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Uterine Artery Embolization

Arghavan SallesAdvanced RadiologySeptember 15, 2005

Arghavan Salles MSIVGillian Lieberman, MD


Overview

I. Case presentationII. Imaging and leiomyomataIII. Classification of leiomyomataIV. Selection for UAEV. UAE techniqueVI. Post-procedural care and complicationsVII. Further investigationsVIII. References


HistoryUterine artery embolizations (UAE, also known as uterine fibroid embolization, UFE) have been performed since the 1970s for hemostasis in women post-partum, post-cesarean, post-abortion, post-hysterectomy1-3

It has also been used to treat arteriovenousmalformations of the pelvis, placenta previa, and placenta accretaIn 1995, Ravina and Herbreteau1 were the first to report the use of UAE for treatment of leiomyomataafter having incidentally noted shrinkage of fibroids when using UAE for the above indications


Case46 year old woman with menorrhagiaUp to 24 consecutive days of menstruation per cycleAlso feels abdominal pressurePast medical and surgical history non-contributoryUltrasound revealed fibroids prior to consultation with the interventionalistPap smear and endometrial biopsy WNL


Work-up of Patients for UAE4

General medical history and physical examination-important to ask about symptoms, pregnancy history, recent Pap smears, and infection as part of complete history

Gynecologic examination-important to rule out other causes for symptoms

Laboratory testing-typically order CBC, PT/PTT/INR, BUN/creatinine to assess for anemia, coagulopathy, renal insufficiency

Imaging-Ultrasound or MRI

Pap test


Epidemiology of LeiomyomataOccur in 20-40% of women of reproductive age4,5

Account for 30-70% of hysterectomies in the United States4-5

Most common benign indication for hysterectomy3

20-50% of women with leiomyomata have menorrhagia, dysmenorrhea, pelvic pressure, urinary frequency, pain, infertility, or a palpable abdominal-pelvic mass4,8

Most common symptoms are heavy menstrual bleeding (78%), pain (59-75%), and bulk-related (82-98%)4,7,9

Occur most often and at a younger age and larger size of lesions in black women7


Differential Diagnosis10

It is important to exclude other pelvic pathology that may be contributing to the patient’s symptoms in order to determine whether UAE is appropriate.Diffuse adenomyosis (ectopic endometrial glands and stroma within the myometrium)-symptoms are often similar to those resulting from leiomyomata

Focal adenomyosis (adenomyoma)-may be distinguished from leiomyomata on MRI11


Differential Diagnosis, cont.Solid adnexal massFocal myometrial contraction-transient phenomenon that mimics leiomyomata and disappears with repeat imaging

Uterine leiomyosarcoma-often difficult to distinguish on imaging studies-in over 1400 patients who had hysterectomy for presumed leiomyomata followed for five years, 0.49% had leiomyosarcoma12


MRI for Pre-operative PlanningMR is the most accurate imaging technique for detection and localization of leiomyomata for pre-operative planning2,4,9,10,12-14

-Ultrasound may be used but is less accurate, especially in obese patientsMR is 90% sensitive and specific for adenomyosis11

Treatment options vary depending on characterization of lesions (see Treatment Options)Important to determine depth of extension into myometrium to minimize risk of uterine perforation for anticipated hysteroscopic resections10


MRI for Pre-operative Planning, cont.

Pedunculated subserosal and submucosalleiomyomata may detach from the uterus after UAE-pedunculated subserosal leiomyomata may settle into the pelvis becoming a nidus of infection-pedunculated submucosal leiomyomata may be passed or may become lodged in the cervix or vagina becoming a nidus of infection10

Uterine arteries seen with MRA may help guide embolization10

MRA may help exclude contributions to the leiomyomata from ovarian or other vessels10

