Evaluation of Junctional Zone Differential and Ratio as Possible Markers of Clinical Efficacy in Uterine Artery Embolization of Adenomyosis

Evaluation of Junctional Zone Differential and Ratio as Possible Markers of Clinical Efficacy in Uterine Artery Embolization of Adenomyosis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of Junctional Zone Differential and Ratio as Possible Markers of Clinical Efficacy in Uterine Artery Embolization of Adenomyosis Kolos Turtóczki, Hyunsoo Cho, Sorour Dastaran, Pál N. Kaposi, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4164108/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 Jul, 2024 Read the published version in CVIR Endovascular → Version 1 posted 5 You are reading this latest preprint version Abstract Introduction Uterine artery embolization is a well-established method of adenomyosis treatment. Changes in uterine volume and maximal junctional zone thickness (JZmax) after embolization are thoroughly analyzed in the literature. Changes in other suggested morphological diagnostic markers of adenomyosis (junctional zone differential – JZdiff - and junctional zone ratio - JZratio) on the other hand are rarely evaluated. This single-center retrospective study aimed to analyze the changes in morphological parameters used for the MR imaging diagnosis of adenomyosis (including JZdiff and JZratio) after UAE. Clinical effectiveness and safety were also analyzed. Materials and methods Patients who underwent UAE for adenomyosis from 2008-2021 were evaluated. Adenomyosis was diagnosed based on JZmax, JZdiff, and JZratio measured on MR imaging. To assess clinical efficacy numerical-analog-quality-of-life (QoL) score was routinely obtained from patients at our centre. MRI morphological data were analyzed. Wilcoxon signed-rank test, uni- and multivariate regression models, Pearson product-moment correlation, and Kruskal-Wallis tests were used for statistical analysis. Results From our database of 801 patients who underwent UAE in 14 years, preprocedural MR images were available in 577 cases, 15 patients had pure adenomyosis (15/577, 2.6%). Uterine volume, JZmax, and JZdiff decreased significantly after UAE; QoL score increased significantly. A significant correlation was found between QoL change vs. JZmax and JZdiff change. Permanent amenorrhoea and elective hysterectomy 5 years after UAE were both 7.1%. Conclusion Change of JZdiff after UAE in adenomyis is a potential marker of clinical success. UAE is clinically safe and effective treatment in adenomyosis. Level of Evidence : Level 4, Case Series. adenomyosis embolization MRI clinical efficacy safety Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Adenomyosis is characterised by the presence of heterotopic endometrial glands and stroma deep within the myometrium with adjacent myometrial hyperplasia [ 1 ]. Heavy menstrual bleeding, pain, and fertility issues are the most common symptoms affecting 2/3 of premenopausal women with adenomyosis [ 2 ]. Magnetic Resonance (MR) imaging is currently used as a second-line investigation technique for adenomyosis after transvaginal ultrasound with a higher sensitivity, specificity, and lower operator dependence than the latter [ 3 ]. Diagnosis of adenomyosis on MRI is based on identifying direct and indirect signs. T1 or T2 hyperintense submucosal microcysts are considered the only direct sign of the disease representing ectopic endometrial glandular and stromal components displaced in the inner myometrium [ 4 ]. Maximalis junctional zone thickness (JZmax) > 12 mm was the main indirect diagnostic criteria of the disease for a long time. Due to the conflicting values for the sensitivity and specificity of this threshold, other indirect signs were introduced [ 5 ]. Junctional zone differential (JZdiff) is the difference between the maximal and the minimal thickness of the junctional zone. The junctional zone ratio (JZratio) is the ratio of the junctional zone thickness and the myometrial thickness at the location of maximal JZ thickness [ 6 ]. Uterine artery embolization (UAE) has been proposed as a minimally invasive alternative to hysterectomy in the treatment of patients with symptomatic adenomyosis [ 7 – 10 ]. A decrease in uterine volume and JZmax after embolization is a well-documented finding in the literature [ 9 ]. However, only scarce data is available regarding the change and possible predictive role of JZdiff and JZratio [ 11 ]. This single-centre retrospective study aimed to assess the change in MR morphological parameters after UAE in adenomyosis and to analyse the relation of morphological and clinical parameters. Long-term follow-up information is also provided. MATERIALS AND METHODS All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in this study. Ethical approval was given by the Research Ethical Committee of XXXXXXXXXX (172/2022). Reports and MR images of all patients from our UAE database containing 801 patients who had UAE in the period between April 1, 2008, and September 30, 2021, were reviewed by a senior radiology resident (XX) and validated by a certified radiologist (YY) with experience in female pelvic MR imaging for more than 20 years to identify patients with adenomyosis. All patients who had preprocedural MRI examination where the images were still available were enrolled. PostUAE MR imaging for the pure adenomyosis patients was performed at 7.6 ± 3.8 months. MR imaging was performed with 1.5 T and 3.0 T systems (Philips Ingenia 1.5 T, Philips Achieva 1.5 and 3.0 T, and Siemens Magnetom Harmony 1.0 T). MRI protocol contained T1, T2, and T1 contrast-enhanced sequences. Adenomyosis was diagnosed if T1 or T2 hyperintense submucosal microcysts were detected as the principal direct sign of the disease [ 4 ]. Adenomyosis was also diagnosed if the maximal junctional zone thickness (JZmax) was greater than 12 mm. In the case of a JZmax measurement between 8 and 12 mm, the diagnosis was given if the JZdiff was higher than 5 mm and the JZratio was higher than 0.4 [ 12 , 13 ]. Junctional zone differential (JZdiff), and junctional zone ratio (JZratio) were also obtained in each case [ 6 ]. The minimal thickness was measured on the anterior and posterior uterine walls, for the calculation of the JZ differential, the smaller value was used regardless of which wall the maximal JZ thickness was measured (Fig. 1 ). Differences between pre- and postprocedural values of uterine volume (Uvol), JZmax, JZdiff, and JZratio were obtained. Non-perfused volume on contrast-enhanced T1 sequences following embolization were categorized as total, partial or none. Preprocedural MRI morphological parameters (JZmax, JZdiff, JZratio, Uvol) were correlated with preUAE QoL score. Correlation between UAE-induced change in MRI morphological parameters and change in QoL score was also analysed. PreUAE MRI morphological parameters and change in QoL score were correlated. All embolization procedures were performed using standard procedures by the same interventional radiologist (XX) with more than 20 years of experience. A catheter was inserted using the unilateral right common femoral artery access, and super-selective angiography of both uterine arteries was obtained with a 4F catheter. Embolization was achieved by injecting non-spherical polyvinyl alcohol (PVA) particles into each uterine artery (500–710 µm, COOK PVA-500, Bloomington, IN, USA; 500–700 and 355–500 µm Contour, Boston Scientific-Target Therapeutic, Fremont, CA, USA) until it reached a near-stasis flow state. The volume of injected PVA was noted. The puncture site was manually compressed after the procedure. Patients routinely received antibiotic prophylaxis (amoxicillin-clavulanic acid or clindamycin). Tramadol, meloxicam, metamizole-Na, nalbuphine, and drotaverine were additionally given for postoperative pain control. At our centre clinical success was routinely assessed by interviews where patients were asked whether their symptoms have improved, have improved partially, or have not improved; also if they would recommend UAE to other patients with symptomatic adenomyosis. A numerical analogue quality-of-life (QoL) score (0: intolerable symptoms, 100: perfect QoL) was obtained before and after the embolization in all patients to assess the clinical efficacy of the procedure [ 14 , 15 ]. A difference between pre- and postUAE values of QoL was obtained. Long-term clinical follow-up for QoL score was also analyzed. Complications were documented. Follow-up time ended by the last office meeting/telephone interview, or at the time of menopause or elective hysterectomy. Data are expressed as median and range. Wilcoxon signed-rank test, uni- and multivariate regression models, Pearson product-moment correlation, and Kruskal-Wallis tests were used for statistical analysis (R Statistical Software, v4.1.2; R Core Team 2021). P values < 0.05 were considered statistically significant. RESULTS From our database of all UAE patients (801 patients between April 2008 and September 2021), 577 patients had available MR reports and images before UAE. Pre- and postUAE MR images and reports were available in 420 cases. Pure adenomyosis without uterine fibroids was identified in 15 cases; 12 of 15 patients had pre- and post-procedural MRI. The mean age of patients at the time of UAE was 44.4 ± 5.4 years. The mean value of the total amount of injected PVA during UAE was 3.0 ± 1.5 ml. No significant correlation could be observed between preprocedural MRI morphological factors and preprocedural QoL score, or QoL score change. Pre- and post-procedural MR parameters are presented in Table 1 : Uvol, JZmax, and