{"paper_id":"42db269a-aefb-486b-98cc-fe4d8c9e22aa","body_text":"Evidences in Uterine Artery Embolization:\nAR a d i o l o g i s t’sP r i m e r\nPavankumar Bellala 1 Jineesh Valakkada 1 Anoop Ayyappan 1 Santhosh Kumar 1\n1 Department of Imaging Sciences and Interventional Radiology,\nSreechitra Institute of Medical Sciences and Technology,\nTrivandrum, Kerala, India\nJ Clin Interv Radiol ISVIR 2023;7:87 –96.\nAddress for correspondence Jineesh Valakkada, MD, Department of\nImaging Sciences and Interventional Radiology, Sreechitra Institute of\nMedical Sciences and Technology, Trivandrum 695011, Kerala, India\n(e-mail: jineesh174@gmail.com).\nIntroduction\nDiseases related to the uterus, such as uterine fibroids,\nadenomyosis, and pregnancy-related uterine and placental\ndiseases constitute a major part of morbidity in women.\nMany of these patients eventually undergo invasive surgi-\ncal therapy when medical management fails. Minimally\ninvasive therapies such as uterine artery embolization\n(UAE) are safe and effective for many of these conditions.\nHowever, there are concerns regarding appropriate indica-\ntions, future infertility risk, and radiation injury with UAE.\nThe published literature is heterogenous and often confus-\ning. We attempt to provide an updated and comprehensive\nevidence-based review regarding indications, the role of\nimaging, technical aspects, complications, radiation and\ninfertility concerns of uterine artery embolization in vari-\nous uterine pathologies.\nUAE for Fibroids\nUterine fibroids are the most common benign pelvic tumors\nin women with a prevalence ranging from 4.5 to 68% depend-\ning on study population. 1 Around 25 to 50% of these patients\nare symptomatic with bleeding or pelvic pain. Around 30% of\nthese patients resort to invasive surgical therapies including\nmyomectomy or hysterectomy.\n1 The number of UAE proce-\ndures for fibroids is increasing and various societies have\nsuggested guidelines with subtle differences ( ►Table 1 ).\nWhile the Society of Interventional Radiology (SIR) guide-\nlines of 2014 recommended UAE for all symptomatic fib-\nroids, the Royal College of Gynecology (RCOG) endorses\nprimary myomectomy as the first line option in patients\nwho wish for future pregnancy, with UAE reserved for\nsurgically un fit patients.\n2 The Cardiovascular Interventional\nRadiology Society of Europe (CIRSE) standards of practice\nKeywords\n► uterine artery\nembolization\n► fibroids\n► arteriovenous\nmalformation\n► pseudoaneurysm\n► perinatal period\n► ectopic pregnancy\nAbstract Uterine artery embolization is an established minimally invasive therapy for symptom-\natic fibroids. It has also been used for other diseases of the uterus, including\nadenomyosis, uterine arteriovenous malformation, ectopic pregnancy, abnormal\ninvasive placenta, and postpartum hemorrhage. In this review, we provide an updated\nand comprehensive review of uterine artery embolization based on the evidence\npublished. We review the indications, the role of MRI, technical aspects, and\ncomplications of the procedure. The issues with a future pregnancy, risk of infertility,\nand fetal radiation are discussed as well.\narticle published online\nOctober 23, 2022\nDOI https://doi.org/\n10.1055/s-0042-1758050.\nISSN 2457-0214.\n© 2022. Indian Society of Vascular and Interventional Radiology. All\nrights reserved.\nThis is an open access article published by Thieme under the terms of the\nCreative Commons Attribution-NonDeri vative-NonCommercial-License,\npermitting copying and reproduction so long as the original work is given\nappropriate credit. Contents may not be used for commercial purposes, or\nadapted, remixed, transformed or built upon. (https://creativecommons.org/\nlicenses/by-nc-nd/4.0/)\nThieme Medical and Scienti fic Publishers Pvt. Ltd., A-12, 2nd Floor,\nSector 2, Noida-201301 UP , India\nTHIEME\nReview Article 87\nArticle published online: 2022-10-23\n\nguidelines of 2015 concur with RCOG guidelines and do not\nsupport UAE in subserosal fibroids with a stalk diameter less\nthan 50% of the tumor diameter and when there is a common\narterial supply to both uterus and ovaries. 