Volume 20, Issue 9 , Pages 1172-1175, September 2009
Safety and Effectiveness of Uterine Artery Embolization in Patients with Pedunculated Fibroids
Article Outline
Purpose
To assess complications and outcomes of uterine artery embolization (UAE) in women with pedunculated fibroids in a large single-center patient cohort.
Materials and Methods
From a database with prospectively collected data from 716 women treated with UAE between 1996 and 2008, 29 women were identified with 31 pedunculated fibroids. Magnetic resonance images obtained before and 3 months after UAE were used to calculate stalk diameter change and volume reduction of both the pedunculated fibroid and uterus. Two observers assessed the overall percentage infarction and infarction of pedunculated fibroid. Complications were recorded and long-term clinical follow-up (mean, 33 months; range, 10–78 months) assessed with use of a questionnaire.
Results
The mean reduction in uterine and pedunculated fibroid volume was 37% and 33%, respectively. The mean reduction in stalk diameter was 0.3 cm (95% confidence interval [CI]: 0.18, 0.52 cm) or 13% from initial mean diameter. Stalk enhancement was not affected by UAE. The mean pedunculated fibroid infarction and mean overall infarction rates were 87% and 92%, respectively, for observer 1 and 88% and 92% for observer 2, with good interobserver variability. All women returned the questionnaire and no early or late complications of UAE were reported (0%; 95% CI: 0.0%–13.9%).
Cconclusions
In this small series of pedunculated subserosal fibroids treated with UAE, no complications occurred. The findings suggest that the use of UAE to treat pedunculated subserosal fibroids may be safe and effective.
Abbreviations: CI, confidence interval, UAE, uterine artery embolization
UTERINE artery embolization (UAE) is increasingly offered as a safe and effective alternative to myomectomy or hysterectomy for symptomatic uterine fibroids (1, 2, 3, 4, 5, 6, 7, 8, 9). The presence of pedunculated fibroids is considered a relative contraindication for UAE (10, 11, 12). If a pedunculated fibroid becomes septic after embolization, a hysterectomy is needed; involvement of the bowel due to infection or formation of adhesions may necessitate concomitant partial bowel resection. However, the frequency of such serious complications is unknown. Recent studies of small patient groups indicated that UAE for pedunculated fibroids may be safer than previously thought (13, 14). The objective of our study was to retrospectively assess the complications and outcomes of UAE as a treatment for patients with pedunculated fibroids selected from a large single-center cohort.
Materials and Methods
Patients
This retrospective study was approved by the institutional review board, and the need for informed consent was waived. From an institutional database with prospectively collected data from 716 women with symptomatic uterine fibroids treated with UAE between 1996 and 2008, 29 women were identified with 31 pedunculated fibroids, defined as a stalked subserosal fibroid with a stalk diameter of less than half of the fibroid diameter (15). All 29 women were premenopausal, andthe mean patient age was 44 years (median age, 44 years; age range, 34–51 years).
Embolization Technique
UAE was performed after selective catheterization of the left uterine artery and by guiding the catheter into the right uterine artery by means of the Waltman loop maneuver. Bilateral embolization by means of a unilateral approach was performed in all women. The use of a microcatheter was left to the discretion of the physician. In women who desired future pregnancy, embolization was performed on two sides at the same time to limit radiation exposure to the ovaries. Various embolic agents with diameters of 500–900 μm were used. The angiographic embolization endpoint was a complete occlusion of branches to the perifibroid plexus, with sluggish flow in the ascending segment of the uterine artery, and leaving the main uterine artery, cervicovaginal branches, and utero-ovarian anastomoses patent.
