Uterine Artery Embolization

The following excerpts from medical journal articles provide more specific information about UAE (also called UFE), the adverse effects, politics, and economics. Some of the articles note a conflict of interest on the part of the authors of the study as well as financial support from device manufacturers, pharmaceutical manufacturers, embolic material manufacturers including polyvinyl alcohol particles (PVA) and Microspheres, and the Society Of Interventional Radiologists. It is important to note that not all medical journals have a policy that requires disclosure of financial conflict of interest.

There are several medical journal articles. Please scroll down for the complete list.

The Positive Effect of Targeted Marketing on an Existing Uterine Fibroid Embolization Practice

Howard B. Chrisman, MD, MBA, Pat Auveek Basu, MD, MBA, and Reed A. Omary, MD
Journal of Vascular Interventional Radiology
March 2006; 17:577-581

"The authors tested the hypothesis that an advertising strategy focused on a defined target market can expand an existing uterine fibroid embolization practice."

"Based on the analysis the authors determined that the target audience was professional black women aged 35 to 45."

"The 17 extra cases performed over 3 months represented a 27% increase in case volume. Total professional cash collections for these cases (including MR imaging) were $58,317. The cost of advertising was $8,000. As a result of existing infrastructure, no additional costs were necessary. This resulted in a net revenue gain $50,317 and a nonannualized rate of return of approximately 625%."

"As Interventional Radiologists look to develop and expand existing practices, traditional marketing tools such as those utilized in this study can be used to facilitate practice growth for specific clinical programs, such as uterine artery embolization. Defining a target market can significantly expand an existing uterine fibroid embolization practice. The optimal choice of targeted media awaits verification from future studies."

"The study was assisted by the aid of a single industrial partner, Biosphere, who provided financial and strategic resources. The industrial partner shared their marketing analysis of the local health care environment with respect to UAE."

"Newer theories of competitive strategy advocate anticipating how a competitor might react to a given strategy (elements of "game theory") or choosing a certain strategy that would lead a competitor to react a certain way."

"Our marketing analysis of the current uterine fibroid market strongly suggests that a direct advertising approach would be successful."

"Since fibroids occur twice as frequently in black women and most commonly between the ages of 35 to 45, this demographic was selected as our target audience."

"One measure of marketing productivity is simply return on investment. A specific weekly magazine N'Digo, was selected due to its readership demographics. It is a free weekly magazine targeting black women with a self-reported weekly readership of 500,000."

"The net profit can be divided by certain variables to obtain certain benchmarks such as average profit per call ($559), average profit per clinic visit ($1438), average profit per case performed ($2959) and average profit per week of advertising ($6289)."

"The increased revenue only represents the professional fee and does not account for increased revenue via the technical component. Although the hospital is not willing to disclose the technical component collections, readers who practice in hospital-based interventional radiology groups may consider sharing the marketing costs with the hospital."

Fibroid Embolisation: A Technique Not Without Significant Complications

A. Vashisht, J.W.W. Studd, A.H. Carey, J. McCall, P.R. Burn, J.C. Healy and J.R. Smith
British Journal of Obstetrics and Gynecology
September 2000; 107: p.1166-1170

"One woman died following septic shock and multiple organ failure and is excluded from the numerical analysis."

"One woman was readmitted for opioid analgesia control six weeks after the procedure, due to degeneration of her fibroid."

"One woman developed a urinary tract infection three days after embolisation and was commenced on antibiotics according to culture sensitivity. She recovered well at home, but was readmitted 10 days following fibroid embolisation with sudden, severe abdominal pain. She was found to have overwhelming sepsis and disseminated intravascular coagulation. She was resuscitated initially, and a total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed eight hours later, revealing an infected uterus containing a large necrotic submucous fibroid. She was admitted to the intensive therapy unit, and died 15 days later from a massive haemothorax complicating multi-organ failure."

"More recently, details from another unit have emerged, reporting a further death following uterine artery embolisation."

"Another concern regarding uterine artery embolisation is the effect it may have on subsequent blood supply to the ovaries and uterus. The effects on subsequent fertility are unclear. There are reports of possible premature ovarian failure."

Fatal Sepsis after Uterine Artery Embolization with Microspheres

Sjoerd de Blok, MD, PhD, Cees de Vries, MD, Helma M. Prinssen, MD, Hans L.G. Blaauwgeers, MD and Lorine B. Jorna-Meijer, MD
Journal of Vascular and Interventional Radiology
Vol. 14 No. 6 June 2003: p.779-783

"A case report of fatal sepsis after uterine artery embolization (UAE) with microspheres is presented."

"Surgical therapy consisting of hysterectomy or enucleation was refused because of persisting with to preserve fertility. For this reason, the patient agreed to under the less-invasive therapy of UAE."

"Five days later, she returned to the hospital with a 1-day history of gastrointestinal symptoms: diarrhea, vomiting, and increasing abdominal pain."

"She was transferred immediately to the intensive care unit on suspicion of septic shock or retroperitoneal bleeding. Despite intravenous infusion of colloids, her condition deteriorated quickly and a rapid swelling of the abdomen was seen."

"Within 1.5 hour after admission, she was brought to the operation room for emergency laparotomy while being resuscitated. At surgery, the abdomen was full of pus and the uterus and bowel system appeared to be necrotic. Resuscitation failed and she died during surgery of septic shock resulting in disseminated intravascular coagulation and multiple organ failure."

Fatal Septicaemia after Fibroid Embolisation

Arvind Vashisht, John Studd, Adam Carey, Paul Bum
The Lancet
July 24, 1999; 354 (9175): p.307-308

"Post-embolisation syndrome is a well documented disorder that occurs in many parts of the body after embolisation. Nonetheless, clinicians must be vigilant for any sign of infection after embolisation. In our practice, we obtain blood cultures as well as computed tomography scans of the pelvis. An abscess is clear on such imaging, and requires surgical treatment."

Pelvic Sepsis Complicating Embolization of a Uterine Fibroid

Stephen Robson, Kay Wilson, David Munday and Ruben Sebben
The Austrailan and New Zealand Journal of Obstetrics and Gynaecology
1999; 39: 4: p. 516-7

"We present a cautionary tale as a reminder that new therapeutic techniques may carry a potential for severe complications."

"In view of her nulligravid status, she requested treatment that would have the least impact on her future fertility."

"On the 24th day after the procedure, she presented with increasing lower abdominal pain, diaphoresis, malaise, and an offensive vaginal discharge."

"Vaginal examination demonstrated severe pelvic tenderness. Swabs were taken for microbiological testing. Ultrasonography demonstrated a multiloculated collection cephalad to the uterus."

"At laparotomy, dense fibrinous adhesions of omentum, large and small bowel encased the pelvis. Approximately one litre of purulent fluid with a strong 'anaerobic' smell was drained from the pelvis. All the pelvic tissues were inflamed and oedematous."

"Unfortunately, in the case described the principal aims of the procedure were not met, in particular, avoidance of surgery and preservation of fertility. It is highly likely that this woman will have adhesive disease involving the pelvis, and bilateral salpingectomy has rendered her sterile."

"They should understand that there is fertility and life-threatening."

Necrotic Leiomyoma and Gram-Negative Sepsis Eight Weeks After Uterine Artery Embolization

Matthew Aungst, MD, Mark Wilson, MD, Karen Vournas, MD, and Sarah McCarthy, MD
Obstetrics and Gynecology
November 2004; Vol. 104, No. 5, Part 2: p.1161-1164

"Eight weeks postembolization, the patient, who had been essentially asymptomatic, presented in septic shock from gram-negative anaerobic bacteria. She underwent hysterectomy and bilateral salpingo-oophorectomy for a large infarcted necrotic leiomyomas and partial uterine necrosis."

"The patient received doxycycline before the procedure and for a week postprocedure."

"The patient was well after the embolization procedure until the 4 days before her admission, when she developed pelvic cramps and heavy vaginal bleeding. The initial evaluation in the emergency department found the patient to be in septic shock, with a temperature of 39.78°C, heart rate of 163 beats per minute, blood pressure of 99/60 mm Hg, and anuric."

"The patient's homodynamic status stabilized after receiving 5 units of packed red blood cells. After reversal of her anticoagulation with vitamin K and 5 units of fresh frozen plasma, the patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy."

Buttock Necrosis After Uterine Artery Embolization

Danielle M. Dietz, MD, Kurt R. Stahlfeld, MD, Surendra K. Bansal, MD, and Wayne A. Christopherson, MD
Obstetrics & Gynecology
November 2004; Vol. 104, No. 5, Part 2: p.1159-1161

"We present a case of nontarget embolization resulting in full-thickness buttock necrosis requiring surgical debridement."

"Two weeks postprocedure, the patient was complaining of buttock pain when sitting or lying supine. On examination, 2 large ecchymotic areas on the right buttock were noted."

"At follow-up 2 weeks later, however, the skin had broken down revealing significant areas of underlying necrosis."

