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Good evening, everyone. This is I are bites. Session to uterine fibroid embolization. I'm your host, Chris, and was got Nile his hosting as well. And, uh, speaker this evening is Doctor Doctor Energy Mandel say, without forever the all handover. I hate you guys. Enjoy this talk. Cool. Thanks, Chris. So as Christmas and my name's in drum, one of the radiology trainees based knocks that, um I'm going to spend the next kind of 45 50 minutes talking about fibroid embolization. Um, in terms of the age of the session, I think I wanted to have a bit of clinical background. Just so we know kind of the presentation and how the hell fibroids present. I'll go through some of the imaging modalities that commonly used We'll go through some of the mansion options not just embolization, but some of the surgical options as well on. Then we'll go on to talk about embolization on briefly touch upon some other uh, I I are interventions, the women's health. Although that that's not really the main focus of the talk. Um, but the decent times come up in med school exams. Well, um, so in introduction to fibroids, Essentially, fibroids are benign tumors of the myometrium. So the innermost layers, the endometrium, the muscle There's the myo, and then outside you got cirrhosis. Um, and the reason that's important is I put this diagram here to show that the pathogenesis is pretty much the same as how cancers grow. So the native cell has mutations and has unregulated growth. But the difference is it's not a malignant tumor. It's a benign tumor, so it won't spread outside the in a location that it's grown. Um, so as with cancers, there's some kind of genetic factors, and there's also some environmental factors, and one of some of those interactions will result in abnormal growth dysplasia and eventually a mass, which will be a Bible. And the difficulty in estimating the president is that lots of these patients are asymptomatic, and so lots of patients will actually have fibroids on D. We don't know about which is why there's a huge variation in the literature in how prevalence the condition ist. So depending on the population on which imaging methods they use, that varies between about 5% all the way up to 70% Um, and the main problem with it is a quality of life problems. So in the USA alone it costs $34 billion a year, half of which is from lost productivity because of symptoms. So in terms of treatments, it's all to do with quality of life treatment out, which is important, Um, and kind of mentioned because those were the main outcome measures for which we measure the success of treatment on in terms of risk factors. Again, there's lots of different ones that are quoted, but the most consistent one is having a black race. So black women are 2 to 3 times more likely to get by brides. Uh, no, I only get them, but they're more likely to present with a younger age on the more likely to present with abnormal bleeding. Um, we don't really know why is probably some kind of genetic factor, maybe some dietary kind of issues. So there was, Ah, one paper that suggested Read me increases your ratio by 1.4. I don't know if that's true, but ultimately we don't really know the reasons why. But we do know that that's an important risk. On aged, it does increase with age although after I want to hit menopause, then usually a Bible, it shrink because they are hormone dependent and family history again, probably related to genetic factors. Um, I've heard Eastern there because it does increase the growth of fibroids, but it doesn't cause their generation. That's more of a probably genetic things and in terms of location. So they're all within the myometrium. But depending on where they protrude their called different things. Um, so if here is the subject Cozaar fibroid on, that's because it protruding into the innermost layer and then into the uterine cavity on intramural one is a fibroid that's purely in the muscle layer that doesn't really protruding out or the subserosal one. But Trudeau's on the external surface like this. And then there's a special type called pedunculated fibroids, which have this narrow stalk here on. Then they have this, uh, the fibroids there, um, and again as important implications the planning treatment. This is something you might see. It's just more of an academic classifications system on. It just describes what degree off, you know, extension. It is on each surface, but it's a bit beyond escape of the talk, but I thought, I just include it increase. You've seen it before. Um, and as mentioned, half of patients with fibroids don't present, and they don't cause any symptoms. But if they do cause segment of symptoms, then they usually present in three main ways. On the most common is heavy bleeding, and that's either heavy bleeding on the period. Or sometimes it can cause bleeding between. But usually it's predominately heavy, period and sometimes can cause pain as well. A second type of symptoms. That it can present its bulk related symptoms. Because you can imagine it's a large mass and so that exerts pressure on nearby structures. And so they can often present with a chronic pain, chronic pressure type pain rather than acutely. All those fibroids can present acutely as well. On the third main way they could present is with reproductive dysfunctions. Um, so predominately that's infertility. We'll go into which types of fibroids, in particular courts. That, and the other way it can present is, uh, with postpartum hamburger so often, Um, you don't know that somebody has fibroids when it comes to the delivery stage. They might have postpartum hemorrhage for another explained reason on sometimes it may just be a fly boy that's causing that, Um, and then mass effects go beyond the symptoms, because if