MRI may help predict post-procedural outcome12


Effect of MRI on Diagnosis14

Interventional radiologists were asked to give pre-imaging and post-imaging diagnoses and treatment plans for 60 women evaluated for UAEAxial HASTE, Axial GRE, Sagittal T2 TSE, and coronal SHARP series were usedInitial diagnoses changed in 18% of casesMRI detected unsuspected pelvic masses, demonstrated adenomyosis, detected degenerated fibroids, and documented lack of pelvic pathologyChanged treatment plans in 22% of cases-57/60 were to undergo UAE prior to imaging-After MR, 8 went to surgery, 2 had clinical management, and one had biopsy


MRI Characteristics

Nondegenerated uterine leiomyomata are well-circumscribed masses with homogeneously decreased signal intensity compared to the outer myometrium on T2-weighted images10

Cellular leiomyomas may have higher signal intensity on T2-weighted images and enhance post-contrast10


MRI Characteristics, cont.Degenerated leiomyomata have variable appearances depending on the type of degeneration10

-hyaline or calcific degeneration has low signal on T2-weighted images-Cystic degeneration has high signal on T2-weighted images. Cystic areas do not enhance post-contrast.-Myxoid degeneration has very high signal on T2-weighted images and may enhance minimally post-contrast.-Necrotic lesions have variable intensity on T1-weight images and have low signal on T2-weighted images.

It is important to assess enhancement because lesions that do not enhance are not as likely to respond well to embolization


MRI Characteristics, cont.Don’t forget our differential diagnoses:

Focal myometrial contraction-low signal on T2-weighted images11

Adenomyosis-low myometrial signal intensity, enlarged junctional zone* (>12 mm), high signal intensity foci (myometrial cysts), poor definition of endomyometrial junction, and poor definition of lesion borders11

Adenomyoma-focal thickening of junctional zone, poorly defined margins, minimal mass effect11

*junctional zone is between the endometrium and myometrium and consists mostly of smooth muscle


Normal Uterus

Endometrial stripe

Uterus

Cervix

Vagina

T2-weighted sagittal image

Bladder

PACS, BIDMC


Our patient

T2-weighted sagittal image showing leiomyomata in various locations with homogenous signal characteristics

Subserosal

Intramural

Endometrial stripe

Uterus

PACS, BIDMC


Our patient

T2-weighted axial image of the same patient

Intramural

Endometrial stripe

Uterus

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Vasculature

T1-weighted post-contrast image in the same patient showing enhancement of leiomyomata with dilated uterine arteries (white arrows)

Enhancement

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Classification of Leiomyomata10

Most commonly occur in the myometrium of the uterus but may occur in cervix (8% of the time)Submucosal-project into endometrial canal-least common subtype but most often symptomatic

Intramural-within myometrium-most common subtype, usually asymptomatic

Subserosal-beneath the serosa-if pedunculated, may torse and cause pain or infection

Ghai, et al.


Submucosal

Intramural

SubserosalAdenomyosis(junctional zone measures ~15 mm)

Examples of Leiomyomata

T2-weighted sagittal image PACS, BIDMC


More examples

Submucosal Intramural

T2-weighted sagittal image T2-weighted sagittal image

Endometrial stripe

Endometrial stripe

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Enhancement

T1-weighted axial image prior to administration of contrast showing homogeneous low signal in leiomyomata

T1-weighted axial image after administration of contrast showing enhancement of leiomyoma

Leiomyoma Enhancement

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Indications for Intervention10

Bleeding-most frequent symptom, usually manifests as menorrhagia or menometrorrhagia-menstrual irregularities may be due to loss of symmetric uterine contractions

Pressure on adjacent organs-mass effect on the bladder may cause urinary frequency or incontinence-may cause hydroureter or hydronephrosis if impinging on the ureter-may cause constipation due to effects on the rectum


Indications for Intervention, cont.Pain-usually due to acute degeneration which can often occur during pregnancy-may be secondary to torsion of subserosal lesions or prolapse of submucosal lesions

Infertility-may occur as a result of compression of the fallopian tubes from intramural leiomyomata in the cornual regions or intraligamentous regions-may be a result of faulty implantation due to submucosal lesions


Treatment Options10

Medical Management-GnRH inhibits the secretion of gonadotropins hypoestrogenicstate amenorrhea decreased size of fibroids/uterus-regrowth if stop treatment-risk osteoporosis-may use pre-operatively prior to hysterectomy, myomectomy, or hysteroscopic myomectomy

