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23 Embolization of Bone Tumors 229
Suggested Readings
1. Huddleston JR, Johnson SP. Embolization of painful neoplasms. In Ray CE Jr (ed), Pain
Management in Interventional Radiology: New York, NY, Cambridge University Press, 2008,
pp.199–216.
2. Liapi E, Geschwind JF. Transcatheter and ablative therapeutic approaches for solid malignancies. J Clin Oncol 2007;25(8):978–986.
3. Tegtmeyer CJ, Spinosa DJ, Matsumoto AH. Angiography of bones, joints, and soft tissues. In
Baum S (ed), Abrams’ Angiography: Boston, Little Brown and Company, 1997, pp.1813–1820.
Chapter 24
Uterine Fibroid Embolization
Sriharsha Athreya and Jon G. Moss
Clinical Features
• Uterine leimyoma (fibroids) are the most common benign tumor i n the female
pelvis.
• Heavy menstrual bleeding (HMB), pelvic pain, and pressure are the most
common symptoms.
• There is an association with infertility and early pregnancy loss.
Diagnostic Evaluation
Before undergoing uterine artery embolization (UAE), the patient should be seen by
a gynecologist and an interventional radiologist.
Gynecologic Examination
• Appropriate measures taken before UAE to exclude cervical cancer, endometrial
carcinoma, or endometrial hyperplasia as a cause of bleeding.
• Pregnancy test to exclude pregnancy.
Laboratory
• Full blood count—to screen for anemia.
• Coagulation screen—optional but essential if any history of liver disease or
anticoagulant therapy.
• Renal function—serum creatinine.
• Hormone profile —optional, may be useful as a baseline indicator of pituitary–
ovarian function.
Imaging: pre-procedure imaging (Figs. 24.1a and 24.2a) is essential to
• Confirm diagnosis of fibroids
• Assess the size, location, and number of fibroids
Transcatheter Embolization and Therapy,
Techniques in Interventional Radiology, DOI 10.1007/978-1-84800-897-7_24,
C
Springer-Verlag London Limited 2010
231
232 S. Athreya and J.G. Moss
• Assess vascularity
• Detect other pathology, e.g., adenomyosis
Note that no imaging can reliably differentiate leiomyosarcoma from leiomyoma.
Contrast-enhanced MRI (CEMRI): CEMRI is the imaging modality of choice.
CEMRI
• Characterizes fibroids better than ultrasound.
• Enhancement reflects vascularity (Figs. 24.1b and 24.2b ).
Fig. 24.1 (a) Pre-UAE T1 sagittal showing a large intramural fibroid (arrows). (b) Pre-UAE T1
sagittal post-gadolinium showing enhancement of the fibroid (arrows). (c) Post-UAE T1 sagittal showing the fibroid to have completely involuted. (d) Post-UAE T1 sagittal post-gadolinium
showing complete fibroid involution with no enhancement
24 Uterine Fibroid Embolization 233
a
c
b
d
Fig. 24.2 (a) Pre-UAE T1 sagittal showing a large intramural fibroid (arrowheads). (b) Pre-UAE
T1 sagittal post-gadolinium showing enhancement of the fibroid (arrowheads). (c)Post-UAET1
sagittal showing the fibroid (arrowheads). (d) Post-UAE T1 sagittal post-gadolinium showing
partial enhancement and incomplete fibroid involution (arrowheads)
• Devascularization demonstrates fibroid infarction (Figs. 24.1d and 24.2d).
• Is excellent for establishing anatomical location.
• Is good for detecting adenomyosis.
Pelvic ultrasound (US): US is readily available and cheap but is operator
dependent. Compared to CEMRI ultrasound is
• Less able to provide anatomical definition
234 S. Athreya and J.G. Moss
• Poor at detecting adenomyosis
• Less able to assess vascularity
Transvaginal Ultrasound (TVUS)
• Easily available, cheap
• Slightly intrusive examination for some women
• Less good for large-volume uterus and multiple fibroids
Indications
These include the following:
• Symptomatic leimyoma—asymptomatic fibroids are common and require no
treatment.
• Patient prefers a minimally invasive intervention to surgery.
• Patient wishes to conserve uterus for either fertility or cultural reasons.
• Not suitable for or unwilling to have a myomectomy.
