Update on Endovascular Therapy for Fibroids and Adenomyosis

Uterine fibroids and adenomyosis are prevalent benign neoplasms that can lead to serious deleterious health effects including life-threatening anemia, prolonged menses, and pelvic pain; however, up to 40% of women remain undiagnosed. Traditional treatment options such as myomectomy or hysterectomy can effectively manage symptoms but may entail longer hospital stays and hinder future fertility. Endovascular treatment, such as uterine artery embolization (UAE), is a minimally invasive procedure that has emerged as a well-validated alternative to surgical options while preserving the uterus and offering shorter hospital stays. Careful patient selection and appropriate techniques are crucial to achieving optimal outcomes. There have been advancements in recent times that encompass pre- and postprocedural care aimed at enhancing results and alleviating discomfort prior to, during, and after UAE. Furthermore, success and reintervention rates may also depend on the size and location of the fibroids. This article reviews the current state of endovascular treatments of uterine fibroids and adenomyosis.

fibroid - adenomyosis - embolization - uterine artery embolization - interventional radiologyPublication History Article published online: 10 August 2023 © 2023. Thieme. All rights reserved. Thieme Medical Publishers, Inc. 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA -

- 1 Krentel H, De Wilde RL. Prevalence of adenomyosis in women undergoing hysterectomy for abnormal uterine bleeding, pelvic pain or uterine prolapse - a retrospective cohort study. Ann Med Surg (Lond) 2022; 78: 103809-103809 - 2 Baird DD, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol 2003; 188 (01) 100-107 - 3 Stewart EA, Nowak RA. Uterine fibroids: hiding in plain sight. Physiology (Bethesda) 2022; 37 (01) 16-27 - 4 Ramirez-Caban L, Kannan A, Goggins ER, Shockley ME, Haddad LB, Chahine EB. Factors that lengthen patient hospitalizations following laparoscopic hysterectomy. JSLS 2020; 24 (03) e2020.00029 - 5 Stovall DW. Alternatives to hysterectomy: focus on global endometrial ablation, uterine fibroid embolization, and magnetic resonance-guided focused ultrasound. Menopause 2011; 18 (04) 437-444 - 6 Kröncke T. An update on uterine artery embolization for uterine leiomyomata and adenomyosis of the uterus. Br J Radiol 2022; 96 (1143): 20220121 - 7 Coyne KS, Harrington A, Currie BM, Chen J, Gillard P, Spies JB. Psychometric validation of the 1-month recall uterine fibroid symptom and health-related quality of life questionnaire (UFS-QOL). J Patient Rep Outcomes 2019; 3 (01) 57-10 - 8 Yang L, Navuluri R. Uterine fibroids and adenomyosis: imaging and treatment. Contemporary Diagnostic Radiology 2021; 44 (22) 1-7 - 9 Caridi TM. Uterine artery embolization for adenomyosis. Tech Vasc Interv Radiol 2021; 24 (01) 100726-100726 - 10 Vaidya S, Dighe M. Uterine fibroid embolization imaging: interventionalist's perspective. Ultrasound Q 2009; 25 (04) 185-194 - 11 Çakır Ç, Kılınç F, Deniz MA, Karakaş S. Can pre-procedural MRI signal intensity ratio predict the success of uterine artery embolization in treatment of myomas?. Turk J Med Sci 2021; 51 (03) 1380-1387 - 12 Munro MG, Critchley HOD, Broder MS, Fraser IS. FIGO Working Group on Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet 2011; 113 (01) 3-13 - 13 Lacayo EA, Richman DL, Acord MR. et al. Leiomyoma infarction after uterine artery embolization: influence of embolic agent and leiomyoma size and location on