UTERINE FIBROID EMBOLIZATION FROM START TO FINISH Neil Shah, M.D. Samir Shah, M.D. Henry Dalsania, M.D. Bhumin Patel, M.D. Zachary Abramson, M.D. Baptist Memorial Hospital- Memphis Multicare Good Samaritan Hospital Division of Vascular and Interventional Radiology

FINANCIAL DISCLOSURES • 

Neil Shah, M.D. •  None

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Samir Shah, M.D. •  None

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Henry Dalsania, M.D. •  None

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Bhumin Patel, M.D. •  None

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Zachary Abramson, M.D. •  None

LITERATURE • 

Accepted by the American Congress of Obstetrics and Gynecology, Uterine Fibroid Embolization is an an established alternative to surgical hysterectomy 1.

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The results of the controversial EMMY Trial initially revealed overall complication rates2: •  Major Complication: 4.9% vs 2.7% in hysterectomy group •  Minor Complication from discharge – 6 weeks: 58% vs 40% in hysterectomy group

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5 year follow up of the EMMY Trial reported similar health related quality of life (HRQOL) and improved urinary symptoms and defecation function3.

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Another study revealed no significant differences between UFE and hysterectomy group with overall similar quality of life at 12 months 4. •  UFE was associated with significantly faster recovery while posting a 1 year major adverse event rate of 12% when compared to 20% in the hysterectomy arm. •  9% required repeat embolization or hysterectomy for inadequate symptom control.

Indications5.

I• 

Uterine Fibroids

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Minor

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Pelvic pain

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Contrast Allergy

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Menorrhagia.

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Coagulopathy

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GU/GI manifestations.

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Renal Failure

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Desire to remain fertile

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GnRH

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Prior Radiation

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Adenomyosis

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Postpartum Hemorrhage

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Uterine Artery Pseudoaneurysms

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Contraindications

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Absolute

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Hysterectomy

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Pregnancy

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Caesarean section

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Malignancy

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Active infection.

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Immunosuppression

Uterine AVM • 

Traumatic

CLINIC CONSULT Symptom Evaluation • 

Pain

Menstrual History6. • 

•  Characterization

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•  Chronicity •  Alleviation • 

Genitourinary Systems •  Dysuria •  Polyuria •  Constipation

Menorrhagia: Prolonged bleeding lasting longer than 7 days

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Length of cycle

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Number of heavy-flow days

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Frequency of Tampon/pad changes

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Dysmenorrhea

MR IMAGING • 

Examination Technique7.

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Location8:

•  Pelvic phased array coil

•  Subserosal- beneath serosa

•  4-6 hour preimaging fast: Decreases peristalsis

•  Intramural- within myometrium •  Submucosal: beneath mucosal lining

•  Sequences

•  Pedunculated : relative contraindication.

•  Orthogonal T2-W FSE •  Axial T1-W

•  Intracavitary Fibroids

•  With and without FS

•  Post embolization expulsion may lead to pain, cramping, or infection5.

•  Precontrast and Dynamic Post Contrast T1-W FS Gradient echo images •  Optional DWI with ADC.

•  Cervix • 

Enhancement

PROCEDURE • 

Commonly performed from bilateral femoral, unilateral femoral, or transradial approaches

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Embolization performed under live fluoroscopy with 500-700 micron calibrated microspheres

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Right common femoral artery access with placement of 5 French vascular sheath

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Periodic flushing with 1 ml 1% Lidocaine IA

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Reverse curve flush catheter (RCFC) placed in abdominal aorta and aortoiliac angiography performed

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RCFC used with 0.035” wire to select left common iliac artery

Completion DSA with endpoint reached when sluggish flow demonstrated in uterine artery and diminished vascularity to the uterine fibroids

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Microcatheter removed

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RCFC exchanged for 5 Fr angled glide catheter which is used to select left internal iliac artery

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Subselective angiography performed and microcatheter/microwire used to select uterine artery

Glidewire and left internal iliac angled glide catheter used to form Waltman loop in the abdominal aorta

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Looped glide catheter used to select right internal iliac artery and DSA performed

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DSA performed and microcatheter advanced beyond non-target branches in the horizontal segment

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Microcatheter used to select right uterine artery and DSA performed with subsequent embolization performed as on the left side

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DSA performed to reconfirm visualization of fibroids and lack of non-target extrauterine branches

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Equipment removed and right CFA hemostasis achieved

ANATOMY • 

Figure #1 demonstrates a right femoral access pelvic arteriogram in AP projection. The patient was a 38 year old female, who complained of menorrhagia and pelvic pain. MR imaging demonstrated a solitary intramural fibroid, measuring 5.6 x 6.3 x 6.3 cm and centered in the fundus.

