Risk of Intrauterine Infectious Complications after Uterine Artery Embolization

Pantoea agglomerans bacteraemia after uterine artery embolisation: an unusual pathogen

A woman in her 40s presented to the emergency department (ED) with a 3-week history of nausea, vomiting and diarrhoea. Blood cultures were positive for Serratia and Pantoea agglomerans spp. One month before her ED visit, she underwent targeted uterine artery embolisation with particles by an interventional radiologist. Uterine artery embolisation is considered a safe alternative to surgical removal of fibroids or hysterectomy. The patient was initially treated with targeted antibiotics for a large infected uterine fibroid but ultimately required a hysterectomy for source control. To our knowledge, this is the first documented case of P. agglomerans infecting a uterine fibroid.

Comparing magnetic resonance imaging and ultrasound in the clinical evaluation of fibroids prior to uterine artery embolization

PURPOSE

Uterine artery embolization has become established as a frontline treatment for uterine leiomyomata. In planning embolization, preprocedural imaging can further characterize pathology and anatomy, but it may also reveal coexisting diagnoses that have the potential to change clinical management. The purpose of this study is to compare the diagnostic outcomes of ultrasound and MRI performed for patients prior to undergoing embolization.

METHODS

The study cohort consisted of 199 patients who underwent uterine artery embolization at a single academic institution between 2013 and 2018. Prior to embolization, all patients had an MRI confirming a leiomyomata diagnosis. Additionally, 118 patients underwent transvaginal ultrasound within five years prior to MRI. MRI findings were analyzed and, when applicable, compared to prior ultrasound impressions to assess for the incidence of new findings. The diagnoses of interest were adenomyosis, hydrosalpinx, predominantly infarcted leiomyomata, and large intracavitary leiomyomata. Data were collected from retrospective chart review and included demographics, symptomology, and imaging reports.

RESULTS

199 patients ultimately underwent embolization for treatment of MRI-confirmed leiomyomata. Of 118 patients who also had an ultrasound within five years prior to their MRI, 26 (22.0%) received a second gynecologic diagnosis based on MRI findings that was not previously seen on ultrasound. Of 81 patients who only had an MRI before embolization, 19 (23.5%) received a second gynecologic diagnosis not previously documented. The most common coexisting pathology was adenomyosis, presenting in 34 (17.1%) patients with leiomyomata, followed by large intracavitary leiomyomata (8, 4.0%), infarcted leiomyomata (7, 3.5%), and hydrosalpinx (6, 3.0%),.

CONCLUSIONS

When considering uterine artery embolization for the treatment of symptomatic leiomyomata, preprocedural MRI is superior to ultrasound in detecting coexisting pathologies, including adenomyosis and hydrosalpinx. It can also better characterize leiomyomata, including identifying lesions as intracavitary or infarcted. These findings have the potential to alter clinical management or contraindicate embolization entirely.

Effectiveness and safety of prophylactic abdominal aortic balloon occlusion for patients with type III caesarean scar pregnancy: a prospective cohort study

BACKGROUND

Caesarean scar pregnancy (CSP) is a special type of ectopic pregnancy with a high risk of massive haemorrhage. Few studies have focused on the efficacy of prophylactic abdominal aortic balloon occlusion as a minimally invasive method in caesarean section. This study aimed to evaluate the effectiveness and safety of prophylactic abdominal aortic balloon occlusion for patients with type III CSP.

METHODS

This was a prospective cohort study. Patients with type III CSP in the First Affiliated Hospital of Zhengzhou University from January 2020 to June 2022 were enrolled. Eligible patients received prophylactic abdominal aortic balloon occlusion (defined as the AABO group) or uterine artery embolization (defined as the UAE group) before laparoscopic surgery. Clinical outcomes included intraoperative blood loss, body surface radiation dose, hospitalization expenses, and time to serum β-hCG normalization, and safety were also assessed.

RESULTS

A total of 68 patients met the criteria for the study, of whom 34 patients were in the AABO group and 34 patients were in the UAE group. The median intraoperative blood loss in the AABO and UAE groups was 17.5 (interquartile ranges [IQR]: 10, 45) and 10 (IQR: 6.25, 20) mL, respectively (P = 0.264). The body surface radiation dose of the AABO group was much lower than that of the UAE group (5.22 ± 0.44 vs. 1441.85 ± 11.59 mGy, P < 0.001). The AABO group also had lower hospitalization expenses than the UAE group (2.42 ± 0.51 vs. 3.42 ± 0.85 *10^5 yuan, P < 0.001). The average time to serum β-hCG normalization in the AABO group was 28.9 ± 3.21 d, which was similar to that in the UAE group (30.3 ± 3.72 d, P = 0.099). In addition, the incidence of adverse events in the AABO group was lower than that in the UAE group (5.9% vs. 58.8%, P < 0.001).

