Uterine Artery Embolization

What are Uterine Fibroids? 

Uterine fibroids are benign tumors of the uterus.  Symptoms from fibroids, the most common of which is excessive bleeding, can be anywhere from mild to disabling.  Fibroids are not cancers, but they can cause symptoms such as the following:

  Heavy menstrual bleeding

  Abdominal swelling (protrusion)

  Pelvic pressure

  Pain or spasms (similar to labor pains)

  Pressure on the bladder (frequent urination)

  Pressure on the rectum (constipation)

  Discomfort during sexual relations

  Interference with fertility

  Premature labor

  Repeated miscarriages


Pregnancy complications associated with fibroids may be the following: 

 

- Spotting or bleeding

- Fibroid degeneration due to the loss of blood supply to the fibroid

- Premature labor

- Premature delivery

- Birth canal blocked by the fibroid causing a c-section

- Infant growth

- Emergency hysterectomy during delivery due to hemorrhage

- Fibroid enlarging in size, which causes pain and pressure

 

What are the ‘Types of Uterine Fibroids’? 


At the Doctor consultation the Doctor and/or patient can mark on the diagram where the uterine fibroids are located and place a check mark beside the type(s) of fibroids.

 

"Uterus illustration used by permission of Francis Hutchins, Jr. M.D. - The Fibroid Book 2nd Edition".

 

Submucosal (or Submucous) fibroid - This type is located beneath the lining of the uterus.  The fibroid can develop a thin stalk or even enter the vagina.
 

Intramural fibroid - They stay mostly embedded within the middle of the wall of the uterus.


Subserosal (or Subserous) fibroid - This type grows towards the outside of the uterus and can press on the organs surrounding the uterus such as the bladder or rectum.


Pedunculated fibroid - This type of fibroid can develop when a fibroid grows on a stalk, which is called a pedicle.  This can be a subserosal fibroid growing out into the abdomen or a submucosal fibroid growing into the endometrial cavity. The stalk can get twisted which can cause severe pain, although this is extremely rare.
 

Interligamentous fibroid - It can grow sideways between the layers of the broad ligament (a band of fibrous connective tissue that supports the uterus). 


Parasitic fibroid - This fibroid attaches itself to another organ, such as the tube, the mesentery, or a loop of bowel.  Its uterine stalk gradually degenerates until the fibroid is no longer a part of the uterus at all. (This fibroid is the rarest of all the types.)

What is Uterine Artery Embolization (UAE) (i.e. Uterine Fibroid Embolization - UFE)? 

 

One of the most effective treatments for bleeding is to stop the blood supply to the area that is bleeding by blocking the vessels from the inside, this is known as “embolization”.  Embolization of the arteries to the uterus has been used as a treatment for severe uterine bleeding after surgery or childbirth since at least the late 1970s, and is used as a treatment for uterine fibroids. 

 

Reference:  Ravina JH, Herbreteau D, Ciraru-Vigneron N, Bouret JM, Houdart E, Aymard A, MerlandJJ, “Arterial Embolization to Treat Uterine Myomata”; Lancet September 9, 1995, (Entrez Pubmed).

 

What is an Interventional Radiologist?  

 

Interventional Radiologists are trained to perform radiologist and surgical procedures.  In 2002 the Society of Cardiovascular and Interventional Radiology changed its name to the Society of Interventional Radiology.  Before the change, those named Fellows of the organization had the option of appending FSCVIR after their titles (just like Gynecologists use FACOG).  Those who have become Fellows since the name change use FSIR.


Reference:  To locate an Interventional Radiologist in your area – web site URL:
http://directory.sirweb.org/eseries/scriptcontent/index_members_search.cfm

 

What should a woman expect when getting the UAE procedure?

The Interventional Radiologist (IR) will see the patient for a consultation before scheduling any procedure.  Before seeing the Interventional Radiologist, patients should have an MRI examination of the pelvis and a blood count.  Patients should also have a Pap smear within the last year.  After seeing the Interventional Radiologist some patients may need to see their gynecologist for an office procedure called an endometrial biopsy, which is similar to a Pap smear. 

On the day of the procedure women are admitted to the Short Procedure Unit, have some blood drawn, an IV started, and a catheter placed in the bladder.  Antibiotics are administered and choices of conscious sedation or spinal analgesia are offered. 

Short Procedure Unit:  The patient will take off all her clothes and put on a hospital gown.  Some women like to wear cotton socks to keep their feet warm.  The patient may have a Transdermal Scopolamine patch put behind her ear for nausea, which is kept in place for 4 more days after the UAE procedure.

