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.