Undergoing Uterine Artery Embolization Research Articles

8477 Uterine Artery Embolization Via Transradial Versus Transfemoral Arterial Access: Technical and Clinical Results

<h3>Study Objective</h3> To compare the technical and clinical outcomes of transradial (TRA) versus transfemoral (TFA) access in patients undergoing uterine artery embolization (UAE) for symptomatic uterine fibroids. <h3>Design</h3> Retrospective study. <h3>Setting</h3> Single institution, tertiary care center in Northeastern USA from 2015-2021. <h3>Patients or Participants</h3> Patients undergoing uterine artery embolization at our institution (n=43) were included. <h3>Interventions</h3> Uterine artery embolization via transradial or transfemoral access. <h3>Measurements and Main Results</h3> A retrospective analysis was conducted for 2 cohorts: 15 procedures were performed via TRA and 28 procedures were performed via TFA. Median age was 45 years in both groups and procedure type was determined based off of surgeon and patient preference. Indications for embolization included: menorrhagia (n=33), dysmenorrhea (n=9), anemia (n=15), and bulk symptoms (n=34). Patients with malignancy of the uterus or ovaries, infection, renal failure, and desire for future fertility were excluded. Five vascular surgeons performed all procedures at one institution. Technical success, pain improvement, operative time and length of stay were assessed. Technical success, defined as successful delivery of embolic agent into target artery, was achieved for all patients in both cohorts. Mean procedure time was 166 minutes in TRA group and 140 min in TFA group. There was no significant difference in subjective pain changes at post-operative clinic visits and length of stay between groups. <h3>Conclusion</h3> While both TRA and TFA access achieved equal technical success, TRA access did come with increased operative time. As major drivers of increasing use of TRA include earlier time to ambulation after the procedure, earlier discharge from the hospital, and higher patient satisfaction, these outcomes warrant future investigation. Nonetheless, transradial access in uterine artery embolization represents a safe and feasible minimally invasive approach with a comparable safety profile to transfemoral access in the management of symptomatic uterine fibroids.

Nonrandomized Clinical Trial of the Effectiveness of a Laxative Treatment Protocol to Time of First Bowel Movement After Uterine Artery Embolization Procedure: A Pilot Study

PurposeThe purpose of this pilot study was to determine the efficacy of a proactive laxative protocol for constipation prevention in patients undergoing uterine artery embolization (UAE). DesignA nonrandomized clinical trial. MethodsA nonrandomized trial study design was piloted using a convenience sample of 35 patients undergoing UAE in the course of 1 year. FindingsThere was a statistically significant difference (P < .0001) in time of first bowel movement after UAE when patients followed a proactive laxative protocol. A combination of senna and stool softener taken twice a day for 2 days preoperatively was associated with a shorter time to first bowel movement postoperatively. ConclusionsThis pilot study supports the benefits of a proactive laxative protocol in helping achieve procedural recovery uncomplicated by constipation in patients undergoing UAE.

Incidence of Gynecologic Cancers in Women after Uterine Artery Embolization

To characterize the short-term incidence of gynecologic cancer after undergoing uterine artery embolization (UAE). Retrospective cohort study. Commercial insurance claims database. Total of 15 393 United States women aged 18 to 64 years who underwent UAE between 2007 and 2017. We used the IBM MarketScan (Armonk, NY) claims to identify adult women without previous gynecologic cancer diagnoses undergoing UAE between 2007 and 2017. Database queries identified women with any diagnostic or procedure codes related to gynecologic malignancies occurring in the first 3 years after UAE. A malignancy diagnosis was suggested by recurrent malignancy-related claims not linked exclusively to diagnostic testing (e.g., transvaginal ultrasound) and malignancy codes linked to tissue pathology claims. Incidence of malignancy diagnosis was calculated. Rates of endometrial sampling in the year before UAE were identified. Thirty-one women undergoing UAE had gynecologic cancer diagnoses within 3 years of the procedure (22 of 31, 71% uterine cancers; 7 of 31, 23% ovarian cancers; and 2 of 31, 6% cervical cancers). On average, cancer diagnoses were made 1.1 ± 0.9 years after UAE. One in 497 women undergoing UAE was diagnosed with a gynecologic malignancy within 3 years, with an incidence of 1.1 malignancies per 1000 person-years. Cancer incidence increased with age at the time of UAE: short-term malignancy diagnoses were made in 1 in 377 women aged 45 to 54 years, and 1 in 79 women aged 55 to 64 years. In the year before UAE, 28% (4311 of 15 362) of women without cancer, and 23% (5 of 22) of women diagnosed with uterine cancer had preprocedural endometrial sampling. These data can inform risk/benefit counseling and shared decision-making regarding UAE and its alternatives. Short-term malignancies after UAE highlight the importance of preprocedure evaluation in symptomatic women and women with age-related risk.

