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BackTable / VI / Topic / Procedure
Uterine Fibroid Embolization
Uterine fibroid embolization (UFE) procedure is for women with symptomatic uterine fibroids. UFE is a minimally invasive surgery that utilizes small particles for embolization of a woman's uterine fibroids (aka leiomyomata). This procedure was first reported in 1997 and since then has continued to gain acceptance as a safe and effective uterine-sparing procedure to control symptoms related to fibroids. Typically, both uterine arteries are catheterized and embolized to stasis or sub-stasis. However, variant anatomy can be present and should be considered for embolization in some patients. Often UFE and UAE (uterine artery embolization) are used interchangeably. However, UAE more broadly refers to embolization of the uterine arteries for indications outside of fibroids such as adenomyosis or postpartum hemorrhage. The technical components of a UFE procedure for fibroids are relatively straightforward. The pre and post uterine fibroid embolization procedure management contains a fair level of nuance and can vary widely between providers. The UFE procedure information & technique below may help shape a practice to be more effective and efficient.
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Pre-Procedure Prep
Background
• Fibroids (leiomyoma, myoma, fibromyoma, fibroleiomyoma)
• Benign smooth muscle tumor
• Most common benign pelvic neoplasm
• 50% of patients with fibroids have symptoms
Transjugular Liver Biopsy Indications
• Symptomatic uterine fibroids in patients who would like to avoid surgery
Menorrhagia (most common)
Adenomyosis
Bulk symptoms
• Pelvic pain
• Pelvic pressure
• Urinary frequency
• Constipation
Contraindications
• Asymptomatic fibroids
• Pregnancy
• Pelvic malignancy suspected
• Uncorrectable bleeding diathesis
• Severe renal insufficiency
• Prior pelvic radiatio
Other Considerations:
• Size of fibroids or uterus is not contraindication
• Stalk size not a contraindication although pedunculated subserosal fibroids do not respond as well and are often good candidates for myomectomy
• IUD: may not be necessary to remove
Pre-Procedural Workup
• H&P with specifics regarding bleeding cycle and/or bulk symptoms
• Pap smear
• Consider endometrial biopsy for vaginal bleeding > 21 days or bleeding lasting longer than 10 days
• MRI before clinic visit although some operators will use ultrasound exclusively
• Submucosal fibroids deserve attention and patient education on risk of potential fibroid expulsion, infection or need for surgery
• Desire to preserve future fertility
Uterine Fibroid Embolization Podcasts
Listen to leading physicians discuss uterine fibroid embolization on the BackTable VI Podcast. Get tips, tricks, and expert guidance from your peers and level up your practice.
Episode #367
In this episode, host Dr. Aaron Fritts interviews Dr. Aaron Kovaleski on good old-fashioned TV and radio marketing. Aaron is an interventional radiologist and founder of Endovascular Consultants of Colorado, who has found success in using tried and true methods of advertising to grow his practice.
Episode #262
On this episode, BackTable VI host Dr. Christopher Beck shares the mic with two Maternal Fetal Medicine (MFM) specialists, Drs. Roxane Rampersad at Washington University and Tony Shanks at Indiana University, to discuss cross-specialty management of postpartum hemorrhage (PPH) between OBGYN and interventional radiology (IR).
Episode #217
Dr. Merve Ozen, interventional radiologist, and Dr. Mark Hoffman, minimally invasive gynecologic surgeon (MIGS), discuss how collaboration between IR and gynecologic surgery provides comprehensive medical, surgical, and interventional treatment options for women suffering from uterine fibroids, pelvic congestion syndrome and other causes of chronic pelvic pain.
Episode #192
In this episode we talk with Dr. John Lipman about his journey to going solo and opening an Outpatient Based Lab (OBL) dedicated to minimally invasive women's interventions, including Uterine Fibroid Embolization (UFE). John also gives us advice on the importance of finding your Ikigai in practice, the secret to a long and happy career!
