Pelvic sepsis complicating embolization of a uterine fibroid

Efficacy of Embolization in Acquired Uterine Vascular Malformations: An Experience in Tertiary Care Centre in India

OBJECTIVE

 To determine the efficacy of Uterine Artery Embolization in patients with bleeding acquired uterine arteriovenous malformations (AVMs).

METHODS

 A prospective review of all patients who underwent Uterine Artery Embolization at our institution between July 2015 and April 2022 was performed. 225 patients were diagnosed with a uterine vascular malformation on doppler and corresponding MRI imaging. All patients underwent transcatheter embolization of the uterine arteries. Embolic agents in the 375 procedures included Histoacryl glue only (n = 326), polyvinyl alcohol (PVA) particles and Histoacryl glue (n = 29), PVA particles (n = 5), Gelfoam (n = 5), coils (n = 4), PVA particles and coils (n = 3), Histoacryl glue and Gelfoam (n = 2), and Histoacryl glue and coils (n = 1).

RESULTS

 A total of 375 embolization procedures were performed in 225 patients. 90 patients required repeat embolization for recurrence of bleeding. The technical success rate of embolization was 100%. The clinical success rate was 92%: bleeding was controlled in 222 of 225 patients and three patients underwent a hysterectomy. 60 of the 225 patients had uneventful intrauterine pregnancies carried to term. The 210 patients who underwent successful embolization had no recurrence of bleeding at a median follow-up of 53 months (range, 5-122 months) after treatment. 15 patients were eventually lost to follow-up. One minor complication (0.4%) of non-flow-limiting dissection of the internal iliac artery occurred.

CONCLUSION

 Uterine Artery Embolization is a safe, effective, minimally invasive method to treat uterine AVMs with long-term efficacy, which can provide the preservation of fertility.

Two cases of leiomyoma necrosis after thermal balloon endometrial ablation

The presence of intramural leiomyomas is not necessarily a contraindication to thermal balloon endometrial ablation, provided there is minimal distortion of the endometrial cavity. We report 2 cases of necrosis of intramural leiomyomas after the procedure. These cases illustrate a potential complication of thermal balloon endometrial ablation that has been reported only once previously in the medical literature.

Predictive factors for fibroids recurrence after uterine artery embolisation

OBJECTIVES

To assess clinical failure and symptom recurrence after uterine artery embolisation (UAE) and to define predictive factors.

DESIGN

Prospective study of a case series.

SETTING

Gynaecology and radiology departments of a French University Hospital.

POPULATION

Eighty-five women who underwent embolisation for the treatment of uterine fibroids.

METHOD

Vascular access was obtained via the right common femoral artery. Free-flow embolisation was performed using 150-250 mum polyvinyl alcohol particles and an absorbable particle sponge.

MAIN OUTCOME MEASURES

Clinical failure was defined as persistence of symptoms at three months of follow up and recurrence as return of symptoms. The main outcome measure was the need for further treatment after UAE.

RESULTS

Results are available for 81 patients. Median follow up was 30 months. There were 15 clinical failures and recurrences requiring further treatment (eight hysterectomies, five hysteroscopic resections for submucous fibroids, one second embolisation and one woman refusing further treatment). Recurrence-free survival rate at 30 months (no clinical failure, no recurrence) was 82.8% (95% CI 73.7-91.8%). Multivariate analysis identified two predictive factors: dominant fibroid size on ultrasound imaging (each 1 cm increase: HR = 1.68, 95% CI 1.10-2.69) and number of fibroids (each additional fibroid: HR = 1.34, 95% CI 1.08-1.66).

CONCLUSIONS

Symptom recurrence rate 30 months after fibroid embolisation was 17.2%. Fibroid size and number were predictive factors for recurrence. As most recurrences occurred after two years, we recommend that patients be monitored clinically and that imaging be for more than two years after UAE.

Necrotic Leiomyoma and Gram-Negative Sepsis Eight Weeks After Uterine Artery Embolization

BACKGROUND

Uterine artery embolization for symptomatic leiomyomata is generally safe, but rare life-threatening complications, including sepsis, can result.

