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Year : 2002  |  Volume : 12  |  Issue : 1  |  Page : 67-69
Uterine artery embolization


Department of obstetric and Gynecology, Inonu University Medical Faculty, Malatya, Turkey

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Keywords: Uterine Artery Embolisation (UAE), Fibroid

How to cite this article:
Onder C, Seyma H, Kaya S. Uterine artery embolization. Indian J Radiol Imaging 2002;12:67-9

How to cite this URL:
Onder C, Seyma H, Kaya S. Uterine artery embolization. Indian J Radiol Imaging [serial online] 2002 [cited 2019 Nov 22];12:67-9. Available from: http://www.ijri.org/text.asp?2002/12/1/67/28419
Pelvic and genital bleeding is a major cause of morbidity and mortality in many disorders of the female genital tract. Transcatheter uterine artery embolization (UAE) has emerged as a highly effective percutaneous technique for controlling obstetric and gynecologic hemorrhage. Uterine myomas are the most frequent cause of nonacute abnormal uterine bleeding. UAE is an effective therapy in the management of symptomatic myomas and may prove to be a valuable alternative to hysterectomy, myomectomy and medical therapy. The procedure is generally well tolerated by patients, and possesses the advantages of shorter hospitalizations and potential fertility preservation. In this paper one case of postpartum hemorrhage and one case of uterine fibroid with menorrhagia and pelvic pressure that were successfully managed with bilateral uterine artery embolization have been reported [1],[2].


   Case 1 Top


A 42-year-old woman gravida 4, para 4, presented with vaginal bleeding lasting for three months and anemia secondary to uterine fibroid. The gynecologic examination revealed a bigger uterus than the normal size and on the speculum examination there was an active bleeding from the external cervical os. An enlarged uterus (approximately 9 cm x 7 cm x 6 cm) with a fundal fibroid (approximately 6.5 cm x 6 cm x 6 cm) was seen at transvaginal ultrasonography (TV-US). The endometrial biopsy showed proliferative endometrium without evidence of malignancy. The patient was treated with birth control pills and medroxyprogesterone acetate (Provera; Pharmacia & Up-john , Kalamazoo, MI). The vaginal bleeding did not reduce inspite of the progesterone therapy. Since the patient did not desire any future fertility and being refractory to the medical management, hysterectomy was advised. Since the patient did not accept a surgical procedure a less invasive procedure of uterine artery embolization was planned. Preprocedural magnetic resonance (MR) imaging showed a uterus measuring 9 cm x 7 cm x 6 cm with an intramural fibroid with central necrosis in the fundal localization measuring 6.5 cm x 6 cm x 6cm. Postcontrast imaging revealed significant contrast enhancement of the solid component [Figure - 1]a

The patient was discharged on the first postprocedural day and given oral pain medications. But six weeks later the patient was readmitted to the unit again with amenorrhea, hot flushes, sweating and insomnia. The laboratory evaluation revealed, increased levels of follicle stimulating hormone (46 mlU/ml) (FSH), luteinising hormone (44 mlU/ml) (LH) and decreased level of oestradiol (22 pmol/L). Due to these hormonal levels it was considered that premature /transient ovarian failure had occurred in association with uterine artery embolization. Follow-up examination showed that reduced symptoms and menstrual bleeding resumed two months later, and serum FSH and LH levels were found to be 3.48 mIU/mL and 2.49 mIU/mL respectively. Follow-up MR images obtained 3 months later revealed a uterus measuring 8 cm x 7 cm x 5 cm with a total degenerated fibroid which shows a significant decrease to 4 cm x 4.5 cm x 4.5 cm. Postcontrast imaging revealed a non-enhancing fibroid and an insignificant decrease in uterine size [Figure - 1]b