UFE Procedure
Pre-Procedural Medications
Antibiotics
• Routine prophylaxis recommended but no consensus on drug choice
• 1g Cefazolin (Ancef) IV
Pain control: 10 mg Dexamethasone 1 hour prior to procedure
Scopolamine patch for antiemetic
Intraprocedural Pain Control
• Fentanyl and versed
• Ketorolac (Toradol) 30 mg IV - administer after first uterine artery embolized
• Acetaminophen 1000 mg IV - administer after second uterine artery embolized
• Can give at many time points before, during or after UFE
Anatomy
• Uterine artery arises at 1st or 2nd branch from anterior division of internal iliac artery - best seen in contralateral oblique (~50%)
• UA may arise as trifurcation of UA, anterior division and posterior division - best seen ipsilateral oblique (~40%)
• Absent UA (1%) - look for ovarian supply
• Aberrant vascular supply: round ligament artery, internal pudendal, IMA
Access
• Femoral or bilateral femoral access
• Radial
Select Uterine Artery
• Select internal iliac artery, preferably anterior division
• Contralateral or ipsilateral oblique: ovarian take-off can be seen best in either obliquity (contralateral oblique slightly more common). Puff contrast to identify take-off before DSA
• If uterine artery large enough, can catheterize directly with 4 or 5 Fr hydrophilic coated catheter
• Often, uterine artery catheterized with microcatheter: spasm less an issue and can bypass non-uterine branches
• Position microcatheter in horizontal segment of uterine artery - attempt to bypass cervicovaginal branch
• Obtain DSA in AP projection
Selecting the internal iliac artery ipsilateral to groin access
• Not an issue with radial access
• Not really an issue with femoral access
• Sos catheter - can pull catheter directly into internal iliac artery
• Waltman loop
• Roberts uterine catheter (RUC)
Embolize Uterine Artery
• Embolize to sub-stasis
• Pruned-tree appearance on DSA with sluggish flow in uterine artery for 5 or more cardiac beats
Embolic agent choice:
Background:
• Diameter of perifibroid plexus 500-800 μm - target for embolization
• Utero-ovarian anastomosis < 500 μm - avoid embolizing
Data supports:
• Particulate PVA - both 355-500 and 500-710 μm
• Embospheres 500-700 μm
• Embozene 700 μm
Following Embolization
• Administer 5 -10 ml (50-100 mg) of preservative free 1% lidocaine
• Remove microcatheter
• Consider flush aortogram to evaluate for ovarian supply to fibroids
• Remove sheath
Uterine Fibroid Embolization Articles
Read our exclusive BackTable VI Articles for quick insights on uterine fibroid embolization, provided by physicians for physicians.
Endovascular approaches for fibroid treatment have gained traction as increasing evidence supports its use in most patient populations. In episode 10 of the BackTable podcast, Dr. Keith Pereira and Dr. Chris Beck discuss marketing strategies and ways to increase referrals when building a UFE practice.
Post Uterine Fibroid Embolization Procedure
Post-Procedural Care
Concept: multimodal therapy is more effective than increased amounts of narcotics
• Some admit overnight with dilaudid PCA
• IV hydration
• Antiemetics: 4-8 mg Zofran IV
• PO and IV pain control
• 15-30 mg IV Toradol Q 6-8 hours
Many patients can be discharged same day
Discharge Medications
• Oxycontin extended release 10 mg. 1 tab BID PO x 3 days
• Ibuprofen 800 mg PO Q8 hours x 3 days
• Percocet PRN
• Zofran 4 mg tabs PO Q6 hours PRN nausea
• Laxative: docusate (Colace) and senna (Senokot) both over-the-counter
Follow-Up
• Patient education: needs to be alert for fever, chills, foul smelling discharge, increasing pain, which may indicate uterine infection.
