The Ulster Medical Journal, Volume 67, No. 2, pp. 139-141, November 1998.

Case Report

The use of transcatheter embolisation to treat uterinefibroidsP K Ellis, I M G Kelly, P P Fogarty

Accepted 26 June 1998

Uterine leiomyomata (fibroids) are thecommonest benign pelvic tumours. Therapeuticoptions include hormone manipulation or surgicalmanagement, myomectomy if the patient wishesto retain fertility, or hysterectomy. We describethe use of transcatheter arterial embolisation in apatient who presented with a large uterine fibroidand pressure symptoms.

CASE REPORT A forty-two year old femalepatient presented with acute urinary retention.She was admitted to hospital where a urethralcatheter was passed. She described a severalmonth history of occasional difficultycommencing the flow of urine but was otherwisewell with no relevant past medical history.Initial assessment included ultrasound, whichshowed a large uterine fibroid lying at the posterioraspect of the uterus, with a diameter in excess often centimetres. Hypervascularity was observedon colour doppler imaging. After discussion oftherapeutic alternatives with the patient, wedecided on transcatheter percutaneousembolisation of the uterine arteries.

Prior to the procedure a prophylactic iv bolus ofcefuroxime (750 mg) and metronidazole (400mg) was given. The procedure was performedunder conscious sedation (midazolam andfentanyl) with physiological monitoring.An initial puncture was performed at the rightcommon femoral artery and a 5-French arterialsheath was placed. A 5-French pigtail catheterwas placed in the aorta, and pelvic angiographydemonstrated enlarged uterine arteries withmultiple dilated abnormal tortuous vessels,corresponding to the uterine fibroid (fig 1).The aortic bifurcation was then crossed using a 5-French Cobra II catheter, (Cordis, Roden, theNetherlands). The internal iliac artery was selected

and subsequently the left uterine artery wascannulated using the road mapping facilityavailable on angiographic equipment. Polyvinylalcohol (PVA) foam particles of size 500 to 710microns (Cook, Bloomington, In) were mixed

406. ........:.. . .i.o,O.v:. i .8 !,

Fig 1. Pelvic Arteriogram: Multiple, dilated, tortuousvessels are identified centrally within the pelviscorresponding to the large uterine fibroid.

Royal Victoria Hospital, Department of Radiology,Grosvenor Road, Belfast BT12 6BA.

P K Ellis, MRCP, FRCR, Consultant Radiologist.I M G Kelly, MRCPI, FRCR, Consultant Radiologist.

The Ulster Hospital, Department of Obstetrics andGynaecology, Dundonald, Belfast BT16 ORH.

P P Fogarty, MD, MRCOG, Consultant Obstetrician andGynaecologist.

Correspondence to Dr Ellis.

C) The Ulster Medical Society, 1998.

140 The Ulster Medical Journal

with dilute contrast media and were slowlyinjected under fluoroscopic guidance until flowin the left uterine artery was abolished.

A 5-French Sos-Omni selective catheter (Angio-Dynamics, Queensbury, NY) was then usedthrough the arterial sheath to select the ipsilateralright internal iliac artery. A guidewire was placeddistally within this artery and an exchange wasperformed for a Cobra catheter. Again PVAparticles were injected slowly with dilute contrastmedium, until flow in the right uterine artery wasalso abolished.

A repeat pelvic angiogram was performed andthis demonstrated continued minimal filling ofboth uterine arteries. The procedure was thenperformed for a second time in each artery withfurther embolisation usingPVA particles. A smallpledget of Gelfoam (Upjohn, Kalamazoo, MI)was placed at the origin of each uterine artery.Following this procedure pelvic angiographydemonstrated occlusion of both uterine arteries,with no evidence offilling ofthe abnormal uterinefibroid vessels. (fig. 2)

..:.....

Ultrasound examination..... ;j;;,immediately followg

wihiUthe fibroidoncolour Dope imging,

and multiple echogenic..f iw.i.ti the fibr....;:h:.::.!.i'.:Pp..

representing aggregat so..f i ............m..(f}ieb> - iX :: :::: 3:^.!:: '; .... . , . eNi-g Ue - .: ! _ -8*gig 3)o o ;r.

gli8ifi32's f fs..~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~......

f~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~..............

f filn of th utrn arere is identi...:.._...fied.ffff

teg11!prcdue de o stae!n:oe evieneol f flowwihi th fi ri on clou !::op;:p::ljjer imagin.gi,

-;S p -iY.o- ..

A8.:::. . sE118 R}::: s S IIS BS Bis~~~~~~.. .. ..... .. {.. X_

1 1 X3 -

Fig 3. Ultrasound of pelvis: The large uterine fibroid iswell seen. Multiple echogenic (bright) focirepresent aggregates of embolic material.