the the fiber would is really big, compress on the nobody returned and cause hydronephrosis or it can compress the bowel nearby. Or it could even compress the Varian vein or no, the pelvic pains and cause a venous congestion. And then the fibroid itself on may undergo degeneration. And that can cause like a cute type pain. Or it can also under a calcification, which, um, it's not necessarily a clinical thing, but you might stay on imaging eso Often there's lots of, like hell that calcifications and in particular, like Ah, if you're reporting, say, a CT baby look renal. So bladder stones you might see fibroids of stones, and it's just annoying distractor. I'm trying to find the renal stones, and we mentioned before that Easter gyn drives the growth of fibroids, and so often they're worse and in pregnancy. And sometimes patients may present for the first time in pregnancy so and they had a fibroid all along. But because of the increased Easter gyn ah, they present with heavy bleeding during the pregnancy period, onto predominantly heavy bleeding is how they present into healthcare, and that's largely determined by location. So sub mucosal want in. The intramural ones tend to bleed, um, a bit more, but the size is a bit irrelevant, so even very small fibroids can bleed a lot. And sometimes even large ones don't bleed very much, so it's not consistently related to size. Bolt symptoms are usually not the presenting feature, but often, if you really take a good history, they may. They may come out in the history that all they had a bit of niggling pain or pressure feeling for a while. So it's present in its present in most, most patients. But it's not often the reason they present the healthcare on then. Of course, reproductive complications is the other branch of symptoms that we mentioned and the reason why the main reason why it causes it it because it distorts the endometrial cavity and implantation is effective on. But it's usually some mucosal fibroids that it most intramural little bit. But the subserosal fibroids they haven't they don't really have much of an effect on pregnancy rate. If you look at the data and so it's thought to be because of the physical distortion. That, of course, is infertility. And then the other thing, too, is remember. It's, you know, I always think in the differential. Could it be cancer predominantly if the post menopausal any post menopausal bleeding is cancer until proven otherwise, um, certain red flag symptoms that are always worth asking about sacred, any clocking. So if the history is really, really sure and wrap it, then that's in more in keeping with the malignant growth rather than the 91, particularly if the older and post menopausal those signals that should think about cancer or anything else that makes you think that Oh, this is going pretty quickly. You should always consider endometrium is a cause of the bleeding on. Don't assume that it's a fibroid. So the reason why that's important. If someone might have a fibroid and then present with bleeding either, you know, perimenopause their post menopausally. You know, you don't assume that it is necessarily due to the fibroid and always think every time they present like to be something else that just so you don't miss, you know another cause of it. So I'm going to the main imaging methods for fibroids. Um, so there's a few different imaging methods, but I just wanted to ask you a question. If you just pop smartness on the chat as to what you think, the most accurate imaging that that is the fibroids. No, just pause for a minute. People can. You gotta go. Got couple answers rolling. Answer. MRI, MRI. Yeah. Um, so just move on to the MRI is the most accurate. Yes, but it's not the first line. One and second, anyone mentioned what the first line is is often in them. Final questions, they might say. What's the first line burst? So what's the most accurate? And it's an important distinction to make deserving of the question wrong. The ultrasound is an answer. Uh, can I Don't be more specific on ultrasound. Have got TV ultrasound as well. Yeah, is ultrasound, which is the first line, and it's got a very high sensitivity for picking up fibroids on. But usually it has to be done TV. So you always start with a trans abdominal ultrasound because it's a lot less invasive. But you don't. You often don't pick up fibroids because the views you get and not as good. Um, I'll show you a couple of pictures in a second, but actually, usually a patient will have an ultrasound for another reason. On fibroids, incidentally, detected on that always posed is a risk for another risk, but a dilemma, because you have to think. Okay, there's these clinical symptoms, and I've seen a fibroid on imaging. But is it likely that this image in finding explains the clinical symptoms? And so that's often the reason why it's tricky because, um difficult, sometimes characterized exactly where is like So if someone is presenting with heavy bleeding on, do you think they've got subserosal? Fibroid subserosal fibroids are less likely to present with bleeding, so there's always were thinking in the back of your mind, like, Is there something else to explain this chronic symptoms on on ultrasound, they have a very variable appearance, so usually they appeared darker on ultrasound was hypoechoic compared to the normal tissue. But bending on what's happened to the fiber that might care of it. Different as like house, um, calcium appears different on ultrasound. Here's that shadow that, or if the fibroid is generated, or as like cystic areas, they won't show up on ultrasound. Um, on the other. Complicating factor is if it documented fibroids, it might look like it's near the adnexa and looked like that next mass on go. Those are a bit of the tricky things on ultrasound, so it's not perfect. But