• Phone call or clinic visit at 1 month
• Clinic visit 6 month
• MRI for troubleshooting issues such as signs of infection, fibroid expulsion, persistent vaginal discharge or incomplete resolution of symptoms
Uterine Fibroid Embolization Complications
• Amenorrhea
• Prolonged vaginal discharge
• Fibroid expulsion: usually occurs within first 6 months
• Septicemia
• Pulmonary embolism
• Ovarian failure and premature menopause
• Postembolization syndrome: common
Outcomes
• Approximately 50% reduction in fibroid size
• Approximately 50% reduction in uterine size
• > 90% reduction in abnormal uterine bleeding and bulk symptoms
• On 5 year follow-up: Re-intervention rate: 26%
Important Trials:
• REST trial
• EMMY trial
Uterine Fibroid Embolization Demos
Watch video walkthroughs of uterine fibroid embolization on the BackTable VI expanded content network.
References
[1] Chehab MA, Thakor AS, Tulin-Silver S, et al. Adult and Pediatric Antibiotic Prophylaxis during Vascular and IR Procedures: A Society of Interventional Radiology Practice Parameter Update Endorsed by the Cardiovascular and Interventional Radiological Society of Europe and the Canadian Association for Interventional Radiology. J Vasc Interv Radiol. 2018;29(11):1483-1501.e2. doi:10.1016/j.jvir.2018.06.007
[2] de Bruijn AM, Ankum WM, Reekers JA, et al. Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 10-year outcomes from the randomized EMMY trial. Am J Obstet Gynecol. 2016;215(6):745.e1‐745.e12. doi:10.1016/j.ajog.2016.06.051
[3] Dariushnia SR, Nikolic B, Stokes LS, Spies JB; Society of Interventional Radiology Standards of Practice Committee. Quality improvement guidelines for uterine artery embolization for symptomatic leiomyomata. J Vasc Interv Radiol. 2014;25(11):1737‐1747. doi:10.1016/j.jvir.2014.08.029
[4] Spies JB. Current evidence on uterine embolization for fibroids. Semin Intervent Radiol. 2013;30(4):340‐346. doi:10.1055/s-0033-1359727
[5] Smeets AJ, Nijenhuis RJ, Boekkooi PF, Vervest HA, van Rooij WJ, Lohle PN. Is an intrauterine device a contraindication for uterine artery embolization? A study of 20 patients. J Vasc Interv Radiol. 2010;21(2):272‐274. doi:10.1016/j.jvir.2009.10.016
[6] Pisco JM, Bilhim T, Duarte M, Santos D. Management of uterine artery embolization for fibroids as an outpatient procedure. J Vasc Interv Radiol. 2009;20(6):730‐735. doi:10.1016/j.jvir.2009.01.029
[7] Goodwin SC, Spies JB. Uterine fibroid embolization. N Engl J Med. 2009;361(7):690‐697. doi:10.1056/NEJMct0806942
[8] Gonsalves C. Uterine artery embolization for treatment of symptomatic fibroids. Semin Intervent Radiol. 2008;25(4):369‐377. doi:10.1055/s-0028-1103001
[9] Hehenkamp WJ, Volkers NA, Birnie E, Reekers JA, Ankum WM. Symptomatic uterine fibroids: treatment with uterine artery embolization or hysterectomy--results from the randomized clinical Embolisation versus Hysterectomy (EMMY) Trial. Radiology. 2008;246(3):823‐832. doi:10.1148/radiol.2463070260
[10] Chrisman HB, Minocha J, Ryu RK, Vogelzang RL, Nikolaidis P, Omary RA. Uterine artery embolization: a treatment option for symptomatic fibroids in postmenopausal women. J Vasc Interv Radiol. 2007;18(3):451‐454. doi:10.1016/j.jvir.2006.12.723
[11] Mara M, Fucikova Z, Maskova J, Kuzel D, Haakova L. Uterine fibroid embolization versus myomectomy in women wishing to preserve fertility: preliminary results of a randomized controlled trial. Eur J Obstet Gynecol Reprod Biol. 2006;126(2):226‐233. doi:10.1016/j.ejogrb.2005.10.008
Disclaimer: The Materials available on https://www.BackTable.com/ are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Podcasts
Articles
Building a UFE Practice
Contributors
Dr. Mary Costantino
Dr. Aaron Kovaleski
Dr. John Lipman
Dr. Keith Pereira