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UTERINE FIBROID EMBOLISA TION DR INDRAJEET MANDALAims Know about the clinical presentation and imaging modalities of fibroids Know about the management options for fibroids Understand the basics of uterine artery embolisation for fibroids Know about some other IR interventions for women’s healthIntroduction to fibroids Fibroids are benign tumours of the myometrium Genetic/environmental factors result in transformation of the normal myometrial cell, dysplasia & abnormal growth Prevalence estimates vary (4.5–68.6%) depending on diagnostic method & population studied USA cost - $34.4bn, up to $17bn due to lost productivity from QoLRisk Factors Black race - most consistent risk factor ● 2-3x more likely to have fibroids ● More likely to present at a younger age ● More likely to present with AUB ● Unclear why - ?genetics ?diet Age Family history Oestrogen - increases growth, but isn’t responsible for the genesis of fibroidsFibroid locationsFIGO Classification SystemClinical Presentation Asymptomatic Clinically significant fibroids usually present in 3 main ways: ● Heavy or prolonged menstrual bleeding. Often associated pain. ● Bulk-related symptoms, such as pelvic pressure and pain (usually chronic, dull and intermittent in nature) ● Reproductive dysfunction (ie, infertility or obstetric complications - PPH) Other mass effects: hydronephrosis, bowel obstruction or venous congestion Any fibroid may undergo degeneration or calcification Worsened in pregnancy - may present for the 1st time during pregnancy, either as antenatal bleeding or post-partum haemorrhageClinical Presentation - continued Heavy bleeding ● Predominant symptom in 65%, present in 84% ● Largely determined by location - submucosal (esp. if protruding into cavity) and intramural ● Size is of secondary importance Bulk symptoms ● Predominant symptom in 23%, present in 83% Reproductive complications ● Related to degree of endometrial cavity distorsion ● Submucosal fibroids implicated most (0.3 pregnancy rate vs normal), intramural (0.6) or subserosal (negligible effect)Clinical Presentation - could it be cancer? Always distinguish pre vs post-menopausal bleeding Look out for red flags that suggest uterine sarcoma ● Short history of symptoms ● Older age ● Growth in post-menopausal period ● Any other feature that signals rapid growth Anyone age 40, consider endometrial biopsy - don’t assume HMB is due to the fibroidImagingImaging Multiple imaging modalities exist for investigating fibroids What is the most accurate imaging method for fibroids?Ultrasound Ultrasound is 1st line for investigating fibroids. Sensitivity 95-100% for <10w uterus. Usually needs to be done TV for good views; TA can pick up large fibroids Often TVUS is done for other reasons + fibroids are incidentally detected Appearances: ● Generally, fibroids appear hypoechoic compared to the normal myometrium. ● May contain calcifications (particularly if degenerated) or cystic areas ● Adnexal mass - a pedunculated fibroid can look like an adnexal massTA Ultrasound Trans-abdominal (TA) Trans-vaginal (TV) ● Probe placed on lower abdomen ● Smaller, high frequency internal probe ● Requires full bladder ● Empty bladderOther imaging modalities Saline-infusion ultrasonography ● Infusion of saline into the uterine cavity ● Allows assessment of protrusion into cavity and better visualisation of submucosal fibroids (can be missed on regular TVUS) ● Performed if there are fertility concerns or if hysteroscopic resection planned MRI ● Best investigation for investigating size/number fibroids; not usually needed ● Done before myomectomy - helps plan expected depth of myometrium ● Can be done before UAE - MRI features are thought to predict outcomeUltrasound pre/post saline infusion Ultrasound images of a fibroid with doppler Saline infusion sonographyMRI Most accurate imaging method but not always needed for diagnosis Appearance varies a lot Quantifies size, number and extent - useful for surgical planning Helps identifying other aetiologies e.g. adenomyosis Particularly important for identifying pedunculated fibroids (risk of detachment -> infection)Treatment OptionsTreatment Options Asymptomatic fibroids don’t need treatment or routine follow up Observation, medical or surgical options exist Location is important - affects technical success of certain procedures TCRF General principles: ● Try symptom control first. ● If this fails (common), consider intervention Patient questions: 1. Do they want children in the future? 