JZdiff decreased significantly after UAE (p = 0.003, 0.013, and 0.023, respectively); there was no significant change in JZratio (p = 0.5529). A representative case is shown in Fig. 2 . A significant correlation was found between QoL change and JZmax change (p = 0.005, r = 0,776), and between QoL change and JZdiff change (p = 0.016, r = 0,704), while no significant correlation could be found between QoL change and uterine volume change and between QoL change and JZratio change. Non-perfused volume was total in 1 case (1/12, 8.3%), partial in 5 cases (5/12, 41.7%), and none in 6 cases (6/12, 50%). QoL score significantly improved both in the partial (QoL score change 81 ± 19, p = 0.029) and none (QoL score change 61 ± 27, p = 0.031) groups; there were no significant differences between the “partial” and “none” groups neither in the preUAE QoL score nor in the postUAE QoL score, nor in the QoL score changes. Clinical follow-up data are presented in Table 2 . Clinical data, changes in QoL score and any complications were available from 14 patients (14/15, 93.3%). All patients reported clinical success, and at least partial improvement in their symptoms (14/14, 100%; n = 12 “Yes”, n = 2 “partially), and all of them would recommend UAE to other patients (14/14, 100%). The mean follow-up time was 64.6 ± 46.5 months (range: 9-147 months). QoL score increased significantly 1 year after UAE (p = 0.001), the increase was permanent up to 11 years ( Table 2; Fig. 3 ). Permanent amenorrhoea was observed in one 47-year-old patient within 1 year (1/14, 7.1%), this patient considered menopause at this age as an advantage and not as a complication. For a 44-year-old patient, elective hysterectomy was performed 5 years after UAE (1/14, 7.1%). DISCUSSION Morphological data Multiple papers showed a uterus volume decreased 8–54% within a year following UAE assessed by MRI [ 9 ]. Our data (25 ± 14%) on pure adenomyosis falls within the range reported in the literature. The decrease of JZmax following UAE was 12.0–33% in the studies of 1999–2010 [ 10 ]. In the other systematic review of studies between 2001–2016, 4 papers reported a decrease in JZ of 13.7–38%, however, most papers (26/30, 86.7%) cited in this systematic review did not report on JZ [ 9 ]. JZ thickness was shown to be thicker in patients who underwent hysterectomy for persistent symptoms [ 14 ], however, the insufficient response was not correlated with significantly thicker JZ in another paper [ 15 ]. Our finding of a 15% mean reduction in JZ thickness is in line with previous reports. Besides the widely used junctional zone thickness, JZ differential and JZ to myometrial ratio have also been suggested as objective measures to improve the diagnostic accuracy of MRI in adenomyosis [ 6 , 13 , 16 ]. Kitamura et al. found no significant decrease in JZratio after embolization of 19 patients with pure or dominant adenomyosis [ 11 ] – our findings regarding JZratio change align. This is the first study to our knowledge to report on the correlation between QoL change and junctional zone characteristics. A significant correlation between QoL change vs. JZmax change, and QoL change vs. JZdiff change underlines the importance of these measurements and their relation to the imaging appearance of adenomyosis. JZmax is the classic and long-debated MR morphological factor still in use in everyday practice that forms the base of the imaging diagnosis of adenomyosis and is a main pillar in some aspects of disease classification [ 13 , 16 , 17 ]. JZdiff on the other hand is considered as a second-line measurement in imaging diagnosis. Based on our findings JZdiff could have a more significant role in the imaging diagnosis than it is presently used and the ever-evolving classification of adenomyosis as a marker of junctional zone inhomogeneity. Moreover, the change of JZdiff after UAE in adenomyosis may be a potential marker of clinical success. The infarction rate of adenomyosis following UAE seems to be smaller than that of fibroids, its reported range is 44.2%-82.5%, however, most studies (26/33, 78.8%) have not reported the infarction rate [ 9 ]. Bae et al concluded that an infarction cut-off rate of < 34.4% has 7 times higher risk of symptom recurrence [ 18 ]. One other study, however, showed that correlation between improvement of symptoms and imaging at 3 months follow-up was statistically not significant [ 19 ]. Our results resonate with this latter paper: there was a significant improvement in QoL score in both the „none” and „partial” group, in addition, symptom improvement (increase in QoL sore) was not significantly different between the „none” and „partial” group, thus total infarction of the adenomyotic region seems not to be a prerequisite for clinical success. The exact mechanism of heavy menstrual bleeding and dysmenorrhoea in adenomyosis, and the mechanism of how UAE improves symptoms in adenomyosis is not fully understood. Microvessel density, endometrial surface and overall uterine size may be contributing factors [ 11 , 20 ]. Following embolisation, as opposed to normal myometrium, adenomyotic tissue presumably is not capable of opening up vessels, thus, it may be less tolerant to ischaemia [ 20 , 21 ]. Clinical data (patient satisfaction, short-term and long-term clinical success, complications) The overall satisfaction in the systematic review by Popovic et al. was 75.7% [ 10 ]. The more recent systematic review reported patient satisfaction rates for 12 months) for pure adenomyosis and combined adenomyosis was 74.0% and 85.4%, respectively. A recent study showed 90% clinical success [ 20 ]. The longest follow-up (95 ± 9 months) was reported by de Bruijn et al [ 22 ]. Our data with the second longest follow-up data (mean follow-up time was 65 ± 47 months [median 55, range: 9-147 months]) on patients with pure adenomyosis showed 100% patient satisfaction (symptom improvement „yes” in 85.7%, „partial” in 14.3%), all our patients would recommend UAE to another patient with adenomyosis. Clinical follow-up in the literature is mostly provided as symptom improvement; UFS-QoL scores (n = 5) or HRQOL (n = 1) were analysed only in 20.0% (6/30) of the studies, showing significant improvements in UFS-QOL [ 9 ]. Uterine fibroid questionnaires have been used since adenomyosis-specific QoL questionnaires are not available. We used numerical analogue QoL score to assess clinical efficacy, which was used in previous publications [ 23 , 24 ] to assess clinical effectiveness of UAE in symptomatic uterine fibroids, however, this score is not specific for fibroid symptoms, it gives a score for the clinical improvement of preUAE symptoms. Popovic showed that not all studies reported on complications; among the reported cases, 13.2% (1.5 to 29.3%) had a hysterectomy, the majority occurring approximately 12 months (range 2–27 months) after UAE (10). In the review by de Bruijn from 2017, only 20/30 (66.6%) studies reported on complications; hysterectomy in the short-term ( 12 months) follow-up were 7.2 and 7.0%, respectively. Hysterectomy was 18% with 7-year follow-up (22). In our cohort, the hysterectomy rate was 7.1% with the second longest follow-up period of 65 ± 47 months. In the systematic reviews, permanent amenorrhea occurred in 20.9%, all > 45 years old (10); it was 6.3%, all > 40 years old (3), our data showed similar results (7.1%) at the age of 47 years. Other published complications included spontaneous fibroid expulsion in 10 patients, four suspected endometritis, all responded well to broad-spectrum antibiotics, and deep venous thrombosis in the calf in 1 case (9). In the study of the longest (7-year) follow-up, 36% of the patients experienced the absence of menstrual periods for at least 12 months [ 22 ]. No death or serious adverse event (including emergency hysterectomy) occurred [ 9 , 10 ]. Strengths and limitations This is the first study to our knowledge to report on the correlation between QoL change and junctional zone characteristics in adenomyosis after UAE with the second longest clinical follow-up. Limitations include a low number of patients in this single centre, retrospective study. Procedures performed within a long period. CONCLUSION UAE is safe and clinically effective for up to 11 years in pure adenomyosis. A randomized controlled trial confirmation would be essential, thus, such data from the QUESTA trial are much awaited [ 25 ]. The level of non-perfused areas seems not to be a prerequisite to clinical improvement. JZdiff as a marker of junctional zone inhomogeneity may have a more significant role in the MR imaging diagnosis of adenomyosis. Changes of JZmax and JZdiff after UAE in adenomyosis are potential markers of clinical success. Further research is needed with a larger number of patients to establish the potential role of the marker to test its relationship with other junctional zone characteristics. List of abbreviations JZ Junctional zone JZdiff Junctional zone differential JZmax Maximal junctional zone thickness JZratio Junctional zone ratio HRQOL Health-related quality of life MRI Magnetic Resonance Imaging PVA Polyvinyl alcohol QoL Quality of life UAE Uterine artery embolization UFS-QOL Uterine Fibroid Symptom and Health-related Quality of Life Uvol Uterine volume Declarations Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study. Consent for publication Consent for publication was obtained for every individual person’s data included in the study. