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Uterine artery embolization for abnormal bleeding

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References

Transvaginal ultrasound is usually performed 3 to 6 months and 1 year after UAE to determine whether existing fibroids have been infarcted and begun to decrease in volume. It also reveals any uterine or adnexal complications.

In addition, this imaging provides a new baseline measurement of fibroid volume, against which any subsequent increase in size (which may indicate regrowth of fibroids or undiagnosed leiomyosarcoma) can be compared.11

Key findings of outcome studies

Two large series reported significant improvement in AUB in 77% to 90% of fibroid cases, and bulk-related symptoms were controlled in 86% to 91%.6-8 In these studies, average uterine volumes decreased by 35% and 58% at 3 and 12 months, respectively, with dominant fibroid shrinkage of 42%. Several large series also reported high patient satisfaction (91% to 93%) and significant improvement in quality-of-life measures.4,6-8

Side effects and complications

Although UAE is considered very safe, it carries some risks. Spies et al17 reported on complications in 400 consecutive patients undergoing UAE for fibroids at their institution:

  • 1.25% serious complication rate
  • 5% overall periprocedural morbidity rate
  • no deaths and no major permanent injuries

In addition, 1 patient required hysterectomy as a result of a complication, and 1 patient had an undiagnosed leiomyosarcoma, which was discovered during an elective myomectomy 31 months after UAE.

Goldberg et al 18 reported another case with delayed diagnosis of leiomyosarcoma following UAE. In our series of 705 patients, 1 had an undiagnosed leiomyosarcoma, which presented as a pelvic mass 15 months after UAE. She subsequently underwent hysterectomy.

When to suspect leiomyosarcoma

Unlike hysterectomy or myomectomy, no tissue is obtained in UAE for pathologic diagnosis to exclude leiomyosarcoma, which is found in approximately 0.1% to 0.4% of women with fibroids and is difficult to differentiate from a benign leiomyoma using clinical tests or imaging.17-18

Suspect leiomyosarcoma if the fibroids continue to grow even after technically successful embolization.

Infection is rare, but can be lethal

A small number of patients have experienced infection, which usually is controlled with antibiotics. In a series of 414 UAE procedures in 410 fibroid patients, Rajan et al19 reported:

  • 1.2% rate of intrauterine infection requiring intravenous antibiotic therapy and/or surgery
  • no significant difference seen with various embolic agents, quantity of embolic particles, se of preprocedure antibiotics, or size or location of the dominant fibroid.

However, at least 2 deaths have been reported due to infection since UAE for fibroids was introduced in the mid-1990s: 1 fatal sepsis in a woman who underwent UAE for fibroids and 1 other sepsis fatality.17,20 The first case was caused by necrosis of the vaginal wall and uterine cervix. At autopsy, microspheres were found not only in arteries in the leiomyomata and myometrium, but also in the parametria and vagina, causing ischemic necrosis.

Amenorrhea or worsened AUB

In some cases, amenorrhea can follow UAE for fibroids due to ovarian embolization and subsequent ovarian failure.6-8,17

The literature indicates a rate of:

  • 1% to 2% in patients less than 45 years of age
  • 15% to 20% for perimenopausal women 45 and older

Worsening of uterine bleeding is rare after UAE, but can occur. Kerlan et al21 reported massive uterine bleeding 1 month after UAE in a woman who underwent the procedure for menorrhagia. When she was treated with emergent hysterectomy, a bleeding ulceration of the endometrium overlying the necrotic fibroid was found.

Other complications include spotting, hot flashes, fever, vaginal discharge, mood swings, pain at the puncture site, and dysuria.6-8,17

Our UAE experience

The New England Fibroid Center began offering fibroid embolization in 1997. Since then, we have performed 705 procedures at 5 hospitals in the Greater Boston region, with a technical success rate of 99%. Technical failure occurred in 1% of patients; these women had very difficult vascular anatomy involving uterine arteries, or ovarian arteries formed the dominant blood supply to the fibroids.

Clinical success or improvement was seen in 80% of women with bulk-related symptoms and 94.3% with bleeding symptoms.

Clinical failure occurred in 5.7% of women (1.6% required repeat UAE and 1.4% hysterectomies due to persistent symptoms).

Complications occurred in 4% of cases (2% rate of premature ovarian failure, 1.5% rate of transvaginal passage of infarcted fibroids, and 0.5% rate of groin hematoma). There were no major complications requiring transfusion or emergent surgeries such as hysterectomy.

Fertility after UAE

LISA’S CASE

“Cure” and pregnancy

Lisa successfully underwent UAE, and had no symptoms after the procedure. The uterine fibroids resolved almost completely in 1 year.

Three years after the procedure, she became pregnant and delivered a healthy, full-term infant.

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