CONCLUSION

Prophylactic AABO was equally as effective as UAE in patients with type III CSP but was safer than UAE during and after the operation.

Transcatheter Uterine Artery Embolisation in Treating Secondary Haemorrhage Post Hysterectomy: A Life-Saving Approach

Hysterectomy, which is a surgical procedure to remove all or a part of the uterus, is one of the most commonly done procedures by a gynaecologist. However, it may be associated with a number of complications. Haemorrhage following hysterectomy is a life-threatening complication. One of the most common complications is haemorrhage, whether primary or secondary. The various options to treat secondary haemorrhage post hysterectomy are uterine artery embolization (UAE) or surgical re-exploration. Here, we present a case of secondary haemorrhage post hysterectomy treated with uterine artery embolization and describe the numerous advantages of UAE as a novel approach to stop bleeding post hysterectomy over the traditional surgical re-exploration method.

Current Strategies for Prevention of Infection After Uterine Artery Embolisation

Uterine artery embolisation (UAE) is a safe and effective procedure for symptomatic uterine fibroids with an estimated rate of post-operative intra-uterine infection of 0.9-2.5%. While rates of infection have remained low over the past two decades, there is variation in infection prevention practices. Intra-uterine infection after UAE may occur via access site haematogenous spread or ascension of vaginal flora through the cervical canal. Although the evidence base is immature, risk factors for infection including previous pelvic infection, hydrosalpinx, endocervical incompetence, diabetes, smoking, obesity, respiratory disease, and immunosuppression should be assessed during the pre-operative consultation with the interventional radiologist to tailor a plan for minimising infection, which may include optimisation of any modifiable risk facts and prophylactic antibiotics.

Endovascular uterine artery interventions

Percutaneous vascular embolization plays an important role in the management of various gynecologic and obstetric abnormalities. Transcatheter embolization is a minimally invasive alternative procedure to surgery with reduced morbidity and mortality, and preserves the patient's future fertility potential. The clinical indications for transcatheter embolization are much broader and include many benign gynecologic conditions, such as fibroid, adenomyosis, and arteriovenous malformations (AVMs), as well as intractable bleeding due to inoperable advanced-stage malignancies. The most well-known and well-studied indication is uterine fibroid embolization. Uterine artery embolization (UAE) may be performed to prevent or treat bleeding associated with various obstetric conditions, including postpartum hemorrhage (PPH), placental implantation abnormality, and ectopic pregnancy. Embolization of the uterine artery or the internal iliac artery also may be performed to control pelvic bleeding due to coagulopathy or iatrogenic injury. This article discusses these gynecologic and obstetric indications for transcatheter embolization and reviews procedural techniques and outcomes.

Evaluation of the Effect of Routine Antibiotic Administration after Uterine Artery Embolization on Infection Rates

PURPOSE

To evaluate the effect of routine administration of post-procedural antibiotics following elective uterine artery embolization (UAE) on infectious complication rates.

MATERIALS AND METHODS

The charts of patients who underwent UAE between January 2013 and September 2019 were retrospectively reviewed. Prior to January 15, 2016, all patients received post-procedural antibiotics with 500 mg of ciprofloxacin twice a day orally for 5 days. After January 15, 2016, none of the patients received post-procedural antibiotics. All patients in both groups received pre-procedural intravenous antibiotics. The post-procedural antibiotics group included 217 patients (age, 44.7 ± 6 years); the no-antibiotics group included 158 patients (age, 45.4 ± 5.6 years). Patients in the no-antibiotics group had a significantly higher rate of diabetes mellitus (P = .03) but fewer cases of adenomyosis (P = .048). Otherwise, demographic and fibroid characteristics were similar between the groups.

RESULTS

Six infectious complications (6/375, 1.6%) were recorded. No statistically significant difference (P = .66) was observed in the number of infections between the post-procedural antibiotics group (4/217, 1.8%) and the no-antibiotics group (2/158, 1.3%). Three of the 6 infectious complications presented with malodorous vaginal discharge (3/375, 0.8%) and received nominal therapy. The 3 remaining complications (0.8%) were considered major and included 2 patients (0.5%) who underwent hysterectomy and 1 patient (0.3%) who underwent myomectomy. The major infection rate was 0.9% (2/217) in the post-procedural antibiotics group and 0.7% (1/158) in the no-antibiotics group (P = 1). There were no 90-day post-procedural mortalities.

CONCLUSIONS

Discontinuation of routine post-procedural antibiotics with ciprofloxacin after elective UAE did not result in increased rates of infectious complications within the first 90 days post procedure.

Uterine Artery Embolisation for Women with Giant Versus Non-giant Uterine Fibroids: A Systematic Review and Meta-analysis

BACKGROUND

Evidence supporting uterine artery embolisation (UAE) for giant fibroids (≥ 10 cm and/or uterine volume ≥ 700 CC) remains sparse. We performed a systemic review and meta-analysis of UAE outcomes for symptomatic giant versus non-giant fibroids.

