Uterine Artery Embolization

• What are some common uses of the procedure?
• How should I prepare for the procedure?
• What does the equipment look like?
• How does the procedure work?
• How is the procedure performed?
• What will I experience during and after the procedure?
• Who interprets the results and how do I get them?
• What are the benefits vs. risks?
• What are the limitations of the procedure?

Known medically as uterine artery embolization, this is a fundamentally new approach to the treatment of fibroids that blocks the arteries that supply blood to the fibroids. It is a minimally invasive procedure, which means it requires only a tiny nick in the skin, and is performed while the patient is conscious but sedated — drowsy and feeling no pain.

VIA interventional radiologists were among the first in the tristate area to perform UAE for the treatment of uterine fibroids and have one of the largest experiences with the procedure in the tristate area.  VIA interventional radiologists are members of the national uterine fibroid registry, a large multicenter research trial to investigate the benefits of UAE.

Uterine Artery Embolization

Uterine Artery Embolization
The interventional radiologist makes a small nick in the skin (less than one-quarter of an inch) at the crease at the top of the leg to access the femoral artery, and inserts a tiny tube (catheter) into the artery. Local anesthesia is used so the needle puncture is not painful. The interventional radiologist steers the catheter through the artery to the uterus using X-ray imaging (fluoroscopy) to guide the catheter's progress. The catheter is moved into the uterine artery at a point where it divides into the multiple vessels supplying blood to the fibroids.

An arteriogram (a series of images taken while radiographic dye is injected) is performed to provide a road map of the blood supply to the uterus and fibroids.

Artery Blockage in UAE
The interventional radiologist slowly injects tiny plastic (polyvinyl alcohol or PVA) or gelatin sponge particles the size of grains of sand into the vessels. The particles flow to the fibroids first, wedge in the vessels and cannot travel to other parts of the body. Over several minutes, the arteries are slowly blocked. The embolization is continued until there is nearly complete blockage of the blood flow in the vessel.

The procedure is then repeated on the other side so the blood supply is blocked in both the right and left uterine arteries. Some physicians block both uterine arteries from a single puncture site, while others puncture the femoral artery at the top of both legs. After the embolization, another arteriogram is performed to confirm the results. The skin puncture where the catheter was inserted is cleaned and covered with a bandage.
As a result of the restricted blood flow, the tumor (or tumors) begin to shrink.

Fibroid embolization usually requires a hospital stay of one night, although some women do go home the same day. About six to eight hours of bed rest is typical after the procedure. Pain-killing medications and drugs that control swelling typically are prescribed following the procedure to combat cramping, which is a common side effect. Fever also is an occasional side effect, and is usually treated with acetaminophen. Total recovery generally takes one to two weeks, but can take longer.

While embolization to treat uterine fibroids has been performed for more than six years, embolization of arteries in the uterus is not new. The procedure has been used successfully by interventional radiologists in uterine arteries for more than 20 years to treat heavy bleeding after childbirth. Today, fibroid embolization is being performed at hospitals and medical centers across the country, in Canada and around the world. As of the end of 1998, about 1,500 to 2,000 fibroid embolization procedures had been done world-wide. VIA physicians have the largest experience with embolization procedures in Northern Kentucky and have pioneered the use of UAE for the treatment fibroids. In addition, the physicians of VIA were 4/’;[participants in the national Uterine Fibroid Registry, a large multicenter study to further investigate uterine fibroid disease and its treatment.

What Are Some Common Uses Of The Procedure?

Fibroid Types

By far the most common reason for embolizing the uterine arteries is to treat symptoms caused by fibroid tumors. This is accomplished by stopping the growth of fibroid tumors and attempting to shrink them. Because the effects of uterine fibroid embolization (UFE) on fertility are not yet known, the ideal candidate is a premenopausal woman with symptoms from fibroid tumors who no longer wishes to become pregnant, but wants to avoid having a hysterectomy (surgical removal of the uterus). Uterine fibroid embolization may be an excellent alternative for women who, for reasons of health or religion, do not want to receive blood transfusions—as may be necessary if open surgery is carried out. The procedure also benefits women who for any reason cannot receive general anesthesia.

Embolization of the uterine arteries also may be used to halt severe bleeding following childbirth or caused by malignant gynecological tumors.

How Should I Prepare For The Procedure?

A woman considering uterine fibroid embolization needs a gynecological work-up to make sure that fibroid tumors are the actual cause of her symptoms. Imaging of the uterus by magnetic resonance imaging (MRI) or ultrasonography is performed to fully assess the size, number and location of the fibroids. Occasionally your gynecologist may want to take a direct look by performing laparoscopy. If bleeding is a major symptom, a biopsy of the endometrium—the inner lining of the uterus—may be done to rule out cancer.

