role of u
on in gyynecologgy practicce
e intertrollinor cay withgynec
nancy, gestational trophoblastic disease or carcinoma cervix.Cu
Wo98%earounmajorimprovement and improvement in the overall quality oflife following UAE. Pregnancies have been reported afterthe procedure. However, pregnancy outcome was worsewhen compared with that of the general population. Miscar-
between the two approaches, reproductive outcome wassuperior in the myomectomy group.7
Uterine broid embolization has several advantages over
aConsultant Vascular and Interventional Radiology, bSenior consultant, Department of Obstetrics and Gynaecology, Apollo Hospitals, Banner-
Apollo Medicine 2012 SeptemberVolume 9, Number 3; pp. 206e211 Review Articleriage rates are higher; the risk for abnormal placentation isincreased; and an increased incidence of preterm deliveryand postpartum hemorrhage has been reported.
conventional hormone suppression (progestogens andGnRHanalogs) and surgical procedures (myomectomy, hysterec-tomy), including avoidance of the side effects of drug therapyand postoperative complications resulting from surgery.8ghatta*CorreReceivCopyrihttp://drrently, UAE is being used mostly for treating uterines. UAE is recommended to women with symptom-broids who wish to retain their uteruses and avoidy. It selectively blocks the feeding arteries that supplyto the broids and causes ischemic necrosis and
quent absorption or expulsion of leiomyoma.1
rldwide technical success rates reported for UAE are100%.2e4 The decrease in broid and uterine size isd 50% by the end of the rst year post procedure. Theity of patients have reported signicant symptom
SURGERY VERSUS EMBOLIZATION
Few randomized controlled trials have compared UAEsurgical management. The EMMY trial (EMbolizversus hysterectoMY) reported similar symptom imprment rates between the two groups, and 76.5% of patrandomized to UAE were able to avoid surgery.6 Theby Mara and colleagues compared myomectomyUAE. Although symptom improvement was siThe role of uterine artery emboliz
S. Kheda Amitha Vikramaa,*, Ramamurthy Chit
Uterine artery embolization (UAE) is a minimally invasivsupply to the uterus. UAE has been very useful for concervical pregnancy, gestational trophoblastic diseasetreating uterine broids. It requires a shorter hospital stasummarizes the role of this relatively new technique in
Copyright 2012, Indraprastha Medical Corporation L
Keyword: Uterine artery embolization, Hemorrhage, In
Uterine artery embolization (UAE) is a relatively new, mini-mally invasive interventional radiological technique toocclude the arterial supply to the uterus. UAE has been prac-ticed over more than 20 years for controlling hemorrhagefollowing delivery/abortion, in ectopic or cervical preg-Road, Bangalore 560076, India.sponding author. email: email@example.com:30.3.2012; Accepted: 29.6.2012; Available online: 5.7.2012ght 2012, Indraprastha Medical Corporation Ltd. All rights reservedx.doi.org/10.1016/j.apme.2012.06.008HISTORICAL ASPECTS
UAE was rst reported in 1995, by Ravina et al.5 Theynoted that several women with symptomatic leiomyomatawho underwent UAE as a pre-hysterectomy treatment hadsignicant clinical improvement to an extent that hysterec-tomy was no longer required.n in gynecology practice
ventional radiological procedure to occlude the arterialg hemorrhage following delivery/abortion, in ectopic orrcinoma cervix. Currently it is being mostly used forearly resumption to normal activity. This review brieyologic practice.
conservative treatment involving vaginal packing and admin-
Major causes of bleeding include uterine atony, lower
genital tract lacerations or hematoma, retained placentaltissue, placenta accreta or percreta, rupture or inversion ofthe uterus and coagulopathy. Secondary postpartum hemor-rhage occurring more than 24 h after delivery is mainlyrelated to retained gestational products. In a study involving27 cases of primary postpartum hemorrhage, Pelage et al12
reported that selective arterial embolization was successfulin 25 cases after failure of medical management. Emboliza-tion failed in one of the patients with palcenta accreta wholater underwent hysterectomy.
Placenta accreta is one of the major causes of hysterec-13istration of uterotonic drugs. With persistent bleeding,vascular ligation or hysterectomy may be needed.11 Surgicaltreatment, however, sometimes may be technically difcultto perform and may fail to control hemorrhage. For thesereasons, transcatheter embolization of the uterine arteriesmay represent an interesting alternate technique in the treat-ment of intractable bleeding, preserving future fertility.The advantages of UAE compared with hysterectomyinclude avoidance of surgical risks, shorter hospitalization,and the potential for maintaining fertility. However, onemust remember that, unlike hysterectomy, UAE is palliativerather than curative.