METHODS

The literature was systematically reviewed. Research studies of UAE as an adjunct to surgery, and those not using peri-operative MRI were excluded. Primary outcomes were fibroid size and uterine volume reduction, procedure time, length of hospital stay, reinterventions, patient symptom improvement/satisfaction and complications.

RESULTS

We identified four observational studies (839 patients; giant = 163, non-giant = 676). Both groups demonstrated reduction in fibroid size and uterine volume after UAE, with equivocal difference in uterine volume reduction (Mean difference (MD) - 0.3 95% confidence interval (CI) - 3.8 to 3.1, p = 0.86) and greater reduction in non-giant dominant fibroid size (MD - 5.9 95% CI - 10.3 to - 1.5, p < 0.01). Giant fibroids were associated with 5.6 min longer mean operative time (MD 5.6 min 95% CI 2.6-8.6, p < 0.01) and 4.8 h longer mean hospital stay (MD 4.8 h 95% CI 1.1-8.6, p = 0.01). Patient symptoms/satisfaction outcomes were summarised, but too heterogeneous for meta-analysis. Major complication and reintervention rates were low, with a statistically higher rate of major complications (Odds ratio (OR) 4.7 95% CI 1.5-14.6, p < 0.01) and reinterventions (OR 3.6 95% CI 1.7-7.5, p < 0.01) in giant fibroids.

CONCLUSIONS

Current evidence shows UAE is a safe and effective option to treat giant fibroids. However, the limited available data indicate a relatively higher risk of complications and reinterventions when compared with non-giant fibroids. Patients should be selected, counselled and managed accordingly.

LEVEL OF EVIDENCE

Level III, Systematic review of retrospective cohort studies.

Uterine Artery Pseudoaneurysm: A Life-Threatening Cause of Vaginal Bleeding in the Emergency Department

BACKGROUND

Vaginal bleeding is a common presenting complaint in the emergency department (ED); life-threatening hemorrhage is rare. Uterine artery pseudoaneurysm (UAP) is an uncommon but potentially life-threatening cause of vaginal bleeding that is most likely to present primarily to EDs, given its delayed postpartum or postoperative presentation.

CASE REPORT

A 25-year-old female gravida two, para one, who was 19 days post dilation and evacuation for an elective termination of a pregnancy at 20 weeks, presented to the ED with profuse vaginal bleeding. She was hypotensive and tachycardic at presentation, requiring resuscitation with 0.9% normal saline and transfusions of packed red blood cells. Transvaginal ultrasound completed in the ED demonstrated a pulsatile mass in the cervix with internal "ying-yang" flow on Doppler images, suggestive of a uterine artery pseudoaneurysm within the cervix. The patient underwent emergent uterine artery embolization with resolution of bleeding and improvement in her hemodynamic status. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: UAP is an uncommon cause of vaginal bleeding, but UAP rupture can be life-threatening. UAP is an important differential diagnosis for vaginal bleeding, particularly in the postpartum or postoperative setting. Delaying diagnosis may worsen bleeding in the setting of a ruptured UAP if treatment is pursued for alternative diagnosis; for example, treating retained products of conception with a dilation and curettage. Being aware of UAP and how to diagnose it will allow early proper treatment and more favorable patient outcomes.

Efficacy and Safety of Prophylactic Uterine Artery Embolization in Pregnancy Termination with Placenta Previa

PURPOSE

To appraise the efficacy and safety of prophylactic uterine artery embolization in pregnancy termination with placenta previa.

METHODS

A cohort of 54 consecutive patients with placenta previa underwent prophylactic uterine artery embolization before vaginal delivery from February 2012 to March 2015. Vaginal delivery was attempted in all patients. Cesarean section or hysterectomy was introduced when vaginal delivery failed.

RESULTS

Vaginal delivery succeeded in 50 patients (93.6%) and failed in 4 patients (6.4%), thereupon converted to cesarean delivery. No patients resorted to hysterectomy. Six patients (11.1%) underwent blood transfusion. None of clinical characteristics, including maternal age, gestational age, history of abortion, history of cesarean delivery, and volume of vaginal bleeding, was significantly associated with complete placenta previa (P > 0.05). However, patients with complete placenta previa had a significantly lower successful rate of vaginal delivery than did patients without complete placenta previa (81 vs 100%, P = 0.038). The rate of complications was 3.7%. No major complications were observed.

CONCLUSION

Uterine artery embolization is an effective and safe technique to assist pregnancy termination with placenta previa, which may lower the risk of cesarean section, hysterectomy, and blood transfusion.

Uncommon Complication of Uterine Artery Embolization: Expulsion of Infarcted Myoma and Uterine Sepsis

Uterine leiomyomas are the most common benign tumors in young females and leading cause of hysterectomy. Uterine artery embolization is a safe option for women who wish to retain their uterus. Several complications have been reported including expulsion and sepsis. MRI is a useful pretreatment tool to predict results and outcomes. We report a case of a 44-year-old female with a history of uterine fibroids with the largest one being intracavitary. Patient underwent uterine artery embolization that was complicated by endomyometritis that failed antibiotics, leading to sepsis and hysterectomy.

