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Uterine artery embolisation for management of uterine fibroids

Uterine artery embolisation (UAE) is an image-guided, minimally-invasive procedure performed by interventional radiologists to treat women with symptomatic uterine fibroids. Prospective, randomised studies such as the EMMY (embolisation vs hysterectomy) and REST trials that compare UAE with hysterectomy confirm that the procedure is a safe and effective alternative to hysterectomy for fibroid disease.

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Figure A: Embolic particles occluding the arterial perfusion of fibroid tissue

Embolisation particles (500-to-700um) are injected through a catheter under fluoroscopic guidance into the uterine arteries. The embolic particles stop the perfusion of the fibroid tissue, inducing infarction, resulting in a progressive reduction in fibroid volume over time, with symptomatic relief.

Selection

Patients are referred to Interventional Radiology (IR) for consideration of UAE by a gynaecologist. Prior to a consultation with IR, contrast-enhanced magnetic resonance imaging (MRI) is performed to determine the volume, distribution and perfusion of fibroid tissue and exclude further pathology.

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Figure B: Selective catheterisation of the left uterine artery demonstrates the vascularity of fibroid tissue pre-embolisation

A consultation is performed in the interventional radiology clinic, where the patient is provided with a detailed overview of their imaging and UAE prior to obtaining informed consent weeks prior to booking.

Indication

UAE is indicated for symptoms related to uterine fibroid disease, specifically heavy menstrual bleeding, severe dysmenorrhoea or anaemia (level I evidence). UAE is also indicated for fibroid-related pelvic pain or urinary urgency and bowel symptoms (level III evidence).

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Figure C: Reduced perfusion of the fibroid tissue during embolisation

Contraindications

UAE is contraindicated in pregnancy, active pelvic inflammatory disease or gynaecological cancer. General contraindications to IR procedures include contrast allergy, impaired renal function and coagulopathy.

The relative contraindications include the desire to maintain child-bearing potential, as the preservation of fertility is not assured in the current literature. Pregnancy is well documented in patients who have had UAE performed and the procedure can be considered if patients are not suitable for myomectomy (surgical resection of fibroids with conservation of the uterus).

Pedunculated fibroids with a stalk diameter 50 per cent narrower than the diameter of the fibroid may in theory separate from the surface of the uterine body following ischaemic necrosis following UAE, with a risk of sepsis (level III evidence).

Pre-procedure

The use of gonadotrophin-releasing hormone (GnRH) analogues should be discontinued two weeks prior to UAE, as their use may hinder the technical success of UAE.  The removal of an intrauterine device is recommended prior to UAE.

A complete blood count should be available for patients with a history of menorrhagia. Renal function should be acquired from high-risk patients. In cases of impaired renal function (eGFR <60ml/min/1.73m²), patients are treated according to the European Society of Urogenital Radiology guidelines.

Patients are admitted the day of the procedure under the care of IR and fasting for four hours pre-UAE. The patient is consulted by the pain service from the department of anaesthesia to discuss pain relief following UAE. Premedication with suppositories (diclofenac) is used prior to transfer to IR.

Procedure

UAE is performed under conscious sedation with non-invasive monitoring. Following aseptic preparation of the right groin and placement of local anaesthetic to the skin and subcutaneous tissues, puncture of the right common femoral artery is performed, with placement of a small vascular sheath in the groin.

Selective catheterisation of the respective uterine arteries is performed under fluoroscopy prior to the injection of embolic particles.

Patients are required to lie supine for four hours post-procedure to ensure haemostasis of the arterial puncture.

Post-procedure

It is important to acknowledge that UAE may induce significant post-procedural pain secondary to ischaemic changes within the fibroids and myometrium. The pain characteristically evolves towards the end of the procedure and is most intense during the first 24 hours after UAE, with a peak at around seven hours.

Interventional radiology departments will have pain management protocols using a combination of intravenous patient-controlled analgesia (PCA), anti-inflammatories and antiemetics. The patient is usually discharged 24 or 48 hours post UAE, depending on local practice.

Complications related to UAE typically occur in the first week after discharge. Patients may develop a post-embolisation syndrome characterised by self-limiting nausea and pyrexia, which is managed with anti-inflammatories.

Patients are advised to contact the IR service if they feel unwell or develop pelvic pain, high-fever, pelvic tenderness or an offensive vaginal discharge in the weeks following UAE. This is in order to exclude the possibility of evolving sepsis secondary to expulsion of sloughed necrotic fibroid tissue, which would require an emergent gynaecology opinion to remove tissue from the endometrial cavity or endocervical canal. Pulmonary embolism and deep-vein thrombosis are reported in less than 1 per cent of patients. Permanent amenorrhoea is reported in less than 2 per cent of women.

Outcomes

The majority of patients can resume their normal activities within three-to-four weeks post-UAE. Patients are advised that the optimum effect of UAE is seen at six months. A follow-up contrast-enhanced MRI is performed prior to a follow-up consultation with IR at six months post-UAE.

Compared to hysterectomy, UAE results in minimal blood loss, shorter hospital stay and a quicker resumption of work in the short-term. The EMMY trial is a Dutch randomised, controlled trial that set out to compare the clinical outcome and health-related quality of life of patients treated with UAE with those treated with hysterectomy for heavy menstrual bleeding caused by uterine fibroids. The results show that the majority of patients (around two-thirds) can avoid having a hysterectomy.

Conclusion

UAE is a minimally-invasive procedure for the management of fibroid disease. Prospective, randomised studies such as the EMMY and REST trials, which compare UAE with hysterectomy, confirm that the procedure is a safe and effective alternative to hysterectomy for fibroid disease.

Interventional Radiologists throughout the Republic of Ireland perform UAE. The standards of practice are governed by The Faculty of Radiology of the Royal College of Surgeons in Ireland and by the Cardiovascular and Interventional Society of Europe.

The outcome of UAE is summarised below:

Technical success

95-to-97 per cent (REST and EMMY).

Clinical outcome

88 per cent satisfactory outcome at 12 months (REST).

92 per cent moderately satisfied or more at 24 months. (EMMY).

Secondary hysterectomy

4 per cent at 12 months (REST).

23 per cent at 24 months   & (EMMY).

11 per cent at 32 months     & (REST).

28 per cent at 60 months     & (EMMY).

References

Hehenkamp WJK, Volkers NA, Birnie E, Reekers JA, Ankum WM (2008). Symptomatic uterine fibroids: Treatment with uterine artery embolisation or hysterectomy. Results from the randomised clinical embolisation versus hysterectomy (EMMY) trial. Radiology 246:823-832.

The REST Investigators (2007): Uterine artery embolisation versus surgery for symptomatic uterine fibroids. N Engl J Med 356:360-370.

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