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request Competing interests The authors declare that they have no competing interests. Funding This study was not supported by any funding. Author contribution Conceptualization: Kolos Turtóczki, Hyunsoo Cho, Sorour Dastaran, Ildikó Kalina, Viktor Bérczi Data curation: Kolos Turtóczki, Hyunsoo Cho, Sorour Dastaran, Viktor Bérczi Formal analysis: Pál N. Kaposi Funding acquisition: Nándor Ács, Viktor Bérczi Investigation: Kolos Turtóczki, Hyunsoo Cho, Sorour Dastaran, Ildikó Kalina, Viktor Bérczi Methodology: Kolos Turtóczki, Pál N. Kaposi, Zoltán Tömösváry, Ildikó Kalina, Viktor Bérczi Project administration: Kolos Turtóczki, Ildikó Kalina, Viktor Bérczi Resources: Zoltán Tömösváry, Szabolcs Várbíró, Nándor Ács, Viktor Bérczi Software: Pál N. Kaposi Supervision: Ildikó Kalina, Viktor Bérczi Validation: Pál N. Kaposi, Ildikó Kalina, Viktor Bérczi Visualization: Kolos Turtóczki, Viktor Bérczi Writing-original draft: Kolos Turtóczki, Viktor Bérczi Writing-review & editing: Kolos Turtóczki, Pál N. Kaposi, Nándor Ács, Szabolcs Várbíró, Ildikó Kalina, Viktor Bérczi Acknowledgments Not applicable. References Kim MD, Kim YM, Kim HC, et al. Uterine artery embolization for symptomatic adenomyosis: a new technical development of the 1-2-3 protocol and predictive factors of MR imaging affecting outcomes. J Vasc Interv Radiol. 2011;22(4):497-502. doi:10.1016/j.jvir.2011.01.426 Lohle PNM, Higué D, Herbreteau D. Uterine artery embolisation in women with symptomatic adenomyosis. Presse Med. 2019;48(4):435-439. doi:10.1016/j.lpm.2019.03.013 Gordts S, Grimbizis G, Campo R. Symptoms and classification of uterine adenomyosis, including the place of hysteroscopy in diagnosis. Fertil Steril. 2018;109(3):380-388.e1. doi:10.1016/j.fertnstert.2018.01.006 Novellas S, Chassang M, Delotte J, et al. MRI characteristics of the uterine junctional zone: from normal to the diagnosis of adenomyosis. AJR Am J Roentgenol . 2011;196(5):1206-1213. doi:10.2214/AJR.10.4877 Celli V, Dolciami M, Ninkova R, et al. MRI and Adenomyosis: What Can Radiologists Evaluate?. Int J Environ Res Public Health. 2022;19(10):5840. Published 2022 May 11. doi:10.3390/ijerph19105840 Rees CO, Nederend J, Mischi M, van Vliet HAAM, Schoot BC. Objective measures of adenomyosis on MRI and their diagnostic accuracy-a systematic review & meta-analysis. Acta Obstet Gynecol Scand . 2021;100(8):1377-1391. doi:10.1111/aogs.14139 Ma J, Brown B, Liang E. Long-term durability of uterine artery embolisation for treatment of symptomatic adenomyosis. Aust N Z J Obstet Gynaecol. 2021;61(2):290-296. doi:10.1111/ajo.13304 Mailli L, Patel S, Das R, et al. Uterine artery embolisation: fertility, adenomyosis and size - what is the evidence?. CVIR Endovasc . 2023;6(1):8. Published 2023 Feb 27. doi:10.1186/s42155-023-00353-2 de Bruijn AM, Smink M, Lohle PNM, et al. Uterine Artery Embolization for the Treatment of Adenomyosis: A Systematic Review and Meta-Analysis. J Vasc Interv Radiol . 2017;28(12):1629-1642.e1. doi:10.1016/j.jvir.2017.07.034 Popovic M, Puchner S, Berzaczy D, Lammer J, Bucek RA. Uterine artery embolization for the treatment of adenomyosis: a review. J Vasc Interv Radiol . 2011;22(7):901-909. doi:10.1016/j.jvir.2011.03.013 Kitamura Y, Allison SJ, Jha RC, Spies JB, Flick PA, Ascher SM. MRI of adenomyosis: changes with uterine artery embolization. AJR Am J Roentgenol . 2006;186(3):855-864. doi:10.2214/AJR.04.1661 Agostinho L, Cruz R, Osório F, Alves J, Setúbal A, Guerra A. MRI for adenomyosis: a pictorial review. Insights Imaging . 2017;8(6):549-556. doi:10.1007/s13244-017-0576-z Chapron C, Vannuccini S, Santulli P, et al. Diagnosing adenomyosis: an integrated clinical and imaging approach. Hum Reprod Update . 2020;26(3):392-411. doi:10.1093/humupd/dmz049 Smeets AJ, Nijenhuis RJ, Boekkooi PF, Vervest HA, van Rooij WJ, Lohle PN. Long-term follow-up of uterine artery embolization for symptomatic adenomyosis. Cardiovasc Intervent Radiol . 2012;35(4):815-819. doi:10.1007/s00270-011-0203-1 Nijenhuis RJ, Smeets AJ, Morpurgo M, et al. Uterine artery embolisation for symptomatic adenomyosis with polyzene F-coated hydrogel microspheres: three-year clinical follow-up using UFS-QoL questionnaire. Cardiovasc Intervent Radiol . 2015;38(1):65-71. doi:10.1007/s00270-014-0878-1 Bazot M, Daraï E. Role of transvaginal sonography and magnetic resonance imaging in the diagnosis of uterine adenomyosis. Fertil Steril . 2018;109(3):389-397. doi:10.1016/j.fertnstert.2018.01.024 Kobayashi H, Matsubara S. A Classification Proposal for Adenomyosis Based on Magnetic Resonance Imaging. Gynecol Obstet Invest. 2020;85(2):118-126. doi:10.1159/000505690 Bae SH, Kim MD, Kim GM, et al. Uterine Artery Embolization for Adenomyosis: Percentage of Necrosis Predicts Midterm Clinical Recurrence. J Vasc Interv Radiol . 2015;26(9):1290-6.e2. doi:10.1016/j.jvir.2015.04.026 Jha RC, Takahama J, Imaoka I, et al. Adenomyosis: MRI of the uterus treated with uterine artery embolization. AJR Am J Roentgenol . 2003;181(3):851-856. doi:10.2214/ajr.181.3.1810851 Liang E, Brown B, Rachinsky M. A clinical audit on the efficacy and safety of uterine artery embolisation for symptomatic adenomyosis: Results in 117 women. Aust N Z J Obstet Gynaecol . 2018;58(4):454-459. doi:10.1111/ajo.12767 Antero MF, Ayhan A, Segars J, Shih IM. Pathology and Pathogenesis of Adenomyosis. Semin Reprod Med . 2020;38(2-03):108-118. doi:10.1055/s-0040-1718922 de Bruijn AM, Smink M, Hehenkamp WJK, et al. Uterine Artery Embolization for Symptomatic Adenomyosis: 7-Year Clinical Follow-up Using UFS-Qol Questionnaire. Cardiovasc Intervent Radiol . 2017;40(9):1344-1350. doi:10.1007/s00270-017-1686-1 xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx – hidden for the blinded version xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx – hidden for the blinded version de Bruijn AM, Lohle PN, Huirne JA, et al. Uterine Artery Embolization Versus Hysterectomy in the Treatment of Symptomatic Adenomyosis: Protocol for the Randomized QUESTA Trial. JMIR Res Protoc . 2018;7(3):e47. Published 2018 Mar 1. doi:10.2196/resprot.8512 Tables Table 1 . MRI parameters before and after UAE. Wilcoxon signed-rank test were used for statistical analysis. A negative value in difference implies an increase. Before After Difference in percentage Difference (p values) Median Range Median Range Median Range Uterus volume (cm3) 298 612 182 624 26% 48% 0.0025 JZmax (mm) 41 59 29 35 11% 62% 0.0133 JZdiff (mm) 33 60 21 39 12% 85% 0.0226 JZratio 0.88 0.29 0.92 0.26 -0.02% 0.4% 0.5529 Table 2 . Short- and long-term clinical data. Wilcoxon signed-rank test was used for statistical analysis in case of short-term data. Kruskal-Wallis rank sum test was used for statistical analysis in case of long-term data. Short-term Median Range p values Number of patients QoL score before UAE 5 30 0.0011 14 QoL score 1 year after UAE 95 70 14 Difference in QoL score before and after UAE 75 70 Long-term QoL score 3 years after UAE 97.5 70 1 8 QoL score 5 years after UAE 77.5 70 0,2012 6 QoL score 7 years after UAE 95 40 0,4227 5 QoL score 9 years after UAE 95 20 1 3 QoL score 11 years after UAE 87.5 15 1 2 Cite Share Download PDF Status: Published Journal Publication published 18 Jul, 2024 Read the published version in CVIR Endovascular → Version 1 posted Editorial decision: Major revision 29 Apr, 2024 Reviewers agreed at journal 05 Apr, 2024 Reviewers invited by journal 05 Apr, 2024 Editor assigned by journal 03 Apr, 2024 First submitted to journal 30 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4164108","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":287853321,"identity":"ca2f3d67-822c-449e-a20d-dded46b36b81","order_by":0,"name":"Kolos Turtóczki","email":"data:image/png;base64,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","orcid":"https://orcid.org/0009-0007-3296-3230","institution":"Semmelweis University: Semmelweis Egyetem","correspondingAuthor":true,"prefix":"","firstName":"Kolos","middleName":"","lastName":"Turtóczki","suffix":""},{"id":287853322,"identity":"810a3cff-417e-4d3a-bcc5-1b327f169393","order_by":1,"name":"Hyunsoo Cho","email":"","orcid":"","institution":"Semmelweis University: Semmelweis Egyetem","correspondingAuthor":false,"prefix":"","firstName":"Hyunsoo","middleName":"","lastName":"Cho","suffix":""},{"id":287853323,"identity":"12e085a1-f1d3-49f5-8cb4-7e0b63191ea8","order_by":2,"name":"Sorour Dastaran","email":"","orcid":"","institution":"Semmelweis University: Semmelweis Egyetem","correspondingAuthor":false,"prefix":"","firstName":"Sorour","middleName":"","lastName":"Dastaran","suffix":""},{"id":287853324,"identity":"f1875c7e-0761-402a-8645-4ec482fcaf4b","order_by":3,"name":"Pál N. Kaposi","email":"","orcid":"","institution":"Semmelweis University: Semmelweis Egyetem","correspondingAuthor":false,"prefix":"","firstName":"Pál","middleName":"N.","lastName":"Kaposi","suffix":""},{"id":287853325,"identity":"763a6141-1f48-41d9-88ed-de3194afc3e1","order_by":4,"name":"Zoltán Tömösváry","email":"","orcid":"","institution":"Semmelweis University: Semmelweis Egyetem","correspondingAuthor":false,"prefix":"","firstName":"Zoltán","middleName":"","lastName":"Tömösváry","suffix":""},{"id":287853326,"identity":"51da28dd-57ec-443d-82c9-01a9ba2ccfe9","order_by":5,"name":"Szabolcs Várbíró","email":"","orcid":"","institution":"Semmelweis University: Semmelweis Egyetem","correspondingAuthor":false,"prefix":"","firstName":"Szabolcs","middleName":"","lastName":"Várbíró","suffix":""},{"id":287853327,"identity":"51628d38-b50c-4a0e-a7b1-23867362c580","order_by":6,"name":"Nándor Ács","email":"","orcid":"","institution":"Semmelweis University: Semmelweis Egyetem","correspondingAuthor":false,"prefix":"","firstName":"Nándor","middleName":"","lastName":"Ács","suffix":""},{"id":287853328,"identity":"b66e7d4a-d69a-4224-b949-fbaa6c071d30","order_by":7,"name":"Ildikó