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Cicero R. Habito Gillian Lieberman, MD November 2001 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 StudentR. Cicero Name Habito Gillian Lieberman, MD Agenda I. Patient Presentation II. Discussion A. What are Fibroids? B. Signs and symptoms C. Treatment Options D. Uterine Artery Embolization as a Treatment Procedure E. Literature Review 2 Cicero R. Habito Gillian 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 3 Cicero R. Habito Gillian Lieberman, MD Sagittal Pelvic MRI fibroids cervix vagina 4 Cicero R. Habito Gillian Lieberman, MD Sagittal Pelvic MRI fibroids 5 Cicero R. Habito Gillian Lieberman, MD Diagnosis: Multiple Uterine Fibroids, predominantly of the Intramural Type 6 Cicero R. Habito Gillian Lieberman, MD Fibroids • Benign tumors of uterine smooth muscle • uterine fibroid = leiomyoma/fibromyoma • not considered to be precancerous • may arise in various parts of the uterus • single most common cause for hysterectomy Uterine fibroids Uterine arteries feeding fibroids From www.ufecenter.com 7 Cicero R. Habito Gillian Lieberman, MD Fibroids • Fibroids are named according to their position in the uterus: submucosal, intramural and subserosal from www.fibroidworld.com 8 Cicero R. Habito Gillian 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, AfricanAmericans, and overweight women 9 Cicero R. Habito Gillian 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? 10 Cicero R. Habito Gillian 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... 11 Cicero R. Habito Gillian 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 12 Cicero R. Habito Gillian Lieberman, MD Surgical management Uterus: Pre and Post Myomectomy • 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 Excised fibroid/myoma From www.isisfertility.com 13 Cicero R. Habito Gillian Lieberman, MD Surgical management View of Uterus Intraoperatively • 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 14 Cicero R. Habito Gillian 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 15 Cicero R. Habito Gillian 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 16 Cicero R. Habito Gillian 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) 17 Cicero R. Habito Gillian 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 18 Cicero R. Habito Gillian 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 19 Cicero R. Habito Gillian 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 20 Cicero R. Habito Gillian Lieberman, MD Review of Pelvic Vasculature From http://esap.stanford.edu 21 Cicero R. Habito Gillian Lieberman, MD Aortic bifurcation Common iliacs L Internal Iliac R Internal Iliac L External Iliac R External Iliac 22 Aortogram (runoff study) Cicero R. Habito Gillian Lieberman, MD L internal iliac L uterine artery Iliac arteries (RPO) 23 Cicero R. Habito Gillian Lieberman, MD Feeding vessels catheter L uterine artery Selective arteriogram of L uterine artery 24 Cicero R. Habito Gillian Lieberman, MD “blush” showing prominent blood supply Selective Arteriogram of L uterine artery (mid to late phase) 25 Cicero R. Habito Gillian 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 26 Cicero R. Habito Gillian 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. 27 Cicero R. Habito Gillian Lieberman, MD Polyvinyl Alcohol • 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. 28 Cicero R. Habito Gillian Lieberman, MD Cessation of flow 29 Selective Arteriogram of L Uterine Artery Post Embolization Cicero R. Habito Gillian Lieberman, MD Selective occlusion of L uterine artery Selective Arteriogram of L Uterine Artery Post Embolization 30 Cicero R. Habito Gillian 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 31 Cicero R. Habito Gillian Lieberman, MD Uterine artery Selective Arteriogram of R Uterine Artery Pre Embolization 32 Cicero R. Habito Gillian Lieberman, MD “blush” showing prominent blood supply Selective Arteriogram of R Uterine Artery Pre Embolization 33 Cicero R. Habito Gillian Lieberman, MD Cessation of flow through R uterine artery Selective Arteriogram of L Uterine Artery Post Embolization 34 Cicero R. Habito Gillian 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 35 Cicero R. Habito Gillian 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 36 Cicero R. Habito Gillian 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 37 Cicero R. Habito Gillian 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 38 Cicero R. Habito Gillian Lieberman, MD Controversies • Exposure of the Ovaries to Radiation? • Fertility status post embolization? • Long term effects of PVA particles in body? 39 Cicero R. Habito Gillian Lieberman, MD 40 Cicero R. Habito Gillian Lieberman, MD 41 StudentR. Cicero Name Habito Gillian 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 42 StudentR. Cicero Name Habito Gillian Lieberman, MD Acknowledgements • Many thanks to the following who helped make this presentation possible: • Gillian Lieberman, MD • Pamela Lepkowski • BIDMC Interventional Radiology Staff • Bijan Sadri • George Dyer 43