Uterine Fibroid Embolization: A Case Based Introduction

Uterine Fibroid Embolization: A Case Based Introduction

Cicero R. Habito University of the Philippines College of Medicine

(Visiting Clerk, Harvard Medical School)Gillian Lieberman, MD

Cicero R. HabitoGillian Lieberman, MD

November 2001


Agenda

I. Patient PresentationII. Discussion

A. What are Fibroids?B. Signs and symptomsC. Treatment OptionsD. Uterine Artery Embolization as a

Treatment ProcedureE. Literature Review

Student NameGillian Lieberman, MD

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Our Patient• 48 y.o. F, G0P0, consulting for several years

history of severe menorrhagia secondary to known fibroid uterus. Patient had developed severe anemia requiring parenteral iron therapy, and control of symptoms was unsuccessful with oral contraceptive pills

• Except for enlarged uterus, essentially normal physical exam

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fibroids

cervix

vagina

Sagittal Pelvic MRI

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fibroids

Sagittal Pelvic MRI

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Diagnosis: Multiple Uterine Fibroids,

predominantly of the Intramural Type

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Fibroids

• Benign tumors of uterine smooth muscle

• uterine fibroid = leiomyoma/fibromyoma

• not considered to be pre- cancerous

• may arise in various parts of the uterus

• single most common cause for hysterectomy From www.ufecenter.com

Uterine fibroids

Uterine arteries feeding fibroids

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Fibroids

• Fibroids are named according to their position in the uterus: submucosal, intramural and subserosal

from www.fibroidworld.com

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Fibroids

• most common tumor of the pelvis in females• 20 to 25% of women of childbearing age• arise at menarche and regress after menopause,

suggesting estrogen dependence • only a minority are symptomatic (estimated at

10-30%) • cause unknown, but more common in

nulliparous middle aged females, African- Americans, and overweight women

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Signs and Symptoms• menorrhagia/metrorrhagia/menometrorrhagia• dysmenorrhea; dyspareunia• frequent urination caused by a large tumor pressing

against the bladder• backaches or constipation from pressure on the bowel• rarely, a sudden pain in the lower abdomen• small fibroids may go unnoticed for years• infertility?

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Treatment options

• How are uterine fibroids currently treated?– Small and/or no symptoms: no treatment;

regular follow-up with US and pelvic exam– if with symptoms, various treatments are

available...

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Treatment options• Medical management

– NSAIDS, oral contraceptives, progesterones, GnRH agonists (Lupron)

– pros: non-invasive, may shrink fibroids– cons: cause not eliminated with NSAIDS;

infertility with contraceptives; Lupron use usually limited to 6 months, may induce premature menopause and osteoporosis

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Surgical management• myomectomy

– myomectomy apparently successful in about 80% of cases

– pros: fertility can be preserved; well established procedure

– cons: risk of post-op bleeding, only part of uterus is treated and recurrence can occur; not all fibroids amenable; adhesions can lead to infertility

From www.isisfertility.com

Uterus: Pre and Post Myomectomy

Excised fibroid/myoma

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Surgical management

• Hysterectomy– pros: 100% curative,

no risk of future cancer, well established procedure

– cons: major surgery with potential surgical complications, emotional effects, diminished sexual function, long recovery From www.vesalius.com

View of Uterus Intraoperatively

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Surgical Management

• Hysteroscopic resection– possible if fibroids

are submucous and projecting into uterine cavity

– cons: only a small subset of patients are candidates; risk of recurrence

From www.fibroidworld.com

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Uterine Fibroid Embolization

• Embolization of uterine arteries for severe post-partum or post-traumatic hemorrhage performed for nearly 20 years now

• In 1990: Jacques-Henri Ravina, a French gynecologist, began performing embolization prior to hysterectomy to decrease surgical blood loss

• however, patients noticed improvement of symptoms and would cancel surgery

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Who is a Candidate for UFE?• Symptomatic patients seeking non-surgical

treatment• Fibroids as definitive diagnosis• Uterine Size of less than 20 weeks (below

umbilicus)• Patient off GnRH for 8 weeks prior to UFE

(relative)

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UFE: Procedure

• Uses angiographic techniques to place a catheter into uterine arteries

• Patient under conscious sedation and local anesthesia

From www.ufecenter.com

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UFE: Procedure

• Arterial access via a needle puncture into femoral artery

• catheter advanced over aortic bifurcation and into the uterine artery on the side opposite the puncture

From www.fibroidoptions.com

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UFE: Procedure

• Before embolization, an arteriogram is performed to check patency of vessels and provide a roadmap of the blood supply to the uterus and fibroids

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Review of Pelvic Vasculature

From http://esap.stanford.edu

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Aortogram (runoff study)

Aortic bifurcation

R Internal IliacL Internal Iliac

Common iliacs

R External IliacL External Iliac

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Iliac arteries (RPO)