A Case of Pyomyoma following Uterine Fibroid Embolization and a Review of the Literature

Background. Since its introduction in 1996, uterine fibroid embolization (UFE) has become standard medical practice in the management of symptomatic uterine fibroids. An extremely rare complication, pyomyoma, has been reported only 5 times previously in the literature following UFE. Case. A 37-year-old woman underwent UFE for symptomatic leiomyomas of the uterus. Signs and symptoms of uterine infection ensued, beginning at 6 days following the procedure. Recurrent fevers and increasing leukocytosis despite the intravenous administration of appropriate antibiotics eventually necessitated surgical intervention on postprocedure day #18. Conclusion. An extremely rare complication of UFE is herein presented, pyomyoma, with a review of other reported cases. Commonalities are sought among these few reported cases with the hope of increasing diagnostic acumen in the detection of this disease.

Uterine artery embolization: pre- and post-procedural evaluation using magnetic resonance imaging

Magnetic resonance (MR) imaging has become the preferred method in assessing the uterus and pelvis prior to and following uterine artery embolization (UAE). The multiplanar imaging capabilities, increased spatial and contrast resolution, anatomic detail and assessment of fibroid viability that MR provides over ultrasound allows for accurate pre-treatment planning and post-treatment assessment. The purpose of this article is to demonstrate the use of MR in the selection of patients, anatomic evaluation and procedural planning before UAE, describe the use of MR in evaluating treatment response after UAE and illustrate the use of MR in identifying post-UAE complications. An understanding of these principles is essential in guiding appropriate therapy, determining treatment effectiveness and identifying associated complications before and after UAE.

Fibroid infected with Escherichia coli requiring surgical removal following uterine artery embolization

BACKGROUND

Uterine fibroid necrosis and infection is a rare but potentially serious event following uterine artery embolization (UAE). We describe a case of surgical removal of an infected necrotic uterine fibroid.

CASE

A 31-year-old Jehovah's Witness with severe anemia presented with sepsis following UAE. The uterus was preserved by performing transvaginal surgical removal. Final pathology demonstrated Escherichia Coli infection of the necrotic fibroid. The patient improved postoperatively.

CONCLUSION

Surgical removal of an infected necrotic fibroid may be a preferred option for women wishing to avoid hysterectomy following UAE. Appropriate case selection and optimization of hemoglobin concentration before UAE is important to minimize complications.

Beyond hemostasis: spectrum of gynecologic and obstetric indications for transcatheter embolization

Percutaneous vascular embolization is a useful therapeutic option for a wide range of gynecologic and obstetric abnormalities. Transcatheter embolization procedures performed with the use of radiologic imaging for guidance are minimally invasive and may obviate surgery, thereby decreasing morbidity and mortality and safeguarding the patient's future fertility potential. To integrate this treatment method optimally into patient care, knowledge is needed about the clinical indications for therapeutic embolization, the relevant vascular anatomy, technical considerations of the procedure, and the potential risks and benefits of embolization. The most well-known and well-studied transcatheter embolization technique for treating a gynecologic-obstetric condition is uterine fibroid embolization. However, the clinical indications for transcatheter embolization are much broader and include many benign gynecologic conditions, such as adenomyosis and arteriovenous malformations, as well as intractable bleeding due to inoperable advanced-stage malignancies. Uterine artery embolization may be performed to prevent or treat bleeding associated with various obstetric conditions, including postpartum hemorrhage, placental implantation abnormality, and ectopic pregnancy. Embolization of the uterine artery or the internal iliac artery also may be performed to control pelvic bleeding due to coagulopathy or iatrogenic injury, and ovarian vein embolization has been shown to be effective for the management of pelvic congestion syndrome. The article discusses these and other gynecologic and obstetric indications for transcatheter embolization, provides detailed descriptions of imaging findings before and after embolization, and reviews procedural techniques and outcomes.

Complications and reinterventions in uterine artery embolization for symptomatic uterine fibroids: a literature review and meta analysis

PURPOSE

To perform a literature review of the spectrum of complications associated with UAE relative to surgery and compare the risk of reintervention as well as minor, major, and overall complications.

MATERIALS AND METHODS

Literature review was conducted in PubMed, MEDLINE, Cochrane, and CINAHL databases, and meta-analysis was performed.