"The patient was admitted to the hospital for intravenous broad-spectrum antibiotics and operative debridement. The necrotic lesions extended 6cm deep to superficially involve the gluteus maximus muscle."

Uterine Necrosis after Uterine Artery Embolization for Leiomyoma

Claire D. Godfrey, MD and Edward A. Zbella, MD
Obstetrics and Gynecology
November 2001; 98(5 Part 2): p.950-952

"A woman with a large uterine leiomyoma underwent elective uterine artery embolization and 2 months later developed diffuse uterine necrosis requiring exploratory laparotomy, total hysterectomy, and left salpingo-oophorectomy."

"Possible complications include procedure-related groin hematomas, infection at the arterial puncture site, guide-wire perforation of the arteries, and thromboemoblic phenomena, as well as fever, malaise, pelvic pain, endometritis, ischemia of pelvic organs, and procedure failure."

"The uterine cavity contained necrotic debris and pus that leaked into the intraperitoneal cavity. There were also extensive adhesions of the uterus to the small bowel and omentum, as well as a left hydrosalpinx. Total abdominal hysterectomy and left salpingo-oophorectomy were performed."

"With the advent of direct marketing to patients by hospitals and radiologists regarding this procedure, it is important that all serious complications of uterine artery embolization be reported so that appropriate protocols can be established to minimize such complications in the future. These complications also should be reported, so that patients contemplating uterine artery embolization can give fully informed consent."

Uterine Necrosis After Arterial Embolization for Postpartum Hemorrhage

J.P. Cottier, MD, A. Fignon, MD, F. Tranquart, MD, PhD, and D. Herbreteau, MD
Obstetrics and Gynecology
Vol. 100 No. 5, Part 2, November 2002: p.1074-7

"Histopathology of the hysterectomy specimen revealed massive zonal ischemic myometrial necrosis of the inner half of the mometrial wall with calcifications and sclerosis."

"Deaths after uterine artery embolization have also been reported."

"After uterine artery embolization for leiomyomata, characteristic histologic features within the leiomyomata include massive necrosis, vascular thrombosis, and intravascular foreign material that elicit a histiocytic and foreign body giant cell reaction. Small foci of myometrial necrosis beyond the confines of the leiomyomata have been occasionally reported. Polyvinyl alcohol particles also carry a risk of massive myometrial necrosis, as illustrated in this case."

Labial Necrosis After Uterine Artery Embolization for Leiomyomata

Thomas J. Yeagley, Jay Goldberg, Thomas A. Klein, and Joseph Bonn
Obstetrics and Gynecology
2002; 100:881-2

"Nontarget embolization has been reported during uterine artery embolization, involving ovarian failure and unilateral deep buttock pain."

"Immediately after the uterine artery embolization procedure, the patient complained of right lower extremity pain radiating from her buttock to her toes."

"On the day after the embolization, she developed right-sided vulvovaginal burning. Over the subsequent 2 days, her lower extremity pain decreased and her vulvar symptoms increased."

"A 1 X 3-cm hypopigmented, necrotic appearing area, which was exquisitely tender to touch, was noted on the right labium minus."

"Nontarget embolization of the labium was presumed to be the cause of her symptoms."

Massive vault necrosis with bladder fistula after uterine artery embolisation

Amr H. El-Shalakany, Mohammad H. Nasr El-Din, Gamal A. Wafa, Mohammad E. Azzam, Ahmad El-Dorry
British Journal of Gynecology
February 2003, Vol. 110 pp. 215-216

"The woman was discharged on the fourth day and was readmitted eight days later with a profuse watery vaginal discharge and complete incontinence of urine. She had widespread necrosis of the cervix and vaginal vault, more anteriorly, extending to involve the bladder."

"Through a lower transverse abdominal incision, hysterectomy with removal of both ovaries and uterine tubes was carried out. The uterus was shrunken and friable and came away easily."

"Other major complications include pulmonary embolism, ovarian failure and vaginal expulsion of a submucous myoma after embolisation."

Reversal of Flow in the Ovarian Artery during Uterine Artery Embolization

Kristen A. Wolanske, MD et al
Journal of Vascular & Interventional Radiology
June 2003; 14:785787

"This case report focuses on the potentially serious complication of flow reversal up the ovarian artery into the aorta during UAE."

"In the alarming case described herein, we observed complete reversal of flow in the ovarian artery, including reflux into the aorta, during routine embolization of the left UA."

"Two bottles of polyvinyl alcohol particles were injected, but it seemed that, although flow in the UA was slowing, there were still several large uterine branches filling, with rapid washout of the embolic mixture."

"She reported a rash limited to the anterior abdominal wall approximately 3 days after the procedure."

"The patient's bleeding stopped briefly after the procedure but resumed, and the patient ultimately underwent elective hysterectomy for definitive treatment."

Ischemic Uterine Rupture and Hysterectomy 3 Months after Uterine Artery Embolization

Abraham R. Shashoua, M.D., Nelson H. Stringer, M.D., Julie B. Pearlman, M.D., Behnaz Behmaram, M.D.
The Journal of the American Association of Gynecologic Laparoscopists
May 2002; 9(2): p.217-220

"However, several major complications are described in the literature, including ovarian failure, a UAE which required laparoscopic myomectomy, prolapsing myoma requiring hysterectomy, septicemia, pulmonary embolization, and death. The exact frequency and extent of complications associated with UAE have yet to be documented."

"The abdominal cavity contained 1000 dl of pus with no evidence of gastric or duodenal perforation. Examination of the pelvis revealed a necrotic uterus that was enlarged to 16cm with a 12cm subserosal myoma protruding into the right broad ligament."

"Total abdominal hysterectomy was performed."

"Therefore, the possibility of uterine rupture resulting in total abdominal hysterectomy must be considered in informed consent for women who desire future pregnancy."

Massive Vaginal Hemorrhage after Uterine Fibroid Embolization

Robert K. Kerlan Jr, James O. Coffey, Marilyn S. Milkman, Jeanne M. LaBerge, Mark W. Wilson, Kristen A. Cea Wolanske, and Roy L. Gordon
Journal of Vascular & Interventional Radiology
2003; 14:1465-1467

"The patient did well and was without complications for almost 1 month after the procedure, at which time she began bleeding heavily and was admitted to another hospital with a hematocrit level of 34."

"Fluid resuscitation was initiated and she received a transfusion of 2 U of packed red blood cells. She was treated conservatively with oral contraceptives and the bleeding initially stopped. However, 48 hours later, the hemorrhage recurred and she underwent an emergency total abdominal hysterectomy."

"Embolization material was identified in several large blood vessels of the adjacent myometrium and also within vessels of the larger of the two fibroids."

"There was focal ulceration of the endometrium overlying the large infarcted fibroid (Fig. 3)."

Uterine Artery Embolization in the Treatment of Symptomatic Uterine Fibroid Tumors (EMMY Trial): Periprocedural Results and Complications

Nicole A. Volkers, MD et al
Journal of Vascular Interventional Radiology
March 2006; 17:471-480

"The overall complication rates were 28.3% during the patients' hospital stay and 60.5% for the 6 weeks after discharge."

"The most frequent minor complication was groin hematoma (14.8%). A total of seven patients (8.6% had sudden hypertension after UAE (systolic blood pressure >140mm Hg and/or diastolic blood pressure >90mm Hg.)."

"In all patients except one, the increase in blood pressure was observed immediately after the UAE procedure. In one patient, hypertension started 2 days after the procedure and a pulmonary embolism occurred 4 days after UAE."

"A total of 90 complications occurred in 51 patients (63.0%)."

"There were 46 unscheduled visits to a physician by 30 patients (37.0%) within the first 6 weeks after discharge, mainly because of pain and/or fever. Nine patients (11.1%) experienced an SIR-defined major complications after discharge. All were readmitted to the hospital, seven (77.8%) within the first week after discharge."

Sexual Dysfunction after Uterine Artery Embolization

A.C. Lai, S.C. Goodwin, S.M. Bonilla, A.P. Lai, T. Yegul, S. Vott, and M. DeLeon
Journal of Vascular & Interventional Radiology
June 2000; 11(6): p.755-8

"At a 6-week follow-up visit, the patient reported that she had lost the ability to achieve orgasm, both internal and clitoral, during sexual intercourse, which she noticed 6 days after the procedure."

"Reported complications from uterine artery embolization have been related to either angiography or ischemia due to either target or nontarget embolization. Angiographic complications include femoral hematoma, pseudoaneurysm, arteriovenous fistula, and contrast-material-induced renal failure. Ischemic complications due to target embolization of the uterus include pelvic infections, such as acute endometritis. In one patient, the degenerating infarcted fibroid became a source of aseptic necrosis within the endometrial cavity, leading to abscess formation and possibly to perforation of the uterine fundus. Two cases of death after embolotherapy have been reported. Last, ischemic complications from nontarget embolization of the arterial supply to the ovaries made possible."

