Uterine fibroids - Publications

ask4UFE- 5 de Dezembro de 2017

Could UFE Be a Fertility-Restoring Treatment Option? This Study Says Yes.

Alicia Armeli

Uterine fibroids are the most frequently seen noncancerous tumors of the female reproductive system, affecting nearly 70% of white women and over 80% of black women by age 50.1 Given their frequency, how these uterine growths impact fertility is an important topic—but one that isn’t entirely understood.

Just as important as understanding how this condition may affect your ability to conceive is choosing a fibroid treatment that protects it. Currently, surgically removing fibroids—a procedure called myomectomy—is considered the only treatment recommended to women thought to suffer from fibroid-related infertility. But according to a study published in the journal Radiology, minimally invasive uterine fibroid embolization (UFE) may help restore fertility in women with uterine fibroids who were previously unable to conceive.2

“Exploring UFE as a treatment option for women who desire pregnancy is of major importance,” explains João Martins Pisco, MD, PhD, from the Department of Interventional Radiology at Saint Louis Hospital in Lisbon, Portugal, and study co-author. “It’s a minimally invasive technique performed under local anesthesia with shorter hospital stay.”

Unlike surgery, UFE only requires a small puncture in the wrist or groin area. A doctor called an interventional radiologist then inserts a small tube called a catheter. With the use of real-time imaging, the catheter is guided through the arteries that lead to the uterine arteries. Tiny particles called embolic are injected into the uterine arteries, blocking blood flow to the fibroids. This process, called embolization, leaves fibroids without a blood supply, causing them to gradually shrink over time.

Even though UFE is less invasive than surgery, it still isn’t fully supported by the medical community as a fibroid treatment option for women wanting to become pregnant. Concerns the procedure may impede circulation to the uterine lining and the ovaries has categorized UFE as a treatment option only for women who don’t desire future pregnancy.

To gain more knowledge on this issue, Dr. Pisco and his colleagues examined pregnancy rates following UFE among 359 women with fibroids and/or adenomyosis who were previously unable to conceive.2 Adenomyosis causes the inner uterine lining to abnormally grow into the wall of the uterus, which can also negatively impact fertility.

Of the women participating in the study, 160 underwent partial embolization—a technique where only the small vessels are embolized, leaving the large vessels intact—instead of conventional UFE to potentially better preserve fertility.2 Conventional UFE embolizes all uterine artery branches.

All women were followed up for an average of almost 6 years.2 During this time, 149 women became pregnant (41.5%) at least once, and 131 women gave birth to 150 babies. For over 85% of these women, it was their first pregnancy. Since the time of writing the study, more pregnancies and newborns have been recorded. Obstetric complication rates were low at 23.1% for conventional UFE and 14.6% for partial UFE; however, it was noted that these rates are comparable with rates of the general population.

Neither conventional nor partial UFE seemed to negatively affect fertility but instead may have restored it. “Several of these women weren’t able to conceive despite having been submitted to IVF and many to myomectomy,” Dr. Pisco says. “They were only able to conceive after a UFE procedure.”

What’s more, UFE had a clinical success rate of almost 79% in treating fibroid-related symptoms, such as heavy menstrual bleeding and pelvic pain and pressure.2 Even though partial UFE only embolizes small artery branches, it still cut off blood supply to the dominant fibroid by more than 90% and wasn’t linked with higher rates of repeat intervention. Throughout the study, UFE was repeated in 28 women whose MRI scans showed incomplete treatment, with 11 of these patients going on to get pregnant for the first time.

This is good news especially as research in this area continues. Partial embolization might be able to reduce blood supply to the fibroids without limiting circulation to the uterus and ovarian arteries, potentially allowing for a better pregnancy rate and lower complication rate.2 A study comparing partial and conventional UFE is the next step.

Giving women who want to protect their fertility or restore it, as Dr. Pisco mentions, is important particularly for those who aren’t the best candidates for myomectomy or who have had no prior success with the surgery. “UFE is the only effective option when a woman has multiple fibroids or fibroids that are very large,” Dr. Pisco notes. Myomectomy may also be difficult if large fibroids are located within the uterine wall—a type called intramural—or just under the inner uterine lining—a type called submucosal.2 For these patients, having UFE as an option is essential.

In this study, an increased likelihood of pregnancy following UFE was linked to having a dominant submucosal fibroid as well as when UFE restricted fibroid blood supply by 90% or more, which both conventional and partial approaches are capable of doing.2 Treating fibroids to this degree, the study explains, stops them from growing and allows them to continue to shrink during pregnancy.

Whether UFE holds a place as a viable treatment for women desiring pregnancy is still being investigated. But with UFE research constantly unfolding, the number of options we have is increasing, as is our hope for something better.

ABOUT THE AUTHOR   Alicia Armeli is a Freelance Writer and Editor, Registered Dietitian Nutritionist, and Certified Holistic Life Coach. She has master’s degrees in English Education and Nutrition. Through her writing, she empowers readers to live optimally by building awareness surrounding issues that impact health and wellbeing. In addition to writing, she enjoys singing, traveling abroad, and volunteering in her community. She is a paid consultant of Merit Medical.

ABOUT THE DOCTOR   João Martins Pisco, MD, PhD, is director of interventional radiology at St. Louis Hospital, chief radiologist at Hospital Pulido Valente, and professor of radiology at New University of Lisbon in Lisbon, Portugal. He is a world-renowned expert in embolization procedures and treats patients all over the globe. In addition to his practice, Dr. Pisco lectures regularly at international medical conferences and has written thousands of published book chapters and papers.

REFERENCES

  1. Baird, D. D., Dunson, D. B., Hill, M. C., et al. (2003). High cumulative incidence of uterine leiomyoma in black and white women: Ultrasound evidence.Am J Obstet Gynecol, Jan; 188(1), 100–107.
  2. Pisco, J. M., Duarte, M., Bilhim, T., et al. (2017). Spontaneous pregnancy with a live birth after conventional and partial uterine fibroid embolization. Radiology, Oct; 285(1):302-310.

September 17

INTERVENTIONAL NEWS

 

52 –  Spontaneous Pregnancy with a Live Birth after Conventional and Partial Uterine Fibroid Embolization

Radiology online / June 14,  2017

 

1. Embolização das artérias uterinas no tratamento de fibromiomas. Resultados preliminares

Pisco, J. Martins; Guerra, Adalgisa; Monteiro, Mª Manuel; Santos, Daniela Dias; Santos, A. Ribeiro; Branco, Jorge.
Arquivos da Maternidade Dr. Allfredo da Costa 2005, nº 2, vol XV, pág. 39-47.

Summary
Six cases of symptomatic uterine fibroids treated by uterine artery embolization are presented. The percutaneous intervention performed under local anaesthesia is described and the results are presented. Technical and clinical success was obtained in every patient with resolution of the symptoms and size reduction of the fibroid and uterus. There were no complications.
It is concluded that uterine artery embolization is an efficient and safe treatment in symptomatic uterine fibroids.

2. Embolização das artérias uterinas nos fibromiomas: 1 ano de experiência

Pisco, J. Martins; Duarte, Marisa; Santos, Daniela Dias; Guerra, Adalgisa; Monteiro, Mª Manuel; Castaño, João; Bicho, Clara, Branco, Jorge.
Arquivos da Maternidade Dr. Allfredo da Costa 2005, nº 2, vol XVI, pág. 22-29.

Summary
Uterine artery embolization was performed in 66 patients with symptomatic fibroids, with technical success of 98.5% and clinical success of 95.5%. Following embolization there was symptoms improvement and size reduction of the fibroids and uterus. It is conclude that the uterine artery embolization in an efficient and safe treatment with low morbility.

3. Embolização das artérias uterinas: terapêutica alternativa eficaz para os fibromiomas

Pisco, J. Martins; Duarte, Marisa; Monteiro, Mª Manuel; Guerra, Adalgisa; Santos, Daniela Dias; Castaño, João; Bicho, Clara, Branco, Jorge.
Patient Care 2005; 10 (108):101 – 105 (1st prize, considered the best paper of the year 2005)

Summary
UAE is a new and important alternative in the treatment of symptomatic uterine fibroids, it is a microinvasive procedure, with low morbidity, effective and safe.

4. Embolização das artérias uterinas nos fibromiomas. Resultados iniciais e a médio prazo

Pisco, J. Martins; ; Castaño, João Duarte, Marisa; Guerra, Adalgisa; Santos, Daniela Dias Monteiro, Mª Manuel; Henriques, Hermínia; Bicho, Clara, Branco, Jorge.
Revista de Obstetrícia e Ginecologia, Vol. XXIX – nº 4, Abril 2006

Summary
UAE was performed, under local anaesthesia in 200 patients, age ranged between 23 and 57 years old, 192 with uterine fibroids, 4 associated with adenomyosis and 4 with pure adenomyosis.
Ninety two were treated as outpatient. There were 21 recurrences, with clinical success in 179 (89.5%). New embolization was performed in 6 patients, with clinical improvement in 5 patients, therefore the secondary success occurred in 184 patients (92%). There were 3 major complications, 2 of them were hysterectomy (1.5%). It is concluded that UAE is a efficient procedure with short and medium term good results and low morbidity.

5. Is a two month hormone free period enough for efficacy of UAE for fibroids?

J.M.Pisco; M. Duarte; A. Guerra; M.M. Monteiro; D. Santos; J. Castaño; F.M. Pires.
Hospital St. Louis, Hospital Pulido Valente, Lisbon

CIRSE, 10 SETEMBRO 2006, ABSTRACT BOOK, PAG. 184

Purpose:
To evaluate if a 2 months period without hormone therapy is enough for a good outcome of uterine artery embolization for fibroids in patients who are under hormone therapy.

Material and methods:
Six patients who underwent uterine artery embolization for fibroids were under hormone therapy. Before embolization they stopped the hormones for a 2 months period since the last hormone injection. Ultrasound and enhanced MR was performed in all patients before, 2 weeks and 6 months following uterine arteries embolization. Before hormone therapy all patients had haemorrhage longer than 10 days.
Embolization was performed with polyvinyl alcohol particles. Six months after embolization a second embolization was performed.

Results:
In every patient there was some decrease of the haemorrhage following uterine artery embolization. However, in all of them there was recurrence following 2 months. The enhanced MR showed ischemia less than 10% and only slight decrease in size of the fibroids and uterus. Six months following embolization, a second embolization was performed. The uterine artery branches of the second angiography had a larger calibre than those of the first angiography in which the vessels had some spasm. Following second embolization there was significant decrease of the haemorrhage, of the fibroid and uterus size and the fibroid ischemia increased over 90%.

Conclusion:
A two months period hormone free is not enough for efficient uterine artery embolization for fibroids.

6. Outpatient uterine artery embolization for fibroids

J.M.Pisco; M. Duarte; M.M. Monteiro; D. Santos; A. Guerra; J. Castaño; F.M. Pires.
Presented at CIRSE, 10 SETEMBRO 2006, ABSTRACT BOOK, PAG. 185

Purpose:
To evaluate if uterine artery embolization can be performed as an outpatient procedure without increasing risks.

Material and methods:
One hundred sixty-two patients underwent uterine artery embolization during a 19- month period. Embolization was performed with polyvinyl alcohol particles (153 of 162 patients) or tris-acryl gelatine micro spheres (9 of 162 patients). In 103 patients the embolization was performed as inpatient procedure and in 59 as outpatient procedure. These 59 patients were discharged 6-9 hours after the procedure. Analgesic, anti-inflammatory, antibiotics and antiemetic were given before, during and after embolization. At discharge, the patients were informed about the constitutional symptoms they could expect after the embolization and a questionnaire was given to evaluate the pos embolization symptoms. All patients received our telephone call at 24, 48 and 72 hours after discharge and were follow-up for at least 30 days after the procedure. A retrospective comparison was performed of the pos-embolization symptoms of the inpatient and outpatient uterine artery embolization.

Results:
None of the patients discharged 6-9 hours after the procedure, returned to the hospital after discharge. At the first follow-up phones call, the reported symptoms were: pelvic pain, nausea-vomiting, haemorrhage and abdominal distension. The symptoms were controlled with discharge medications in all patients. All patients were satisfied with the early home discharge. There was no difference of the pos-embolization symptoms between the inpatients and outpatient embolization.

Conclusion:
With close follow-up and specific medication, uterine artery embolization can be performed safely as out patient procedure.

7. The safety of uterine artery embolization for large fibroids

J.M.Pisco; M. Duarte; M.M. Monteiro; D. Santos; A. Guerra; J. Castaño; F.M. Pires.
Presented at CIRSE, 10 SETEMBRO 2006, ABSTRACT BOOK, PAG. 245

Purpose:
To evaluate the safety of uterine artery embolization for large uterine fibroid.

Material and methods:
Fifty two women underwent uterine artery embolization for large uterine fibroid age 23-54, mean 40,6years).
Enhanced MR was performed before, 2 weeks and 6 months after the procedure. The fibroid size ranged from 10 to 30 cm. Embolization was performed with polyvinyl alcohol particles or embospheres. At discharge a questionnaire was given to every patient to evaluate the embolization symptoms. All patients were follow-up for at least 30 days after the procedure.

Results:
Uterine artery embolization was performed successfully in every patient.Two major complications occurred that consisted on expulsion of the fibroid. One of the patients required hysterectomy. No permanent sequela was observed in the other patient. Complications in the remaing patients were minor and will be presented.

Conclusion:
Uterine artery embolization for large fibroids is a safe procedure.

8. Uterine Artery Embolization under acupuncture on uterine fibroids

J. Martins Pisco, Mitsuharu Tsuchiya, Anabela Neves, Marisa Duarte, Daniela Santos.
Presented at SIR, MARCH 02 2007, ABSTRACT BOOK, PAG. 120

Purpose:
To evaluate if acupuncture maybe an alternative to the use of pharmacologic sedation / analgesia on uterine artery embolization (UAE) of uterine fibroids.

Material and methods:
The study population included 12 white women who underwent UAE under acupuncture (36 – 48 years old). No pharmacologic sedation / analgesia was given before or during UAE but only anti-inflammatory and antibiotics. No local anaesthesia was given. UAE was performed by single femoral approach and both uterine arteries were embolized with polyvinyl alcohol (PVA). In the first 2 treated patients (group A) analgesic, anti-inflammatory and antihemetic were given 4 hours after embolization. In the remaining 10 patients (group B) anti-inflammatory (Ketorolac triomethamide -15 mg) and analgesic (paracetamol – 500 mg) in a reduced dose, were started after embolization to control pain. For nausea and vomiting, prochloperamide (50 mg) i.v. was given as antihemetic.

