (13%) of 15 there was disagreement. In both cases of disagreement, three-dimensional color Doppler sonography showed collateral flow not depicted by uterine artery arteriography The mean reduction in quantitated vascularity after uterine artery embolization was 44% (range, 19%-78%).

CONCLUSIONS

Three-dimensional color Doppler sonography accurately depicts fibroid vascularity and in some cases can reveal collateral flow not depicted by uterine artery arteriography.

Outcomes following unilateral uterine artery embolisation

Uterine artery embolisation has been described as successful only when both arteries are embolised. However, results in patients with one congenitally absent or previously ligated artery are unknown. Women suffering from symptomatic uterine myomata were treated at a university teaching hospital, a community hospital and an outpatient surgery centre. Retrospective review of patient response to embolisation was assessed by chart review and questionnaire. Uterine and dominant fibroid size response was assessed by comparing pre- and post-embolisation ultrasound examinations. This study analysed three patient groups within the general population: those who underwent unilateral embolisation because of technical failure, those who ultimately underwent bilateral embolisation after initial technical failure and those who underwent unilateral embolisation because of an absent uterine artery. 12 patients underwent unilateral embolisation, 4 of whom underwent this procedure because of an absent uterine artery. Three of these four patients had a congenitally absent uterine artery arising from the internal iliac artery and all three experienced successful outcomes. The fourth patient had a previously ligated internal iliac artery and her symptoms worsened after the procedure. Eight patients had unilateral embolisation due to technical failure. Five of these patients underwent a subsequent procedure during which the contralateral uterine artery was embolised. Four of these five patients had successful outcomes and one was lost to follow-up. Another of the eight patients suffered an arterial injury leading to technical failure, and was lost to follow-up. Of the two remaining patients with unilateral technical failure, only one had a successful outcome. This study concluded that patients who undergo unilateral embolisation for technical reasons should be offered a second embolisation procedure shortly after the initial procedure. Patients with a congenitally absent uterine artery may respond with similar success to those who underwent bilateral embolisation. In contrast, the patient with a previously ligated internal iliac artery failed. The numbers in this study are too small for statistical analysis and subsequent studies should be performed to confirm these findings.

Uterine artery embolisation for the treatment of symptomatic fibroids in 114 women: reduction in size of the fibroids and women's views of the success of the treatment

OBJECTIVE

To assess the reduction in size of fibroids following uterine artery embolisation and to analyse women's views of the success of treatment.

DESIGN

An uncontrolled case series of 114 consecutive women who underwent uterine artery embolisation for the treatment of fibroids over two years.

SETTING

The Diagnostic and Interventional Radiology Department at The Royal Surrey County Hospital, Guildford, UK.

METHODS

Bilateral uterine artery embolisation was performed for the treatment of symptomatic fibroids. Magnetic resonance imaging was carried out before and six months following embolisation. Women completed outcome questionnaires following their treatment.

MAIN OUTCOME MEASURES

The sites. imaging signal characteristics and percentage reduction in the volume of three dominant fibroids were determined from the magnetic resonance scans. Outcome was measured by questionnaire. Women were asked whether their symptoms resolved completely, improved, remained unchanged or deteriorated.

RESULTS

One hundred and sixty-five fibroids of 114 women (mean age 42) were analysed. Forty-five percent of women had complex fibroid masses and 50% had fibroids > or =8.5cm in diameter. The median reduction in the fibroid volume was 58%. The median reduction of the volume of complex fibroid masses, submucous fibroids, fibroids > or =8.5cm and fibroids with high and low signal on T2 weighted sequences were 58%, 63%, 50%, 62% and 51%, respectively. Ninety-one percent of the women's symptoms had resolved or improved following embolisation.

DISCUSSION

The majority of women were satisfied with their outcome. We have shown that uterine artery embolisation is a successful treatment for symptomatic fibroids of all types, sizes and signal characteristics.

Uterine artery embolization using gelatin sponge particles alone for symptomatic uterine fibroids: midterm results

OBJECTIVE

The purpose of this study was to assess the safety and effectiveness of uterine artery embolization using gelatin sponge particles alone for women with symptomatic uterine fibroids.

