Percutaneous embolization of the uterine fibroids
What is a uterine fibroids?
Uterine fibroids or fibroids are non-cancerous (benign) tumors that develop in the muscular wall of the uterus.
Most of them do not produce symptoms but if they are large or multiple they can lead to severe menstrual pain and / or bleeding which can lead to anemia.
What are the most common symptoms?
Symptoms depend on the size of the fibroid and its location (subserous, intramural, or submucosal). Fibroids are very common among women over the age of 30 and the vast majority do not cause problems. The most common and important symptoms are:
Alterations in menstruation with prolonged and abundant bleeding, even with blood clots. This hemorrhage can lead to anemia
Pain in the back and legs
Pain during the performance of the sexual act
Pain, weight and swelling in the abdomen
Compression on the urinary bladder producing constant and / or frequent desire to urinate
Compression on the gut causing narrowing
How is myoma diagnosed?
Myomas are commonly suspected by routine gynecological examination and are confirmed by imaging techniques: transvaginal ultrasound, CT scan and MRI.
Ultrasound and medical control are sufficient for the control and monitoring of small and asymptomatic fibroids. Large fibroids with many symptoms may require other imaging techniques. Magnetic resonance imaging and ultrasound are both harmless and painless.
What is the treatment of uterine fibroids?
Until recently, the treatment of uterine fibroids was limited to pain medication, hormone therapy, or surgery, including removal of the uterus. Myoma embolization is a non-surgical alternative that results in significant reduction in size and improvement of symptoms, leaving the uterine fibroids without blood irrigation. The patient must be visited by a gynecologist before performing an embolization to carry out a complete assessment (Word, 46 KB) of his illness.
What is myoma embolization?
It is performed by interventional radiology techniques that require minimal invasion. Through catheterization by a simple puncture in the groin, and under X-ray control (fluoroscopic) we will plug the arteries that feed the tumor itself, using small balls of gelatin.
Pain and abdominal swelling are two common effects of this technique. Occasionally, fever appears for 24-48 hours, which can be treated with paracetamol (Termalgin) or magnesium metamizole (Notolil). Powerful painkillers are used epidural, venous and oral to combat pain. In our experience, good pain control is achieved through intravenous sedation and even treatment can be performed on an outpatient basis.
Subsequently, painkillers are given orally for one week.
Who does the embolization?
The procedure is performed by the interventional radiologist in the specialized rooms for this. However, other medical professionals (gynecologists, anesthetists, general radiologists, etc.) are involved in the diagnostic and therapeutic process. Interventional radiologists are physicians who have special training in diagnosing and treating processes, using sophisticated, tiny x-ray tools or other imaging techniques.
In general, interventionist techniques are less invasive and more secure with shorter hospitalization and convalescence times.
The interventional radiologist works closely with the rest of the specialists to ensure that the patient receives the best possible care and care.
Where is the embolization performed?
The Interventional Radiology ward is a hospital room that meets special conditions for asepsis. It has sophisticated imaging equipment (X-rays and ultrasound) as well as human staff and the technical means of vital control and resuscitation to ensure patient safety.
What are the medical outcomes of embolization?
Medical studies show that 80 to 95% of patients have improved symptoms. More than 80% of patients had a significant reduction in their fibroids volume.
Are there risks in myoma embolization?
Uterine artery embolization is a safe technique, but like most medical procedures it can also have some complications. The pain is the most common and occurs due to lack of blood supply to the uterus, an important fact that requires special analgesia. In the first hours nausea, vomiting and fever may occur which are usually controlled with proper medication. A small percentage of patients developed an infection that was controlled by antibiotic therapy. Only 1% of patients with uterine alteration considered hysterectomy as a potential treatment. Finally, post-embolization-induced menopause has been reported in 2-10% of cases.
It should not be forgotten that hysterectomy and myomectomy can also have infectious, hemorrhagic complications, tissue adhesion and abdominal organs.
How pain control is performed during treatment
Some groups of physicians manage pain with intravenous and oral painkillers, and in other cases with epidural anesthesia, quickly and effectively controlling pain.
In selected cases, treatment is performed on an outpatient basis with satisfactory results.
Can I have children after embolization?
There are no conclusive studies in this regard. It is advisable to avoid getting pregnant during the first months after embolization. Some women had uncomplicated pregnancies after a uterine artery embolization for myoma.
After the procedure, what should you expect to happen?
Most of the patients experienced severe pain caused by myoma infarction, in addition to ischemia occurring in the rest of the uterus and which was controlled by appropriate analgesia.
The combination of morphine and anti-inflammatory drugs administered intravenously is the most effective method of pain management. The maximum intensity of the pain appears in the first hours starting to decrease after 12 hours postprocedure.
Nausea and vomiting
This is a relatively common side effect due to myoma ischemia on the one hand and pain medication on the other. In general with medical treatment they are usually adequately controlled.
Home registration at 24/48 hours. What do you expect to happen?