RESULTS

In randomized clinical trials, common complications were discharge and fever (4.00 %), bilateral uterine artery embolization (UAE) failure (4.00 %), and postembolization syndrome (2.86 %). Two trials showed a significantly decreased risk in major complications with UAE, with odds ratios (ORs) of 0.07143 (0.009426-0.5413) and 0.5196 (0.279-0.9678). None of the trials showed a significant difference in OR for minor complications of UAE. None of the trials showed a significant difference in risk for overall complications of UAE. Three trials showed a significantly increased risk for reintervention with UAE with ORs of 10.45 (2.654-41.14), 2.679 (1.289-5.564), and 9.096 (1.269-65.18). In 76 nonrandomized studies, common complications were amenorrhea (4.26 %), pain (3.59 %), and discharge and fever (3.37 %). In 41 case studies, common complications were discharge and fever (n = 22 cases), repeat UAE (n = 6 cases), and fibroid expulsion (n = 5 cases).

CONCLUSION

Overall, UAE has a significantly lower rate of major complications relative to surgery, but it comes at the cost of increased risk of reintervention in the future. Educating patients about the rate and types of complications of UAE versus surgery, as well as the potential for reintervention, should help the patient and clinician come to a reasoned decision.

Conservative laparoscopic approach to a perforated pyomyoma after uterine artery embolization

We describe a conservative laparoscopic approach to treatment of a perforated pyomyoma after uterine artery embolization. A 36-year-old woman came to our emergency department 8 weeks after undergoing uterine artery embolization. She reported painful abdominal cramps. Physical examination revealed fever, tachycardia, hypotension, abdominal pain with rebound tenderness and pain during bimanual examination. Ultrasonography showed a fundal/subserosal leiomyoma and a moderate amount of fluid in the abdominal cavity. Because the patient desired preservation of the uterus, a laparoscopic approach was used for drainage and lavage of a perforated pyomyoma. The patient had an uneventful recovery and remained well at follow-up visits. Second-look diagnostic laparoscopy enabled treatment of the adhesions formed and revealed patent fallopian tubes. Surgery has been the primary approach to pyomyoma. However, hysterectomy leads to irreversible sterility and myomectomy can be difficult to perform. Therefore, there is need for a less invasive intervention in women who seek conservative treatment. Recently, computed tomography-guided drainage was successfully performed in two patients with pyomyoma. To our knowledge, this is the first report of a successful conservative laparoscopic approach to pyomyoma.

Prophylactic antibiotic guidelines in modern interventional radiology practice

Modern interventional radiology practice is continuously evolving. Developments include increases in the number of central venous catheter placements and tumor treatments (uterine fibroid therapy, radio- and chemoembolization of liver tumor, percutaneous radiofrequency and cryoablation), and new procedures such as abdominal aortic aneurysm stent-graft repair, vertebroplasty, kyphoplasty, and varicose vein therapies. There have also been recent advancements in standard biliary and urinary drainage procedures, percutaneous gastrointestinal feeding tube placement, and transjugular intrahepatic portosystemic shunts. Prophylactic antibiotics have become the standard of care in many departments, with little clinical data to support its wide acceptance. The rise in antibiotic-resistant strains of organisms in all hospitals worldwide have forced every department to question the use of prophylactic antibiotics. The authors review the evidence behind use of prophylactic antibiotics in standard interventional radiology procedures, as well as in newer procedures that have only recently been incorporated into interventional radiology practice.

Outcomes following fibroid expulsion after uterine artery embolization

PURPOSE

To evaluate retrospectively the sequelae of fibroid expulsion (FE) after uterine artery embolization (UAE).

MATERIALS AND METHODS

From a population of 759 UAE procedures performed from July 1999 to June 2009, 37 patients were found to have a uterine fibroid communicating with the endometrial cavity resulting in "bulk" FE with the passage of large fragments or an entire tumor or "sloughing" FE with shedding or "melting" of the tumor. Medical records and magnetic resonance images were evaluated for clinical information and tumor characteristics, respectively.

RESULTS

The mean age of patients with FE was 43 years ± 5 (SD), with 12 nulliparous and 25 parous. Expulsion took place a mean of 14.8 weeks ± 17.7 after UAE (range, 1.6-105.9 wk). FE was asymptomatic in 5% of cases (n = 2) and symptomatic in 95% (n = 35). Among symptomatic cases, 89% (n = 31) had bulk expulsion and 11% (n = 4) had sloughing expulsion. Forty-nine percent of patients (n = 18) had tumor expulsion at home or had an office/emergency room transvaginal myomectomy (TVM), 27% (n = 10) underwent operative TVM, and 8% (n = 3) had hysteroscopic resection. Urgent and elective hysterectomies were performed in 11% (n = 4) and 5% of cases (n = 2), respectively. Nulliparous women showed a trend toward undergoing hysterectomy compared with parous women (33% vs 8%; P =.07, Fisher exact test).

CONCLUSIONS

Most women tolerate FE well, with approximately half needing no operative intervention, but some may need to undergo hysteroscopy, operative TVM, or even hysterectomy. Nulliparous women are potentially at greater risk to require hysterectomy.