L uterine artery

L internal iliac

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catheter

L uterine artery

Selective arteriogram of L uterine artery

Feeding vessels

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Selective Arteriogram of L uterine artery (mid to late phase)

“blush” showing prominent blood supply

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UFE: Procedure

• Polyvinyl alcohol particles are injected to block blood flow to fibroids

• Caseous necrosis results, followed by hyaline sclerosis

From www.fibroidoptions.com

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Polyvinyl Alcohol• Most common nonabsorbable particulate agent

currently in use.• Prepackaged polyvinyl alcohol particles (Ivalon,

Biodyne, Contour Emboli) are provided in a range of sizes, from 150 to 1000 microns.

• Smaller particle sizes are most frequently used in the embolization of vascular tumors.

• Larger sizes are more useful in the occlusion of larger, high flow vascular malformations.

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• the extremely irregular surface of each particle creates a high coefficient of friction, which often results in adhesion of the particles to the wall of the vessel

• Blood flow is usually eliminated• The clot that forms between the particles may

eventually recanalize. This limitation can be partially overcome by packing the vessel with higher concentrations of small PVA particles followed by more proximal occlusion with larger particle sizes or microcoils.

Polyvinyl Alcohol

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Selective Arteriogram of L Uterine Artery Post Embolization

Cessation of flow

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Selective occlusion of L uterine artery

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UFE: Procedure

• Both uterine arteries are embolized to ensure that entire blood supply to fibroids is blocked

• done using either single or double catheter technique

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Selective Arteriogram of R Uterine Artery Pre Embolization

Uterine artery

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Selective Arteriogram of R Uterine Artery Pre Embolization

“blush” showing prominent blood supply

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Cessation of flow through R uterine artery


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What to Expect After the Procedure

• Post-embolization Syndrome • Pelvic pain accompanied by flu like

symptoms, persisting for a few days to a few weeks

• Due mainly to release of toxins from tissue necrosis

• Well controlled by pain medications

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What to Expect After the Procedure

• Size of the fibroids and the uterus diminish slowly with time with the maximum effect seen within the first 6 months (typically, within 2-3 months)

• Menstrual cycles will be interrupted and will be abnormal for a period of 3-4 months

• Most women, but not all, will have return of normal menses

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Complications• Serious complications rare, less than 4% of

patients• Only 2 deaths reported out of almost 10,000

patients treated worldwide so far– 1 death from septicemia– 1 death from pulmonary embolism

• Other potential complications include femoral hematoma, allergic reactions, vessel injury, infection and sexual dysfunction

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Possible causes of complications:

• Fibroids fed by a single uterine artery in tandem with the contralateral ovarian artery– in this case, both may

be embolized, but with risk of inducing menopause

• Complete misembolization of ovarian artery– Leads to premature

menopause

From www.uterinefibroids.com

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Controversies

• Exposure of the Ovaries to Radiation?• Fertility status post embolization?• Long term effects of PVA particles in body?

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References• Goodwin S, Vedantham S, McLucas B, Forno A, Perrella R. Preliminary experience with

uterine artery embolization for uterine fibroids. JVIR 1997; 8:517-26.• Ravina J, Herbreteau D, Ciraru-Vigneron N, Bouret J, Houdart E, Aymard A, et al. Arterial

embolisation to treat uterine myomata. Lancet 1995; 346:671-2• Rougier-Chapman D, Key SM, Ryan JM. Uterine Artery Embolization for the treatment of

symptomatic fibroid disease. Applied Radiology; September 2001:11-17.• Smith S, Sewall L, Handelsman A. A clinical failure of uterine fibroid embolization due to

adenomyosis. JVIR 1999; 10:1171-4.• Spies JB. Uterine Artery Embolization: Literature Review. Http://www.fibroidoptions.com• Spies J, Scialli A, Jha R, Imaoka I, Ascher S, Fraga V, et al. Initial Results from uterine fibroid

embolization for symptomatic leiomyomata. JVIR 1999; 10:1159-65.• Siskin G, Stainken B, Dowling K, Meo P, Ahn J, Dolen E. Outpatient uterine artery

embolization for symptomatic uterine fibroids: experience in 49 patients. JVIR 2000; 11:305-11• Spies J. Uterine Fibroid embolization for leiomyomata: mid-term results. JVIR 2000.• Vashisht A, Studd J, Carey A, Burn P. Fatal septicemia after fibroid embolisation. Lancet

1999; 354 (9175):307-8


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Acknowledgements

• Many thanks to the following who helped make this presentation possible:

• Gillian Lieberman, MD• Pamela Lepkowski• BIDMC Interventional Radiology Staff• Bijan Sadri• George Dyer


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Uterine Fibroid Embolization: A Case Based Introduction