Uterine Fibroid Embolization

Uterine Fibroid Embolization

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Pre-Procedure

Background:
• Fibroids (leiomyoma, myoma, fibromyoma, fibroleiomyoma)
• Benign smooth muscle tumor
• Most common benign pelvic neoplasm
• 50% of patients with fibroids have symptoms

Indications:
• Symptomatic uterine fibroids in patients who would like to avoid surgery
Menorrhagia (most common)
Bulk symptoms
• Pelvic pain
• Pelvic pressure
• Urinary frequency
• Constipation
Adenomyosis

Contraindications:
• Asymptomatic fibroids
• Pregnancy
• Pelvic malignancy suspected
• Uncorrectable bleeding diathesis
• Severe renal insufficiency
• Prior pelvic radiation

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

Preprocedural 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

Procedure

Preprocedural 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

Procedure:
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



Post-Procedure

Postprocedural 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

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 505 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

Related Procedures

No related procedures.

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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


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Literature

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