it is the first line on imaging method for investigating by boards, and so they talk about ultrasound generally on go through the different types. So either you can have a trans abdominal ultrasound, um, or a trans vaginal ultrasound. So the abdominal one is where the probe is placed on the patient's lower tummy on. The patient needs a full bladder for the scan because the bladder is used as an acoustic window to transmit the sound and get good pictures. Um, where's the trans vaginal? It's more invasive. There's an endo cervical probe that it's smaller ondas higher frequency, and the reason you do that is because you get closer to the structures you want to visualize, not get better quality images. If you look on the left here, it's just a normal trans abdominal ultrasound where you try to look at the uterus. Me see, the bladder is here and then the uterus is deeper, and I mean, it's okay, but you look on the right. This is the Transvaginal ultrasound. Then you can see it's the that Procrit bit more rounded on the quality of image that you get is a lot better and say, if you think you could try and assess if I brought it on this trans abdominal image, then it could be quite difficult unless it's absolutely massive. Where is the trans vaginal sounds? A little bit better on, so you can, you know, spot smaller fibroids, particular the ones that are close to the because of like a sub mucosal fibroids. And so these are just some pictures to show what fibroids look like. So here on the top left, this is all like normal myometrium, and you got this dark, oval shaped thing. At the top is a small, low echogenicity area on the ultrasound, and that's usually a classic, its appearance of a small fibroid. And then again, on the bottom left, you can see another fibroid, but this one is actually a subserosal fibroid because you can see the boundary of the Myometrium and extends beyond that. So again it's the Hypo Echo ECG Mass that it extends out. And then on the right here, this is a calcified fibroid on. It could be a bit difficult to make out the exact foundries, but the calcifications get all the way up to the They're just so you can see the calcified bits which is costing the shadow. And then within that you've got the fibroid itself on a list. Skaters actually indenting onto the bladder. And so for this patient, they might have some, you know, issues with urine frequency and voiding in terms of other imaging modalities. The one I had mentioned. This saline infusion ultrasonography and what that is is infused in few saline within the uterine cavity and then reach down them on. The reason you do that is to assess how far the fibroid is protruding into the cavity. Um allows better visualization off sub mucosal ones, which might be missed on a regular ultrasound. Or you might miss take it for ah, intramural one. Um, and that's important because, as we mentioned that sub mucosal ones are more likely to cause fertility problems on are treated differently. So it's important to recognize the sub mucosal once a different to the intramural ones. And then you mentioned that MRI is the best investigation and will quantify the size and number of fibroids well, that you don't always need it. But it is better to have one before we before you do any treatment for it. And it really, really helps with the surgical planning. And you can also do it before in embolization because there's some data to suggest that features an MRI, are thought to predict outcome. But that's not routinely done everywhere, although I think most places will do an MRI that before they do an embolism, a shin on this is a picture to show in the difference. That saline infusion does so on the left. Here, you can see this hypoechoic area, and it probably is a sudden because of fiber. You can see it kind of indenting on around here, but it's always difficult to tell, you know. You don't know how much it's protruding, then the infusion saline into the cavity in on the right, you can see, actually, this is protruding, really, really heavily into the cavity. That's probably, you know, the reason why, if they presented infertility, this could be a. It's a pretty damning reason on why it might be, um, and then this just on MRI picture to show what Fibro could look like on MRI again. The appearance varies a lot of pending on it, but you can see that there's a big circular growth that's different from the uterine myometrium, Um, and that's the most accurate method. You don't always need it, but particularly it's done for treatment planning, and the other benefit of memory is it helps identify other causes of the patient symptoms, particularly for heavy bleeding. And, you know, my assists is another common cause. And so it's important to differentiate what's causing the symptoms again for treatment. Planning on the other reason why it's worth doing it because it's particularly important for looking at the donkey elated fibroids on The reason for that is, if he embolized one of those, there's a higher risk off detachment compared to a regular fibroids. And so if the fibroids detach into the peritoneal cavity, say, for like the subserosal ones, there's a higher risk of infection, so you don't want to and belies those. You can help it cool. So we move on to the different treatment options that are available. So is he mentioned a symptomatic fibroids. They don't need any treatment or followup. You know, you just leave them alone. But if they're symptomatic, then you then you have to treat it basically on the three options observation. See if it goes away medical treatments, which have a relatively limited role, but they they are good. The first line on then surgical options and again you mentioned location is important is it determines. What do you do into the general approach to treating as you