Uterine Fibroid Embolization - Lieberman's eRadiologyeradiology.bidmc.harvard.edu/LearningLab/genito/powell2.pdf · 3 Anthony Powell Gillian Lieberman, MD Uterine Fibroids zLeiomyoma-

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Anthony PowellGillian Lieberman, MD

Uterine Fibroid Uterine Fibroid EmbolizationEmbolization

Anthony Powell, HMS IVBeth Israel Deaconess Medical Center

Gillian Lieberman, MD

September 2001

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Patient, CMPatient, CM48 yo F, pre-menopausal with unremarkable past medical historyDeveloped abnormal uterine bleeding 4 years ago, initially as heavy bleeding w/ periods (menorrhagia). Within past 1.5 years had progressed to consistent bleeding every day. Has had an associated anemia for 2 years.Over past 2 months she developed pelvic pain, worse with menstruation.Dx’d with large uterine fibroid approx 2 years ago. Was followed initially, and showed little change in size over 2 years. Pt bothered by worsening sx’s over last few months. She does not desire treatment with medicine, and is reluctant to undergo surgery

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Uterine FibroidsUterine Fibroids

Leiomyoma- benign proliferation of uterine smooth muscle cellsHormonally responsive to estrogrogenGrowth during pregnancyRegression during menopause

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EpidemiologyEpidemiology

20% - 30% of women develop fibroids by age 403 to 9 times higher incidence in African-American womenIncreased incidence during pregnancyMalignant conversion to leiomyosarcoma is extremely rare

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History and SymptomsHistory and Symptoms

50% - 65% of patients are asymptomaticAbnormal uterine bleeding most common symptom (+/- anemia)Pelvic pressure / painIncreased infertilityMass effect:– urinary symptoms– constipation

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Classification Based on Classification Based on LocationLocation

SubmucosalIntramural (most common)SubserosalPedunculatedParasitic (becomes attached to pelvic viscera and develops own blood supply)

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Common LocationsCommon Locations

Image: Callahan TL, Caughey AB, Heffner LJ: Blueprints in Obstetrics and Gynecology, 2nd ed. Blackwell, 2001

Pedunculated

Submucosal

IntramuralSubserosal

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Ultrasound Imaging of Ultrasound Imaging of FibroidsFibroids

Most common diagnostic toolHypoechoic compared to normal myometriumHeterogeneousAppear somewhat circumscribedMust differentiate from Focal MyometrialContractions (FMC) isoechoic, transient, homogenous

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US image of Fibroid US image of Fibroid

Images: BIDMC, Dept of Radiology, 2001

Sagittal

Fibroid

UterusFibroid

US image of Fibroid US image of Fibroid

Images: BIDMC, Dept of Radiology, 2001 10


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Other Imaging OptionsOther Imaging Options

MRI excellent for determining size and position of fibroids pre-operativelyHysterosalpingogramHysteroscopy

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MR Imaging of MR Imaging of CM’sCM’s Fibroids, Fibroids, Coronal SectionsCoronal Sections


Bladder

Fibroids

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Fibroid


Bladder

Uterus

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Fibroids



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MR Imaging of MR Imaging of CM’sCM’s Fibroids,Fibroids, Axial SectionsAxial Sections


Fibroids

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Fibroids



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FibroidsFibroids

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Traditional Treatment of Traditional Treatment of FibroidsFibroids

Depends on size, location, age, pregnancy status, desire for future pregnancyMedical (hormonal tx):

Provera (progesterone)DanazolLupron (GnRH agonist)

Surgical: Myomectomy (open, laproscopic, hysteroscopic)Hysterectomy

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EmbolizationEmbolization TherapyTherapy

Deliberate blockage of blood vessels with embolic agentsUsually performed to stop hemorrhage (e.g. gibleed, post-partum hemorrhage)Also used as an adjunct to surgery in treatment of some benign and malignant tumors

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Key Steps for Safe Key Steps for Safe EmbolizationEmbolization

Quality preliminary angiography anatomy, planningConsider collateral pathways carefullyUse shortest, straightest approachAlways secure stable catheter positionVerify catheter position before introduction of embolic agentUse continuous floroscopy during embolization

