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

2. 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

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 5yr
Gp A 100% % % %
Gp B 90-99% % % %
Gp C <90% % % %
Symptom control significantly better for Gp A.
(Katsumori CVIR :66–72) 10

11. 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

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

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 vs Myo (Mara et al CVIR 2006,2008)
UAE MYO
Total treated (42 lap)
Single myoma (%)
>5 fibroids (%)
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

20. 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)

21. 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 Jul;24(7):925-30

22. 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)

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

24. 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.

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

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

27. 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%)

28. 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

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

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

31. 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)

32. 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

33. Thank you