Eighty female patients were referred for UAE for symptomatic fibroids. UAE for fibroids was decided after discussion of treatment options in a fibroid multidisciplinary team meeting. Exclusion criteria were a positive pregnancy test, uterine or adnexal infection, suspected gynecologic malignancy, patients with renal impairment, and hypersensitivity to contrast media.
Patients were examined in both gynecology and IR clinics with a full detailed history, including the menstrual history, duration and amount of bleeding, and full laboratory investigations. Informed consent was obtained from all patients and patient information leaflets were given to them during the clinic visit.
Pre and post procedure pelvic MRI
Pelvic MRI was performed using a GE Signa Excite (GE Medical Systems, USA) 1.5 Tesla MRI scanner. Pre- and post-interventional MRIs were performed according to standard identical protocols.
The MRI sequences used in the study were sagittal T2 fast spin echo (FSE), axial T2 FSE, axial T1 FSE, and post contrast axial T1 fat-saturated imaging. Assessment criteria were the site and number of fibroids, the calculation of pre and post embolization uterine and dominant fibroid volumes, and the estimation of the percentage of dominant fibroid infarction on the post embolization MRI scans.
Clinical symptomatic improvement was assessed with by calculation of symptom severity score and a health-related quality of life questionnaire (HR-QOL) before and 6 months after UAE.
Technique of uterine artery embolization
The procedure was done under fluoroscopic guidance using a Siemens Artis-Q Angiography machine with a ceiling mounted system. The machine is capable of serial radiography and digital subtraction. Non-ionic contrast media (Omnipaque 300) was used in all patients (Figs. 1 and 2).
The embolization procedure was performed by certified interventional radiologists in our institution (R.M. with 30 years experience in interventional radiology, A.K. 15 years experience, and A.E. 10 years experience). Each operation was performed by two operators to decrease operative time and radiation exposure.
The patient is positioned in the supine position, and both groins are prepped with antiseptic solution. Bilateral common femoral arteries access is achieved using the Seldinger technique after infiltration of local anesthesthetic agent (10 ml lidocaine) around the femoral artery.
Then 4F Rim catheters (Rosch Inferior Mesenteric Torcon Beacon Tip catheter, Cook Medical, USA) are advanced over the aortic bifurcation over 0.035 hydrophilic guidewires (Radiofocus® Terumo) to reach the contra-lateral internal iliac artery. Catheterization of the uterine artery is then performed, and the catheter tip is placed in the transverse portion of the uterine artery. Arteriography is performed to confirm a satisfactory position.
In some patients, it was difficult to access the correct position with the Rim catheter. In these cases, a 2.7F microcatheter (Progreat 2.7F microcatheter, Terumo Medical Corporation, Europe) was used to go further to access the appropriate position. Pulsed fluoroscopy (2 pulses per second) is used to opacify the entire fibroid uterus and to decrease patient radiation dose.
Embolization is started using 355 to500 μm non-spherical polyvinyl alcohol particles (Contour PVA, Boston Scientific, USA), which are then upsized to 500 to 710 μm and 710–1000 μm.
The end point for embolization is stasis of contrast within the transverse segments of the uterine arteries for approximately 10 cardiac pulsations.
The operators usually wait for a period of 5 min to allow any remaining embolic material clumping to redistribute, and they then reconfirm adequate stasis by performing repeat angiography.
Following UAE, patient-controlled analgesia with the administration of intravenous analgesia and anti-inflammatory drugs may be used to assist in pain control in the early post procedure period.
After UAE, patients are observed overnight in the hospital to ensure adequate access to pain and anti-nausea medications and to enable observation of the femoral access site.
Merits and limitation of technique
The merits of the uterine fibroid embolization are as follows: avoidance of hysterectomy, minimally invasive technique, shorter hospital stay, and shorter recovery time. However, this technique cannot be used in patients with uterine or adnexal infections, renal impairment, and patients with known history of hypersensitivity to contrast media.
Statistical analysis
The collected data were coded, tabulated, and statistically analyzed using the SPSS program (Statistical Package for Social Sciences) software version 25.
Descriptive statistics were done for parametric quantitative data by mean, minimum, and maximum of the range, while they were done for categorical data by number and percentage.
Analyses were done for parametric quantitative data using paired samples T test.
The level of significance was taken at a P value of < 0.05.