Interventional radiology in management of gynecological disorders
- Ducksoo Kim, MD
Ducksoo Kim, MD
- Professor of Radiology
- Boston University School of Medicine
- Stephen D Baer, MD
Stephen D Baer, MD
- Section Editors
- Deborah Levine, MD
Deborah Levine, MD
- Section Editor — Imaging
- Professor of Radiology
- Director of Ob/Gyn Ultrasound
- Department of Radiology
- Beth Israel Deaconess Medical Center
- Robert L Barbieri, MD
Robert L Barbieri, MD
- Editor-in-Chief — Obstetrics, Gynecology and Women's Health
- Section Editor — General Gynecology and Female Reproductive Endocrinology
- Kate Macy Ladd Professor of Obstetrics, Gynecology and Reproductive Biology
- Harvard Medical School
Percutaneous transcatheter interventional procedures are increasingly being employed in the management of obstetric and gynecological disorders [1-3]. This technology offers a minimally invasive and potentially cost effective alternative for management of several common obstetrical and gynecological problems. It is most commonly used for managing fibroids and postpartum hemorrhage. However, these procedures have not been evaluated against other treatment modalities in large randomized trials.
TRANSCATHETER EMBOLIZATION PROCEDURE
Percutaneous transcatheter embolization (PTE) procedures are typically performed under fluoroscopic guidance in the radiology suite. Intravenous conscious sedation and narcotics, local anesthetics, nonopioid analgesics, or nonsteroidal antiinflammatory agents are administered for management of anxiety and pain. Many radiologists give intravenous broad spectrum antibiotic prophylaxis to reduce the risk of infection, although randomized controlled clinical trials have never validated the use of antibiotics in this setting for reduction of postoperative morbidity . Antibiotic prophylaxis for gynecologic procedures is shown in the table (table 1) and discussed separately. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Surgical site infection prevention'.)
The Seldinger technique is used to introduce a catheter into the femoral artery (figure 1A) . The catheter is then advanced into the hypogastric or uterine artery, depending upon the indication for the procedure. After subselective catheterization, diagnostic angiography of the artery is obtained to confirm proper position, look for extravasation suggestive of acute bleeding, and evaluate for abnormal vascularity associated with chronic bleeding. Transcatheter embolization of one or more arteries can then be performed (figure 1A-B).
Tiny particles or microspheres (polyvinyl alcohol particles, 500 to 700 and/or 700 to 900 microns in size or tris-acryl gelatin microspheres, 500 to 700 and/or 700 to 900 microns in size) (picture 1) are used to embolize hypervascular lesions, such as leiomyomas or adenomyosis, associated with multiple large feeding vessels. However, particulate embolic agents should be avoided when iliac or uterine or ovarian arteriovenous malformation/fistula are targeted because inadvertent pulmonary embolization may result. Gelfoam, coils, and glue are more effective than microspheres for embolization of large arteries associated with acute obstetrical hemorrhage, arteriovenous malformation, or some fistula.
Uterine fibroid embolization (UFE) is based upon the hypothesis that reduction of myometrial arterial blood flow will result in infarction of fibroids and control symptoms . It is an option for symptomatic premenopausal women who wish to retain their uterus, escape side effects associated with prolonged medical therapy, and avoid surgical treatment (eg, hysterectomy, myomectomy) [7,8]. UFE is rarely indicated in postmenopausal women . Other relative contraindications to UFE include current use of GnRH analogs, submucosal fibroids, and, possibly, plans for future pregnancy. The procedure is discussed in detail separately. (See "Uterine leiomyoma (fibroid) embolization".)
- Hovsepian DM, Bonn J, Eschelman DJ, et al. Fallopian tube recanalization in an unrestricted patient population. Radiology 1994; 190:137.
- Casola G, vanSonnenberg E, D'Agostino HB, et al. Percutaneous drainage of tubo-ovarian abscesses. Radiology 1992; 182:399.
- Gooding JM, D'Agostino HB, Plaxe SC. Transcervical metallic stents for drainage of uterine collections. J Vasc Interv Radiol 1999; 10:629.
- Ryan JM, Ryan BM, Smith TP. Antibiotic prophylaxis in interventional radiology. J Vasc Interv Radiol 2004; 15:547.
- SELDINGER SI. Catheter replacement of the needle in percutaneous arteriography; a new technique. Acta radiol 1953; 39:368.
- Ravina JH, Herbreteau D, Ciraru-Vigneron N, et al. Arterial embolisation to treat uterine myomata. Lancet 1995; 346:671.
- McLucas B, Goodwin S, Adler L, et al. Pregnancy following uterine fibroid embolization. Int J Gynaecol Obstet 2001; 74:1.