Contraindications
Absolute
• Recent or ongoing pelvic infection.
• Diagnosis of fibroids is in doubt.
• Post-radiotherapy to pelvis—risk of tissue necrosis with embolization.
• General contraindications to angiography such as uncorrectable coagulopathy,
severe iodinated contrast allergy.
Relative
• Pedunculated and intraligamentous fibroids—risk of peritoneal adhesions following UAE.
• Fibroids extending into the endometrial canal. This may lead to fibroid expulsion
into the endometrial canal, leading to cervical os obstruction.
• Concomitant adenomyosis—controversial area. Adenomyosis can respond to
UAE but less well than fibroids.
• Wishing to preserve fertility and is suitable for a myomectomy—some weak
evidence of superior reproductive outcomes with myomectomy.
• Renal insufficiency.
24 Uterine Fibroid Embolization 235
Normal Anatomy
• The uterine arteries typically arise from the anterior division of the internal iliac
artery.
Aberrant Anatomy
Collateral supply can arise from the following:
• Ovarian arteries
• Lumbar arteries
• External iliac arteries (rarely)
• Artery of the round ligament
Pre-treatment Patient Information
It is advisable to have an initial consultation in a clinic environment (ideally a
radiology clinic) to explain the following:
• The procedure, complications, and expectations
• Alternatives to UAE
• Periprocedural medication, pain relief
• Post-embolization syndrome symptoms
• Follow-up regime
Equipment
• Non-selective catheters: Pigtail catheter for flush aortogram to assess the arterial
supply in recurrent embolization procedures. Aortagrams are not typically needed
for all UAE procedures.
• Selective catheters: personal preference is important. 5Fr hydrophilic cobra
(Terumo, Europe), 5Fr Vanschie 1,11,111 catheters (COOK, Europe), and occasionally other shapes may be useful.
• Microcatheters for selective embolization are useful to prevent arterial spasm
and are becoming increasingly standard.
Embolic Agents
• Variety of embolic agents, with little evidence to support one over the other. Poly
vinyl alcohol (PVA) (Cook, Europe), Beadblock (Terumo, Europe), Embospheres
(BVM Medical, UK), Gelatin sponge (Johnson & Johnson, Europe). Commonest
size used is in the range 500–700 μ. 700–1000 μ size is often used with the newer
236 S. Athreya and J.G. Moss
agents. Larger agents are also useful following initial embolization with smaller
particles, e.g., after 3–4 units of 500–700 size.
• Coils should not be employed as they do not provide distal embolization and
prevent repeat embolization.
Medication
Uterine artery embolization is itself not a painful procedure but post-embolization
pain is almost universal and requires active management.
• Pain control: adequate pain relief is a must during the pre-, peri-, and post-UAE
period. Usually a combination of non-steroidal anti-inflammatory analgesia and
opioids are needed. Some centers use patient-controlled analgesia. It may be
helpful to establish a pain-control protocol involving the anesthetic department.
• Sedation: a short-acting benzodiapine such as midozolam is administered intra-
venously. An intraprocedural short-acting narcotic such as fentanyl is typically
used in conjunction with a benzodiazepine.
• Infection control: broad spectrum antibiotics are administered in many centers,
though there is no good evidence to support their use.
• Sickness control: antiemetics should be routinely administered.
Procedure
Access
• Almost always the femoral artery.
• Bilateral femoral arterial approach is employed in some centers. Requires two
operators and it probably reduces the radiation dose if the procedure is performed
simultaneously.
Angiography
Low-dose pulsed fluoroscopy should be used whenever possible. Angiographic runs
should also be limited in order to reduce radiation dose. The uterine artery is usually
hypertrophied and easy to recognize (Fig. 24.3).
• Following femoral arterial access, the contralateral iliac artery is selected.
• Using a contralateral oblique projection, road map, the internal iliac artery is
selected.
• Using an ipsilateral oblique, the anterior division of the internal iliac artery is
selected.
24 Uterine Fibroid Embolization 237
Fig. 24.3 Left internal iliac artery angiogram showing an enlarged and tortuous left uterine artery
(arrows)
• A microcatheter is then used to access the uterine artery. This helps prevent spasm
and allows effective free flow directed embolization
• The uterine artery is embolized to an angiographic end point (see below).