try symptom control. First, you can try various or contraceptives or, um, other treatments to control bleeding rather than treat the fibroid itself. But if this fails and often it does that, then you would consider, um, doing some kind of intervention. On the main things to know from the patient are if they want Children on future plans for fertility, but also they they want to keep the uterus because those air too important questions that will help, you know, decide what treatment is best for them. Uh, so hysterectomy has always been traditionally done for the treatment on, you know, the rationale is very simple if you don't have a uterus, that you don't have any fibroids and say it's a very definitive procedure and it will, it will work pretty much, Um, and especially if the woman or a bit older on def, the post menopausal. Ah, there's considerate. You'd consider adding you for actimates taking the ovaries out, Um, because you would take away the risk of ovarian cancer. But of course, you wouldn't do that on someone premenopausal because you would then cause premature menopause and then need HRT, which you know you don't want to do. So that's always another consideration. When you're doing it is strep to me on this could be done in multiple ways. It's an abdominal hysterectomy is through a large incision. A laparoscopic one is laproscopic, or it can also be done vaginal, depending on help. Take the the uterus is, and so for patients who were definitely completed. The family that said it definitely don't want any more kids on they're approaching menopause or post menopausal, then it is the best treatment because is definitive. But obviously, with any major surgery, there are loads of the potential complications. So, uh, surgical risk gives an important one to consider if they've had previous operations. Then again, that makes the procedure difficult longer. In any case, it's longer us longer anesthetic time and higher risk of complications and again be a miser important factor as well, because it's another perioperative factor that increases the risk. Generally, it's a much longer hospital admission and stay compared to all of the other treatment. Um, and also for some, there's cultural considerations of wanting to keep the uterus. So in some cultures, it's viewed as know kind of losing. Womanhood of that makes sense. And so for that group, it's important to consider that and know about the other treatment. See can recommend them if that's what you want. Um, so history scopic resection or tea? Sciarra wasn't acronym. That's the preferred treatment. If it's a sub, mucosal fibroids because you know it's protruding into the cavity, so that's the best way to approach it to get rid of it, General, it's better for smaller lesions. The bigger the lesion is, the more difficult the procedure is, Um, but also, if it's a bigger fibroid, it has a higher risk off bleeding within the procedure, and you might have to abandon. But if it's predominantly, it was just a sudden because of fibroids. This is the first line treatment for it, although know all centers will offer it on. Then the other option is, um, my maximum, which is removal of just the fibroid. But you keep the rest of the Miami trip on again that committed macroscopically or open. But if you want to do it laparoscopically, then the fibroid has to be small enough. Take up in the port. And so the largest one is really, really big, or there's absolutely load of them. You can't do a myomectomy last. Stop it early. It has to be an open operation on degenerate. It's an effective procedure. About 80% have symptomatic relief from the from the operation. Um, I thought I'd ask his question just to see if anyone has of the guests on what is the largest size fibroid that's been removed, not stop it. It's It's more intense. Activators got a couple people saying 50. It's a bit higher than that, actually, 21 centimeters, and it weighed 3 kg. So, um, that must have been a very difficult operation on, you know. It would not have been fun. Teo sits that one. Sure. So normally they wouldn't attempt if it's 21 centimeters, but yeah, just a bit of trivia in that. My met me Hope so. Then we want Teo embolization, which is the main interventional treatment for fibroids. Um, again, I lost a couple of questions and look to your pictures here. Um, and I want just a couple of answers on how each of those might link to fibroid embolization. Um, and again, I would just call us for a second. The one on the left, This's scan of the brain. That's something to do with your own on. Um, the one on the right is what they used to use for cameras before they had to take pictures on film. So just given a minute for any guesses, but no. Or is it not? Well, I think it's quiet to just gets randomly. So, um, the first five or embolization is actually done by a neuro radiologist. They really know why my I was doing fibroid embolization. But that was done in 1974 uh, in France on the reason I put the photograph of development because the material that's used to develop it was the original. And Bill is a shin material. Use the PVA, um, to do the procedure. Um, so yet you to one artery embolization. So what you're actually embolize ing is the blood supply to the uterus. And so it's the actual procedure is you try an artery embolization, but you can do this procedure for other indications, like things that are not fibroids, um, so they're often used interchangeably, but the actual procedure is embolization of the uterine artery. And the reason for that is that fibroids are very vascular, so in their growth. But as any tumor grows on or release vascular growth factors and cause near vascular ization, the new blood vessels to form on. So these are very, very basket low that has a rich blood supply. Until the rationale for the embolization