"However, the loss of internal orgasm by our patient can possibly be accounted for by the disrupted uterine arterial flow that concomitantly nourishes the uterio-vaginal plexus."

"The cervicovaginal branch of the uterine artery is often embolized during embolotherapy, thus, the uteriovaginal plexus may be compromised by the ischemic changes."

"Thus, the impeded arterial flow to the uterus may create an ischemic condition injuring nerves essential to a woman's ability to have and/or experience uterine contractions."

Uterine Fistula Induced by Hysteroscopic Resection of an Embolized Migrated Fibroid: A Rare Complication after Embolization of Uterine Fibroids

Pierandrea De Iaco, M.D., Rita Golfieri, M.D., Tullio Ghi, M.D., Giuseppe Muzzupapa, M.D., Michela Ceccarini, M.D., and Luciano Bovicelli, M.D.
Fertility and Sterility
April 2001; 75(4): p.818-820

"Complications of transcatheter embolization have not yet been reported because of small series with short follow-up."

"We report on a patient in whom hysteroscopic removal of a fibroid that had migrated through the uterine wall produced a uterine fistula. This complication was unexpected, since the patient reported no symptoms. The uterine fistula may be caused by severe shrinkage of the residual myometrial tissue after embolization."

Vesicouterine fistula after uterine artery embolization: A case report

Carmen J. Sultana, MD, Jay Goldnerg, MD, Laura Aizenman, MD, and Joanna K. Chon, MD
American Journal of Obstetrics and Gynecology
2002; 187(6): p.1726-7

"Uterine artery embolization (UAE)...is widely marketed directly to the public as a benign, nonsurgical alternative to hysterectomy and myomectomy."

"...postprocedural complications have been reported, including recurrent infection and pyometria, pulmonary embolus, angiographic complications, hemorrhage from prolapsing myoma, sexual dysfunction, delayed diagnosis of leiomyosarcoma, ovarian failure, and uterine necrosis. We present a case of postembolization vesicouterine fistula and extrusion of fibroids into the bladder that required partial cystectomy and hysterectomy for repair."

"Laparotomy for repair was performed, with hysterectomy and resection of a large amount of necrotic bladder tissue surrounding a 3-cm vesicouterine fistula."

"This is the first reported case of fistula involving the bladder after UAE. A possible explanation for the complication is that the blood supply to the posterior bladder was affected by the procedure."

"Extensive uterine infarction and necrosis leading to hysterectomy have been reported."

Ovarian Reserve after Uterine Artery Embolization for Leiomyomata

Togas Tulandi, MD, Aref Sammour, MD, David Valenti, MD, Timothy J. Child, MD, Laurent Seti, MD, and Seang Lin Tan, MD
Fertility and Sterility
July 2002; 78(1): p.197-198

"It seems that premature menopause after embolization occurs predominantly in older women. Whether uterine artery embolization decreases ovarian function in younger women is unknown."

"The declining ovarian reserve is also indicated by the decreasing number of antral follicles. The most likely mechanism of declining ovarian reserve and premature menopause after uterine artery embolization is embolization of the utero-ovarian collateral circulation. This effect compromises blood supply to the ovaries."

"Uterine artery embolization may hasten ovarian failure."

"However, in agreement with others, we found permanent ovarian failure with severe menopausal symptoms in a 40-year-old woman immediately after uterine artery embolization."

Ovarian Artery Supply of Uterine Fibroids as a Cause of Treatment Failure after Uterine Artery Embolization: A Case Report

Boris Nikolic, MD, James B. Spies, MD, Suhny Abbara, MD, and Scott C. Goodwin, MD
Journal of Vascular & Interventional Radiology
October 1999; 10(9): p.1167-1170

"Five months after the UAE, the patient was referred for reevaluation and possible reembolization. Despite the gonadotropin-releasing agonist and UAE therapy, she had continued heavy menstrual bleeding, pelvic pain, frequent abdominal swelling, and back pain."

"The patient was referred for surgical therapy and underwent uncomplicated supracervical hysterectomy 2 months later."

"We have presented a case that represents only one possible cause for failure, but it was our intent to report that treatment failure from UAE might occur despite a technically successful intervention."

"We believe that selective catheterization is therefore technically difficult and time-consuming and entails a risk of vascular damage and alteration of ovarian function."

Ovarian Failure after Uterine Artery Embolization for Treatment of Myomas

N.H. Stringer, T. Grant, J. Park, and L. Oldham
Journal American Association of Gynecologist Laparoscopists
August 2000; 7(3): p.395-400

"Nontargeted embolization of ovarian arteries has always been considered a possible complication of UAE."

"Certain immediate postprocedure complications, such as allergic reactions to contrast medium, bleeding at the catheter insertion site, or catheter perforation of a vessel, should be managed by the interventional radiologist. Many other complications occurring weeks or months after UAE, such as, sepsis, excessive uterine bleeding, retention of necrotic pieces of myoma, pulmonary emboli, postembolization syndrome, and ischemic necrosis of the uterus requiring hysterectomy, should be managed by the gynecologist."

"Bilateral blockage of the uterine artery decreases blood flow to the uterus by approximately 42%."

"The connection between ovarian and uterine arteries opens the possibility of nontargeted embolization of ovarian arteries even in a procedure that, technically, successfully embolizes the uterine artery."

"The gynecologist should carefully inform women of this possible and unavoidable complication of UAE when performed for treatment of uterine myomas."

Embolic Microspheres Within Ovarian Arterial Vasculature After Uterine artery Embolization

John F. Payne, MD, Stanley J. Robboy, MD, and A. F. Haney, MD
Obstetrics & Gynecology
Vol. 100, No. 5, Part 1 November 2002: p.883-6

"A 39-year-old woman underwent emergency hysterectomy after uterine artery embolization embolic micropheres found within the ovarian arterial vasculature."

"Because of a deteriorating clinical situation, she underwent an exploratory lapartomy, total hysterectomy, bilateral salpingo-oophorectomy, extensive adhesiolysis, and bowel serotomy repair."

"When the ovary becomes ischemic after uterine artery embolization, it would be anticipated to undergo necrosis similar to that observed in the myometrium after uterine artery embolization."

"There may be an intrinsic risk related to uterine artery embolization of altered ovarian function with embolic material migrating to the ovarian arterial vasculature and compromising blood flow."

The Impact of Uterine Fibroid Embolization on Resumption of Menses and Ovarian Function

Howard B. Chrisman, MD, Mark B. Saker, MD, Robert K. Ryu, MD, Albert A. Nemcek, Jr., MD, Melvin V. Gerbie, MD, Magdy P. Milad, MD, Steven J. Smith, MD, Luke E. Sewall, MD, Reed A. Omary, MD, MS, and Robert L. Vogelzang, MD
Journal of Vascular & Interventional Radiology
June 2000; 11(6): p.699-703

"All patients were believed to be premenopausal and had been evaluated by an attending gynecologist to confirm the diagnosis of uterine fibroids and to exclude endometrial cancer."

"In 10 of 66 patients (15%), menstruation did not resume after treatment, with an average follow-up of 49 weeks (range, 24-76 weeks)."

"Although the etiology of ovarian failure in our patients remains uncertain, we postulate a number of possible etiologies, including vascular causes and changes in the local (uterine/ovarian) hormonal milieu."

"After observing a number of these ovarian vessels, we postulate that they are potentially embolized to some degree during UFE. The degree to which a woman's ovaries are inadvertently embolized and the effect that this process has on ovarian function is unknown at this time."

"Perhaps the pivotal question is whether UFE should be recommended for women who desire future fertility and/or maintenance of ovarian function."

The Vascular Impact of Uterine Artery Embolization: Prospective Sonographic Assessment of Ovarian Arterial Circulation

Robert K. Ryu, MD, Howard B. Chrisman, MD, Reed A. Omary, MD, MS, Simka Miljkovic, RDMS, Albert A. Nemcek, Jr, MD, Mark B. Saker, MD, Scott Resnick, MD, James Carr, MD, and Robert L. Vogelzang, MD
Journal of Vascular and Interventional Radiology
September 2001; 12(9): p.1071-1074

"Of note, the incidence of premature ovarian failure after UAE for symptomatic fibroids was recently reported to be as high as 14%."

"Besides the immediate effect of premature ovarian failure on fertility, there are potentially significant long-term health consequences."

"Of the 17 completed studies, nine (53%) demonstrated complete loss of appreciable Doppler arterial signal in the ovary after UAE."

"The etiology of premature ovarian failure after UAE is unknown."

"The findings show immediate and significant ovarian vascular changes after UAE."

"This particular example provides compelling evidence of incidental ovarian arterial collateral embolization as a result of UAE with correlative findings in two imaging modalities."

"Most likely, the cause of premature ovarian failure is multifactorial."