Most patients have menstrual-like abdominal pain during the first days. That is why during the first week you must follow the planned treatment regimen with anti-inflammatory and analgesics.
The presence of fever, not higher than 38º C, is common. At the same time the appearance of flow in greater quantity than usual can also be normal and disappears during the first week.
Full recovery and restart of normal activity is usually 10-15 days after the procedure.
Informative documents on myoma embolization (in Spanish):
The development of interventional procedures in recent years has been very prominent in various areas of vascular and non-vascular pathology. Particular emphasis is placed on the territory of neurovascular pathology with the various treatments performed in this area: embolization of cerebral aneurysms, embolization of cranio-facial hypervascular tumors, embolization of the dural arteriovenous fistulas and cerebral and spinal arteriovenous malformations, intraarterial rescue stroke treatment and in angioplasty / stenting of intra- and extracranial carotid and vertebral stenosis.
Specialized units in interventional neuroradiology have a high-end digital angiograph that allows in situ 3D rotational cerebral angiography and CT in situ, obtaining the correct therapeutic assessment and planning and showing the vascular angioarchitecture in all three dimensions of both the aneurysms and arteriovenous malformations.
Our unit consists of two Siemens Axiom Artis equipment equipped with three-dimensional reconstruction consoles. Two radiologists from the interventional radiology unit have a preferential dedication to neurointerventions, which are part of a clinical group at the Sabadell Hospital for neurovascular pathology in collaboration with neurologists, neurosurgeons, neurosurgeons, anesthetists and intensivists.
Our portfolio of services is as follows:
Global angiographic study of supra-aortic trunks
Selective angiographic study of the brain and spinal cord
Embolization of cerebral aneurysms in subarachnoid hemorrhage and incidental aneurysms
Functional studies and embolization of cerebral and spinal arteriovenous malformations
Angiographic studies and embolization of cerebral and spinal cord arteriovenous fistulas
Pre-surgical and / or palliative embolization of tumors at the cranio-facial level and at the level of the spine
Angioplasty / carotid and vertebral stenosis intra- and extracranial
Endovascular rescue treatment for hyperacute stroke with mechanical and / or pharmacological systems
Intracranial sinus venous samplings by hormonal determination
Carotid and vertebral occlusion test
Endoluminal treatment of intracranial venous sinus stenosis and thrombosis
Mechanical rescue thrombectomy in ischemic stroke
Selective cerebral angiography of the left internal carotid. M1-2 segment obstruction of the left middle cerebral artery. Mechanical removal of the thrombus.
Selective cerebral angiography of the left internal carotid. Complete recanalization of the M1-2 segment of the left middle cerebral artery. TC control 24 hours later.
Brain aneurysm embolization with balloon remodeling technique
Selective cerebral angiography of the left internal carotid. Anterior communicating artery aneurysm. Wrapping with microcoils with remodeling technique.
Selective left internal carotid brain angiography and 3D reconstruction. Complete embolization of the aneurysm.
In many cases, neurovascular pathology is acute and has a severe severity, which entails establishing well-defined treatment strategy mechanisms. The multidisciplinary team of the Hospital, made up of several specialists, has developed guidelines and protocols for action that require effective and early treatment of this neurocritical pathology.
Frequently asked questions:
What is interventional neuroradiology?
It is a subspecialty of Radiodiagnosis that deals with the diagnosis and treatment of neurovascular pathology.
How are these treatments performed?
Basically most of the procedures are performed with small catheters which, after puncture of the femoral artery, allow access to the brain, neck and spinal cord.
What is a brain aneurysm?
It is an abnormal dilation that appears on the wall of an artery in the brain. When the aneurysm ruptures, it causes severe cerebral hemorrhage and early treatment is needed to prevent bleeding from the aneurysm.
The risk of rupture of the aneurysms is 0,2-3% per year and the first symptom that the patient can refer to is an abrupt headache, the most intense of his life. Aneurysmal rupture causes subarachnoid hemorrhage and is a medical emergency.
MRI of the lower limbs
Conventional arteriography has traditionally been the technique of choice for the study of vascular pathology caused by atherosclerosis of the arteries of the lower limbs. Despite being a well-known technique, it is not without its complications.
Magnetic resonance angiography (MRI) is a technique already used in many vascular territories (carotids, renal arteries, abdominal aorta, ...) with optimum results. With the development of new resonance technologies, it is now possible to perform a complete vascular study of the lower limb arteries in just 30 minutes and with few complications. In our unit we use Siemens Symphony 1.5 Tesla resonance with member-specific antenna, automatic table motion and high-resolution sequences to produce high-quality diagnostic images.
The ARM allows visualization of the complete arterial tree of the MMII with a venous injection of a contrast that does not impair renal function (gadolinium-DTPA). The absence of nephrotoxicity makes patients with renal failure, especially diabetics, the best candidates for this test. The fact that there is no need for an arterial puncture is also an advantage for patients with coagulation problems.
