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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.

Uterine Fibroid Embolization (UFE) Procedure

Learn more on the BackTable VI Podcast

BackTable is a knowledge resource for physicians by physicians. Get practical advice on Uterine Fibroid Embolization and how to build your practice by listening to the BackTable VI Podcast, reading exclusing BackTable Articles, and following the work of our Contributors.

Ep 192 Going All In on the OBL and Finding Your Ikigai with Dr. John Lipman
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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

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 #217

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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.

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Episode #192

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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!

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Episode #72

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John Lipman, MD discusses UFE practice building, patient workup, and embolization technique in his dedicated Women's interventional practice, Atlanta Interventional Institute.

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Episode #36

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Dr. Mary Costantino tells us the story of how she built her OBL practice in Portland and discusses the advantages of performing UFE and other procedures in the outpatient setting.

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Episode #10

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Dr. Keith Pereira and Dr. Chris Beck discuss building their UFE practice and transradial versus transfemoral approaches.

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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.

UFE practice recovery room

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

• 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

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.

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Podcasts

Building a Comprehensive Women’s Health Practice: Collaboration with GYN with Dr. Mark Hoffman and Dr. Merve Ozen on the BackTable VI Podcast)
Going All In on the OBL and Finding Your Ikigai with Dr. John Lipman on the BackTable VI Podcast)
Uterine Fibroid Embolizations in the OBL with Dr. John Lipman on the BackTable VI Podcast)
Building an Outpatient UFE Practice with Dr. Mary Costantino on the BackTable VI Podcast)
Uterine Fibroid Embolization with Dr. Keith Pereira and Dr. Christopher Beck on the BackTable VI Podcast)
New Tools to Treat Severe Distal Femoropopliteal Disease with Dr. John Rundback on the BackTable VI Podcast)

Articles

UFE practice recovery room

Building a UFE Practice

Contributors

Dr. Mary Costantino on the BackTable VI Podcast

Dr. Mary Costantino

Dr. John Lipman on the BackTable VI Podcast

Dr. John Lipman

Dr. Keith Pereira on the BackTable VI Podcast

Dr. Keith Pereira

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