SUBJECTS AND METHODS

During 38 months, 60 patients (age range, 32-52 years; mean age, 42.5 years) with symptomatic uterine fibroids underwent uterine artery embolization. Only gelatin sponge particles, approximately 500-1000 microm in diameter, were used in all patients. The improvement of clinical symptoms was assessed by questionnaire. Reduction of the largest tumor and uterine volume reductions were assessed using MR imaging. The follow-up period ranged from 1 to 38 months (mean, 10.6 months).

RESULTS

Menorrhagia improved markedly or moderately in 41 (98%) of 42 of patients 4 months after embolization and in 20 (100%) of 20 patients 1 year after embolization. Bulk-related symptoms improved markedly or moderately in 31 (97%) of 32 of patients 4 months after embolization and in 19 (100%) of 19 of patients 1 year after embolization. MR imaging revealed that the mean largest tumor volume reduction rates were 55% at 4 months and 70% at 1 year after embolization, and the mean uterine volume reduction rates were 40% at 4 months and 56% at 1 year after embolization. Follow-up MR imaging showed no new fibroids and no regrowth of existing fibroids. No major complications were observed in any women.

CONCLUSION

We suggest that uterine artery embolization with gelatin sponge particles alone is a safe and effective treatment for symptomatic fibroids. The outcomes bear comparison with those of uterine artery embolization using polyvinyl alcohol particles, which have been reported in the literature.

Leiomyomata treated with uterine artery embolization: factors associated with successful symptom and imaging outcome

PURPOSE

To determine whether baseline variables are associated with treatment success after uterine artery embolization for treatment of uterine leiomyoma.

MATERIALS AND METHODS

Two hundred consecutive patients who underwent uterine artery embolization at one institution were prospectively examined. Baseline clinical variables measured included age, race, prior oral contraceptive use or progesterone treatment, prior gonadotropin-releasing hormone agonist treatment, and prior births. Imaging parameters were baseline uterine volume, baseline leiomyoma volume and location, and number of leiomyomas. After treatment, follow-up imaging and questionnaire data were obtained at 3 and 12 months. Associations between baseline characteristics and outcome variables of interest were assessed by using linear regression, logistic regression, Pearson product moment correlation coefficients, and Kendal tau correlation coefficients, with adjustment for confounding variables when indicated.

RESULTS

Regression models indicated that larger dominant leiomyoma volume was associated with a smaller percentage reduction in volume at 3 months (P =.03). A submucosal leiomyoma location was associated with a greater volume reduction at 3 months (P =.04), but this difference did not persist at 12 months (P =.09). The odds of reported menstrual bleeding improvement at 3 months were higher with a submucosal leiomyoma location (P =.04); however, this association was not statistically significant after adjustment (P =.07). The odds of improved bulk-related symptoms were not associated with leiomyoma volume change or location.

CONCLUSION

Smaller baseline leiomyoma size and submucosal location are more likely to result in a positive imaging outcome. There are limited associations between other baseline parameters and either symptom change or imaging outcome.

Therapeutic failure of uterine fibroid embolization caused by underlying leiomyosarcoma

The authors describe an unusual case in which continued growth of uterine fibroids in a postmenopausal patient after polyvinyl alcohol embolization therapy prompted hysterectomy, which revealed an underlying leiomyosarcoma. The surgery was nearly fatal as a result of venous bleeding, and parasitization of blood from adjacent bowel by the tumor was noted. The difficulty of preoperative diagnosis of leiomyosarcoma and the need for diligent follow-up after uterine fibroid embolization are discussed.

Addition of laparoscopic uterine nerve ablation to laparoscopic bipolar coagulation of uterine vessels for women with uterine myomas and dysmenorrhea

STUDY OBJECTIVE

To assess the effectiveness of laparoscopic uterine nerve ablation (LUNA) in women with dysmenorrhea caused by uterine myomas treated by laparoscopic bipolar coagulation of uterine vessels (LBCUV).

DESIGN

Prospective, randomized, longitudinal study (Canadian Task Force classification II-1).

SETTING

Private practice, university-affiliated hospital.

PATIENTS

Eighty-five women with uterine leiomyomas and associated dysmenorrhea.

INTERVENTION

Laparoscopic bipolar coagulation of uterine vessels with or without LUNA.