Next patients go to the Radiology Department for ultrasound pictures of the pelvis, to measure the uterus and size of the fibroids.  The information is used to decide on any changes that need to be made from the routine procedure, and as a baseline for further follow-up studies. 

The Angiography Suite is where the procedure is performed.  The Interventional Radiologist sterilizes the skin lying on top of a large artery located in the groin area with an iodine solution and numbs it with a local anesthetic.  The injection for the anesthetic may sting and burn for a few seconds.  A needle is inserted into the artery and exchanged for a plastic catheter about the thickness of a strand of spaghetti. 

Watching under X-ray the Interventional Radiologist then maneuvers the catheter into the main arteries supplying the uterus and injects small plastic particles to plug up the blood vessels supplying the fibroids.  X-ray dye is injected through the catheter to show the vessels during this process, and the patient may feel sensations of warmth from these injections (Figure A).

AX-ray dye is injected through the catheter to show the vessels during this process, and the patient may feel sensations of warmth from these injections (Figure A).

Once the catheter is in position, the IR injects particles of a special plastic that block the blood vessels supplying the uterine fibroids (Figure B). B


“Illustration (Figures A & B) by Mr. John Byrnes, Used with permission of Image Guided Surgery Associates, PC”
 

Once the catheter is in position, the IR injects particles of a special plastic that block the blood vessels supplying the uterine fibroids (Figure B).  The particles are round and are about the same size as grains of salt.
 

When the procedure is over, the catheter is removed from the artery and pressure is applied at the small puncture site to stop the bleeding.  The patient is wheeled to her room and must stay in bed for several hours to avoid any bleeding at the puncture site (the patient can sit up, eat, read, or watch television). The patient is allowed to get out of bed after this period, which is typically about six hours. 
 

Loss of blood supply to the fibroids may cause cramping to occur shortly after the procedure, which may cause some patients to have to stay over night at the hospital.  The trained nursing staff know the proper techniques to handle the patients after having the UAE procedure done and the patient gets round the clock attention as needed.  The next day the patient is released to go home with detailed instructions on what to do and phone numbers to contact the IR if needed.  If any prescriptions are required the patient is given them at this time.  The next day the IR will call to see how the patient is doing and answer questions.

February 2006 update:  Depending on how the patient is feeling she may not have to stay over night at the hospital.  Medications are the same.  About 90% of the patients go home the same day. The only other change is that the Doctor may keep the patient on fluids only (whether in the hospital or at home) until the morning after the UAE.  No other changes in how they are cared for.  Patients are typically discharged 6-7 hours after the procedure.  If any prescriptions are required the patient is given them at this time.  The next day the IR will call to see how the patient is doing and answer questions.

Note:  After the procedure the patient may receive anti-inflammatory drugs (example Motrin or one of its relatives).  A narcotics (usually Morphine) is available through a PCA (Patient Controlled Analgesia) pump, which is self-administered by the patient by pushing the demand button. 

Prescriptions vary because of each patient's medical situation (examples of medication:  Motrin, Percocet, and Surfak for constipation).  Always ask your Doctor if you have questions about medication.

In about three months another ultrasound or MRI of the pelvis may be scheduled by the IR to measure the reduction of the uterus and fibroids.  At this time, the average woman’s uterus has decreased by 50% in volume, and volume reduction continues for as much as a year (if not longer).  Individual fibroids decrease by about 65%, if not more, at 3 months.  After three months a follow up with your Gynecologist will need to be done.

What tests need to be performed for the UAE?

Sometimes a Doctor will order an endometrial biopsy.   An endometrial biopsy involves placing a small suction tubing through the cervix, and "vacuuming" a small amount of the endometrium (lining of the uterus).  The test is helpful in detecting cancer.   Some Gynecologist’s will numb the cervix (paracervical block) before doing the procedure, which is painless to do, and greatly decreases the discomfort of the procedure.  The Doctor may advise the patient (unless there is some reason why they shouldn't) to take 800 mg of ibuprofen or similar medicine 2 hours before the procedure.

 

Magnetic Resonance Imaging (MRI) and/or Ultrasound tests:

- MRI before as part of the consultation/pre-UAE evaluation.
- Ultrasound the day of the UAE procedure.
- Ultrasound at Post UAE three months.
- Ultrasound at Post UAE one year, and then annually.
- Contrast-enhanced MRI if there is any recurrence of symptoms or problems.

Questions to ask the Interventional Radiologist (IR)?

One should ask about the physician’s training and experience with embolization procedures in general and UAE in particular.  It would be helpful to ask if the Doctor’s experience fulfills the published training standards for UAE.  The other important issue is to be sure that the IR takes the responsibility to care for the UAE patient after the procedure is completed.