• The procedure is then repeated on the ipsilateral uterine artery—it is essential to
embolize both sides to produce satisfactory infarction.
Flush aortography is usually not required but can be helpful in patients with
abnormal arterial anatomy and in patients undergoing repeat UAE, to identify any
non-uterine blood supply.
Angiographic Appearance
• The uterine arteries are usually hypertrophied, tortuous, and laterally displaced.
A hypervascular delayed phase is also visualized.
The angiographic end point: the exact end point of embolization remains
controversial. Commonly employed end points are as follows:
• Complete stasis over either five or ten cardiac beats.
• Complete stasis with reflux back along the angiographic catheter.
238 S. Athreya and J.G. Moss
• A “pruned-tree” appearance with maintained forward flow in the main uterine
artery.
Re-embolization of Uterine Artery
• Useful option in patients with persistent or recurrent symptoms who do not wish
surgery.
• A CEMRI should be done first to confirm either incomplete i nfarction or new
fibroid formation.
• If the ovarian arteries are to be embolized, then the risk of ovarian failure must
be discussed with the patient in advance.
Arterial Puncture Site
• Manual compression is adequate and a closure device is not usually required.
Post-embolization Syndrome
• Almost inevitable following UAE.
• Ensure that the patient and ward staff are appropriately briefed and aware that it
can be treated effectively.
• Treatment is supportive and consists of fluids, analgesia, and anti-inflammatory
medication (see chapter on post-embolization syndrome).
Follow-Up
• Follow-up is essential and, a local post-procedure protocol agreed and written
down.
• A common protocol is 1, 6, and 12 monthly clinical assessment.
• Repeat imaging within first 6 months is highly desirable; CEMRI is the ideal
imaging modality.
Treatment Failures
• 20–25% at 2–5 years.
• Usually due to incomplete fibroid infarction or rarely new fibroid formation.
• Best assessed with CE MRI.
• Treatment options for initial failures include myomectomy, hysterectomy, and
repeat UAE.
24 Uterine Fibroid Embolization 239
Specific Complications
Immediate—occurring during the procedure or in first few days.
• Groin hematoma, arterial dissection, pseudoaneurysm formation.
• Non-target embolization typically to the other pelvic organs. Should not occur
with good technique.
Early (first 30 days)
• Post-embolization syndrome—flu-like symptoms, with pain, nausea, and fever.
Raised white cell count and inflammatory markers.
Late (after first 30 days)
• Infection: may present with non-specific flu-like symptoms, fever, purulent
discharge. Requires prompt investigation and may necessitate hysterectomy.
Infection should be considered in cases where post-embolization syndrome
persists beyond 10 days.
• Vaginal discharge.
• Fibroid expulsion: in up to 10% (more common with submucosal fibroids).
• Ovarian failure leading to amenorrhea.
• Endometritis: treated with antibiotics and usually responds well. Occasionally
hysterectomy is required.
• Ischemic vaginal or uterine damage.
• Sexual dysfunction—may be due to embolization of the cervicovaginal arterial
branches.
Suggested Reading
1. Edwards RD, Moss JG, Lumsden MA, Wu O Murray LS, Twaddle S, Murray GD. Committee
of the Randomised Trial of Embolisation versus Surgical Treatment of Fibroids. Uterine artery
embolisation versus surgery for symptomatic fibroids. NEJM 2007;356:360–70
2. Dutton S, Hirst A, McPherson K, Nicholson T, Maresh M. A UK multicentre retrospective
cohort study comparing hysterectomy and uterine artery embolisation for the treatment of
symptomatic uterine fibroids (HOPEFUL study): main results on medium-term safety and
efficacy. BJOG 2007;114: 1340–51.
3. Pelage J-P, Cazejust J, Pluot E, Le Dref O, Laurent A, Spies JB, Chagnon S, Lacombe P.
Uterine Fibroid Vascularization and Clinical Relevance to Uterine Fibroid Embolization.
RadioGraphics 2005;25(Special Issue): S99–117
Appendix
UAE—uterine artery embolization
INR—international normalized ratio
PVA—poly vinyl alcohol
CE MRI—contrast-enhanced magnetic resonance imaging
USS—ultrasonography