Kalina","email":"","orcid":"","institution":"Semmelweis University: Semmelweis Egyetem","correspondingAuthor":false,"prefix":"","firstName":"Ildikó","middleName":"","lastName":"Kalina","suffix":""},{"id":287853329,"identity":"82e15295-016e-4980-b450-6f1d7a07c365","order_by":8,"name":"Viktor Bérczi","email":"","orcid":"","institution":"Semmelweis University: Semmelweis Egyetem","correspondingAuthor":false,"prefix":"","firstName":"Viktor","middleName":"","lastName":"Bérczi","suffix":""}],"badges":[],"createdAt":"2024-03-25 14:41:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4164108/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4164108/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s42155-024-00468-0","type":"published","date":"2024-07-18T16:13:13+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":54449716,"identity":"390aa6e4-95f5-4451-8f97-a1ad93d81090","added_by":"auto","created_at":"2024-04-10 17:39:58","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":684585,"visible":true,"origin":"","legend":"\u003cp\u003eSagittal T2W image of a 50-year-old patient. JZmax (orange arrow) is 42 mm. JZmin (yellow arrow) is 20 mm. JZdiff is 22 mm in this case (JZmax-JZmin). Myometrial thickness at the point of JZmax (blue arrow) is 55 mm. JZratio is 0.76 (JZmax/ myometrial thickness at the point of JZmax). The green arrow marks a T2 hyperintense focus within the thickened junctional zone. The radiological diagnosis of uterine adenomyosis is evident.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4164108/v1/b25197bf14b5985f4e334210.jpeg"},{"id":54449718,"identity":"4972202e-1924-4c21-a03e-ec66c52bfd40","added_by":"auto","created_at":"2024-04-10 17:39:58","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":418316,"visible":true,"origin":"","legend":"\u003cp\u003ePreprocedural (A) and postprocedural (B) sagittal T2W images of a 49-year-old patient. The postprocedural examination was obtained 6 months after the UAE. Inserted sagittal contrast-enhanced T1-weighted image shows a necrotic area without contrast enhancement (red arrow on inserted image). Jzmax (marked by an orange arrow on both images) was 35 mm before, and 21 mm after UAE. The minimal junctional zone thickness (JZmin) is marked by a yellow arrow on both images. JZdiff (JZmax-JZmin) was 33 mm before, and 16 mm after UAE. JZratio (not marked on images) was 0.88 and 0.84 before and after UAE, respectively. Uterus volume (not marked on the images) was 182 cm3 and 90 cm3 before and after UAE, respectively.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4164108/v1/002a1d4dc7b54877eec9d556.jpeg"},{"id":54449715,"identity":"44cc0ab6-912b-4bb5-b4c9-6d8793abef15","added_by":"auto","created_at":"2024-04-10 17:39:58","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":211993,"visible":true,"origin":"","legend":"\u003cp\u003eLong-term follow-up data on QoL score. Numbers on the curve indicate the number of patients.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4164108/v1/a9095360ff83ab9c94345936.jpeg"},{"id":61595258,"identity":"8e077da4-c438-4f53-9ce0-7e82c3dc9664","added_by":"auto","created_at":"2024-08-01 17:21:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1764680,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4164108/v1/d35e409d-e15d-491b-b3c2-9e1d7e1e7d26.pdf"}],"financialInterests":"","formattedTitle":"Evaluation of Junctional Zone Differential and Ratio as Possible Markers of Clinical Efficacy in Uterine Artery Embolization of Adenomyosis","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eAdenomyosis is characterised by the presence of heterotopic endometrial glands and stroma deep within the myometrium with adjacent myometrial hyperplasia [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Heavy menstrual bleeding, pain, and fertility issues are the most common symptoms affecting 2/3 of premenopausal women with adenomyosis [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Magnetic Resonance (MR) imaging is currently used as a second-line investigation technique for adenomyosis after transvaginal ultrasound with a higher sensitivity, specificity, and lower operator dependence than the latter [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Diagnosis of adenomyosis on MRI is based on identifying direct and indirect signs. T1 or T2 hyperintense submucosal microcysts are considered the only direct sign of the disease representing ectopic endometrial glandular and stromal components displaced in the inner myometrium [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Maximalis junctional zone thickness (JZmax)\u0026thinsp;\u0026gt;\u0026thinsp;12 mm was the main indirect diagnostic criteria of the disease for a long time. Due to the conflicting values for the sensitivity and specificity of this threshold, other indirect signs were introduced [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Junctional zone differential (JZdiff) is the difference between the maximal and the minimal thickness of the junctional zone. The junctional zone ratio (JZratio) is the ratio of the junctional zone thickness and the myometrial thickness at the location of maximal JZ thickness [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUterine artery embolization (UAE) has been proposed as a minimally invasive alternative to hysterectomy in the treatment of patients with symptomatic adenomyosis [\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. A decrease in uterine volume and JZmax after embolization is a well-documented finding in the literature [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, only scarce data is available regarding the change and possible predictive role of JZdiff and JZratio [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis single-centre retrospective study aimed to assess the change in MR morphological parameters after UAE in adenomyosis and to analyse the relation of morphological and clinical parameters. Long-term follow-up information is also provided.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in this study. Ethical approval was given by the Research Ethical Committee of XXXXXXXXXX (172/2022).\u003c/p\u003e \u003cp\u003eReports and MR images of all patients from our UAE database containing 801 patients who had UAE in the period between April 1, 2008, and September 30, 2021, were reviewed by a senior radiology resident (XX) and validated by a certified radiologist (YY) with experience in female pelvic MR imaging for more than 20 years to identify patients with adenomyosis. All patients who had preprocedural MRI examination where the images were still available were enrolled. PostUAE MR imaging for the pure adenomyosis patients was performed at 7.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8 months.\u003c/p\u003e \u003cp\u003eMR imaging was performed with 1.5 T and 3.0 T systems (Philips Ingenia 1.5 T, Philips Achieva 1.5 and 3.0 T, and Siemens Magnetom Harmony 1.0 T). MRI protocol contained T1, T2, and T1 contrast-enhanced sequences.\u003c/p\u003e \u003cp\u003eAdenomyosis was diagnosed if T1 or T2 hyperintense submucosal microcysts were detected as the principal direct sign of the disease [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Adenomyosis was also diagnosed if the maximal junctional zone thickness (JZmax) was greater than 12 mm. In the case of a JZmax measurement between 8 and 12 mm, the diagnosis was given if the JZdiff was higher than 5 mm and the JZratio was higher than 0.4 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Junctional zone differential (JZdiff), and junctional zone ratio (JZratio) were also obtained in each case [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The minimal thickness was measured on the anterior and posterior uterine walls, for the calculation of the JZ differential, the smaller value was used regardless of which wall the maximal JZ thickness was measured (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eDifferences between pre- and postprocedural values of uterine volume (Uvol), JZmax, JZdiff, and JZratio were obtained. Non-perfused volume on contrast-enhanced T1 sequences following embolization were categorized as total, partial or none. Preprocedural MRI morphological parameters (JZmax, JZdiff, JZratio, Uvol) were correlated with preUAE QoL score. Correlation between UAE-induced change in MRI morphological parameters and change in QoL score was also analysed. PreUAE MRI morphological parameters and change in QoL score were correlated.\u003c/p\u003e \u003cp\u003eAll embolization procedures were performed using standard procedures by the same interventional radiologist (XX) with more than 20 years of experience. A catheter was inserted using the unilateral right common femoral artery access, and super-selective angiography of both uterine arteries was obtained with a 4F catheter. Embolization was achieved by injecting non-spherical polyvinyl alcohol (PVA) particles into each uterine artery (500\u0026ndash;710 \u0026micro;m, COOK PVA-500, Bloomington, IN, USA; 500\u0026ndash;700 and 355\u0026ndash;500 \u0026micro;m Contour, Boston Scientific-Target Therapeutic, Fremont, CA, USA) until it reached a near-stasis flow state. The volume of injected PVA was noted. The puncture site was manually compressed after the procedure. Patients routinely received antibiotic prophylaxis (amoxicillin-clavulanic acid or clindamycin). Tramadol, meloxicam, metamizole-Na, nalbuphine, and drotaverine were additionally given for postoperative pain control.