3 All these guide-\nlines emphasize the bene ficial role of UAE in patients with\nsymptomatic fibroids who have heavy menstrual bleeding\nand pain and who wish to preserve the uterus. UAE is\nrelatively contraindicated in patients with symptoms due\nto pressure on pelvic structures such as the rectum and\nbladder, as the volume reduction may be insuf ficient to\neliminate pressure effects. According to the fifth radiological\ngynecological expert meet consensus, absolute contraindi-\ncations for UAE include viable pregnancy, active pelvic\ninfection, and malignancy of uterus/ovaries. The relative\ncontraindications include GnRH analog treatment in previ-\nous 3 months, isolated submucosal fibroid (type 0 and 1-\nEuropean society for Gynecological endoscopy classi fica-\ntion), isolated pedunculated subserosal fibroids, and fibroids\nsupplied by the ovarian artery.\n4\nSurgery versus UAE for Fibroids\nThe FUME trial, an RCT comparing UAE with myomectomy,\nfound signi ficant and equal improvement in quality of life\n(QoL) in both arms at 2 years with shorter length of hospital\nstay (2.0 vs. 6.0 days, p < 0.0001) as well as fewer complica-\ntions (2% in UAE and 8% in myomectomy) with the UAE.\n5 The\nEMMY trial, which compared 10-year outcomes of UAE and\nmyomectomy, showed that UAE was an acceptable alterna-\ntive to surgical treatment in women who wish to preserve\nthe uterus.\n6 However, reintervention rates due to residual\nlesion within 2 years were high in UAE compared with\nmyomectomy (14% vs. 4% in myomectomy). Sandberg et al\nfound that reintervention after 5 years was 14.4% in UAE,\nwhereas after myomectomy, it was 12.2%.\n7 Meta-analysis of\nsurgical methods versus UAE showed UAE having fewer\nmajor complications (RR, 1.65 [95% CI, 1.32 –2.06];\np < 0.00001) compared with surgery but higher reinterven-\ntion rates after 5 years (RR of 5.01).\n8\nThe recent FEMME trial that evaluated the cost utility of\nmyomectomy versus UAE showed UAE to be associated with\nhigher costs (difference of 645 pounds) in 4 year horizon 9\nThese results point out that the short-term results of UAE are\ngood, while the long-term results of myomectomy are better,\nas UAE may require frequent reinterventions.\nInvestigations\nA trans-abdominal ultrasound is recommended for preoper-\native workup. However, pre-procedure MRI can help in\npredicting the treatment response of UAE. Fibroids are\nusually hypointense on T2-weighted images. However,\nTable 1 Comparison of indications and contraindications for UAE by different societies\nIndications Contraindications\nACR appropriateness\ncriteria 2017\n Symptomatic fibroids in middle-aged and childbear-\ning women with multiple fibroids do not wish to\nbecome pregnant in future but want to conserve the\nuterus\n Single fibroid of less than 3 cm with adenomyosis or\npedunculated sub-serosal fibroid in middle age\nwomen\n Viable pregnancy\n Active pelvic infection\nCIRSIE standards of\npractice guidelines-2015\n Symptomatic fibroids\n As a part of palliation/adjunct to surgery in case of\nuterine/ovarian malignancy\n C a nb ec o n s i d e r e di nw o m a nw h ow a n t st ob e c o m e\npregnant and myomectomy is contraindicated but\nnot as the first choice\n Viable pregnancy\n Active infection of the uterus\n Malignancy of uterus/ovaries\n Relative contraindications\n Who wants to become pregnant.\n Pedunculated subserosal fibroid with\nstalk diameter less than 50% of tumor\ndiameter\n Presence of common arterial supply\nfor both uterus and ovaries.\n Presence of intrauterine contraceptive\ndevice\nSIR 2014  Symptomatic fibroid  Viable pregnancy\n Active infection of the uterus\n Malignancy of uterus/ovaries\nRCOG 2013  Symptomatic fibroids\n Fibroids and adenomyosis coexistence\n Contraindication/ unwillingness/unsuccessful\nsurgery\n Active genital tract infection\n Viable pregnancy\n Asymptomatic fibroid\n Relative contraindications\n Pedunculated submucosal fibroid with\nan a r r o ws t a l k\n Pedunculated subserosal fi\nbroid.\n Large fibroid causing bulk symptoms\n(volume reduction is not suf ficient)\n Women who wish to preserve fertility\nJournal of Clinical Interventional R adiology ISVIR Vol. 7 No. 2/2023 © 2022. Indian Society of Vascular and Interventional Radiology. All rights res erved.\nUterine Artery Embolization Bellala et al.88\n\n\nmoderate degrees of T2 hyperintensity can be seen in hyper-\ncellular fibroids, whereas marked hyperintensity suggests\ndegeneration10. Duvnjak et al had shown that higher ratio\n(>2.6) of T2 hyperintensity of fibroids compared with adja-\ncent myometrium was associated with increased volume\nreduction of more than 50% of the fibroid.\n11 Fibroids with T1\nhyperintensity respond poorly due to hemorrhagic necrosis\nor fat within. 