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Mechanical Embolic AgentsMechanical Embolic Agents

Coils:– Provides permanent occlusion– For medium to small arteries– Mechanically occludes and promotes thromboembolism

via intimal damageBalloons:– Permanent occlusion of large vessels– Rarely used, requires experience

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Particulate Embolic AgentsParticulate Embolic Agents

Gelfoam– Temporary occlusion lasts a few days to weeks– When used for hemorrhage, will give vessel time to

healPolyvinyl Alcohol (PVA)– Permanent occlusion– For multiple small arteries, arterioles, or capillaries – Wedges in vessel causing thrombosis and fibrosis

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Liquid Embolic AgentsLiquid Embolic Agents

Act as sclerosantsMost difficult to control and least forgiving of error; requires considerable experienceSodium Tetradecyl Sulphate (SDS)– Used in embolization tx of varicocoeles

Absolute Alcohol (EtOH)– Causes cell death via dehydration thrombosis– Painful to patient

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Uterine Fibroid Uterine Fibroid EmbolizationEmbolization (UFE) (UFE)

Alternative to traditional medical and surgical txfor palliation of sx’s assoc w/ leiomyomaRavina first reported UFE in 1995Subsequent studies (Spies et al, Goodwin et al, Bradley et al, Worthington-Kirch et al) have shown UFE to be effective in controlling sx’s in 80%-90% of pts, as well as effective in substantially reducing fibroid size

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Indications for UFEIndications for UFE

Heavy menstrual bleeding (+/- anemia)Pelvic pain or pressureCompressive urinary symptomsFailure, refusal, unsuitability of medical txUnsuitability or undesired surgical tx?For pts who desire to maintain future fertility:– Failed previous myomectomy?– Last resort before hysterectomy?

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Uterine AnatomyUterine AnatomyBladder

Cervix of Uterus

Cardinal Ligament (transverse cervical lig)

Uterine artery

Internal Iliac artery

Images: Netter, FH: Atlas of Human Anatomy, 2nd ed. Novartis, 1997

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Arterial AnatomyArterial Anatomy

External Iliac artery

Internal Iliac artery

Obturator artery

Umbilical artery

Uterine artery


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Arterial AnatomyArterial AnatomyAbdominal Aorta A.

External Iliac A.

Internal Iliac A.

Common Iliac A.

Obturator A.

Umbilical A.

Uterine A.

Superior Gluteal A.

Inferior Gluteal A.

Internal Pudendal A.


AnteriorPosterior

The uterine artery is the 3rd anterior branch of the internal iliac artery

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ProcedureProcedure

1. Pre-procedural imaging US vs. MRI 2. IV antibiotics (skin flora and gram – coverage)

and conscious sedation3. Femoral arterial access4. Angiography for visualization of arterial

anatomy and fibroids5. Bilateral selective uterine artery catheterization

with 5 F catheter under fluoroscopic guidance6. Catheter placement into transverse portion of

uterine artery (in cardinal ligament)

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ProcedureProcedure

7 Identification of arterial anatomy and branches feeding fibroids using angiography

8 Embolization with PVA particles (mixed w/ lidocaine and contrast) until stasis or near stasis

9 Final arteriogram to ensure adequate embolization (like to see residual flow to normal myometrial branches)

10 Post-procedure observation (usu overnight stay)11 Pain control12 Follow-up clinic, and possibly f/u imaging

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CM’sCM’s UFE ImagesUFE Images

Pre-embolization angiography



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Internal iliac artery

Catheter in external

iliac artery

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Right Internal Iliac Right Internal Iliac CatheterizationCatheterization



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Fibroid



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Fibroid



Fibroid

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Selective Right Uterine Artery Selective Right Uterine Artery CatheterizationCatheterization



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Fibroid

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Left Internal Iliac Left Internal Iliac CatheterizationCatheterization



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Selective Left Uterine Artery Selective Left Uterine Artery CatheterizationCatheterization



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Fibroid

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Post Post EmbolizationEmbolization AngiographyAngiography