Hysterectomy-traditional option, does not preserve fertility

Myolysis-neodymium:yttrium-aluminum-garnet laser or bipolar needle electrodes-thermal injury leads to degeneration-may also lead to pelvic adhesions


Treatment Options, cont.Myomectomy-enucleation of leiomyoma with preservation of uterus-can be performed open, hysteroscopically, laparoscopically-risk of recurrence is 27% at 10 years10, 10% at 5 years6

Hysteroscopic:-60% rate of pregnancy after hysteroscopic myomectomy10

-appropriate for submucosal or submucosal-intramural leiomyomata-risk of uterine perforation

Laparoscopic:-appropriate for pedunculated subserosal leiomyomata

Uterine Artery Embolization-inject various particles into uterine artery to achieve stasis-may preserve fertility (see Fertility? slides)


Comparing Options15

400 consecutive patients were followed after UAEComplications were categorized using two classification systems:-Society of Cardiovascular and Interventional Radiology -American College of Obstetricians and Gynecologists

Date on complications over the first 30 days were reported


Comparing Options15

Procedure Life- threatening events

Unintended procedures

Readmissions

Myomectomy 1.5% 4.5% 1.5%

Hysterectomy 1.0% 9.6% 2.5%

UAE* 0.5% 2.5% 3.5%

*Most common complication requiring hospitalization was leiomyoma tissue passage


Selection for UAE4

Symptomatic leiomyomataExclusion of those who are pregnant, have a pelvic malignancy, or have active pelvic infectionPatient choice


Relative Contraindications to UAE2,4

CoagulopathySevere allergy to contrast materialRenal impairmentImmunocompromisedPrevious pelvic irradiation or surgeryChronic endometritisStrong desire for future fertilitySuberosal pedunculated lesions (usually safe if the attachment to the uterus spans more than 50% of the diameter of a subserosal lesion)


Seldinger Technique16

Technique used for interventional proceduresInsert needleInsert wire through needleEnlarge skin incisionExchange needle for sheath and dilatorRemove dilator and use sheath


Vascular Anatomy17


Angiographic Safety

Minimize radiation dose to the patient during all interventional procedures2,3

-collimate images-small gap between patient and image intensifier-take as few images as possible


UAE Technique: I 4,15

Usually unilateral femoral approach using 4 or 5 French catheterPerform abdominal arteriogram with digital subtraction with ileofemoral run-off to visual vessels-assess for arteriovenous malformations, shunting, collateral vessels (ovarian, round ligament, cervical, pelvic)


Abdominal Arteriogram

Right internal iliac artery

Left internal iliac artery

Right uterine artery Left uterine artery

Catheter in aorta

PACS, BIDMC


UAE Technique: II

Then perform arteriogram from both internal iliac vessels using Bookstein catheter18

-vascular supply to leiomyomata often comes from both uterine arteries so both are embolized

Access uterine arteries using Tracker catheter and perform arteriogram


Left Uterine Artery Right Uterine Artery

Prior to Embolization

Right uterine arteryLeft uterine artery

Catheter

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UAE Technique: III

Inject embolization agent of choiceTarget is distal occlusion of arteries feeding leiomyomataEnd-point is usually complete occlusion of vesselsAccess both uterine arteries and perform arteriogram again to demonstrate decreased flow


Embolization Materials

Polyvinyl alcohol (usually 355-500 microns)Tris-acryl gelatin microspheresGelatin sponge particlesMust avoid vasospasm for adequate delivery of particles9

-may use nitroglycerin to treat vasospasm


After embolization

Left Internal Iliac Artery Right Internal Iliac Artery

Right uterine artery—occluded Left uterine artery—occluded

Catheter

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Consequences of UAE5

Myoma necrosisReduced uterine volume-most decrease may occur within the first six months although further decrease occurs after that12,13