   Case 2 Top


A 22-year-old woman gravida 1, para 0, with fulminant hepatitis and 36 weeks gestation was evaluated at the intensive care unit. At physical examination it was found that she had jaundice. She was confused and disoriented. The laboratory evaluation showed increased liver enzyme levels beside positive Hbc IgM. Ultrasonographic examination revealed a single gestation compatible with 36 weeks and 2 days. At pelvic examination cervical dilatation 3 cm. and effacement 60%. Non stress test was found reactive. After 16 hours of active trial of labour a 3000 gm female live fetus was delivered with a right mediolateral episiotomy. Inspite of continuous intravenous oxytocin infusion extensive vaginal bleeding was determined. At pelvic and ultrasonographic examination residual placenta and laceration could not be determined. The hemoglobin values changed between 4.4 gr.dl-1 and 7.5 gr.dl-1 . Thirteen units fresh frozen plasma and 10 units of erythrocyte suspension were given to the patient. But vaginal bleeding had continued and the patient became hemodynamically unstable. Due to this condition hypogastric artery ligation was planned. Because of the hemodynamic status and prolonged coagulation tests, surgical intervention was canceled. For that reason a less invasive technique transcatheter uterine artery embolization was planned and performed. Ten hours after the procedure vaginal bleeding completely stopped. One week after embolization the patient was discharged uneventfully.


   Embolization procedure Top


Before arteriography, the patient was monitored with a 3 lead electrocardiogram, pulse oximetry and noninvasive arterial pressure and received prophylactic intravenous antibiotics, (1 g cefazolin sodium, Smith Kline Beecham, Pittsburgh, PA; Eli Lilly, Indianapolis, IN). Arteriography and embolization were performed via percutaneous right femoral artery approach using local anaesthesia with 1% lidocaine (Abbott Industries, N. Chicago, IL) and intravenous sedation with midazolam (Roche Labs, Nutley, NJ). The patient received 50 g mg of fentanyl citrate (Jonssen Pharm.) intravenously at catheterization of the first uterine artery. Both hypogastric arteries were in turn selectively catheterized with a 5 F Siomons catheter. Limited arteriography was obtained to identify the uterine arteries and then both arteries selectively catheterized and further angiogram obtained [Figure - 2]a to show the uterine artery and the vascular supply to the uterus and the fibroid. Polyvinyl alcohol (PVA) particles (BioDyne; Cook), 500-700 m, were used for embolization. PVA particles mixed with contrast were injected through the catheter and flow directed. Embolization was considered as completed when the flow was arrested [Figure - 2]b. The length of the entire procedure was approximately 75 minutes.


   Discussion Top


Bilateral hypogastric artery ligation has also been investigated to be potentially effective as a means of controlling post-partum hemorrhage and preserving fertility. But reported success rates of hypogastric artery ligation have been widely variable, ranging from 40% to 100% in contemporary series [3].

On the other hand because of extensive pelvic collateral network of the gravid pelvis and quick reconstitution of the distal hypogastric artery after proximal ligation, this procedure has been particularly poor in the setting of uterine atony. Other disadvantages of the surgical procedure include failure of hypogastric artery ligation, the need for general anesthesia, infection, bleeding and ureteral injury. In recent years, UAE has proved to be effective in treating bleeding related to diverse obstetric and gynaecologic conditions. The success rates of UAE in the postpartum bleeding was reported to be 97%. Patients who continue to have bleeding after UAE would probably not have benefited from uterine artery ligation and may be candidates for ovarian artery ligation/embolization or hysterectomy. For decades, hysterectomy and myomectomy have been the standard surgical therapies for uterine leiomyomata. In recent years, alternative surgical and medical treatments have been developed, including laparoscopic/hysteroscopic resection and GnRHa [4],[5]. UAE represents a promising new method of treating refractory symptoms related to uterine leiomyomas. Embolization of the fibroids causes acute devascularization and infarction of the leiomyomata. The first therapeutic UAE for fibroids was performed in Paris and reported in 1995 [6],[7]. Patients undergoing embolization can expect excellent short-term results with respect to both menorrhagia and pelvic pain, with concomitant reductions in uterine size and fibroid tumor volume. Symptoms of menorrhagia and pelvic pressure are controlled in 85%-90% [4]. Complications of uterine arterial embolization procedures have been extremely uncommon but fall into three general categories: complications of angiography, pelvic infection, and ischemic phenomena [8,9]. Angiographic complications consist of external iliac artery perforation, groin hematoma, groin infection and contrast related nephrotoxicity. Despite administration of periprocedural prophylactic antibiotics, pelvic or vaginal wall abscess, pyometra, endometritis and salpingitis may occur due to postembolization ischemia or infarction [8],[9]. Hysterectomy may be required when the postembolization syndrome is severe. The major adverse effect following fibroid embolization is pain [10]. Most patients experience considerable uterine cramping after the procedure and require overnight hospitalization for pain control. It is also important to establish an effective pain relief protocol that allows patient controlled analgesia in the postembolization period [10]. The other serious problems after postembolization are the development of amenorrhea associated with transient ovarian failure [4]. Unpublished data from the French group who perform this technique suggests a 5%incidence of this complication [6]. Our patient developed amenorrhea, hot flushes and insomnia 6 weeks after uterine artery embolization. Her serum FSH level at that time was 40.1 mIU/mL. Two months later, uterine bleeding resumed; her serum FSH level was found to be 3.48 mIU/mL.

