Current evidence on uterine embolization for fibroids

Efficacy of intra-arterial lidocaine administration on pain and inflammatory response after uterine artery embolization for symptomatic fibroids

BACKGROUND

There have been conflicting outcomes regarding the use of lidocaine to reduce pain after uterine artery embolization (UAE).

PURPOSE

To investigate the efficacy of intra-arterial lidocaine injection for pain and inflammatory response control within 24 h of UAE for symptomatic uterine fibroids.

MATERIAL AND METHODS

Of 1530 patients who underwent UAE for uterine fibroids in 2007-2021, 5 mL of 1% lidocaine was injected into each uterine artery immediately after UAE in 23 patients. A disease-matched control group (n = 23) who did not receive intra-arterial lidocaine was generated from the same registry. The pain score, white blood cell (WBC) count, C-reactive protein (CRP), neutrophil/lymphocyte ratio (NLR), and fentanyl consumption were compared before and after UAE. Complete infarction of the dominant fibroid was assessed using magnetic resonance imaging.

RESULTS

Significantly lower WBC count, CRP level, and NLR were noted 24 h after UAE in the lidocaine group. No statistically significant difference was noted in the pain score between groups at 0-24 h. The cumulative fentanyl dose administered during the first 24 h after UAE was not significantly different. After embolization, fibroid-related symptoms resolved in all patients. No significant difference was observed in the rate of complete infarction of the dominant fibroid.

CONCLUSION

Lidocaine administration immediately after UAE resulted in a significant reduction in the inflammatory response. However, such a difference in the inflammatory reaction did not contribute to significant reductions in pain scores or fentanyl consumption.

Uterine artery embolization in Tanzania: a procedure with major public health implications

BACKGROUND

The burden of uterine fibroids is substantial in sub-Saharan Africa (SSA), with up to 80% of black women harboring them in their lifetime. While uterine artery embolization (UAE) has emerged as an effective alternative to surgery to manage this condition, the procedure is not available to the vast majority of women living in SSA due to limited access to interventional radiology (IR) in the region. One of the few countries in SSA now offering UAE in a public hospital setting is Tanzania. This study aims to assess the safety and effectiveness of UAE in this new environment.

METHODS

From June 2019 to July 2022, a single-center, retrospective cohort study was conducted at Tanzania's first IR service on all patients who underwent UAE for the management of symptomatic fibroids or adenomyosis. Patients were selected for the procedure based on symptom severity, imaging findings, and medical management failure. Procedural technical success and adverse events were recorded for all UAEs. Self-reported symptom severity and volumetric response on imaging were compared between baseline and six-months post-procedure using paired sample t-tests.

RESULTS

During the study period, 92.1% (n = 35/38) of patients underwent UAE for the management of symptomatic fibroids and 7.9% (n = 3/38) for adenomyosis. All (n = 38/38) were considered technically successful and one minor adverse event occurred (2.7%). Self-reported symptom-severity scores at six-months post-procedure decreased in all categories: abnormal uterine bleeding from 8.8 to 3.1 (-5.7), pain from 6.7 to 3.2 (-3.5), and bulk symptoms from 2.8 to 1 (-1.8) (p < 0.01). 100% of patients reported satisfaction with outcomes. Among the nine patients with follow-up imaging, there was a mean volumetric decrease of 35.5% (p = 0.109).

CONCLUSIONS

UAE for fibroids and adenomyosis can be performed with high technical success and low complication rates in a low-resource setting like Tanzania, resulting in significant symptom relief for patients. Building capacity for UAE has major public health implications not only for fibroids and adenomyosis, but can help address the region's leading cause of maternal mortality, postpartum hemorrhage.