10 The fibroid location can also affect the\nresponse, with submucosal fibroids having higher volume\nreduction compared with intramural or subserosal fibroids\ndue to predominant supply from the uterine radial arteries.12\nKalina et al showed that fibroids with enhancement which is\nmore than the myometrium on gadolinium-enhanced MRI\nshow more signi ficant volume reduction (61.3% vs. 47.6%)\nthan hypo-enhancing fibroids.12 MRI also helps predict\novarian artery supply to fibroids. Normally, the ovarian\narteries are very small and the visualization of ovarian\narteries on pelvic MRA indicates substantial contribution\nfrom them resulting in incomplete embolization if over-\nlooked.\n10 MRI is superior to ultrasound as it allows tissue\ncharacterization of uterine fibroids and helps distinguish\nthem from malignant tumors such as low-grade leiomyosar-\ncoma. Diffusion-weighted MRI and T1 perfusion techniques\nhelp differentiate malignant tumors with a sensitivity of 94%,\nand this distinction is vital as these tumors are treated by\ndefinitive surgery.\n13\nPre-procedure Antibiotics\nThe possible source of infection after UAE is either from the\narterial access site or ascending infection from the vagina by\nstaphylococcus aureus, Staphylococcus epidermis , Streptococ-\ncus,a n d Escherichia coli 14. SIR recommends prophylactic\nintravenous cephazolin (1 –2 g) 1 hour before procedure\nwith the addition of 100 mg of doxycycline, twice daily for\n1 week in cases of associated hydrosalpinx. 14 Though Assaf\net al found no change in the rate of infectious complications\nbetween individuals with and without post-procedure anti-\nbiotics (1.8% vs. 1.3%), RCOG endorses a combination of\ncephalosporin and metronidazole, quinolones or amoxicillin\npost-procedure. However, the choice of antibiotic depends\non local hospital guidelines.\n15\nVascular Access\nThe access artery can be unilateral common femoral artery\n(CFA), bilateral CFA, or radial artery (►Fig. 1). Compared with\nunilateral approach, bilateral femoral access is associated\nwith shorter procedure times (54.9 vs. 62.9 minutes,\np ¼ 0.026), shorter fluoroscopic times (12.8 vs. 16.6 minutes,\np ¼ 0.046) and reduced radiation to ovaries (25% less in\nbilateral access group).\n16 Except for minor groin pain at\nthe puncture site, there was no signi ficant increase in access\nsite complications in the bilateral access group. 17 Radial\naccess is also used, as it has fewer complications rate\ncompared with femoral access. 18 Left radial artery is usually\npreferred due to fewer manipulations needed in the arch of\naorta, thus minimizing the risk of cerebral embolism and\nreducing the distance from the access site to the uterine\nartery (5 –10 cm less compared with right side). Longer\nlength (125 cm) catheters are preferred in the radial route.\n19\nAn RCT by Evgeny et al comparing trans-radial vs. trans-\nfemoral access for UAE in 153 patients showed that trans-\nradial access was associated with shorter procedure times\n(32.2 /C6 7.9 vs. 39.2 /C6 9.7 minutes, p < 0.001), uterine artery\ncatheterization time (12.3 /C6 5.7 vs. 19.0 /C6 6.0 minutes,\np < 0.001) and radiation dose (0.28 /C6 0.14 mSv vs. 0.5 /C6 0.2,\np < 0.001) compared with transfemoral access.\n19\nEmbolization Materials for Fibroid Embolization\nParticulate materials are preferred for fibroid embolization.\nVarious embolic materials include nonspherical polyvinyl\nalcohol particles (PVA, Cook Medical, Bloomington, IL and\nContour, Boston Scienti fic, Natick, MA), spherical tris-acrylic\ngelatin microspheres (Embospheres, Merit Medical inc.,\nUSA), and Polyzene F-coated hydrogel microspheres (Embo-\nzene, Varian Medical Systems, Pala Alto, CA, USA). Nonspher-\nical PVA particles have an irregular shape and tend to occlude\nin the peri- fibroid vascular plexus leading to moderate\nperivascular inflammatory change and partial recanalization\n(90% at 6 months).\n20,21 Spherical PVA particles are associated\nwith less tumor infarction compared with nonspherical PVA\nparticles.22 Embospheres are compressible, allow easy pas-\nsage through the microcatheter and cause less aggregate\nformation within the catheter or in this vasculature. This\nproperty enables deeper penetration into the distal vascula-\nture, resulting in occlusion of more distal arteries.