Transcatheter arterial embolotherapy: a therapeutic alternative in obstetrics and gynecologic emergencies

Transcatheter arterial embolization has become a major treatment modality in a variety of clinical applications, including management of bleeding related to a broad spectrum of obstetric and gynecologic disorders. Embolotherapy has a well-documented role in the management of pelvic and genital tract hemorrhage in the postpartum and postoperative/postcesarean setting. It is also an integral part in the treatment armamentarium of abdominal and cervical ectopic pregnancy, arteriovenous malformation, and gynecologic neoplasms, including more recently, uterine leiomyomata. Based on experiences accumulated over the past decades, embolotherapy has been proven to be highly effective with success rate in the 90 to 100% range in the appropriate clinical settings. It provides visualization of the bleeding site and enables targeted, minimally invasive therapy to achieve hemostasis, which allows preservation of the uterus and hence fertility. In hospitals where experienced personnel and technology is available, transcatheter arterial embolization should be considered in the emergent management of obstetric and gynecologic hemorrhage, particularly when local and conservative measures fail to attain hemostasis.

Uterine artery embolization: a safe and effective, minimally invasive, uterine-sparing treatment option for symptomatic fibroids

Leiomyomas (or fibroids) are exceedingly common lesions. The indications to initiate treatment are based on the symptoms that can arise from their presence. In general, medical therapy should be considered the first line of treatment. Currently, the treatment of fibroids is in evolution. Since uterine artery embolization (UAE) was first described by Ravina et al in 1995, it has been shown to be a safe, efficacious, and cost-effective alternative to traditional surgical options, with data from long-term studies now available. Appropriate patient evaluation and selection are vital; the ideal candidate is one who is premenopausal, has symptomatic fibroids resistant to medical therapy, no longer desires fertility, and wishes to maintain her uterus. Uterine artery embolization is primarily an angiographic procedure, but periprocedural clinical management is critical for patient satisfaction. This article discusses the various embolic materials that are commonly used and available for UAE; understanding the technical nuances is critical for long-term success.

Complications of uterine fibroid embolization

Uterine fibroid embolization (UFE) is an increasingly popular, minimally invasive treatment option for women with symptomatic fibroid disease. UFE therapy in qualified hands is an effective, well-tolerated procedure that offers relief of fibroid symptoms with a low risk of complications. In the acute postprocedural period, immediate complications may relate to vascular access, thromboembolic events, infection, and pain management. Reported major complications include but are not limited to pulmonary embolus, uterine ischemia, necrosis, sepsis, and death. Non-life-threatening complications include altered ovarian and sexual function, subcutaneous tissue necrosis, expulsion of fibroid tissue, and treatment failure. Awareness of the known complications of UFE may allow more rapid diagnosis and effective therapeutic responses to complications when they occur.

[Therapeutic embolization of uterine leiomyomas: cases requiring surgery]

OBJECTIVE

To retrospectively analyze the clinical, radiolgical, and histological findings in patients with uterine leiomyomas (LU) that required surgical intervention after embolization.

MATERIAL AND METHODS

Between July 1999 and January 2006, we embolized 182 patients with LU. Eight of these patients subsequently required surgical resection of the tumor. We reviewed clinical data, imaging findings, embolization technique, and reasons for surgery, histological findings in the resected specimens, identification and location of the embolizing material, presence and type of necrosis in the LU, and associated pathology in adjacent organs.

RESULTS

The 8 patients that required surgery represented 4.3% of all patients embolized for LU. Surgery was necessary due to technical failure in two patients (1.02%), complications in three (1.64%) and failed treatment in the remaining three 3 (1.64%). The mean maximum diameter of the LU was 9.8 cm (range: 4-17 cm). The mean volume of the LU was 491.88 ml (range: 30-1.365 ml) The mean age of the patients was 37.7 years (range: 28-48 years). Global necrosis was evident in 6 LU; necrosis was hyaline type in 3 and inflammatory in the remaining 3. The embolizing material was detected in the LU in one case, in the uterine myometrium in two cases, and in the ovary in one.

CONCLUSION

Less than 5% of cases of LU required surgery after embolization; the risk of surgery after embolization was greater in large lesions. When the embolization technique was adequate, histological study confirmed global necrosis of the tumors, although this was not accompanied by clinical improvement.

Postembolization syndrome: changes in white blood cell counts immediately after uterine artery embolization

Postembolization syndrome (PES) after transcatheter uterine artery embolization (UAE) is classically described as including self-limited pain, nausea, vomiting, and fever. However, the expected components of PES after UAE might also include leukocytosis, the incidence and magnitude of which have not yet been determined. A retrospective review of 78 patients who underwent elective UAE for symptomatic leiomyomas showed an increase in white blood cell (WBC) counts within 24 hours after the procedure in 86% of patients, with clinically defined leukocytosis (WBC count >11,000/microL) present in 21% of patients. Interventional radiologists and other clinicians involved in the care of these patients should expect such changes and not be alarmed regarding early infectious complications.

