Video Learning SessionUterine Artery Embolization

Uterine Fibroids

Intramural

Pedunculated

submucosal

Subserosal

fibroid

Submucosal

Fibroid

Pedunculated

subserosal

Location

Fibroid-Related Symptoms

• Heavy menstrual bleeding

• Pelvic pain

• Pelvic pressure /bloating/ swelling

• Urinary frequency

• Constipation

• Infertility

Pluridisciplinary Evaluation and Management

No treatment

Gynecologist Medical treatment

Radiologist Embolization

Surgery

Gynecological Consultation

• Past medical history

• Past surgical history

• Past gynecological history (PID)

• Past obstetrical history

• Allergy

• Transfusions

• Impact of uterine fibroids (QOL)

Physical Examination

• General examination

• Speculum: cervix, polyp, cervical fibroid, pap-smear +++

• Vaginal examination: pain, volume, adnexal mass, uterinesoftness

• Rectal examination +++: endometriosis

• Breast examination +++

Accepted Clinical Indications

• Symptomatic women

• Confirmed diagnosis of fibroids

• Failed medical treatment

• Previous myomectomy

• Women refusing hysterectomy

Pelvic MRI

Current Indications

• Symptomatic fibroids

• Surgical indication such as hysterectomy or

multiple myomectomy

• No desire for future pregnancy

• Multiple intra-mural fibroids

• Avoid pedunculated sub-serous fibroids

• Adenomyosis

Contra-Indications

• Asymptomatic woman

• Non realistic expectations

• Cosmetic motivations

• Large pedunculated subserosal fibroid

• Simple surgical procedure available (i.e.

hysteroscopic resection of a 3-cm submucosal

fibroid FIGO type 0 or 1

Clinical case

• 41 y.o. women with symptomatic fibroids

• Heavy menstrual bleeding 7 days with iron deficiency

• Severe associated pelvic pain

• Failure of hormonal treatment using Ulipristal (Esmya)

• G3P3

• No desire for future pregnancy

• Active woman, professional sports coach

Pelvic MRI

Cross-Over

Cobra-shaped catheter

Left Internal IliacArtery CatheterizationRight anterior oblique projection with 30°angulation

Cobra-shaped catheterHydrophylic 0.035-inch wire

Internal Iliac Artery

Uterine Artery

AngiographyLeft internal iliac

Oblique Projections

RAO 25

LAO 25

Where Would You Place your Microcatheter?

1

2

3

4

2

3

4

1

Superselective leftuterine arterycatheterizationRoad-mapping technique

Microcatheter 2.7/2.8-F

Left uterine artery

Pre-embolizationangiography

Variation

Ovarian Artery

Flush Pelvic Aortogram

Right Ovarian Artery

Microcatheter

Variation: Round Ligament Artery

Flow-Directedembolization using>500 µm microspheres

Uterine-to-Ovarian Artery Anastomosis

Per Embolization

Protection of the Ovary

Post Embolization

Post-embolization

Waltman’s Loop

Right Internal IliacArterycatheterization

Reverse-curvedcatheter

Right internal iliacartery and uterinearterycatheterization

Reverse-curvedcatheter

Superselective Right uterine arterycatheterizationRoad-mapping technique

Microcatheter 2.7/2.8-F

Flow-Directedembolization using>500 µm microspheres

Embolization End-Points

Near-stasis Stasis

Postembolization Evaluation

• Normal menses 3 days lighter

• Improvement of pelvic pain

• Normal professional activity

• Very satisfied with the results

• Would certainly recommend embolization to family and friends (actually she did)

Uterus - 30%

F1 - 40%

F2 – 35%

Postembolization Pelvic MRI

Take-Home Points

• Be clinically involved (office visit, pluridisciplinary meetings)

• Good quality pelvic MRI

• Embolization alternative to hysterectomy and multiple myomectomy

• Straightforward technique: microcatheter in all cases, calibrated microspheres > 500 µm

• Rare anatomical variations