Interventional Radiology in Obstetrics and Gynecology: Updates in Women's Health

Interventional radiology has had an expanding role in women's health over the past few decades, with recent accelerated growth and development. Interventional radiology is fundamental in the treatment of multiple conditions that affect women, including pelvic venous disease, uterine fibroids, and adenomyosis, and in postpartum management. Patient workup, classification, and treatment techniques have continued to evolve as interventional radiology has become more prevalent in the treatment of patients affected by these conditions. The authors provide a review of the pathophysiology of, patient workup for, and treatment of pelvic venous disease and uterine artery embolization for various disease processes. The authors also highlight updates from the past 5-10 years in diagnosis, classification, and treatment strategies. ^© RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Embolization for the treatment of large, complex fibroids in an outpatient setting: A report of 2 cases

Uterine leiomyomas are the most common benign pelvic tumors in premenopausal women, causing significant morbidity. Uterine fibroid embolization is a minimally invasive alternative to traditional open or laparoscopic surgeries for the management of symptomatic uterine leiomyoma. For large fibroids, hospitalization after treatment is often required. However, there are limited data on patients with large, complex uterine leiomyomas treated by embolization. This report of 2 cases describes 2 females with large, complex fibroids causing pain and decreased quality of life who were evaluated and treated with embolization in the outpatient setting. Each patient underwent transradial cannulation and uterine artery embolization under local anesthesia or conscious sedation and returned home without complication. For women wishing to preserve their uterus, uterine fibroid embolization is an effective nonsurgical alternative to hysterectomy and myomectomy in an outpatient setting. If standard protocols are followed, embolization by way of transradial artery catheterization is safe for the treatment of large, complex, symptomatic fibroids in the outpatient setting; however, additional studies with larger cohorts are warranted. Accessing the uterine arteries transradially reduces the risk of intra- and post-operative complications for patients, reduces their time spent in a hospital, and minimizes operating costs.

Ovarian arteries embolization in women with persistent symptoms following uterine arteries embolization for uterus fibroids

PURPOSE

In patients with persisting symptoms after uterine arteries embolization (UAE), ovarian arteries embolization (OAE) may play a role to improve symptoms and decrease subsequent surgery rates. In a retrospective cohort, we aimed to investigate the efficacy and safety of OAE in females with recurrent or persistent symptoms following UAE.

METHODS

We performed a retrospective analysis of prospectively collected cases at a single reference academic hospital; we identified patients who benefited from OAE for persisting symptoms following UAE from 2008 to 2021. Outcome variables included the rates of subsequent surgery, a quality-of-life questionnaire with the UFS-QOL tool, the MRI reduction in uterine and fibroids volumes and the fibroid devascularization rate.

RESULTS

Among 1300 women treated with UAE during the study period, 18 eventually received OAE and were included (mean age 44 ± 4.3 SD). There was no OAE procedural complication. There was a decrease in uterine volume and a complete devascularization of the dominant fibroid in 10/11 (90.9%) patients who underwent 12 months MRI. Three women underwent subsequent hysterectomy. Among 10/18 patients who answered the quality-of-life questionnaire after a mean follow-up of 70 months, eight reported an improvement or stability of symptoms.

CONCLUSION

OAE for persisting symptoms after UAE was associated with improvement or stability of quality-of-life in most study subjects and less than a fifth of the cohort underwent hysterectomy after OAE. This study highlights the role of OAE as an adjunct to UAE.

Uterine artery embolisation for IVC syndrome and severe lower extremity oedema secondary to IVC compression from massive fibroids

A 66-year-old woman was admitted to an outside facility with leg swelling and dyspnea on exertion. Initial workup revealed severe aortic stenosis and congestive heart failure (CHF) thought to be the culprit; however, a CT performed in the emergency department revealed massive uterine mass resulting in significant inferior vena cava (IVC) compression. Her cardiac status precluded hysterectomy, due to concerns regarding intraoperative fluid shifts decreasing preload in the setting of preload dependence in severe aortic stenosis. Similarly, her degree of IVC compression was thought to make valve replacement unacceptably dangerous, so she was referred to interventional radiology for consideration of uterine artery embolisation (UAE) to relieve IVC compression. She underwent UAE without complication, and her leg swelling nearly completely resolved at follow-up.

Pregnancy success and outcomes after uterine fibroid embolization: updated review of published literature

