ELECTIVE EMBOLISATION

UTERINE FIBROIDS

Introduction

Last updated: apr 5, 2023

Uterine fibroids, the most common type of tumor among women of reproductive age, are associated with heavy menstrual bleeding, abdominal discomfort, subfertility, and a reduced quality of life. For women who wish to preserve their uterus and who have not had a response to medical treatment, myomectomy and uterine-artery embolization are therapeutic options.

 

Presentation

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Internal Iliac Artery
Internal Iliac Artery
Internal Iliac Artery
 

Anatomy

Beware

  • The cervicovaginal branch arises from the transverse segment of the UA and supplies blood to cervix and vagina
  • A persistent sciatic artery, which can cause ischemic damage of the lower limb

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Indications

Symptomatic fibroids

  • Hemorhage
  • Subfertility
  • Repeat myomectomy
  • Poor surgical outcome
  • Difficult to resect fibroids
  • Patient choice
Adenomyosis 4

In about two thirds of uterine artery embolization-treated patients with symptomatic uterine fibroids a hysterectomy can be avoided. Health-related quality of life 10 years after uterine artery embolization or hysterectomy remained comparably stable. Uterine artery embolization is a well-documented and less invasive alternative to hysterectomy for symptomatic uterine fibroids on which eligible patients should be counseled. 2 3

 

Contra indications

Absolute

  • Risky patients
  • Postmenopausal
  • Risk of sarcoma
  • Hormone replacement therapy
  • Earlier embolisation premenopausal
  • Adenomyosis
  • Short term gains
  • Limited long term success
  • Possible endometriosis
  • Prior surgery/other disease

Relative

 

Workup

Clinical Evaluation

  • Heavy menstrual bleeding (menorrhagia),
  • Pelvic pain or pressure
  • Urinary frequency
  • Infertility
  • Recurrent pregnancy loss.
Physical exam
  • Pelvic examination
Imaging Studies
  • Transvaginal ultrasound
  • Saline infusion sonohysterography
  • MRI when ultrasound is inconclusive
  • Hysteroscopy
Laboratory Tests
  • CBC
  • Pregnancy test
  • Thyroid function tests
  • Other hormone levels (FSH, LH, prolactin)

 

Materials

Essentials

  • Standard Angiography set
  • Cobra catheter x 2
  • Y-connector x 2
  • Luer lock stop cock x 2
  • Stiff Terumo wire 180 cm
  • Standard Terumo wire 180 cm
  • Progreat microcatheter
  • 500—700-900 micron particles
  • Angioseal 6F x 2

Non-Essentials

 

Positioning the patient

  • Supine

 

The procedure in steps

  • Perform infiltration with Lidocaine and Bupivacaine.
  • Utilize retrograde access with a 6F sheath (45 cm). Administer 5000 IU of Heparin.
  • Use an up-and-over technique with RIM.
  • Access the proximal anterior division of the AII, with ipsilateral oblique projection.
  • Conduct superselective catheterization of the uterine artery (counting distal branches, targeting the 4th branch).
  • Embolize with particles to achieve a "pruned tree" appearance.
  • Be vigilant for collateral circulation and avoid non-target embolization, especially in the cervicovaginal branch.
  • Employ closure devices bilaterally.
  • SOP

Other contributory arteries

  • Ovarian
  • Round ligament
  • Obturator
  • External pudendal from femoral
  • Deep circumflex
  • Superior rectal
  • Median sacral
  • Iliolumbar

 

Tips and tricks

  • Aortography is needed to identify other potential contributory arteries, such as ovarian arteries, in patients with persistent or recurrent bleeding after embolization of bilateral UAs and IIAs.

 

Complications

  • Post-thrombotic syndrome: < 100%
  • Groin hematoma: < 5%
  • Infection and myoma expulsion: < 2%
  • Non-target embolization: < 1%
  • Mortality: < 1%

Giant fibroids

  • > 10 cm and/or uterine volume > 700 ml)
  • More risk of infection, pain, need for re-intervention

 

Post-op

 

Report

Time out akkoord. Procedure onder epiduraal. Patient in rugligging. Wassen met chloorhexidine en steriel afdekken. Echografisch geen stenose in de AFCD. Retrograde toegang, met 25 cm lange 6F sheaths. 5000 IE Heparine.

Up-and-over selektieve katheterisatie van de beide arteria uterinas tot voorbij de cervicovaginale tak met behulp van een Progreat 0.018" katheter.

Vervolgens embolisatie met 500-700 micon partikels, tot een "pruned tree" beeld onstaat.

Angioseal beiderzijds.

 

Literature

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  2. Dungan, J. S. (2011). Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 5-year outcome from the Randomized Emmy Trial. Yearbook of Obstetrics, Gynecology and Women's Health, 2011, 444–445. https://doi.org/10.1016/j.yobg.2011.05.198

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DISCLAIMER

The information contained herein has been obtained from sources believed to be reliable. However, no warranty as to the accuracy, completeness or adequacy of such information is implied. No liability is accepted for errors, omissions or inadequacies in the information contained herein or for interpretations thereof. The reader assumes sole responsibility for the selection of these materials to achieve its intended results. The opinions expressed herein are subject to change without notice.

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