Author(s)

P. Petruzzi, V. Vallini, B. Ginanni, F. Bianchi, I. Bargellini, R. Cioni, A. Cicorelli, C. Vignali, C. Bartolozzi.

Patient

female, 47 year(s)

The patient was a 47 year old woman with recurrent dysmenorrhoea and menorrhagia. In 2007, a gynaecological examination revealed many uterine leiomyomas, with a maximum diameter of 8cm. The patient was treated medically and surgically with persistent symptoms.

A pelvic MRI was performed, revealing uterine enlargement and a large leiomyoma (85x72x78mm) with areas of intralesional haemorrhage (Fig 1); at dynamic MRI after intravenous administration of gadolinium chelate, the lesion showed a non-enhancing central portion and a peripheral area of significant contrast enhancement (Fig 2).
Patient underwent digital subtraction angiography, that revealed the obstruction of the right uterine artery (outcome of previous myomectomy) and the presence of hypertrophic right ovarian artery and left uterine artery, feeding the cranial and left portion of the mass (Fig 3).
The hypertrophic arteries were selectively catheterized with a 3-F coaxial catheter system and embolization was performed with Embosphere 500-700μm (9 ml) and 700-900μm (4 ml) for the left uterine artery and 700-900μm (2 ml) for the right ovarian artery (Fig 4).
The post-embolization angiograms confirmed adequate vessels occlusion (Fig 5).
No complications were observed after treatment and the patient was discharged after 24 hours. At 6 months follow-up the patient is symptom-free.

Uterine fibroids are common tumours that may cause menorrhagia, pelvic pressure symptoms and reproductive disorders.
Treatment options include hysterectomy (menopause age), myomectomy, uterine artery embolization (UAE), myolysis, and medical therapy. Treatment must be individualized based on the presence and severity of symptoms, the desire to preserve childbearing capacity, the importance of uterine preservation, infertility related to uterine cavity distortions, and previous pregnancy complications related to fibroid tumours. UAE may be the best treatment option for women with symptomatic fibroids who are not candidates for surgery or who do not wish to accept the risks of an operative procedure but pregnancy, active infection, and suspicion of uterine or ovarian cancer are absolute contraindications for UAE. The procedure is performed under local anaesthesia, by femoral arterial access, and sedation is required to control the pain during the treatment.
Selective catheterization and embolization of both uterine arteries, which are the predominant source of blood flow to fibroid tumours in most cases, is the cornerstone of treatment.
The tumour itself is relatively hypovascular and its interior is supplied by small centripetal arteries that originate in a rich perifibroid arterial plexus composed of arteries with diameters of 500-1000µm in most cases. Therefore, for targeted embolization of the perifibroid arterial plexus, injection of particles with diameters larger than 500µm is generally recommended, with the tip of catheter lying in the horizontal portion of the artery to occlude them.
Complete embolization of both uterine arteries (to stasis) may lead to myometrial and/or endometrial ischemia, with potentially disastrous consequences, such as endometrial atrophy or extensive uterine necrosis. Moreover, excessive embolization may injure normal myometrium, ovaries or fallopian tubes and lead to uterine necrosis or infection or to ovarian failure. Therefore the common post-embolization angiographic end point is occlusion of the uterine arterial branches to the fibroid tumour while antegrade flow is maintained in the main uterine artery.
The effect of embolization on menorrhagia is immediate, whereas 4-6 months occur to appreciate tumour shrinkage. Data on long-term follow up are still emerging, and they show a 20–25% risk of re-intervention for persistent or recurrent symptoms after embolization.
Indeed, an additional supply to the fibroid may come from the ovarian artery in about 5%–10% of cases and it is a potential predictor of treatment failure or recurrence.
Collateral ovarian supply to uterine fibroids detected during UAE should be considered clinically significant if the aortogram obtained after UAE shows ovarian arteries that are large or have rapid flow. In these scenarios, ovarian artery catheterization and injection may be performed.
Ovarian artery supply to uterine fibroids is more frequently found in women who have undergone pelvic surgery and those with previously diagnosed tubal or ovarian disease and/or large fundal fibroids. In women with an additional supply to the fibroid tumour from the ovarian arteries, the additional embolization is considered if no clinical improvement has been observed and the fibroids are still viable, but the procedure is performed considering the risks related to ovarian artery embolization.