Results:
No pos-embolization symptoms were referred by any patient, during the UAE and the following 4 hours. At this time, the first 2 patients (group A) referred some pain, nausea and vomiting, but all symptoms were controlled easily by analgesic plus antihemetic. The remaining 10 patients (group B) referred only light pain, nausea or vomiting. All patients were discharged from the hospital – 8 hours after the procedure.

Conclusion:
Acupuncture maybe an alternative to the use of pharmacologic sedation / analgesia before and during the embolization and to reduce the dose of analgesics, anti-inflammatory and antihemetic that should be administrated after UAE in order to control the pos-embolization syndrome.

9. Uterine Fibroid Embolization with cetoprofen – loaded PVA particles

J. Martins Pisco, Marisa Duarte, Ana Ferreira, Tiago Bilhim, Daniela Santos, F.M. Pires.
Presented at SIR, MARCH 02 2007, ABSTRACT BOOK, PAG. 13

Purpose:
To evaluate if pelvic pain following uterine artery embolization (UAE) can be reduced using cetoprofen – loaded PVA particles.

Material and methods:
UAE was performed in 80 patients, age 25 – 52 years (mean 39, 5) with polyvinyl alcohol (PVA) particles. Cetoprofen (100 mg) was added to PVA particles in a randomized way. Thus in 40 patients PVA particles were loaded with the anti-inflammatory and in another patients 40 PVA particles were used without cetoprofen. Fifty three patients who were asymptomatic 8 hours after embolization were discharged as outpatients. The remaining 27 spent overnight at the hospital and were discharged the next morning. Daily for a week, patients recorded their level of pain and then the score sheets were mailed in. Comparison was made between the pain score of the patients in both groups.

Results:
There was a significant difference of pos-embolization pelvic pain only in the day of embolization. Thus, 13 of the patients in the group without cetoprofen refereed severe or very severe pain and none of the patients in the cetoprofen group mentioned it. As a result of severe or very severe pain 17 in patients without cetoprofen were treated as inpatients and only 10 patients in the cetoprofen group spent the overnight at the hospital. Two of the patients without cetoprofen were rehospitalized for 2 days due to severe pain. Fifty three patients were treated as outpatients, 29 of them in the cetoprofen group and 24 in the group without cetoprofen. There were no adverse effects in the cetoprofen group patients.

Conclusion:
There is reduced severe pelvic pain following UAE with cetoprofen – loaded PVA particles. Turther studies with more patients are important to evaluate the ideal dose and the anti-inflamatory to lower post UAE pain.

10. Management of Uterine Artery Embolization in patients under hormone therapy

J. Martins Pisco, Marisa Duarte, Ana Ferreira, Tiago Bilhim, Daniela Santos.
Presented at SIR, MARCH 02 2007, ABSTRACT BOOK, PAG. 121

Purpose:
To evaluate if a delay on uterine artery embolization (UAE) until first menstruation following agonist plus transdermal mitroglicerin can improve the results in patients under hormone is efficient in patients under hormone therapy (GnRH).

Material and methods:
Eighteen women, age 23 to 40 years (mean 34, 6) with symptomatic fibroids and haemorrhage longer than 10 days were under hormone therapy (GnRH) with monthly injection for at least 3 months. Ultrasound and enhanced MR were performed before, 2 weeks and 6 months following UAE. For embolization polyvinyl alcohol (PVA) particles were used. In 6 patients (group A) UAE was performed 2 months after the last administration of hormones and was repeated 6 months later. The remaining 12 patients (group B) waited until they finished the first menstruation following the last hormone administration. At that time they started to place transdermal nitroglycerine patch (10 mg/ 24h) over the skin for 3 weeks and then embolization was performed.

Results:
Following embolization there was clinical improvement in all patients, however in the first 6 patients (group A) there was recurrence 2 months later. In these patients fibroid as proved by ischemia was inferior to 50% enhanced MR fibroid. The angiography at the time of the second embolization showed that the uterine artery branches had a larger calibre than prior to the first embolization in which the vessels showed some spasm. Following the second embolization there was significant decrease of the haemorrhage, fibroid and uterus size and the fibroid ischemia was over 90%. After embolization of the other 12 patients (group B) there was not any recurrence and the MR showed ischemia superior 90% in every patient.

Conclusion:
UAE may not be an efficient procedure if performed 2 months after the last injection of hormones (GnRH). However, UAE is efficient if there is a delay on the embolization until the first menstruation after the last injection of hormones followed by transdermal nitroglicerine patch.

11. The safety of uterine artery embolization as an outpatient procedure

J. Martins Pisco; Marisa Duarte; Ana Ferreira; Tiago Bilhim; Daniela Santos; F.M. Pires.
Presented at SIR, MARCH 02 2007, ABSTRACT BOOK, PAG. 15

Purpose:
To evaluate if uterine artery embolization (UAE) can be performed safely as an outpatient procedure without increasing complications.

Material and methods:
Two hundred ten patients underwent UAE during a 22 month period in a single center. Embolization was performed with polyvinyl alcohol particles (PVA) (198 of 210 patients) and tris-acryl gelatine micro spheres (12 of 210 patients). Six to eight hours following UAE 82 patients with mild symptoms were discharged and the remaining 128 patients stayed in the hospital. Gadolinium enhanced MR imaging was performed prior to EAU and 2 weeks following the procedure in all patients and 6 months after the procedure in 34 patients. The clinical and MR imaging findings were evaluated before and after the procedure. At discharge, the patients were informed about thel symptoms that might occur. A questionnaire was given to all patients to evaluate the pos-embolization symptoms and the grade of satisfaction. A retrospective comparison was performed of the pos-embolization symptoms of the patients who stayed in the hospital and those who were discharged in the same day after UAE.

Results:
None of the patients discharged 6-8 hours after the procedure, returned to the hospital after discharge. The reported symptoms after discharge were: pelvic pain in 80, 5% (66 of 82), nausea-vomiting in 42, 6% (35 of 82), haemorrhage in 19,5% (16 of 82) and abdominal distension in 7,3% (6 of 82). The symptoms were controlled with discharge medications in all patients The MR imaging of the 82 outpatients was: complete infarction in 78,1% (64 of 82), partial infarction in 7,3% (6 of 82) and no infarction in 14,6% (12 of 82).There was no difference in the evaluation of the pos-embolization symptoms and the MR findings between the patients treated as inpatients and those treated as outpatients although the inpatient symptoms were more severe. The overall clinical improvement was 90, 5%. All patients were satisfied with the early home discharge and decreased hospital cost.

Conclusion:
With close follow-up and specific medication, uterine artery embolization can be performed safely as out patient procedure, without increasing morbidity and with great satisfaction.

12. The acupuncture on uterine artery embolization of uterine fibroids

João Pisco, Mitsuharu Tsuchiya, Anabela Neves, Marisa Duarte, Ana Ferreira, Tiago Bilhim, Daniela Santos.
Presented at CIRSE, 11 de Setembro de 2007; Abstracto book, page 248

Purpose:
To evaluate if acupuncture can be an alternative to the use of pharmacologic sedation / analgesia on uterine artery embolization (UAE).

Materials and Methods:
Twenty six women with uterine fibroids underwent UAE under acupuncture. No pharmacologic sedation / analgesia or local anaesthesia was given before or during UAE. Needles connected to electrostimulator were placed 10 mn before the procedure started. To the first 2 treated patients (group A) analgesic, anti-inflammatory and antihemetic were given 4 hours after embolization. To the remaining 24 patients (group B) those drugs in a reduced dose, were started after the end of embolization.

Results:
No post-embolization symptoms were referred by any patient, during the UAE. Four hours later the first 2 patients (group A) referred some pain, nausea and vomiting, but all symptoms were controlled easily by analgesic plus antihemetic. The remaining 24 patients (group B) referred only light pain, nausea or vomiting. All patients were discharged from the hospital 8 hours after the procedure.

Conclusion:
Acupuncture can be an alternative to the use of pharmacologic sedation / analgesia given before and during the embolization. However analgesics, anti-inflammatory and antihemetic in reduced dose should be administrated after UAE.

13. How to reduce the severity of pain after uterine artery embolization of fibroid for leiomyomata

João Pisco, Marisa Duarte, Ana Ferreira, Tiago Bilhim, Daniela Santos, João Castaño.
Presented at CIRSE, 11 de Setembro de 2007; Abstracto book, page 317

Purpose:
To evaluate if the severity of pain after uterine artery embolization (UAE) for leiomyomata can be reduced with specific medication started before the procedure.

Material and methods:
Eighty women with symptomatic uterine fibroids were treated by UAE. Anti-inflammatory, anti-histaminique and acid-suppressing (proton pump inhibitor) were taken 1 day and 6 hours before embolization and repeated just before, during and after embolization. The asymptomatic patients were discharged 6 to 8 hours after embolization as outpatients. The symptomatic patients spent the overnight in the hospital as inpatients and were discharged the next morning.

Results:
During UAE, only 5 patients felt some pain. After UAE, 45 patients did not refer any symptom, 26 felt some pain and 9 severe pain. Six patients spent the overnight in the hospital and the remaining were discharged 6 – 8 hours after UAE. There was not difference of the pre-embolization symptoms, the age of the patients, and the size of fibroids of the patients treated as outpatients and those discharged next morning.

Conclusion:
Severity of pain after uterine artery embolization for leiomyomata can be reduced with specific medication given the night before and 6 hours before the procedure.

14. The efficacy and safety of repeated uterine artery embolization

João Pisco, João Castaño, Marisa Duarte, Ana Ferreira, Tiago Bilhim, Daniela Santos.
Presented at CIRSE, 11 de Setembro de 2007; Abstracto book, page 314

Purpose:
To evaluate if repeated uterine artery embolization (UAE) for leiomyomas is effective and safe.

Method and materials:
At a single center, UAE was repeated 6 to 12 months after the first embolization in 32 patients who had failure to previous embolization. Gadolinium enhanced MR imaging was performed before, 2 weeks and 6 months after each procedure. In two patients the embolization war repeated twice.

Results:
MR imaging following the first UAE showed incomplete infarction in 26 patients and growth of new leiomyoma in 6 patients. Following 2nd embolization there was clinical improvement in all patients but 2. The follow up control MR imaging after repeated embolization showed complete infarction of the fibroids in 27 patients, partial infarction in 3 patients and no change in 2 patients. In 2 patients with complete infarction and clinical improvement following the 2nd embolization, one year later, there was recurrence due to regrowth of a new fibroid. After second repeated embolization there was clinical improvement again. One fibroid was expelled after 2nd embolization without sequelae. There were no other major complications following repeated UAE.

Conclusion:
Repeated UAE on failures due to incomplete infarction following initial embolization is a safe and effective treatment for recurrences of uterine fibroids.

15. How to reduce the post-embolization syndrome and to performe uterine artery embolization as an outpatient procedure

João Pisco, Marisa Duarte, Ana Ferreira, Tiago Bilhim, Daniela Santos, F. Moura Pires
Presented at RSNA 26 de Novembro de 2007, Abstract book, pag. 524

Clinical relevance/application:
Management of postembolization symptoms is the key to performe Uterine Artery Embolization (UAE) as an outpatient procedure.

Purpose:
To evaluate if the association of anti-histaminique, anti-inflammatory and acid suppressing drugs plus good information before UAE can reduce the post-embolization syndrome (PES) and increase the number of outpatients.

Method and materials:
Two hundred forty patients, with symptomatic uterine fibroids underwent UAE. Eighteen and six hours before embolization the patients were medicated with omeprazole, diclofenac potassium and hydroxyzine. After embolization the asymptomatic patients or with mild symptoms were released from the hospital 6 – 8 hours after UAE as outpatients. The patients were informed about the constitutional symptoms they could expected and the corresponding medication. The clinical presentation and the post-embolization symptoms of the outpatients and inpatients were compared.

Results:
Two hundred thirty one patients were treated as outpatients and nine as inpatients. There were 2 readmissions to control pain and vomiting, therefore the number of inpatients increased to 11 (4.6%) and the number of outpatients decreased to 229 (95.4%). There was no relation of the clinical presentation, fibroid and uterus size before embolization with the PES. The PES of the inpatients were markedly worse just in the first 12 hours after UAE.

Conclusion:
The association of anti-histaminique, anti-inflammatory and acid suppressing drugs plus good information of the constitutional symptoms and corresponding medication before UAE reduce the PES and increase the number of outpatients (95.4%).

16. Embolização das artérias uterinas nos fibromiomas. Resultados iniciais e a médio prazo.

João Martins Pisco, Marisa Duarte, Tiago Bilhim, Ana Ferreira, Daniela Dias Santos, João Castaño
Revista Intervencionismo, 2007; 7.1: 27-31

Summary:
UAE was performed in 342 patient’s age between 23 and 58 years (mean 40.4 years).
223 had uterine fibroids 15 associated adenomyosis and 4 pure adenomyosis.
202 patients spent the night in the hospital, and 3 spent 2 days in the hospital. There were recurrence in 43 patients, therefore the clinical success was 90.4%. UAE was repeated in 18 patients and there were good results in 15 patients, therefore the secondary clinical success after new UAE was 99.7%. There were 3 major complications, 2 of them were treated by hysterectomy.
It is concluded that UAE is an efficient procedure, with short and medium term good results and low morbidity.

17. Embolização das artérias uterinas nos fibromiomas: resultados clínicos e imagiológicos em 500 doentes.

João Martins Pisco, Marisa Duarte, Ana Ferreira, Tiago Bilhim, Daniela Dias Santos, João Castaño
Revista Patient Care, Vol.13, Nº134, Fevereiro 2008, pags. 83 – 88

Summary:
The results of UAE in 500 patients show that the procedure is a minimally invasive with low morbidity and high efficacy at medium term.

18. Escleroterapia do varicocelo da veia ovárica – resultados a curto e longo prazo.

João M. Pisco, Marisa Duarte, Tiago Bilhim, José Daniel Menezes, José Pereira Albino, Luís Mota Capitão, Jorge Branco
Revista Acta Obstétrica e Ginecologia Portuguesa, Vol.2 N1 Janeiro /Março 2008, 5 – 11

Summary:
In a 8 years period, 36 patients with clinical suspection of pelvic varicocele that was proven in 38 patients.
Sclerotherapy of ovarian vein was technically successful in every case. There was clinical improvement with complete resolution of every symptom in 29 patients (89.9%) and partial improvement in 6 (17.1%). The long term results between 1 and 6 years (mean 37 years), showed total resolution in 27 patients (77.1%) and recurrence in 8 (22.9%).
In 4 recurrences there was improvement following second sclerotherapy. Therefore there was improvement in 31 patients (88.6%) of the patients.
It is a concluded that sclerotherapy of ovarian vein is a safe and efficient treatment in ovarian vein varicocele.

