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Uterine artery embolisation to Uterine artery embolisation to treat symptomatic myomastreat symptomatic myomas
Maritta Hippeläinen
Dept. of Gynaecology,
Kuopio University Hospital 9/03
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Uterine artery embolisation (UAE)/ Uterine artery embolisation (UAE)/ Uterine fibroid embolisation (UFE)Uterine fibroid embolisation (UFE)
• embolisation– vascular occlusion using
different kind of occlusion agents
• embolisation in gynaecology 1979->– first to control bleeding
• postpartum• after surgery
• to treat myomas 1993– Ravina et al. Lancet 1995
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Arterial embolisation to treat uterine myomataArterial embolisation to treat uterine myomataRavina et al. Lancet 1995;346:671-672
•
– 16 patients, aged 34-48 years
– embolisation:14 menorrhagia, 2 mass• 4 palliative (embolism, obesity, diabetes, AIDS)
• 12 as alternative to surgery (10/93->)
– results• symptoms resolved: n= 11 (+3 partial)
• volume reduction 20-80%
• myomectomy/ hysterectomy: n=2 – (mean follow-up of 20 months (range 11-48)
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Uterine artery embolisationUterine artery embolisation-description of the procedure
• performed by a radiologist– one of the femoral arteries is
catheterised (1.7mm)
• local anesthesia– usually sedation with a narcotic
and benzodiazepam
• pelvic angiography is performed to define the vascular tree
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Uterine artery embolisation
• the uterine arteries are identified and cathetherized
• arteriography is performed:– anomalies?
– no other organs are affected
PRE
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Uterine artery embolisation...Uterine artery embolisation...
• polyvinyl alcohol particles (PVA) are injected until there is complete bilateral vascular occlusion (permanent)
• myomas: endarteries– lack of blood and
oxygen• ->shrinking
• myometrium: good collaterals! POST
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Uterine myomas: before and 18 h after Uterine myomas: before and 18 h after embolisation (MRI)embolisation (MRI)
Residual perfusion 3%
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Good resultsGood results
• > 90 % no technical problems
• 80- 95 % of cases satisfied
– significant relief of menorrhagia
– volume reduction 50%• 20-80% (6-9 months)
– 2002 > 15 000 cases (estimated)
– 1998: n=193
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UAE: complications and special UAE: complications and special features good to knowfeatures good to know
• pain 100%– 6-12 h, intensity variable-why?
• angiography complications <1% – groin hematoma, allergic reactions
– necrosis of other organs -theoretical
• post embolisation syndrome (PES)(15%)– fever, nausea, fatigue, leucosytosis
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UAE, complications…UAE, complications…
• infections (1-17%, PES?)• expulsions of submucosal fibroids ( 5%)• amenorrhea (1-2%, >45y, 5-10% >45y)
– POF– endometrial effect?
• increasing number of case reports– sepsis, embolisation, necrosis of the uterine/ vaginal wall…
• severe complications rare– 3 fatal reported (mortality 0.2%o)
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Uterine fibroid embolization:nonsurgical treatment Uterine fibroid embolization:nonsurgical treatment for symptomatic fibroids.for symptomatic fibroids. McLucas ym. University of McLucas ym. University of
California (J Am Coll Surg 2001)California (J Am Coll Surg 2001)
• 167/ 183 were embolized: bleeding disorders
• 163 bilaterally, 4 unilaterally
• no complications (pain!)• after 6 months: 88% satisfied
– The size of the uterus about 49% smaller
• 3.5% hysterectomy (n=6, 1 for infection)
• 5% passed submucous myomata
• 2.3% POF (n=4)
• After 12 months n= 46: the size of the uterus about 52% smaller
• why failure?
– earlier pelvic surgery (adenomyosis?)
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The Ontario uterine fibroid The Ontario uterine fibroid embolization trial embolization trial Fertil Steril 2003Fertil Steril 2003
• multicenter prospective study (8 hospitals)• n=538, UAE • results 3 months:
– median uterine/fibroid volume reduction 35/42%– significant improvement
• dysmenorrhea 77%• menorrhagia 83%• urgency 86%
– amenorrea3-7% <40y (40% > 50y) – 91% expressed satisfaction with UAE
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UAE in Kuopio University Hospital UAE in Kuopio University Hospital (KUH) 3/2000->(KUH) 3/2000->
• alternative to hysterectomyalternative to hysterectomy– n=20 n=20 – no adnexal diseaseno adnexal disease– no prolapseno prolapse
prospective clinical trialprospective clinical trial9/02->9/02->
– randomisation (n=100):• hysterectomy/embolisation
– embolisation group (n=50)
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Embolisation versus hysterectomy? Embolisation versus hysterectomy? -which is best for women in Savo? 9/02->-which is best for women in Savo? 9/02->
• 53 patients with symptomatic myomata
• MRI• embolisation randomised hysterectomy
• n=14 n= 22(100!) n= 17
• psychological (7) -wanted (11) operative risks (5) -contracept? (3)
• fear for oper. (2) -no MRI! (2)-pain? (1)
• embolisation(12) operation(10)• Follow-up 3years
• MRI 6 and 18 months
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Characteristics of the women embolised Characteristics of the women embolised
in KUH, n=46in KUH, n=46• mean age 50.3 years (range 40-63v)
• healthy 66.7%
• no pregnancies 29.4%
• HRT 41.7%
• anemia 37.5%
• mass, pelvic pressure 62.5%
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About the fibroids embolised in KUH..About the fibroids embolised in KUH..