"These preliminary findings show clear and unequivocal evidence of significant vascular derangements in ovarian arterial circulation immediately after UAE as evidenced by a complete loss of appreciable arterial flow or an increase in vascular impedance. Given the temporal relationship of the UAE procedure to US examination, we suggest that these changes occur as a direct result of inadvertent embolization of the ovary via uterine-ovarian arterial collaterals."

Ovarian Function after Uterine Artery Embolization for Leiomyomata: Assessment with Use of Serum Follicle Stimulation Hormone Assay

James B. Spies, MD, Antoinette R. Roth, BS, Sheila M. Gonsalves, RN, MA, and Kerry M. Murphy-Skrzyniarz, RN, MS
Journal of Vascular & Interventional Radiology
April 2001; 12(4): p.437-442

"The mechanism for the apparent change in ovarian function that occasionally occurs after UAE is not known. We suggest three possibilities: First, because UAE requires fluoroscopic and angiographic imaging, the radiation exposure may affect the function of the ovaries."

"A second possibility is that embolic material can pass through the tubo-ovarian arcade to the ovary and cause a direct ovarian injury. A third possibility is that some women's ovaries may depend on flow from the uterine artery."

The Future Interventional Radiologist: Clinician or Hired Gun?

Mark O. Baerlocher, BSc, and Murray R. Asch, MD, FRCPC
Journal of Vascular & Interventional Radiology
December 2004; 15:1385-1390

"In this case, so-called turf wars may break out even among the two types of radiologists."

"Finally, separation would certainly lead to a substantial decrease in the bargaining and political power of each respective group, which is very important when dealing with various governmental and regulatory organizations including the American Medical Association, the American Board of medical Specialties, and the Centers for Medicaid and Medicare Services."

"We may find that the dominant force in the near future is the common drive of the medical community and the public toward noninvasive procedures: assuming interventional radiologists will retain at least some of their "turf" (a fair assumption), greater demand will translate into more opportunity for the interventional radiologist to practice closer to 100% interventional radiology."

"The interventionalist has a duty of care to the patient, and in such cases in which the interventionalist and patient agree on a treatment and the referring physician disagrees, the procedure should be performed; any considerations of a future quid pro quo are irrelevant."

"To this end then, there has been much talk of a name change. In the 2000 Charles T. Dotter Lecture, Keller suggested the terms "minimally invasive surgery" and "image-guided surgery."

"If the name is to be changed the new name should include within it some reference to radiology and/or intervention and no mention of the word "surgery": changing the name to one that does not include "radiology" and/or one that includes "surgery" may further isolate interventional radiology from the broader field of diagnostic radiology and, in the process, open the door to additional loss of "turf". "

"The solution, simply, is intensive pubic relations campaigning."

"imagine it: a celebrity talking about how she noticed abdominal bloating, urinary frequency, and heavy periods a year ago, later diagnosed with fibroids, and given the "option" of a hysterectomy, only to find out later about a new branch of radiology, interventional radiology, which can perform a minimally invasive UAE procedure."

"Or imagine an "Oprah" episode on UAE in which women who have undergone UAE procedure are interviewed, along with others who have had a hysterectomy (in fact, this seems like something that may be of interest to the show)."

"The public's view may well be our largest ally."

"From the view of the public, turf wars among specialties are likely beneficial if there is an acceptable level of care maintained and mandated by the respective institutions. In nearly all business models, competition benefits the buyer and essentially creates a market economy: those who can provide the best and quickest service will win the competition with other sellers. In this sense, medicine is not all that much different."

"So why, then, do others want to perform "our" procedures, and what can be done to protect our turf?"

"Funding from industry is more easily obtained when it is directed at promoting specific products as opposed to general interventional radiology advertising."

Transarterial Embolization of the Uterine Arteries: Patient Reactions and Effects on Uterine Vasculature

Adel Aziz, Oswald M. Petrucco, Satoru Makinoda, Gunnar Wikholm, Paul Svendsen, Mats Brannstrom and Per Olof Janson
Acta Obstetricia et Gynecologica of Scandinavica
March 1998; 77(3): p.334-340

"An obvious clinical risk is that the reduction of blood flow to the adnexa would result in ovarian-tubal dysfunction."

"The possible side effects of the procedure include groin hematoma, infection at the arterial puncture site, guide wire perforation of arteries and thrombo-embolic phenomena."

Pathologic Features of Uteri and Leiomyomas Following Uterine Artery Embolization for Leiomyomas

Terence J. Colgan, Gaylene Pron, Eva J. M. Mocarski, John D. Bennett, Murray R. Asch, and Andrew Common
The American Journal of Surgical Pathology
27(2); 167-177, 2003

"In all cases PVA emboli were identified within smooth muscle tumors of the uterine body, its periphery, cervix, uterine body, myometrium and/or the adnexa. A fibroid foreign body giant cell type of chronic inflammatory reaction was seen within 1 week of UAE and persisted with visible PVA for up to 14 months post UAE."

"Five of eight cases coming to surgery for complications showed necrotizing endomyometritis with tissue infarction. PVA particles are recognizable in post-UAE specimens."

"Surgical pathologic examination of neoplasms resected following innovative treatment modalities may provide important insights into the mechanism of action of the new treatment modality and its unanticipated side effects of outcomes."

Patient Radiation Dose Associated With Uterine Artery Embolization

B. Nikolic, J.B. Spies, M.J. Lundsten, and S. Abbara
Jan. 2000, 214(1): p.121-125

"Three patients in whom vaginal and skin dose measurements were obtained were excluded from analysis because their mean vaginal radiation dose measurements were substantially lower than those in the average patient despite long fluoroscopic times and large exposure numbers. This was probably due to the temporary exclusion of the vaginal detectors from the x-ray beam field."

"On occasion, repeat embolization was necessary, and an additional final angiogram was obtained on that side."

"Given the doses to both the skin and the ovaries that we measured, however, it is possible that effects will occur in some patients who undergo particularly long or complicated procedures."

"We believe that for the remaining patients in whom radiation measurements were obtained, the vaginal detectors were permanently within the x-ray beam field and that one or both ovaries were always within the primary beam field during the entire UAE procedure. Partial exclusion of the detectors from the field might have occurred to a much lesser extent, however, even in these remaining patients, with the result being an underestimation of the absorbed ovarian dose."

"It should be noted, however, that the absorbed ovarian dose is not determined purely by using the fluoroscopic time and exposure numbers. It is also substantially influenced by each patient's individual ovarian location and body habitus. In one of our study patients (patient 16), for instance, the estimated absorbed ovarian dose was substantially higher than the average value despite below-average fluoroscopic time and exposure numbers."

"The dose level that might cause alteration of ovarian function is not known, and there does not appear to be a clear dose threshold for ovarian failure."

"It thus appears that UAE results in ovarian and skin doses that are at least 30-100 times higher than those during conventional diagnostic radiographic examinations..."

Influence of Radiographic Technique and Equipment on Absorbed Ovarian Dose Associated with Uterine Artery Embolization

B. Nikolic, S. Abbara, E. Levy, I. Imaoka, M.L. Lundsten, R.C. Jha, and J.B. Spies
Journal of Vascular & Interventional Radiology
October 2000; 11(9): p.1173-1178

"One additional concern is the absorbed ovarian dose (AOD) that is associated with UAE because the ovaries are probably in the primary radiation beam during the entire procedure. We have previously estimated the mean AOD as 22.34 cGy, which is a magnitude lower than that from pelvic irradiation for Hodgkin disease, but also significantly higher than from standard fluoroscopic diagnostic procedures."

"In all measurements, the radiation beam was collimated to the central pelvis, as in the typical UAE procedure."

"As our measurements show, variations in anatomy with even slight differences in ovarian position or ovarian displacement by a myomatous uterus can substantially alter AOD. In the current study, the dose absorbed by the right ovary was substantially higher than the left-sided AOD."

"Prolonged fluoroscopy usually occurs during selective catheterization of the uterine arteries, which can be technically quite challenging. Use of magnification during UAE, especially if combined with oblique fluoroscopy, causes additional substantial increase of the AOD over nonmagnified fluoroscopy of equal duration."

Fibroid-related Menorrhagia: Treatment with Superselective Embolization of the Uterine Arteries and Midterm Follow-up

Jean-Pierre Pelage, MD, Olivier Le Dref, MD, Philippe Soya, MD, PhD, Moored Kardache, MD, Henri Dahan, MD, Martine Abitbol, MD, Jean-Jacques Merland, MD, Jacques-Henri Ravina, MD, and Roland Rymer, MD
May 2000; 215: p.428-431

"Six (8%) women complained of amenorrhea after the procedure. Of these six women, two had transient amenorrhea and four had permanent amenorrhea. Necrotic fragments of a pedunculated submucosal myoma were expelled through the cervix during the 1st month after the procedure in four women. In another woman with a large submucosal fibroid, hysterectomy had to be performed because of acute septic uterine necrosis that was revealed by pelvic pain, fever, and an increased leukocyte count 17 days after embolization."