19. The impact of different size of PVA particles for uterine artery embolization for leiomyomas: a randomized study
João Pisco, Marisa Duarte, Tiago Bilhim, Daniela Santos, Ana Ferreira, António Oliveira

Presented at CIRSE 2008, Abstract book pag. 372

Purpose:

To evaluate wheter the different size of PVA particles for uterine artery embolization (UAE) for leiomyomas change the post embolization symptoms and the outcome of embolization.

Material and methods:

Eighty patients were randomly assigned for UAE with PVA 355 – 500 µ (40 patients group – a) or with 500 – 710 µ particles (40 patients – group b). The short term recovery was evaluated by post embolization symptoms. Contrast material enhanced magnetic resonance imaging was performed before UAE and 6 months after UAE to evaluate the degree of tumour ischemia and the uterus and fibroid volume reduction. Data were analyzed with use of ANCOVA test.

Results:

There were no differences in the baseline clinical presentation of both groups. Clinical follow-up was obtained in 70 patients. The degree of pain after embolization was greater with 355-500µ particles however the differences of the post embolization symptoms after UAE with different particles size was not significant (p=060). The differences of tumour ischemia and the volume reduction of the uterus and fibroid after UAE with 355 – 500 µ and 500 – 710 µ particles were not significant (p=0.40).

Conclusion:

The different size of PVA particles does not change the post embolization symptoms and the outcome of tumour infarction and uterus and fibroid volume reduction after UAE.

20. Spherical, non-spherical or combination of polyvinyl alcohol particles for uterine artery embolization for leiomyomas: a randomized study.

João Pisco, Marisa Duarte, Tiago Bilhim, Daniela Santos, Ana Ferreira, António Oliveira
Presented at CIRSE 2008, Abstract book pag. 372

Purpose:

To evaluate wheter the shape of the polyvinyl alcohol (PVA) particles used for uterine artery embolization (UAE) has an impact on the effectiveness of embolization.

Material and methods:

One hundred and nine patients were randomly assigned to UAE with spherical (39 patients – group A), non-spherical (42 – Group B) or a combination of PVA particles (28 – group C). The size of PVA particles was 350 – 500 µ and 500 – 700 µ. For the purpose a randon number table was used. Enhanced magnetic resonance imaging was performed before UAE and 6 months after UAE to evaluate the degree of tumor infarction and the uterus and fibroid volume reduction. Data were analised with the Ancova test.

Results:

There were no differences in the 3 groups at baseline clinical presentation. The mean rate of volume reduction of the uterus at 6 months was 18.9% for patients of group A, 32.7% for group B, and 29.3% for group C. The mean rate of volume reduction of the fibroid at 6 months was 37.5% for group A 46.2% for group B and 38.9% for group C.
There was a greater and significant uterus volume reduction in patients of group B in comparison to the other patients (p= 0.04). The fibroid volume reduction and the degree of tumor ischemia of the patients of different groups was not significant (p=0.303).

Conclusion:

Non-spherical PVA particles has greater uterus and fibroid volume reduction than spherical particles or a combination of particles.

21. Pelvic pain after uterine artery embolization: a prospective randomized study of polyvinyl alcohol particles mixed with ketoprofen versus bland polyvinyl alcohol particles

João M. Pisco, Marisa Duarte, Tiago Bilhim, Ana Ferreira , Daniela Santos, F. Moura Pires, A. G Oliveira.
JVIR 2008; 19 (11): 1537 – 42

Purpose:
To evaluate whether pelvic pain following uterine artery embolization (UAE) can be decreased using ketoprofen mixed with polyvinyl alcohol (PVA).

Methods and Materials:
Randomized prospective study in 80 patients (25 – 52 years; mean 41.0 years) undergoing UAE with PVA particles between March and August 2006. Forty patients were administered PVA particles mixed with Ketoprofen (100 mg), and 40 patients bland PVA particles. Fifty three patients who were asymptomatic 8 hours after embolization were discharged. The remaining 27 spent the night at the hospital. Pain scores in both groups were compared during the first 8 hours post-procedure, at discharge and the following day. The results of embolization were evaluated after 6 months.

Results:
Thirteen patients reported severe or very severe pain in the group without ketoprofen (32.5%) and none in the other group, as determined by a numeric pain score scale (p=0.0015). Nineteen patients without ketoprofen were treated as inpatients (47.5%), but only 10 in the ketoprofen group (25%). These differences were not statistically significant (p=0.16). Two of the patients without ketoprofen (2.5%) were readmitted within 12 hours following discharge due to severe pain. The differences in the clinical outcome, as well in the uterus and fibroid sizes after 6 months were not statistically significant (p > 0.05).

Conclusion:
There was statistically significant post-embolization pain reduction, during the first 8 hours after the procedure, following UAE with ketoprofen mixed with PVA. There were no other changes of the post embolization symptoms. UAE with Embozene microspheres under acupuncture. Preliminary results. International symposium on endovascular therapy. Miami, 21 de Janeiro 2009.

INTRODUCTION
Uterine artery embolization (UAE) is usually a painful procedure (1). Pain after the procedure can occur as a single symptom. The post-embolization syndrome is characterized by the association of pain with other symptoms such as nausea, vomiting, pelvic pain, general malaise, fever and leukocytosis (2, 3). Management of these post-embolization symptoms, and of pain in particular, is paramount if UAE is to be performed as an outpatient procedure (4). Several different strategies, involving oral, intravenous, epidural, and/or patient-controlled analgesia, have been utilized in an attempt to manage the pain associated with UAE (3, 4, 5, 6, 7, 8, 9). Different protocols have used analgesic and/or anti-inflammatory agents along with the embolizing agents. Previously, pain control has been addressed using ibuprofen-loaded microspheres for uterine artery embolization (10, 11). This technique can release high concentrations of ibuprofen at the site of the uterine fibroids, which makes it a promising approach for the control of post-embolization pain (11).

Polyvinyl alcohol (PVA) has been mixed with ketorolac to control post-embolization pain (12). PVA has also been mixed with other different types of drugs such as lidocaine hydrochloride. Pelage et al (13) have described a technique in which they added lidocaine hydrochloride to the PVA mixing cup. Lidocaine has also been used as an intra-arterial infusion before and after the embolization of fibroids with PVA, resulting in a decrease of post procedure pain. However, it has been found to be associated with moderate to severe vasospasm (14, 15).

Another agent that has been previously used is ketoprofen (13). Ketoprofen is a propionic acid-derived non steroidal anti-inflammatory drug employed as an analgesic and anti-inflammatory agent that can be given orally, topically, i.v. or i.m. Pelage et al (13) have also used ketoprofen i.m. one hour before UAE and the following days after the procedure with good results in the control the post-embolization pain.

Therefore, we began the administration of 100mg of ketoprofen i.m. before UAE, which has reduced the pain symptoms. We then decided to use ketoprofen mixed with the PVA particles in order to determine whether this procedure could reduce post-embolization pain following UAE.

METHODS AND MATERIALS
From March to August 2006, we conducted a randomized prospective study in 80 consecutive patients who were being treated by UAE. Forty patients were administered ketoprofen loaded PVA particles (Group A) and 40 patients were administered PVA particles without ketoprofen (Group B).

The main indications for UAE were menorrhagia, bulk related symptoms, dysmenorrhea and dyspareunia. There was no case of concomitant adenomyosis. Patients seeking future fertility were not excluded. The study was approved by the Institutional Review Board. All patients gave written informed consent.

The patients, but not the operator, were blinded to the technique being used. The patients were randomized using a computer assisted method (randomization by computer-generated random numbers).

Contrast enhanced pelvic Magnetic Resonance (MR) was performed in every patient before embolization to evaluate baseline volume of the uterus and of the largest fibroid (volume= length x depth x width x 0.5233). Contrast-enhanced pelvic MR imaging was performed by using a 1.5 T system (Philips) Axial, – sagital and coronal imaging examinations were performed with TSE T2. T1 weighted MR images, axial and sagital images were obtained before and after gadolinium injection (2ml/second). MR angiography was obtained by specific software to detect contrast arrival.

The uterine arteries of the patients in group A were embolized with nonspherical PVA particles (Contour, Boston Scientific) mixed with an anti-inflammatory. For the purpose of this study, ketoprofen (100 mg) was added to the 50% solution of saline and contrast media containing PVA particles. The uterine arteries of the patients in group B were embolized with PVA particles alone, without ketoprofen.

Before embolization, all patients were medicated with an anti-histaminic (hydroxyzine 25 mg p.o., Atarax, UCB), an acid suppressing drug (omeprazole 20 mg i.v., Bluepharma), anti-inflammatory drugs (ketoprofen 100 mg i.m., Profenid, Victoria; and diclofenac potassium 50 mg per os, Voltaren, Novartis), analgesic (tramadol 100 mg i.v., Tramal, Grunental), an antiemetic (Metoclopramide 25 mg i.v, Primperan, Sanofi-Aventis) and an antibiotic (Cefazolin 1g i.v., Cefamezin, Hikma) (table I).

Embolization was performed under local anesthesia by the right femoral artery approach with a single 5Fr cobra shaped catheter and hydrophilic guide wire. A microcatheter was used only when necessary. To catheterize the right uterine artery, the Waltman’s loop was formed.

We started the embolization with a vial of 300 – 500µm PVA particles for each uterine artery and completed with 500-700µm PVA particles, recording of the amount of embolic material used in each patient. The end point chosen for embolization was slow flow or “near stasis” in the main uterine artery (16), as shown by nonfilling of the arterial branches to the fibroids, the interruption of the flow in the uterine artery or the contrast refluxed toward the origin of the uterine artery.

During embolization the patients were medicated with anti-inflammatory (piroxicam 20 mg i.v., Felden, Pfizer; and ketorolac tromethamine 30 mg i.v., Toradol, Roche were administered after catheterization and before embolization of each uterine artery), as well as an analgesic (metamizol 2 g i.v., Nolotil, Bochinger Ingelhiem).

Upon finishing the embolization, the patients were medicated with analgesics (metamizol 2 g i.v.; tramadol 100 mg i.v. and paracetamol 1g i.v.), anti-inflammatory drugs (ketorolak tromethamine 30 mg i.v.) and antiemetics (metoclopramide 25 mg i.v. and ondansetron 4 mg i.v., Hikma).

Immediately after the procedure and every 2 hours thereafter up to discharge the patients were asked to rate verbally their severity of pain by a rating score from 0 (sensation of no pain) to 10 (the worst pain). The peak pain score was recorded from each patient. The degree of pain was evaluated the following morning and on a daily basis during 4 days.

The other post-embolization symptoms were also registered the following hours after embolization, at discharge and the following morning (table IV).

The standard protocol for both groups was same day discharge when possible. Five hours after the procedure, all asymptomatic patients and those with mild symptoms without nausea or vomiting had a light meal, started oral medication and were discharged from the hospital, 6 to 8 hours after embolization, as outpatients. The remaining patients spent the night at the hospital as inpatients and were discharged the next morning, 18 hours later.

At discharge, the patients were medicated with hydroxyzine 25 mg o.d., levofloxacine 250 mg b.i.d. (Tavanic, Sanofi – Aventis), diclofenac potassium 50 mg t.i.d., paracetamol 1g t.i.d. and clonixidine 100 mg t.i.d (Clonix, Janssen – Cilag). As on-demand medication, the patients were given tramadol 37.5 mg plus paracetamol 325 mg and codeine 30 mg (Dol-U-Ron, Neo-Framaceutica) for pain, and dimenhydrinate 100 mg (Enjomin, Codilab) as suppositories for vomiting.

At first consultation, at admission to the hospital and at discharge, the patients were informed both verbally and in written about the post-embolization constitutional symptoms they could expect and the corresponding medication. At discharge the patients were given the cellular phone number of one of the interventional radiologists and 2 questionnaires to be filled daily for a week and then weekly for 4 weeks, and once 6 months after the procedure. The patients were questioned concerning their satisfaction with their time of discharge.

After discharge from the hospital the patients received our daily telephone call, for 4 days. After being filled, the score sheets were mailed in.
Comparison of the symptoms of both groups was made on the day of embolization after the procedure, at the time of discharge and in the morning following embolization.

The overall results of embolization were evaluated at 6 months after the procedure by contrast enhanced pelvic MR, by the answers to the questionnaires and by clinical observation in 76 patients. Four patients were lost (2 from each group) to follow up.

The Fisher’s exact test, the Student’s t-test and the Wilcoxon rank-sum test were used to compare the clinical presentation and the post-embolization results between groups. Changes from baseline were compared between groups with analysis of covariance. Statistical significant difference were assumed when p<0.05.

RESULTS

UAE was performed in 80 consecutive patients, age 25 – 52 years (mean 41.0 years). Seventy six patients were Caucasian and four were African. There were no statistically significant differences of the baseline data of patients of both groups (table II). The technical success rate for bilateral uterine artery embolization was 97.5% (78 out of 80). In 2 patients only one uterine artery was embolized due to the small size and tortuosity of the other uterine artery.

The mean total volume of PVA particles used per patient was 3.23 c.c. in Group A, and 3.31 c.c. in Group B, with no statistically significant differences between groups (p=0.60).

During embolization only 5 patients reported 1 to 2 score pain. There was an allergic contrast reaction in one patient that was treated with hydroxyzine and corticosteroids.

The mean pain score (rated from 0 to 10) during the first 8 hours post-embolization (before discharge) was 1.575 in Group A and 4.275 in Group B. In Group A, pain score ranged from 0 to 5, while in Group B, pain score ranged from 0 to 10. These differences were statically significant (P=0.0015), (table III). There were 13 patients (32.5%) with severe or very severe pain in the group without ketoprofen (Group B), while none in the other group reported it (Group A). There were 9 patients without pain and 20 patients with light pain in Group A, while there were 6 patients without pain and 10 patients with light pain in Group B (table IV). These differences were statistically significant (p=0.0086).

At discharge and during the next morning after UAE there were no statistically significant differences in mean pain scores between Group A and Group B (p=1.0; p=0.45).