\n20 Inflam-\nmation with embosphere is less intense compared with\nnonspherical PVA. 23 A meta-analysis by Das et al showed\nno superiority of the available embolic materials for UAE. 20\nFig. 1 A 31-year-old female patient presented with menorrhagia\nand dysmenorrhea due to uterinefibroid. She underwent bilateral UAE with\n500 to 700 micron-sized PVA particles. Preprocedure sagittal T2 imaging\n(image A) shows hypointensity of mass (white arrow) as compared with\nadjacent myometrium (white arrow head). The presence of T2 hypointense\nis associated with poor response. Images B and C show dilated bilateral\nuterine artery (arrowheads in image B and C) with multiple corkscrew\ntype of branches (arrow in image C) supplying fibroid (star in image C).\nImage D shows no filling of vessels after uterine artery embolization.\nJournal of Clinical Interventional R adiology ISVIR Vol. 7 No. 2/2023 © 2022. Indian Society of Vascular and Interventional Radiology. All rights res erved.\nUterine Artery Embolization Bellala et al. 89\n\n\nThe choice of the size of particles is also important due to the\npresence of utero-ovarian anastomosis that measures\n/C24 350 µm in size. Small PVA particles with a size less than\n350 µm though have better penetration into distal vessels,\ncausing more intense ischemic necrosis of fibroids and\ntherapeutic response but have a higher chance of non-target\nembolization through utero-ovarian anastomosis (\n►Fig. 2 ).\nPVA particles of 500 to 750 microns result in more proximal\nocclusion, but with less non-targeted embolization. 24 In a\nstudy comparing 350 to 500 micron and 500 to 700 micron,\nthere was no difference in outcomes at 6 months though\nsmaller PVA was associated with higher post-procedure\npain.\n24 A detailed description of various embolization mate-\nrials used in UAE is given in ►Table 2 .\nFig. 2 Anatomy of uterine artery. ( A), (B) diagrammatic and angiographic image of internal iliac artery which divides into anterior and posterior branch.\nFrom the posterior division (yellow arrow) superior gluteal artery. Iliolumbar and lateral sacral arises caliber. From the anterior division, infe rior gluteal\nartery (green arrow) is a large branch coursing outside the pelvis. Other branches from anterior division include obturator artery which passes\nthrough obturator foramen and have a distal fork like configuration (blue arrowhead), Internal pudendal artery (yellow arrowhead) which passes through\ngreater sciatic foramen reentering the pelvis through lesser sciatic foramen providing vascular supply to pelvic organs. Uterine artery (white arr ow)\narising from inferior gluteal artery has a‘U’ shaped course with descending (orange arrow), transverse (white arrow) and ascending course (blue arrowhead)\nas shown in image ( C). Cervicovaginal arteries (black arrow) arise from the transverse part of uterine artery and need to be spared while embolization to\nprevent vaginal ischemia.\nTable 2 Embolization agents in UAE, advantages and disadvantages and speci ficu s e\nAgent Property Advantage Disadvantages Specific use\nPVA particle\nNon-spherical\n(500–700)\n Irregular particles\n Causes arteriolar\nocclusion\n Permanent agent\n Less ovarian failure due\nto larger size\n Proximal occlusion\n Catheter clumping\nFibroids\nPVA particle.\nNon-spherical\n(350–500)\n Irregular particles\n Causes arteriolar\nocclusion\n Better distal emboliza-\ntion in\n More chances of\npassing through\nutero-ovarian anasto-\nmosis\n More pain\nLess preferred com-\npared with 500 –700\nparticles\nEmbospheres  Spherical particles\n Uniform size\n Less catheter block\n Better and uniform pen-\netration\n Lesser pain\n Higher cost Fibroids\nNBCA  Liquid permanent\nembolic\n Can permeate distally in\ncase dif ficult emergency\ncannulation\n Uterine ischemia Refractory PPH, distal\npseudoaneurysm\nGelfoam  Temporary agent  Concentration can be\nadjusted for proximal or\ndistal embolization\n No risk for permanent\nischemia\n Temporary agent Post-partum\nhemorrhage\nVascular Coils  Permanent agents,\nproximal artery\nocclusion\nInability to prevent flow\nthrough collaterals\nJournal of Clinical Interventional R adiology ISVIR Vol. 7 No. 2/2023 © 2022. Indian Society of Vascular and Interventional Radiology. All rights res erved.