"In 68 (85%) women, the immediate postoperative course was characterized by intense pelvic pain, which was managed by using the patient-controlled analgesic pump."

"A local complication was observed in one woman and consisted of the partial dissection of the left uterine artery."

"Because of ethical considerations and limited information regarding the long-term effects of polyvinyl alcohol particles that remain in the interstitial tissue adjacent to the arterial wall, embolization was performed only in women who did not desire future pregnancy."

Persistent vaginal discharge after uterine artery embolization for fibroid tumors: Cause of the condition, magnetic resonance imaging appearance, and surgical treatment

Woodruff J. Walker, FRCR, Tyrone T. Carpenter, MRCOG, Andrew S. H. Kent, MD
American Journal of Obstetrics and Gynecology
2004; 190: p.1230-3

"A review of the first 400 cases was published recently. The reviewers noted that 4% of patients subsequently had chronic vaginal discharge that lasted longer than 8 weeks and that they described as a "major irritant". Flexible hysteroscopy demonstrated the cause of the discharge to be a persisting sinus that connected a superficial necrotic excavation within the fibroid tumor to the endometrial cavity through a perforation in the endometrium. This resulted in a slow persistent drainage of necrotic material into the uterus and subsequently the vagina."

"It would appear that there is a breakdown in the thin layer of myometrium that intervenes between the fibroid tumor and the uterine cavity."

Comparison of Long-Term Outcomes of Myomectomy and Uterine Artery Embolization

Michael S. Broder, MD, Scott Goodwin, MD, Gary Chen, MD, Linda J. Tang, MD, Mary M. Costantino, MD, Michael H. Nguyen, MD, Tugce N. Yegul, MD, and Heike Erberich, MD
Obstetrics & Gynecology
November 2002; 100(5): p.864-8

"Women who had embolization were more likely than those who had myomectomy to need further invasive treatment (surgery or repeat embolization) in the 3-5 years after the index procedure."

"Patients in the embolization group were more likely than those in the myomectomy group to have further invasive therapy, with 29% (15/51) of the embolization group and 3% (1/30) of the myomectomy group having such treatment (P=.004). These surgeries included one hysterectomy in the myomectomy group and six hysterectomies, eight myomectomies, and one repeat embolization in the embolization group."

"In our retrospective study, women who had embolization were substantially more likely to need further invasive treatment than those who had myomectomy, and this difference was not simply a function of the length of follow-up."

"The higher recurrence rate after embolization is biologically plausible since, unlike myomectomy, this procedure does not remove myomas."

Review of Readmissions Due to Complications from Uterine Fibroid Embolization

H. Mehta, C. Sandhu, M. Matson, A.-M. Belli
Clinical Radiology
2002; 57: p.1122-1124

"Seven patients (17%) required readmission."

"Infective complications are a recognized risk of UAE, although the true incidence is uncertain, as some patients will be successfully treated in the community and not come to hospital attention."

"In conclusion, there is a significant readmission rate following UAE that is related to infective complications despite the use of prophylactic antibiotics at the time of the procedure."

Fibroid-related Menorrhagia: Treatment with Superselective Embolization of the Uterine Arteries and Midterm Follow-up

Jean-Pierre Pelage, MD, Olivier Le Dref, MD, Philippe Soya, MD, PhD, Moored Kardache, MD, Henri Dahan, MD, Martine Abitbol, MD, Jean-Jacques Merland, MD, Jacques-Henri Ravina, MD, and Roland Rymer, MD
May 2000; 215: p.428-431

"Six (8%) women complained of amenorrhea after the procedure. Of these six women, two had transient amenorrhea and four had permanent amenorrhea. Necrotic fragments of a pedunculated submucosal myoma were expelled through the cervix during the 1st month after the procedure in four women. In another woman with a large submucosal fibroid, hysterectomy had to be performed because of acute septic uterine necrosis that was revealed by pelvic pain, fever, and an increased leukocyte count 17 days after embolization."

"In 68 (85%) women, the immediate postoperative course was characterized by intense pelvic pain, which was managed by using the patient-controlled analgesic pump."

"A local complication was observed in one woman and consisted of the partial dissection of the left uterine artery."

"Because of ethical considerations and limited information regarding the long-term effects of polyvinyl alcohol particles that remain in the interstitial tissue adjacent to the arterial wall, embolization was performed only in women who did not desire future pregnancy."

Factors Affecting Early Surgical Intervention After Uterine Artery Embolization

Haya Al-Fozan and Togas Tulandi
36 CME Review Article Obstetrical and Gynecological Survey
Vol. 57, No. 12

"Uterine infection may be more common in the presence of submucosal myoma. In fact, in the first reported death after embolization, a submucosal myoma was discovered."

"Surgical and histopathologic findings revealed that often all pelvic organs, including the appendix, were involved in the infection. Consequently, besides the uterus, infected fallopian tubes, ovaries, and appendix have to be removed as well."

"Bowel necrosis and subserous myoma. Embolization of subserosal myoma, especially with bowel adhesions, can lead to bowel necrosis."

An unusual clinical and histological consequence of uterine arterial embolization of a fibroid

Annabelle Burnham, Alan Crystal and E. Peter H. Torrie
Gynecological Endoscopy
2000 9, 201-203

"She was readmitted to hospital 6 weeks after the embolization, with persistent menorrhagia, and severe right iliac fossa pain."

"At operation a large necrotic fibroid was seen in the uterine cavity."

"The results of the histological examination of the fibroid that was initially resected after uterine artery embolization are worthy of further comment. Sections showed large numbers of fragments of leiomyoma with virtually complete infarction. Distorted ragged vascular spaces were seen, some of which contained minute black agglomerated particles, which were considered to be the polyvinyl alcohol used to embolize the fibroid."

"Overall, the patient suffered quite a prolonged period of intermittent morbidity."

Uterine Artery Embolization for Fibroids: Understanding the Technical Causes of Failure

James N Spies, MD
Journal of Vascular & Interventional Radiology
2003; 14: p.11-14

"Whereas, in the short term, a partially infracted fibroid may not affect outcome, over the longer term, the fibroid is likely to regrow and symptoms can recur. Even in instances in which the uterine volume decreases and the dominant fibroid shrinks, recurrence can be predicted when infarction of substantial fibroids is not achieved."

"It is more difficult to determine the embolization endpoint when using microspheres."

"Because they may pack more tightly, complete occlusion of the uterine artery with microspheres will cause unnecessary pain at a minimum and injury to the myometrium at worst, because the redistribution of the embolic material and recanalization may be less likely."

Uterine Artery Embolization

Ann B. DeMello, RN
AORN Journal
April 2001; 73(4): p.790-813

"This blockage causes fibroid muscle cells to degenerate and form scar tissue, which causes fibroids to shrink."

"The patient also is informed that the detrimental effects of embolization on fertility are not known. If the patient desires children, the radiologist will not perform UAE."

"The nurse prepares a continuous heparin drip (i.e., 500 mL 0.9% normal saline with 1,000 units of heparin) and attaches it to a pressure infusion bag that will be used to maintain sheath patency."

"Allergic reactions may be mild to severe, and most occur within seconds of exposure. A rash, hives, or itching indicate a mild reaction. Severe reactions include difficulty breathing, wheezing, chest discomfort or tightness, swelling of the face or tongue, nausea and vomiting, abdominal pain, and cramping. Anaphylaxis is a sudden and severe allergic reaction that progresses rapidly and can lead to anaphylactic shock and death within minutes if medical intervention is not provided."

"Extreme cases of allergic reactions may require intubation and cardiopulmonary resuscitation to manage the patient's care. In the event of an allergic reaction, the procedure is terminated immediately, and the nurse and radiologist provide supportive care until the patient's condition stabilizes."

"One serious complication is injury to the uterus from decreased blood flow or infection."

Uterine Artery Embolization: A Minimally Invasive Technique for the Treatment of Uterine Fibroids

Gordon C.H. Wong, BA, Susie J. Muir, MD, Annie P.W. Lai, MD, and Scott C. Goodwin, MD
Journal of Women's Health & Gender-Based Medicine
May 2000; 9(4): p.357-62

"As with any invasive procedure, UAE carries risks, including death, which has been reported twice in the world literature in over 4000 cases. There is a risk of allergic reaction to periprocedural medications. The angiographic complications include groin infection, groin bleeding and hematoma, contrast-induced renal failure, and vascular damage."

"One patient had significant vascular damage and ultimately required a femoral-femoral bypass to repair an iliac occlusion secondary to dissection. Target organ embolization complications include uterine infection, uterine perforation, sexual dysfunction, and fibroid sloughing."

"Fibroid sloughing with passage out through the vagina has occurred in approximately 5% of patients, which results in a very good outcome for the patient unless the fibroid gets stuck as it tries to pass through the cervix. If the tissue is left in place, it can become infected. Sloughing tissue, if it does not pass immediately, should be removed by a surgical procedure."