outcome. J Vasc Interv Radiol 2017; 28 (07) 1003-1010 - 14 Koziarz A, Patel NR, Kennedy SA. et al. Uterine artery embolization for pedunculated subserosal fibroids: a systematic review and meta-analysis. J Vasc Interv Radiol 2022; 33 (09) 1025-1031.e3 - 15 Kunchala S, Dumoff K, Shafique K, Kinson MS, Shlansky-Goldberg RD. Expulsion of diffuse adenomyosis following uterine artery embolization. J Vasc Interv Radiol 2020; 31 (11) 1908-1911 - 16 Sanampudi S, Gabriel G, Hoffman M, Raissi D. Impending fibroid expulsion on MRI after uterine fibroid embolization. Radiol Case Rep 2019; 14 (06) 673-677 - 17 Andrews RT, Spies JB, Sacks D. et al; Task Force on Uterine Artery Embolization and the Standards Division of the Society of Interventional Radiology. Patient care and uterine artery embolization for leiomyomata. J Vasc Interv Radiol 2009; 20 (07) S307-S311 - 18 Khalsa B, Costantino M, Goodwin S. Uterine artery embolization followed by elective myomectomy for the treatment of intracavitary fibroids: preliminary experience. J Vasc Interv Radiol 2017; 28 (02) S47 - 19 Kohi MP, Spies JB. Updates on uterine artery embolization. Semin Intervent Radiol 2018; 35 (01) 048-055 - 20 Management of symptomatic uterine leiomyomas: ACOG Practice Bulletin, Number 228. Obstetrics and Gynecology (New York 1953) 2021; 137 (06) e100-e115 - 21 Committee Opinion No. 557: Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstetrics and Gynecology (New York 1953) 2013; 121 (04) 891-896 - 22 Horton AW, Patel U, Belli AM. An unusual arterial supply to the uterus. A case report and review of anatomy-implications for uterine artery embolization. Clin Radiol 2010; 65 (12) 1038-1042 - 23 Kim HS, Paxton BE. Development of a hypertrophic ovarian artery after uterine artery embolization with polyvinyl alcohol particles. Cardiovasc Intervent Radiol 2007; 30 (05) 1033-1036 - 24 Matson M, Nicholson A, Belli AM. Anastomoses of the ovarian and uterine arteries: a potential pitfall and cause of failure of uterine embolization. Cardiovasc Intervent Radiol 2000; 23 (05) 393-396 - 25 Wang MQ, Liu FY, Duan F, Wang ZJ, Song P, Song L. Ovarian artery embolization supplementing hypogastric-uterine artery embolization for control of severe postpartum hemorrhage: report of eight cases. J Vasc Interv Radiol 2009; 20 (07) 971-976 - 26 Ozen M, Momin S, Myers CB, Hoffman M, Raissi D. Primary bilateral ovarian artery embolization for uterine leiomyomatosis in the setting of a rare anatomic variant - hypoplastic uterine arteries. Radiol Case Rep 2021; 16 (09) 2426-2428 - 27 Razavi MK, Wolanske KA, Hwang GL, Sze DY, Kee ST, Dake MD. Angiographic classification of ovarian artery-to-uterine artery anastomoses: initial observations in uterine fibroid embolization. Radiology 2002; 224 (03) 707-712 - 28 Ozen M, Birmingham E, Hoffman M, Raissi D. Non-surgical management of abdominal ectopic pregnancy with uterine artery embolization. Radiol Case Rep 2022; 17 (05) 1631-1633 - 29 Laughlin-Tommaso S, Barnard EP, AbdElmagied AM. et al. FIRSTT study: randomized controlled trial of uterine artery embolization vs focused ultrasound surgery. Am J Obstet Gynecol 2019; 220 (02) 174.e1-174.e13 - 30 Himiniuc LMM, Murarasu M, Toma B. et al. Transradial embolization, an underused type of uterine artery embolization approach: a systematic review. Medicina (Kaunas) 2021; 57 (02) 1-10 - 31 Sher A, Garvey A, Kamat S. et al. Single-system experience with outpatient transradial uterine artery embolization: safety, feasibility, outcomes, and early rates of return. AJR Am J Roentgenol 