is that if you block the blood supply, even reduce the growth of the fibroids, shrink it down, and then reduce the symptoms of the fibroids on tradition, it been done for patients who course surgical candidates or have really high anesthetic risk. So you mentioned before, particularly B m I. But other comorbidities, like spiritually Izzie's or cardiac disease. Um, if they've had prior abdominal surgery, that makes them. I meant to be a lot more difficult. Every time you go in on doing operation, you haven't inflammatory reaction and causing agents. That makes the subsequent one much higher risk, you know, particularly for blood loss and that kind of thing on. So a lot of them may have had either like their appendix out or cesarean sections, and it's important to ask the well with that in the history cause they had a couple of those then, like you heard, is, it's ah, scarring is higher, and it's just gonna be a lot of trick here to do surgically. And so those patients would be suited for an ambulance, a shin on also those patients who have AH desire for quicker recovery or return to work. Um, so embolization doesn't need a general anesthetic. It's done under local on. Usually it's done as a day case or is an inpatient stay for just a day, Um, which is a lot quicker than myomectomy and definitely a lot quicker than a hysterectomy on. So that's another main reason why patients opt the embolization on the outcome, particularly for bleeding but also about symptoms is good. Usually 90% of patients experience an improvement in their symptoms. Um, the effect on fertility hour isn't really known. So traditionally, myomectomy is preferred because we don't know the effects of embolization on fertility. Then it's not recommended, although there's a recent trial, which is the same trial, which had a surprising result of the pregnancy rate was higher in the fibroid embolization group, which is good. It's a bit of a controversy, but I think generally speaking, with the guidelines, um, if the fertility effect is still relatively unknown, Um, and the other dimension is the reintervention rates are a bit higher compared to my matter to me. Eso Within five years, myomectomy and reintervention rate off about 17 to 20% but it's it's a bit higher in the embolization group, about 25%. So I thought I'd recap a bit of the anatomy, so it's always difficult. Pelvic mass growing up. Um, it's always difficult and friend, if you have been in the aisle rooms at all, if you ever get quist on the anatomy, it's ah, often a bit tricky. I know this means about prostate ambulance a shin, but kind of applies for the uterine artery as well. Um, so, essentially the abdominal aorta branches into the common iliac saw on the left and right at the level of alcohol and on the common, I lack splits again into the external while Yeah, and that becomes the family artery. And the internal on that splits into the anterior and posterior division. The you try an artery is a branch of the anterior division off the internal area artery. And so here, on the right, if you look at the angiogram and this is the internal, I get artery on the uterine artery. Is this one that's going towards the midline then? And I broke squiggly. And it usually has this torture its course, Um, as opposed to some of the other vessels, they're a little bit straight, and the seldinger techniques important concept to cover it. Well, it's no. The principle of all or most of the high are procedures that we do. Um, so the principle of that is, um if you use it, if you get a guidewire somewhere, then you can You can do anything pretty much said, particularly for vessels. How that's applied is that the ultrasound probe is used. Teo, you look at the vessels on initial access has done with just a needle. Um, and once needle access has gained you then pass a wire through that needle, remove the needle. So you got your guidewire abscess. Um, and then he put a sheet over this guidewire, um, so that she has basically, like a fancy cannula, but it's got a hemostatic bowel, that the end of it so that you can pass instruments through. But then blood doesn't come back on. Did just secures your vascular access so that you can gonna do what you need to do for the procedure. And so I got some pictures on how ultrasound access is going. So the first step is you get a view of the artery in long, and the importance of selecting the right side is important. So if you want to access the family artery, you should go ideally above the bike a shin. You don't want to hit an area that's calcified, but and also you wanna aim where it's right in front of the bone, because if there is a problem, you need to be able to compress the artery against the bone because that manual compression is usually the treatment. If that's, you know, bleeding and stuff. Um, so in terms of the right area, that's what you're aiming. And then once you've got this view, you can then get your needle access so you'd infiltrate with local first all the way down to the, um, like, the best of all on. Then you use the needle with a 45 degree and go on, drop some guidance in order to get access, and then once you have access and that could be either radial or femoral. So this is a picture of radial access, So I thought I'd show you this. Um, the radial artery is cannulated, and then a specific thing for radial artery is use a radial cocktail, which is a mix of a few drugs in order to prevent spasm. There's a calcium channel blocker and the couple of drugs that child never remember. The dose is off. That's given Teo, you know, make sure that you reduce spasm. It's a small artery than the family one. And once you have your access and your she thin you then never get a catheter down to the aorta into the internal. I'll yaks and then into the you tryin artery and do the