"One case of sciatic nerve injury and buttock injury was temporary and resolved over a 3-month period."

"Endometrial hyperplasia with atypia or neoplasia, uterine adenomyosis, pelvic infection or malignancy, pregnancy, coagulopathies, severe systemic disease, long-term steroid use, acute vasculitis, prior irradiation of the pelvis, severe contrast allergies, and renal failure are contraindications to the procedure."

"Vaginal expulsion of submucosal fibroids occurred in 4 patients after the procedure. One patient reported permanent amenorrhea following UAE."

"Six patients eventually elected to have a hysterectomy. One patient had endometritis and underwent hysterectomy 5 weeks after UAE. A second patient underwent hysterectomy at 5 months and 2 weeks after UAE because of ongoing ureteral compression, and histopathological studies demonstrated a large degenerative fibroid, vascular occlusion, and a dermoid cyst. A third patient was lost to detailed follow-up. The fourth patient had hysterectomy at 14 months after UAE because of failure of therapy, and histopathological tests of the uterus showed adenomyosis and cervical squamous metaplasia. The fifth patient underwent hysterectomy at 4 months and 2 weeks after the procedure and had adenomyosis and chronic hematometra. The sixth patient developed renal cell carcinoma and underwent nephrectomy and hysterectomy 7 months after UAE."

"Walker et al performed 91 bilateral UAE in 88 patients, and >80% of the patients reported that the procedure was completely successful. There were 2 serious complications involving Escherichia coli infections, a tubo-ovarian abscess (TOA) and a necrotic purulent fibroid, which led eventually to hysterectomy. Particulate matter was found in the ovarian arteries of the patient with TOA."

"A third complication occurred in a patient who became anemic and required a blood transfusion at 4 weeks after UAE."

Uterine Restoration after Repeated Expulsion of Myomas after Uterine Artery Embolization

Afaf Felemban, MD, Lawrence Stein, MD, and Togas Tulandi, MD
Journal of the American Association of Gynecologic Laparoscopists
August 2001; 8(3): p.442-444

"Twenty-one days after the procedure the woman spontaneously expelled solid tissue of 2.6 2.1 1.1 cm per vagina. Six and 14 days later she passed tissue of 5.0 3.0 1.5 cm and 9.0 5.0 3.0 cm, respectively. The last specimen consisted of three myomas attached together. All specimens were soft like gelatin. Histopathologic examination of the three specimens revealed infarcted myoma with inflammation."

"Fifteen women underwent dilatation and curettage and vaginal myomectomy to complete the expulsion process."

Late Leiomyoma Expulsion after uterine Artery Embolization

Henri Marret, MD et al
Journal of Vascular & Interventional Radiology
December 2004; 15:1483-1485

"Early complications of UAE include technical complications (eg, hematoma at the puncture point, vessel dissection) and method-related complications (eg, contrast material allergy, necrotic tissue infection, early menopause caused by ovary embolization). However, little is known about recurrences and late complications because follow-up rarely exceeds 24 months. Most recurrences would seem to occur after 2 years as a result of the progression of an existing leiomyoma or the occurrence of new leiomyomas. A known side-effect of UAE, which may become a complication, is vaginal expulsion of the leiomyoma."

"The patient remained free of symptoms until February 2003 (44 months after UAE), when she reported a purulent vaginal discharge."

"Hysteroscopic exploration in June 2003 confirmed the presence of a posterior leiomyoma, which was partly necrotic and protruded into the uterine cavity. Biopsy confirmed hyalinizing and ischemic necrosis with an inflammatory reaction."

"In conclusion, UAE necessitates long-term follow-up and women should be warned of late complications."

Transcervical Expulsion of a Fibroid as a Result of Uterine Artery Embolization for Leiomyomata

Suhny Abbara, MD, James B. Spies, MD, Anthony R. Scialli, MD, Reena C. Jha, MD, Janice M. Lage, MD, and Boris Nikolic, MD
Journal of Vascular & Interventional Radiology
April1999; 10(4): p.409-411

"Approximately 2%-8% of patients sustain a severe ischemic injury of the uterus, resulting in the need for hysterectomy or myomectomy. Goodwin et al have reported a case of pyometrium as a result of UAE also requiring a hysterectomy."

Pregnancy after uterine artery embolization for leiomyomata: A series of 56 completed pregnancies

Woodruff J. Walker, FRCE, Simon J. McDowell, MBCHB
American Journal of Obstetrics & Gynecology
2006 195, 1266-71

"Thirty-three (58.9% of the 56 pregnancies had successful outcomes. Six (18.2% of these were premature. Seventeen (30.4%) pregnancies miscarried."

"There were 6 cases of postpartum hemorrhage (18.2%)."

Permanent amenorrhea associated with endometrial atrophy after uterine artery embolization for symptomatic uterine fibroids

Giovanna Tropeano, MD et al
Fertility and Sterility
January 2003 Vol. 79, No. 1

"The patient remained amenorrheic from the procedure."

"postprocedure hysteroscopy showed an atrophic endometrium, and endometrial biopsy confirmed endometrial atrophy."

"The mechanism for endometrial atrophy in our patient remains uncertain, but it seems likely that it was related to an impact of the procedure on overall endometrial blood supply."

Pregnancy after uterine artery embolization to control haemorrhage from gestational trophoblastic tumour

J. McIvor, DMRD, FRCR and E. W. Cameron, MRCP, FRCR
British Journal of Radiology
July 1996: 69(823): p.624-629

"The potential risks and benefits of the procedure were discussed when consent was obtained. The possibility of buttock pain and claudication was emphasized."

"In some cases, this practice resulted in reflux of PVA particles from the catheterized artery into other arteries."

"Severe haemorrhage recurred in one of these patients (Case 1) 30 months after embolization and 15 months after delivery."

"Severe pain in the right buttock and thigh developed 3 days after one procedure (Case 3, second embolization). She was treated with narcotic analgesics for 24h and required milder analgesics for a further 2 weeks, but claudication in the right buttock took 6 months to resolve completely. Another patient (Case 1) developed severe pain in the right buttock and thigh after embolization which was treated in hospital with narcotic analgesics for 2 days. The pain resolved completely within a week."

"Serious complications resulting from therapeutic embolization of the internal iliac arteries include perineal skin sloughing, uterovaginal and rectovesicovaginal fistulae."

"There have been two reports of bladder necrosis, which probably refer to the same patient, who had extensive pelvic vein thrombosis at the time of embolization. Occasional reports of neurological defects affecting the lower limbs have probably been caused by embolization of the companion artery of the sciatic nerve (arteria comitans nervi ischiadici) and seem to be more common if liquid embolization materials or very small particles are used."

Pain after Uterine Artery Embolization for Leiomyomata: Can Its Severity be Predicted and Does Severity Predict Outcome?

Antoinette R. Roth, BS, James B. Spies, MD, Sheila M. Walsh, RN, MA, Bradford J. Wood, MD2, Jackeline Gomez-Jorge, MD, and Elliot B. Levy, MD
Journal of Vascular and Interventional Radiology
September 2000; 11(8): p.1047-1052

"We do not know why there is such variability in the degree of shrinkage of fibroids after embolization, despite evidence of complete infarction on MRI."

Intraarterial Lidocaine for Pain Control after Uterine Artery Embolization for Leiomyomata

J. Andrew Keyoung, BA, Elliot B. Levy, MD, Antoinette R. Roth, BS, Jakeline Gomez-Jorge, MD, Thomas C. Chang, MD, and James B. Spies, MD
Journal of Vascular & Interventional Radiology
September 2001;12(9): p.1065-1069

"UAE for leiomyomata can result in significant pain, and it is not certain to what extent different embolic particle types and sizes or variation in embolization endpoints may affect the severity of pain."

"Toxic symptoms of generalized twitching, convulsions, severe breathing difficulties, loss of consciousness, or total disorientation in normal volunteers requires an intravenous dose of lidocaine of 880-1040 mg with plasma levels at 4.8-5.8 mg/L. The subconvulsive dose of lidocaine in a normal subject was 750 mg administered intravenously with the average plasma concentration at 4.9 mg/L. Most of these volunteers reported symptoms such as twitching, moderate anxiety, difficulty opening the eyes, and euphoria."

Outpatient Uterine Artery Embolization for Symptomatic Uterine Fibroids: Experience in 49 Patients

Gary P. Siskin, MD, Brian F. Stainken, MD, Kyran Dowling, MD, Patricia Meo, RN, Jiyong Ahn, MD, and Eric G. Dolen, MD
Journal of Vascular & Interventional Radiology
March 2000; 11(3): p.305-311

"A follow-up phone call was performed within 24 hours of discharge. At that time, reported symptoms included pelvic pain/cramping in 41 of 49 (83.7%), fatigue in 37 of 49 (75.5%), nausea/vomiting in 23 of 49 (46.9%) and a nonpurulent vaginal discharge in nine of 49 (18.4%)."