MEASUREMENTS AND MAIN RESULTS

Of 85 patients who entered the study, 41 were assigned to undergo LBCUV-LUNA (group A), which was successful in 40 (97.6%). In 44 women assigned to have LBCUV only (group B), 43 (97.7%) underwent successful surgery. Eighty women completed 1-, 3-, and 6-month follow-up (38 group A, 42 group B). The groups did not differ significantly in age, history of abdominopelvic surgery, intraperitoneal adhesions, endometriosis, concomitant surgery, and operating time. Seven (18.4%) of 38 women in group A and 12 (28.6%) of 42 in group B experienced lower abdominal pain postoperatively. Acceptable pain was defined as a score of zero or 1: 31 and 30 women in groups A and B reported scores of zero; 3 and 2 reported scores of 1; 4 and 8 reported scores of 2; zero and 2 reported scores of 3; and no patients reported scores of 4. The frequency and severity of postoperative pain were less in group A than in group B (both p <0.05). The efficacy of both methods was almost equal in shrinking the uterus and dominant myoma, and in improving menorrhagia and bulk-related symptoms. Dysmenorrhea improvement was 84.2% and 61.9% in groups A and B at 3 months and 92.1% and 73.8% at 6 months, respectively. This was more significant in group A than in group B (p <0.05).

CONCLUSION

Our results suggest that LUNA may decrease postoperative ischemic pain and improve dysmenorrhea associated with uterine myomas treated by LBCUV.

Laparoscopic myomectomy after failure of uterine artery embolization

A patient experienced continuing pain and growth of a broad-based pedunculated myoma 6 months after uterine artery embolization (UAE). A 7-cm myoma was found growing directly from the serosa of the fallopian tube and was removed laparoscopically. To our knowledge, this is the first report of laparoscopic myomectomy performed after failure of UAE. This case identifies one of the predictable limitations of UAE of which gynecologists must be cognizant when recommending the procedure.

The vascular impact of uterine artery embolization: prospective sonographic assessment of ovarian arterial circulation

PURPOSE

The etiology of premature ovarian failure after uterine artery embolization (UAE) is unknown. The authors prospectively assessed ovarian arterial circulation before and after UAE with use of ultrasonography (US). The authors hypothesize that nontarget embolization of the ovary occurs during routine UAE.

MATERIALS AND METHODS

Twenty-three women (mean age of 42.6 years; range, 35-51 y) participated in the study. Grayscale, color, and pulsed-wave Doppler US studies were performed immediately before and after UAE. Resistive index (RI) and pulsatility index (PI) were calculated. The proportion of women who developed increased vascular impedance after UAE was statistically assessed with use of the Yates-corrected chi(2) test.

RESULTS

Seventeen of 23 patients (74%) completed the study. Nine of 17 (54%) showed complete loss of ovarian arterial perfusion after UAE. Six of 17 (35%) had increases in RI and PI, whereas two of 17 (11%) had decreases in RI and PI. The increase in vascular impedance after UAE in 15 of 17 patients was significant (P <.0001).

CONCLUSION

Loss of detectable ovarian arterial perfusion occurs in the majority of patients undergoing UAE. Ovarian vascular impedance increases in nearly all patients as a result of UAE. The authors conclude that inadvertent nontarget embolization of the ovarian arterial bed occurs during routine UAE.

Intraarterial lidocaine for pain control after uterine artery embolization for leiomyomata

PURPOSE

To evaluate the effectiveness of intraarterial lidocaine in controlling pain after uterine artery embolization (UAE).

MATERIALS AND METHODS

In this double-blind prospective study, patients undergoing UAE received preservative-free 1% lidocaine or saline solution (control) in the uterine arteries before embolization. Postprocedural pain was managed with patient-controlled intravenous morphine. Attempted doses, number of doses received, total morphine dose, and maximum pain numeric rating scale (NRS) score during the postprocedural hospitalization were recorded and compared. Three-month follow-up magnetic resonance (MR) imaging and symptomatic questionnaires were collected and compared.

RESULTS

Ten patients received lidocaine and eight patients received placebo. Moderate to severe vasospasm was noted in seven patients after lidocaine injection, whereas no vasospasm was noted in the placebo group (P =.004). Patients in the lidocaine group had lower NRS pain scores than those in the placebo group (P =.012), whereas there was no difference in morphine requirement between treated patients and control subjects. The study was terminated after 18 patients were treated as a result of unexpected vasospasm.

CONCLUSIONS

Intraarterial 1% lidocaine is associated with moderate to severe vasospasm. Lidocaine significantly lowers subjective pain, but there is no difference in analgesic requirements. The routine use of intraarterial lidocaine is not recommended for pain control until the long-term effects of vasospasm on outcome is known.