What Does The Equipment Look Like?

Several different types of particles are available for uterine fibroid embolization. These include polyvinyl alcohol (a material resembling coarse sand), gelatin sponge (Gelfoam), and microspheres. All of these types of embolization agents have been shown to be safe and effective for uterine fibroid embolization. Regardless of the type of particles used, they wedge in the uterine vessels, avoiding the risk that they will travel to distant parts of the body.

How Does The Procedure Work?

Uterine Artery Embolization

By blocking blood flow to the fibroids, uterine fibroid embolization in effect "starves" them of the blood they need to grow. When deprived of blood, the tumor masses die, and then develop into scar tissue and shrink in size. The symptoms they previously caused become less bothersome or disappear altogether. Multiple fibroids may be treated at the same session by uterine fibroid embolization, and even very large ones can be effectively treated by this procedure.

How Is The Procedure Performed?

Uterine fibroid embolization is carried out in an angiography suite equipped with an x-ray machine, where sterile conditions are maintained. Your heart rate, blood pressure, electrocardiogram, breathing and blood oxygen level will be monitored constantly during the procedure, which typically takes between 60 and 90 minutes.

After injecting a sedative to make you sleepy and a local anesthetic to numb the skin at the groin, the interventional radiologist will make a small nick in the skin less than a quarter inch long and thread a thin tube (catheter) into the femoral artery. Using x-ray guidance, and periodic injections of radiographic contrast material to map the blood vessels, the catheter is threaded into the uterine arteries. Under x-ray observation, the particles are injected until blood flow in the uterine arteries is blocked. In most cases, both uterine arteries can be treated through a single catheter insertion. After completing uterine fibroid embolization, the site of skin puncture is cleaned and bandaged.

What Will I Experience During The Procedure?

Most patients having uterine fibroid embolization remain overnight in the hospital for pain control and observation. Patients typically experience pelvic cramps for several days after uterine fibroid embolization, and possibly mild nausea and low-grade fever as well. The cramps are most severe during the first 24 hours after the procedure, and improve rapidly over the next several days. While in the hospital, the discomfort usually is well controlled with a narcotic pump, which dispenses intravenous pain medication. Oral pain medication will be provided when you are discharged home the following day. Most patients will recover from the effects of the procedure within one to two weeks after uterine fibroid embolization, and will be able to return to their normal activities.

It usually takes two to three months for the fibroids to shrink enough so that bulk-related symptoms such as pain and pressure improve. It is common for heavy bleeding to improve during the first menstrual cycle following the procedure.

Most women are able to return to work one to two weeks after uterine fibroid embolization, but occasionally patients take longer to recover fully.

Who Interprets The Results And How Do I Get Them?

The interventional radiologist who performs your procedure will interpret the results and will work with your gynecologist or primary care physician to ensure proper follow-up care.

Expected Results
Fibroid embolization was first studied in the United States by Scott Goodwin, M.D., of the University of California Los Angeles, who reported his results in 1997. Since that time, a number of interventional radiologists have studied the procedure and have reported similar success with the technique reported by Dr. Goodwin.

The results of studies that have been published or presented at scientific meetings report that 78 percent to 94 percent of women who have the procedure experience significant or total relief of pain and other symptoms, with the large majority of patients considerably improved. The procedure has been successful even when multiple fibroids are involved. Most patients have rated the procedure as "very tolerable." The expected average reduction in the volume (size) of the fibroids is 50 percent after three months, with a reduction in the overall size of the uterus of about 40 percent.

The long-term outcome is not known as only short-term follow-up is available. It is not yet known if the fibroids can re-grow, however no recurrences have occurred in women who have been followed for up to six years.

What Are The Benefits Vs. Risks?

Benefits

• Minimally invasive: Uterine fibroid embolization (UFE) is less invasive than either open surgery to remove fibroid tumors, or surgically removing the uterus itself. Patients ordinarily can resume their usual activities weeks earlier than if they had a hysterectomy. Blood loss during uterine fibroid embolization is minimal, the recovery time is much shorter than for hysterectomy, and general anesthesia is not required.
• Relief of symptoms: Follow-up studies have shown that approximately 85 percent of women who have their fibroids treated by uterine fibroid embolization experience either significant reduction or complete resolution of their fibroid-related symptoms. This is true both for women with heavy bleeding, and for those with bulk-related symptoms such as pelvic pain or pressure. Overall, fibroids will shrink to half their original size six months after uterine fibroid embolization.
• Durable effect: Follow-up studies lasting several years have shown that it is rare for treated fibroids to regrow or for new fibroids to develop after uterine fibroid embolization. This is because all fibroids present in the uterus, even small early-stage masses that may be too small to see on imaging studies, are treated during the procedure. UFE is a more permanent solution than another option, hormone therapy, because when hormonal treatment is stopped the fibroid tumors usually grow back. Regrowth also has been a problem with laser treatment of uterine fibroids.

