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Uterine Artery Embolization for Abnormal Bleeding

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Uterine Artery Embolization for Abnormal Bleeding After a small catheter is threaded through OBGMANAGEMENT a femoral artery under angiographic imaging and guided into the uterine arteries, polyvinyl alcohol particles or trisacryl gelatin microspheres are released to block the blood vessels that feed the fibroids (or adenomyosis), causing them to shrink Ducksoo Kim, MD Director of Cardiovascular and Interventional Radiology Professor of Radiology and Surgery University of Massachusetts Medical Memorial Health Care Worcester, Mass Stephen D. Baer, MD, MPH Instructor of Obstetrics and Gynecology, Harvard Medical School, Staff ObGyn at Brigham and Women’s Hospital, Quincy Medical Center, Caritas Carney Hospital, Caritas St. Elizabeth Medical Center, and Beth Israel Deaconess Medical Center, Boston, Mass IN THIS ARTICLE CASE-BASED LEARNING ❙ Preoperative Uterine artery embolization imaging: An enormous fibroid for abnormal bleeding and adenomyosis How to treat women with fibroids or adenomyosis, Page 49 the most common myometrial causes of premenopausal ❙ Imaging: abnormal uterine bleeding. Before and after Page 53 Angiography .LISA’S CASE. Pages 49, 58 MRI Ablation fails to ease symptoms Lisa is a 38-year-old mother of 2 who shrink, and her symptoms returned 5 initially reported menometrorrhagia, months after the procedure. DISCHARGE INSTRUCTIONS WALLET INFO-CARD dysmenorrhea, urinary frequency, pelvic Lisa heard about uterine artery When to call pressure, and increasing abdominal girth. embolization (UAE) through the media your doctor These symptoms worsened over 3 years and now asks about it. Her uterus is Page 54 before Lisa saw a physician and was 20-week size with an irregular contour. IMAGE: TODD BUCK diagnosed with uterine fibroids. When Magnetic resonance imaging (MRI) offered hysterectomy or endometrial shows a single large fibroid filling the ablation (cryomyolysis), she chose the uterus. Her hematocrit is 22. latter. However, her fibroids failed to Is uterine UAE right for her? 48 OBG MANAGEMENT • July 2005 PREOPERATIVE IMAGING Lisa’s case: Large fibroid Angelina’s case: Adenomyosis A large fibroid occupies the entire uterus Global uterine enlargement and diffuse (size 20-weeks) adenomyosis, with a junctional zone thickness of 14 mm (arrow) Sagittal fast spin-echo T2 weighted pelvic MRI .ANGELINA’S CASE. treated using embolization techniques. Menorrhagia and a “boggy” uterus The main advantages of UAE in treat- Angelina, 35, has 2 children and a 10-year ing these diseases:1-8,12,13 history of menorrhagia, dysmenorrhea, • Less invasive than surgery, with sub- and anemia. Pelvic examination reveals a stantially less recovery time and lower 10-week size, “boggy” uterus, and MRI morbidity shows global enlargement of the uterus • Usually performed under local anesthe- with a thickened junctional zone, which is sia and intravenous conscious sedation FAST TRACK characteristic of adenomyosis. • No worry about adhesions The ideal patient Her previous physician recommended • Virtually no blood loss or need for hysterectomy after medical therapy failed, transfusion; UAE may be especially is premenopausal, but Angelina is reluctant to undergo surgery. attractive for patients who refuse or can- has symptomatic Is UAE an option? not receive blood products for health or fibroids and/or religious reasons. oth women are very likely to benefit adenomyosis, from UAE, since the ideal candidate has failed therapy, is premenopausal with symptomatic and wants or needs B ❚ Impressive success rates fibroids and/or adenomyosis and has either to avoid surgery failed medical or surgical therapy or wants UAE has demonstrated excellent technical or needs to avoid surgery.1-11 (98% to 100%) and high clinical success This article describes the therapeutic rates (80% to 95%) in the treatment of role of UAE in women with abnormal fibroids.1-8,13 The clinical success rate is uterine bleeding (AUB) due to uterine lower for adenomyosis (56% to 92%), but fibroids and/or adenomyosis—the most UAE often provides sufficient clinical relief frequent myometrial causes of pre- to obviate surgery.9,10,13 menopausal AUB. Although UAE was not initially rec- Other, less frequent myometrial disor- ommended for women desiring future fer- ders (eg, hypervascular pathologies such as tility—because of the 4% risk of prema- intramyometrial and parametrial vascular ture menopause—the pendulum is now malformations or neoplasms) can also be swinging in the other direction. If the risks www.obgmanagement.com July 2005 • OBG MANAGEMENT 49 ▲ Uterine artery embolization for abnormal bleeding of myomectomy are great due to the In some cases, extensive endometriosis anatomic size or position of fibroids or is the cause of menorrhagia or