Initial experience with use of tris-acryl gelatin microspheres for uterine artery embolization for leiomyomata

PURPOSE

To assess the safety and effectiveness of tris-acryl gelatin microspheres (Embospheres) in the treatment of leiomyomata by uterine artery embolization.

MATERIALS AND METHODS

This was a Phase I study of 30 patients with symptomatic leiomyomata. Each patient underwent ultrasound imaging and completed questionnaires regarding symptoms and health status at baseline and 3 and 6 months after treatment. Bilateral embolization was performed with use of tris-acryl gelatin microspheres. Summary statistics were used to characterize the demographic and procedure data. Paired t-tests were used to assess change in the severity of menstrual bleeding and health-related quality of life.

RESULTS

Bilateral embolization was technically successful in all patients. Three months after treatment, menstrual bleeding was markedly improved as assessed by menorrhagia questionnaire (P <.0001) and menstrual calendar (P <.0001). Pelvic pain and discomfort was improved in 92% of cases. Physical component summary scores of the SF-12 also increased from baseline at 3 months (P =.02) and at 6 months (P =.01). Minor complications occurred in nine patients; there were no major complications.

CONCLUSION

Although limited, this initial experience suggests that tris-acryl gelatin microspheres are an effective and safe embolic agent for the treatment of uterine leiomyomata.

Uterine artery embolization for the treatment of adenomyosis: clinical response and evaluation with MR imaging

OBJECTIVE

This study was performed to evaluate the MR imaging appearance and clinical response of patients undergoing uterine artery embolization for the treatment of menorrhagia due to adenomyosis.

MATERIALS AND METHODS

A retrospective review of 15 patients with adenomyosis and menorrhagia who underwent uterine artery embolization was performed. The diagnosis of adenomyosis was based on established MR imaging criteria. Clinical response was assessed at a minimum of 3 months after embolization. Follow-up MR imaging was performed 6 months after embolization.

RESULTS

Of the 15 patients in this study, five had diffuse adenomyosis without evidence of uterine fibroids, one had focal adenomyosis without evidence of uterine fibroids, and the remaining nine had adenomyosis with one or more fibroids. At follow-up, 12 (92.3%) of the 13 patients reported significant improvement in presenting symptoms and quality of life. One patient continued experiencing menorrhagia, and one patient experienced amenorrhea during the 5 months of follow-up after embolization. MR imaging in nine patients, performed at a mean of 5.9 months after embolization, revealed significant reductions in median uterine volume (42%), median fibroid volume (71%), and mean-junctional-zone thickness (11 mm; 33%; p < 0.5). Six of the nine patients had subendometrial regions of decreased T2 signal intensity after embolization.

CONCLUSION

Uterine artery embolization is a promising nonsurgical alternative for patients with menorrhagia and adenomyosis. Significant improvement in presenting symptoms and in quality of life is associated with decreases in uterine size and junctional zone thickness. Larger prospective studies are needed to establish the safety and efficacy of this procedure for patients with adenomyosis.

A new twist on the Waltman loop for uterine fibroid embolization

The usual ipsilateral approach for uterine artery embolization is to form a Waltman loop. Newer nonbraided 4-F catheters can be problematic because of their tendency to kink or unfold while the loop is being formed. Herein, a modification of the Cope suture technique is described by which a Waltman loop is formed with use of a 4-0 Tevdek suture that allows the catheter to be folded back on itself, drawing it into the ipsilateral iliac artery. If necessary, the catheter can be prevented from unlooping by twisting the catheter on itself to lock it in position. The technique allows for efficient catheterization of the ipsilateral uterine artery.

Gadolinium-enhanced MR imaging in the evaluation of uterine fibroids treated with uterine artery embolization

OBJECTIVE

The purpose of this study was to determine whether tumor volume reduction can be predicted by the infarction rate of uterine fibroids as seen on gadolinium-enhanced MR images obtained immediately after uterine artery embolization.

MATERIALS AND METHODS

In our study, 36 women with symptomatic uterine fibroids successfully underwent uterine artery embolization. Unenhanced and enhanced MR imaging was performed before the procedure and repeated at 1 week, 4 months, and 1 year after the procedure. We retrospectively reviewed enhanced MR images of uterine fibroids after uterine artery embolization. At 4 months after uterine artery embolization, we compared the rate of tumor volume reduction in patients with completely infarcted dominant fibroids with the rate of tumor volume reduction in patients with partially infarcted fibroids.