Imaging
All patients underwent enhanced and contrast medium–enhanced magnetic resonance (MR) imaging before and 3 months after embolization. From baseline MR imaging, the diameter of the pedunculated fibroid stalk and the dimensions of the pedunculated fibroid and uterus were assessed. The diameter change of the stalk and the rates of pedunculated fibroid and uterine volume reduction were assessed by comparing the MR images obtained 3 months after embolization with those at baseline. Volume calculation was done by using the formula of a prolate ellipse (length × depth × width × 0.5233). The pedunculated fibroid infarction rate and overall infarction rate (including the pedunculated and all other present fibroids) were assessed by two observers (A.J.S. and P.N.M.L.) independently at 3-month MR imaging by visual estimation of the decrease in enhancement as compared with that at baseline MR imaging. Infarction rates were subsequently classified as 100%, 90%–99%, 80%–90%, and less than 80% (16).
Outcome and Follow-up
Complications were assessed according to the classification by Goodwin et al (15) by using information collected at the time of the hospital stay or an unanticipated hospital visit and on an interview and questionnaire at the time of 3-month follow-up MR imaging. Symptomatic outcome and patient satisfaction were assessed with serial questionnaires as part of the routine follow-up assessment.
In October 2008, at a mean of 33 months after UAE (range, 10–78 months), all 29 women with pedunculated fibroids received a questionnaire about general well-being, satisfaction with treatment, residual complaints, additional treatment for the same disorder, and the occurrence of late complications necessitating a doctor's attention or hospital admission.
Data Analysis
Complications were calculated as a percentage with 95% confidence interval (CI). The mean volume reduction as a percentage of the initial volume of the pedunculated fibroid and uterus was assessed. The mean pedunculated fibroid stalk diameter reduction and the mean decrease in contrast medium enhancement were expressed as a percentage. The t test was used for the comparison of means. P values less than .05 were considered statistically significant. Interobserver variability of overall and pedunculated fibroid infarction rates was assessed with κ statistics. Statistical analysis was performed with MedCalc 10 statistical software (MedCalc, Mariakerke, Belgium).
Results
The mean diameter of the pedunculated fibroid was 7.45 cm (median, 7 cm; range, 4.5–12.3 cm). The frequency distribution of fibroid sizes is displayed in Figure 1.
Figure 1.
Chart shows the frequency distribution of the maximum diameters of the 31 pedunculated fibroids.
The mean pedunculated fibroid volume was 168 cm3 (median, 99 cm3; range, 26–502 cm3) before UAE and 113 cm3 (median, 53 cm3; range, 15–373 cm3) 3 months after UAE. The mean volume reduction of the pedunculated fibroid was 55 cm3 (95% CI: 28, 82 cm3) or 33% from initial mean volume.
The mean pedunculated fibroid stalk diameter was 2.6 cm (median, 2.5 cm; range, 1.6–5.2 cm) before UAE and 2.3 cm (median, 2.3; range, 1.4–4.1 cm) 3 months after UAE. The mean diameter reduction of the pedunculated fibroid stalk was 0.3 cm (95% CI: 0.18, 0.52 cm) or 13% from initial mean diameter. All 31 stalks enhanced before UAE and 28 enhanced at 3 months;the remaining three cases this could not be evaluated (Fig 2).
Figure 2.
Contrast-enhanced T1-weighted MR images obtained (a) before and (b) 3 months after UAE in a 43-year-old woman. The x-axis shows the number of pedunculated fibroids, and the y-axis shows the diameters of pedunculated fibroids (inset in a). Although the pedunculated fibroid is completely infarcted, vascularization of the stalk is intact (arrow in b).
The mean uterus volume was 600 cm3 (median, 510; range, 47–1,808 cm3) before UAE and 377 cm3 (median, 352 cm3; range, 46–1,131 cm3) at 3 months. The mean volume reduction of the uterus was 223 cm3 (95% CI: 127, 317 cm3) or 37% from initial mean volume.
For observer 1, the mean overall infarction rate was 92% and the pedunculated fibroid infarction rate was 88%. For observer 2, these figures were 92% and 87%, respectively. Interobserver variability was good for both the overall infarction rate (κ = 0.745) and the pedunculated fibroid infarction rate (κ = 0.753).