procedure, says he mentions. Traditionally, it's done family bit closer to the you tryin artery. Um, but generally there's been a move towards doing radial access because, um, patients prefer and the complication rate is a bit lower compared to femoral access. So you might be able to do it as a day case if you radially on. Also, the benefit of radioactive s is the patients could get up early. Um, where is it? They've got femoral access. They have to lie down for a bit of time because otherwise then, um, risks exercise problems. Uh, doesn't mention the navigate the guidewire all the way to the uterine artery. Put a catheter in for it. And once you're there, um, belies it with these particles until Stasis until the blood stops on. Usually it's done bilaterally. So you do both you trying arteries at the same time in terms of embolization, so that you're not 100% how 100% sure how it works. But this diagram kind of explains how how we think it was on to These are the embolic spheres of the particles that are you and they're injected through the catheter. And when they come out of the catheter, they just aggregate within the vessel. And the effectiveness is that it slows down blood flow. And then if he all remember from preclinical med school, it's his Birkavs. Try it. And, uh, when blood flow slows, it clots more easily than that kind of fills in the gap. It also causes an inflammatory reaction and then fibrosis, the vessel, which includes it. And that's kind of how we think, Um, Bill is a Shin works. So this is just some images to show Creon post embolization that's on the left. Here, we've got you on the right side of the picture. We've got this hypervascular fiber to the vessels of the uterine artery and smaller vessels of this hyper vascular area. So then, um, Bolic material was injected and then on the right picture on you can see those hypervascular areas they're gone on. So this is ah, successful and bill is a shin off the you tryin artery on this side. And so this patient would have ah bilateral embolization for the procedure, Um, after the procedure, I think pain control is the main issue to get on top of. It's the main reason why patients require an overnight admission. Um, so once you do the embolization, if it necrosis is, that process can cause a lot of pain on bigger fibroids sent to cause more pain on. It doesn't start immediately after the procedure. Usually it starts a couple of hours after and it heats around 12 hours, which is why they needed it when they need an overnight stay. Um, but it yourself limited, and it's treated often with a PCA, but it's important to be corrected with it. So say, if you're be looking after these patients on the ward, right, thumb up works that loads and lane release and be very liberal with it on. Be proactive with it because otherwise and that might be stuck in the middle of the night waiting a lot of pain relief so you don't proactively, then that just, you know, helps you get on top of the pain control. Um, there's lots of other different techniques that are used various people to interrupt here. Lidocaine. It's something that's been trialed dexamethasone is well, and then the Hypogastric nerve block is one of these newer things. I don't know too much about that. Um, of those of you you've seen cases on Twitter. There's been a few where they're like, We've done a nerve block and they were out by three hours after the case or something like that. It's not routinely done, but I just thought mentioned that it exists. And it's a technique for improving pain control because I think that's the main, you know, issue that we need to get on top off up to the case. Um, some patients undergo what's called post embolization syndrome kind of inflammatory reaction. But if you go around malaise that self limiting with and sets on goes away after a few days, Um, and the other one, particularly with the dunk, elated fibroids, is explosion. So, like fibroid can detach from the stock on. That's fine, unless I get stuck, in which case, often these patients can present with paying into the emergency department. Um, so it's worth noting, and that's an early complication off. Um, Bill is a shin, and some patients get discharged after the procedure, but again, that's usually self limiting. Always, my indicate infection, which is a complication of any procedure. So that's a another complication that can happen some kinds and then follow up imaging. So on the left here it's, Ah, fibroid on an MRI, and when he gets infarcted, it gets darker, and then she drinks over time. So on the left, it's a bit bigger. And then, after embolization, it's impacted and smaller. Ondo. This is less likely to cause symptoms after the embolization, Um, so that summarized the main features of both the embolization. My next meal used intramural on subserosal fibroids, Um, but the procedure is done differently. Say it's radial family access. Ramble is a shin myomectomy is done either laproscopically or open surgery. Um, typically the stairs a lot shorter for the embolization. They don't need a general anesthetic, and there's a lot less tissue trauma. So the recovery periods of it quicker. All those you mentioned before that reintervention rate is a little bit higher on. These are some other complications that talked about, So yeah, in summary, in terms of treating fibroids, do is try a symptom control first, either with NSAID or Ultram perspectives or tranexamic acid is often used for bleeding, but the treatment options depend on where the fibroid is. Submucosal. You try for a hysteroscope e intervention. First, it's intramural subserosal. Then you choose between a mymectomy or embolization. If it's a higher risk of surgery than animal is Asian is preferred and Brazil fertility's desire than my map. To me, it's prefer because of the unclear