RESULTS

Enhanced MR images obtained 1 week after uterine artery embolization revealed that 100% infarction rates of the dominant uterine fibroids were achieved in 33 women (92%), and 70--90% infarction rates were seen in the remaining three (8%). They also revealed that of a total of 204 fibroids in these patients, 100% infarction was achieved in 199 fibroids (98%). Enhanced MR images obtained 4 months after uterine artery embolization showed that tumor volume reduction of the completely infarcted dominant fibroids (n = 23) was 60% +/- 18%, whereas that of the partially infarcted fibroids (n = 5) was 35% +/- 27% (p = 0.0367).

CONCLUSION

Gadolinium-enhanced MR imaging is a useful diagnostic technique for uterine fibroids after uterine artery embolization because it assesses the degree of infarction in the embolized fibroids, which corresponds to the subsequent tumor volume reduction.

Pregnancy following uterine fibroid embolization

OBJECTIVE

This paper seeks to evaluate the ability to deliver term pregnancies following uterine fibroid embolization, and to identify impediments to pregnancy in the embolization procedure.

STUDY DESIGN

Four physicians performed embolization procedures at various facilities. Patients were asked if fertility was an issue prior to embolization. We measured follicle-stimulating hormone levels before and after embolization. Clinical follow-up, six months following embolization was obtained by interview. Patients were questioned regarding attempts to conceive, menstrual history, and subsequent pregnancy.

MAIN OUTCOME MEASURES

Complications were calculated upon the entire patient population, whether or not fertility was identified as a goal. Fertility risks from embolization were identified. We measured radiation exposure in a random consecutive group of 50 women undergoing embolization. All patients who conceived were asked the details of the pregnancy.

RESULTS

Four hundred women underwent uterine fibroid embolization between 1996 and 1999. One hundred and thirty nine patients stated a desire for fertility after embolization. Of these, 52 were <40 years old. Seventeen pregnancies have been reported in 14 women. Five spontaneous abortions were observed. Ten women have had normal term deliveries and two women are currently pregnant. No perfusion problems, either during the pregnancy or labor, were reported. The average radiation dosage calculated for 50 women undergoing embolization was 14 rads. Four women under 45 years old suffered premature menopause (10/1000). Two women underwent hysterectomy as a complication of embolization (5/1000).

CONCLUSION

The risks of infertility following embolization, premature menopause, and hysterectomy are small, as is the radiation exposure during embolization. These risks compare favorably with those associated with myomectomy. Fertility rates appear similar to patients undergoing myomectomy. No problems, either during pregnancy or delivery, have been observed after embolization. The course of pregnancy and delivery was normal after embolization with no maternal or fetal complications reported. These findings confirm results from other centers. Desire for future pregnancy is not a contraindication to fibroid embolization.

Utility of nonselective abdominal aortography in demonstrating ovarian artery collaterals in patients undergoing uterine artery embolization for fibroids

PURPOSE

To review the incidence of ovarian collateral supply to uterine fibroids as demonstrated by nonselective abdominal aortography before uterine artery embolization (UAE) and to evaluate the effect of such visualization on interventional management.

MATERIALS AND METHODS

The aortograms of 51 consecutive patients (mean age, 42.4 y; range, 30--53 y) undergoing UAE for symptomatic uterine fibroids were reviewed retrospectively for the visualization of ovarian arteries extending into the pelvis. If ovarian arteries were visualized, their size relative to the ipsilateral external iliac artery was measured. Arteries believed large enough to represent a significant blood supply to the uterine fibroids were further evaluated after UAE to determine whether flow persisted.

RESULTS

In 13 of 51 patients (25%), a total of 18 ovarian arteries were identified. They were bilateral in five patients and unilateral in eight. Their sizes relative to the ipsilateral external iliac artery ranged from 8% to 57% (mean, 26%). Eight ovarian arteries with a relative size > or = 25% were further evaluated. Five of the eight (62.5%) were not visible after UAE. Of the three persistent ovarian collateral arteries, two were successfully embolized. The patient with the untreated collateral artery experienced persistent menorrhagia.

CONCLUSION

Preembolization aortography with the catheter tip at level of the renal arteries demonstrated ovarian collateral arteries in 25% of patients with uterine fibroids. However, their detection influenced treatment in only 6% of the reported cases.