All 29 patients responded to the late follow-up questionnaire. There were no early or late complications of UAE (0%; 95% CI: 0.0%, 13.1%). Four patients underwent a hysterectomy at various intervals after UAE due to persistent complaints with persisting enhancing fibroids. In three of these patients, the pedunculated fibroid was not dominant and was completely infarcted. In these three patients, no adhesions were found at surgery. In one patient who underwent hysterectomy, the presumed pedunculated fibroid showed persistent enhancement. However, this was revealed to be a leiyomyosarcoma at pathologic examination. In this patient, extensive adhesions were present during surgery. The remaining 25 women reported improvement or cure of presenting symptoms with a high degree of treatment satisfaction.
Discussion
We found that the use of embolization in symptomatic patients with pedunculated fibroids was safe and effective; after a mean follow-up of 33 months, no early or late complications had occurred. Although four patients needed hysterectomy during the follow-up period, the indication for this additional therapy was not related to the presence of the pedunculated fibroid.
The general conception that pedunculated fibroids are a relative contraindication for UAE is based on three cases as part of three early series (12–14). In two of these three cases, septic necrosis of pedunculated fibroids necessitated emergent hysterectomy. In one woman, the septic pedunculated fibroid was closely related to the bowel and partial bowel resection had to be performed. The third case reported a liquefied change of a pedunculated fibroid leading to an increased size. It must be noted that these early reports did not provide detailed information on important clinical and imaging parameters such as the diameter of the stalk and the size of the pedunculated fibroid before and after embolization. Moreover, the relative frequency of these complications was not accounted for.
Although never documented, there is a general fear that necrosis of the stalk of the pedunculated fibroid may lead to separation of the pedunculated fibroid from the uterus into the abdominal cavity. To clarify this postulation, we evaluated the change in vascularization of the stalk by comparing contrast-enhanced MR images obtained before and after UAE. Remarkably, the enhancement and thus vascularization of the stalk remained unaffected by the embolization in all patients where it could be evaluated, whereas devascularization and volume reduction of the pedunculated fibroid was significant and in the same magnitude as for the intramural fibroids. Probably, the arterial supply to the stalk is by uterine stroma arteries and not by uterine artery branches to the perifibroid plexus. Following our embolization protocol, we did not encounter any overembolization that might lead to stalk devascularization and infarction. With a proper embolization technique, the fear of separation of pedunculated fibroids from the uterus after embolization seems at least premature.
Our finding that embolization of pedunculated fibroids is safe and effective is in concordance with two recent smaller studies with 12 and 16 patients with pedunculated fibroids who underwent UAE (13,14). In both studies, pedunculated fibroid infarction was effective and no complications occurred. In addition, in these studies stalk vascularization was not affected by the embolization in all patients in whom it could be evaluated. A limitation of our study is the limited patient group. However, pedunculated fibroids are rare in the population with symptomatic fibroids that are treated with UAE—in our series just over 4% (29 of 716). A strong point of our study is that patients were well documented with complete and long-term clinical follow-up.
The available data thus far indicate that serious complications of UAE in pedunculated fibroids are probably rare. There is no reason to believe that the complication rate of UAE in patients with pedunculated fibroids is higher than that in patients with intramural fibroids. Perhaps the subserosal location of the fibroids may predispose for the formation of intraabdominal adhesions, but this has not yet been elucidated (17). Although these data are derived from a small number of patients, they suggest that patients with symptomatic fibroids in the presence of a pedunculated subserosal fibroid may still be treated safely with UAE.
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None of the authors have identified a conflict of interest.
PII: S1051-0443(09)00595-8
doi:10.1016/j.jvir.2009.06.002
© 2009 SIR. Published by Elsevier Inc. All rights reserved.
Volume 20, Issue 9 , Pages 1172-1175, September 2009