dysmenor- adenomyosis, the risk-benefit ratio may rhea, often coexisting with fibroids, and shift to UAE to allow preservation of UAE may not be beneficial.11 reproductive capacity.1-8,11 Finally, a subserosal leiomyoma that is Though embolization has been per- sufficiently pedunculated (attachment formed since the early 1970s for acute and point 50% of the diameter) can be at risk chronic bleeding associated with various for detachment from the uterus, a situation medical conditions,14 the first report of that may necessitate surgical intervention.11 UAE did not come until 1995.1 Since then, the procedure has seen rapid growth worldwide, with approximately 50,000 cases performed. About 14,000 cases were ❚ Preop exam and imaging performed in the US last year.2 At the physical examination, the fibroid Although our practice has no fixed size uterus usually is enlarged with an irregular limitation, ideally a uterus less than 20 contour, and adenomyosis usually presents weeks’ gestational size is preferred. as a globally enlarged, “boggy” uterus (typically 6- to 10-weeks’ gestational size). Contraindications • Viable pregnancy MRI is the preferred imaging • Active pelvic infection We prefer MRI since fibroids can be • Presence of an intrauterine device missed with ultrasound due to the limited (though the IUD may be removed field of view. MRI more accurately defines before the procedure) the size, location, and extent of disease. It • Undiagnosed pelvic or adnexal mass also may better differentiate fibroids from • Pelvic malignancies such as ovarian or adenomyosis. endometrial carcinoma MRI clearly depicts uterine zonal • History of pelvic radiation, since UAE anatomy and enables accurate classifica- FAST TRACK may cause ischemic necrosis of the tion of individual masses by their locations: MRI enables uterus and adjacent organs due to pre- submucosal, intramural, or subserosal. existing radiation-induced vasculitis When adenomyosis is present, T2- classification with diffuse vascular narrowing. weighted MRI demonstrates diffuse ade- of masses nomyosis (about 66%) with global as submucosal, Relative contraindications enlargement of the uterus and diffuse • Renal insufficiency, though we have thickening of the junctional zone (at least intramural, used gadolinium, a nonnephrotoxic 12 mm, highly predictive finding) with or subserosal MRI contrast medium, for women homogeneous low signal intensity. Focal with high blood creatinine levels adenomyosis (33%) can be seen as an ill- • History of severe allergic reaction to defined, poorly marginated focal mass iodinated contrast medium, though (adenomyoma) of low signal intensity gadolinium can also be used in these within the myometrium.15,16 patients • Coagulopathy Transvaginal ultrasound • Desire to preserve fertility, since it In women with fibroids, ultrasound usual- cannot be assured based on current ly demonstrates an enlarged uterus with data. However, uncomplicated preg- lobulations, contour abnormality, or mass nancies and normal deliveries have effects. been reported after UAE, so this pro- In women with adenomyosis, it usual- cedure may still be preferred for ly demonstrates ill-defined, heterogeneous women who refuse or cannot under- echotexture and small anechoic areas with- go myomectomy.11 in the myometrium of asymmetrically 50 OBG MANAGEMENT • July 2005 Uterine artery embolization for abnormal bleeding ▲ enlarged uteri, with indistinct endometrial- ANGIOGRAPHY myometrial borders and subendometrial Before UAE: Hypervascular fibroids 15 halo thickening. Right uterine artery Left uterine artery Include endometrial biopsy The patient should have a normal Pap test during the 12 months leading up to UAE,11 and should undergo endometrial biopsy to exclude carcinoma. Laboratory tests should include a complete blood count, blood urea nitro- gen/creatinine, follicle-stimulating hor- Right and left uterine arterial branches supply hypervascular uterine fibroids. mone, human chorionic gonadotropin, and coagulation tests. After UAE: Uterine arteries occluded Right uterine artery Left uterine artery ❚ Technique UAE begins with insertion of a small catheter (4-5 French) through a femoral artery in conjunction with percutaneous angiography. The catheter is guided into the uterine arteries—left first, then right— and contrast medium is injected into each artery to confirm the position of the Both uterine arteries successfully occluded, including their branches. catheter and the presence of fibroids or adenomyosis, which appear as hypervascu- lar lesions in angiograms (see above, right). ❚ Patient care UAE usually requires 1 to 2 hours. Conscious sedation, NSAIDs, FAST TRACK and antibiotics Embolic agents Intravenous conscious sedation in conjunc- The patient Polyvinyl alcohol (PVA) particles or tris- tion with nonsteroidal anti-inflammatory should have
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