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

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

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

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

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

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

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

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

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

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) 10

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

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

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

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

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

UAE: Technique and Outcomes RCT 121 women UAE vs Myo (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.

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)

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

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)

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

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)

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

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.

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

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

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%)

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 years for patients <40yrs 10% by 5 years for patients between 40 and 50 yrs Repeat UAE, myomectomy or hysterectomy

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

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

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)

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

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