Females with symptomatic leiomyomas (fibroids) wishing to maintain fertility are faced with difficult treatment choices. These include uterine fibroid embolization (UFE), myomectomy, hormonal therapy, MRI high intensity focused ultrasound, and myolysis. This review focuses on UFE, one of the most commonly accepted minimally invasive procedural choices among patients with symptomatic fibroids wishing to retain the option of becoming pregnant in the future, and makes comparisons to myomectomy which has historically been the surgical choice for fertility-preserving fibroid treatment. Pubmed and Google Scholar searches using keywords such as: uterine artery embolization, uterine fibroid embolization, pregnancy, complications, infertility were performed between Jan 1, 2019 and May 10, 2019. Publications were chosen based on their inclusion of information pertaining to fertility or pregnancy after UFE without being limited to single case reports.Randomized controlled trials comparing myomectomy and UFE are limited due to study size and confounding variables, but through registry data and familiarity with referring clinicians, UFE has gained wide acceptance. Healthy pregnancies following UFE have been sporadically reported but the actual fertility rate after UFE remains uncertain. Conversely, low birth weight, miscarriage and prematurity have been associated with UFE. Despite inherent risks of possible fertility issues after UFE, the procedure remains an option for females with clinically symptomatic fibroids who desire pregnancy. However, additional research regarding rates of conception and obstetrical risks of infertility following UFE is necessary.

Uterine Artery Embolization in Patients With Autoimmune Disease: A Matched Case-Control Study

OBJECTIVE. The purpose of this study is to investigate the safety of uterine artery embolization (UAE) for symptomatic leiomyomas in patients with autoimmune disease. MATERIALS AND METHODS. Of 1183 patients who underwent UAE for symptomatic leiomyomas, nine patients (mean age, 42.6 years; range, 34-49 years) with autoimmune disease were included in this study. An age- and disease-matched control group (n = 8) was randomly generated from our patient registry to compare the effectiveness and safety of UAE in patients with autoimmune disease. Volume reduction rates of the uterus and dominant leiomyoma and the change in C-reactive protein (CRP) levels before and after UAE were compared. RESULTS. Except for one patient who had Takayasu arteritis and indiscernible uterine arteries on angiogram, UAE was technically successful in both groups. All of the patients who underwent technically successful UAE experienced improvement or resolution of symptoms (16/16; 100%). Complete necrosis of dominant fibroids was achieved in all patients (16/16; 100%). Although there was no significant difference in the mean initial CRP level before UAE (0.4 ± 0.14 mg/L vs 1.06 ± 1.26 mg/L; p = 0.067), it was significantly higher in the autoimmune group 1 day after UAE (1.23 ± 0.6 mg/L vs 9.54 ± 6.63 mg/L; p = 0.001). There was no significant difference in the volume reduction rates of uterus and dominant leiomyoma. In the autoimmune group, there was one major adverse event that was not related to underlying disease. CONCLUSION. In patients with autoimmune disease, UAE could be considered for symptomatic leiomyomas, as long as the underlying disease is well controlled.

The rationale, design, and methods of a randomized, controlled trial to evaluate the efficacy of single-dose dexamethasone in reducing post-embolization syndrome in patients undergoing uterine artery embolization

Background

Uterine artery embolization (UAE) is a minimally invasive technique well established for treating symptomatic uterine fibroids. However, the post-procedure recovery for UAE involves a notable inflammatory process in response to ischemia known as post-embolization syndrome (PES). PES encompasses transient leukocytosis, low-grade fever, and can result in readmission of up to 10% of patients. In surgical settings, multiple studies have demonstrated the efficacy of glucocorticoids in reducing inflammation and associated pain. However, this approach has not yet been assessed in predominantly ischemia-driven PES.

Methods

This paper describes the protocol of a prospective randomized, double-blind, placebo-controlled, multi-center trial to test the efficacy and safety of single-dose dexamethasone on inflammatory responses, pain, nausea, and readmission rates after UAE. The study will enroll pre-menopausal patients between 25 and 55 years (planned enrollment, n = 60) with MRI confirmed symptomatic fibroids. Patients will be randomly allocated into two groups: single-dose intravenous dexamethasone plus standard of care or placebo (normal saline) plus standard of care.

Results

The primary endpoint is the patient pain score 4 h following the UAE procedure. Secondary endpoints include pain scores at 7 h and 24 h following UAE; narcotic usage in the first 24 h following UAE; and serum inflammatory markers (white blood cell count, C-reactive protein [CRP], interleukin-6 [IL-6], and cortisol) 24 h after UAE.

Conclusion

Given the high incidence of post-procedure pain and difficulty with pain control after uterine artery embolization, results of this trial may directly influence the standard of care in perioperative management of patients undergoing UAE.

