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
Cicero R. HabitoGillian Lieberman, MD
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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Cicero R. HabitoGillian Lieberman, MD
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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Cicero R. HabitoGillian Lieberman, MD
Diagnosis: Multiple Uterine Fibroids,
predominantly of the Intramural Type
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Cicero R. HabitoGillian Lieberman, MD
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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Cicero R. HabitoGillian Lieberman, MD
Fibroids
• Fibroids are named according to their position in the uterus: submucosal, intramural and subserosal
from www.fibroidworld.com
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Cicero R. HabitoGillian Lieberman, MD
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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Cicero R. HabitoGillian Lieberman, MD
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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Cicero R. HabitoGillian Lieberman, MD
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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Cicero R. HabitoGillian Lieberman, MD
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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Cicero R. HabitoGillian Lieberman, MD
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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Cicero R. HabitoGillian Lieberman, MD
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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Cicero R. HabitoGillian Lieberman, MD
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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Cicero R. HabitoGillian Lieberman, MD
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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Cicero R. HabitoGillian Lieberman, MD
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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Cicero R. HabitoGillian Lieberman, MD
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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Cicero R. HabitoGillian Lieberman, MD
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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Cicero R. HabitoGillian Lieberman, MD
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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Cicero R. HabitoGillian Lieberman, MD
Aortogram (runoff study)
Aortic bifurcation
R Internal IliacL Internal Iliac
Common iliacs
R External IliacL External Iliac
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Cicero R. HabitoGillian Lieberman, MD
catheter
L uterine artery
Selective arteriogram of L uterine artery
Feeding vessels
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Cicero R. HabitoGillian Lieberman, MD
Selective Arteriogram of L uterine artery (mid to late phase)
“blush” showing prominent blood supply
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Cicero R. HabitoGillian Lieberman, MD
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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Cicero R. HabitoGillian Lieberman, MD
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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Cicero R. HabitoGillian Lieberman, MD
• 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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Cicero R. HabitoGillian Lieberman, MD
Selective Arteriogram of L Uterine Artery Post Embolization
Cessation of flow
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Cicero R. HabitoGillian Lieberman, MD
Selective Arteriogram of L Uterine Artery Post Embolization
Selective occlusion of L uterine artery
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Cicero R. HabitoGillian Lieberman, MD
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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Cicero R. HabitoGillian Lieberman, MD
Selective Arteriogram of R Uterine Artery Pre Embolization
Uterine artery
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Cicero R. HabitoGillian Lieberman, MD
Selective Arteriogram of R Uterine Artery Pre Embolization
“blush” showing prominent blood supply
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Cicero R. HabitoGillian Lieberman, MD
Cessation of flow through R uterine artery
Selective Arteriogram of L Uterine Artery Post Embolization
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Cicero R. HabitoGillian Lieberman, MD
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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Cicero R. HabitoGillian Lieberman, MD
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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Cicero R. HabitoGillian Lieberman, MD
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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Cicero R. HabitoGillian Lieberman, MD
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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Cicero R. HabitoGillian Lieberman, MD
Controversies
• Exposure of the Ovaries to Radiation?• Fertility status post embolization?• Long term effects of PVA particles in body?
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Cicero R. HabitoGillian Lieberman, MD
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
Student NameGillian Lieberman, MD