During the 4 days after the procedure 8 patients in group A and 9 patients in group B referred pain.

There were also no statistically significant differences in the other post-embolization symptoms, at time of discharge, during the next morning and the next 4 days after UAE, between Group A and Group B (table IV).

The symptoms at discharge were: light pain (score 1 to 2) in 23 (28.8%), fatigue in 14 (17.5%), anorexia in 5 (6.3%), abdominal swelling in 3 (3.8%), and vaginal bleeding in 2 (2.5%).

The symptoms in the morning following embolization were light pain (score 1 to 2) in 20 (25%), fatigue in 11 (13.8%), anorexia in 5 (6.3%), vaginal bleeding in 5 (6.3%) and abdominal swelling in 3 (3.8%).

During the next 4 days after UAE 2 patients (2.5%) reported low grade fever, 4 (5%) had abdominal swelling and 3 (3.8%) had constipation.

Fifty three patients (66.25%) were asymptomatic 8 hours post-embolization and were discharged as outpatients. The remaining 27 (33.8%) stayed overnight at the hospital and were discharged the following morning, therefore being considered as inpatients.

Two of the patients in Group B (2.5%) were readmitted during the first 12 hours following discharge due to severe pain (score 6 to 7), while there were no readmissions in Group A. Both patients had fibroids smaller than 150c.c. Therefore, the total number of inpatients was 19 (47.5%) in Group B, and 10 (25%) in Group A. Conversely, the number of outpatients was 21 (52.5%) in Group B and 30 (75%) in Group A (table V). These differences were not statistically significant (p=0.16).

Patient satisfaction concerning time of discharge (p=0.49) was 100% in Group A, and 97.5% in Group B (one patient in this group was dissatisfied by the degree of pain after discharge and consequent readmission).

The mean time between the day of the procedure and return to work was 6.1 days overall (range 3 – 12 days) with 6.3 days in Group A and 6.2 days in Group B.

As minor complications, 5 patients reported light pain (score 1 to 2) during embolization. There was a mild allergic contrast reaction in one patient (1.3%) that was treated with hydroxyzine and corticosteroids.

As major complications there were 2 readmissions (2.5%) for the reasons described above and 1 fibroid expulsion (1.3%), 5 months after embolization, without any sequel.

There were 3 patients (3.8%) over 50 years of age who started a period of amenorrhea post-embolization that lasted 4 months. One was from Group A and two from Group B.

There was neither arterial spasm nor adverse reactions in both groups.

There were no statistically significant differences in the clinical outcome six months after the procedure between the two groups (table VI). Six months after embolization there was an improvement of menorrhagia in 34 patients (34/38 = 89.5%) from Group A and 34 (34/36 = 94.4%) from Group B (p=0.68), of dysmenorrhea in 12 patients (12/13 = 92.3%) from Group A and 9 (9/10 = 90%) from Group B (p=0.62), of bulk-related symptoms in 11 patients (11/12 = 91.7%) from Group A and 12 (12/14 = 85.7%) from Group B (p=0.81), and of dyspareunia in 12 patients (12/16 = 75 %) from Group A and 9 (9/11 = 81.8%) from Group B (p=0.34).

The mean decrease rate of uterus and dominant fibroid volumes were 52.2% and 42.3% in Group A, and 51.5% and 55.5% in Group B, respectively (table VII). These differences were not statistically significant (p=0.55; p=0.56).

DISCUSSION
Pelvic pain is, by far, the most common side effect and complication after UAE (1). The pain severity after UAE can not be predicted (17). As mentioned by Worthington – Kirsh et al (9) the pain experienced after embolization follows a consistent pattern over time. Pain increases over the first 2 hours after the procedure and then plateaus for several hours. Pain then decreases fairly rapidly to a much lower level.

Usually, UAE is performed as an inpatient procedure. One of the largest studies is the Ontario Trial (18) involving 555 patients with a mean stay of 1.3 nights. Following discharge, 10% returned to the emergency department and 3% required readmission.

To perform UAE as an outpatient procedure, there are simplified protocols for pain control that reduce symptoms, with the average pain being described as mild cramping, and many patients reporting no pain at all (3, 5, 6, 7).

Another relevant factor to discharging patients early after embolization is patient information as suggested by Siskin et al (5). For this purpose, during initial consultation, at hospital admission and at discharge, patients were given detailed information verbally and in written about the constitutional symptoms that may occur and the corresponding medication.

As suggested by Siskin et al (5), ketorolak has potent analgesic and moderate anti-inflammatory activity and may potentiate the action of the tramadol given previously. Due to the administration of ketorolak tromethamine just before the embolization of each uterine artery, only 5 of our patients reported light pain during the procedure. Siskin et al (5) administered ketorolak tromethamine after the embolization of each uterine artery but we do it beforehand and we continue it after the embolization. After performing the embolization, metamizol, tramadol, paracetamol and ketorolak are administered sequentially. After discharge, the pain is controlled by diclofenac potassium, paracetamol, clonixidine and hydroxizine. If needed, pain medication also includes tramadol plus paracetamol and codeine (5).

In addition to these protocols there are other techniques to control pelvic pain after UAE: embolizing agents loaded with analgesic/anti-inflammatory drugs such as ibuprofen (10, 11); mixing the embolizing agent with ketorolak (12) or lidocaine (13); or injecting lidocaine directly intra-arterially (14, 15).

For further reduction of post-embolization pain, we mixed ketoprofen with PVA particles in this prospective study with 80 randomly selected patients.

Our results showed a reduction in post-embolization pain during the first 8 hours following the procedure has been shown in those patients treated with ketoprofen mixed with the PVA particles. The mean post-embolization pain for patients treated with PVA mixed with ketoprofen was less severe than the one for patients treated with PVA alone. There were 13 patients (32.5%) with severe or very severe pain in the group without ketoprofen (Group B), while none in Group A have reported it. There were more patients without pain or with light pain in Group A than in Group B. These differences were statistically significant (p=0.0086).

From our results, the differences in pain severity and other post-embolization symptoms between both groups were not significant at discharge, the morning after or during the 4 days following UAE.

Thus, PVA particles mixed with ketoprofen help relieving the pain during the first 8 hours post-embolization, with no effect in the post-embolization pain after discharge. There were no adverse reactions or arterial spasm in both groups. Thus, the use of PVA particles mixed with ketoprofen intra-arterially was not associated with arterial spasm. This innovation contributes to perform UAE as a less severe pain procedure.

There were no effects on the clinical outcome (menorrhagia, dysmenorrhea, bulk symptoms and dyspareunia) or on the reduction of the uterus and fibroid when using PVA particles mixed with ketoprofen (p=0.68, p=0.62, p=0.81, p=0.34, p=0.55; p=0.56).

There were no statistically significant differences in the degree and finishing point of embolization between groups, translated by the similar amount of PVA used, by the reduction of uterus and dominant fibroid and by the clinical improvement at 6 months in both groups.

This study has limitations. The patient number is small and uterine artery embolization was performed using only a single dose of an anti-inflammatory drug. Further studies with more patients and different doses or different types of anti-inflammatory drugs will be important. Moreover, the operators were aware of whether or not they were using ketoprofen loaded PVA particles, which can induce bias.

In conclusion, early administration of specific medication for pain, nausea and vomiting and good patient information about the post embolization symptoms, the use of ketoprofen mixed with the embolizing agent can decrease the post embolization symptoms at the day of the procedure, so that most patients can safely be discharged from the hospital within 8 hours.

REFERENCES

  1. Spies JB, Spector A, Roth AR, Baker CM, Skrynarz LM, Skrynarz KM. Complications after uterine artery embolization for leiomyomas. Obstet Gynecol 2002; 100:873–880.
  2. Bruno J, Sterbis K, Flick P, et al. Recovery after uterine artery embolization for leiomyomas: a detailed analysis of its duration and severity. J Vasc Interv Radiol 2004; 15:801-807.
  3. Klein AK, Schwartz ML. Uterine artery embolization for the treatment of uterine fibroids: an outpatient procedure. Am J Obstet Gynecol 2001; 184:1556-1563.
  4. Baerlocher MO, Asch MR, Hayeems EZ, Rajan DK. Uterine artery embolization – inpatient and outpatient therapy: a comparison of cost, safety, and patient satisfaction. Can Assoc Radiol J 2006; 57:95-105.
  5. Siskin GP, Stainken BF, Dowling K, Meo P, Ahn J, Dolen EG. Outpatient uterine artery embolization for symptomatic uterine fibroids: experience in 49 patients. J Vasc Interv Radiol 2000; 11:305-311.
  6. Goodwin SC, Walker WJ. Uterine artery embolization for the treatment of uterine fibroids. Curr Opin Obstet Gynecol 1998; 10:315-320.
  7. Ryan JM, Gainey M, Glasson J, Doherty, J, Smith TP. Simplified pain-control protocol after uterine artery embolization. Radiology 2002; 224:610-611.
  8. Al-Fozan H, Dufort HJ, Kaplow M, Valenti D, Tulandi T. Cost analysis of myomectomy, hysterectomy, and uterine artery embolization. Am J Obstet Gynecol 2002; 187:1401-1404.
  9. Worthington-Kirsch RL, Koller NE. Time course of pain after uterine artery embolization for fibroid disease. Medscape Womens Health 2002; 7:4-4.
  10. Laurent A., Pelage JP. Anti-inflammatory effect of Ibuprofen-loaded embolization microspheres in sheeps uterus. J Vasc Interv Radiol Supplement 2006; 17:39-39.
  11. Laurent A, Pelage JP, Kasselouri A, Prognon P, Guiffant G. Ibuprofen-loaded embolization microspheres versus ibuprofen solution: in vitro and in vivo release studies. J Vasc Interv Radiol Supplement 2006; 17:39-40.
  12. Newman JS, Moon E, Bradley L, Morar K, Heil L, Lieber ML. Pain control following uterine fibroid embolization using ketorolak-loaded PVA particles. Presented at the 2006 SIR Annual Scientific Meeting; April 2, 2006; Toronto.
  13. Pelage JP, Dref O, Soyer P, et al. Fibroid-related menorrhagia: treatment with superselective embolization of the uterine arteries and midterm follow-up. Radiology 2000; 215:428-431.
  14. Songhua Z, Yi L, Guoliang W, Hongjie H et al. Effectiveness of intra-arterial anesthesia for uterine fibroid embolization using dilute lidocaine. Eur Radiol 2005; 15:1752–1756.
  15. Keyoung JA, Levy EB, Roth AR, et al. Intraarterial lidocaine for pain control after uterine artery embolization for leiomyomata. JVIR 2001; 12:1065-1069.
  16. Spies JB, Bruno J, Czeyda-Pommersheim F, Magee ST, Ascher SA, Jha RC. Long-term outcome of uterine artery embolization of leiomyomata. Obstet Gynecol 2005; 106:933-939.
  17. Roth AR, Spies JB, Walsh SM, Wood BJ, Gomez-Jorge J, Levy EB. Pain after uterine artery embolization for leiomyomata: can its severity be predicted and does severity predict outcome?. J Vasc Inter Radiol 2000; 11:1047–1052.
  18. Pron G, Mocarski E, Bennett J, et al. Tolerance, hospital stay, and recovery after uterine artery embolization for fibroids: The ontario uterine fibroid embolization trial. J Vasc Interv Radiol 2003, 14:1243-1250.

Pelvic pain after uterine artery embolization: a prospective randomized study of polyvinyl alcohol particles mixed with ketoprofen versus bland polyvinyl alcohol particles Pelvic pain after uterine artery embolization: a prospective randomized study of polyvinyl alcohol particles mixed with ketoprofen versus bland polyvinyl alcohol particles Pelvic pain after uterine artery embolization: a prospective randomized study of polyvinyl alcohol particles mixed with ketoprofen versus bland polyvinyl alcohol particles Pelvic pain after uterine artery embolization: a prospective randomized study of polyvinyl alcohol particles mixed with ketoprofen versus bland polyvinyl alcohol particles Pelvic pain after uterine artery embolization: a prospective randomized study of polyvinyl alcohol particles mixed with ketoprofen versus bland polyvinyl alcohol particles

22. Uterine artery embolization under electroacupuncture for uterine fibroids

João M. Pisco, MD, Mitsuharu Tsuchiya, MD, Tiago Bilhim, MD, Marisa Duarte, MD, Daniela Santos, MD, Antonio G. Oliveira MD
Presented at SIR, San Diego, 2009 March 9, Abstract book pag. S32

Purpose:
To evaluate whether electroacupuncture is a safe and effective method in alternative to pharmacologic sedation/analgesia on uterine artery embolization (UAE) for uterine fibroids.

Methods and Materials:
Non-randomized prospective study in 70 consecutive patients (age range, 27 – 56 years; mean age 39.5 years) undergoing UAE with polyvinyl alcohol particles (PVA), between August 2006 and January 2007, 33 patients chose to perform UAE under acupuncture (Group A) while 37 patients were treated under local anesthesia (Group B). Pain scores (rated from 0 to 10) in both groups were compared during, after the procedure before discharge, at discharge and the next morning. The outcomes of UAE were evaluated at 6 months.

Results:
The mean pain score during embolization was 0.36 in Group A (under electroacupuncture) and 0.84 in Group B (under local anesthesia); after embolization and before discharge it was 2.80 in Group A (ranging from 0 to 7), and 3.97 in Group B (ranging from 0 to 10), at discharge it was 0.99 in Group A and 1.64 in Group B and next morning it was 1.06 in Group A and 1.15 in Group B. These differences were not statistically significant. All patients were discharged from the hospital 4 to 8 hours after the procedure, but only one patient in each group was not, due to severe pain.

The differences in the clinical outcome as well as in the uterus and fibroid volume sizes at discharge and at 6 months, were not statistically significant (p = 0.04).

Conclusion:
Electroacupuncture is a valuable alternative to the use of pharmacologic sedation / analgesia for uterine artery embolization. There was no statistically significant post-embolization pain difference, and on the outcome of patients treated by UAE under electroacupuncture or under local anesthesia.

23. Management of Uterine Artery Embolization for fibroids as an outpatient procedure

João M. Pisco, MD, Tiago Bilhim, MD, Marisa Duarte, MD, Daniela Santos, MD
Presented at SIR, San Diego, 2009 March 9, Abstract book pag. S33

Purpose:
To evaluate whether it is safe to perform Uterine Artery Embolization (UAE) as an outpatient procedure.