Uterine artery embolization: the role in obstetrics and gynecology

OBJECTIVE

Evaluation of the studies for the use of uterine artery embolization in various conditions in both obstetrics and gynecology.

DESIGN

Literature review.

RESULTS

Uterine artery embolization was successful in controlling postpartum hemorrhage in 94.9% of the cases. It was effective in controlling the bleeding in 96% of cases with uterine arteriovenous malformations and in 100% of the cases with abdominal and cervical pregnancies. Recently, it has been introduced as a line of treatment for uterine fibroids. It controlled bleeding in 82-92% of cases, and lead to 20-64% reduction in size of fibroids.

CONCLUSIONS

Uterine artery embolization is of significant value in treating certain hemorrhagic conditions in obstetrics and gynecology including postpartum hemorrhage, ectopic pregnancy, and arteriovenous malformations. Its use in treatment of uterine fibroids is new and needs more collaborative studies by gynecologists and intervention radiologists to evaluate issues related to necrosis of the tumor, sepsis, and the long-term effect on size and recurrence rate.

Uterine artery embolization for leiomyomata: resource use and cost estimation

PURPOSE

The objective of this study is to provide an assessment of the facility cost associated with uterine artery embolization (UAE) for leiomyomata and to provide a basis for the estimation of cost so as to compare UAE with surgical approaches.

MATERIALS AND METHODS

Information was gathered from the clinical/accounting system for 23 patients who had UAE performed at a single institution. Cost-to-charge ratios and microcosting were employed to derive cost estimates. A detailed meta-analysis was also performed on the resource use parameters reported in the literature.

RESULTS

Facility costs range from 2,058 dollars to 4,951 dollars and the mean total cost is 3,080 dollars. The radiology procedure and observation stay are the largest contributors to facility cost. The average length of stay is 21.5 hours with a range from 8 hours to 48 hours. The estimates from this analysis provide a good approximation of facility cost; there are no significant differences in resource use between this study and the meta-analysis.

CONCLUSIONS

The facility cost of UAE (3,080 dollars) compares favorably with hysterectomy, the cost of which ranges from 3,100 dollars to 4,900 dollars depending on the type of procedure performed. This cost information can be used to analyze the cost effectiveness of UAE compared to alternate therapies.

Ovarian function after uterine artery embolization for leiomyomata: assessment with use of serum follicle stimulating hormone assay

PURPOSE

To determine if uterine artery embolization (UAE) for leiomyomata causes a change in ovarian function as measured by serial basal follicle stimulating hormone (FSH) assay.

MATERIALS AND METHODS

Sixty-three patients undergoing UAE for symptomatic leiomyomata had blood samples obtained on day 3 of a menstrual cycle before UAE and on day 3 during menstrual cycles 3 and 6 months after treatment. Analysis of variance was used to detect differences in FSH levels among age groups at each interval. Repeated measures analysis of variance was used to determine if individual mean change occurred for the group as a whole and for each age group. Onset of new menopausal symptoms was compared between groups with use of the chi(2) test.

RESULTS

There was no significant change in basal FSH levels for the group as a whole (P =.16), but there was a statistically significant difference when age groups were compared (P =.03). Individual change of >2 SD from baseline mean FSH level occurred at 6 months in seven patients, all 45-50 years of age. Four of these patients (15% of patients over age 44) had FSH levels increase to more than 20 IU/L. chi(2) analysis did not reveal any difference among the groups studied in the onset of menopausal symptoms.

CONCLUSIONS

Most patients had no change in ovarian function as measured by basal FSH after UAE. For patients aged 45 or older, there is approximately a 15% chance of an increase in basal FSH into the perimenopausal range.

Uterine artery embolization

The use of uterine artery embolization is a new approach in the treatment of uterine fibroids. Embolization is a technique in which blood vessels that supply nutrients and oxygen to fibroids are blocked. This blockage causes the fibroid muscle cells to degenerate and form scar tissue, thus shrinking the fibroid. Usually the fibroid no longer causes symptoms. This minimally invasive procedure involves an overnight hospital stay and results in a reduction of fibroid symptoms. Most women notice the greatest improvement in the first eight weeks. This procedure has been performed only since 1990 and, therefore, long-term results are unknown.