\nUterine Artery Embolization Bellala et al.90\n\n\nPain Management\nSignificant pain after fibroid embolization is due to ische-\nmia of the uterus releasing lactate and adenosine that\nstimulate chemosensitive receptors. The pain is usually\nsevere and cramping in nature and is most severe in the\ninitial 2 to 3 hours, and stabilizes by 8 to 12 hours. It can also\nbe seen as part of post embolization syndrome, which may\npresent with fever and fatigue, commonly on the third post-\nprocedure day. Various pain management strategies are\ndescribed, including NSAIDs and opioids, patient-controlled\nanalgesia, nerve block, and intrauterine artery injection of\nanalgesics. A systematic review showed that the combina-\ntion of NSAIDs, acetaminophen and intrauterine injection of\nlignocaine had better control of pain compared with NSAIDS\nonly.\n25 Intraarterial use of lignocaine (20 –200 mg) into\nuterine arteries after embolization helps in the reduction\nof post-procedure pain for 7 hours (half-life of lignocaine\n90–120 minutes) with reduced requirement of narcotic\ndose.\n26 Superior hypogastric nerve block (SNBH) effectively\nreduces procedural pain and decreases the need for opioid\nanalgesic. It is done by instilling 3 mL of 0.5% ropivacaine\n(75–100 mg) or 15 –20 mL of 0.5% bupivacaine at the level\nbelow the abdominal aortic bifurcation (L5 level) and the\nanesthetic effect usually lasts for 8 to 12 hours.\n27,28 The\ninjection can be done fluoroscopically after locating the\naortic bifurcation by a catheter or angiogram. 28 Post-proce-\ndure, patient-controlled analgesia (PCA) for 24 hours fol-\nlowed by naproxen 500 mg BD or ibuprofen 800 mg three\ntimes a day next seven days is effective in reducing post\nembolization syndrome.\n28 Opioids including fentanyl, mor-\nphine, hydromorphine, hydrocodone, and oxycodone can\nalso be considered in cases of severe pain.\nFertility and Ovarian Reserve Function Post-uterine\nFibroid Embolization\nA significant concern related to uterine fibroid embolization\nis future fertility. The cause of infertility includes (1) reduced\nblood supply to uterine endometrium, (2) residual distortion\nof uterine cavity by any embolized involuting fibroid having a\nsubmucosal extension, thereby resulting in abnormal pla-\ncentation and miscarriage, and (3) a decrease in ovarian\nfunction due to nontarget ovarian embolization through\nutero-ovarian anastomosis.\n29 The risk of ovarian failure after\nthe UAE is high in women more than 45 years of age. A\nsystematic review by Karsen et al showed that the pregnancy\nrate was lesser in patients undergoing UAE (50% vs. 78%) with\na higher miscarriage rate compared with myomectomy (60%\nvs. 20%).\n30 A RCT by Mara et al showed that myomectomy had\na superior reproductive outcome than UAE within 2 years of\ntreatment with higher pregnancy rate (78% vs. 50% p < 0.05)\nand lower abortion rate (23% vs. 64%, p < 0.05).\n31 A system-\natic review by Sandberg et al suggested that if a patient is a\nsurgical candidate and concerned about future pregnancy,\nmyomectomy should be the first choice.\n7,32 UAE may be\nconsidered in fibroids, that are surgically challenging to treat\nin sub-fertility patients. 32 The diminution of ovarian reserve\nleading to infertility after UAE is controversial. Razavi et al\nclassified the utero-ovarian anastomosis (UOA) into three\ntypes (►Table 3 ) and described a high change ovarian failure\nafter UAE in type Ib, and type III UOA and in patients with age\nmore than 45 years. 33 Sheikh et al described the use of coils\nand 700 to 900 µm PVA particles to occlude the UAO in type\n1b and type III to reduce ovarian failure. 34 However, a\nsystematic review by Tare et al that compared case –control\nand three cohort studies, showed that ovarian reserve as\nmeasured by the level of anti-mullerian hormone (AMH) and\nfollicular stimulating hormone (FSH) was not affected by\nUAE. However, majority of the population included in their\nstudy were less than 40 years. In the EMMY study, which\nanalyzed a homogenous population, the level of FSH used as a\nmeasure of the ovarian reserve was seen to increase after\nembolization more in women over 45 years of age.\n35 In\nsummary, the ovaries of younger age exhibit greater recovery\nafter ischemic damage suggesting that the infertility is more\nlikely to be due to uterine and endometrial causes than\novarian in younger age, compared with those of age > 45\nyears.\nUAE in Adenomyosis\nAdenomyosis ( ►Fig. 3 ) is commonly seen in the fourth to\nfifth decade presenting as dysmenorrhea, menorrhagia, or\nabdominal pain. 36 The management is by medical therapy\nwith hysterectomy reserved for refractory cases. UAE is\nemerging as a potential alternative. Liang et al showed a\nsuccess rate of 88% in controlling bleeding with a pain score\nreduction from 7.45 to 1.32 ( p < 0.001).