Methods and Materials:
Non-randomized retrospective study in 234 patients (age range 24 – 58 years; mean age 40.5 years) undergoing UAE, with Polivynil Alcohol Particles (PVA) between January 2007 and March 2008. Patients were given acid suppressing drugs, nonsteroidal anti-inflammatories, anti-histaminic drugs and laxatives twice on the day before and once in the morning of UAE. Pain score, rated from 0 to 10, was evaluated, using a numeric pain scale. Four to eight hours after the embolization all patients received tramadol 100 mg i.v. and metoclopramide 25 mg i.v. and were discharged from the hospital. The outcome of UAE was evaluated at 6 months by pelvic magnetic resonance and clinical observation.

Results:
The mean pain score during embolization was 0.9, 4-8 hours after embolization 2.5, at discharge 0.9, at first night after discharge 1.1 and next morning 0.7. All patients were discharged from the hospital 4 to 8 hours after the procedure. There were no readmissions. At 6 months there was a clinical improvement of menorrhagia in 92.4% of the patients, of bulk symptoms in 88.6% and of the pain in 80.0%. The uterus and the dominant fibroid volumes reduced 33.7% and 39.3%, respectively.

Conclusion:
With acid suppressing, anti-inflammatory and anti-histaminic drugs started on the day before UAE every procedure can be performed, safely, as an outpatient procedure.

24. Management of Uterine Artery Embolization for Fibroids as an Outpatient Procedure

João M. Pisco, MD, Tiago Bilhim, MD, Marisa Duarte, MD, Daniela Santos, MD
JVIR 2009 20: 730-735

ABSTRACT

Purpose – To evaluate whether it is safe to perform Uterine Artery Embolization (UAE) as an outpatient procedure.
Methods and materials – Non-randomized retrospective study in 234 patients (age range 24 – 58 years; mean age 40.5 years) undergoing UAE, with Polivynil Alcohol Particles (PVA) between January 2007 and March 2008. Patients were given acid suppressing drugs, nonsteroidal anti-inflammatories, anti-histaminic drugs and laxatives twice on the day before and once in the morning of UAE. Pain score, rated from 0 to 10, was evaluated, using a numeric pain scale. Four to eight hours after the embolization all patients received tramadol 100 mg i.v. and metoclopramide 25 mg i.v. and were discharged from the hospital. The outcome of UAE was evaluated at 6 months by pelvic magnetic resonance and clinical observation.
Results – The mean pain score during embolization was 0.9, 4-8 hours after embolization 2.5, at discharge 0.9, at first night after discharge 1.1 and next morning 0.7. All patients were discharged from the hospital 4 to 8 hours after the procedure. There were no readmissions. At 6 months there was a clinical improvement of menorrhagia in 92.4% of the patients, of bulk symptoms in 88.6% and of the pain in 80.0%. The uterus and the dominant fibroid volumes reduced 33.7% and 39.3%, respectively.
Conclusion – With acid suppressing, anti-inflammatory and anti-histaminic drugs started on the day before UAE every procedure can be performed, safely, as an outpatient procedure.
Abbreviations – UAE – Uterine Artery Embolization, PVA – Polyvinyl alcohol.

INTRODUCTION
Many patients have the post-embolization syndrome after uterine artery embolization (UAE), consisting of nausea, vomiting, pelvic pain, low grade fever, fatigue and general malaise in the first hours after the procedure (1). The pain is due to fibroid ischemia and transient ischemia of the normal miometrium. It is expected that there will be some correlation with the volume of tissue infarcted and the severity of this syndrome. However, the severity of this pain is largely unpredictable (2).

There are other post embolization symptoms associated with UAE on the days following the procedure, such as abdominal swelling, constipation, fever vaginal bleeding, pain nausea/vomiting anorexia or fatigue. As most patients will experience 4 to 5 days of postprocedural symptoms, most centers where UAE is performed admit their patients for 1 to 2 days in the hospital after the procedure for abdominal pain or vomiting control (3, 4, 5).

Since the first reports on uterine artery embolization for the treatment of uterine fibroids and most subsequent studies have indicated that patients should be hospitalized at least overnight for pain control. However, some authors have started to perform UAE successfully, sending the patients home on the day of the procedure (6, 7).

There are simplified protocols for pain control that reduce symptoms, with the average pain being described as mild cramping, and many patients describing no pain at all (2, 3, 5, 8, 9, 10). There is a trend in medicine to shift toward ambulatory care, both to increase patient satisfaction and to reduce health care costs. To perform UAE as an outpatient procedure, an effective postembolization medication must be provided to patients (9).

This retrospective study intends to evaluate whether it is possible to perform UAE safely as an outpatient procedure, without increasing complications, by starting acid suppressing and anti-inflammatory drugs previously to the procedure.

METHODS AND MATERIALS
From January 2007 to March 2008, we conducted a retrospective study in patients who were being treated by Uterine Artery Embolization (UAE), and were discharged on the same day (outpatients). We treated 238 patients during this time period. Four patients were excluded because they were admitted for overnight stay at the hospital (inpatients). Two because they preferred to stay in the hospital and the other 2 because of sever pain that persisted at 8 hours after UAE. The remaining 234 patients were discharged on the same day (outpatients) and included. There were no other exclusion criteria. The patients were consecutive referrals.

The main indications for UAE were menorrhagia, bulk related symptoms, and pain. There were no cases of concomitant adenomyosis. Patients seeking future fertility were not excluded. The study was approved by the Institutional Review Board. All patients gave written informed consent.

Contrast enhanced pelvic Magnetic Resonance (MR) was performed in every patient before embolization to evaluate baseline volume of the uterus and of the largest fibroid (volume= length x depth x width x 0.5233). Contrast-enhanced pelvic MR imaging was performed by using a 1.5 T system (Philips). Axial, sagital and coronal imaging examinations were performed with TSE T2. T1 weighted axial and sagital MR images were obtained before and after gadolinium injection (2ml/second). MR angiography was obtained by specific software to detect contrast uptake by the fibroid. There were no exclusion criteria by MR.

As pre embolization medication, the patients had on the previous day at home (at breakfast and dinner), and on the day of UAE (at breakfast), an acid suppressing drug, (omeprazole 20 mg – Bluepharma) an anti-inflammatory (naproxen 1000 mg, Naprosyn, Roche), an anti-histaminic (hydroxizine 25 mg, Atarax, UCB) and a stool softener (sodic docusate and sorbitol 10 mg + 1340 mg as suppositories, Clyss – Go, Prospa) (table I).

Just before embolization the patients had an ansiolytic (diazepam 5 mg sub lingual, Ratiopharm), an acid suppressing drug (omeprazole 20 mg i.v), analgesics (metamizol 2 g i.v, Nolotil, Boehringer Ingelheim and tramadol 100 mg i.v, Tramal, Grunental) antiemetics (metoclopramide 25 mg i.v, Primperan, Sanofi – Aventis and droperidol 0.10 mg i.v., Janssen Cilag) an anti-inflammatory (piroxicam 20 mg i.v., Felden Pfizer), and an antibiotic (Cefazoline 1 g i.v., Bristol Myers Squibb).

During embolization an anti-inflammatory (ketorolak trometamine 30 mg i.v. Toradol, Roche) was administered twice before the embolization of each uterine artery (total amount of 60 mg). Midazolam 1 mg i.v. was given if necessary.

Embolization was performed, under local anesthesia, by using the right femoral artery approach with a single 5Fr cobra shaped catheter and hydrophilic guide wire. Four interventional radiology physicians (five year experience and one with a 3 year experience of UAE) conducted the procedures. One with 32 years of experience on intervention and 5 of UAE experience was present every case with one of the others; one with 10 years experience on interventions and 5 years of UAE; one with a 5 years experience one interventional UAE and another with 3 years experience of interventional UAE. A microcatheter was used only when necessary. To catheterize the right uterine artery, the Waltman’s loop was formed. Both uterine arteries were embolized with nonspherical polyvinyl alcohol (PVA) particles (Contour, Boston Scientific) mixed with ketoprofen 100 mg. We started the embolization with a vial of 300 – 500µm PVA particles for each uterine artery and completed with 500-700µm PVA particles, recording of the amount of embolic material used in each patient. The end point chosen for embolization was slow flow or “near stasis” in the main uterine artery (11), as shown by nonfilling of the arterial branches to the fibroids, the interruption of the flow in the uterine artery or reflux of the contrast medium toward the origin of the uterine artery.

No aortogram was obtained at the end of the procedures and no arterial closure devices were used. After UAE local compression for 5 minutes and compressive bandages were used and patients were allowed to deambulate 3 hours post-embolization. There was no use of bladder catheterization at the time of the embolization procedure.

Upon finishing the embolization the patients had medication as follows: acid suppressing drug (omeprazole 20 mg iv) analgesics (paracetamol 1g i.v. and metamizol 2 g i.v.), anti-inflammatory (ketorolak tromethamine 30 mg i.v. and piroxicam 20 mg i.v.) and antiemetics (metoclopramide 25 mg i.v. and ondasetron 2 mg i.v., Hikma).

Two to three hours after the procedure, all asymptomatic patients and those with mild symptoms without nausea or vomiting had a light meal, started oral medication with tramadol 37.5 mg plus paracetamol 325 mg (Zaldiar, Grunenthal) and were discharged from the hospital, 4 to 8 hours after the procedure. Just before discharge, tramadol 100 mg i.v. plus metoclopramide 25 mg i.v. was given to every patient.

At discharge patients with no symptoms, mild to severe pain, only light fatigue, anorexia, abdominal swelling or minor vaginal bleeding were considered for discharge.

During the embolization, immediately after the procedure and every 2 hours thereafter up to discharge, at discharge, the night of discharge, the following morning and on a daily basis for the next 7 days, the patients were asked to rate verbally their pain severity using a numeric pain score scale rated from 0 (sensation of no pain) to 10 (the worst pain). According to the degree, the pain could be considered as no pain (0), light (1 – 2), moderate (3 – 5), severe (6 – 7) and very severe (8 – 10) and was recorded in a sheet, as described by HusKisson (12). The peak pain score was recorded from each patient. The other symptoms were also recorded. The symptoms were registered in a sheet by the patient or with the help of an accompanying person or a nurse.

The night of embolization, at home, the patients had omeprazole 20 mg, hydroxizine 25 mg, naproxen 500 mg. As on-demand medication, the patients were given tramadol 37.5 mg plus paracetamol 325 mg (Zaldiar) and codeine 30 mg plus paracetamol 500 mg (Dol-U-Ron, Neo-Framaceutica) per os for pain, and dimenhydrinate 100 mg (Enjomin, Codilab) as suppositories for vomiting.

Next day to the procedure the patients started oral medication with omeprazole 20 mg b.i.d., levofloxacine 250 mg b.i.d. (Tavanic, Sanofi – Aventis), naproxen 500 mg bid., and Clyss Go (as suppositories) and were advised not to stay in bed.

At first consultation, at admission to the hospital and at discharge, the patients were informed both verbally and in a written form about the post-embolization constitutional symptoms they could expect and the corresponding medication. At discharge the patients were given the mobile phone number of the interventional radiologists and 2 questionnaires to be filled daily for a week, and once at 6 months after the procedure. The patients were questioned concerning their satisfaction with their time of discharge, the fibroid related symptoms and the quality of life they had prior and after UAE. After being filled, the score sheets were mailed in.

The overall results of embolization were evaluated at 6 months after the procedure by contrast enhanced pelvic MR, by the answers to the questionnaires and by clinical observation in every patient.

RESULTS
UAE was performed as an outpatient procedure in 234 patients, age 24 – 58 years (mean age 40.5 years). Two hundred and sixteen patients were Caucasian and eighteen were African. Table II shows the main symptoms of the patients and the baseline data. The technical success rate for bilateral uterine artery embolization was 98.7% (231 of 234). In 3 patients only one uterine artery was embolized due to the small size, spasm and tortuosity of the other uterine artery. Seventeen patients were lost to follow up and all the remaining patients completed the multiple questionnaires given. All patients took the medication as described on the day before embolization, although there was no collected data regarding their compliance after UAE and the total amount of medication used.

The mean total volume of PVA particles used per patient was 3.68 c.c.

The mean pain score (rated from 0 to 10) was evaluated, so that during embolization 142 patients did not refer any pain, 67 reported pain score of 1 – 2, 23 pain score of 3 – 5 and 2 pain score of 6 – 7 (table III) with a mean pain score of 0.9.

After embolization and before discharge 54 patients did not feel any pain, 42 reported pain score of 1 – 2, 109 pain score of 3 -5 , 23 pain score of 6 – 7 and 6 pain score of 8 – 10 with a mean pain score of 2.5. At discharge there were 96 patients without pain; 132 with pain score of 1 – 2 and 6 with pain score of 3 – 5 with a mean pain score of 0.9. The other symptoms at discharge were: fatigue in 17, anorexia in16, abdominal swelling in 13 and minor vaginal bleeding in 9 (only blood spots without continuing blood loss, need for extra pads or haemodinamic instability) (table IV).

All patients were discharged from the hospital 4 to 8 hours after the procedure and the mean number of hours before discharge after UAE was 6.8 (range 4 – 8 hours).

At home, on the night of discharge, 85 patients had no pain, 139 referred pain score of 1 – 2, 6 pain score of 3 – 5 and 4 pain score of 6 – 7 with a mean pain score of 1.1.

On the morning following embolization 102 patients had no pain, 121 patients had pain score of 1 – 2 and 11 had pain score of 3 – 5 and the mean pain score was 0.7. The other symptoms next morning to UAE were fatigue in 23, anorexia in 21, vaginal bleeding in 18 and abdominal swelling in 26.

During the next 7 days after UAE 20 patients had abdominal swelling, 14 had constipation and 7 patients reported low grade fever.

The mean time between the day of the procedure and return to work was 7.3 days (range 2 – 13 days), and patient satisfaction concerning time of discharge was 99.1%. One patient who had severe pain the night of discharge was not satisfied.

As minor complications, apart from pain, there was nausea/vomiting in 26 patients, fatigue in 23, anorexia in 21, vaginal bleeding in 18, abdominal swelling in 26 and 5 small inguinal hematomas. As major complications there were 4 fibroid expulsions at 2, 3, 5 and 6 months after embolization, without any sequel. The fibroid expulsions were treated with antibiotics (Vibramicine 100 mg, every 12 hours; Amoxicillin and Clavulanate – Augmentin 500 mg every 8 hours), plus analgesics (Zaldiar, every 8 hours) and anti-inflammatory (Naprosyn, every 8 hours) for 5 days and were self-limited. No major blood loss, infections or other associated complications occurred and there was no need for medical assistance in any case.