"Two complications were identified during follow-up. One patient required a hysterectomy at 3 months because of prolonged and intractable pelvic pain."

"Patients are discharged from the radiology observation area with several medications. Meperidine and ketorolac are alternated at 3-hour intervals for the first 24 hours of the recovery period. The strength of the opioid analgesic is then decreased as patients are instructed to substitute hydrocodone for meperidine during the remaining days of the recovery period. Hydrocodone, a semisynthetic opioid structurally related to codeine but at least 6-8 as potent, is delivered in combination with 500 mg acetaminophen. Hydrocodone, like other opioids, exerts its primary effects on the central nervous system and organs containing smooth musculature."

Embolic Occlusion of the Blood Supply to Uterine Myomas: Report of 2 Cases

Raphael Kuhn and Peter Mitchell
Australia and New Zealand Journal of Obstetrics and Gynaecology
February 1999; 39(1): p.120-122

"It is impossible to predict the future of new techniques but not all change is progress."

"An extra comment is that ischaemic necrosis of a fibromyoma can cause adhesions."

"Possible complications of the procedure include pain, local groin haematoma, infarction of target tissue with sloughing of the necrotic myoma, and pyometra."

Uterine Artery Embolization in the Primary Treatment of Uterine Leiomyomas: Technical Features and Prospective Follow-up with Clinical and Sonographic Examinations in 58 Patients

Laurent Brunereau, Denis Herbreteau, Sophie Gallas, Jean-Philippe Cottier, Jean-Luc Lebrun, Francois Tranquart, Florence Fauchier, Gilles Body, and Philippe Rouleau
AJR. American Journal of Roentgenology
November 2000; 175(5): p.1267-1272

"The last 36 embolizations were performed using general anesthesia, including IV injection of propofol (Diprivan; Zeneca-Pharma, Cergy, France), atracurium besylate (Tracrium; Glaxo-Wellcome, Marly-le-Roi, France), and sufentanil (Sufenta; Jansen-Cilag, Issy-les-Moulineaux, France) and inhalation of isoflurane (Forene; Abbott, Rungis, France)."

"Complications of catheterization.-A subintimal dissection of the right external iliac artery occurred during catheterization of the right hypogastric artery in one patient (2%)."

"A small leak of contrast medium occurred in one patient (2%) during catheterization of the right uterine artery. This complication, which was caused by vascular perforation, was immediately and successfully treated by embolization of the uterine artery with an absorbable gelatin sponge."

"One patient (2%) was readmitted to the hospital 3 weeks after treatment for fever and flank pain related to acute pyelonephritis."

"At 6 months.-Of 46 patients, abnormal bleeding had increased in two patients (4%) after a period of stability. Hysterectomy was necessary for one patient and a second embolization procedure for the other."

Uterine Artery Embolization for the Treatment of Uterine Leiomyomata Midterm Results

Scott C. Goodwin, MD, Bruce McLucas, MD, Margaret Lee, MD, Gary Chen, BS, Rita Perrella, MD, Suresh Vedantham, MD, Susie Muir, MD, Annie Lai, MD, James W. Sayre, PhD, and Mabel DeLeon, BS
Journal of Vascular & Interventional Radiology
October 1999; 10(9): p.1159-1165

"No immediate complications were encountered. Subsequent complications included permanent amenorrhea with a documented follicle stimulating hormone increase to menopausal levels in one patient, a moderate groin hematoma in one patient, and a delayed infectious complication resulting in hysterectomy in one patient."

"Our results are not quite as favorable as those reported previously."

"Worthington-Kirsch et al reported an 88% clinical success rate for bleeding symptoms and a 94% clinical success rate for improvement in bulk symptoms. If patients who initially had both bleeding and pain and who eventually failed therapy for either symptom were combined into one group, the overall failure rate would have been higher. In addition, the follow-up period in their report was shorter and higher failure rates can be expected in the long-term."

"Six patients had hysterectomies after the embolization procedure. One patient had an infectious complication 5 weeks after the embolization. Another had renal cell carcinoma, and a third patient had ureteral obstruction."

"Of 88 patients, two had Escherichia coli infections, leading to hysterectomy. One patient had a tubo-ovarian abscess, and the other patient had an infection in the fibroid itself, which eventually resulted in perforation of the fundal myometrium."

"One concern about the embolization procedure is that PVA is permanently implanted."

"The disadvantages are postprocedural pain, the utilization of radiation, the utilization of a permanently implanted material, possible negative impact on fertility, and the risk of uterine or ovarian malignancy in patients who would otherwise have undergone a hysterectomy."

Initial Experience with Use of Tris-acryl Gelatin Microspheres for Uterine Artery Embolization for Leiomyomata

James B. Spies, MD, James F. Benenati, MD, Robert L. Worthington-Kirsch, MD, and Jean-Pierre Pelage, MD
Journal of Vascular & Interventional Radiology
September 2001; 12(9): p.1059-1063

"Ten complications occurred in nine patients, all of which were minor. There was only one technical complication of a procedure, a minor vessel perforation not requiring therapy and having no sequelae. Another patient developed a groin hematoma 7 days after therapy that lasted 22 days."

"One patient had an anxiety attack and vasovagal reaction on the day of the procedure. The complication requiring the longest hospital care was severe constipation causing pelvic pain."

"However, there is data suggesting that PVA may have some undesirable characteristics as well. There is moderate variability in the size distribution of particles when measured dry. The particles swell after they mix with saline solution or contrast material. When wet, they tend to aggregate and may clump within vessels after injection. As a result, PVA's behavior during embolization for leiomyomata can be unpredictable, with demonstrated clumping in the main uterine artery."

Ovarian Vein Embolization for the Treatment of Pelvic Congestion Syndrome: Long-Term Technical and Clinical Results

Geert Maleux, MD, Luc Stockx, MD, Guy Wilms, MD, PhD, and Guy Marchal, MD, PhD
Journal of Vascular & Interventional Radiology
July-August 2000; 11(7): p.859-864

"In two cases, a small fragment of glue migrated to the pulmonary circulation, even though the patient was in upright position and underwent a Valsalva maneuver."

"Two (4%) similar procedure-related complications were noted: migration of glue fragments causing a small lung embolus. Clinically, a transient period of thoracic pain and hemorrhagic sputa were noted."

Therapeutic Failure of Uterine Fibroid Embolization Caused by Underlying Leiomyosarcoma

Andrew A. Common, MD, Eva J.M. Mocarski, MD, Arnost Kolin, MD, Gaylene Pron, PhD, and Jennifer Soucie, MSc
Journal of Vascular & Interventional Radiology
December 2001; 12(12): p.1449-1452

"Embolization was performed from a right femoral approach with a total of five vials of Contour Emboli (polyvinyl alcohol particles, 355-500 µm; Target Therapeutics, Fremont, Ca), as well as Gelfoam pledgets (absorbable gelatin sponge; Pharmacia & Upjohn, Kalamazoo, MI) and a stainless-steel coil (5mm X 3 cm embolization coil; Cook, Bloomington, IN) on each side."

"Because of continued growth of a portion of the fibroid uterus and persistent pain, the patient was advised to undergo hysterectomy."

"The patient required multiple units of packed red blood cells, fresh frozen plasma, and platelets intraoperatively."

"She required a repeat exploration 8 hours postoperatively for continued bleeding."

"With the extremely rapid popularization of UAE as a first-line treatment for symptomatic fibroids, it is essential that interventionalists performing these embolizations be cognizant of the possibility of underlying sarcoma and that follow-up be diligent."

Uterine Artery Embolization in an Undiagnosed Uterine Sarcoma

Ahmed Al-Badr, MBBS, and Wylam Faught, MD, FRCSC
Obstetrics and Gynecology
May 2001; 98(5 Part 2): p.836-837

"Uterine sarcoma cannot be diagnosed except by pathologic examination of a resected specimen. Women considering uterine artery embolization for treatment of apparent leiomyomata should be counseled on the risk of decreased survival by delaying diagnosis and treatment of uterine sarcoma."

Fibroid Embolization

W.J. Walker, J.P. Pelage, and C. Sutton
Clinical Radiology
May 2002; 57(5): p.325-331

"Unfortunately it is not possible to distinguish leiomyosarcoma of the uterus from fibroids as there are no particularly suspicious features on ultrasound or MRI and rapid growth of fibroids has not been shown to be an indication of malignancy. So far three patients with uterine sarcomas have been embolized, one in Toronto, one in Oxford and the other in Paris (pre-operative fibroid embolization)."

"Radiation doses during uterine artery embolization are higher than with common radiological procedures but within acceptable limits."

"It is very possible that a small rate of infective complications leading to hysterectomy is inevitable with this procedure; however, it is important that precautions are taken to recognize any developing infection at an early stage and institute appropriate therapy."

