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Uterine Artery Embolization
Jennifer Greenman, HMS IIIGillian Lieberman, MD
Jennifer Greenman HMS IIIGillian Lieberman, MD
Our Patient : Mrs. L
37 year old African American woman presented with complaints of worsening abdominal cramping, dysmenorrhea, menorrhagia, and intermittent constipation
5 year history of uterine fibroids
Gynecologist noted progressive enlargement of a single intramural uterine fibroid; physical exam was remarkable for a tender, 20-week-size uterus w/o pregnancy
Recent Pap smear and endometrial biopsies WNL
After a trial of aspirin failed to alleviate her symptoms, Mrs. L consulted IR for potential bilateral Uterine Artery Embolization (UAE) therapy
Jennifer Greenman HMS IIIGillian Lieberman, MD
Uterine Fibroids (leiomyomas)
Benign tumors arising from uterine smooth muscle
Unknown etiology: hormone dysregulation and genetic factors likely contributory
High prevalence of asymptomatic patients clouds true incidence; estimates generally range from 20 to 50% of women of child-bearing age, making uterine fibroids the most common solid tumor of the genital tract in women
Risk factors include a positive family history, nulliparity, and obesity
Elevated frequency in Afro-Caribbean women
Jennifer Greenman HMS IIIGillian Lieberman, MD
Fibroid Classification by Location
Jennifer Greenman HMS IIIGillian Lieberman, MD
• Submucosal: bulge into the endometrial cavity; most often associated with heavy menstrual bleeding and infertility
• Intramural: within the muscular wall of the uterus and surrounded by normal uterine tissue; fewest associated symptoms
• Subserousal: develop in the serosa; pedunculated subtype may torse and cause pain
www.ufeinfo.com
Symptoms
Uterovaginal bleeding
Menorrhagia and/or refractory anemia
Feelings of abdominal pressure, discomfort, or pain
Constipation
Urinary disturbances
Dyspareunia
Lower back pain
Jennifer Greenman HMS IIIGillian Lieberman, MD
Symptoms (cont.)
Symptoms are related to the position, size, and direction of tumor growth:
Submucosal fibroids may increase the endometrial surface, resulting in a larger bleeding area
Subserous and intramural tumors may predominantly disturb uterine contractility
Jennifer Greenman HMS IIIGillian Lieberman, MD
Symptoms (cont.)Symptoms are related to the position, size, and direction of tumor growth:
Mass effect may contribute to abdominal pain and pressure, urinary disturbances, constipation, and lower back pain
Jennifer Greenman HMS IIIGillian Lieberman, MD
FibroidUterus
Uterus
Example fig 1: Sagittal T2-weighted MR : Normal Uterus
Example fig 2: Sagittal T2-weighted MR : Pedunculated subserous fibroid compressing adjacent structures
http://www.rad.pulmonary.ubc.ca http://www.rad.pulmonary.ubc.ca
Treatment Options
Medical management• Androgens: induce endometrial atrophy
• Progestins: induce endometrial atrophy
• Hormone-suppressive therapy (GnRH agonists): hypoestrogenic state causes fibroid shrinkage
Surgery• Hysterectomy
• Myomectomy (open or laproscopic)
Myolysis
MR-guided focused ultrasound
Watchful-waiting (peri-menopausal)
Jennifer Greenman HMS IIIGillian Lieberman, MD
An Alternative: Uterine Artery Embolization
UAE is a minimally invasive alternative that involves placement of a catheter and injection of an embolizing agent. Its goal is to induce ischemic infarction of the fibroids, while maintaining endometrial and myometrial perfusion.
Jennifer Greenman HMS IIIGillian Lieberman, MD
www.drfibroid.com/fibroids.htm www.crlsurgical.com
Uterine Artery Detail
Characteristic UA course (left):• Initial descending segment (D)• Transverse segment (T) from which the
cervicovaginal artery (CV) originates• Ascending segment (A)• Numerous intramural arteries (arrows) are also
visible
Jennifer Greenman HMS IIIGillian Lieberman, MD
Fibroid
Digital subtraction angiogram (selective left uterine artery injection)
Example figure 3: Uterine artery detail
Pelage et al, 2005.