Transcatheter uterine artery embolization is of significant value in treating certain hemorrhagic conditions in obstetrics and gynecology including postpartum hemorrhage, and uterine fibroids. Uterine fibroid embolization has several advantages over conventional hormonal suppression and surgical procedures, including avoidance of the side effects of drug therapy and the physical and psychologic trauma of surgery.

 
   References Top

1.Wallach EE: Myomectomy. In: Thompson JD, Rock JA, eds. Te Linde's Operative Gynecology. 7th ed. Philadelphia, Pa: Lippincott, 1992; 647-662.  Back to cited text no. 1    
2.Phillips DR, Milim SJ, Nathanson HG, Haselkorn JS: Experience with laparoscopic leiomyoma coagulation and concomitant operative hysteroscopy. J Am Assoc Gynecol Laparosc 1997; 4:425-433.  Back to cited text no. 2    
3.Evans S, Mc Shane P. The efficacy of internal iliac artery ligation in obstetric hemorrhage. Surg Gynecol Obstet 1985;160:250-3.  Back to cited text no. 3    
4.Goodwin SC, Vendantham S, McLucas B, et al: Preliminary experience with uterine artery embolization for uterine fibroids. JVIR 1997;8:517-526.  Back to cited text no. 4    
5.Nezhat FR, Roemisch M, Nezhat CH, Seidman DS, Nezhat CR: Recurrence rate after laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 1998; 5:237-240.  Back to cited text no. 5    
6.Ravina JH, Herbreteau D, Ciraru-Vigneron N, et al: Arterial embolisation to treat uterine myomata. Lancet 1995; 346:71-71.  Back to cited text no. 6    
7.Ravina JH, Bouret JM, Ciraru-Vigneron N, et al: Recourse to particular arterial embolization in the treatment of some uterine leiomyoma. Bull Acad Natl Med 1997; 181:233-243.  Back to cited text no. 7    
8.Greenwood LH, Glickman MG, Schwartz PE, Morse SS, Denny DF: Obstetric and nonmalignant gynecologic bleeding: treatment with angiographic embolization. Radiology 1987; 164:155-9.  Back to cited text no. 8    
9.Abbas FM, Currie JL, Mitchell S, Osterman F, Rosenshein NB, Horowitz IR: Selective vascular embolization in benign gynecologic conditions. J Reprod Med 1994; 39:492-6.  Back to cited text no. 9    
10.Bakri YN, Linjawi T: Angiographic embolization for control of pelvic genital tract hemorrhage. Acta Obstet Gynecol Scand 1992; 71:17-21.  Back to cited text no. 10    

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Correspondence Address:
C Onder
Department of obstetric and Gynecology, Inonu University Medical Faculty, Malatya
Turkey
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Source of Support: None, Conflict of Interest: None


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[Figure - 1], [Figure - 2]

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