CASE

A 39-year-old woman with primary antiphospholipid syndrome, who was on chronic warfarin therapy, underwent uterine artery embolization for severe menorrhagia and a 12-cm intracavitary leiomyoma. Eight weeks postembolization, the patient, who had been essentially asymptomatic, presented in septic shock from gram-negative anaerobic bacteria. She underwent hysterectomy and bilateral salpingo-oophorectomy for a large infarcted necrotic leiomyoma and partial uterine necrosis. The patient's 8-day hospitalization required extended care in the intensive care unit and blood transfusion and resulted in surgical menopause in a patient who is not a candidate for hormone therapy.

CONCLUSION

Uterine artery embolization is a procedure not without significant risks. From published case reports, it appears that patients most at risk for severe infection of an infarcted leiomyoma after this procedure are those with a large dominant leiomyoma.

Leiomyoma Recurrence after Uterine Artery Embolization

PURPOSE

The purpose of this study was to evaluate the rate of leiomyoma recurrence after uterine artery embolization (UAE) for symptomatic uterine leiomyomas.

MATERIALS AND METHODS

A prospective study of UAE of uterine leiomyomas has been ongoing at the authors' hospital since 1997. The recurrence rate was assessed in June 2002. Vascular access was obtained via the right common femoral artery and free-flow embolization was performed with use of 150-250- micro m polyvinyl alcohol particles and an absorbable particle sponge. Follow-up included clinical and ultrasound (US) examinations at 3, 6, and 12 months, and once per year thereafter.

RESULTS

Eighty-five UAE procedures were performed between January 1997 and June 2000. Five patients were lost to follow-up. Median follow-up was 30 months (range, 2-57 months). There were six immediate failures: one technical failure, three cases of concomitant disease (one case of endometrial cancer and two cases of adenomyosis), and two cases of large subserosal leiomyomas. There were eight late failures or recurrences: one case of leiomyoma progression, seven cases of new leiomyomas. Mean time to recurrence was 27.4 months.

CONCLUSIONS

Although UAE is an effective primary treatment for leiomyomas, this study recorded a recurrence rate of 10% at just more than 2 years. Clinical and US examinations are needed before UAE to exclude pedunculated submucosal leiomyomas and cancers, and must be repeated for more than 2 years after UAE to monitor patients' progress. Longer follow-up and more events are needed to define risk factors for recurrence.

Uterine Artery Embolization for the Treatment of Symptomatic Uterine Fibroids Early Experience in Hamad Medical Corporation and a Review of the Literature

Uterine artery embolisation has been introduced recently as an alternative treatment for fibroids. The purpose of this study was to evaluate the initial results of uterine artery embolisation in the treatment of symptomatic muterine leiomyomata in HMC and review the data from the literature.

On the basis of clinical and ultrasonographic examinations, four women aged between 35 to 44 years with severe fibroid-related menorrhagia were referred for uterine artery embolisation. In allfour cases bilateral embolisation of the uterine arteries was carried out using particles of polyvinyl alcohol (Ivalon, 500-750jum) under local anaesthesia and fluoroscopy I digital subtraction angiography control. Complete occlusion of the arteries supplying the fibroids was achieved resulting in restoration of normal menstrual bleeding. Three patients did not develop any complications, except short post-embolisation discomfort lasting only a few hours. In one case with large fibroids, a post-embolisation syndrome (abdominal pain, sweating, vomiting and increased blood pressure) lasting 48 hours was observed. All the patients expressed satisfaction with the treatment.

Data from the literature indicate that uterine artery embolisation has gained wide acceptance in the treatment of symptomatic uterine fibroids, particularly in patients wishing to avoid total hysterectomy or blood transfusion, although hysteroscopic resection, myolysis and laparoscopic myomectomy remain alternative methods of treatment.

Factors affecting early surgical intervention after uterine artery embolization

Uterine artery embolization (UAE) is an effective technique for the management of uterine myoma. However, complications of this procedure can be serious, including uterine infection and bowel necrosis in conjunction with necrosis of subserous or pedunculated myomas. Treatment failure is more likely to occur in the presence of submucosal myoma associated with a uterine infection or a large myoma of more than 8 cm. Accordingly, patients whose primary symptoms include submucosal myoma and menorrhagia are best treated with a hysteroscopic myomectomy or hysterectomy. The role of the gynecologist is crucial for most effective management and safe use of uterine artery embolization.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader will be able to list the complications of uterine artery embolization for fibroids, to describe postembolization syndrome, and identify the myomas that are more likely to fail uterine artery embolization.