Download Uterine Fibroid Embolization: A Case Based Introduction

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