For Physicians : Protocol

Purpose

  • Treatment of symptomatic uterine leiomyomata with bilateral superselective uterine artery embolization.

Candidates

  • Premenopausal women with symptomatic leiomyomata, without extensive adenomyosis (usually), endometriosis, or other causes for their symptoms, who wish to avoid surgery.
  • Women who have completed childbearing.
  • For women who wish to preserve fertility, and are not candidates for myomectomy, or have recurrent fibroids following myomectomy, UFE may be considered.
  • Ideally, <24 weeks gestational size uterus. Larger uteri may be considered depending on symptoms.
  • Since there is virtually no blood loss, or need for transfusion, UFE may be an ideal treatment for women who wish to avoid transfusion for health or religious reasons.

Contraindications - Absolute

  • Pregnancy
  • Active pelvic or abdominal infection
  • Malignancy

Contraindications - Relative

  • Post-menopausal patients
  • History of severe contrast reaction
  • Renal insufficiency
  • Uncorrectable coagulopathy
  • Presence of IUD – should be removed if possible.
  • Patients with systemic illnesses such as multiple sclerosis, lupus, etc. may experience a flairup of symptoms following the stress of surgery or UFE.

Pre-Procedure Evaluation

  • Thorough history and physical examination performed by gynecologist who determines that symptoms are very likely caused by presence of leiomyomata. UFE will not be performed without a supportive gynecologist.
  • Consultation with Interventional Radiologist.
  • For patients with abnormal bleeding, periods lasting 10 days or longer or intermenstrual bleeding, endometrial biopsy or other sampling procedure to exclude endometrial cancer or dysplasia.
  • MRI of the pelvis to document the size, number, and extent of fibroids and to exclude fibroid mimics such as adenomyosis or endometriosis. The ovaries will also be evaluated.
  • Negative pap smear within last year.
  • Cervical cultures for patients with history of PID, or with discharge.

Procedural Considerations

  • Ancef 1gm IV on call to angio suite.
  • Foley catheter
  • Conscious sedation with fentanyl and versed. Epidural,spinal, or general anesthesia is unnecessary.
  • Single femoral artery access in most cases.
  • Pre-embolization pelvic arteriogram.
  • Toradol 60mg IM upon selective catheterization of first uterine artery.
  • Embolize each uterine artery using Biosphere Embospheres, sized 500-700um and 700-900um. We do not embolize to stasis or near-stasis in the uterine artery. Instead we strive for a "pruned tree" appearance of the peri-fibroid plexus branches.
  • PCA morphine pump connected prior to leaving angio suite.
  • Overnight, 23 hour extended observation in most cases.

Post-Procedure Evaluation

  • Office follow-up visit with Interventional Radiologist within two weeks of procedure.
  • Initial follow-up questions or problems directed to Interventional Radiologist who will enlist help of gynecologist as needed.
  • Three month follow-up with Interventional Radiologist to assess early response to procedure.
  • MRI pelvis at 6 months if symptoms have improved. Sooner if no improvement or worsening of symptoms. Phone/office follow-up to review results of MRI. No further imaging unless symptoms recur. Of the 10% of patients who don’t respond, repeat UFE can be offered to those with persistent enhancement on follow-up MRI.
  • Routine gynecological follow-up thereafter.

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