• submucosal 8.3%
• number of fibroids 1-> >10,
• > 3 fibroids in 47% of cases
• the biggest fibroid medium 7.3 cm– (3.4-11cm)
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UAE: preliminary results in KUHUAE: preliminary results in KUH
• 44/46 no technical problems (2 unilateral)– 1 small retroperitoneal hematoma
– 3 small groin hematomas– 1 trombophlebitis because of contrast medium (MRI)
• pain– 100 % variable , 3 readmission to hospital
• no infections– postembolisation sdr (n=2)
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UAE, Preliminary results UAE, Preliminary results (KUH)(KUH)
• 44/46 of the women satisfied with the procedure– expulsions of myomas, n=3
• 1 hysterectomy
• 2 hysteroskopies
– menorrhagia continues, n=3 (3 months after UAE)
• volume reduction of uterus/myomas variable– 20-80%, WHY?
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One prospective randomized study: One prospective randomized study: hysterectomy/ embolisation(UEA)hysterectomy/ embolisation(UEA)
• Pinto et al. Radiology 2003
• 64 candidates---> 4 refused, 3 some contraindications
• 57 were randomized
• hysterectomy, n=19 Information:UEA?, n=38
• -16 were operated, 37 were embolized
• 3----------------------> + 3
• +1 <----------------------- 1
• 4 were not succeeded (10%!)
• Emergency dept. visits– 20%(major complications) 32% (minor complications)
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Uterine artery embolisation, Uterine artery embolisation, benefitsbenefits
• appears to be effective
• safe, low complication rate
• patient satisfaction high
– easy
– preservation of uterus
• economical
– short hospital stay
– KUH
• UAE 1050 E
• hysterectomy 2000E
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BUT...BUT... • Uterine artery embolisation
– still experimental
– no long term outcome results
• causes of failure?
– size/ location/ vasculature of the myomas?
• recurrence of myomas?
• HRT?
• pregnancy?
– more controlled prospective studies needed!
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A case report: uterine A case report: uterine artery embolisation artery embolisation (KUH)(KUH)
• -46 y woman, healthy
• no pregnancies, infertility problems earlier
• menorrhagia, urgency
• normal status 6 y earlier
• not willing to hysterectomy
• -MRI 14x10x12 cm uterus, several myomas
T2 sagittal: PRE
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Embolisation of uterine arteriesEmbolisation of uterine arteries
PRE POST
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Before and 6 months after Before and 6 months after embolisation: normal menstruationembolisation: normal menstruation
T2 sagittal: PRE
T2 sagittal: 6 kk
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UAE, still UAE, still many many
questions ?questions ?
49-year-old 49-year-old woman, size of woman, size of
dominant dominant myoma 13 cmmyoma 13 cm
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49-year-old woman 18 h after embolization
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49-year-old woman before and 6 months after49-year-old woman before and 6 months after
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MMenorrhagia, enorrhagia, several small several small myomas, one myomas, one
partly partly submucous submucous
(20%).(20%).
18h afterBefore UAE
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Before and 6 months after UAEBefore and 6 months after UAE Hypermenorrhea has disappeared Hypermenorrhea has disappeared
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When embolisation?
• So far, alternative to hysterectomy– pregnancy not desired
– no contraception problems
• operation not a good choice
– risks/ psychological reasons
• for first aid/ to make the operation easier (?)
• growth of fibroids with HRT (?)
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Thank
you
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Key measures for embolisation (surgical precuderes)
expert panel, JVIR 2000;11:509-515
• death
• reoperation
• operative injury
• menorrhagia
• premature menopause
• recurrence of myomata
• satisfaction– randomized trial, prospective registry, disease-spesific quality-
of- life instrument, and cost analysis
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Costs, Kuopio University Hospital
• Embolisation 1050 Euros
• = hysteroskopic resection of myomas
• Hysterectomies 2000 Euros
• MRI 420Euros (EVO)– not necessary
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Society of Cardiovascular and Interventional Radiology (SCVIR)
• kansallinen rekisteri, USA
• 4165 myoomien embolisaatiota (1999)– 25 gynekologista kirurgista toimenpidettä
(?) vaativaa• 1:167
• 6:1000
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Tutkimuksen pääparametrit• Embolisaation tekninen onnistuminen
• hoidon komplikaatiot
• kliininen tulos
– myomien /kohdun muutokset (MRI)
– oireiden lievittyminen/ tyytyväisyys
• hoitoindikaatioiden selkiyttäminen
• UÄ/ MRI/ histologia
• ennustetekijät
• kustannukset
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Satunnaistettu prospektiivinen vertailu-tutkimus myoomien embolisaatiohoidon ja
kohdunpoiston välillä 9/02->
• kirjallisen suostumuksen antaneet peräkkäiset potilaat (n=100), joilla
– hoitoa vaativat myoomat
– indikaatiot kohdunpoistoon
– dg varmistettu: MRI
– ei jodivarjoaineyliherkkyyttä
– ei operaatiota vaativaa laskeumaa (harvoin!)
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How do we do it in Kuopio?How do we do it in Kuopio?
• Women come to the dept. of gynaecology the day before – antibiotic profylaxis,
– pvk, CRP, Kreat
• UAE performed in the interventional radiology suite – 40-90 min– local anesthesia, Dormicum, diazepam iv
• observation in the postoperative dept. 4-6 h: PAIN?
• home the next day– antibiotics + PG-inhibitors 5-7d
– sick leaves about one week
Dex pre