Abstract No. 353 - Comorbid medical conditions in women undergoing uterine artery embolization for symptomatic uterine fibroids and adenomyosis

Purpose The purpose of this investigation is to report the co-morbidities of patients undergoing uterine artery embolization (UAE) for symptomatic uterine fibroids and adenomyosis at a single academic institution Materials and Methods In this retrospective cohort study, medical charts of women consulted for consideration for UAE were reviewed, noting all co-morbidities in addition to uterine fibroid and adenomyosis disease. Data searched for and saved for evaluation included: confirmation of uterine fibroid or adenomyosis disease, self-reported co-morbid medical conditions, age, and weight. Comparison was made with the presence of similar co-morbidities in the general population. Results In a sample of 368 patients, recorded co-morbid medical conditions include: obesity, 22.54%; anemia, 20.92%; transfusion-dependent anemia, 3.26%; hypertension, 14.95%; psychiatric disorder, 8.97%; hypercholesterolemia, 7.33%; hypothyroid, 5.43%; uterine polyps, 3.53%; diabetes mellitus, 2.99%; endometriosis, 2.17%. Conclusion Relative to the general American population, a smaller proportion of our patient population was obese, diabetic, and/or hypertensive. A large proportion of our patients were diagnosed with anemia +/- transfusion dependence, hypercholesterolemia, psychiatric disorders, and hypothyroidism. Despite the average young age of patients undergoing UAE for symptomatic fibroid or /and adenomyosis disease of the uterus, their co-morbid conditions may play a role in their presentation, procedure tolerance, and post embolization clinical outcome.

Resolution of Hydronephrosis after Uterine Artery Embolization for Fibroids

Purpose To determine the prevalence, predisposing factors, and resolution of hydronephrosis among patients undergoing uterine artery embolization (UAE) for fibroids. Materials and Methods From October 2004 to May 2008, 1,114 patients underwent UAE at an academic medical center. Hydronephrosis was found on angiographic images in 101 patients. In 34 of these patients, 3-month ultrasound follow-up was available. The angiographic images were graded for hydronephrosis severity by three interventional radiologist reviewers. The degree of residual hydronephrosis was obtained from ultrasound images or reports in 3-month follow-up imaging. Descriptive statistics summarizing outcomes and interobserver agreement regarding hydronephrosis grade were calculated. In a parallel assessment, prospectively gathered baseline data available from 776 patients undergoing UAE were analyzed to identify predisposing factors to hydronephrosis. Results Among the 34 patients with hydronephrosis and appropriate follow-up, resolution occurred in 28 of 34 (82%) patients. Among the entire study group, 9.0% (101 of 1,114) of patients had unilateral or bilateral hydronephrosis. Hydronephrosis was less frequent in left kidneys (4.5% [35 of 776]) than right kidneys (6.3% [49 of 776]; P = .013). The mean uterine volume in the group with hydronephrosis was greater than in the group without hydronephrosis (1,041 cm 3 vs 609 cm 3; P < .0001), and the mean dominant fibroid volume was also greater (233 cm 3 vs 147 cm 3; P < .0001). Conclusions These results suggest that UAE may result in resolution of hydronephrosis in a notable number of cases. Large uterine size and dominant fibroid size was associated with hydronephrosis.

Is an Intrauterine Device a Contraindication for Uterine Artery Embolization? A Study of 20 Patients

The presence of an intrauterine device (IUD) has been traditionally considered a risk factor for postprocedural infection in patients undergoing uterine artery embolization (UAE). The authors retrospectively evaluated the occurrence of infectious complications following embolization in 20 women with IUDs. After a mean follow-up of 20.5 months, none of the patients developed an infectious complication. One patient required hysterectomy following embolization for persistent pain. Pathologic evaluation of the hysterectomy specimen demonstrated ischemia without evidence of inflammation. This experience suggests that the presence of an IUD might not be considered a contraindication for UAE.

Abstract No. 372: Intra-Procedural Pain Levels in Patients Undergoing Uterine Artery Embolization (UAE): Retrospective Comparison of the Use of Intrathecal Morphine Versus Standard Treatment for Analgesia

Abstract No. 372: Intra-Procedural Pain Levels in Patients Undergoing Uterine Artery Embolization (UAE): Retrospective Comparison of the Use of Intrathecal Morphine Versus Standard Treatment for Analgesia

Markers of muscle ischemia, necrosis, and inflammation following uterine artery embolization in the treatment of symptomatic uterine fibroids

The objective of the study was to quantify markers of myometrial ischemia, necrosis, and inflammation in women undergoing uterine artery embolization (UAE). Women with symptomatic fibroids were randomized to treatment with UAE (n = 14) or abdominal myomectomy (n = 11). Peripheral venous blood samples were taken before and after the procedure, at 24 hours and 6 weeks. Creatine kinase (CK) and ischemia-modified albumin (IMA) were measured as markers of necrosis and ischemia. Inflammation was assessed by measurement of C-reactive protein (CRP). Changes in the markers following UAE and myomectomy were measured. Following UAE, no change was seen in CK or IMA, but CRP was raised only at 6 weeks. At 24 hours after myomectomy, there were significant rises in all 3 markers, with a return to normal by 6 weeks. No significant ischemia or necrosis occurs in the myometrium following UAE, whereas the delayed rise in CRP is likely to reflect necrosis in fibroids.