long term bent long term effects of motility on embolization. And then hysterectomy is usually done nowadays as a last resort. Um, they feel like CCD funding issue in that kind of thing. Um, we haven't really talked much about medical treatment that has a very limited role. So, um, one medical treatment they use is the generators. The hormone, or Zoladex, is You might know it, and so that is basically a hormonal treatment to shrink the size of the fibroids. And it does work. But there's lots of side effects of being on long term hormonal treatment on, but sometimes they use it just for a few months before my neck to me to shrink the size of fibroids and make the operation easier. But as a primary treatment, it doesn't really have much of a role in the management of fibroids, says I mentioned uterine artery embolization is not. The technique is not just used to fibroids, but it's also used to treat post partum hemorrhage to hear of just taking a screenshot. The Royal College of ob GYNs Green top guidelines, which often come up in exams on this, is a section on embolization, and so is an effective treatment for postpartum hemorrhage. So if medical treatment hasn't worked, then your next options are. Either you try an artery legation balloon tamponade or Enbrel is a shin. It's an effective technique, but often the limiting factors and logistics. You know, if something is simple, as how far is the IR person from the maternity? Because if it's like 15 minutes away, it's actually probably impractical to do an embolism, a shin and so that often or depends on local factors and availability of see arms and that kind of thing. But it is an effective way to control bleeding, and it saves. It's directed me usually on, so it is used as an emergency treatment as well. It's in the active setting, the fibroid, um, and last thing wanted to mention on embolization in particular was some the role of global health and you? A So particularly Africa's you mentioned the black race is the most consistent risk back to a fibroids. And so the bird and this, um, very high a swell a cultural issues with keeping the uterus on P. PH. Mortality is also very high, and part of the reason for that obviously is generally poor health care facilities. But the surgical risk is quite high. So it's, you know, any operation. It's high risk. And so embolization plays a role in both of these conditions. But the main trouble is a the lack of skilled operators. And then be the fact that Lalit symbolic materials and capitals air very, very expensive. Um, but they're awesome. Cheaper alternative been investigated. So, uh, here's a vial of something called fair and both, which is basically cut up. Suture is suspended in a solution, and that is use for it's an anabolic material toe close off the vessel, shown to be as effective, almost a zit effective as the particles, but for a fraction of a price. But some of the vials of these am bolic particles cost like 102 100. Where is a vial off? This is much cheaper on. So there are these alternatives being investigated. So it's not all about, like super fancy equipment and stuff. Sometimes it's simple that solutions of the the most effective ones. And so this is have another area, the future, our exploration on. I've just got a couple more slides talking about the role of interventional radiology and other conditions. Um, the first one I want to mention is pelvic congestion syndrome and the role of embolization. Um, so with this I mean, a lot of patients have chronic pelvic pain, and that's defined as non cycling for pain for the story months, Some definitions say six, Uh, And it's a very common condition with a high prevalence, and it forms a higher percentage of gone your barrels, but with a very wide differential diagnosis. And so one of these causes its pelvic congestion syndrome, and one of the key features of it is pain. That's worse on standing because what happens is the veins they reflux. And so when you stand up, then the gravity pulls the blood there and to get more of a pain or discomfort. Um, but then there are obviously other causes of chronic pain that we're kind of be on the scale of this talk. Um, and so a very in vain embolism patient is often used as a treatment for that. The tricky thing is, it's, um a lot of people do have dilated veins, and so again, it's similar problem to five boards, and you see an image in finding. But then how does that relate to the symptoms? And so that's something that's quite specialist. But I thought had mentioned there in vain embolization, because this is something, uh, it's sometimes used as a treatment for, um held the congestions and drink. And then the other thing is Phil open to recanalization eso. Infertility is, ah, multi factorial problem on in cases where there's a fellow pee into blockage, so most commonly is a previous pelvic inflammatory disease. Often it's like a physical closure off the fallopian tube that's causing the infertility. Uh, so one thing you can do is re canalized the fallopian tube. So the top left image here is what we call a haters G or hysterosalpingogram, which is a live X ray with dye inserted into the in the cavity on that shows there's a blockage off this pill. Open shoes, so on the patient's right or the left of your screen. Um, this kind of wispy there is the Lumen of the Philippine June. They're on the other side. You can't see it because it's completely blocked off, and so happens is they pass a guidewire and dilate up, and you can see on the post treatment images that there is now open. And so that's called a fellow pee into Greek analyzation on. It's particularly done from a proximal blocks. Where is it? The block is really, really far. Then it's a bit tricky to get the um so that's just another way, which I, our committee, used some other conditions