November 2001 Uterine Fibroid Embolization: A Case Based Introduction Cicero R. Habito University of the Philippines College of Medicine (Visiting Clerk, Harvard Medical School)
Cicero Student R. Name Habito 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
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
Sagittal Pelvic MRI fibroids cervix vagina 4
Sagittal Pelvic MRI fibroids 5
Diagnosis: Multiple Uterine Fibroids, predominantly of the Intramural Type 6
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 arteries feeding fibroids Uterine fibroids From www.ufecenter.com 7
Fibroids Fibroids are named according to their position in the uterus: submucosal, intramural and subserosal from www.fibroidworld.com 8
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 9
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
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
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
myomectomy Surgical management 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 Uterus: Pre and Post Myomectomy Excised fibroid/myoma From www.isisfertility.com 13
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 View of Uterus Intraoperatively From www.vesalius.com 14
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
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
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
UFE: Procedure Uses angiographic techniques to place a catheter into uterine arteries Patient under conscious sedation and local anesthesia From www.ufecenter.com 18
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
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
Review of Pelvic Vasculature From http://esap.stanford.edu 21
Aortic bifurcation Common iliacs L Internal Iliac L External Iliac R Internal Iliac R External Iliac Aortogram (runoff study) 22
L internal iliac L uterine artery Iliac arteries (RPO) 23
Feeding vessels catheter L uterine artery Selective arteriogram of L uterine artery 24
blush showing prominent blood supply Selective Arteriogram of L uterine artery (mid to late phase) 25
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
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
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
Cessation of flow Selective Arteriogram of L Uterine Artery Post Embolization 29
Selective occlusion of L uterine artery Selective Arteriogram of L Uterine Artery Post Embolization 30
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
Uterine artery Selective Arteriogram of R Uterine Artery Pre Embolization 32
blush showing prominent blood supply Selective Arteriogram of R Uterine Artery Pre Embolization 33
Cessation of flow through R uterine artery Selective Arteriogram of L Uterine Artery Post Embolization 34
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
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
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
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 From www.uterinefibroids.com 38
Controversies Exposure of the Ovaries to Radiation? Fertility status post embolization? Long term effects of PVA particles in body? 39
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Cicero Student R. Name Habito 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
Cicero Student R. Name Habito Acknowledgements Many thanks to the following who helped make this presentation possible: Pamela Lepkowski BIDMC Interventional Radiology Staff Bijan Sadri George Dyer 43