\u003c/p\u003e \u003cp\u003eAt our centre clinical success was routinely assessed by interviews where patients were asked whether their symptoms have improved, have improved partially, or have not improved; also if they would recommend UAE to other patients with symptomatic adenomyosis. A numerical analogue quality-of-life (QoL) score (0: intolerable symptoms, 100: perfect QoL) was obtained before and after the embolization in all patients to assess the clinical efficacy of the procedure [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. A difference between pre- and postUAE values of QoL was obtained. Long-term clinical follow-up for QoL score was also analyzed. Complications were documented. Follow-up time ended by the last office meeting/telephone interview, or at the time of menopause or elective hysterectomy.\u003c/p\u003e \u003cp\u003eData are expressed as median and range. Wilcoxon signed-rank test, uni- and multivariate regression models, Pearson product-moment correlation, and Kruskal-Wallis tests were used for statistical analysis (R Statistical Software, v4.1.2; R Core Team 2021). P values\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eFrom our database of all UAE patients (801 patients between April 2008 and September 2021), 577 patients had available MR reports and images before UAE. Pre- and postUAE MR images and reports were available in 420 cases. Pure adenomyosis without uterine fibroids was identified in 15 cases; 12 of 15 patients had pre- and post-procedural MRI. The mean age of patients at the time of UAE was 44.4\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4 years. The mean value of the total amount of injected PVA during UAE was 3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5 ml.\u003c/p\u003e \u003cp\u003eNo significant correlation could be observed between preprocedural MRI morphological factors and preprocedural QoL score, or QoL score change.\u003c/p\u003e \u003cp\u003ePre- and post-procedural MR parameters are presented in \u003cb\u003eTable\u0026nbsp;1\u003c/b\u003e: Uvol, JZmax, and JZdiff decreased significantly after UAE (p\u0026thinsp;=\u0026thinsp;0.003, 0.013, and 0.023, respectively); there was no significant change in JZratio (p\u0026thinsp;=\u0026thinsp;0.5529). A representative case is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eA significant correlation was found between QoL change and JZmax change (p\u0026thinsp;=\u0026thinsp;0.005, r\u0026thinsp;=\u0026thinsp;0,776), and between QoL change and JZdiff change (p\u0026thinsp;=\u0026thinsp;0.016, r\u0026thinsp;=\u0026thinsp;0,704), while no significant correlation could be found between QoL change and uterine volume change and between QoL change and JZratio change.\u003c/p\u003e \u003cp\u003eNon-perfused volume was total in 1 case (1/12, 8.3%), partial in 5 cases (5/12, 41.7%), and none in 6 cases (6/12, 50%). QoL score significantly improved both in the partial (QoL score change 81\u0026thinsp;\u0026plusmn;\u0026thinsp;19, p\u0026thinsp;=\u0026thinsp;0.029) and none (QoL score change 61\u0026thinsp;\u0026plusmn;\u0026thinsp;27, p\u0026thinsp;=\u0026thinsp;0.031) groups; there were no significant differences between the \u0026ldquo;partial\u0026rdquo; and \u0026ldquo;none\u0026rdquo; groups neither in the preUAE QoL score nor in the postUAE QoL score, nor in the QoL score changes.\u003c/p\u003e \u003cp\u003eClinical follow-up data are presented in \u003cb\u003eTable\u0026nbsp;2\u003c/b\u003e. Clinical data, changes in QoL score and any complications were available from 14 patients (14/15, 93.3%). All patients reported clinical success, and at least partial improvement in their symptoms (14/14, 100%; n\u0026thinsp;=\u0026thinsp;12 \u0026ldquo;Yes\u0026rdquo;, n\u0026thinsp;=\u0026thinsp;2 \u0026ldquo;partially), and all of them would recommend UAE to other patients (14/14, 100%). The mean follow-up time was 64.6\u0026thinsp;\u0026plusmn;\u0026thinsp;46.5 months (range: 9-147 months). QoL score increased significantly 1 year after UAE (p\u0026thinsp;=\u0026thinsp;0.001), the increase was permanent up to 11 years (\u003cb\u003eTable\u0026nbsp;2;\u003c/b\u003e Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Permanent amenorrhoea was observed in one 47-year-old patient within 1 year (1/14, 7.1%), this patient considered menopause at this age as an advantage and not as a complication. For a 44-year-old patient, elective hysterectomy was performed 5 years after UAE (1/14, 7.1%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eMorphological data\u003c/h2\u003e \u003cp\u003eMultiple papers showed a uterus volume decreased 8\u0026ndash;54% within a year following UAE assessed by MRI [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Our data (25\u0026thinsp;\u0026plusmn;\u0026thinsp;14%) on pure adenomyosis falls within the range reported in the literature.\u003c/p\u003e \u003cp\u003eThe decrease of JZmax following UAE was 12.0\u0026ndash;33% in the studies of 1999\u0026ndash;2010 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In the other systematic review of studies between 2001\u0026ndash;2016, 4 papers reported a decrease in JZ of 13.7\u0026ndash;38%, however, most papers (26/30, 86.7%) cited in this systematic review did not report on JZ [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. JZ thickness was shown to be thicker in patients who underwent hysterectomy for persistent symptoms [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], however, the insufficient response was not correlated with significantly thicker JZ in another paper [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Our finding of a 15% mean reduction in JZ thickness is in line with previous reports.\u003c/p\u003e \u003cp\u003eBesides the widely used junctional zone thickness, JZ differential and JZ to myometrial ratio have also been suggested as objective measures to improve the diagnostic accuracy of MRI in adenomyosis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Kitamura et al. found no significant decrease in JZratio after embolization of 19 patients with pure or dominant adenomyosis [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] \u0026ndash; our findings regarding JZratio change align.\u003c/p\u003e \u003cp\u003eThis is the first study to our knowledge to report on the correlation between QoL change and junctional zone characteristics. A significant correlation between QoL change vs. JZmax change, and QoL change vs. JZdiff change underlines the importance of these measurements and their relation to the imaging appearance of adenomyosis. JZmax is the classic and long-debated MR morphological factor still in use in everyday practice that forms the base of the imaging diagnosis of adenomyosis and is a main pillar in some aspects of disease classification [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. JZdiff on the other hand is considered as a second-line measurement in imaging diagnosis. Based on our findings JZdiff could have a more significant role in the imaging diagnosis than it is presently used and the ever-evolving classification of adenomyosis as a marker of junctional zone inhomogeneity. Moreover, the change of JZdiff after UAE in adenomyosis may be a potential marker of clinical success.\u003c/p\u003e \u003cp\u003eThe infarction rate of adenomyosis following UAE seems to be smaller than that of fibroids, its reported range is 44.2%-82.5%, however, most studies (26/33, 78.8%) have not reported the infarction rate [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Bae et al concluded that an infarction cut-off rate of \u0026lt;\u0026thinsp;34.4% has 7 times higher risk of symptom recurrence [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. One other study, however, showed that correlation between improvement of symptoms and imaging at 3 months follow-up was statistically not significant [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Our results resonate with this latter paper: there was a significant improvement in QoL score in both the \u0026bdquo;none\u0026rdquo; and \u0026bdquo;partial\u0026rdquo; group, in addition, symptom improvement (increase in QoL sore) was not significantly different between the \u0026bdquo;none\u0026rdquo; and \u0026bdquo;partial\u0026rdquo; group, thus total infarction of the adenomyotic region seems not to be a prerequisite for clinical success.\u003c/p\u003e \u003cp\u003eThe exact mechanism of heavy menstrual bleeding and dysmenorrhoea in adenomyosis, and the mechanism of how UAE improves symptoms in adenomyosis is not fully understood. Microvessel density, endometrial surface and overall uterine size may be contributing factors [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Following embolisation, as opposed to normal myometrium, adenomyotic tissue presumably is not capable of opening up vessels, thus, it may be less tolerant to ischaemia [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eClinical data (patient satisfaction, short-term and long-term clinical success, complications)\u003c/h2\u003e \u003cp\u003eThe overall satisfaction in the systematic review by Popovic et al. was 75.7% [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The more recent systematic review reported patient satisfaction rates for \u0026lt;\u0026thinsp;12 months follow-up pure adenomyosis and combined adenomyosis 89.6% and 94.3%, respectively; long-term data (\u0026gt;\u0026thinsp;12 months) for pure adenomyosis and combined adenomyosis was 74.0% and 85.4%, respectively. A recent study showed 90% clinical success [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The longest follow-up (95\u0026thinsp;\u0026plusmn;\u0026thinsp;9 months) was reported by de Bruijn et al [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Our data with the second longest follow-up data (mean follow-up time was 65\u0026thinsp;\u0026plusmn;\u0026thinsp;47 months [median 55, range: 9-147 months]) on patients with pure adenomyosis showed 100% patient satisfaction (symptom improvement \u0026bdquo;yes\u0026rdquo; in 85.7%, \u0026bdquo;partial\u0026rdquo; in 14.3%), all our patients would recommend UAE to another patient with adenomyosis.