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Uterine Artery Embolization: Technique and Outcomes

Uterine Artery Embolization: Technique and Outcomes. Anna-Maria Belli EBIR. 1995. Pinto RCT 2003. 21 year history of UAE. RCR/RCOG Guidance 2000. EMMY RCT 2005. MARA RCT 2006. NICE Guidance 2001 & 2004. REST RCT 2007. MARA RCT 2008. US registry 2005. EMMY RCT 2010.

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Uterine Artery Embolization: Technique and Outcomes

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  1. Uterine Artery Embolization:Technique and Outcomes Anna-Maria Belli EBIR

  2. 1995 Pinto RCT 2003 21 year history of UAE RCR/RCOG Guidance 2000 EMMY RCT 2005 MARA RCT 2006 NICE Guidance 2001 & 2004 REST RCT 2007 MARA RCT 2008 US registry 2005 EMMY RCT 2010 Cochrane 2006 RUUSKANEN RCT 2010 HOPEFUL 2007 REST RCT 2011 RCR/RCOG Guidance 2009 FUME RCT 2012 NICE/BSIR registry 2010 REST RCT2013 NICE Guidance 2010 FEMME 2017 Cochrane 2012 RCR/RCOG Guidance 2013 2016

  3. UAE:Technique and Outcomes Patient Selection • Symptoms warranting intervention • Desire to keep uterus (fertility/femininity) • Desire to avoid surgery • Surgery contra-indicated or high risk

  4. UAE:Technique and Outcomes • Symptoms • Severe menorrhagia • Anaemia • Dysmenorrhoea • Pressure effect on bladder / bowel • Contraindications • Viable pregnancy • Suspected malignancy of uterus or ovaries • Contrast allergy / renal impairment • Refusal to accept hysterectomy under any circumstances

  5. UAE:Technique and Outcomes Advantages • Total treatment of uterus (numbers and size of fibroids irrelevant) • Minimally invasive under local anaesthetic • Rapid recovery • Repeatable

  6. UAE:Technique and Outcomes Disadvantages • Fibroids remain in situ • Recurrence of fibroids and symptoms • Possible effect on ovarian reserve • Transient ischaemia of healthy myometrium

  7. UAE:Technique and Outcomes • UAE: Aim to catheterise and embolise both uterine arteries

  8. UAE:Technique and Outcomes • UAE: Aim to catheterise and embolise both uterine arteries

  9. UAE:Technique and Outcomes • UAE: Aim to catheterise and embolise both uterine arteries • 100% infarction of all fibroids

  10. UAE:Technique and Outcomes 221 consecutive patients pre and post UFE CE-MRI Total fibroid infarction rate Symptom control Reintervention @ 5yr Gp A 100% 142 64% 93% 3% Gp B 90-99% 74 34% 71% 15% Gp C <90% 5 2% 60% 20% • Symptom control significantly better for Gp A. (Katsumori CVIR 2008 31:66–72)

  11. UAE:Technique and Outcomes Does UAE technique determine outcome? Use of microcatheters, position of catheter tip for embolisation, univs bilateral technique, end-point of cessation or sluggish flow

  12. UAE:Technique and Outcomes Does UAE technique determine outcome? Outcomes using different embolic agents

  13. UAE:Technique and Outcomes • Embospheres demonstrated greater percentage fibroid devascularisation compared with spherical PVA (no longer available) • No significant difference in outcome demonstrated between any of the other agents • Relevant RCT data required between non-spherical PVA, gelatin sponge and newer calibrated particles such as Embospheres, Embozenes

  14. UAE:Technique and Outcomes Pinto, REST, EMMY, Ruuskanen Surgical arm- hysterectomy • More reinterventions for symptom recurrence after UAE than hysterectomy • More major complications following hysterectomy • More minor and delayed complications post UAE • UAE cost neutral compared with hysterectomy at 5 years despite repeat interventions • Improvement of pressure effects greater with UAE than hysterectomy

  15. UAE:Technique and Outcomes Myomectomy UAE 23% Re-intervention 5 years 28-32% Re-intervention 5 years 30% Re-intervention 7 years

  16. UAE:Technique and Outcomes RCT 121 women UAE vsMyo(Mara et al CVIR 2006,2008) UAE MYO Total treated 58 63 (42 lap) Single myoma (%) 67 64 >5 fibroids (%) 26 33 At 2 yrs, no difference in symptomatic effectiveness, post procedural FSH levels, reintervention rates, or complications.