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Left coronary iliac aa

Left external iliac aa

Left internal iliac aa

Images: BIDMC, Dept of Radiology, 2001 51


Note: Post embolization obliteration of arterial supply to the fibroid

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Risks / ComplicationsRisks / Complications

Vessel dissection or injuryPost-embolization syndrome severe pain, fever, n/v, and myalgias (secondary to systemic inflammatory mediators from tissue infarction)Non-target embolizationEndometritis, sepsis, or abscess formationMenstrual irregularity, transient ammenorrheaSpontaneous passage of fibroid material Premature menopause

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Major Studies of UFEMajor Studies of UFESpies, et. al. b/l UFE in 61 pts w/symptomatic fibroids:

– 89% pts had improvement of menstrual bleeding (mean f/u 8.7 mo)– 96% pts had improvement of pelvic pressure/pain (mean f/u 8.7 mo)– Median uterine vol. reduction of 48% (mean f/u 12.3 mo)– Median dominant fibroid vol. red of 78% (mean f/u 12.3 mo)– 95% of pts were satisfied w/ procedure

Goodwin, et. al. UFE in 60 pts w/symptomatic fibroids:– 81% pts had improvement of sx’s (mean f/u 16.3 mo)– Mean uterine vol. reduction of 42.8% (mean f/u 10.2 mo)– Mean dominant fibroid vol. red of 48.8% (mean f/u 10.2 mo)

Worthington-Kirsh et. al. 53 pts w/symptomatic fibroids:– 88% pts had marked improvement in menstrual bleeding (mean f/u 3 mo)– Mean reduction in fibroid volume of 78% (mean f/u 3 mo)

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ConclusionsConclusions

UFE is a promising and effective alternative to surgical tx in that:

1. Appears effective in controlling symptoms of fibroids (80%-95% of pts experience improvement)

2. Appears effective in substantially reducing fibroid volume

3. Appears to result in a high level of patient satisfaction 4. Appears to be a safe treatment with relatively few

risks and complications(Spies et al, Goodwin et al, Worthington-Kirch et al)

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Future ConsiderationsFuture Considerations

Need for long-term f/u from ongoing trialsUnderstanding potential impact of UFE on future fertility/pregnancy?Determining whether symptoms / fibroids may recur long-termBetter collaboration with gynecologists (most pts now are via self-referral)Ultimately, the need for a randomized controlled clinical trial to compare UFE with myomectomy (gold standard)

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ReferencesReferencesNetter, FH: Atlas of Human Anatomy, 2nd ed. Novartis, 1997Kessel D, Robertson I: Interventional Radiology, a survival guide, 1st ed. Churchill Livingstone, 2000Callahan TL, Caughey AB, Heffner LJ: Blueprints in Obstetrics and Gynecology, 2nd ed. Blackwell, 2001Spies JB, Scialli AR, Jha RC, et al. Initial Results from uterine fibroid embolization for symptomatic leiomyomata. JVIR 1999; 10:1149-1157Goodwin SC, McLucas B, Lee M, et al. Uterine artery embolization for the treatment of uterine leiomyomata. JVIR 1999; 10:1159-1165Bradley E, Reidy F, Forman RG, Jarosz J, Brause PR. Transcatherter uterine artery embolixation to treat large uterine fibroids. Br J Obstet Gyn 1998; 105:235-240Worthington-Kirsh R, Popky G, Hutchins F. Uterine arterial embolization for the management of leiomyomas: quality-of-life assessment and clinical response. Radiology 1998; 208:625-627Hovsepian DM. Uterine Fibroid Embolization: Another Paradigm Shift for Interventional Radiology? JVIR 1999; 10:1145-1147Beth Israel Deaconess Medical Center, Dept of Radiology, Teaching Files, 2001

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AcknowledgementsAcknowledgements

Pamela LepkowskiElvira Lang M.D.Ashutosh Rao M.D.Gillian Lieberman M.D.

Uterine Fibroid Embolization - Lieberman's eRadiologyeradiology.bidmc.harvard.edu/LearningLab/genito/powell2.pdf · 3 Anthony Powell Gillian Lieberman, MD Uterine Fibroids zLeiomyoma-

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