\u003c/p\u003e \u003cp\u003eClinical follow-up in the literature is mostly provided as symptom improvement; UFS-QoL scores (n\u0026thinsp;=\u0026thinsp;5) or HRQOL (n\u0026thinsp;=\u0026thinsp;1) were analysed only in 20.0% (6/30) of the studies, showing significant improvements in UFS-QOL [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Uterine fibroid questionnaires have been used since adenomyosis-specific QoL questionnaires are not available. We used numerical analogue QoL score to assess clinical efficacy, which was used in previous publications [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] to assess clinical effectiveness of UAE in symptomatic uterine fibroids, however, this score is not specific for fibroid symptoms, it gives a score for the clinical improvement of preUAE symptoms.\u003c/p\u003e \u003cp\u003ePopovic showed that not all studies reported on complications; among the reported cases, 13.2% (1.5 to 29.3%) had a hysterectomy, the majority occurring approximately 12 months (range 2\u0026ndash;27 months) after UAE (10). In the review by de Bruijn from 2017, only 20/30 (66.6%) studies reported on complications; hysterectomy in the short-term (\u0026lt;\u0026thinsp;12 months) follow-up group for pure adenomyosis and combined adenomyosis was 2.6% and 1.4%, respectively [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The same numbers for long-term (\u0026gt;\u0026thinsp;12 months) follow-up were 7.2 and 7.0%, respectively. Hysterectomy was 18% with 7-year follow-up (22). In our cohort, the hysterectomy rate was 7.1% with the second longest follow-up period of 65\u0026thinsp;\u0026plusmn;\u0026thinsp;47 months.\u003c/p\u003e \u003cp\u003eIn the systematic reviews, permanent amenorrhea occurred in 20.9%, all \u0026gt;\u0026thinsp;45 years old (10); it was 6.3%, all \u0026gt;\u0026thinsp;40 years old (3), our data showed similar results (7.1%) at the age of 47 years.\u003c/p\u003e \u003cp\u003eOther published complications included spontaneous fibroid expulsion in 10 patients, four suspected endometritis, all responded well to broad-spectrum antibiotics, and deep venous thrombosis in the calf in 1 case (9). In the study of the longest (7-year) follow-up, 36% of the patients experienced the absence of menstrual periods for at least 12 months [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. No death or serious adverse event (including emergency hysterectomy) occurred [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThis is the first study to our knowledge to report on the correlation between QoL change and junctional zone characteristics in adenomyosis after UAE with the second longest clinical follow-up.\u003c/p\u003e \u003cp\u003eLimitations include a low number of patients in this single centre, retrospective study. Procedures performed within a long period.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eUAE is safe and clinically effective for up to 11 years in pure adenomyosis. A randomized controlled trial confirmation would be essential, thus, such data from the QUESTA trial are much awaited [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The level of non-perfused areas seems not to be a prerequisite to clinical improvement. JZdiff as a marker of junctional zone inhomogeneity may have a more significant role in the MR imaging diagnosis of adenomyosis. Changes of JZmax and JZdiff after UAE in adenomyosis are potential markers of clinical success. Further research is needed with a larger number of patients to establish the potential role of the marker to test its relationship with other junctional zone characteristics.\u003c/p\u003e"},{"header":"List of abbreviations","content":"\u003cp\u003eJZ Junctional zone\u003c/p\u003e\n\u003cp\u003eJZdiff Junctional zone differential\u003c/p\u003e\n\u003cp\u003eJZmax Maximal junctional zone thickness\u003c/p\u003e\n\u003cp\u003eJZratio Junctional zone ratio\u003c/p\u003e\n\u003cp\u003eHRQOL Health-related quality of life\u003c/p\u003e\n\u003cp\u003eMRI Magnetic Resonance Imaging\u003c/p\u003e\n\u003cp\u003ePVA Polyvinyl alcohol\u003c/p\u003e\n\u003cp\u003eQoL Quality of life\u003c/p\u003e\n\u003cp\u003eUAE Uterine artery embolization\u003c/p\u003e\n\u003cp\u003eUFS-QOL Uterine Fibroid Symptom and Health-related Quality of Life\u003c/p\u003e\n\u003cp\u003eUvol Uterine volume\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent for publication was obtained for every individual person\u0026rsquo;s data included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was not supported by any funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eConceptualization: Kolos Turt\u0026oacute;czki, Hyunsoo Cho, Sorour Dastaran, Ildik\u0026oacute; Kalina, Viktor B\u0026eacute;rczi\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eData curation: Kolos Turt\u0026oacute;czki, Hyunsoo Cho, Sorour Dastaran, Viktor B\u0026eacute;rczi\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eFormal analysis: P\u0026aacute;l N. Kaposi\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eFunding acquisition: N\u0026aacute;ndor \u0026Aacute;cs, Viktor B\u0026eacute;rczi\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eInvestigation: Kolos Turt\u0026oacute;czki, Hyunsoo Cho, Sorour Dastaran, Ildik\u0026oacute; Kalina, Viktor B\u0026eacute;rczi\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eMethodology: Kolos Turt\u0026oacute;czki, P\u0026aacute;l N. Kaposi, Zolt\u0026aacute;n T\u0026ouml;m\u0026ouml;sv\u0026aacute;ry, Ildik\u0026oacute; Kalina, Viktor B\u0026eacute;rczi\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eProject administration: Kolos Turt\u0026oacute;czki, Ildik\u0026oacute; Kalina, Viktor B\u0026eacute;rczi\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eResources: Zolt\u0026aacute;n T\u0026ouml;m\u0026ouml;sv\u0026aacute;ry, Szabolcs V\u0026aacute;rb\u0026iacute;r\u0026oacute;, N\u0026aacute;ndor \u0026Aacute;cs, Viktor B\u0026eacute;rczi\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eSoftware: P\u0026aacute;l N. Kaposi\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eSupervision: Ildik\u0026oacute; Kalina, Viktor B\u0026eacute;rczi\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eValidation: P\u0026aacute;l N. Kaposi, Ildik\u0026oacute; Kalina, Viktor B\u0026eacute;rczi\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eVisualization: Kolos Turt\u0026oacute;czki, Viktor B\u0026eacute;rczi\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eWriting-original draft: Kolos Turt\u0026oacute;czki, Viktor B\u0026eacute;rczi\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eWriting-review \u0026amp; editing: Kolos Turt\u0026oacute;czki, P\u0026aacute;l N. Kaposi, N\u0026aacute;ndor \u0026Aacute;cs, Szabolcs V\u0026aacute;rb\u0026iacute;r\u0026oacute;, Ildik\u0026oacute; Kalina, Viktor B\u0026eacute;rczi\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eKim MD, Kim YM, Kim HC, et al. Uterine artery embolization for symptomatic adenomyosis: a new technical development of the 1-2-3 protocol and predictive factors of MR imaging affecting outcomes. J Vasc Interv Radiol. 2011;22(4):497-502. doi:10.1016/j.jvir.2011.01.426\u003c/li\u003e\n \u003cli\u003eLohle PNM, Higu\u0026eacute; D, Herbreteau D. Uterine artery embolisation in women with symptomatic adenomyosis. Presse Med. 2019;48(4):435-439. doi:10.1016/j.lpm.2019.03.013\u003c/li\u003e\n \u003cli\u003eGordts S, Grimbizis G, Campo R. Symptoms and classification of uterine adenomyosis, including the place of hysteroscopy in diagnosis. Fertil Steril. 2018;109(3):380-388.e1. doi:10.1016/j.fertnstert.2018.01.006\u003c/li\u003e\n \u003cli\u003eNovellas S, Chassang M, Delotte J, et al. MRI characteristics of the uterine junctional zone: from normal to the diagnosis of adenomyosis. \u003cem\u003eAJR Am J Roentgenol\u003c/em\u003e. 2011;196(5):1206-1213. doi:10.2214/AJR.10.4877\u003c/li\u003e\n \u003cli\u003eCelli V, Dolciami M, Ninkova R, et al. MRI and Adenomyosis: What Can Radiologists Evaluate?. Int J Environ Res Public Health. 2022;19(10):5840. Published 2022 May 11. doi:10.3390/ijerph19105840\u003c/li\u003e\n \u003cli\u003eRees CO, Nederend J, Mischi M, van Vliet HAAM, Schoot BC. Objective measures of adenomyosis on MRI and their diagnostic accuracy-a systematic review \u0026amp; meta-analysis. \u003cem\u003eActa Obstet Gynecol Scand\u003c/em\u003e. 2021;100(8):1377-1391. doi:10.1111/aogs.14139\u003c/li\u003e\n \u003cli\u003eMa J, Brown B, Liang E. Long-term durability of uterine artery embolisation for treatment of symptomatic adenomyosis. Aust N Z J Obstet Gynaecol. 