2021; 216 (04) 975-980 - 32 Nakhaei M, Mojtahedi A, Faintuch S, Sarwar A, Brook OR. Transradial and transfemoral uterine fibroid embolization comparative study: technical and clinical outcomes. J Vasc Interv Radiol 2020; 31 (01) 123-129 - 33 Sofy AA, Tsui S. Comparison of polyvinyl alcohol particles and tris-acryl gelatin microspheres embolic agents used in uterine artery embolization: a systematic review and meta-analysis. Turk J Obstet Gynecol 2023; 20 (01) 74-84 - 34 Worthington-Kirsch RL. Uterine artery embolization: state of the art. Semin Intervent Radiol 2004; 21 (01) 37-42 - 35 Szejnfeld D, Santos RFT, Kambara AM. et al. Uterine artery embolization with highly compressible calibrated microspheres for the treatment of uterine fibroids. Radiol Bras 2022; 55 (04) 231-235 - 36 Zhang Y, Xu Y, Zhang X. et al. 8Spheres conformal microspheres as embolic agents for symptomatic uterine leiomyoma therapy in uterine artery embolization (UAE): a prospective clinical trial. Medicine (Baltimore) 2023; 102 (09) e33099 - 37 Yuan K, Zhang JL, Yan JY. et al. Uterine artery embolization with small-sized particles for the treatment of symptomatic adenomyosis: a 42-month clinical follow-up. Int J Gen Med 2021; 14: 3575-3581 - 38 Spies JB. Recovery after uterine artery embolization: understanding and managing short-term outcomes. J Vasc Interv Radiol 2003; 14 (10) 1219-1222 - 39 Spencer EB, Stratil P, Mizones H. Clinical and periprocedural pain management for uterine artery embolization. Semin Intervent Radiol 2013; 30 (04) 354-363 - 40 Tran-Harding KN, Han Q, Ferrell SC, Raissi D. Postprocedure intravenous patient-controlled analgesia compared to epidural patient-controlled analgesia use after uterine fibroid embolization: a clinical audit. Anesth Essays Res 2019; 13 (02) 287-291 - 41 Katsumori T, Miura H, Yoshikawa T, Seri S, Kotera Y, Asato A. Intra-arterial lidocaine administration for anesthesia after uterine artery embolization with trisacryl gelatin microspheres for leiomyoma. J Vasc Interv Radiol 2020; 31 (01) 114-120 - 42 Yoon J, Valenti D, Muchantef K. et al. Superior hypogastric nerve block as post-uterine artery embolization analgesia: a randomized and double-blind clinical trial. Radiology 2019; 292 (01) 269-269 - 43 Pisanie JLD, Commander CW, Burke CT. Management of postprocedural uterine artery embolization pain. Semin Intervent Radiol 2021; 38 (05) 588-594 - 44 Leonhardt H, Aziz A, Lönn L. Post-embolization syndrome and complete expulsion of a leiomyoma after uterine artery embolization. Acta Obstet Gynecol Scand 2005; 84 (03) 303-305 - 45 Szkodziak P, Pyra K, Szkodziak F. et al. The Lublin protocol of the uterine arteries embolization in the treatment of symptomatic uterine fibroids. J Vis Exp 2020; 2020 (163): 1-44 - 46 Waldron MG, Kassamani YW, O'Mahony AT. et al. Uterine artery embolisation of fibroids and the phenomenon of post-embolisation syndrome: a systematic review. Diagnostics (Basel) 2022; 12 (12) 2916 - 47 Duvnjak S, Andersen PE. Intra-arterial lidocaine administration during uterine fibroid embolization to reduce the immediate postoperative pain: a prospective randomized study. CVIR Endovasc 2020; 3 (01) 10-10 - 48 Kim SY, Koo BN, Shin CS, Ban M, Han K, Kim MD. The effects of single-dose dexamethasone on inflammatory response and pain after uterine artery embolisation for symptomatic fibroids or adenomyosis: a randomised controlled study. BJOG 2016; 123 (04) 580-587 - 49 Ochmanek E, Brown MA, Rochon PJ. Fibroid expulsion after uterine artery embolization. Semin Intervent Radiol 