Approximately one hour following the procedurethe patient developed episodes of sweating andshivering due to the post embolisation syndrome;she was treated using diclofenac sodium, 50 mgsuppository. These symptoms resolved over twohours and the patient was discharged the followingmorning.At six weeks, ultrasound examinationdemonstrated a seventy-five percent reduction inthe total volume of the fibroid. She has reportedno further symptoms.

DISCUSSION

Initial reports of devascularisation of the uterusdetail an effective means of controllingpostpartum haemorrhage.1 High success rates havebeen described with uterine artery ligation inboth postpartum and post-caesarean sectionbleeding. As a logical extension to this,percutaneous transcatheter embolisation has beenused effectively in several situations, includingpostpartum bleeding, uterine arterio-venousmalformation2 and gynaecological malignancybleeding.3 Complication rates for these proceduresare low and the option of surgery is still availableshould success not be obtained.Uterine leiomyomata (fibroids) are commonlyasymptomatic, although uterine enlargement canresult in pressure symptoms with heaviness anddiscomfort. Infarction or torsion may result inpelvic pain. Haemorrhage is a common

C The Ulster Medical Society, 1998.

Embolisation offibroids 141

complication, presumably due at least partly tothe hypervascularity of a uterine fibroid.

In theory, uterine fibroids should be ideally suitedto embolisation as they derive their blood supplyalmost exclusively from the uterine arteries. Thevascular patterns of myomatous uteri have beenwell described previously: essentially there is aperipheral supply of tortuous and dilated vesselsfrom which arise arteries that supply the centralpart of the fibroid. The peripheral supply resultsin a dense persistent tumour blush onangiography.4 As clear anastomoses occurbetween the left and right uterine artery, bothvessels must be embolised to obtain a satisfactorytechnical result. In addition, there is evidencethat there is devascularisation of uterine fibroidsin women who respond well to treatment withhormonal agents (including syntheticprogestogens andLHRH agonists). Investigationwith doppler ultrasound has demonstrated somedevascularisation of fibroids in women who haveresponded well to treatment with hormonaltherapy.5 This further supports the argument forpercutaneous embolisation ofthe uterine arteries.

Few previous reports of uterine fibroidembolisation exist. However, Ravina et al.described a series of sixteen patients, of whomfourteen had heavy and prolonged bleeding, andwho underwent uterine arterial embolisation.6 Ata mean follow-up of twenty months, symptomshad entirely resolved in eleven patients and werepartially relieved in three. All had been previouslytreated with hormonal therapy, with only transientsuccess. Goodwin et. al. at the University ofCalifornia, Los Angeles, described this techniquein eleven patients.7 Eight of nine patients, whothey were able to follow up, reported noticeablesymptomatic improvement at six months.

One potential benefit of percutaneousembolisation is the preservation of normalanatomical structures and therefore fertility. Mostofthe patients in the French study, (Ravina et. al.)returned to normal menstruation, and indeed oneconceived after fifteen months. It would beprudent to await long-term follow-up in largerclinical trials to fully appreciate the long-termpotential benefit, both with respect to the treatmentofthe uterine fibroids and preservation of fertility.In conclusion, percutaneous transcatheter uterinearterial embolisation offers a useful alternative tosurgery in the treatment of uterine fibroids.Potential benefits over surgery include reduced

post-operative complications, lower costs, shorterhospitalisation and the potential preservation offertility. Although short-term results have beenexcellent in our case, and in the two previouslydescribed short series6' 7 further work will benecessary with large controlled trials to assesslong-term benefit.

REFERENCES

1. Waters E G. Surgical management of postpartumhaemorrhage with particular reference to ligation ofuterine arteries. Am J Obstet Gynecol 1952; 64: 1143-8.

2. Vogelzang R L, Nemcek A A, Skrtic Z, Gorrell J,Lurain J R. Uterine arteriovenous malformation:primary treatment with therapeutic embolization. JVasc Interv Radiol 1991; 2: 5 17-22.

3. Basche S, Glaser F H, Hensel G, Spitzbart H, KachelR, Schmeisser G. Percutaneous transvascularembolization as a palliative measure in bleedinggynaecological malignancies of the pelvis. ZentralbGynakol 1990; 112: 1389-98.

4. Farrer-Brown G, Beilby J 0 W, Tarbit M H. Thevascular patterns of myomatous uteri. J. ObstetGynaecol Br Commonwealth 1970; 77: 967-75.

5. Matta W H M, Stabile I, Shaw R W, Campbell S.Doppler assessment of uterine blood flow changes inpatients with fibroids receiving the gonadotropin-releasing hormone agonist Buserelin. Fert Steril 1988;49: 1083-5.

6. Ravina J H, Herbreteau D, Ciraru-Vigneron N et al.Arterial embolisation to treat uterine myomata. Lancet1995; 346: 671-2.

7. Goodwin S C, Vedantham S, McLucas B, Forno A E,Perrella R. Preliminary experience with uterine arteryembolization for uterine fibroids. J Vasc Interv Radiol1997; 8: 517-26.

C) The Ulster Medical Society, 1998.