There were 8 patients (3.4%) over 46 years of age, who started a period of amenorrhea post-embolization that lasted 4.5 months in 6 and that became permanent in 2. There were no drug sensitivities or allergic reactions to the medication or contrast media used.

Six months after embolization there was an improvement of menorrhagia in 146 of 158 patients (92.4%), of bulk-related symptoms in 39 of 44 (88.6%), of pain in 20 of 25 (80.0%). Only 12 out of 158 patients (7.6%) referred persisting menorrhagia, 5 out of 44 patients (11.4%) had persisting bulk-related symptoms and 5 out of 25 patients (20.0%) referred persisting pain (table V). The mean decrease rate of uterus and dominant fibroid volumes were 33.7% and 39.3% respectively. The mean uterine volume after UAE was 297.5 cm3 regarding a pre-embolization volume of 448.7 cm3 (66.3%) and the mean dominant fibroid volume after UAE was 67.1 cm3 regarding a pre-embolization volume of 110.5 cm3 (60.7%) (table VI).

DISCUSSION
To perform UAE as an outpatient procedure it is important to control the post-embolization symptoms, particularity pain and vomiting and the patients should be informed about those symptoms and the corresponding medication.

With good information and specific medication started before the procedure, pain and vomiting are easily controlled, and the patients can be safely released from the hospital 4 – 8 hours after UAE.

In this study we were able to perform UAE as an outpatient procedure in 234 patients and control pain during and after UAE, with the maximum mean pain score of 2.5 (rated from 0-10) during the first 8 hours postembolization. After embolization and before discharge 54 patients (23.1%) did not feel any pain proving the efficacy of the anti-inflammatory (Naprosyn) medication started on the day before and the analgesic association given during and after the procedure. There were only 2 cases of severe pain (6 – 7) during UAE (0.9%) and 29 patients with severe (6 – 7) or very severe (8 – 10) pain before discharge (12.4%). Patients with severe or very severe pain after UAE were offered the option to overnight in the hospital for pain control, but as the pain decreased in the following hours, they preferred to be discharged with the oral medication given. At discharge, the maximum pain intensity felt by patients was moderate pain (3 – 5 score in six patients), with no cases of vomiting. There were 4 patients excluded from this study as they were treated with overnight hospital admission (inpatients), because they preferred (despite no severe post-embolization symptoms) in two cases and due to persisting severe pain in the remaining 2 patients. Thus, we were able to perform UAE as an outpatient procedure in almost all patients treated from January 2007 to March 2008.

As Baerlocher et al. (9) we had no readmissions. Although Goodwin and Walker (7) described 34% of readmissions for pain control. In a subsequent study they had to admit only 15% of their patients because of fever. Klein and Schwartz (6) had a readmission rate of 9% and Al-Fozan et al (5) of 19% for pain or fever control. We think that with the medication given in our protocol pain and fever can be controlled effectively. It is important, however, to give good information to the patients about the symptoms they can expect during the days following UAE, and to contact the interventional radiologist in case of need or any doubt. Total availability to assist the patient in case of need is paramount in order to avoid complications or readmissions and to assure patient confidence.

Post-embolization symptom control is the clinical challenge to perform UAE as an outpatient procedure (5). Several different strategies have been used in an attempt to manage the pain, nausea and vomiting associated with UAE (6, 7, 8, 9, 11).

Goodwin and Walker were the first to perform UAE as an outpatient procedure (7). They used ketorolak i.v. or i.m., before, during and after the procedure and midazolam or fentanyl during the procedure associated with narcotics, NSAID’s and antiemetics (7).

Baerlocher et al. (9) used morphine sulphate through a controlled analgesic pump. After discharge, pain was controlled with NSAISD’s and narcotic analgesic drugs. There were no readmissions in the outpatient group for pain control (9).

Klein and Schwartz (6) used ketorolak, cefazoline, meperidine, hydroxyzine, ibuprofen, promethazine, oxycodone and acetaminophrn orally, and i.v. for severe pain. Droperidol or ondasetron were the antiemetic drugs.

Al-Fozan et al (5) used acetaminophen with codeine, and meperidine or fentanyl if additional pain control was necessary.

For assessing response to treatment, a pain-relief scale must be used. Pain cannot be said to have been relieved unless it has been directly measured. We used numeric pain score scales rated from 0-10, to assess pain before and after the procedure.

In order to reduce the post embolization pain, patients start anti-inflammatory before embolization to decrease the inflammation that may be present in the fibroid and the post embolization symptoms. Besides that, the anti-inflammatory drugs have some analgesic action. For the purpose, the patients take an anti-inflammatory on the day before UAE (at breakfast and dinner) and on the day of UAE (at breakfast). We used naproxen 1000 mg (Naprosyn, Roche) per os and started it on the day before because it has a half life of 12 to 15 hours so that when patients start UAE are already under the anti-inflammatory action, to decrease the inflammation present in almost every fibroid. We also use the acid suppressing medication on the day before UAE to decrease the effects of the anti-inflammatory on gastric mucosa.

One important drug is Ketorolak tromethamine that, as suggested by Siskin et al (4), has potent analgesic and moderate anti-inflammatory activity and may potentiate the action of the tramadol given previously. Due to the administration of anti-inflammatory drugs before embolization and ketorolak tromethamine just before embolization of each uterine artery only 2 of our patients felt severe pain during embolization. Siskin et al inject Ketorolak after embolization of each uterine artery but we do it before and we continue it after embolization.

After discharge the pain is controlled mainly with naproxen and with tramadol plus paracetamol and codeine plus paracetamol if necessary.

In order to reduce vomiting the patients start an acid-supressing drug (omeprazole) that is a proton pump inhibitor before embolization. Vomiting is due to embolization but also to the effect of analgesic and anti-inflammatory drugs in gastric mucosa even if they are injected i.v. Thus, the protection of gastric mucosa may be a reason of the vomiting decrease. For further reduction of vomiting omeprazole associated with metoclopramide and droperidol are injected i.v before embolization and with ondasetron i.v after finishing UAE. After discharge the vomiting is controlled by dimenhydrinate as suppositories.

For patients to be treated by UAE as outpatients it is important the information about post-embolization constitutional symptoms they could expect and the corresponding medication to control pain and vomiting. The patients receive the information about post-embolization symptoms at first consultation, and the information is repeated at admission and before discharge. Apart the oral explanation the patients bring with them a written form with all the symptoms and the corresponding control medication.

The previous administration (the day before and at breakfast on the day of embolization) of acid suppressing and anti-inflammatory drugs for pain, nausea and vomiting, the association of several drugs in low dose after embolization and good information about post-embolization symptoms and the corresponding medication are keys to perform UAE as an outpatient procedure.

Important situations considered risk factors and in which patients could benefit of an overnight stay in the hospital for monitoring are haemodinamic instability during or after UAE, very intense pain or vomiting persisting 4 to 6 hours post-embolization, massive vaginal bleeding, allergic reactions to the contrast media or medication, no family support, no means of secure and safe transportation home, non compliance with the medication or no means of communication with the interventional radiologist after the procedure. Associated important diseases (psychiatric, heart diseases, or other debilitating conditions with increased risk) can be considered relative contraindications to UAE as an outpatient procedure. Long distances between the hospital and home, inguinal hematomas, or large fibroids (bigger than 10 cm) were not considered absolute contraindications to UAE as an outpatient procedure but should be managed on an individual basis. From January 2007 to March 2008, we treated 238 patients, and only 2 patients (0.8%) were excluded due to severe persisting post-embolization pain.

Six months after embolization there was a clinical improvement in 80.0% to 92.4% of patients and a mean decrease rate of uterus and dominant fibroid volumes of 33.7% and 39.3% respectively, proving that UAE as an outpatient procedure can be performed without risking the medium-term results.

In conclusion, using prophylactic pre embolization medication for pain and vomiting UAE can be performed safely as an outpatient procedure with high patient satisfaction rate, without increasing risks regarding the post-embolization symptoms and without risking the medium-term results.

REFERENCES

  1. Spies JB, Spector A, Roth AR, Baker CM, Mauro L, Murphy – Shryarzk K. Complications after uterine artery embolization for leiomyomas. Obstet Gynecol 2002; 100:873–880.
  2. Roth AR, Spies JB, Walsh SM, Wood BJ, Gomez-Jorge J, Levy EB. Pain after uterine artery embolization for leiomyomata: can its severity be predicted and does severity predict outcome? J Vasc Inter Radiol 2000; 11:1047–1052.
  3. Bruno J, Sterbis K, Flick P, et al. Recovery after uterine artery embolization for leiomyomas: a detailed analysis of its duration and severity. J Vasc Interv Radiol 2004; 15:801-807.
  4. Siskin GP, Stainken BF, Dowling K, Meo P, Ahn, J, Dolen, EG. Outpatient uterine artery embolization for symptomatic uterine fibroids: Experience in 49 patients. J Vasc Interv Radiol 2000; 11:305-311.
  5. Al-Fozan H, Dufort HJ, Kaplow M, Valenti D, Tulandi T. Cost analysis of myomectomy, hysterectomy, and uterine artery embolization. Am J Obstet Gynecol 2002; 187:1401-1404.
  6. Klein AK, Schwartz ML. Uterine artery embolization for the treatment of uterine fibroids: an outpatient procedure. Am J Obstet Gynecol 2001; 184:1556-63.
  7. Goodwin SC, Walker WJ. Uterine artery embolization for the treatment of uterine fibroids. Curr Opin Obstet Gynecol 1998; 10:315-320.
  8. Ryan JM, Gainey M, Glasson J, Doherty, J, Smith TP. Simplified pain-control protocol after uterine artery embolization. Radiology 2002; 224:610-611.
  9. Baerlocher MO, Asch MR, Hayeems EZ, Rajan DK. Uterine artery embolization – inpatient and outpatient therapy: a comparison of cost, safey, and patient satisfaction. Can Assoc Radiol J 2006; 57:95-105.
  10. Worthington-Kirsch RL, Koller NE. Time course of pain after uterine artery embolization for fibroid disease. Medscape Womens Health 2002; 7:4.
  11. Spies JB, Bruno J, Czeyda-Pommersheim F, Magee ST, Ascher SA, Jha RC. Long-term outcome of uterine artery embolization of leiomyomata. Obstet Gynecol 2005; 106:933-939.
  12. HusKisson EC. Measurement of Pain. Lancet 1974;2:1127-1131.

25. Uterine artery embolization under electroacupuncture for uterine fibroids

João M. Pisco, MD, Mitsuharu Tsuchiya, MD, Tiago Bilhim, MD, Marisa Duarte, MD, Daniela Santos, MD, Antonio G. Oliveira, MD
JVIR 2009; 20: 860-870

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26. Uterine Artery Embolization for fibroids

Textbook of Peripheral Vascular Intervention, pag. 692-698
2nd Edition – Edil. Richard Heuses e Michel Henry Informa 2008 UK Ltd.

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27 – Uterine Artery Embolization for the Treatment of Leiomyomas and Adenomyosis: A Series of 600 Patients Treated at a Single Centre.

Acta Obstet. Ginecol. Port. 2009;3(4):197-204

Artigo – Acta Obstetrica Ginecologica Portuguesa

28 – Uterine Fibroid Embolization With PVA: Does the Size of PVA Particles Matter?

João M. Pisco, Tiago Bilhim, Marisa Duarte, António G. Oliveira
SIR Abstract Book Pag. S21 – March 14, 2010

Purpose: To evaluate whether different sizes of PVA particles change the outcomes of uterine fibroid embolization (UFE).

Materials and Methods: A randomized prospective study was undertaken in 160 patients with symptomatic fibroids (ages 21 to 56, mean 39.2 years) undergoing UFE with polyvinyl alcohol (PVA) particles from January 2008 to August 2008. There was no significant difference of the clinical presentation of the patients of both groups. Analgesic and anti-inflammatory drugs were given before, during and after the procedure. In 80 patients (group A) the UFE was started with PVA particles of 300 µm, in the remaining 80 patients (group B) UFE was started with PVA particles of 500 µm. The size of particles was chosen by randomization. In both groups UFE was finished with larger particles, if necessary. Visual analogical scales (VAS) were used to measure pain during and after embolization up to discharge. The outcome of UFE was evaluated at 6 months by enhancing pelvic magnetic resonance imaging, clinical observation and questionnaires. Paired t-test and Ancova were used for statistic analysis.

Results: All patients were discharged from the hospital 4 – 8 hours after the procedure, except 4, 2 in each group who spent the night at the hospital, due to severe pain. Mean pain scores during embolization were 1.4 in group A and 1.0 in group B and scores after embolization up to discharge were 4.7 in group A and 3.4 in group B (p= <0.0001).
At 6 months, the uterus and dominant fibroid volumes decreased, 37% and 49% respectively in group A and 36% and 55% in patients of group B (p= 0.31 and 0.62). The differences were or not statistically significant?

Conclusion: There was a significant lower degree of pain during and after UFE when the procedure started with 500 PVA particles, however, the different size of PVA particles did not change the reduction rate of uterus and uterine fibroid at 6 months.

29 – The Outcome of Pregnancy Following Uterine Fibroid Embolization

João M. Pisco, Marisa Duarte, Tiago Bilhim
St. Louis Hospital and University Department of Radiology, Faculty of Medical Sciences, New University of Lisbon
SIR Abstract Book Pag. S21 – March 14, 2010

Abstract

Purpose – To evaluate the outcome of pregnancy after uterine fibroid embolization.
Material and Methods – Uterine fibroid embolization (UFE) was performed in 743 patients, 74 wanted to conceive. None of them could get a successful pregnancy at the time. Polyvinyl alcohol particles (PVA) or Embozene Microspheres were used to embolize the uterine arteries.

Results – From the 74 patients who wanted to become pregnant 39 (52.7%) had spontaneous pregnancies. Their age ranged 29 – 43 years (mean 35.8 years). The time between UFE and conception ranged between 2 and 22 months (mean 10.8). Seven of them had previous unsuccessful miomectomies and one an unsuccessful fertilization in vitro. There were 29 finished pregnancies with 24 successful life births, 3 spontaneous abortions, 1 induced abortion and 1 had a dead new born at 36 weeks.
For 13 women with successful life births it was the first pregnancy whereas 11 had been previously pregnant (5 had a live birth and 6 had 1-5 spontaneous abortions). UFE was performed with PVA in 26 patients and with Embozene microspheres in 3 patients. There were 13 cesarean sections and 11 vaginal deliveries (54.2%). One of cesarean delivery was due to placenta previa.
There were 4 prematures (16.7%) whose gestation lasted 36 weeks in 4 patients. The gestation of the remaining women ranged from 37 to 41 weeks (mean 39 weeks). One of the patients with pre-term delivery had a placenta previa with pos-partum bleeding. There were 4 (16.7%) low birth weights (1.700 Kg, 2.290 Kg, 2.320 Kg and 2.325 Kg). The weight of the remaining newborns ranged between 2.610 kg and 4.900 kg (mean 3.241 Kg). All the babies born presented no significant neonatal problems.
In the remaining 10 patients with ongoing pregnancies the evolution as been normal and are waiting for term.