UAE capitalizes on fibroid vasculature. Typically, the fibroid-supplying arteries branch from the normal uterine arteries. Fibroid vascularization is characterized by increased inflow into numerous irregular intramural vessels and vascular lacunae, very distinct from the low-flow perfusion of the normal myometrium. The increased flow to the fibroids can therefore be used for directed free-flow embolization. For this purpose, it’s typically sufficient to direct the catheter tip into the distal transverse or proximal ascending portion of the uterine artery.
UAE Indications
Symptomatic uterine fibroids verified by US or MRI
Practitioner and patient preference for UAE over other medical or surgical therapies, following detailed discussion of procedural risks, benefits, and alternatives
Recurrent fibroids post-surgical therapies
Conditions contra-indicating surgery
Jennifer Greenman HMS IIIGillian Lieberman, MD
UAE Contra-Indications
Absolute• Asymptomatic fibroids• Infection of UG tract• Septicemia• Pregnancy• Fast growing tumors (suspected
malignancy)• Refusal to undergo hysterectomy
following peri- or post- UEA complications
Relative• Pedunculated or very large
fibroids extending beyond the umbilicus
• Fibroids with irregular bleeding
• Co-existent adenomyosis
• Desire of future pregnancy
• Mild allergy to contrast medium
Jennifer Greenman HMS IIIGillian Lieberman, MD
Differential Diagnosis
Pregnancy
Malignant neoplasm• Uterine
• Ovarian
Adenomyosis
Endometriosis
Cystic mass
Uterine abscess
Jennifer Greenman HMS IIIGillian Lieberman, MD
Pre-Procedural Imaging: US
Most common imaging tool
Fibroids: heterogeneic echogenicity; hypoechoic compared to normal myometrium
Doppler US specifically assesses fibroid and uterine vascularity and flow patterns
Exclusion of associated pathological conditions
• Adenomyosis
• Adenexal masses
• Endometrial carcinoma
Jennifer Greenman HMS IIIGillian Lieberman, MD
Pre-Procedural Imaging: US
Jennifer Greenman HMS IIIGillian Lieberman, MD
Mrs. L
Sagittal US PACS, BIDMC
Fibroid
Pre-Procedural Imaging: MRI
Precise anatomical identification
• Size
• Number
• Uterine tissue layer localization
• Arterial anatomy
Prediction of fibroid response to embolization• Increased signal intensity on T2-weighted images pre-
UAE is usually associated with a considerable reduction in fibroid size post-UAE
Jennifer Greenman HMS IIIGillian Lieberman, MD
Pre-Procedural Imaging: MRI
Jennifer Greenman HMS IIIGillian Lieberman, MD
PACS, BIDMC
Fibroid
Mrs. L: T2-weighted MRI
Coronal
Pre-Procedural Imaging: MRI
Jennifer Greenman HMS IIIGillian Lieberman, MD
PACS, BIDMC
Fibroid
Mrs. L: T2-weighted MRI
Sagittal
Pre-Procedural Imaging: MRI
Jennifer Greenman HMS IIIGillian Lieberman, MD
PACS, BIDMC
Fibroid
Mrs. L: T2-weighted MRI
Axial
Angiography: VasculatureJennifer Greenman HMS IIIGillian Lieberman, MD
Uterine Artery
Common Iliac
Internal Iliac
External Iliac
PACS, BIDMCMrs. L: Flush pelvic aortogram 1
Prior to embolization abdominal angiography was performed to obtain an arterial road map that was used to avoid aberrant vessel embolization during the subsequent procedure. Vascular anomalies, additional vaginal or hypograstric arteries, and major anastomoses between uterine and ovarian arteries were not observed. Dilated, tortuous uterine arteries were identified (first branches off the internal iliac arteries).
Angiography: VasculatureJennifer Greenman HMS IIIGillian Lieberman, MD
PACS, BIDMC
Fibroid
Mrs. L: Flush pelvic aortogram 2
Angiography: VasculatureJennifer Greenman HMS IIIGillian Lieberman, MD
PACS, BIDMC
Fibroid
Mrs. L: Flush pelvic aortogram 3
Procedure
Jennifer Greenman HMS IIIGillian Lieberman, MD
The abdominal aortogram (previous 3 slides) demonstrated a patent, normal infrarenal aorta and patent renal, common, internal and external iliac arteries bilaterally. No obvious antegrade opacification of the uterine arteries was noted.