\n37 The short term (6-\nmonth) success rate described by Kim et al amounts to 82 to\n83%, while Popovic et al showed a long-term (5-year) success\nTable 3 Utero-ovarian anastomosis and signi ficance\nType Morphology Significance\nIa Ovarian artery connects to uterine mural artery and then supplies fibroid. Flow\nin tubal arteries is toward the uterus on selective uterine angiogram\nChances of failure of UAE high\nIb Same as type Ia. Re flux of contrast into an ovarian artery is seen during pre-\nembolization angiogram followed by was hout of contrast washout toward the\nuterus\nOvarian failure risk\nII The ovarian artery directly supplies fibroid apart from uterine artery Chances of residual fibroid\nIII Ovary is supplied by uterine artery with flow in the tuboovarian segment is\ntoward the ovary\nOvarian failure risk\nJournal of Clinical Interventional R adiology ISVIR Vol. 7 No. 2/2023 © 2022. Indian Society of Vascular and Interventional Radiology. All rights res erved.\nUterine Artery Embolization Bellala et al. 91\n\n\nrate of 64.5%. 38,39 The ongoing QUESTA trial that compares\nUAE with hysterectomy in premenopausal women may\nprovide insights regarding the future role of the UAE in\nadenomyosis.\n40 MRI can help in predicting the response:\nlesions with low T2 (higher smooth muscle quantity with\nless extracellular matrix) intensity compared with rectus\nmuscle has been shown to have better therapeutic re-\nsponse.\n38,41 A ratio of rectus to adenomyosis T2 signal\nintensity of more than 0.475 was associated with complete\nnecrosis in such lesions. 41 Lesions with higher vascularity\nalso show better response than lesions without signi ficant\nvascularity.42 Post-procedure MR can predict the midterm\n(2 years) clinical recurrence, with necrosis of less than\n34.3% of volume associated with seven-fold risk of recur-\nrence.\n42 Kim et al using 150 to 250 micron-sized nonspher-\nical PVA particles, followed by 250 to 355 micron and 355 to\n500 micron-sized particles achieved a success rate of 90%.\nHowever, as discussed, smaller particles( < 350 µm) should\nnot be considered in young patients who want to become\npregnant.\n38\nUAE in Arteriovenous Uterine Malformations\nUterine AVMs ( ►Fig. 4 ) are of two types: congenital or\nacquired. Congenital AVM occurs due to a defect in embryo-\nlogical differentiation leading to abnormal arteriovenous\ncommunications.\n43 Even though these are present since\nchildhood, they are commonly noticed during the reproduc -\ntive period and are frequently associated with multiple\nfeeders from other pelvic arteries in addition to uterine\nartery.\n44 Acquired AVMs involve fistulous communication\nbetween uterine artery branches and venous plexuses in the\nmyometrium.\n43 These are more common and seen in con-\nditions with prior uterine interventions, uterine surgery, and\nin gestational trophoblastic disease and infection. 44 Ultra-\nsound is the initial imaging test and shows multiple cystic\nstructures in uterine myometrium on grayscale, and high\nturbulent flow on color flow imaging.44 Doppler parameters\ncan help in guiding treatment. Timmerman et al and Lee et al in\ntheir studies showed AVMs with high PSV (/C21 83 cm/s) required\nembolization whereas lesions with a PSV of less than 39 cm/s\nrequired only conservative medical management.\n45,46 For\nwomen who wish to conserve uterus, expectant management\nand UAE are the main methods of treatment. 47 Hysterectomy\nis considered in individuals who do not wish to have future\npregnancies or in whom UAE has failed.44 As y s t e m a t i cr e v i e w\nby Yoon et al reported that the primary success rate of UAE in\nacquired AVM was 61%, whereas, in cases of repeated emboli-\nzation, it was 91%43. Recent studies by Delplanque and Zhu et al\nshowed that the success rate of UAE was 71% to 87% in acquired\nAVMs.47,48 Sophie et al, in 22 patients, showed reasonable\nfertility rates post UAE (6/7, 85.7%) compared with expectant\nmanagement (2/5, 33.3%), with no miscarriages and ectopic\npregnancy.\n47 Pei et al showed similar results in 62 acquired\nAVMs treated with UAE where 10 patients became pregnant\nand resulted in the delivery of a healthy live baby.