Fibroid calcification after uterine artery embolization: ultrasonographic appearance and pathology

PURPOSE

To describe the ultrasonographic (US) appearance of fibroid calcification occurring after uterine artery embolization (UAE) and discuss its etiology and pathology.

MATERIALS AND METHODS

Twenty-seven of a total of 38 patients were followed up clinically and with duplex US for longer than 6 months after UAE for uterine fibroids. At US, changes in uterine size, fibroid vascularity, and morphology have been recorded. Pathologic studies were performed by one of the authors on resected specimens from a different cohort of patients, at intervals ranging from 4 months to 1 year after UAE.

RESULTS

Twenty patients reported complete resolution of symptoms. In 16 of these, a reduction in fibroid volume of 70%-85% was recorded and, at US, the development of a peripheral hyperechoic rim around an increasingly hypoechoic fibroid was noted. Computed tomography in two patients revealed it to be a rim of calcium. Histologic studies in a different cohort of patients who had undergone hysterectomy at variable intervals after UAE demonstrated early aggregation of polyvinyl alcohol (PVA) particles, an intermediate giant cell inflammatory reaction, and calcification in the periphery of the infarcted fibroid at 6-12 months.

CONCLUSION

Calcification is the end stage of hyaline degeneration. However, its peripheral location is unlike that of natural fibroid involution and hyaline necrosis. Pathologic studies in resected human fibroids after embolization suggest that its development is the end result of aggregation of PVA particles in peripheral fibroid arteries.

Transient ovarian failure: a complication of uterine artery embolization

OBJECTIVE

To report a case of transient ovarian failure shortly after arterial embolization for treatment of uterine fibroids, followed by recovery of ovarian function.

DESIGN

Case report.

SETTING

A university-based hospital.

PATIENT

A 49-year-old woman with menorrhagia and anemia secondary to uterine fibroids and refractory to medical management. The follicle-stimulating hormone (FSH) level on cycle day 3 before the procedure was 8.2 mIU/mL.

INTERVENTION(S)

Bilateral uterine artery embolization for treatment of menorrhagia.

MAIN OUTCOME MEASURE(S)

Serum FSH level.

RESULT(S)

The patient developed amenorrhea and hot flashes 3 months after uterine artery embolization. Her serum FSH level at that time was 140.1 mIU/mL. Four months later, uterine bleeding resumed; her serum FSH level was 2.1 mIU/mL.

CONCLUSION(S)

Uterine artery embolization may hasten ovarian failure. This procedure should be reserved for women who have completed their child-bearing or are poor candidates for myomectomy. Patients should be counseled appropriately about the risk of possible ovarian failure.

Uterine artery embolization: reduced radiation with refined technique

PURPOSE

To determine the estimated absorbed ovarian dose (EAOD) and absorbed skin dose (ASD) that occurs during uterine artery embolization (UAE) using pulsed fluoroscopy and a refined procedure protocol.

MATERIALS AND METHODS

The absorbed dose was measured in 20 patients who underwent UAE procedures. Radiation was limited by using low frequency pulsed fluoroscopy, bilateral catheter technique with simultaneous injections for embolization as well as pre-and postembolization exposures and focus on limitation of magnified and oblique fluoroscopy. Lithium fluoride dosimeters were placed both in the posterior vaginal fornix and on the skin at the beam entrance site. The vaginal dose was used to approximate the EAOD. Fluoroscopy time and exposures were recorded. The mean values for all patients were calculated and compared to our previous results obtained with conventional fluoroscopy and to threshold doses for the induction of deterministic skin injury.

RESULTS

Mean fluoroscopy time was 10.95 min. (range 6-21.3 min.) and the mean number of angiographic exposures was 20.9 (range 14-53). The mean EAOD was 9.5 cGy (range 2.21-23.21 cGy) and the mean ASD was 47.69 cGy (range 10.83-110.14 cGy). This compares to previous results with non-pulsed fluoroscopy of an EAOD of 22.34 cGy (range 4.25-65.08 cGy) and an ASD of 162.32 cGy (range 66.01-303.89 cGy) as well as threshold doses for induction of deterministic radiation injury to the skin (400-500 cGy).

CONCLUSION

When pulsed fluoroscopy is used with emphasis on dose reduction techniques, the EAOD and ASD can be substantially reduced to less than 1/2 (P = .017) and 1/3 (P < .0001) when compared to UAE performed with nonpulsed fluoroscopy. These radiation reduction tools should therefore be applied whenever possible.