Download Uterine Artery Embolization

Arghavan Salles MSIV
Gillian Lieberman, MD
Uterine Artery
Embolization
Arghavan Salles
Advanced Radiology
September 15, 2005
Arghavan Salles MSIV
Gillian Lieberman, MD
Overview
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
Case presentation
Imaging and leiomyomata
Classification of leiomyomata
Selection for UAE
UAE technique
Post-procedural care and complications
Further investigations
References
Arghavan Salles MSIV
Gillian Lieberman, MD
History
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Uterine 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, posthysterectomy1-3
It has also been used to treat arteriovenous
malformations of the pelvis, placenta previa, and
placenta accreta
In 1995, Ravina and Herbreteau1 were the first to
report the use of UAE for treatment of leiomyomata
after having incidentally noted shrinkage of fibroids
when using UAE for the above indications
Arghavan Salles MSIV
Gillian Lieberman, MD
Case
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46 year old woman with menorrhagia
Up to 24 consecutive days of menstruation
per cycle
Also feels abdominal pressure
Past medical and surgical history noncontributory
Ultrasound revealed fibroids prior to
consultation with the interventionalist
Pap smear and endometrial biopsy WNL
Arghavan Salles MSIV
Gillian Lieberman, MD
Work-up of Patients for UAE4
z
General medical history and physical examination
-important to ask about symptoms, pregnancy history, recent Pap
smears, and infection as part of complete history
z
Gynecologic examination
-important to rule out other causes for symptoms
z
Laboratory testing
-typically order CBC, PT/PTT/INR, BUN/creatinine to assess for
anemia, coagulopathy, renal insufficiency
z
Imaging
-Ultrasound or MRI
z
Pap test
Arghavan Salles MSIV
Gillian Lieberman, MD
Epidemiology of Leiomyomata
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Occur 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
Arghavan Salles MSIV
Gillian Lieberman, MD
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.
z Diffuse adenomyosis (ectopic endometrial glands
and stroma within the myometrium)
-symptoms are often similar to those resulting from leiomyomata
z
Focal adenomyosis (adenomyoma)
-may be distinguished from leiomyomata on MRI11
Arghavan Salles MSIV
Gillian Lieberman, MD
Differential Diagnosis, cont.
z
z
Solid adnexal mass
Focal myometrial contraction
-transient phenomenon that mimics leiomyomata and disappears
with repeat imaging
z
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
Arghavan Salles MSIV
Gillian Lieberman, MD
MRI for Pre-operative Planning
z
MR is the most accurate imaging technique for
detection and localization of leiomyomata for preoperative planning2,4,9,10,12-14
-Ultrasound may be used but is less accurate, especially in obese
patients
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MR 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
Arghavan Salles MSIV
Gillian Lieberman, MD
MRI for Pre-operative
Planning, cont.
z
Pedunculated subserosal and submucosal
leiomyomata 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
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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
Arghavan Salles MSIV
Gillian Lieberman, MD
Effect of MRI on Diagnosis14
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Interventional radiologists were asked to give pre-imaging and
post-imaging diagnoses and treatment plans for 60 women
evaluated for UAE
Axial HASTE, Axial GRE, Sagittal T2 TSE, and coronal SHARP
series were used
Initial diagnoses changed in 18% of cases
MRI detected unsuspected pelvic masses, demonstrated
adenomyosis, detected degenerated fibroids, and documented
lack of pelvic pathology
Changed 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
Arghavan Salles MSIV
Gillian Lieberman, MD
MRI Characteristics
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Nondegenerated uterine leiomyomata are
well-circumscribed masses with
homogeneously decreased signal intensity
compared to the outer myometrium on T2weighted images10
Cellular leiomyomas may have higher signal
intensity on T2-weighted images and
enhance post-contrast10
Arghavan Salles MSIV
Gillian Lieberman, MD
MRI Characteristics, cont.
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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.
z
It is important to assess enhancement because
lesions that do not enhance are not as likely to
respond well to embolization
Arghavan Salles MSIV
Gillian Lieberman, MD
MRI Characteristics, cont.
Don’t forget our differential diagnoses:
z Focal myometrial contraction
-low signal on T2-weighted images11
z 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
z 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
Arghavan Salles MSIV
Gillian Lieberman, MD
Normal Uterus
Endometrial
stripe
Uterus
Bladder
Cervix
Vagina
T2-weighted sagittal image
PACS, BIDMC
Arghavan Salles MSIV
Gillian Lieberman, MD
Our patient
Endometrial
stripe
Intramural
Uterus
Subserosal
T2-weighted sagittal image
showing leiomyomata in
various locations with
homogenous signal
characteristics
PACS, BIDMC
Arghavan Salles MSIV
Gillian Lieberman, MD
Our patient
Endometrial
stripe
Intramural
Uterus
T2-weighted axial
image of the same
patient
PACS, BIDMC
Arghavan Salles MSIV
Gillian Lieberman, MD
Vasculature
Enhancement
PACS, BIDMC
T1-weighted post-contrast image in the same
patient showing enhancement of leiomyomata
with dilated uterine arteries (white arrows)
Arghavan Salles MSIV
Gillian Lieberman, MD
Classification of
Leiomyomata10
Most commonly occur in the myometrium of the uterus
but may occur in cervix (8% of the time)
z Submucosal
z
-project into endometrial canal
-least common subtype but most often
symptomatic
z Intramural
-within myometrium
-most common subtype, usually asymptomatic
z Subserosal
-beneath the serosa
-if pedunculated, may torse and cause pain or
infection
Ghai, et al.