\n48 Young age\nand lack of uterine distortion by fibroid are the probable\nreasons for successful pregnancy.47 The choice of embolizing\nmaterial is variable and in cases of ovarian artery supply,\ntemporary occlusion by gelfoam is suf ficient as the main\ngoal is to prevent bleeding. 43\nUAE in Antenatal Bleeding\nThere is increasing use of UAE in controlling antepartum\nbleed in ectopic pregnancy and invasive placenta. Scar\nectopics (\n►Fig. 5 ) require early termination in the first\ntrimester.49 Various treatment options include systemic\nmethotrexate, hysteroscopic resection, dilatation and curet-\ntage. Timor et al showed bleeding rate (due to the slow action\nof the drug, which results in growth of embryo and placental\nFig. 3 A 37-year-old female patient is a known case of adenomyosis.\nShe underwent bilateral UAE with 300 to 50 micron-sized PVA\nparticles. Image A-Sagittal MRI shows increased junctional zone\nthickness of more than 12 mm (arro whead). Angiogram shows dilated\ntorturous bilateral uterine arteries with multiple feeders supplying\nthe uterus (arrow in image B and arrowhead in image C). Post\nembolization angiogram shows occlusion of the uterine artery.\nFig. 4 Uterine AVM in a 26-year-female patient post gestational\ntrophoblastic disease underwent bi lateral UAE with glue emboliza-\ntion. Image A shows an abnormal dilated uterine artery with small\ncommunications (arrowhead), there is an additional pseudoaneurysm\n(arrow). Image B-post glue embolization shows occlusion of the\nfistula, pseudoaneurysm, and uterine artery.\nJournal of Clinical Interventional R adiology ISVIR Vol. 7 No. 2/2023 © 2022. Indian Society of Vascular and Interventional Radiology. All rights res erved.\nUterine Artery Embolization Bellala et al.92\n\n\ntissue) with methotrexate was 62%, thus requiring further\ntreatment.50 Hysteroscopic removal or dilation and curet-\ntage (D & C) in cervical scar ectopic results in profuse life-\nthreatening bleeding due to lack of normal myometrium in\ncervix. UAE has shown to reduce preoperative bleeding in\ncases of surgical evacuation.\n50 Systematic review by Pektas\net al showed 82% of cases treated initially with UAE alone\nrequire further treatment by curettage or methotrexate 49.\nThough the exact time interval between the UAE and evacu-\nation of products is not clearly de fined, it is better to do the\nevacuation as early as possible after UAE, because delaying\nevacuation results in recruitment and development of uter-\nine collaterals.\nAbnormal invasive placenta (\n►Fig. 6 ) includes placenta\naccreta, increta, and percreta. Planned delivery by cesarean\nsection is performed at 34 to 36 weeks of gestation. Endo-\nvascular interventions help in preserving the uterus and\ndecreasing intraoperative bleeding. 51 Endovascular inter-\nventions include prophylactic balloon occlusion (PBO) and\nuterine artery embolization. In PBO compliant balloons are\nplaced under fluoroscopy guidance and are in flated after the\ndelivery of the baby and clamping of the umbilical cord.\nBalloon occlusion can be performed either proximally at the\ninfrarenal abdominal aorta, bilateral common iliac arteries,\nor distally at the internal iliac or uterine arteries. Proximal\nocclusion in the aorta is quick to perform with less radiation\nexposure to the fetus and it also reduces bleeding from\ncollaterals compared with distal occlusion. Uterine artery\nembolization can be considered after balloon occlusion if\nthere is persistent bleeding. In a systematic review, Shahin\net al compared proximal versus distal balloon occlusion and\nreported that proximal balloon occlusion of the abdominal\naorta resulted in better control of blood loss (mean differ-\nence-1.391 mL, p < 0.001), lower hysterectomy rates, and\nless fetal radiation dose.\n52 Wu et al showed average fetal\nradiation dose in aortic balloon occlusion was 5.1 /C6 3m G yi n\n230 patients, whereas the radiation dose with internal iliac\nballoon occlusion was 21 to 61 mGy. 53 The average radiation\ndose absorbed by the skin for 10 to 35 minutes of fluoroscopy\nwas /C24 450 to 1600 mGy, and the dose absorbed by ovaries was\n7 to 378 mGy, which is far less compared with the recom-\nmended dose limits. 54\nUAE in Postpartum Bleed\nPostpartum hemorrhage (PPH) is an important cause of\nmorbidity and mortality worldwide with more than 1 lakh\ndeath per annum.