A left uterine artery arteriogram was then performed, demonstrating a dilated and tortuous left uterine artery supplying the fibroid. Based on these diagnostic findings, a left UAE was performed using 500-700 micrometer Embospheres, and embolization was continued until there was stagnant flow in the left uterine artery (slides 24-26).
The micro-catheter was next positioned in the right uterine artery and a similar embolization was performed. Again, embolization was continued until stagnant flow was observed in the right uterine artery (slides 27-30).
A follow-up abdominal aortogram demonstrated patency of bilateral internal iliac arteries and no further perfusion of the fibroid (slides 31-33).
Mrs. L tolerated the procedure well and no immediate complications were documented. Moderate sedation was provided throughout the total intraservice time of 3 hours, during which Mrs. L’s hemodynamic parameters were monitored continuously.
Left UAE
Jennifer Greenman HMS IIIGillian Lieberman, MD
PACS, BIDMCMrs. L: Digital subtraction angiogram:Selective injection of L uterine artery
Left UAE
Jennifer Greenman HMS IIIGillian Lieberman, MD
PACS, BIDMCMrs. L: Digital subtraction angiogram:Selective injection of L uterine artery
Left UAE
Jennifer Greenman HMS IIIGillian Lieberman, MD
Fibroid
PACS, BIDMCMrs. L: Digital subtraction angiogram:Selective injection of L uterine artery
Right UAEJennifer Greenman HMS IIIGillian Lieberman, MD
PACS, BIDMCMrs. L: Digital subtraction angiogram:Selective injection of R uterine artery
Right UAEJennifer Greenman HMS IIIGillian Lieberman, MD
PACS, BIDMCMrs. L: Digital subtraction angiogram:Selective injection of R uterine artery
Right UAEJennifer Greenman HMS IIIGillian Lieberman, MD
PACS, BIDMCMrs. L: Digital subtraction angiogram:Selective injection of R uterine artery
Right UAEJennifer Greenman HMS IIIGillian Lieberman, MD
Fibroid
PACS, BIDMCMrs. L: Digital subtraction angiogram:Selective injection of R uterine artery
Post-UAE
Jennifer Greenman HMS IIIGillian Lieberman, MD
PACS, BIDMCMrs. L
Post-UAEJennifer Greenman HMS IIIGillian Lieberman, MD
PACS, BIDMCMrs. L
Post-UAEJennifer Greenman HMS IIIGillian Lieberman, MD
PACS, BIDMCMrs. L
Pre-UAE Lack of fibroid enhancement
PACS, BIDMC
Clinical Outcome
Jennifer Greenman HMS IIIGillian Lieberman, MD
Companion Patient 1:Sagittal T2-weighted MRI: pre-UAE
Pelage et al, 2005. Pelage et al, 2005.
F
F
F
F : Fibroid
Well-perfused myometrium
Infarcted
Mrs. L was the most recent patient to receive UAE at our hospital. Thus, her longer-term clinical outcome can not yet be assessed. However, we might expect her fibroids to first show infarction and then, to begin shrinking in size. MRI can accurately demonstrate tumor infarction just 24 hrs post-UAE. The companion patient below well exemplifies this.
Companion Patient 1:Sagittal T2-weighted MRI: 24 hr post-UAE
Six Months Post-UAE
Jennifer Greenman HMS IIIGillian Lieberman, MD
Companion Patient 2Sagittal T2 MRI : pre-UAE
Urinary bladderVaginaRectum
Hel
mbe
rger
al, 2
005.
Mrs. L was the most recent patient to receive UAE at our hospital. Thus, her longer-term clinical outcome can not yet be assessed. However, we might expect her fibroids to shrink significantly in size by 6 months post- UAE, as exemplified by this companion patient (right).
Companion Patient 2Sagittal T2 MRI : 6 months post-UAE
Six Months Post-UAE
Jennifer Greenman HMS IIIGillian Lieberman, MD
Companion Patient 2
Urinary bladder
Hel
mbe
rger
al, 2
005.
Companion Patient 2Coronal T2 MRI : pre-UAE
Companion Patient 2Coronal T2 MRI : 6 months post-UAE
Six Months Post-UAE
Jennifer Greenman HMS IIIGillian Lieberman, MD
Companion Patient 2
Urinary bladder
Hel
mbe
rger
al, 2
005.