A Prospective Multicenter Comparative Study between Myomectomy and Uterine Artery Embolization with Polyvinyl Alcohol Microspheres: Long-term Clinical Outcomes in Patients with Symptomatic Uterine Fibroids

To prospectively evaluate the safety and effectiveness of polyvinyl alcohol (PVA) microspheres in patients undergoing uterine artery embolization (UAE) to treat uterine fibroid tumors and to compare the long-term changes in health-related quality of life (QOL) after UAE with the changes seen after myomectomy. One hundred forty-six patients with uterine myomas were enrolled into this multicenter study, with 77 patients undergoing UAE with PVA and 69 patients undergoing myomectomy. Six-month follow-up was completed for the myomectomy, whereas 2-year follow-up was completed for the UAE group. Outcomes were assessed with the Uterine Fibroid QOL Questionnaire and based on adverse event incidence, time to return to normal activity, and changes in tumor symptom scores, QOL scores, and menorrhagia bleeding scores. For the UAE cohort, changes in total uterine volume and dominant tumor size on magnetic resonance (MR) imaging were assessed. In the UAE cohort, 88.3% of patients experienced a reduction of tumor-related symptoms (increase >or=5 points from baseline measurement) at 6 months, with 75.4% of patients in the myomectomy group experiencing similar improvement. Median QOL questionnaire scores at 6 months were found to be significantly higher in patients treated with UAE (P = .041), with sustained improvement seen at 12 and 24 months. Both procedures resulted in significant reductions in 6-month menorrhagia bleeding scores, with sustained improvement in the UAE cohort at 12 and 24 months. MR imaging at 6 months revealed significant uterine and tumor volume reductions after UAE (P < .05). At least one adverse event occurred in 42% of patients in the myomectomy group, compared with 26% in the UAE group (P < .05). UAE performed with PVA microspheres was associated with greater sustained improvements in symptom severity and health-related QOL and with fewer complications compared with myomectomy. Six-month MR imaging data demonstrated significant reductions in uterine and tumor volumes, although the degree of tissue infarction after UAE was not assessed with contrast medium-enhanced MR imaging.

The Safety and Efficacy of a Percutaneous Closure Device in Patients Undergoing Uterine Artery Embolization

The use of suture-mediated closure devices (SMCDs) in patients undergoing uterine artery embolization (UAE) for symptomatic leiomyomata is controversial. With recent literature suggesting a higher complication rate with the use of SMCDs, their use in this specific population has been questioned. The purpose of this study is to assess the safety and efficacy of SMCDs specifically for those patients undergoing UAE for symptomatic uterine leiomyomata. A prospective database was established in a single high-volume medical center for patients undergoing UAE for symptomatic leiomyomata. Data were tracked prospectively, with technical outcome and complication rates serving as endpoints. UAE was performed in 342 consecutive patients from January 2001 to September 2003. The SMCD was used in 328 of these patients (96%). Successful primary hemostasis was achieved in 320 of 328 patients (97%), with additional manual compression required in the remaining eight patients (3%). No major complications were observed. Minor complications consisted of minor hematomas in four women (1%) and anteriomedial thigh pain in 68 women (21%) within 1 month of follow-up, resulting in an overall complication rate of 22%. All symptoms related to anteromedial thigh pain ipsilateral to the arterial puncture site were managed conservatively with 1 week of oral nonsteroidal antiinflammatory medication. The SMCD provided safe and effective hemostasis in patients undergoing UAE. Transient thigh discomfort, which may result from irritation of the anterior femoral cutaneous nerves (femoral neuralgia syndrome), was uniformly relieved with nonsteroidal antiinflammatory therapy.