The use of the ARM in the arterial pathology of the legs offers diagnostic images without complications, without risk of renal damage and without hospitalization, allowing to reserve the most invasive studies for selected cases.
Loewe C, Schoder M, Rand T. Peripheral vascular occlusive disease: evaluation with contrast-enhanced moving-bed MR angiography versus digital subtraction angiography in 106 patients. AJR Am J Roentgenol 2002; 179: 1013-21
Swan JS, Carroll T, Kennell T, Hesey D, Korosec F, Frayne R, Mistretta C, Grist T. Time-resolved three-dimensional contrast-enhanced MR angiography of the peripheral vessels. Radiology 2002; 225: 43-52
Aurbach EG, Martin ET. Magnetic resonance imaging of the peripheral vasculature. Am Heart J. 2004 Nov; 148 (5): 755-63.
Endoluminal treatment of aortic aneurysms
The Vascular Radiology and Interventional Unit in close collaboration with the Angiology and Vascular Surgery service of Parc Taulí Hospital has been conducting endoluminal treatment of aortic aneurysms since 2003.
What is an aneurysm and what symptoms does it give?
An aneurysm is a dilation of a blood vessel that results from the inability of the thin wall of the vessel to withstand blood pressure. Aneurysms can occur in any artery but are more common at the level of the cerebral circulation or in the aorta. The aorta is the largest artery in the body and is responsible for transporting blood from the heart to the rest of the body. Aortic aneurysms can occur both at the thorax (thoracic aorta) and at the abdominal (abdominal aorta) level, the latter case is much more common and usually occur just above its division in the arteries that carry blood to the legs (iliac arteries).
Most aneurysms do not produce symptoms, in some cases they can cause abdominal or chest pain and at other times they may manifest as a pulsating mass sensation in the abdomen. The absence of symptoms does not mean that an aneurysm is not a potentially dangerous disease.
How is an aneurysm diagnosed?
The absence of symptoms makes the aneurysm diagnosis difficult. The doctor may sometimes suspect a pulsating mass in the abdomen or the pain that determines the imaging test. In most cases, the diagnosis is made accidentally through tests requested for other medical reasons. The best imaging tests for aortic aneurysm diagnosis are ultrasound, CT scan or magnetic resonance imaging (MRI), depending on their location and size.
Why is an aneurysm and what is the risk?
Sometimes the appearance of an aneurysm is favored by the presence of a trauma, aortic disease or hereditary factors. In most cases there is no predisposing factor and they are caused by damage to the artery (atherosclerosis) caused by the presence of high tension, smoking, high cholesterol or heart disease.
The main problem with aneurysms is the risk of rupture, a very serious situation that can lead to the death of the patient.
Chances of rupture of aneurysms depend on their size and growth rate (larger size and larger growth plus risk of rupture) and blood pressure (higher pressure plus risk)
What to do when you have an aneurysm?
Once aortic aneurysm has been diagnosed, the vascular surgeon will decide on treatment based on its location, size, characteristics and symptoms. In most cases the treatment will be to correct the risk factors and request a periodic imaging test (usually a CT scan every 6 months) to monitor the size and appearance of the aneurysm. Other times it will be decided that the risk of rupture is too high and that it will have to be treated.
What types of treatments are there?
For many years the only treatment available was surgical repair of the aorta. The procedure involves opening the abdomen, under general anesthesia, by replacing the damaged and dilated aorta with a synthetic tube (prosthesis). This procedure is very effective and has been performed for many years, yet it is free of complications and is not well tolerated by all patients.
In recent years, a less invasive endoluminal treatment has been developed, consisting of the placement of a metallic synthetic tube (prosthesis) in the damaged aorta through small incisions in the groins. Through the introduction of catheters and their vision through RX appliances it is possible to place the prosthesis against the wall of the aorta and in the right place, checking after that the dilated area has been excluded, that is, it does not receive blood. Endoluminal treatment is less aggressive, has shorter recovery, and fewer complications.
In the hospital, endoluminal treatment is performed in the vascular radiology room. The prostheses are placed by a team of vascular surgeons and interventional radiologists.
What controls should be followed after endoluminal treatment, and what are the complications?
After treatment, the patient must visit his doctor, who will require a CT scan periodically to make sure that the prosthesis is permeable (to allow blood to flow properly) and that the aneurysm begins to decrease in size.
The most common possible complications are that the prosthesis does not completely block the passage of blood to the aneurysm (endoleak), so it would continue to grow, or that the prosthesis will not let blood flow to the lower limbs (thrombosis). In these cases endoluminal or surgical treatment should be indicated again.
Which treatment is most appropriate?
The type of treatment is determined based on the characteristics of the patient and the type and shape of the aneurysm. Not all patients can undergo surgery because of their general state of health, nor are all aneurysms amenable to endoluminal treatment, due to their morphology and location. The doctor together with the patient must evaluate the advantages and disadvantages of each type of treatment and decide jointly on their basis.
Information from the European Society of Cardiovascular and Interventional Radiology (CIRSE)