"In some cases fibroids may be passed vaginally and it is particularly important that if impaction and infection occur the need for hysteroscopic resection is recognized where appropriate."

"A further documented complication of fibroid embolization is ovarian failure."

"The rate of ovarian failure after embolization in women older than 45 years has been estimated at 43% in a recently published study."

Squamous Metaplasia of Endometrium after Uterine Artery Embolization for Symptomatic Leiomyomata

Meera Hameed, MD, Debra S. Heller, MD, and Guy Murphy, MD
Journal of the American Association of Gynecologic Laparoscopists
February 2002; 9(1): p.70-72

"A 53-year-old woman underwent hysterectomy 3 months after UAE for symptomatic leiomyomata and received progestational therapy during the 3-month interval."

"In addition, numerous blood vessels in the uterine and cervical stroma were filled with foreign material consistent with embolization associated with a foreign body giant cell reaction. Endometrium both over the pedunculated leiomyoma and lining adjacent to the uninvolved uterine wall was replaced by mature metaplastic squamous epithelium, as seen in icthyosis uteri. No glandular endometrium was present."

"We saw similar metaplastic squamous epithelium in another specimen, and hysterectomy for failure of uterine shrinkage after embolization showed a leiomyosarcoma."

Symptomatic Fibroleiomyomata: MR Imaging of the Uterus before and after Uterine Arterial Embolization

Reena C. Jha, Susan M. Ascher, Izumi Imaoka, and James B. Spies
October 2000; 217(1): p.228-235

"Submucosal location was a strong predictor of success, with a significantly greater reduction in volume after UAE as compared with the reduction associated with an intramural or subserosal fibroleiomyoma (P<.001)."

"A negative predictor of success in this model was increasing age (= .03). For every decade increase in patient age, the volume reduction decreased by 13%."

"Five patients reported a lack of improvement in either bleeding or pain symptoms. Of these, four had presented with both symptoms. One patient reported worsened bleeding and no change in pain."

Embolotherapy for Myoma-Induced Menorrhagia

Francis L. Hutchins, Jr., MD and Robert Worthington-Kirsch, MD
Obstetrics and Gynecology Clinics of North America
June 2000; 27(2): p.397-405

"Minor complications consist of groin hematoma (not requiring surgical evacuation), allergic reaction to contrast medium, and other minor complications. In the authors' experience, groin hematomas have occurred in six patients, none of whom has required treatment. One patient had a brief episode of upper gastrointestinal bleeding because of narcotic-induced retching."

"Approximately 40% of patients develop a syndrome of fever and malaise in the first 10 to 14 days after UAE. This is associated with leukocytosis but not with the systemic toxicity or increasing pain that one sees in patients who develop endometritis."

"Finally, the current method for embolization is highly skill dependent. Should a simpler method evolve that uses more readily available skills, the procedure would be easier and, in all likelihood, safer."

"One issue, however, both insidiously and predictably has become professional division: whether UAE will be practiced exclusively by interventional radiologists or become a skill practiced by gynecologists. Following is an academic exercise to bring better focus to the inevitable issues of professional 'turf' battles and quality of care."

"Current market forces are transforming gynecology from a surgical specialty to a procedure specialty."

"Finally, the current managed care movement discourages the performance of surgery by economic disincentive (reduced reimbursement). Gynecologists are being encouraged to reinvent themselves as something other than surgeons. Each year there are approximately 200,000 hysterectomies for fibroids plus 18,000 myomectomies. Both these procedures are usually performed electively. Many women elect not to undergo treatment with either of these methods out of fear of surgery, hence, the number of potential selective angiographic procedures for this one diagnosis is substantial. One would then reasonably pose the following question: Because gynecologists will not be busy doing elective surgery, why not become specialists in obstetric and gynecologic radiology?"

Uterine Fibroid Embolization: Another Paradigm Shift for Interventional Radiology ?

David M. Hovspian
Editorial, Journal of Vascular & Interventional Radiology
October 1999; 10(9): p.1145-1147

"Tempting as it may be to treat all comers, interventional radiologists must be careful to avoid being perceived as dilettantes by the gynecologists, who may refuse to collaborate to protect their territory."

"A good strategy for getting involved in UFE, would be to seek out colleagues in gynecology who have an interest in treating fibroid disease and discuss the UFE procedure with them, provide them with articles, and offer to give talks."

"However, the UFE procedure must be considered investigational because many aspects regarding the treatment of fibroids by embolization of the uterine arteries with polyvinyl alcohol particles (the standard UFE agent) are still unknown."

"However, distal arterial blockade theoretically diminishes the chances for sufficient flow to the uterus to support a pregnancy."

"Perhaps the most important issue of all is knowing which outcomes measures are the most relevant. A change in the size of the fibroid or uterus is the most obvious objective criterion because, after all, the goal of UFE is to shrink symptomatic fibroids. But what happens to the fibroids does not necessarily correlate with what happens to the patients."

"Aside from abatement of symptoms in the near term, we really have no information about the long-term effect of UFE on the lives of women with fibroids."

Uterine Artery Embolization to Treat Uterine Fibroids

Lindsay Machan, BMSc, MD, FRCPC, and Michael Martin, MD, FRCPC
Canadian Association of Radiologists Journal
June 2001; 52(3): p.183-187

"There are few procedures in interventional radiology where timely and thoughtful pre- and postprocedure care are as important to building a practice. This is because of the intense and often prolonged clinical consequences of fibroid embolization, the attitude of many gynecologists toward interventional radiology and interventions for fibroids and especially because of the patient demographic."

Uterine Artery Embolization for Leiomyomata: Resource Use and Cost Estimation

Sujha Subramanian and James B. Spies
Journal of Vascular & Interventional Radiology
May 2001; 12(5): p.571-574

"Physician cost was not included in the cost estimates."

Uterine Artery Embolization Improves Fibroids

Sherry Boschert
Ob.Gyn. News
September 1, 2000; p. 22

"Three patients (10%) ultimately went on to have hysterectomies: one due to embolization failure, and two due to postembolization syndrome characterized by severe pelvic pain, fever, and elevated white blood counts."

"The fibroids are starting to grow again in some of the patients treated 4 years ago."

" 'Not included in our study were patients sent from other hospitals who were embolized by radiologists, but the gynecologists there would not take care of the complications,' Dr. Brodman said. The fact that the embolization procedure is performed by radiologists more often than by gynecologists can present management and follow-up problems, he added."

Embolization of the Internal Iliac Artery: Still More to Learn

Michael C. Soulen, Ronald M. Fairman and Richard Baum
Journal of Vascular & Interventional Radiology
May 2000;11(5): p.543-545

"Two new procedures have fascinated the interventional radiology community and caused us to consider internal iliac artery embolization in far more detail than in the past. For uterine fibroid embolization, we plumb the depths of the anterior division."

"After 30 years of embolizing hypogastric arteries, how could we know so little? We have to learn (or re-learn) the arterial anatomy of the ovary, the hormonal pathways of the menstrual cycle, and the control of pelvic pain."

"As with uterine fibroid embolization, more questions are raised than are conclusively answered."

"Internal iliac artery embolization in patients with aortoiliac aneurysms provides an unprecedented opportunity to inflict pain and sexual dysfunction on our patients."

Outpatient Treatment of Fibroids: Skepticism Mounts Over Embolization Procedure

Betsy Bates
Ob.Gyn. News
March 1, 2001; p. 14

"Aggressive pain management is key to making uterine artery embolization an outpatient procedure, Dr. Martin L. Schwartz said at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society."

"Three additional patients were readmitted within a week-one with urinary retention, one with nausea and vomiting that lasted 2 days, and one with 4 days of pain, fever, and a generalized rash. Dr. Schwartz said the third patient represented a common conundrum in the management of UAE patients since 'it is almost impossible to distinguish sepsis from a pretty bad case of postembolization syndrome.'"

"However, 4 of 30 patients developed amenorrhea with elevated follicle-stimulating hormone levels within 6 months of the procedure."

"Physicians in the audience expressed concern about rehospitalization rates, recurrences, and the possibility that uterine cancer might be overlooked with this procedure."

Comparison of particle penetration with non-spherical polyvinyl alcohol versus trisacryl gelatin microspheres in women undergoing premyomectomy uterine artery embolization

G.C. Chua, et al
Clinical Radiology
2005 60, 116-122

"Histologically, non-refractile foreign material within blood vessels either within the fibroid or in the perifibroid tissues could be detected in 10 cases (59%)."

"The normal myometrium and endometrium are inevitably subjected to a certain degree of ischaemic insult, depending on the type and size of the embolic particles used."

"Matson et al. and Wolanske et al. have also reported reflux and reversal of flow in the ovarian arteries during UAE, confirming the risk of non-targeted ovarian embolization in UAE. Ideally, embolization should cause fibroid necrosis without effect on the normal myometrium and ovaries, but in practice this cannot be achieved since it is not possible to perform selective embolization of every fibroid."

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