Conclusion – The most of the pregnancies after uterine fibroid embolization have good outcomes with low morbidity.

30 – Pregnancy Viability and Morbility Following Uterine Fibroid Embolization

J. Pisco, M. Duarte, T. Bilhim
St. Louis Hospital and University Department of Radiology, Faculty of Medical Sciences, New University of Lisbon
Abstract Book pag. 292 – CIRSE 19 – 23 September 2009

Purpose – To evaluate morbility and viability in pregnancy after uterine fibroid embolization.

Material and Methods – Uterine fibroid embolization (UFE) was performed in 468 patients, 71 wanted to preserve their fertility and 62 wanted to become pregnant. Polyvinyl alcohol particles (PVA) 350 – 500 µm, 500 – 700 µm and 700 – 900 µm or Embozene Microspheres 500 µm and 700 µm were used to embolize the uterine arteries. All women were asked to inform the center if they became pregnant.

Results – From the 62 patients who wanted to become pregnant 20 (32.2%) spontaneous had pregnancies. Their age ranged 31 – 43 years (mean 36.1 years). The time between UFE and conception ranged between 4 and 20 months (mean 11.1).

Four of the women had been previously pregnant, 2 had a spontaneous abortion and 2 had live births. For the remaining women it was the first pregnancy. Three of them had a previous unsuccessful miomectomy. UFE was performed with PVA in 18 patients and with Embozene microspheres in 2 patients. One of the pregnant women induced abortion because she was taking isotretinoina and in 5 the evolution of pregnancy has been normal and are waiting for term. All the others had successful pregnancies with live births (70%). There were 6 cesarean sections and 8 vaginal deliveries.

The gestations lasted 36 weeks in 2 patients. The gestation of the remaining women ranged from 38 to 40 weeks (mean 39 weeks). The weight of one of the newborns with 36 weeks gestation was 2.325Kg. The weight of the remaining newborns ranged between 2.610kg and 4.910kg (mean 3.241Kg). All the babies born presented no significant neonatal problems. There were no cases of hypertension, abnormal placenta implantation or pos-part bleeding.

Conclusion – Pregnancy after uterine fibroid embolization is viable with low morbidity.

31. Outpatiente Uterine Fibroid Embolization, 400 Patients in a Single Center

J. Pisco, M. Duarte, T. Bilhim
St. Louis Hospital and University Department of Radiology, Faculty of Medical Sciences, New University of Lisbon;
Abstract Book pag. 363 – CIRSE 19 – 23 September 2009

Purpose – To evaluate the safety of Uterine Fibroid Embolization (UFE) as an outpatient procedure.

Methods and materials – Non-randomized retrospective study in 410 patients (age range 24 – 58 years; mean 40.5 years). Uterine Fibroid Embolization (UFE) was performed under local anesthesia with Polivynil Alcohol Particles (PVA) between March 2006 and March 2008. Patients were given acid suppressing drugs, nonsteroidal anti-inflammatories, anti-histaminic drugs and laxatives twice on the day before and once in the morning of UFE. The same type of drugs was given just before, during and after embolization. Pain score, rated from 0 to 10, was evaluated, using a numeric pain scale. Four to eight hours after the embolization all patients received tramadol 100 mg i.v. and metoclopramide 25 mg i.v. The outcome of UAE was evaluated at 6 months by pelvic magnetic resonance, clinical observation and questionnaires.

Results – The mean pain score during embolization was 0.8, after embolization 2.6, at discharge 0.7, at first night after discharge 1.2 and next morning 0.9. Four hundred patients were discharged from the hospital 4 to 8 hours after the procedure. There were no readmissions. At 6 months there was a clinical improvement of menorrhagia in 91.8% of the patients, of bulk symptoms in 83.5% and of the pain in 78.2%. The uterus and the dominant fibroid volumes reduced 36.8% and 45.3%, respectively.

Conclusion – With acid suppressing, anti-inflammatory and anti-histaminic drugs started on the day before the UFE procedure can be performed, safely, as an outpatient procedure.

32 – The Outcome of Pregnancy following Uterine Fibroid Embolization

João M. Pisco, Marisa Duarte, Tiago Bilhim
Presented at SIR, Tampa, 2010, 15 March

Abstract

Purpose – To evaluate the outcome of pregnancy after uterine fibroid embolization.
Material and Methods – Uterine fibroid embolization (UFE) was performed in 743 patients, 74 wanted to conceive. None of them could get a successful pregnancy at the time. Polyvinyl alcohol particles (PVA) or Embozene Microspheres were used to embolize the uterine arteries.

Results – From the 74 patients who wanted to become pregnant 39 (52.7%) had spontaneous pregnancies. Their age ranged 29 – 43 years (mean 35.8 years). The time between UFE and conception ranged between 2 and 22 months (mean 10.8). Seven of them had previous unsuccessful miomectomies and one an unsuccessful fertilization in vitro. There were 29 finished pregnancies with 24 successful life births, 3 spontaneous abortions, 1 induced abortion and 1 had a dead new born at 36 weeks.

For 13 women with successful life births it was the first pregnancy whereas 11 had been previously pregnant (5 had a live birth and 6 had 1-5 spontaneous abortions). UFE was performed with PVA in 26 patients and with Embozene microspheres in 3 patients. There were 13 cesarean sections and 11 vaginal deliveries (54.2%). One of cesarean delivery was due to placenta previa.

There were 4 prematures (16.7%) whose gestation lasted 36 weeks in 4 patients. The gestation of the remaining women ranged from 37 to 41 weeks (mean 39 weeks). One of the patients with pre-term delivery had a placenta previa with pos-partum bleeding. There were 4 (16.7%) low birth weights (1.700 Kg, 2.290 Kg, 2.320 Kg and 2.325 Kg). The weight of the remaining newborns ranged between 2.610 kg and 4.900 kg (mean 3.241 Kg). All the babies born presented no significant neonatal problems.
In the remaining 10 patients with ongoing pregnancies the evolution as been normal and are waiting for term.

Conclusion – The most of the pregnancies after uterine fibroid embolization have good outcomes with low morbidity.

33 – Uterine Fibroid Embolization With PVA: Does the Size of PVA Particles Matter?

João M. Pisco, Marisa Duarte, Tiago Bilhim
Presented at SIR, Tampa, 2010, 15 March

Purpose: To evaluate whether different sizes of PVA particles change the outcomes of uterine fibroid embolization (UFE).

Materials and Methods: A randomized prospective study was undertaken in 160 patients with symptomatic fibroids (ages 21 to 56, mean 39.2 years) undergoing UFE with polyvinyl alcohol (PVA) particles from January 2008 to August 2008. There was no significant difference of the clinical presentation of the patients of both groups. Analgesic and anti-inflammatory drugs were given before, during and after the procedure. In 80 patients (group A) the UFE was started with PVA particles of 300 µm, in the remaining 80 patients (group B) UFE was started with PVA particles of 500 µm. The size of particles was chosen by randomization. In both groups UFE was finished with larger particles, if necessary. Visual analogical scales (VAS) were used to measure pain during and after embolization up to discharge. The outcome of UFE was evaluated at 6 months by enhancing pelvic magnetic resonance imaging, clinical observation and questionnaires. Paired t-test and Ancova were used for statistic analysis.

Results: All patients were discharged from the hospital 4 – 8 hours after the procedure, except 4, 2 in each group who spent the night at the hospital, due to severe pain. Mean pain scores during embolization were 1.4 in group A and 1.0 in group B and scores after embolization up to discharge were 4.7 in group A and 3.4 in group B (p= <0.0001).
At 6 months, the uterus and dominant fibroid volumes decreased, 37% and 49% respectively in group A and 36% and 55% in patients of group B (p= 0.31 and 0.62). The differences were or not statistically significant?

Conclusion: There was a significant lower degree of pain during and after UFE when the procedure started with 500 PVA particles, however, the different size of PVA particles did not change the reduction rate of uterus and uterine fibroid at 6 months.

34 – Pregnancy After Uterine Fibroid Embolization

Pisco JM, Duarte M, Bilhim T, Cirurgião F, Oliveira AG.
Fertil Steril. 2011; 95 : 1121 – 24.

35 – Long Term Outcome of Uterine Fibroid Embolization

João M. Pisco, Marisa Duarte, Tiago Bilhim, Hugo R. Tinto, António G. Oliveira
CIRSE 2010 – Abstractbook Pag 381; P-180 Outubro 2-6 Valença – Espanha

 

36 – Uterine Artery Embolization and Beyond for Symptomatic Uterine Fibroids and Adenomyosis

Tiago Bilhim; João M. Pisco; Sandra M. Duarte; Hugo A. Rio Tinto.
RSNA 2010, Chicago
Poster RSNA – 02 Dezembro 2010

 

Purpose/AIM
1.To review the clinical presentation of uterine fibroids and adenomyosis;
2.To review the major imaging findings based on sonography and MR imaging;
3.To review the role of uterine artery embolization (UAE);
4.To focus on new research concerning treatment options and fertility sparing treatments.

Content organization
• Clinical manifestations of adenomyosis and uterine fibroids
• Indications and guidelines for treatment
• Review of imaging findings before and after UAE
– Sonography
– MRI
• Medical therapeutic options
• First-line treatment options
– UAE
– Endometrial ablation
– Hysterectomy
– Myomectomy
• UAE – sample cases and clinical results; fertility after UAE.
• New research treatment options
– MR-guided focused ultrasound surgery
– Myolysis

Summary
Major teaching points: 1.MRI allows detecting fibroid and junctional zone ischemia after UAE; 2. UAE is one of the first-line treatment options for symptomatic fibroids although results are not so encouraging regarding adenomyosis; 3. New research has proven that UAE does not induce ovarian or uterine dysfunction in women younger than 40 years of age and that the procedure can have fertility rates comparable to myomectomy; 4. There are new treatment options needing further studies.

37 – Quality of Life After Uterine Fibroid Embolization in Women with Symptomatic Uterine Fibroids: Midterm Results

Author List: Sandra Marisa Duarte, João Martins Pisco, Tiago Bilhim, Hugo Alexandre Meireles Rio Tinto
RSNA 2010, Chicago
Poster RSNA – 02 Dezembro 2010

Purpose/AIM
To assess the mid term outcomes of fibroid-associated quality of life (QOL) after uterine fibroid embolization (UFE).
To evaluate the impact of MRI imaging findings, the ischemia achieved after UFE and the type and size of embolic material in QOL outcomes
To assess the QOL in the subgroup of women who desire to become pregnant
UFE indications

Content organization
Retrospective mid term follow-up analysis of 325 patients treated with UFE.
UFS-QOL-Uterine Fibroid Symptom and Quality of Life questionnaire.
Symptoms severity and impact on health-related quality of life for women with uterine fibroids.
Parameters in fibroid-related quality of life after UFE.
Correlation with MRI findings, fibroid and uterine size shrinkage, and ischemia achieved after UFE and the embolic material.
Fibroid-related QOL for women who desire a future pregnancy. UFE method.

Summary
UFE is an effective, safety and minimally invasive option to treat symptomatic uterine fibroids.
The quality of life implications include resolution of symptoms and patient-reported satisfaction after treatment.
This study evaluate if EFU significantly improves women’s health-related quality of life, regarding the mid-term results.

38 – High Rate of Successful Pregnancies with Live Births After Uterine Fibroid Embolization.

João M. Pisco; Sandra M. Duarte; Tiago Bilhim; Hugo A. Rio Tinto
Comunicação oral – RSNA 2010, Chicago

Purpose
To evaluate the rates of spontaneous and successful pregnancies, with live births, and the complications after uterine fibroid embolization.

Method and materials
Uterine fibroid embolization (UFE) was performed in 782 patients, in a single center, and 81 of them wanted to conceive. None of the patients could get a successful pregnancy at the time of embolization. UFE was performed, as an outpatient procedure, by single femoral approach with a C2F5 catheter and both uterine arteries were embolized. Polyvinyl alcohol (PVA) particles 300μ, 500μ and 700μ and Embozene microspheres 500μ and 700μ were used as embolic agents.

Results
From the 81 patients who wanted to become pregnant, 48 (59.3%) had spontaneous pregnancies. Age ranged 27 – 43 years (mean 36.2); time between UFE and conception ranged 2 – 26 months (mean 10.6). From the 48 patients with spontaneous pregnancies, seven had 18 previous unsuccessful miomectomies and three had 7 unsuccessful in vitro fertilizations. The treatment offered to the remaining patients was hysterectomy in 10 and miomectomy in 12 (in 6 an eventual hysterectomy could not be rule out). There were 44 finished pregnancies with 38 successful life births (86.4%), 4 spontaneous abortions (9.1%), 1 induced abortion (due to patient taking isotretinoine) and 1 stillbirth at 36 weeks. There were 3 pre term gestations (7.9%) that lasted 33 weeks in one patient and 36 weeks in two patients. The full term gestation of the remaining 35 women ranged from 37 to 41 weeks (mean 39 weeks). There were 2 cases of placenta previa (5.3%). There were 5 low birth weights (13.2%) – 1.700 Kg, 1.980 Kg, 2.290 Kg, 2.320 Kg and 2.325 Kg. The weight of the remaining 33 newborns ranged between 2.610 Kg and 4.900 Kg (mean 2.920 Kg). For 25 women it was the first pregnancy whereas 13 had been previously pregnant. There were 26 cesarean sections (68.4%) and 12 vaginal deliveries. All the babies born presented no significant neonatal problems. In the remaining 4 patients with ongoing pregnancies the evolution has been normal and are waiting for term.

Conclusion
There were 59.5% of spontaneous pregnancies after UFE, and 86.4% of those had successful pregnancies with live births and low rate of complications.

Clinical relevance/application
This work represents the largest series of spontaneous pregnancies after UFE, with the best rate of successful pregnancies, and the lowest rate of complications.