2. Do they want to keep the uterus?Hysterectomy Historically, hysterectomy has been the gold standard treatment. Rationale simple: no uterus = no fibroids. Definitive. Consider adding a BSO to reduce risk of ovarian cancer - only for older women due to risk of premature menopause/needing HRT Approaches: ● Abdominal ● Laparoscopic - assisted (LAVH) or total (TLH) ● VaginalHysterectomy Patients who have definitely completed their family = ideal treatment Considerations: ● Surgical risk. Higher if previous operations, BMI, etc. ● Prolonged hospital admission/stay ● Cultural considerations of wanting to keep uterusHysteroscopic resection (TCRF) TCRF is preferred for submucosal fibroids Technically difficult procedure - higher if intramural extension Generally better for smaller lesions Larger fibroids have risk of bleedingMyomectomy Myomectomy - removal of the fibroid & preserving remainder of myometrium Approaches - laparoscopic or open Laparoscopy generally not done if largest fibroid >10cm or >5 fibroids - needs open Symptomatic relief - 80%What is the largest size fibroid removed laparoscopically? 21cm (weighed 3.4kg)Uterine Artery EmbolisationHow does each of these link to UFE?How does each of these link to UFE? The first uterine fibroid embolisation was Polyvinyl alcohol (PVA) was the original embolic material performed by a French neuroradiologist in 1974 used. That same material is used in photographic film.Uterine Artery Embolisation Fibroids are very vascular - rationale is that blocking this reduces growth and therefore symptoms of fibroid. Patient selection: ● Poor surgical candidates or high anaesthetic risk ● Prior abdominal surgery ● Desire for quicker recovery/return to work Outcome for HMB and bulk symptoms good - approx. 90% of patients experience improvement in symptoms Fertility effect is unknown - hence myomectomy preferred in patients desiring fertility. Although recent data is calling that into question… Reintervention rates relatively high vs myomectomyVascular Anatomy Aorta -> CIA -> IIA Branch of the internal iliac arterySeldinger Technique Modified seldinger technique is the key principle for all of interventional radiology: ● Needle placed in target under ultrasound guidance ● Guidewire through the needle ● Remove needle ● Place a sheath over wire to secure access - basically a cannula w/ hemostatic valveUltrasound guided accessCannulating uterine artery & embolisation stepsUAE Procedure Procedure: ● Access via femoral (classic) or radial (newer). ● Navigate guidewire into UA ● Catheter placed over wire into UA ● Embolized with particles til stasis ● Procedure done bilaterallyMechanism of embolisationPre/post embolisation Pre-embolisation shows hypervascular fibroid on the left Post-embolisation shows occluded arteryPost-UAE Pain control is critical - usually requires overnight admission ● Necrosis of the fibroid can cause significant pain ● Associated with volume of fibroid ● Self limited - subsides within 24h. Treated with PCA. ● Other strategies - hypogastric nerve block, dexamethasone, intra-arterial lidocaine Post-embolisation syndrome - fever and malaise, usually self limiting < 1 week Fibroid expulsion - conservatively managed unless stuck at cervical os Vaginal discharge - itself self limiting, but could indicate infectionFollow up imagingUAE vs myomectomy key features UAE Myomectomy Main indication Intramural & subserosal Intramural & subserosal Procedure Radial/femoral Laparoscopic or abdominal/open Length of stay Shorter Longer Reintervention Higher Lower rate Complications Pain Bleeding Post embolisation syndrome Infection Fibroid expulsion Iatrogenic injury Vaginal Discharge Adhesions Non target embolization Premature menopauseSummary of treatment Trial of symptom control first e.g. with TXA/NSAIDs Treatment options: ● Submucosal - aim for TCRF first ● Intramural/subserosal - choose between myomectomy or UAE ○ High surgical risk patient - UAE > myomectomy ○ Fertility desired - myomectomy > UAE Hysterectomy usually done as a last resort Medical treatment has a limited role - only used to shrink fibroids preopUAE for Post-partum haemorrhage Embolisation is also used as a treatment for life threatening PPH Effective technique, but practical considerations limit its use RCOG Green-top Guideline No. 52Global Health & UAE - a brief intro Fibroid disease burden is high in Africa Huge cultural issues with keeping uterus PPH mortality is also extremely high UAE plays a role in both conditions, but lack of skilled operators is the main bottleneck IR isn’t all about fancy equipment - cheaper alternatives being investigated e.g. FAIR-EmboIR & Women’ s Health - Other InterventionsPelvic Congestion Syndrome & Embolisation Chronic pelvic pain - non-cyclical pelvic pain for 3-6+ months ● Very common - 1 in 7 prevalence, 10% of all gynaecology referrals ● Wide differential Pelvic congestion syndrome is one cause. Particular feature = pain worse on standing. Others include endometriosis, adhesions, prior PID. Controversial as many have asymptomatic dilated veins; no strict cutoff value Ovarian vein embolisation often used as a treatmentInfertility & Fallopian tube recanalisation Infertility - common problem with multiple causes Fallopian tube blockage can occur e.g. due to previous PID Recanalisation can be done - better for proximal blocksFurther Reading Links RCOG Guidelines: https://www.rcog.org.uk/globalassets/documents/guidelines/23-12-2013_rcog_rcr_uae.pdf Fibroid Burden in Africa - A Perspective: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7344264/ FAIR Embo: https://interventionalnews.com/fair-embo/Thank you for watching!