Updates on Uterine Artery Embolization

Uterine fibroids (leiomyomas) are the most common benign neoplasm of the female pelvis and have a lifetime prevalence exceeding 80% among African American women and approaching 70% among Caucasian women. Approximately 50% of women with fibroids experience symptoms which may include menorrhagia that may result in anemia, bulk symptoms with bladder and bowel dysfunction and abdominal protrusion, dysmenorrhea, and infertility. Hysterectomy remains the most common treatment option for fibroids and concerns have been raised about the overuse of this procedure. Uterine artery embolization (UAE) is now a well-established uterine preserving and minimally invasive therapy for symptomatic fibroids. Since its introduction, strong evidence for safety and efficacy of UAE has been generated with low rates of complications. This review will discuss UAE for the management of symptomatic uterine fibroids with special focus on emerging technical approaches and novel periprocedural patient care.

Uterine Artery Embolization for Pedunculated Subserosal Leiomyomas: Evidence of Safety and Efficacy

PURPOSE

To evaluate safety and efficacy of uterine artery embolization (UAE) for pedunculated subserosal (PS) leiomyomas.

MATERIALS AND METHODS

Of 1,069 patients who underwent UAE for symptomatic leiomyomas or adenomyosis from 2007 to 2016, 55 patients (mean age 40.3 y ± 4.8) with 66 PS leiomyomas (mean diameter 6.61 cm ± 2.04) were enrolled. Each PS leiomyoma was categorized into 1 of 2 groups: high-risk PS leiomyoma (stalk diameter < 25% of diameter of leiomyoma) and low-risk PS leiomyoma (stalk diameter 25%-50% of diameter of leiomyoma). MR imaging was performed 3 months after UAE. Rates of infarction and volume reduction were compared between PS leiomyomas and non-PS dominant leiomyomas and between high-risk and low-risk PS leiomyomas. Complications related to PS leiomyomas were assessed.

RESULTS

At a median follow-up of 96 days (range, 36-348 d) after UAE, none of the patients (0%) had complications related to PS leiomyomas, even among high-risk cases. Mean volume reductions of 38.2% and 38.4% were achieved for PS leiomyomas and non-PS dominant leiomyomas, respectively (P = .953). There were 3 (5.5%) minor adverse events, but none were related to PS leiomyoma. There was no significant difference in volume reduction and infarction rates between low-risk and high-risk PS leiomyomas.

CONCLUSIONS

UAE is safe and effective in patients with PS leiomyomas even for high-risk cases (stalk diameter < 25% of diameter of leiomyoma). PS leiomyoma should not be considered a contraindication for UAE.

Uterine fibroid embolization with acrylamido polyvinyl microspheres: prospective 12-month clinical and MRI follow-up study

Background Uterine fibroid embolization (UFE) is an effective minimally invasive treatment aimed to obtain complete fibroid infarction. Purpose To evaluate the degree of fibroid infarction after embolization with acrylamido polyvinyl alcohol microspheres (Bead Block). Material and Methods This prospective study included 26 pre-menopausal women in the period October 2013 to January 2015. UFE with the use of Bead Block microspheres 700-900 µm was obtained until flow stasis was achieved. Contrast-enhanced magnetic resonance imaging (MRI) was used to define residual contrast enhancement in the total fibroid burden and enhancement >10% was defined as insufficient embolization. The dominant fibroid volume and total uterine volume changes were assessed. Clinical outcome was analyzed using the quality of life questionnaire (UFS-QOL). Results Twenty-four of the 26 patients (92%) had a technically successful UFE with complete flow-stop in both uterine arteries. Twenty-two of the 26 patients (85%) completed 3 months of MRI control and 20 patients (77%) completed 12 months of MRI control. There were 16 of 22 patients (73%) with complete fibroid burden infarction and/or without residual contrast enhancement of the fibroids of more than 10% at 3 months of control. Six of 22 patients (27%) had insufficient fibroid burden infarction with residual contrast enhancement of more than 10%. Twenty-two and 18 of 26 patients completed the 3-month and 12-month questionnaire, respectively. UFS-QOL analyses showed that 91% of the patients had significant clinical improvement. Conclusion Sixteen of the 22 patients had complete fibroid burden infarction using Bead Block microspheres (700-900 µm); however, unacceptably high insufficient fibroid burden infarction in almost one-fourth of the patients were recorded.