Arghavan Salles MSIV
Gillian Lieberman, MD
Examples of Leiomyomata
Subserosal
Adenomyosis
(junctional zone
measures ~15 mm)
Intramural
Submucosal
T2-weighted sagittal image
PACS, BIDMC
Arghavan Salles MSIV
Gillian Lieberman, MD
More examples
Endometrial
Submucosal stripe
T2-weighted sagittal image
Intramural
Endometrial
stripe
T2-weighted sagittal image
PACS, BIDMC
Arghavan Salles MSIV
Gillian Lieberman, MD
Enhancement
Leiomyoma
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
PACS, BIDMC
Arghavan Salles MSIV
Gillian Lieberman, MD
Indications for Intervention10
z
Bleeding
-most frequent symptom, usually manifests as menorrhagia or
menometrorrhagia
-menstrual irregularities may be due to loss of symmetric uterine
contractions
z
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
Arghavan Salles MSIV
Gillian Lieberman, MD
Indications for Intervention, cont.
z
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
z
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
Arghavan Salles MSIV
Gillian Lieberman, MD
Treatment Options10
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Medical Management
-GnRH inhibits the secretion of gonadotropinsÆhypoestrogenic
stateÆamenorrheaÆdecreased size of fibroids/uterus
-regrowth if stop treatment
-risk osteoporosis
-may use pre-operatively prior to hysterectomy, myomectomy, or
hysteroscopic myomectomy
z
Hysterectomy
-traditional option, does not preserve fertility
z
Myolysis
-neodymium:yttrium-aluminum-garnet laser or bipolar needle electrodes
-thermal injury leads to degeneration
-may also lead to pelvic adhesions
Arghavan Salles MSIV
Gillian Lieberman, MD
Treatment Options, cont.
z
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
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Uterine Artery Embolization
-inject various particles into uterine artery to achieve stasis
-may preserve fertility (see Fertility? slides)
Arghavan Salles MSIV
Gillian Lieberman, MD
Comparing Options15
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400 consecutive patients were followed after
UAE
Complications were categorized using two
classification systems:
-Society of Cardiovascular and Interventional Radiology
-American College of Obstetricians and Gynecologists
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Date on complications over the first 30 days
were reported
Arghavan Salles MSIV
Gillian Lieberman, MD
Comparing Options15
Procedure
LifeUnintended
threatening procedures
events
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
Arghavan Salles MSIV
Gillian Lieberman, MD
Selection for UAE4
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Symptomatic leiomyomata
Exclusion of those who are pregnant, have a
pelvic malignancy, or have active pelvic
infection
Patient choice
Arghavan Salles MSIV
Gillian Lieberman, MD
Relative Contraindications to
UAE2,4
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Coagulopathy
Severe allergy to contrast material
Renal impairment
Immunocompromised
Previous pelvic irradiation or surgery
Chronic endometritis
Strong desire for future fertility
Suberosal pedunculated lesions (usually safe if the
attachment to the uterus spans more than 50% of
the diameter of a subserosal lesion)
Arghavan Salles MSIV
Gillian Lieberman, MD
Seldinger Technique16
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Technique used for
interventional procedures
Insert needle
Insert wire through needle
Enlarge skin incision
Exchange needle for
sheath and dilator
Remove dilator and use
sheath
Arghavan Salles MSIV
Gillian Lieberman, MD
Vascular Anatomy17
Arghavan Salles MSIV
Gillian Lieberman, MD
Angiographic Safety
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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
Arghavan Salles MSIV
Gillian Lieberman, MD
UAE Technique: I 4,15
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Usually unilateral femoral approach using 4
or 5 French catheter
Perform abdominal arteriogram with digital
subtraction with ileofemoral run-off to visual
vessels
-assess for arteriovenous malformations, shunting,
collateral vessels (ovarian, round ligament, cervical,
pelvic)
Arghavan Salles MSIV
Gillian Lieberman, MD
Abdominal Arteriogram
Catheter in aorta
Left internal iliac
artery
Right internal iliac
artery
PACS, BIDMC
Right uterine artery
Left uterine artery
Arghavan Salles MSIV
Gillian Lieberman, MD
UAE Technique: II
z
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
z
Access uterine arteries using Tracker
catheter and perform arteriogram
Arghavan Salles MSIV
Gillian Lieberman, MD
Prior to Embolization
Left Uterine Artery
Right Uterine Artery
Catheter
Left uterine artery
Right uterine artery
PACS, BIDMC
Arghavan Salles MSIV
Gillian Lieberman, MD
UAE Technique: III
z
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Inject embolization agent of choice
Target is distal occlusion of arteries feeding
leiomyomata
End-point is usually complete occlusion of
vessels
Access both uterine arteries and perform
arteriogram again to demonstrate decreased
flow
Arghavan Salles MSIV
Gillian Lieberman, MD