39 – Polyvinyl Alcohol(PVA) Particle Size for Uterine Artery Embolization: A Prospective Randomized Study of Initial Use of 350 – 500 µM Particles Versus Initial Use of 500 – 700 µM Particles

Tiago Bilhim, MD, João M. Pisco, MD, Marisa Duarte, MD, and António G. Oliveira., MD
J. Vasc. Radiol. 2010

 

40 –  How to Perform Every Uterine Fibroid Embolization as an Outpatient Procedure – SIR 26 March 2011, “Abstract book of SIR-113) –  

Purpose – To evaluate whether it is feasible and safe to perform every uterine fibroid embolization (UFE) as an outpatient procedure, with the use of a specific mediation protocol.

Material and Methods – Six hundred and fourteen patients (age range 23-59 years; mean age 40.9) with symptomatic fibroids underwent UFE with polyvinyl alcohol particles or Embozene microspheres between January 2007 March 2010. Patients were given acid-suppressing drugs, nonsteriodal anti-inflammatory drugs and anti-histaminics drugs twice a day, for 2 days before UFE and once on the morning of UFE. Just before the procedure the same medication plus other anti-inflammatory and analgesic were given orally. During and after embolization anti-inflammatory, analgesic and anti-emetic drugs were given intravenously. At discharge the patients were medicated with anti-inflammatory and analgesic drugs given orally plus an anti-emetic as suppositories. Pain score rated from 0 to 10 was evaluated using a numeric pain scale during UFE, after the procedure, at discharge, at the nigth of discharge and on the following morning. The results of UFE were evaluated at 6 months by pelvic magnetic resonance imaging and questionnaires.

Results – The mean pain score was 0.6 during embolization, 2.3 after embolization, 0.4 at discharge, 0.9 the first night after discharge and 0.4 the next morning. All patients were discharged from the hospital 3 to 8 hours after the procedure, without any overnight hospital admission or readmission. The volumes of the uterus and dominant  fibroid decreased 36.8% and 48.2%, respectively, at 6 months.

Conclusion – With acid-suppressing, anti – inflammatory, and anti – histaminic drugs started two days before the procedure every UFE can be performed safely as an outpatient procedure.

Pregnancy after uterine fibroid embolization

 

41 –  Abstract present CIRSE 2011

42 –  Long – term Outcome of Uterine Fibroid Embolization with Successful Pregnancy Rate (CIRSE 2011)

JM Pisco, MD, Lisbon, PORTUGAL; SM Duarte, MD; T Bilhim, MD; H A Rio Tinto, MD; L C Fernandes, MD

PURPOSE
Determine the long-term outcome, and the successful pregnancy rate of uterine fibroid embolization (UFE), with MR evaluation, of a large series, in a single center.

METHOD AND MATERIALS
Retrospective study includes 587 consecutive patients with symptomatic uterine fibroids who underwent UFE with PVA. The patients were followed from 36 to 81 months (median 47 months) after the procedure. Eighty two of them wanted to become pregnant. MR was performed before UFE, 6 and 12 months after the procedure. After 1 year, MR was performed in 167 patients. The overall results of embolization were evaluated by the answers to written questionnaires and by MR. Patient satisfaction results were classified as satisfied or not satisfied. UFE was considered successful if there was clinical improvement, without recurrence, fibroid total ischemia and volume reduction, or successful pregnancy with life birth.

RESULTS
The age of the patients ranged from 23 to 57 (mean 40.9) years. Long-term follow-up was possible in 571 women. Long-term clinical success was observed in 484 patients (84.8%) (menstrual bleeding, pain and bulk-related symptoms improved in 86.8%, 81.9% and 83.2% respectively). Satisfaction rate was 91.4%. MR showed further shrinkage of the fibroids, up to 5 years, of the complete ischemic fibroids. The mean dominant fibroid volume reduction was 61.1% and the uterus volume reduction was 53.5%. At each follow-up control time, the clinical failures were related to partial infarction and regrowth of one or more fibroids, except in 4 patients who showed new growths. The patients with clinical failure had the following treatment: repeated embolization 54 patients, hysterectomy 13 patients, myomectomy 12 patients and no treatment 8 patients. There were 34 finished successful pregnancies with life births (41.5%), 3 spontaneous abortions, 1 induced abortion. The age of the pregnant range from 29 to 43 (mean 36.8).

CONCLUSION
UFE with PVA in patients with symptomatic leiomyomas provides long term clinical success, for most patients, high rate of successful pregnancies and continuous shrinkage of the completed ischemia fibroids up to 5 years.

43 –  The Safety and efficacy of partial uterine fibroid embolization for a spontaneous successful and finished pregnancy  with life birth (CIRSE 2011)

João M. Pisco, Marisa Duarte, Tiago Bilhim, Hugo Rio Tinto, Lúcia Fernandes

PURPOSE
To evaluate the safety, and the rate of spontaneous, successful and finished pregnancy with life birth following partial uterine fibroid embolization.

METHODS
Uterine fibroid embolization (UFE) was performed in 1158 patients, in a single center, and 126 of them wanted to conceive. None of the patients could get a successful pregnancy at the time of embolization. UFE was performed, by single femoral approach with a C2F5 catheter and both uterine arteries were partially embolized. Partial embolization was performed and only fibroid vessels were blocked. UFE was repeated in 5 patients due to incomplete ischemia of the fibroids and 3 of them had spontaneous abortion after first embolization. Polyvinyl alcohol (PVA) particles 300, 500 and 700 and Embozene microspheres 500 and 700 were used as embolic agent.

RESULTS
From the 126 patients who wanted to become pregnant, 74 (58.7%) had spontaneous pregnancies, without any medical assisted reproduction technique. Their age ranged 22 – 43 years (mean 36.8 years). The time between UFE and conception ranged between 2 and 39 months (mean 10.9). From the 74 patients with spontaneous pregnancies, 9 had 19 previous unsuccessful myomectomies and 4 had 9 unsuccessful in vitro fertilization. The treatment offered to some of the remaining patients before spontaneous pregnancy was hysterectomy in 16 and myomectomy in 19. However, in 12 of 19 women with offered myomectomy an eventual hysterectomy could not be rule out. There are 64 finished pregnancies with 55 successful life births (85.9%), 7 spontaneous abortions (10.9%), 1 induced abortion and 1 stillbirth at 36 weeks, after 5 unsuccessful myomectomies and 1 in vitro fertilization, before UFE. There are 10 ongoing pregnancies. Four of the 7 patients with spontaneous abortions after UFE had 1 to 4 spontaneous abortions, before UFE. Only 3 of 6 spontaneous abortions did not have any spontaneous abortion before UFE. The procedure was repeated in 5 patients with incomplete ischemia of the fibroid, and 3 of them had spontaneous abortion after first UFE. To the patients with successful live births, UFE was performed with PVA in 49 patients and with Embozene microspheres in 6 patients.

There were 5 pre-term gestations (9.9%) and 34 weeks in 2 patients and 36 weeks in the other three patients. The full term gestation of the remaining 54 women ranged from 37 to 41 weeks (mean 38.2 weeks). There were 2 cases of placenta previa (3.6%). There were 5 low birth weights (9.9%) – 1.700 Kg, 1.980 Kg, 2.290 Kg, 2.320 Kg and 2.325 Kg. The weight of the remaining 50 newborns ranged between 2.610 Kg and 4.900 Kg (mean 3.095 Kg). For 41 women with successful life births it was the first pregnancy whereas 14 had been previously pregnant (7 had a live birth and 7 had 1-4 spontaneous abortions). There were 37 cesarean sections (67.3%) and 18 vaginal deliveries. All the babies born presented no significant neonatal problems. In the remaining 10 patients with ongoing pregnancies the evolutions has been normal and are waiting for term.

CONCLUSION
Partial uterine fibroid embolization is safe and efficient with high rate of spontaneous pregnancies (58.7%) and live birth (85.9%).

44 – Free Papers  CIRSE 2012

Magnetic Ressonance (MR) findings before and after Uterine Artery Embolization (UAE) for uterine leiomyomas and adenomyosis.

J.Pereira; L.Fernandes; M.Duarte; T.Bilhim; H.R.Tinto; J.Pisco

Magnetic Ressonance (MR) findings before and after Uterine Artery Embolization (UAE) for uterine leiomyomas and adenomyosis.

Learning objectives: To review the MR imaging features of uterine leiomyomas and adenomyosis before and after UAE. To identify pre and postreatment MR imaging features that may be associated with clinical outcome after UAE.

Background: UAE is an increasingly performed, minimally invasive alternative to hysterectomy or myomectomy for women with symptomatic uterine fibroids. Clinical failure after UAE for leiomyomas has been attributed to the presence of undiagnosed adenomyosis, frequently due to the absence of screening MR imaging. More so, fibroid ischemia after UAE is a known predictive factor of clinical success.

Clinical findings/procedure details: Pictorial review describing the pre and post embolization MR features of uterine leiomyomas and adenomyosis. The major pulse sequences, protocols and relevant findings will be discussed. Before UAE, Angio MR sequences may help plan the procedure and the T2-weighted images allow a confident diagnosis of adenomyosis (low myometrial signal intensity, diffuse or focal thickening of the junctional zone, highsignal-intensity foci corresponding to myometrial cysts, poor definition of the endomyometrial junction, and poor definition of lesion borders). MR allows accurate evaluation of the leiomyomas before and after UAE (number, location, volume). Post-treatment analysis of fibroid ischemia on gadolinium enhanced T1-weighted images is related to treatment outcome and should be assessed.

Conclusion: MR imaging is a useful tool for interventional radiologists performing UAE. Knowledge of the major pulse sequences and imaging findings before and after UAE is paramount. MR imaging may help differentiate uterine leiomyomas and adenomyosis. Quantitative assessment of signal intensity and morphologic changes before and after UAE may help predict clinical outcome.

45 – 59311 – Incomplete uterine fibroid embolization for patients who want to conceive Featured Paper

J.Pisco; M.Duarte; T.Bilhim; H.R.Tinto; L.Fernandes; J.Pereira

59311 – Incomplete uterine fibroid embolization for patients who want to conceive Featured Paper

Purpose – To evaluate pregnancy outcome following incomplete uterine fibroid embolization.

Material and Methods – Uterine fibroid embolization (UFE) was performed in 158 patients who could not get a successful pregnancy before embolization and wanted to conceive. Partial embolization was performed blocking only the small vessels. Polyvinyl alcohol (PVA) particles were used as embolic agent.

Results – From the 158 patients, 85 (53.8%) had spontaneous pregnancies without any medically assisted reproduction technique. Their age ranged from 22 to 43 years (mean 37.1 years). There are 75 finished pregnancies: 63 successful life births (84%), 9 spontaneous abortions (12.1%), 2 induced abortion, 1 stillbirth at 36 weeks and 10 ongoing pregnancies. The procedure was repeated in 6 patients with incomplete fibroid ischemia, and 3 of them had spontaneous abortion after first UFE. There were 5 preterm gestations (7.9%), 2 cases of placenta previa (3.2%), 5 low birth weights (7.9%) and 39 cesarean sections (61.9%).

Conclusion – Partial uterine fibroid embolization is a safe and efficient procedure with low morbidity, high rate of spontaneous pregnancies (53.8%) and live birth (84%).

46 –  Posters  CIRSE 2012

How to perform uterine artery embolization as an outpatient technique – technical and clinical aspects

Lúcia Fernandes, Hugo Rio Tinto, Tiago Bilhim, Marisa Duarte, José Pereira, Luís Campos Pinheiro, Joao Martins Pisco

[DDET see more »]

P-176

How to perform uterine artery embolization as an outpatient technique – technical and clinical aspects

Lúcia Fernandes, Hugo Rio Tinto, Tiago Bilhim, Marisa Duarte, José Pereira, Luís Campos Pinheiro, Joao Martins Pisco

Learning Objectives  – To describe the usual pelvic arterial anatomy and its variants and review the key aspects of this endovascular treatment.

To discuss the impact of the different vascular imaging findings in the safety and the technical success of this angiographic based treatment as an outpatient technique.

Background  – Uterine fibroid embolization (UFE) is a uterus sparing and highly effective technique. Recovery period is short and serious complications are rare. UFE can be performed as an outpatient procedure, the control of post embolization symptoms being the main challenge in this setting.

Clinical Findings or Procedure Details – We retrospectively review the clinical and imaging findings of all the patients that underwent UFE at our institution, from 2006 to 2011. Uterine fibroid embolization (UFE) was performed under local anesthesia with polivynil alcohol particles (PVA). Patients were given acid suppressing drugs, nonsteroidal anti- inflammatory, anti- histaminic drugs and laxatives twice on the day before and once in the morning of UFE. Pain score, rated from 0 to 10, was evaluated, using a numeric pain Scale. Four to eight hours after the embolization all patients received tramadol 100 mg i.v. and metoclopramide 25 mg i.v. The outcome of UFE was evaluated at 6 months by pelvic magnetic resonance, clinical observation and questionnaires.

Conclusion – With the understanding of uterine artery anatomy, their variants and appropriated medication started on the day before, the UFE procedure can be performed, safely, as an outpatient procedure.

[/DDET]

47 SIR 2012 , March 25, San Francisco

The Safety and Efficacy of Partial Uterine Fibroid embolization for a spontaneous successful and finished pregnancy with life birth

J.M. Pisco, M. Duarte, T. Bilhim, H. Rio Tinto, L. Fernandes; Saint Louis Hospital, Lisbon, Portugal

the safety

48 UFE Pharmaceuticals

Tiago Bilhim, Joao Martins Pisco

 49 March 24 – SIR 2014 S. Diego

Free Paper Presented:

 

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50 – CIRSE 2014 (Oral Presentation) Spontaneous and successful live birth pregnancy after uterine arteries embolization, for women with uterine fibroid – 109 live births

 

João Pisco, Marisa Duarte, Fernando Cirurgião, Marcela Forjaz, Tiago Bilhim, Hugo R. Tinto, Lúcia Fernandes, José Pereira, António G. Oliveira

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51 – The Vascular Intervention Radiology  in Portugal: Past and Present

CCI14122015

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Comentários: 5

  1. stewart stanley says:

    can anyone tell me how to make contact with professo
    João Martins Pisco, I would like to have the Prostatic artery embolizationo operation as soon as possible…The website is in Portuguese so very difficult to make contact there…?

    S.S

  2. Sage Leising says:

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  3. elizabetep says:

    The Phone number is 213216557

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