2019; 36 (02) 126-132 - 50 Shlansky-Goldberg RD, Coryell L, Stavropoulos SW. et al. Outcomes following fibroid expulsion after uterine artery embolization. J Vasc Interv Radiol 2011; 22 (11) 1586-1593 - 51 Gozzo C, Failla G, Musumeci A. et al. Microspheres vaginal discharge as a complication after uterine artery embolization for intramural/submucosal fibroid. Radiol Case Rep 2021; 16 (06) 1591-1595 - 52 Dariushnia SR, Nikolic B, Stokes LS, Spies JB. Society of Interventional Radiology Standards of Practice Committee. Quality improvement guidelines for uterine artery embolization for symptomatic leiomyomata. J Vasc Interv Radiol 2014; 25 (11) 1737-1747 - 53 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 (02) 290-296 - 54 Caridi TM, De la Garza-Ramos C, Brook OR. et al. Uterine artery embolization for symptomatic adenomyosis: proceedings from a Society of Interventional Radiology Foundation Research Consensus Panel. J Vasc Interv Radiol 2022; 33 (05) 586-592 - 55 Kroencke TJ, Scheurig C, Lampmann LEH. et al. Acrylamido polyvinyl alcohol microspheres for uterine artery embolization: 12-month clinical and MR imaging results. J Vasc Interv Radiol 2008; 19 (01) 47-57 - 56 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 (04) 497-502 - 57 Luo Y-H, Xi IL, Wang R. et al. Deep learning based on MR imaging for predicting outcome of uterine fibroid embolization. J Vasc Interv Radiol 2020; 31 (06) 1010-1017.e3 - 58 Firouznia K, Ghanaati H, Sanaati M, Jalali AH, Shakiba M. Uterine artery embolization in 101 cases of uterine fibroids: do size, location, and number of fibroids affect therapeutic success and complications?. Cardiovasc Intervent Radiol 2008; 31 (03) 521-526 - 59 Katsumori T, Yoshikawa T, Miura H. Insufficient leiomyoma infarction in uterine artery embolization: relationship with tumor location. J Vasc Interv Radiol 2019; 30 (05) 668-675.e1 - 60 Siskin GP. Optimizing fibroid infarction rates after uterine artery embolization. J Vasc Interv Radiol 2019; 30 (05) 677-678 - 61 Llewellyn O, Patel NR, Mallon D, Quinn SD, Hamady M. Uterine artery embolisation for women with giant versus non-giant uterine fibroids: a systematic review and meta-analysis. Cardiovasc Intervent Radiol 2020; 43 (05) 684-693 - 62 Leonardo-Pinto JP, Maghsoudlou P, Salazar GM. et al. Diagnosis of gynecologic malignancy after the treatment of presumed benign fibroid disease with interventional radiology procedures: a retrospective cohort study. Fertil Steril 2023; S0015-0282 (23)00171-1 - 63 Mailli L, Patel S, Das R. et al. Uterine artery embolisation: fertility, adenomyosis and size - what is the evidence?. CVIR Endovasc 2023; 6 (01) 8 - 64 Akhatova A, Aimagambetova G, Bapayeva G. et al. Reproductive and obstetric outcomes after UAE, HIFU, and TFA of uterine fibroids: systematic review and meta-analysis. Int J Environ Res Public Health 2023; 20 (05) 4480 - 65 Zanolli NC, Bishop KC, Kuller JA, Price TM, Harris BS. Fibroids and fertility: a comparison of myomectomy and uterine artery embolization on fertility and reproductive outcomes. Obstet Gynecol Surv 2022; 77 (08) 485-494 - 66 Ghanaati H, Avanaki MA, Ghavami N. et al. Pregnancy rate and outcomes following uterine artery embolization for uterine arteriovenous malformations: a systematic review and meta-analysis. J Vasc Interv Radiol 2023; S1051-0443 (23)00227-0 - 67 Jiang L, Han Y, Song Z, Li Y. Pregnancy outcomes after uterus-sparing operative treatment for adenomyosis: a systematic review and meta-analysis. J Minim Invasive Gynecol 2023; S1553-4650 (23)00113-9