Embolization Materials
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Polyvinyl alcohol (usually 355-500 microns)
Tris-acryl gelatin microspheres
Gelatin sponge particles
Must avoid vasospasm for adequate delivery
of particles9
-may use nitroglycerin to treat vasospasm
Arghavan Salles MSIV
Gillian Lieberman, MD
After embolization
Left Internal Iliac Artery
Right Internal Iliac Artery
Catheter
Right uterine artery—occluded
Left uterine artery—occluded
PACS, BIDMC
Arghavan Salles MSIV
Gillian Lieberman, MD
Consequences of UAE5
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Myoma necrosis
Reduced uterine volume
-most decrease may occur within the first six months although
further decrease occurs after that12,13
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Improved menorrhagia
Decreased pelvic pain
Arghavan Salles MSIV
Gillian Lieberman, MD
Efficacy of UAE
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Return 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 leiomyomata
because these may have an alternate blood supply from ovarian
arteries or from other organs to which they may be attached12
Arghavan Salles MSIV
Gillian Lieberman, MD
Efficacy, cont.
z
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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
z
Ovarian collateral supply, unrecognized malignancy,
misdiagnosis of adenomyosis, underembolization
may all lead to treatment failure4,13
Arghavan Salles MSIV
Gillian Lieberman, MD
Complications3,15
Based on two separate studies of 400 women in each
study:
z Febrile morbidity (2%)
-post-embolization fever is common within the first few postprocedural days
z
z
z
Hemorrhage (0.75%)
Unintended procedure (2.5%)
Life-threatening events (0.5%)
-pulmonary embolus
-one case of septic shock
Arghavan Salles MSIV
Gillian Lieberman, MD
Complications, cont.
z
Readmission (3.5%)
-infection was most likely to occur in women with large
fibroids or pedunculated subserosal fibroids
z
z
z
Overall morbidity (5%)
Fibrosis of uterus (rare)
Premature ovarian failure, infections, uterine
discharge, necrosis, death from sepsis
Arghavan Salles MSIV
Gillian Lieberman, MD
Periprocedural Concerns
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Usually conscious sedation is used during the procedure
Some may give antibiotics, but there is no consensus on
what to use
Important to monitor patient’s radiation dose
Most interventionalists admit the patients for a short stay
Pain
-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-up
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Nausea
-second most common complaint post-procedure
Arghavan Salles MSIV
Gillian Lieberman, MD
Post-procedural Care4
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Follow-up phone call within 24-48 hours to monitor
pain/nausea control
If 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 antibiotics
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Office visit 1-3 weeks after procedure
-assess symptoms, healing
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Imaging 3-6 months after procedure
Long-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
Arghavan Salles MSIV
Gillian Lieberman, MD
MR Monitoring: 1/3/05
Pre-embolization, T2-weighted axial
image showing large intramural
fibroids
Pre-embolization, Post-gadolinium T1weighted image shows the lesions are
avidly enhancing.
PACS, BIDMC
Arghavan Salles MSIV
Gillian Lieberman, MD
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
Arghavan Salles MSIV
Gillian Lieberman, MD
Questions
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Is UAE effective in treating patients with
adenomyosis?
Does UAE preserve fertility?
Arghavan Salles MSIV
Gillian Lieberman, MD
Adenomyosis
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The efficacy is UAE in patients with adenomyosis is
difficult to assess as most patients with
adenomyosis also have leiomyomata
There 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
Arghavan Salles MSIV
Gillian Lieberman, MD
Fertility?
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z
z
It is unclear whether UAE preserves fertility
in women
Some 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
Arghavan Salles MSIV
Gillian Lieberman, MD
Fertility?, cont.
z
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
z
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
Arghavan Salles MSIV
Gillian Lieberman, MD
Conclusion
z
z
z
z
z
UAE has fewer complications than other
interventions9,15
Minimally invasive, safe way to treat uterine
leiomyomata
Shorter 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
Arghavan Salles MSIV
Gillian Lieberman, MD
References
1. 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.
Arghavan Salles MSIV
Gillian Lieberman, MD
References, cont.
9. Walker WJ, Pelage JP. Uterine artery embolization for symptomatic fibroids:
clinical results in 400 women with imaging follow up. BJOG 2002;109:12621272.
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.
Arghavan Salles MSIV
Gillian Lieberman, MD
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.