Clinical care of patients undergoing uterine artery embolization

Uterine artery embolization (UAE) is a relatively recent, safe, and minimally invasive procedure for women experiencing symptomatic fibroids. This process of percutaneous occlusion of blood vessels to disrupt blood flow will consequently impede nourishment to the uterine fibroids and cause infarction. To have proper patient treatment to optimize overall clinical success, guidelines should be rigorously followed. This article will delineate a suitable patient care process for UAE in which subsequent interventional radiologists can employ.

Uterine artery embolization as a treatment for symptomatic uterine fibroids: a review of literature and case report

PURPOSE

To provide a case presentation and review of the literature on uterine artery embolization (UAE) as a treatment alternative for symptomatic uterine fibroids and to guide the nurse practitioner (NP) in patient selection, education, and periprocedural management of patients undergoing this procedure.

DATA SOURCES

Research articles, clinical articles, and case studies pertaining to UAE.

CONCLUSIONS

UAE is a safe, well tolerated, and effective nonsurgical treatment option for symptomatic uterine fibroids. This uterus-sparing procedure has low complication rates with excellent clinical outcomes and high patient satisfaction rates. The majority of women who undergo UAE report marked reduction in the severity of fibroid specific symptoms and significant improvement in their quality of life. Uterine fibroids are common in women and often produce symptoms that have a negative impact on quality of life.

IMPLICATIONS FOR PRACTICE

The NP is instrumental in identifying which patients may be appropriate candidates for UAE, educating them about the risks and benefits of the procedure, and managing these patients before and after the procedure.

Antibiotic Prophylaxis in Interventional Radiology—Anything New?

Every interventional procedure can result in infective complications. Generally the incidence is low; however, with newer and more aggressive techniques the infection risk is more prevalent and can result in serious adverse outcomes to our patients. Antibiotic prophylaxis has become commonplace; however, there is little controlled data to underpin our regimens and most choices are based on surgical practice and anecdotal evidence. The rise of antibiotic resistance and treatment of many immunocompromised patients further compounds the difficulties faced. The purpose of this article was to examine the evidence that is presented regarding antibiotic prophylaxis in interventional radiology and highlight how we integrate this into our daily practice. In particular we will focus on evolving procedures and techniques that are associated with a high incidence of infection.

Uterine Artery Embolization in the Treatment of Symptomatic Uterine Fibroid Tumors (EMMY Trial): Periprocedural Results and Complications

PURPOSE

Uterine artery embolization (UAE) is an emerging treatment for symptomatic uterine fibroid tumors. This study was performed to evaluate the periprocedural results of the UAE procedure and identify risk factors for technical failure, fever after UAE, pain, and other complications.

MATERIALS AND METHODS

As part of a multicenter, randomized trial to compare UAE versus hysterectomy in patients with symptomatic uterine fibroid tumors, 81 patients underwent UAE. Univariate and multivariate analyses were used to identify predictors for technical failure, postprocedural fever, complications as defined by the Society of Interventional Radiology (SIR), and pain scores.

RESULTS

The technical failure rate according to SIR guidelines was 5.3% (95% CI, 2.3%-10.1%). The procedural failure rate was 17.3% (95% CI, 9.8%-27.3%). Bilateral failure occurred in four of 81 patients and unilateral failure occurred in 10 of 81 patients. Technical failure occurred mainly as a result of difficult anatomy (3.7%) or absence of the uterine artery (3.1%). The overall complication rates were 28.4% during the patients' hospital stay and 60.5% for the 6 weeks after discharge. The risk of technical failure was found to increase in the presence of a single fibroid tumor (odds ratio [OR], 6.21; 95% CI, 1.65-23.41; P = .007) and/or a small uterine volume (<500 cm(3); OR, 10.8; 95% CI, 1.25-93.36; P = .03). The amount of embolization material was associated with the onset of fever after UAE (OR, 2.05; 95% CI, 1.09-3.87; P = .027), major complications (OR, 5.68; 95% CI, 2.05-15.75; P = .001), and high pain scores (OR, 1.97; 95% CI, 1.08-3.58; P = .027).

CONCLUSIONS

The procedural failure rate for UAE was higher than those reported by others, mainly as a result of difficult anatomy and absence of a uterine artery in some cases. The risk of procedural failure was increased for patients with single fibroid tumors and/or small uterine volumes. A clear dose-effect response was revealed between the amount of embolization material used and the risk for postprocedural fever, major complications, and severe pain.