Companion Patient 2Axial T2 MRI : pre-UAE
Companion Patient 2Axial T2 MRI : 6 months post-UAE
Clinical Outcome
Procedure shows high technical success rate, ranging between 81 and 91%
Symptoms of menorrhagia, dysmenorrhea, pelvic pressure, and/or urinary urgency are controlled in 73-97% of patients
Reduction in fibroid size: 42-83%
Reduction in uterine size: 43-58%
> 90% patients are satisfied with procedure and report a significantly improved quality of life
Preserved fertility
Shorter recovery time than surgery
Jennifer Greenman HMS IIIGillian Lieberman, MD
Potential Complications Angiography Complications
• Haematoma in the pelvis
• Contrast medium reaction
• Dissection of internal iliac or uterine artery
• Rupture of vesicle artery branch
Post-embolization syndrome prolonged hospitalization
Pelvic Infection
Ischemic phenomena• Severe, prolonged pelvic pain
• Transient or permanent amenorrhea
• Sexual dysfunction related to nontarget embolization (cervicovaginal branch)
• Embolization of nontarget organs (bowel, bladder, buttock, nerves)
Adverse drug reaction
Pulmonary embolism
Jennifer Greenman HMS IIIGillian Lieberman, MD
Treatment Comparison
Jennifer Greenman HMS IIIGillian Lieberman, MD
Hysterectomy Myomectomy UAE
Overall morbidity 40% 39% 5%
Febrile morbidity 26% 33% 2%
Readmission 2.5% 1.5% 3.5%
Unintended operative procedure 9.6% 4.5% 2.5%
Life-threatening event 1.0% 1.5% 0.5%
Sawin et al, 2000.
Conclusions
Uterine fibroids are a common condition in women and often cause symptoms that negatively impact quality of life
UAE is a safe, well-tolerated, and an effective alternative treatment for symptomatic uterine fibroids
UAE is a reasonable option for women who wish to preserve their uterus and avoid surgery and a prolonged recovery period
UAE has low complication rates with excellent clinical outcomes and high patient satisfaction rates
Jennifer Greenman HMS IIIGillian Lieberman, MD
Future Considerations
Continued effort to reduce radiation exposure
Effect on pregnancy
Long-term effect of embolic agents
Recurrence rate reduction
Jennifer Greenman HMS IIIGillian Lieberman, MD
References• Uterine artery embolization as a treatment option for uterine myomas.
Obstet Gynecol Clin North Am. 2006 Mar;33(1):125-44. Review.• The management of uterine leiomyomas.
J Obstet Gynaecol Can. 2003 May;25(5):396-418.• Uterine fibroid embolization: nonsurgical treatment for symptomatic fibroids.
J Am Coll Surg. 2001 Jan;192(1):95-105.• Uterine Fibroid Vascularization and Clinical Relevance to Uterine Fibroid Embolization. (Pelage et al.)
Radiographics. 2005 Oct;25 Suppl 1:S99-118. • Long-term follow up of uterine artery embolisation--an effective alternative in the treatment of fibroids.
BJOG. 2006 Apr;113(4):464-8.• Imaging manifestations of complications associated with uterine artery embolization.
Radiographics. 2005 Oct;25 Suppl 1:S119-32. • Uterine artery embolization of symptomatic uterine fibroida . Initial success and short-term results.
Acta Radiol. 2001 Mar;42(2):234-8.• Risk of intrauterine infectious complications after uterine artery embolization.
J Vasc Interv Radiol. 2004 Dec;15(12):1415-21.• Uterine fibroids: uterine artery embolization versus abdominal hysterectomy for treatment--a prospective, randomized, and
controlled clinical trial. Radiology. 2003 Feb; 226(2):425-31.
• Percutaneous uterine artery embolization for the treatment of symptomatic fibroids: current status.Eur J Radiol. 2005 Apr;54(1):136-47.
• Embolization of uterine fibroids (Helmberger). Abdom Imag. 2004 Nov; 29:267-277.
• Comparability of perioprative morbidity between abdominal myomectomy and hysterectomy for women with uterine leiomyomas.Am J Obstet Gyn. 183:1448-1455.
Jennifer Greenman HMS IIIGillian Lieberman, MD
Acknowledgments
Brian Callahan, MD
Gillian Lieberman, MD
Gordon Greenman, MD
Pamela Lepkowski
Larry Barbaras
Jennifer Greenman HMS IIIGillian Lieberman, MD