Case 497_03 -- Embolization of uterine fibroids

Fig. 1. Pelvic angiogram shows bilaterally enlarged and tortuous uterine arteries.

Fig. 2. Early arterial phase image from a selective right uterine artery angiogram.

Case Reference No. CC-497-03

A 40 year-old woman, gravida 2 para 2, presented with a 10-month history of worsening menorrhagia and chronic pelvic discomfort. Physical examination revealed an enlarged, lobulated uterus of approximately 15-week gestational size. Ultrasound examination revealed multiple hypoechoic masses in an enlarged uterus, representing multiple fibroids. Hemoglobin was 9.6 g (moderate anemia), despite 6 months of oral iron replacement. Serum beta HCG was negative. The remainder of the history, physical, and laboratory examination were essentially normal.

The patient expressed a strong desire to avoid a surgical procedure, thus uterine artery embolization was elected as the primary management. The procedure was performed under intravenous conscious sedation. Approximately 100 mL of iodinated contrast material were used. The therapeutic portion required four vials of polyvinyl alcohol (PVA) particles and four Gianturco coils.

Fig. 3. Later image demonstrates the marked hypervascularity of the myomatous uterus.

Fig. 4. Postembolization angiography. The left uterine artery was similarly embolized.

After the procedure, the patient developed moderate to severe postembolization cramping. This was controlled with intravenous narcotics via PCA (morphine sulfate, 1 mg IV per bolus, 6-minute lockout, no constant dose). The patient used the PCA boost device three times over the next 12 hours. The remainder of the postprocedure course was uneventful. The patient was much more comfortable at 12 hours and was discharged with Ibuprofen for pain control.

During follow-up, the menorrhagia has stopped. Normal menses have been maintained. At 5 months follow-up, the patient's hemoglobin is 15 g. There has been significant improvement in the patient's chronic pelvic discomfort. Ultrasound at 6 months postprocedure is pending.

Questions

1) We embolize to complete stasis using 500-700 micron-sized PVA particles. I add Gianturco coils in the main portion of the uterine artery to decrease the possibility of delayed non-target from a Venturi effect. Are there other embolization materials that may be more effective?

2) Does anyone have any thoughts on the anesthesia/analgesia protocol currently used? Since the major indication for overnight admission is pain management, a different anesthesia regimen might allow outpatient treatments.

3) It is known that GnRH analogs (eg, Luprolide acetate) cause significant reduction in blood flow to the uterus as a whole and to individual fibroids during their duration of action. Would one expect Luprolide pretreatment to decrease the amount of ischemic pain? Would one expect Luprolide pretreatment to decrease the effectiveness of the embolization?

4) Does anyone have any thoughts about the potential effects of this procedure upon fertility?

5) How widely is this practiced? How many members plan to begin offering this therapy?