Risks

• Catheter-related risks: Any procedure that involves placement of a catheter inside a blood vessel, including uterine fibroid embolization, carries certain risks. These risks include damage to the blood vessel, bruising or bleeding at the puncture site, and infection. When performed by an experienced interventional radiologist, the chance of any of these events occurring during uterine fibroid embolization is less than one percent.
• Allergy to x-ray contrast material: An occasional patient may have an allergic reaction to the x-ray contrast material used during uterine fibroid embolization. These episodes range from mild itching to severe reactions that can affect a woman's breathing or blood pressure. Women undergoing uterine fibroid embolization are carefully monitored by a physician and a nurse during the procedure, so that any allergic reactions can be detected immediately and reversed.
• Passage of fibroid tissue: From two percent to three percent of women may pass small pieces of fibroid tissue after uterine fibroid embolization. This occurs when fibroid tissue located near the lining of the uterus die and partially detaches. Women with this problem may require a procedure called D & C (dilatation and curettage) to be certain that all the material is removed so that bleeding and infection will not develop.
• Early onset menopause: In the majority of women undergoing uterine fibroid embolization, normal menstrual cycles resume after the procedure. However, in approximately one percent to five percent of women, menopause occurs shortly after uterine fibroid embolization. This appears to occur more commonly in women who are older than 45 years when they have the procedure.
• Need for hysterectomy: Although the goal of uterine fibroid embolization is to cure fibroid-related symptoms without surgery, some women may eventually need to have a hysterectomy because of infection or persistent symptoms. The likelihood of requiring hysterectomy after uterine fibroid embolization is low—less than one percent.
• X-ray exposure: Women are exposed to x-rays during uterine fibroid embolization, but exposure levels usually are well below those where adverse effects on the patient or future children would be a concern.
• Future fertility: The question of whether uterine fibroid embolization reduces fertility has not yet been answered, though a number of healthy pregnancies have been documented in women having the procedure. Because of this uncertainty, physicians may recommend that a woman with symptom-producing fibroids who wishes to have more children consider surgical removal of the individual tumors rather than uterine fibroid embolization. A majority of women who have uterine fibroid embolization are no longer interested in childbearing. In some women, however, fibroid tumors are the cause of infertility and the best treatment may be to embolize them. For each individual it is difficult to predict whether the uterine wall will be weakened enough by uterine fibroid embolization to pose a problem during delivery of an infant. It may well be worthwhile to do an ultrasound study in a pregnant woman who has had the procedure so as to assess the state of the uterus.

Side Effects/Complications
Fibroid embolization is considered to be very safe, however, there are some associated risks, as there are with almost any medical procedure. Most patients experience moderate to severe pain and cramping in the first several hours following the procedure; some experience nausea and, possibly, fever. These symptoms can be controlled with appropriate medications. Most symptoms are substantially improved by the next morning, however, there may be some pain and cramping for several days or more. Many women report returning to work within a week of having the procedure.

Complications occur in fewer than 3 percent of patients. Serious possible complications include injury to the uterus from decreased blood supply or infection. This is uncommon and hysterectomy to treat either of these complications occurs in less than 1 percent of patients. Injury to other pelvic organs is possible but has not yet been reported and the chance of other significant complications is less than 1 percent.

Long-term complications are not expected, although questions about potential side effects remain.

It is not known what effect, if any, fibroid embolization has on the menstrual cycle. The overwhelming majority of women who have had embolization have had decreased bleeding with normal menstrual cycles. There have been a few women, most of whom are near the age of menopause, whose menstrual periods have stopped after the procedure. It is uncertain whether these cases are a result of decreased ovarian function resulting from the procedure. Based on this limited information, it appears that the procedure may cause a loss of menstrual cycles (premature menopause) in a very small number of patients.

What Are The Limitations Of Uterine Fibroid Embolization?

Uterine fibroid embolization (UFE) should not be done in women who have no symptoms from their fibroid tumors; when cancer is a possibility; or when there is inflammation or infection in the pelvis. Uterine fibroid embolization also should be avoided in pregnant women and when the kidneys are not working properly—a condition known as renal insufficiency. A woman who is very allergic to contrast material containing iodine should receive another treatment option.

At present, it remains difficult for women in some parts of the country to learn about uterine fibroid embolization or make arrangements to have the procedure. Not all gynecologists are familiar with this relatively new method of treating uterine fibroids, and rely instead on the conventional approach—surgery.