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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
UTERINE FIBROID EMBOLIZATION FROM START TO FINISH
FINANCIAL DISCLOSURES • Neil Shah, M.D.
• None
• Samir Shah, M.D.
• None
• Henry Dalsania, M.D.
• None
• Bhumin Patel, M.D.
• None
• 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 hysterectomy1. • 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
• 5 year follow up of the EMMY Trial reported similar health related quality of life (HRQOL) and improved urinary symptoms and defecation function3.
• Another study revealed no significant differences between UFE and hysterectomy group with overall similar quality of life at 12 months4. • 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.
• Minor • Contrast Allergy • Coagulopathy • Renal Failure • Desire to remain fertile • GnRH • Prior Radiation
• Absolute • Pregnancy • Malignancy • Active infection. • Immunosuppression
• Uterine Fibroids • Pelvic pain • Menorrhagia.
• GU/GI manifestations. • Adenomyosis
• Postpartum Hemorrhage • Uterine Artery Pseudoaneurysms
• Hysterectomy • Caesarean section
• Uterine AVM
• Traumatic
I Indications5. Contraindications
• Menorrhagia:
• Prolonged bleeding lasting longer than 7 days
• Length of cycle
• Number of heavy-flow days
• Frequency of Tampon/pad changes
• Dysmenorrhea
• Pain
• Characterization
• Chronicity
• Alleviation
• Genitourinary Systems
• Dysuria
• Polyuria
• Constipation
CLINIC CONSULT
Symptom Evaluation Menstrual History6.
• Examination Technique7. • Pelvic phased array coil • 4-6 hour preimaging fast:
Decreases peristalsis • Sequences
• Orthogonal T2-W FSE • Axial T1-W
• With and without FS • Precontrast and Dynamic
Post Contrast T1-W FS Gradient echo images
• Optional DWI with ADC.
• Location8: • Subserosal- beneath serosa • Intramural- within myometrium • Submucosal: beneath mucosal
lining • Pedunculated : relative
contraindication. • Intracavitary Fibroids
• Post embolization expulsion may lead to pain, cramping, or infection5.
• Cervix • Enhancement
MR IMAGING
• Commonly performed from bilateral femoral, unilateral femoral, or transradial approaches
• Right common femoral artery access with placement of 5 French vascular sheath
• Reverse curve flush catheter (RCFC) placed in abdominal aorta and aortoiliac angiography performed
• RCFC used with 0.035” wire to select left common iliac artery
• RCFC exchanged for 5 Fr angled glide catheter which is used to select left internal iliac artery
• Subselective angiography performed and microcatheter/microwire used to select uterine artery
• DSA performed and microcatheter advanced beyond non-target branches in the horizontal segment
• DSA performed to reconfirm visualization of fibroids and lack of non-target extrauterine branches
• Embolization performed under live fluoroscopy with 500-700 micron calibrated microspheres
• Periodic flushing with 1 ml 1% Lidocaine IA • Completion DSA with endpoint reached when
sluggish flow demonstrated in uterine artery and diminished vascularity to the uterine fibroids
• Microcatheter removed • Glidewire and left internal iliac angled glide
catheter used to form Waltman loop in the abdominal aorta
• Looped glide catheter used to select right internal iliac artery and DSA performed
• Microcatheter used to select right uterine artery and DSA performed with subsequent embolization performed as on the left side
• Equipment removed and right CFA hemostasis achieved
PROCEDURE
• 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.
• Anatomy
• A) Aorta
• B) Common Iliac Artery
• C) External Iliac Artery
• D) Internal Iliac Artery
• E) Common Femoral Artery
• F) Deep Femoral (Profunda) Artery
• G) Superficial Femoral Artery
• H) Uterine Artery
• I) Superior Gluteal Artery
• J) Obturator Artery
ANATOMY
A
B
C D
E
F G
H
I
J
Figure 1
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 3 Figure 4
Figure 5
• Vital Signs and neuro checks • Monitor Puncture site • Keep punctured extremity straight and immobile for 2 hours if
closure device was used
• 6 hours if no closure device • Keep supine • Remove Foley at midnight, Ambulate prior to DC
• Dilaudid PCA: • Bolus dosing 0.1-0.2 mg every 10 min with 10 min
lockout.
• May consider 1mg/hour basal rate with increase to 2mg basal rate/hr and up to 0.4 mg dilaudid every 10 min.
• Ibuprofen 600 mg QID • Toradol 30mg IV q 6 hours • Antiemetics: Zofran, Decadron, Ativan
• Vital Signs • Cardiac Monitor • Pulse ox
• Foley Catheter • NPO
• Labs • PT/INR, CBC, CMP, B-hCG
• IVF: 0.9NS at 150-200 ml per hour
• Prophylaxis: • Rocephin 1G, Zosyn 3.375G, Ampicillin 2G, or
Vancomycin 1G • Toradol 30mg IV prior to procedure
• Sedation: • Versed and Fentanyl OR Anesthesia with MAC
ORDERS Preprocedure Postprocedure
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.
• Post Embolization Syndrome
• Fever, Nausea, Emesis, Pain, and Malaise
• Pulmonary Embolism
• Non-target embolization
• Ovaries
• Labial necrosis9
• Buttock Necrosis10
• Lower Extremity
• Sexual Dysfunction
• Incomplete Embolization • Fibroid Regrowth • Uterine infection • Uterine Necrosis • Uterine Artery Rupture/Dissection • Minor Complications
• Pain • Hematoma • Access
• Pseudoaneurysm • AV Fistula
COMPLICATIONS
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.