\n55 It is de fined as blood loss of more than\n1000 mL of blood associated with features of volume loss\nsuch as hypotension and tachycardia. It can be primary,\nwhich occurs within the first 24 hours due to uterine atony,\nFig. 6 A 33-year-female patient with placenta percre ta invading bladder at 35 weeks of gestation underwent bilateral internal iliac arteries\nballoon placement before delivery. Image ( A) showing the fetus (blue arrowhead) with vascular placental blush. Bilateral femoral artery\naccess was done and 10 mm x 2 cm balloon was placed in the both internal iliac artery (arrowsheads in image B and image C). The patient\nwas then taken for cesarean section and the balloons were in flated after the delivery of fetus, followed by hysterectomy. The perioperative\nblood loss was 350 mL, which was signi ficantly low compared with a surgery for placenta percreta.\nFig. 5 Case of scar ectopic in a 34-year-old female patient awaiting\ncurettage-prophylactic bilateral uterine artery embolization is\ndone using gelfoam. In image A, abnormal feeders to the uterus\n(arrow) and fetal head can also be noted (arrowhead). Image B-Post\ngel foam embolization of uterine artery shows stoppage of flow.\nJournal of Clinical Interventional R adiology ISVIR Vol. 7 No. 2/2023 © 2022. Indian Society of Vascular and Interventional Radiology. All rights res erved.\nUterine Artery Embolization Bellala et al. 93\n\n\ntrauma to the genital tract, retained placental tissues or\ncoagulopathic disorders or secondary (occurring 24 hours to\n12 weeks) due to retained placental tissue, infection, coagul-\nopathy, uterine artery pseudoaneurysm (\n►Fig. 7 )o rA V M56.\nThe latest FIGO guidelines recommend UAE for refractory PPH\nuncontrolled by medical and nonsurgical methods, provided\nthere is availability of skilled personnel.\n57 UAE can be consid-\nered when conservative management fails. It is preferable to\nperform angiography after 30 minutes of administration of\nuterotonics, as these drugs cause vasospasm, obscuring the\ntotal extent of the problem. During angiography, contrast\nextravasation is seen in 21 to 52% of cases, and the most\ncommon source of bleeding is from distal branches of the\nuterine artery, or vaginal arteries. Absorbable gel foam as\nembolizing material is preferred as it stops bleeding and allows\nrecanalization within 2 to 4 weeks, thereby preventing ische-\nmia.\n55 Liquid embolics such as N-butyl cyanoacrylate are used\nonly when the total permanent occlusion of the vessel is\nrequired in recurrent or refractory PPH or in large pseudoa-\nneurysms.\n58 In cases where the bleeding site is not identified,\nempirical embolization of bilateral uterine arteries or anterior\ndivision of the internal iliac artery can be attempted. 58 Sys-\ntematic review by Zhang et al showed that UAE was successful\nin controlling bleeding in 90.5% of cases with 91 to 100% of\nthese cases resuming their normal menstruation during fol-\nlow-up.\n54 Study by Lee et al in 251 patients with primary PPH\nshowed successful rate of UAE in 88% of patients with dissemi-\nnated intravascular coagulation and massive transfusion as\nindependent predictors for clinical failure.\n59\nConclusion\nIn conclusion, uterine artery embolization is a safe, effective,\nand minimally invasive technique in treating various uterine\npathologies such as fibroids, adenomyosis, and uterine vas-\ncular malformations. It can help reduce bleeding and pre-\nserve the uterus in abnormal invasive placenta and scar\nectopic pregnancy. Proper patient selection and consider-\nation of appropriate technical aspects can achieve better\nsuccess rate.\nFunding\nNone.\nConflict of Interest\nNone declared.\nReferences\n1 Marsh EE, Al-Hendy A, Kappus D, Galitsky A, Stewart EA, Kerolous\nM. Burden, prevalence, and treatment of uterine fibroids: a survey\nof U.S. women. J Womens Health (Larchmt) 2018;27(11):\n1359–1367\n2 Dariushnia SR, Nikolic B, Stokes LS, Spies JBSociety of Interven-\ntional Radiology Standards of Practice Committee. Quality im-\nprovement guidelines for uterine artery embolization for\nsymptomatic leiomyomata. J Vasc Interv Radiol 2014;25(11):\n1737–1747\n3 Rand T, Patel R, Magerle W, Uberoi R. CIRSE standards of practice\non gynaecological and obstetric haemorrhage. 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Radiology 2012;264(03):903 –909\nJournal of Clinical Interventional R adiology ISVIR Vol. 7 No. 2/2023 © 2022. Indian Society of Vascular and Interventional Radiology. All rights res erved.\nUterine Artery Embolization Bellala et al.96","source_license":"CC0","license_restricted":false}