2021;61(2):290-296. doi:10.1111/ajo.13304\u003c/li\u003e\n \u003cli\u003eMailli L, Patel S, Das R, et al. Uterine artery embolisation: fertility, adenomyosis and size - what is the evidence?. \u003cem\u003eCVIR Endovasc\u003c/em\u003e. 2023;6(1):8. Published 2023 Feb 27. doi:10.1186/s42155-023-00353-2\u003c/li\u003e\n \u003cli\u003ede Bruijn AM, Smink M, Lohle PNM, et al. Uterine Artery Embolization for the Treatment of Adenomyosis: A Systematic Review and Meta-Analysis. \u003cem\u003eJ Vasc Interv Radiol\u003c/em\u003e. 2017;28(12):1629-1642.e1. doi:10.1016/j.jvir.2017.07.034\u003c/li\u003e\n \u003cli\u003ePopovic M, Puchner S, Berzaczy D, Lammer J, Bucek RA. Uterine artery embolization for the treatment of adenomyosis: a review. \u003cem\u003eJ Vasc Interv Radiol\u003c/em\u003e. 2011;22(7):901-909. doi:10.1016/j.jvir.2011.03.013\u003c/li\u003e\n \u003cli\u003eKitamura Y, Allison SJ, Jha RC, Spies JB, Flick PA, Ascher SM. MRI of adenomyosis: changes with uterine artery embolization. \u003cem\u003eAJR Am J Roentgenol\u003c/em\u003e. 2006;186(3):855-864. doi:10.2214/AJR.04.1661\u003c/li\u003e\n \u003cli\u003eAgostinho L, Cruz R, Os\u0026oacute;rio F, Alves J, Set\u0026uacute;bal A, Guerra A. MRI for adenomyosis: a pictorial review. \u003cem\u003eInsights Imaging\u003c/em\u003e. 2017;8(6):549-556. doi:10.1007/s13244-017-0576-z\u003c/li\u003e\n \u003cli\u003eChapron C, Vannuccini S, Santulli P, et al. Diagnosing adenomyosis: an integrated clinical and imaging approach. \u003cem\u003eHum Reprod Update\u003c/em\u003e. 2020;26(3):392-411. doi:10.1093/humupd/dmz049\u003c/li\u003e\n \u003cli\u003eSmeets AJ, Nijenhuis RJ, Boekkooi PF, Vervest HA, van Rooij WJ, Lohle PN. Long-term follow-up of uterine artery embolization for symptomatic adenomyosis. \u003cem\u003eCardiovasc Intervent Radiol\u003c/em\u003e. 2012;35(4):815-819. doi:10.1007/s00270-011-0203-1\u003c/li\u003e\n \u003cli\u003eNijenhuis RJ, Smeets AJ, Morpurgo M, et al. Uterine artery embolisation for symptomatic adenomyosis with polyzene F-coated hydrogel microspheres: three-year clinical follow-up using UFS-QoL questionnaire. \u003cem\u003eCardiovasc Intervent Radiol\u003c/em\u003e. 2015;38(1):65-71. doi:10.1007/s00270-014-0878-1\u003c/li\u003e\n \u003cli\u003eBazot M, Dara\u0026iuml; E. Role of transvaginal sonography and magnetic resonance imaging in the diagnosis of uterine adenomyosis. \u003cem\u003eFertil Steril\u003c/em\u003e. 2018;109(3):389-397. doi:10.1016/j.fertnstert.2018.01.024\u003c/li\u003e\n \u003cli\u003eKobayashi H, Matsubara S. A Classification Proposal for Adenomyosis Based on Magnetic Resonance Imaging. Gynecol Obstet Invest. 2020;85(2):118-126. doi:10.1159/000505690\u003c/li\u003e\n \u003cli\u003eBae SH, Kim MD, Kim GM, et al. Uterine Artery Embolization for Adenomyosis: Percentage of Necrosis Predicts Midterm Clinical Recurrence. \u003cem\u003eJ Vasc Interv Radiol\u003c/em\u003e. 2015;26(9):1290-6.e2. doi:10.1016/j.jvir.2015.04.026\u003c/li\u003e\n \u003cli\u003eJha RC, Takahama J, Imaoka I, et al. Adenomyosis: MRI of the uterus treated with uterine artery embolization. \u003cem\u003eAJR Am J Roentgenol\u003c/em\u003e. 2003;181(3):851-856. doi:10.2214/ajr.181.3.1810851\u003c/li\u003e\n \u003cli\u003eLiang E, Brown B, Rachinsky M. A clinical audit on the efficacy and safety of uterine artery embolisation for symptomatic adenomyosis: Results in 117 women. \u003cem\u003eAust N Z J Obstet Gynaecol\u003c/em\u003e. 2018;58(4):454-459. doi:10.1111/ajo.12767\u003c/li\u003e\n \u003cli\u003eAntero MF, Ayhan A, Segars J, Shih IM. Pathology and Pathogenesis of Adenomyosis. \u003cem\u003eSemin Reprod Med\u003c/em\u003e. 2020;38(2-03):108-118. doi:10.1055/s-0040-1718922\u003c/li\u003e\n \u003cli\u003ede Bruijn AM, Smink M, Hehenkamp WJK, et al. Uterine Artery Embolization for Symptomatic Adenomyosis: 7-Year Clinical Follow-up Using UFS-Qol Questionnaire. \u003cem\u003eCardiovasc Intervent Radiol\u003c/em\u003e. 2017;40(9):1344-1350. doi:10.1007/s00270-017-1686-1\u003c/li\u003e\n \u003cli\u003exxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx \u0026ndash; \u003cem\u003ehidden for the blinded version\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003exxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx \u0026ndash; \u003cem\u003ehidden for the blinded version\u003c/em\u003e\u003c/li\u003e\n \u003cli\u003ede Bruijn AM, Lohle PN, Huirne JA, et al. Uterine Artery Embolization Versus Hysterectomy in the Treatment of Symptomatic Adenomyosis: Protocol for the Randomized QUESTA Trial. \u003cem\u003eJMIR Res Protoc\u003c/em\u003e. 2018;7(3):e47. Published 2018 Mar 1. doi:10.2196/resprot.8512\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e. MRI parameters before and after UAE. Wilcoxon signed-rank test were used for statistical analysis. A negative value in difference implies an increase.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.810040705563093%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"18.453188602442335%\" colspan=\"2\"\u003e\n \u003cp\u003eBefore\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.010854816824967%\" colspan=\"2\"\u003e\n \u003cp\u003eAfter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.880597014925375%\" colspan=\"2\"\u003e\n \u003cp\u003eDifference in percentage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.845318860244234%\"\u003e\n \u003cp\u003eDifference\u003c/p\u003e\n \u003cp\u003e(p values)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.83695652173913%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"10.597826086956522%\"\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.880434782608695%\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.016304347826088%\"\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.880434782608695%\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.63586956521739%\"\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.277173913043478%\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.875%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.83695652173913%\"\u003e\n \u003cp\u003eUterus volume (cm3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.597826086956522%\"\u003e\n \u003cp\u003e298\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.880434782608695%\"\u003e\n \u003cp\u003e612\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.016304347826088%\"\u003e\n \u003cp\u003e182\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.880434782608695%\"\u003e\n \u003cp\u003e624\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.63586956521739%\"\u003e\n \u003cp\u003e26%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.277173913043478%\"\u003e\n \u003cp\u003e48%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.875%\"\u003e\n \u003cp\u003e0.0025\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.83695652173913%\"\u003e\n \u003cp\u003eJZmax (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.597826086956522%\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.880434782608695%\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.016304347826088%\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.880434782608695%\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.63586956521739%\"\u003e\n \u003cp\u003e11%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.277173913043478%\"\u003e\n \u003cp\u003e62%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.875%\"\u003e\n \u003cp\u003e0.0133\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.83695652173913%\"\u003e\n \u003cp\u003eJZdiff (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.597826086956522%\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.880434782608695%\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.016304347826088%\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.880434782608695%\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.63586956521739%\"\u003e\n \u003cp\u003e12%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.277173913043478%\"\u003e\n \u003cp\u003e85%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.875%\"\u003e\n \u003cp\u003e0.0226\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.83695652173913%\"\u003e\n \u003cp\u003eJZratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.597826086956522%\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.880434782608695%\"\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.016304347826088%\"\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.880434782608695%\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.63586956521739%\"\u003e\n \u003cp\u003e-0.02%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.277173913043478%\"\u003e\n \u003cp\u003e0.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.875%\"\u003e\n \u003cp\u003e0.5529\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e. Short- and long-term clinical data. Wilcoxon signed-rank test was used for statistical analysis in case of short-term data. Kruskal-Wallis rank sum test was used for statistical analysis in case of long-term data.