Uterine artery embolization (UAE, uterine fibroid embolization, or UFE) is a procedure in which an interventional radiologist uses a catheter to deliver small particles that block the blood supply to the uterine body. The procedure is primarily done for the treatment of uterine fibroids and adenomyosis. Compared to surgical treatment for fibroids such as a hysterectomy, in which a woman's uterus is removed, uterine artery embolization may be beneficial in women who wish to retain their uterus. Other reasons for uterine artery embolization are postpartum hemorrhage and uterine arteriovenous malformations.
Medical uses Uterine fibroids are the most common type of benign uterine tumor and are composed of smooth muscle. They often cause bulk-related symptoms, which can be characterized by back pain, heaviness in the pelvic area, abdominal bloating. Uterine artery embolization may be done to treat bothersome bulk-related symptoms as well as abnormal or heavy uterine bleeding due to uterine fibroids. Fibroid size, number, and location are three potential predictors of a successful outcome. Specifically, studies have demonstrated that submucosal (directly underneath the uterine lining) fibroids demonstrated the largest reduction in size while subserosal (outer layer of the uterus) had the smallest reduction. Uterine artery embolization may also be appropriate for the treatment of adenomyosis, which is when the lining of the uterus aberrantly grows into the muscle of the uterus. Symptoms of adenomyosis include heavy or prolonged menstrual bleeding and painful menstrual periods. Uterine artery embolization can also be used to control heavy uterine bleeding for reasons other than fibroids, such as postpartum obstetrical hemorrhage. Many women who experience postpartum hemorrhage may be successfully treated with medication or uterine balloon tamponade. However, in cases where women continue to bleed, uterine artery embolization may be an appropriate option. A less common indication for uterine artery embolization is for the treatment of uterine arteriovenous malformations which can be a cause of abnormal uterine bleeding or life-threatening bleeding. Roughly half of women with uterine arteriovenous malformations are born with them while the remaining form following surgical interventions or may be due to uterine tumors.
Contra-indications Prior to undergoing UAE, the patient should be evaluated for the following absolute contra-indications to the procedure: a viable pregnancy, a current infection that is not being treated, or gynecologic malignancy (except for cases where UAE is being used as a procedure in addition to treatment for the cancer). Relative contra-indications for the procedure include a severe contrast allergy since contrast is necessary to visualize the arteries during the procedure, kidney impairment since contrast may cause damage to the kidneys, or coagulopathy (blood disorder that causes prolonged or excessive bleeding). However, all of the stated relative contra-indications can be managed with appropriate pre-operative planning.
Risks/Complications The rate of serious complications is comparable to that of myomectomy or hysterectomy. The advantage of somewhat faster recovery time is offset by a higher rate of minor complications and an increased likelihood of requiring surgical intervention within two to five years of the initial procedure. An analysis of 15,000 women found that those who had myomectomy required fewer additional procedures, including hysterectomies, to treat fibroids over the next five years than those who had uterine artery embolization. Complications include the following:
Death is a very rare complication that may be caused by pulmonary embolism or sepsis (the presence of pus-forming or other pathogenic organisms, or their toxins, in the blood or tissues) resulting in multiple organ failure The cause of a pulmonary embolism is attributed to the time where patients are immobile following the procedure, which makes the formation of a deep venous thrombosis and subsequent pulmonary embolism more likely. Infection from tissue death of fibroids, leading to endometritis (infection of the uterus) resulting in lengthy hospitalization for intravenous antibiotics Fibroid expulsion (fibroids push out through the vagina). The occurrence of this is highly variable and dependent on the location of the fibroid within the uterine tissue. When it does occur, it most commonly happens about 3 months following treatment. Post-embolization syndrome – characterized by acute and/or chronic pain, fevers, malaise, nausea, vomiting and severe night sweats; foul vaginal odor coming from infected, necrotic tissue which remains inside the uterus; hysterectomy due to infection, pain or failure of embolization Misembolization from microspheres or polyvinyl alcohol particles flowing or drifting into organs or tissues where they were not intended to be, causing damage to other organs or other parts of the body such as ovaries, bladder, rectum, and rarely small bowel, uterus, vagina, and labia. Failure – continued fibroid growth, regrowth within four months Menopause – iatrogenic, abnormal, cessation of menstruation and follicle stimulating hormones elevated to menopausal levels Hematoma, blood clot at the incision site; vaginal discharge containing pus and blood, bleeding from incision site, bleeding from vagina, life-threatening allergic reaction to the contrast material.
Technique
Pre-operative preparation Prior to a uterine artery embolization, patients should undergo a clinic visit with their gynecologist, have a recent Pap smear, and an endometrial biopsy in cases where abnormal uterine bleeding is a presenting symptom. A clinic visit can then be made with the interventional radiologist performing the uterine artery embolization so that a thorough history and physical exam can be taken. Recent diagnostic imaging such as a pelvic magnetic resonance imaging (MRI) should also be reviewed by the interventional radiologist to rule out possible malignancy, evaluate uterine anatomy, and discuss the likelihood of fibroid passage with the patient.
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