Improved menorrhagiaDecreased pelvic pain


Efficacy of UAEReturn to work after 17 days9

Usually feel better within 1 week2,3

83-84% noted improved menorrhagia9,13

86% improved urinary frequency/urgency13

79% improved pain9

Decreased duration of menstruation (7.6 to 5.4 days)13

82% had decreased bloating or swelling9

91-97% satisfied with the procedure9,13

Average shrinkage of fibroids by 42-73%9,13

Average shrinkage of uterine volume 35%13

May be less effective for pedunculated subserosal leiomyomatabecause these may have an alternate blood supply from ovarian arteries or from other organs to which they may be attached12


Efficacy, cont.Control symptoms in 80-94% of women9

Most effective in those with high blood flow or high cellularity3

Some women go on to have normal pregnancies7

Failure rates 4-21%13

Amenorrhea 2-15%13

-thought to be due to decreased uterine vascularity, inadvertent occlusion of ovarian vessels, or possible effect of radiation

Ovarian collateral supply, unrecognized malignancy, misdiagnosis of adenomyosis, underembolizationmay all lead to treatment failure4,13


Complications3,15

Based on two separate studies of 400 women in each study:Febrile morbidity (2%)-post-embolization fever is common within the first few post- procedural days

Hemorrhage (0.75%)Unintended procedure (2.5%)Life-threatening events (0.5%)-pulmonary embolus-one case of septic shock


Complications, cont.

Readmission (3.5%)-infection was most likely to occur in women with large fibroids or pedunculated subserosal fibroids

Overall morbidity (5%)Fibrosis of uterus (rare)Premature ovarian failure, infections, uterine discharge, necrosis, death from sepsis


Periprocedural ConcernsUsually conscious sedation is used during the procedureSome may give antibiotics, but there is no consensus on what to useImportant to monitor patient’s radiation doseMost interventionalists admit the patients for a short stayPain-most women experience severe pain which is worst in the first 24 hours-may discharge most patients post-procedural day 1 with adequate medication and follow-upNausea-second most common complaint post-procedure


Post-procedural Care4

Follow-up phone call within 24-48 hours to monitor pain/nausea controlIf patient develops temperature more than four days after the procedure or has increasing pain, should be readmitted9

-should then obtain blood cultures, urinalysis/urine culture, CBC, vaginal swabs, MRI-start on antibioticsOffice visit 1-3 weeks after procedure-assess symptoms, healingImaging 3-6 months after procedureLong-term follow-up necessary-check for infections, expulsion of materials, chronic endometritis, chronic vaginal discharge, irregular menses, amenorrhea which may all develop more than one year after the procedure


MR Monitoring: 1/3/05

Pre-embolization, T2-weighted axial image showing large intramural fibroids

Pre-embolization, Post-gadolinium T1- weighted image shows the lesions are avidly enhancing.

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MR Monitoring: Successful Embolization

Axial T1 pre-contrast (LAVA)

Axial T1 post-contrast (LAVA)

Patient had embolization 2/11/05. These images were acquired 3/8/05. Uterine size prior to embolization was 25 cmx15 cmx9.4 cm and is now 13.6 cmx8.4 cmx9.3 cm. Large intramural fibroid was 7 cmx4.7 cmx5.3 cm and now is 5.3 cmx6.0 cmx5.6 cm. On post-contrast images, the mass is now devascularized.

PACS, BIDMC


Questions

Is UAE effective in treating patients with adenomyosis?Does UAE preserve fertility?


AdenomyosisThe efficacy is UAE in patients with adenomyosis is difficult to assess as most patients with adenomyosis also have leiomyomataThere is currently one study following women with symptomatic adenomyosis without leiomyomata11

Results thus far indicate that 55% of patients show clinical improvement 2 years after UAE11

Most patients with both leiomyomata and adenomyosis are treated with UAE because it is difficult to definitively attribute their symptoms to one or the other


Fertility?

