Uterine artery embolization (UAE) is an interventional radiological technique to occlude the arterial supply to the uterus and is performed for various reasons.
Uterine artery embolization has been practised for more than 20 years for controlling hemorrhage following delivery/abortion, in ectopic or cervical pregnancy, gestational trophoblastic disease or carcinoma of the cervix.
The technique was first reported as an effective intervention for fibroids in 1995 when Ravina et al noted that several women with symptomatic leiomyomata who underwent uterine artery embolization as a pre-hysterectomy treatment had significant clinical improvement to an extent that hysterectomy was no longer required.
It is now estimated that more than 100,000 UAE procedures may have been performed so far for the treatment of fibroids.
- intramural fibroids
- dysfunctional uterine bleeding
- other less common indications include
Patients with fibroids, and their related problems, probably present the largest group who is most able to benefit from percutaneous treatment. Presently people with uterine fibroids traditionally undergo total abdominal, vaginal or laparoscopic assisted hysterectomies around the world. The figure in the United States is about 60,000 hysterectomies per year. In less developed and more populous countries like India, the numbers may be even higher. There is an increasing need for non-invasive or less invasive alternatives for uterine fibroids and dysfunctional bleeding.
- contraindications to angiography
- severe anaphylactoid reaction to contrast media
- uncorrectable coagulopathy
- severe renal insufficiency
- active pelvic infection
- prior pelvic radiation
- connective tissue disease
- prior surgery with adhesions (relative)
In addition, many international obstetrics practice guidelines acknowledge that the effect of uterine artery embolization (UAE) on pregnancy is understudied and thus currently do not recommend performing UAE on women who maintain a future desire for pregnancy. Exceptions to this may include women who have severe anemia or symptoms associated with fibroids, have failed conservative measures and have contraindications to surgery or those who consent to UAE within an approved research protocol.
- a thorough evaluation of patients symptoms and signs in consultation with a gynecologist
- pelvic ultrasound and MRI
- Pap smear and endometrial biopsy
- relevant history of other medical problems
Any catheter suitable for contralateral and ipsilateral uterine artery cannulation
- Robertson uterine catheter (RUC): commonly used selective catheter for pelvic angiography
- Cobra glidecath: can also be used
- right internal mammary catheter: may be used, but less common
If the above mentioned catheters are not available, bilateral common femoral artery puncture is an option for contralateral access to the uterine arteries.
The type of embolic agent selected will depend on the indication.
- PVA (300-350 microns)
postpartum hemorrhage or vaginal bleeding
- gel foam particles
- coils (occasionally)
- n-butyl-cyanoacrylate (glue)
- IV Fluids
- local anesthesia
The intravenous fluids, analgesia, antiemetics and antibiotics need to be continued during the postprocedural period.
- angiography complications
- post-embolization syndrome
- uterine artery dissection/rupture
For vaginal bleeding
- alleviates need for emergency hysterectomy
- resumption of menstruation
- successful pregnancy after UAE for postpartum hemorrhage (PPH)
- unsuspected abnormalities treated during UAE for PPH
- menorrhagia/dysmenorrhea and metrorrhagia improve in 70-95% of cases
- hospital stay is rarely >48 hours
- patients are often back to work within 10 days
- no post laparotomy complications
- mean uterine volume reduction by 26-59%
- fibroid volume reduction by 40-75% (at the end of 6 months)
- the overall complication rate is at ~10% with major complications at ~1.5%
- American College of Obstetrics and Gynecology (ACOG) in 2008 issued guidelines that patients with fibroids may be given an option of uterine artery embolization 9
- NICE(UK): in 2007 recommended uterine artery embolization with surgery as a first line treatment option
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- 7. Spielmann AL, Keogh C, Forster BB et-al. Comparison of MRI and sonography in the preliminary evaluation for fibroid embolization. AJR Am J Roentgenol. 2006;187 (6): 1499-504. doi:10.2214/AJR.05.1476 - Pubmed citation
- 8. Martin, J., Bhanot, K., & Athreya, S. (2012). Complications and Reinterventions in Uterine Artery Embolization for Symptomatic Uterine Fibroids: A Literature Review and Meta Analysis. CardioVascular and Interventional Radiology. doi:10.1007/s00270-012-0505-y
- 9. ACOG practice bulletin. Alternatives to hysterectomy in the management of leiomyomas. (2008) Obstetrics and gynecology. 112 (2 Pt 1): 387-400. doi:10.1097/AOG.0b013e318183fbab - Pubmed