  17. UAE:Technique and Outcomes FUME Trial • 82 UAE vs 81 abdominal myomectomy- “fibroid clearance” • SFQOL significantly improved in both • Major complications 3% UAE vs 8% myo • Reinterventions at 2 years 14% UAE vs 3% myo (Manyonda et al CVIR 2012)

  18. UAE:Technique and Outcomes FEMME trial comparing UAE in all ages with all types of myomectomy (UK) • 130 women in each arm • QOL, ovarian reserve, reintervention rates and cost

  19. UAE:Technique and Outcomes Review of the literature • Arterial flow to the ovary is likely to be transiently occluded during UAE. Despite this the incidence of clinically apparent injury to ovarian reserve is low • Results of 10 studies on hormonal assessment of ovarian reserve showed no observable effect on ovary in women <45yrs (Kaump & Spies JVIR 2013)

  20. UAE:Technique and Outcomes • Systematic review (2013) of 21 studies of UAE • Pregnancy rates following UAE are comparable to age-adjusted rates in general population • Cumulative pregnancy rate 58.6% • Mean age of patients was 36 years • Cumulative pregnancy rate following UAE for PPH was 87.2 % Mohan PP, Hamblin MH, Vogelzang RL. Uterine artery embolization and its effect on fertility. J Vasc Interv Radiol. 2013 Jul;24(7):925-30

  21. UAE:Technique and Outcomes Meta-analysis & Review • 227 completed pregnancies post UAE • Spontaneous abortion rate 35% vs 16.5% for non-UAE fibroid controls • PPH 14% vs 2.5% • Pre-term delivery, IUGR & malpresentation not increased (Homer & Saridogan Fertil Steril 2010)

  22. UAE:Technique and Outcomes “The evidence for the beneficial effect of myomectomy or UAE on fertility and pregnancy outcomes is weak …….”

  23. UAE:Technique and Outcomes The fibroid will shrink! • They will to some extent, but large ones remain large • Expectation of 40-50% fibroid volume reduction • Volume reduction does not correlate with symptom improvement.

  24. UAE:Technique and Outcomes Submucosal fibroids Fibroid extrusion & impaction (10%)

  25. UAE:Technique and Outcomes Submucosal fibroids Vaginal discharge (16%)

  26. UAE:Technique and Outcomes Maintaining the uterus maintains fertility Premature menopause (1.5-7%) ……. age dependent (<1%) in women <40 yrs Post treatment infection rate (2%) Infection requiring hysterectomy (<1%)

  27. UAE:Technique and Outcomes Only one treatment necessary! Further treatment may be required for recurrent symptoms The younger at first treatment, the more likely this is Risk is: 25% by 5 yearsfor patients <40yrs 10% by 5 years for patients between 40 and 50 yrs Repeat UAE, myomectomy or hysterectomy

  28. UAE:Technique and Outcomes A minimally invasive treatment means pain free Womb attack!

  29. UAE:Technique and Outcomes Mean Pain Score Time (Hour)

  30. UAE:Technique and Outcomes Hypogastric Nerve Block • 21G spinal needle to L5 & 20cc of 0.25% chirocaine or 0.75% ropivacain • Provides 8 hours of pain relief 108 women HNB (81) compared with epidural anaesthesia (27) Opiate dose measured as peroral equivalent was 149.21mg (epidural) cw 19.33mg (HNB) p<0.001 No significant complications (Binkert et al CVIR 2015)

  31. UAE:Technique and Outcomes Summary • Quality of evidence on safety and efficacy of UAE is adequate • Technique – no evidence for superiority of embolic….yet • Women choose after being fully informed • Better data on fertility outcomes required

  32. Thank you

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