It is unclear whether UAE preserves fertility in womenSome series have included women who have gone on to have normal pregnancies (12 patients in a series of 400 women9)1

Amenorrhea after UAE is often transient due to decreased uterine vascularity


Fertility?, cont.The rate of amenorrhea after the procedure is significantly higher in older women-3% in women under age 4013

-41% in women age 50 or older13

-2% under age 4515

-rate of ovarian failure in the general population is 4% under age 4515

Amenorrhea may be attributed to:-transient decreased uterine vascularity-anastomoses between uterine and ovarian arteries causing embolization materials to inadvertently decrease vascular supply to the ovaries13


ConclusionUAE has fewer complications than other interventions9,15

Minimally invasive, safe way to treat uterine leiomyomataShorter hospital stay and reduced cost compared to surgical treatment8,9

Has been shown to be more cost-effective than hysterectomy19

Adenomyosis and fertility need to be further investigated


References1. Ravina JH, Herbreteau D. Arterial embolisation to treat uterine myomata. Lancet

1995;346:671-2.2. Goodwin SC, Wong GCH. Uterine artery embolization for uterine fibroids: A

radiologist’s perspective. Clin Ob Gyn 2001;44:412-424.3. Zupi E, Pocek M, Dauri M, et al. Selective uterine artery embolization in the

management of uterine myomas. Fertil Steril 2002;79:107-111.4. Andrews RT, Spies JB, Sacks D, et al. Patient care and uterine artery

embolization for leiomyomata. J Vasc Interv Radiol 2004;15:115-120. 5. Kjerulff KH, Erickson AB, Langerberg PW. Chronic gynecologic conditions

reported by US women: Findings from the National Health Interview Survey, 1984 to 1992. Am J Public Health 1996;86:195-6.

6. Broder MS, Goodwin S, Chen G, et al. Comparison of long-term outcomes of myomectomy and uterine artery embolization. Ob Gyn 2002;100:864-8.

7. Pron G, Cohen M, Soucie J, et al. The Ontario uterine fibroid embolization trial. Part 1. Baseline patient characteristics, fibroid burden, and impact on life. Fertil Steril 2003;79:112-9.

8. Buttram VC Jr, Reiter RC. Uterine leiomyomata: etiology, symptomatology, and management. Fertil Steril 1981;36:433-445.


References, cont.9. Walker WJ, Pelage JP. Uterine artery embolization for symptomatic fibroids:

clinical results in 400 women with imaging follow up. BJOG 2002;109:1262- 1272.

10. Murase E, Siegelman ES, Outwater EK, et al. Uterine leiomyomas: Histopathologic features, MR imaging findings, differential diagnosis, and treatment. RadioGraphics 1999;19:1179-1197.

11. Pelage JP, Jacob D, Fazel A, et al. Midterm results of uterine artery embolization for symptomatic adenomyosis: Initial experience. Radiology 2005;234:948-953.

12. Ghai S, Rajan DK, Benjamin MS, et al. Uterine artery embolization for leiomyomas: Pre- and postprocedural evaluation with US. RadioGraphics 2005;25:1159-1176.

13. Pron G, Bennett J, Common A, et al. The Ontario uterine fibroid embolization trial. Part 2. Uterine fibroid reduction and symptom relief after uterine artery embolization for fibroids. Fertil Steril 79:120-7.

14. Omary RA, Vasireddy S, Chrisman HB, et al. The effect of pelvic MR imaging on the diagnosis and treatment of women with presumed symptomatic uterine fibroids. J Vasc Interv Radiol 2002;13:1149-1153.


References, cont.15. Spies JB, Spector A, Roth AR, et al. Complications after uterine artery

embolization for leiomyomas. OB Gyn 2002;100:873-880.16. Roberts: Clinical Procedures in Emergency Medicine, 4th ed. 2004 Elsevier.

Accessed online 8/13/05.17. Gray, Henry. Anatomy of the Human Body, 20th Ed. Accessed on bartleby.com

9/13/05. 18. Fellmeth B, Bookstein JJ, Lurie A. Ultralong, reverse-curve angiographic

catheter. Radiol 1989;172:872-3.19. Beinfeld MT, Bosch JL, Isaacson KB, et al. Cost-effectiveness of uterine artery

embolization and hysterectomy for uterine fibroids. Radiol 2004;230:207-213.