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"509\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.650294695481335%\" valign=\"bottom\"\u003e\n \u003cp\u003eShort-term\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.966601178781925%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"11.198428290766207%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.966601178781925%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"21.218074656188605%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"0%\" height=\"21\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.650294695481335%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.966601178781925%\"\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.198428290766207%\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.966601178781925%\"\u003e\n \u003cp\u003ep values\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.218074656188605%\"\u003e\n \u003cp\u003eNumber of patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"21\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.650294695481335%\" valign=\"bottom\"\u003e\n \u003cp\u003eQoL score before UAE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.966601178781925%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.198428290766207%\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.966601178781925%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.0011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.218074656188605%\" valign=\"bottom\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"20\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"47.855530474040634%\" valign=\"bottom\"\u003e\n \u003cp\u003eQoL score 1 year after UAE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.89841986455982%\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.866817155756207%\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.37923250564334%\" valign=\"bottom\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"21\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.650294695481335%\" rowspan=\"2\"\u003e\n \u003cp\u003eDifference in QoL score before and after UAE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.966601178781925%\" rowspan=\"2\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.198428290766207%\" rowspan=\"2\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.966601178781925%\" rowspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"21.218074656188605%\" rowspan=\"2\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"0%\" height=\"30\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"NaN%\" height=\"30\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.650294695481335%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.966601178781925%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"11.198428290766207%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.966601178781925%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"21.218074656188605%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"0%\" height=\"21\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.650294695481335%\"\u003e\n \u003cp\u003eLong-term\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.966601178781925%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"11.198428290766207%\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.966601178781925%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"21.218074656188605%\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"0%\" height=\"21\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.650294695481335%\" valign=\"bottom\"\u003e\n \u003cp\u003eQoL score 3 years after UAE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.966601178781925%\" valign=\"bottom\"\u003e\n \u003cp\u003e97.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.198428290766207%\" valign=\"bottom\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.966601178781925%\" valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.218074656188605%\" valign=\"bottom\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"21\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.650294695481335%\" valign=\"bottom\"\u003e\n \u003cp\u003eQoL score 5 years after UAE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.966601178781925%\" valign=\"bottom\"\u003e\n \u003cp\u003e77.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.198428290766207%\" valign=\"bottom\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.966601178781925%\" valign=\"bottom\"\u003e\n \u003cp\u003e0,2012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.218074656188605%\" valign=\"bottom\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"21\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.650294695481335%\" valign=\"bottom\"\u003e\n \u003cp\u003eQoL score 7 years after UAE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.966601178781925%\" valign=\"bottom\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.198428290766207%\" valign=\"bottom\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.966601178781925%\" valign=\"bottom\"\u003e\n \u003cp\u003e0,4227\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.218074656188605%\" valign=\"bottom\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"21\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.650294695481335%\" valign=\"bottom\"\u003e\n \u003cp\u003eQoL score 9 years after UAE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.966601178781925%\" valign=\"bottom\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.198428290766207%\" valign=\"bottom\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.966601178781925%\" valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.218074656188605%\" valign=\"bottom\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"21\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"41.650294695481335%\" valign=\"bottom\"\u003e\n \u003cp\u003eQoL score 11 years after UAE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.966601178781925%\" valign=\"bottom\"\u003e\n \u003cp\u003e87.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.198428290766207%\" valign=\"bottom\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.966601178781925%\" valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.218074656188605%\" valign=\"bottom\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"0%\" height=\"21\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"cvir-endovascular","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cire","sideBox":"Learn more about [CVIR Endovascular](https://www.springer.com/journal/42155)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/cire/default.aspx","title":"CVIR Endovascular","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"adenomyosis, embolization, MRI, clinical efficacy, safety","lastPublishedDoi":"10.21203/rs.3.rs-4164108/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4164108/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUterine artery embolization is a well-established method of adenomyosis treatment. Changes in uterine volume and maximal junctional zone thickness (JZmax) after embolization are thoroughly analyzed in the literature. Changes in other suggested morphological diagnostic markers of adenomyosis (junctional zone differential – JZdiff - and junctional zone ratio - JZratio) on the other hand are rarely evaluated. This single-center retrospective study aimed to analyze the changes in morphological parameters used for the MR imaging diagnosis of adenomyosis (including JZdiff and JZratio) after UAE. Clinical effectiveness and safety were also analyzed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients who underwent UAE for adenomyosis from 2008-2021 were evaluated. Adenomyosis was diagnosed based on JZmax, JZdiff, and JZratio measured on MR imaging. To assess clinical efficacy numerical-analog-quality-of-life (QoL) score was routinely obtained from patients at our centre. MRI morphological data were analyzed. Wilcoxon signed-rank test, uni- and multivariate regression models, Pearson product-moment correlation, and Kruskal-Wallis tests were used for statistical analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom our database of 801 patients who underwent UAE in 14 years, preprocedural MR images were available in 577 cases, 15 patients had pure adenomyosis (15/577, 2.6%). Uterine volume, JZmax, and JZdiff decreased significantly after UAE; QoL score increased significantly. A significant correlation was found between QoL change vs. JZmax and JZdiff change. Permanent amenorrhoea and elective hysterectomy 5 years after UAE were both 7.1%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChange of JZdiff after UAE in adenomyis is a potential marker of clinical success. UAE is clinically safe and effective treatment in adenomyosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLevel of Evidence\u003c/strong\u003e: Level 4, Case Series.\u003c/p\u003e","manuscriptTitle":"Evaluation of Junctional Zone Differential and Ratio as Possible Markers of Clinical Efficacy in Uterine Artery Embolization of Adenomyosis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-10 17:39:53","doi":"10.21203/rs.3.rs-4164108/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2024-04-30T03:16:15+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2024-04-05T20:20:05+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-05T09:32:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-04T01:13:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"CVIR Endovascular","date":"2024-03-30T05:41:11+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"cvir-endovascular","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cire","sideBox":"Learn more about [CVIR Endovascular](https://www.springer.com/journal/42155)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/cire/default.aspx","title":"CVIR Endovascular","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"b4a1b82d-7b9d-4169-8966-a6b9b6b5ff00","owner":[],"postedDate":"April 10th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-08-01T16:19:37+00:00","versionOfRecord":{"articleIdentity":"rs-4164108","link":"https://doi.org/10.1186/s42155-024-00468-0","journal":{"identity":"cvir-endovascular","isVorOnly":false,"title":"CVIR Endovascular"},"publishedOn":"2024-07-18 16:13:13","publishedOnDateReadable":"July 18th, 2024"},"versionCreatedAt":"2024-04-10 17:39:53","video":"","vorDoi":"10.1186/s42155-024-00468-0","vorDoiUrl":"https://doi.org/10.1186/s42155-024-00468-0","workflowStages":[]},"version":"v1","identity":"rs-4164108","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4164108","identity":"rs-4164108","version":["v1"]},"buildId":"J0_U0BvcaRcwD8yVFaRlm","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}