Endovascular Embolization by Transcatheter Delivery of Particles: Past, Present, and Future

Minimally invasive techniques to occlude flow within blood vessels, initially pioneered in the 1970s with autologous materials and subsequently advanced with increasingly sophisticated engineered biomaterials, are routinely performed for a variety of medical conditions. Contemporary interventional radiologists have at their disposal a wide armamentarium of occlusive agents to treat a range of disease processes through a small incision in the skin. In this review, we provide a historical perspective on endovascular embolization tools, summarize the current state-of-the-art, and highlight burgeoning technologies that promise to advance the field in the near future.

Clinical Efficacy and Complications of Uterine Artery Embolization in Symptomatic Uterine Fibroids

We decided to evaluate the efficacy and complications of uterine artery embolization (UAE) in patients with symptomatic uterine fibroids. Sixty-five premenopausal patients, without considering the fibroids size and its location, were treated by bilateral UAE. At baseline and after 3, 6, and 12 months MRI was obtained to determine the uterine length and fibroid diameter. In addition, symptoms of the patients were documented at these follow-up schedules. UAE was successful in 62 (95.4%) cases. Complete infarction rate of the fibroid was 83.1%. After 12 months, the uterine length showed a decrease of 55.7% (mean of 9.4 cm) and the diameter of the dominant fibroid revealed a decrease of 52.1% (mean of 3.4 cm). Menorrhagia improved in 45 cases (91.8%), abdominal mass in 24 cases (82.28%), urinary symptoms in 17 cases (85%), pelvic pain in 21 cases (84%), and dysmenorrhea in 25 cases (80.6%). At final follow-up performed after one year, complete infarction of the fibroma was demonstrated in 49 patients (83.1%). Two cases achieved successful pregnancy in the one year follow-up period. Five patients developed post-embolization syndrome which necessitated admission to the hospital. Twenty-two patients presented and complained of pain for which outpatient pain management was done. UAE was a successful treatment for uterine fibroids that preserved the uterus, had minimal complications, and required short hospitalization and recovery.

Potential of minimally invasive procedures in the treatment of uterine fibroids: a focus on magnetic resonance-guided focused ultrasound therapy

Minimally invasive treatment options are an important part of the uterine fibroid-treatment arsenal, especially among younger patients and in those who plan future pregnancies. This article provides an overview of the currently available minimally invasive therapy options, with a special emphasis on a completely noninvasive option: magnetic resonance-guided focused ultrasound (MRgFUS). In this review, we describe the background of MRgFUS, the patient-selection criteria for MRgFUS, and how the procedure is performed. We summarize the published clinical trial results, and review the literature on pregnancy post-MRgFUS and on the cost-effectiveness of MRgFUS.

Embolization of uterine fibroids from the point of view of the gynecologist: pros and cons

Uterine artery embolization (UAE) is a minimally invasive procedure with large symptomatic potential in treatment of women with uterine leiomyomas. Due to specificities of this method and possible complications the appropriate indication is crucial. Patient’ symptoms, age, plans for pregnancy, and surgical and reproductive history play a major role in decision-making regarding appropriate subjects for UAE. Close cooperation between the gynecologist and the interventional radiologist is necessary. UAE is usually offered as an alternative to surgical treatment. In patients with no fertility plans, it is a less invasive option than abdominal hysterectomy, with a comparable effect on fibroid-related symptoms and quality of life. The need for reintervention is markedly greater in patients after UAE (up to 35% within 5 years) than after hysterectomy. Women with large symptomatic fibroids wishing to retain the uterus and ineligible for minimally invasive (laparoscopic or vaginal) hysterectomy are good candidates for UAE. However, studies comparing UAE with minimally invasive hysterectomy are lacking. Use of UAE in younger women desiring pregnancy is more controversial, mainly because of the significant risk of miscarriage (as high as 64% in some studies) as well as the increased risk of other complications of pregnancy, such as preterm delivery, abnormal placentation, and post-partum hemorrhage. The risk of infertility or subfertility following UAE is unknown. Even poor candidates for myomectomy should be carefully selected for UAE after counseling about all possible adverse effects on fertility. Good prospective studies focused on fertility comparing UAE with no treatment or with myomectomy are needed but would be ethically questionable. This review summarizes the current knowledge regarding the benefits and potential risks of UAE from the point of view of the gynecologist, who should be responsible for proper indication of this treatment.