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Anatomy

A

B

D

C

I E H J

Figure 1

G F

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A) Aorta

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B) Common Iliac Artery

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C) External Iliac Artery

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D) Internal Iliac Artery

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E) Common Femoral Artery

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F) Deep Femoral (Profunda) Artery

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G) Superficial Femoral Artery

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H) Uterine Artery

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I) Superior Gluteal Artery

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J) Obturator Artery

CASE CORRELATION 43 year-old white female with a history of 3 prior Cesarean sections. She presents to the clinic with menorrhagia, lower abdominal pressure, and cramping during menses. She reports monthly menses lasting approximately 7-8 days with heaviest days changing her tampons every 2-3 hours. Her symptoms have worsened over the past 2-3 years. She does not desire to maintain her fertility. MR Imaging demonstrates an enlarged uterus with a dominant enhancing intramural fibroid along the dorsal aspect of the uterine body, figure 2. Figure 3 demonstrates left radial approach aortogram with enlargement and tortuosity of the bilateral uterine arteries. A microcatheter was than used to cannulate the right uterine artery, figure 4. The large fibroid was visualized and 500-700 micron Embospheres were administered. Figure 5 demonstrates pruning of uterine artery branches and decreased flow.

Figure 2

Figure 5

Figure 3

Figure 4

ORDERS Preprocedure

Postprocedure

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Vital Signs

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Vital Signs and neuro checks

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Cardiac Monitor

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Monitor Puncture site

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Pulse ox

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Keep punctured extremity straight and immobile for 2 hours if closure device was used

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Foley Catheter

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NPO

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Keep supine

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Labs

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Remove Foley at midnight, Ambulate prior to DC

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Dilaudid PCA:

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PT/INR, CBC, CMP, B-hCG

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IVF: 0.9NS at 150-200 ml per hour

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Prophylaxis: • 

Rocephin 1G, Zosyn 3.375G, Ampicillin 2G, or Vancomycin 1G

6 hours if no closure device

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Bolus dosing 0.1-0.2 mg every 10 min with 10 min lockout.

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May consider 1mg/hour basal rate with increase to 2mg basal rate/hr and up to 0.4 mg dilaudid every 10 min.

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Toradol 30mg IV prior to procedure

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Ibuprofen 600 mg QID

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Sedation:

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Toradol 30mg IV q 6 hours

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Antiemetics: Zofran, Decadron, Ativan

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Versed and Fentanyl OR Anesthesia with MAC

Discharge Medications and Instructions •  • 

•  Levoquin 500 mg PO for 10 days Ibuprofen 600 mg PO q6 hours for 10 days PRN pain Oxycodone 5 mg PO, 1-2 tabs q 4-6 hours PRN pain •  Zofran 4 mg PO q8 hours PRN nausea •  Follow up in clinic in 1 week or if symptomatic •  Follow up MRI in 3 months.

COMPLICATIONS • 

Post Embolization Syndrome

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Incomplete Embolization

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Fibroid Regrowth

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Uterine infection

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•  Fever, Nausea, Emesis, Pain, and Malaise Pulmonary Embolism

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Uterine Necrosis

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Non-target embolization

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Uterine Artery Rupture/Dissection

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Minor Complications

•  Ovaries

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•  Labial necrosis9

•  Pain

•  Buttock Necrosis10

•  Hematoma

•  Lower Extremity

•  Access

Sexual Dysfunction

•  Pseudoaneurysm •  AV Fistula

REFERENCES 1. 

American College of Obstetricians and Gynecologists. ACOG practice bulletin: alternatives to hysterectomy in the management of leiomyomas. Obstet Gynecol 2008;112(2 pt 1):387–400.

2. 

Hehenkamp, W.J., Volkers, N.A., Donderwinkel, P.F. et al. Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids (EMMY trial): peri- and postprocedural results from a randomized controlled trial. Am J Obstet Gynecol. 2005; 193: 1618–1629

3. 

Van der Kooij, Sanne M. et al. Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 5-year outcome from the randomized EMMY trial. American Journal of Obstetrics & Gynecology , Volume 203 , Issue 2 , 105.e1 - 105.e13

4. 

REST Investigators. Uterine-Artery Embolization versus Surgery for Symptomatic Uterine Fibroids. N Engl J Med 2007; 356:360-370.

5. 

Stokes LS, Wallace MJ, Godwin RB, et al. Quality Improvement Guidelines For Uterine Artery Embolization for Symptomatiic Leiomyomas. J Vasc Interv Radiol. 2010 Aug;21(8):1153-63.

6. 

Bulman JC, Ascher SS, Spies JB. Current concepts in uterine fibroid embolization. RadioGraphics 2012; 32(6):1735–1750

7. 

ACR-SAR-SPR Practice Parameter for the Performance of Magnetic Resonance Imaging (MRI) of the Soft-Tissue Components of the Pelvis Res. 4-2015.

8. 

Kitamura Y, Ascher SM, Cooper C, et al. Imaging manifestations of complications associated with uterine artery embolization. RadioGraphics 2005; 25: S119-S132.

9. 

Yeagley TJ, Goldberg J, Klein TA, Bonn J. Labial Necrosis After Uterine Artery Embolization for Leiomyomata. Obstet Gynecol. 2002 Nov; 100(5 Pt 1):881-2.

10.  Dietz DM, Stahlfeld KR, Bansal SK, Christopherson WA. Buttock Necrosis After Uterine Artery Embolization. Obstet Gynecol. 2004 Nov; 104(5 Pt 2):1159-61.