UAE patients can expect excellent short-term and mid-term results with regards to menorrhagia, pelvic pain,bulk-related symptoms, and reductions in uterine volume.Longer term results are not known.
Recovery is shorter than recovery from hysterectomy oropen myomectomy (7e10 days versus 6 weeks).3,9
Symptomatic broids, dysfunctional uterine bleeding,adenomyosis; excessive bleeding due to uterine artery pseu-doaneurysm, arterio-venous malformations, trauma andpost curettage.
EMBOLIZATION IN POSTPARTUMHEMORRHAGE
Postpartum hemorrhage remains a major cause of maternalmortality throughout the world.10 Rapid identication ofthe source and control of bleeding are necessary becausethe situation is potentially life threatening. In most cases,primary postpartum hemorrhage can be managed with
The role of uterine artery embolizationtomy after embolization because of persistent bleeding.Failures are also likely to occur with unilateral treatmentand in patients who have undergone bilateral ligation ofthe hypogastric artery before embolization.A complete history and physical examination is necessary,as well as ultrasonographic or magnetic resonance imaging(MRI) of pelvis to allow proper treatment. Uterine andbroid volume measurements provide a baseline for deter-mining the degree of postprocedural reduction in broidand uterine volume.
In a preliminary report, Jha et al attached prognosticsignicance to both the location and vascularity of broidson MR imaging.14 Mizukami et al also have reporteda possible prognostic value for preprocedural MRI bydemonstrating better response to embolization in patientswith intermediate or high-signal intensity within theirbroids on T2-weighted images (Fig. 7).15
Laboratory studies include hematocrit, coagulationprole and serum creatinine.
Withhold GnRH agonist therapy at least 12 weeks prior tothe procedure. Premedication is usually with prophylacticantibiotics, corticosteroids, antiemetics, and analgesics.UAE is usually performed under conscious sedation. Corti-costeroids are well documented to reduce the incidence ofpostembolization syndrome after embolization of solidtumors. John J. Bissler et al16 reported that the use ofa short-term tapering dose of corticosteroid was successfulin reducing postembolization syndrome as compared withthe reported literature and also improved patient comfort.
The procedure time is 45e135 min with 90% of the proce-dures lasting from 50 to 75 min. There is an average proce-dural exposure of 20 rad to the ovaries. Most patients aredischarged within 24 h; however, hospitalization for up to48 h is sometimes required for the management of postop-erative pain. The majority of patients return to normal activ-ities within 1 week.17
Common femoral artery is punctured using an 18GCONTRAINDICATIONS
Absolute contraindications include active infection andpregnancy. Relative contraindications include coagulop-athy, severe allergy to iodinated contrast, renal insuf-ciency, prior pelvic irradiation and prior bilateral ligationof iliac arteries. It is also not advisable in women desirousof future pregnancy.
Review Article 207puncture needle and access secured by a 5F sheath. Usuallythe right common femoral artery is punctured and rarelybilateral punctures may be required. A pigtail catheter ispositioned at the lower abdominal aorta and a ush
angiogram is obtained to identify the right and left uterinearteries; ovarian, lumbar, or other collateral parasiticsupplies to a large myomatous uterus may be seen. Uterinearteries are the predominant feeders in most of the cases(Figs. 1, 3 and 5). They are selectively cannulated usinga 5F catheter or a microcatheter and embolized using300e500 or 500e700 micron poly-vinyl-alcohol (PVA)particles, sparing the cervico-vaginal branch (Figs. 2, 4and 6).
Histologically, PVA particles adhere to the vessel wall,causing slow ow within that vessel. The result is intralu-minal thrombus formation, inammatory reaction,foreign-body reaction, and focal angionecrosis of the vesselwall. The foreign-body reaction induced by PVA is re-ported to persist up to 28 months after embolization.
Most patients will have postembolization syndrome which
Fig. 2 Postembolization check angiogram showing non-opa-cication of the uterine artery and opacication of the cervico-vaginal branch which is not embolized.
208 Apollo Medicine 2012 September; Vol. 9, No. 3 Amitha Vikrama and Chitrais similar to solid tumor postembolization syndrome andtypically las