Uterine artery embolization is used to treat bothersome bulk-related symptoms or abnormal or heavy uterine bleeding due to uterine fibroids or for the treatment of adenomyosis. Fibroid size, number, and location are three potential predictors of a successful outcome. Long-term patient satisfaction outcomes are similar to that of surgery. There is tentative evidence that traditional surgery may result in better fertility. Uterine artery embolization also appears to require more repeat procedures than if surgery was done initially. It has shorter recovery times. Uterine artery embolization is thought to work because uterine fibroids have abnormal vasculature together with aberrant responses to hypoxia. Uterine artery embolization can also be used to control heavy uterine bleeding for reasons other than fibroids, such as postpartum obstetrical hemorrhage. and adenomyosis.
Adverse effects
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. Complications include the following:
Infection from tissue death of fibroids, leading to endometritis resulting in lengthy hospitalization for administration of intravenous antibiotics
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
Ovarian damage resulting from embolic material migrating to the ovaries
Loss of ovarian function, infertility, and loss of orgasm
Failure – continued fibroid growth, regrowth within four months
Menopause – iatrogenic, abnormal, cessation of menstruation and follicle stimulating hormones elevated to menopausal levels
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
Severe, persistent pain, resulting in the need for morphine or synthetic narcotics
Hematoma, blood clot at the incision site; vaginal discharge containing pus and blood, bleeding from incision site, bleeding from vagina, fibroid expulsion, unsuccessful fibroid expulsion, life-threatening allergic reaction to the contrast material, and uterine adhesions
Procedure
The procedure is performed by an interventional radiologist under moderate sedation. Access is commonly through the radial or femoral artery via the wrist or groin, respectively. After anesthetizing the skin over the artery of choice, the artery is accessed by a needle puncture. An access sheath and guidewire are then introduced into the artery. In order to select the uterine vessels for subsequent embolization, a guiding catheter is commonly used and placed into the uterine artery under X-ray fluoroscopy guidance. Once at the level of the uterine artery an angiogram with contrast is performed to confirm placement of the catheter and the embolizing agent is released. Blood flow to the fibroid will slow significantly or cease altogether, causing the fibroid to shrink. This process can be repeated for as many arteries as are supplying the fibroid. This is done bilaterally from the initial puncture site as unilateral uterine artery embolizations have a high risk of failure. With both uterine arteries occluded, abundant collateral circulation prevents uterine necrosis, and the fibroids decrease in size and vascularity as they receive the bulk of the embolization material. The procedure can be performed in a hospital, surgical center or office setting and commonly take no longer than an hour to perform. Post-procedurally if access was gained via a femoral artery puncture an occlusion device can be used to hasten healing of the puncture site and the patient is asked to remain with the leg extended for several hours but many patients are discharged the same day with some remaining in the hospital for a single day admission for pain control and observation. If access was gained via the radial artery the patient will be able to get off the table and walk out immediately following the procedure. The procedure is not a surgical intervention, and allows the uterus to be kept in place, avoiding many of the associated surgical complications.