Uterine Artery Embolization as a Treatment Option for Uterine Myomas

Information is still being collected on the long-term clinical responses and appropriate patient selection for UAE. Prospective RCTs have not been performed to compare the clinical results from UAE with more conventional therapies for symptomatic uterine leiomyomata. At least three attempts at conducting such RCTs have been unsuccessful because of poor patient accrual that related to differing patient expectation and desires, clinical bias, insurance coverage, and the tendency that patients who have exhausted other treatment options may be disposed more favorably to less invasive treatments. Other comparative studies have serious limitations. For example, the retrospective study that compared outcomes after abdominal myomectomy with UAE suggested that patients who received UAE were more likely to require further invasive treatment by 3 years than were recipients of myomectomy. Lack of randomization introduced a selection bias because women in the group that underwent UAEwere older and were more likely to have had previous surgeries. A prospective study of "contemporaneous cohorts," which excluded patients who had sub-mucosal and pedunculated subserosal myomas, sought to compare quality of life measures and adverse events in patients who underwent UAE or hysterectomy. The investigators concluded that both treatments resulted in marked improvement in symptoms and quality of life scores, but complications were higher in the group that underwent hysterectomy over 1 year. In this study,however, a greater proportion of patients who underwent hysterectomy had improved pelvic pain scores. Furthermore, hysterectomy eliminates uterine bleeding and the risk for recurrence of myomas. Despite the lack of controlled studies that compared UAE with conventional surgery, and despite limited extended outcome data, UAE has gained rapid acceptance, primarily because the procedure preserves the uterus, is less invasive, and has less short-term morbidity than do most surgical options. The cost of UAE varies by region, but is comparable to the charges for hysterectomy and is less expensive than abdominal myomectomy. The evaluation before UAE may entail additional fees for diagnostic testing, such as MRI, to assess the uterine size and screen for adenomyosis. Other centers have recommended pretreatment ultrasonography, laparoscopy, hysteroscopy, endometrial biopsy, and biopsy of large fibroids to evaluate sarcoma. Generally,after UAE the recovery time and time lost from work are less; however, the potential need for subsequent surgery may be greater when compared with abdominal myomectomy. Any center that offers UAE should adhere to published clinical guidelines,maintain ongoing assessment of quality improvements measures, and observe strict criteria for obtaining procedural privileges. After McLucas advocated that gynecologists learn the skill to perform UAE for managing symptomatic myomas, the Society of Interventional Radiology responded with a precautionary commentary on the level of technical proficiency that is necessary to maintain optimum results from UAE. The complexity of pelvic arterial anatomy, the skill that is required to master modern coaxial microcatheters, and the hazards of significant patient radiation exposure were cited as reasons why sound training and demonstration of expertise be obtained before clinicians are credentialed to perform UAE.A collaboration between the gynecologist and the interventional radiologist is necessary to optimize the safety and efficacy of UAE. The primary candidates for this procedure include women who have symptomatic uterine fibroids who no longer desire fertility, but wish to avoid surgery or are poor surgical risks. The gynecologist is likely to be the primary initial consultant to patients who present with complaints of symptomatic myomas. Therefore, they must be familiar with the indications, exclusions, outcome expectations, and complications of UAE in their particular center. When hysterectomy is the only option, UAE should be considered. Appropriate diagnostic testing should aid in the exclusion of most, but not all, gynecologic cancers and pregnancy. Other contraindications include severe contrast medium allergy, renal insufficiency, and coagulopathy. MRI may be used to screen women before treatment in an attempt to detect those who have adenomyosis; patients should be aware that UAE is less effective in the presence of solitary or coexistent adenomyosis. Because some women may experience ovarian failure after UAE, additional studies to determine basal follicle-stimulating hormone and estradiol before and after the procedure may provide insight into UAE-induced follicle depletion.UAE is a unique new treatment for uterine myomas, and is no longer considered investigational for symptomatic uterine fibroids. There is international recognition that data are needed from RCTs that compare UAE with surgical alternatives. Current efforts to provide prospective objective assessment of treatment outcomes and complications after UAE will help to optimize patient selection and clinical guidelines. FIBROID should provide critical data for the assessment of safety and outcomes measures for women who receive UAE for symptomatic uterine myomas.

Uterine Artery Embolization for Leiomyomas: Pre- and Postprocedural Evaluation with US

Transabdominal and transvaginal ultrasonography (US) are commonly used to assess the uterus and pelvis prior to and following uterine artery embolization (UAE) for symptomatic leiomyomas (fibroids). Preprocedural US may help identify relative contraindications for UAE, whereas postprocedural US can help determine the quality and quantity of fibroid involution and help identify any complications associated with the procedure. The consulting radiologist should be familiar with certain typical postprocedural US findings, which might otherwise be improperly interpreted, leading to unnecessary intervention. Magnetic resonance (MR) imaging or computed tomography will frequently provide the most accurate information in UAE patients with certain pathologic conditions, and early study results suggest that MR imaging may be helpful in predicting treatment response. Nevertheless, US is a readily available first-line imaging modality and a well-accepted method for both pre- and postprocedural evaluation of patients who undergo UAE. A proper understanding of the US findings in this patient population allows objective determination of treatment response and detection of most of the commonly recognized complications that are associated with UAE.