Percutaneous cannulation of the femoral artery is performed by a properly trained and experienced interventional radiologist (164) (Fig. 15.8). Embolization of the uterine artery and its branches is accomplished by injecting gelatin sponges, polyvinyl alcohol particles (PVA), or trisacryl gelatin microspheres via the catheter until occlusion, or slow ﬂow, is documented. Total radiation exposure (approximately 15 cGy) is comparable to one or two computed tomography scans or barium enemas (165).
Tissue hypoxia secondary to UAE causes postprocedural pain that usually requires pain management in the hospital for 1 day. NSAID medications are usually taken for 1 to 2 weeks, and many women return to normal activity within 1 to 3 weeks. Approximately 5% to 10% of women have pain for longer than 2 weeks (165). Ten percent of women require readmission to the hospital for postembolization syndrome, characterized by diffuse abdominal pain, nausea, vomiting, low-grade fever, malaise, anorexia, and leucocytosis. Treatment with intravenous ﬂuids, NSAID medications, and pain management usually leads to resolution of symptoms within 2 to 3 days (165). Persistent fever should be managed with antibiotics. Failure to respond to antibiotics may indicate sepsis, which needs to be aggressively managed with hysterectomy.
The largest prospective study reported to date includes 555 women ages 18 to 59 (mean, 43), 80% of whom had heavy bleeding, 75% had pelvic pain, 73% had urinary frequency or urgency, and 40% of women had required time off work due to fibroid-related symptoms (166). Telephone interviews 3 months after UAE found that menorrhagia improved in 83% of women, dysmenorrhea improved in 77%, and urinary frequency in 86%. Mean fibroid volume reduction of the dominant fibroid was 33% at 3 months, but improvement in menorrhagia was not related to preprocedural uterine volume (even >1,000 cm3) or to the degree of volume reduction obtained. Of note, two women (0.4%) had continued uterine growth and worsening pain and were found to have sarcomas. The hysterectomy rate due to complications was 1.5%. Within the follow-up period, 3% of women under 40, but 41% of women over 50, had amenorrhea.
A prospective, randomized trial comparing hysterectomy and UAE in 177 women with symptomatic fibroids found that major complications were rare (167). Hospital stay was significantly shorter for UAE (2 versus 5 days), but UAE was associated with more readmissions (9 versus 0) for pain and/or fever in the 6-week postoperative period. Significant complications included one woman who required resection of a submucous fibroid and one who had sepsis in the UAE group and one woman who had a vesico-vaginal fistula following hysterectomy.
Figure 15.8 A–C: UAE techniques. A. A catheter is threaded to the uterine arteries and embolic material injected to block off blood ﬂow to the uterus.
Estimates suggest that more than 100,000 UAE procedures have been performed worldwide with 12 deaths Therefore, the estimated mortality rate of 1/10,000 compares well with the mortality rate of approximately 3/10,000 for a similar group of women under age 50 and without malignancy or compromised immunity undergoing hysterectomy (168).