Reference:  “Patient Care and Uterine Artery Embolization for Leiomyomata”,
 J Vasc Interv Radiol. 2004 National Guideline Clearinghouse.

Interventional Radiologist UAE Training Standards and Board Certifications?

All physicians who perform the UAE procedure should have the following training:  Fifteen hours of formal Continuing Medical Education (CME) accredited study in the basic principles of the diagnosis and management of fibroid disease.

(1) Fellowship in Interventional Radiology involves a full year of training in just IR, which includes the full range of procedures including sophisticated vascular catheterization and embolizations.  Training in skills of recognizing pitfalls that can lead to serious complications during UAE procedures and how to manage the problems.

(2) Practice experience of 100 arteriograms, of which at least 50 must include placement of the catheter into specific branches of the vessels supplying the bodily organs.  Perform at least 25 embolization procedures and show documentation on these procedures.

(3)Proctorship – trained under the guidance of an experienced physician in UAE procedures completes 100 arteriographic procedures without significant complications.  Catheterize both uterine arteries in minimum of 25 patients successfully and safely.  In addition anyone who wishes to perform UAE should have a minimum of five hours of CME study in the specific area of Radiation Protection and Safety. 

Board Certification:  Interventional Radiologists have base training as Diagnostic Radiologists, and should be Board Certified. 

In addition, both the American Board of Radiology (for MDs) and the American Osteopathic Board of Radiology (for DOs) have a subspecialty board certification for Interventional Radiologists. A fully-trained Interventional Radiologist should have this subspecialty board certification.

Reference:  “Training Standards for Physicians Performing Uterine Artery Embolization for Leiomyomata:  consensus statement developed by the Task Force of Uterine Artery Embolization and the standards division of the Society of Cardiovascular and Interventional Radilogy- August  2000”,
JVIR, Jan. 2001 (Entrez Pubmed).

 

Assessment of Organ Radiation Dose Associated with Uterine Artery Embolization?

 

The principle of using X-rays for diagnosis or interventional procedures is that the benefit outweighs the risk.

There has been a recent article comparing x-ray machines/techniques with a lot of complicated figures which would be confusing for the general public. Glomset O et al, Acta Radiol, 2006 March 47(2):179. The effective dose of 22-32 milliSieverts for bilateral uterine artery embolisation is comparable to approximately two CT scans or about 5-10 years of natural background radiation.

Suffice to say, their conclusion is that the skin, uterine and ovarian doses are low for fibroid embolisation. The ovarian dose is below the threshold for any temporary or permanent sterility. The chance of any radiation-induced cancer was considered as not significant.

Reference:
"Assessment of Organ Radiation Dose Associated with Uterine Artery Embolization", Acta Radiol. 2006 Mar;47(2):179-85.  (Entrez PubMed)

 

 

Some things to watch for after the procedure (ask your Doctor for a list and instructions): 

·         Temperature greater than 100.5

·         Vaginal discharge

·         Passing any fibroid tissue

·         An odor from the discharge that creates a foul smell.

·         Constipation

·         Women who decide on the spinal anesthesia sometimes develop a headache after the procedure – calling the Doctor (IR) and pushing fluids and caffeine may be suggested.

·         Pain that the pain medication did not get rid of.

·         Continue to maintain a calendar diary of what you are experiencing after the UAE (bleeding, how many pads, size of the pads, how often did you have to change the pads, discharge, fibroid tissue discharge, temperature, how often and how much pain medication, etc.).  The calendar diary is a good way for you to keep a record of how you are feeling in case you need to talk to your Doctor.
 

                 Note:  When you have a question, call your Doctor for instructions.

Doctors Info Web Directory
 
   References on Hope For Fibroids Organization web site:


Suggestions From Post UAE Women:
http://www.hopeforfibroids.org/patientsuggestions.html

Patient Discussion Guides are found at the following web site URL:  http://www.hopeforfibroids.org/questionstoask.html

- Methods of Management of Uterine Fibroids Guide
- Questions to ask the Doctor Lists (3)
- Medical Terms
- Bibliographies (Uterine Artery Embolization and Uterine Fibroids):  http://www.hopeforfibroids.org/research.html#bib

Note:  Entrez PubMed is a “free” service to locate medical articles, web site URL:  http://www.pubmed.gov.


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Uterine Artery Embolization Guide, Hope For Fibroids, Inc.,  (e-mail) hope@hopeforfibroids.org   Copyright 2006-2007
Revised:  June 2, 2007