Comparison of particle penetration with non-spherical polyvinyl alcohol versus trisacryl gelatin microspheres in women undergoing premyomectomy uterine artery embolization

The purpose of this study was to compare the depth of vascular penetration of non-spherical polyvinyl alcohol (PVA) versus trisacryl gelatin microspheres (MS) in women undergoing uterine artery embolization (UAE) immediately before transabdominal myomectomy. A total of 17 patients who had been referred for embolization before myomectomy underwent bilateral uterine artery embolization using either 355-500 microm PVA (group A) or 700-900 microm MS (group B). The depth of penetration of the particles was assessed by identifying their presence and location in the resected specimen. Of the 17 women enrolled in this study, 10 were in group A and 6 in group B. One woman underwent embolization using both types of particle and was excluded from the analysis. Embolic particles were significantly (p = 0.048) more frequently located within the fibroid (4/6, 67%) in Group B than Group A (1/10, 10%). Particles were also identified in the perifibroid tissues in 4/6 (67%) in Group B and 4/10 (40%) in Group A, with no statistical difference. There were no procedural complications. MS particles (700-900 microm) penetrate significantly deeper into leiomyomata compared with non-spherical PVA (355-500 microm). MS may therefore confer advantages in UAE, as they may more specifically target the fibroid, allowing an earlier end-point to embolization and minimizing ischaemic damage to normal myometrium and ovaries.

Quantified short-term outcome of uterine artery embolization with gelatin sponge particles and lipiodol for symptomatic myoma

Objective To investigate and quantify clinical outcomes and spectral Doppler analyses of uterine arteries in patients with myoma undergoing uterine artery embolization (UAE) with gelatin sponge particles and lipiodol. Design Prospective observational study. Setting Tertiary medical center. Patient(s) Forty premenopausal women with symptomatic myoma. Intervention(s) Uterine artery embolization with gelatin sponge particles and lipiodol. Main outcomes measure(s) Hemoglobin, hematocrit, CA-125, pictorial blood loss assessment, visual analogue pain scale, questionnaire for symptoms, tumor volume, and spectral Doppler analyses of uterine arteries. Result(s) The mean follow-up period was 8.1 months (range, 6–12). Menstrual flow improved in 29 of 35 patients (83%) and decreased significantly by 78.4%. Menstrual pain improved in 27 of 35 patients (77%) and decreased significantly by 70%. Hematocrit and CA-125 improved significantly. The mean percentage reductions of uterine and myomal volumes were 40.2% and 54.9%, respectively. The mean peak systolic velocity of the uterine arteries decreased by 52%. The major complication rate was 2.56%. There was no correlation between tumor volume reduction and clinical outcome. Conclusion(s) Uterine artery embolization with gelatin sponge particles and lipiodol had satisfactory short-term outcomes, comparable to those associated with polyvinyl alcohol particles. Quantified and semiquantified measurements provided objective assessment of clinical outcomes. Serum CA-125 might play a role in clinical follow-up. Reduction of tumor volume is not predictive of UAE efficacy.

Current Status of Suture-mediated Closure: What Is the Cost of Comfort?

TWO articles in the current issue of JVIR contribute to the current understanding of suture-mediated closure devices. The first, by Wagner et al (1), describes an almost 5% risk of significant arterial complications after use of the Perclose device (Perclose, Redwood City, CA) in patients undergoing uterine artery embolization (UAE). Two patients in their trial required long-term anticoagulation and a third underwent a bypass with eventual amputation of a gangrenous toe. The second article, by Hoffman et al (2), describes reactive narrowing of 44.7% and 59.3% of the femoral artery immediately after deployment of the Perclose and SuperStitch (Sutura, Fountain Valley, CA) devices in a swine model.

The Ontario Uterine Fibroid Embolization Trial. Part 1. Baseline patient characteristics, fibroid burden, and impact on life

Objective To determine baseline characteristics of women undergoing uterine artery embolization (UAE) for symptomatic fibroids. Design Multicenter, prospective, single-arm clinical treatment trial. Setting Eight Ontario university and community hospitals. Patient(s) Five hundred fifty-five women undergoing UAE for fibroids. Intervention(s) Baseline questionnaires completed before UAE. Main outcome measure(s) Questionnaires were analyzed for demographic, medical, and gynecologic histories. Fibroid symptoms, impact of symptoms, previous consultations, and treatments were also analyzed. Result(s) The Ontario cohort (66% white, 23% black, 11% other races) had an average age of 43. Thirty-one percent were under age 40. Most women were university educated (68%) and working outside the home (85%). Women reported heavy menstrual bleeding (80%), urinary urgency/frequency (73%), pain during intercourse (41%), and work absences (40%). They experienced fibroid-related symptoms for an average of 5 years and consulted with on average of three gynecologists before UAE. High fibroid life-impact scores were reported by 58%. Black women were significantly younger (40.7 vs. 44.0 years), more likely to experience symptoms longer (7 vs. 5 years), and more likely to undergo myomectomy before UAE (24% vs. 9%) than white women. Conclusion(s) Our study illustrates that large numbers of women with highly symptomatic fibroid disease are averse to surgery despite their burden of suffering and are actively seeking alternatives to hysterectomy.