on. I've just concluded these for the reading links if you wanted to particularly further. Medical students in the audience read the guidelines because they're often tested in a final exams on you know, the management of particularly PPH. Also, fibroids is low on go. I'm not certain. Excellent talking to really enjoyed. There's, um, some of the office. A few moments of anyone wants to pop any other questions in the chat, and one come in there. So So with Jimmies. Generally, our question, if you take a long course, reach the chart. But we'll wait to see if you finish that question off. But overall injured, I think a very interesting walk through and and obviously highlight in the global health side of it as well, which is, you know, been been publicized more recently. This good Ted talk under under topic as well. If people want to have a look at that a swell more recent on by Dr Macros, Um, and Chris. Any comments from your side? Anything you wanted to highlight? I was just wondering what they tell us a bit about, Um sickly. I are any stuff. Rikers are seeing the disease burden so much higher in luck. He knows. And I'm aware of red toe I r. Than if you didn't eat more with this particular interest and you have thing. Yeah, I think it's part of a global mission, Really, Because the in East Africa, there's this of it. I mean, in all of us in most of the countries, there's not many interventional radiologists, but I think just African particular is a low number. Roto. I ours, they will train them on ambulance a shin at all. But I think they're starting with even more basic things, like biopsies and drains on once all of those air established, then probably embolization is gonna be the next one. Um, because in terms of priority, like I think the emergency Hi. Ah, procedure. Is it going to be, like, higher priority over the elective ones on. So, like, a particularly a drain like an abscess strain is going to be the most important thing, because after antibiotics, that's the only thing you can do. But the steps that you know to throw in sepsis on go. That's what they've started on. But I think that they'll progress on to embolization for postpartum hemorrhage on bleeding. No. Do you have any further kind of information about roto what they've been doing? Because I understand that what they do is they take medical students, radiology trainees, consultants out there, um, help teach. Basically, I have two in into a few webinars about it, but again, there the best source of information for it would be to find them on Twitter. But they do offer medical student elective opportunities. Um, obviously that there's some cost or somethin raising associated with that. But there have been a few that I've I've seen gone along there. Um, actually, I'll come back to see if we can try and go with this question. Sorry, Jimmy. For some reason, I hadn't completely scroll down. But you do have a full question there. So if you take a long course to reach the tera, get vessels. So if you go a radioactive and then go all the way down with your wires and catheters to the U try, actually, does this run a risk of breaking off plaques? Causing just limbal is a shins. Ah, and if so, does the risk rise of extended distances from access points to target vessels? No. My appreciation for that is that in order to reach these areas, that obviously you're going to need quite long wires, but also quite maneuverable lawyers. So they're you know, they're they're not necessarily the ones that are going to be hashed against the vessels and causing that risk. Um, but again there's, there's, there's that risk exists, I guess, regardless, I'm not sure if it increases based on distance. I don't know if you have anything on that Androgel? Yeah, I guess it depends on the disease burden as well. Like the atherosclerosis is usually kind of. I guess you have the disease burden in the aorta, but your luminous quite big. So, you know, you've got a lot of rooms. If you're using a a traumatic wire in a big blue moon, I think it quite unlikely to break off. You know, any plants and they order? I think it's more for the record vascular stuff where you're in small vessels that been included for a long time. You're more likely to cause distal amble is a shin because I think it's unlikely in a fibroid embolization for those reasons. Fair enough. Good question, I think. Get us thinking a little bit. Anyway, um, if anyone has got any further questions, then feel free to drop them in the chap. But, you know, we will probably bring things to close and just thank you again. India, for what was a very interesting presentation. Thank you for spending the time and secret path for it so well, thanks so much for hosting a session and just a shout out to the next one. will be covering a prostate artery. Embolization. Um, another exciting announcement that we've got our junior is is now recruiting. But next committee eso we posted the ad out or not better really follow a social media. Then we have to post the links as well. Eso we're looking for kind of motivated junior doctor's medical students who want to get involved with us on organized and bar events. Going forward as if you were interested in that. Pleased you check out our social media or sorry Crestor. Feel like I've stolen some of your and truly you're talking and, uh, let you very under that. No, you got easier at seven. Yeah, none of us would be here if you haven't stopped the diet genius know whatsoever. Thank you for checking in on day if if you have no money, is if you know people that haven't managed to watch it live today. Let them know they will be able to watch this again on the capture up and get their certificate for the do's. And that goes for order. The other eye are bites sessions. Is that what she's a real good evening? Everybody? Yes,