- Goldberg J, Pereira L, Berghella V. Pregnancy after uterine artery embolization. Obstet Gynecol 2002; 100:869.
- Committee on Gynecologic Practice, American College of Obstetricians and Gynecologists. ACOG Committee Opinion. Uterine artery embolization. Obstet Gynecol 2004; 103:403.
- Azziz R. Adenomyosis: current perspectives. Obstet Gynecol Clin North Am 1989; 16:221.
- Bird CC, McElin TW, Manalo-Estrella P. The elusive adenomyosis of the uterus--revisited. Am J Obstet Gynecol 1972; 112:583.
- Siskin GP, Tublin ME, Stainken BF, et al. Uterine artery embolization for the treatment of adenomyosis: clinical response and evaluation with MR imaging. AJR Am J Roentgenol 2001; 177:297.
- Chen C, Liu P, Lu J, et al. [Uterine arterial embolization in the treatment of adenomyosis]. Zhonghua Fu Chan Ke Za Zhi 2002; 37:77.
- Kim MD, Won JW, Lee DY, Ahn CS. Uterine artery embolization for adenomyosis without fibroids. Clin Radiol 2004; 59:520.
- Pelage JP, Jacob D, Fazel A, et al. Midterm results of uterine artery embolization for symptomatic adenomyosis: initial experience. Radiology 2005; 234:948.
- Kim MD, Kim S, Kim NK, et al. Long-term results of uterine artery embolization for symptomatic adenomyosis. AJR Am J Roentgenol 2007; 188:176.
- Ghai S, Rajan DK, Asch MR, et al. Efficacy of embolization in traumatic uterine vascular malformations. J Vasc Interv Radiol 2003; 14:1401.
- Fleming H, Ostör AG, Pickel H, Fortune DW. Arteriovenous malformations of the uterus. Obstet Gynecol 1989; 73:209.
- Liddle AD, Davies AH. Pelvic congestion syndrome: chronic pelvic pain caused by ovarian and internal iliac varices. Phlebology 2007; 22:100.
- Thurmond AS, Novy M, Uchida BT, Rösch J. Fallopian tube obstruction: selective salpingography and recanalization. Work in progress. Radiology 1987; 163:511.
- Thurmond AS. Selective salpingography and fallopian tube recanalization. AJR Am J Roentgenol 1991; 156:33.
- Thurmond AS, Machan LS, Maubon AJ, et al. A review of selective salpingography and fallopian tube catheterization. Radiographics 2000; 20:1759.
- Confino E, Friberg J, Gleicher N. Preliminary experience with transcervical balloon tuboplasty. Am J Obstet Gynecol 1988; 159:370.
- Maubon A, Rouanet JP, Cover S, et al. Fallopian tube recanalization by selective salpingography: an alternative to more invasive techniques? Hum Reprod 1992; 7:1425.
- Thurmond AS, Rösch J. Nonsurgical fallopian tube recanalization for treatment of infertility. Radiology 1990; 174:371.
- Thurmond AS. Pregnancies after selective salpingography and tubal recanalization. Radiology 1994; 190:11.
- Honoré GM, Holden AE, Schenken RS. Pathophysiology and management of proximal tubal blockage. Fertil Steril 1999; 71:785.
- Papaioannou S, Afnan M, Sharif K. The role of selective salpingography and tubal catheterization in the management of the infertile couple. Curr Opin Obstet Gynecol 2004; 16:325.
- Tanaka Y, Tajima H, Sakuraba S, et al. Renaissance of surgical recanalization for proximal fallopian tubal occlusion: falloposcopic tuboplasty as a promising therapeutic option in tubal infertility. J Minim Invasive Gynecol 2011; 18:651.
- Tinelli A, Prudenzano R, Malvasi A, et al. Emergency endovascular nanopharmacologic treatment in advanced gynecological cancers. Int J Gynecol Cancer 2010; 20:1250.
- Lim AK, Agarwal R, Seckl MJ, et al. Embolization of bleeding residual uterine vascular malformations in patients with treated gestational trophoblastic tumors. Radiology 2002; 222:640.
- Yamashita Y, Harada M, Yamamoto H, et al. Transcatheter arterial embolization of obstetric and gynaecological bleeding: efficacy and clinical outcome. Br J Radiol 1994; 67:530.
- Banaschak A, Stösslein F, Kielbach O, et al. [Therapeutic vascular embolization in life-threatening gynecologic hemorrhages]. Zentralbl Gynakol 1985; 107:1050.
- Pelage JP, Le Dref O, Mateo J, et al. Life-threatening primary postpartum hemorrhage: treatment with emergency selective arterial embolization. Radiology 1998; 208:359.
- Hansch E, Chitkara U, McAlpine J, et al. Pelvic arterial embolization for control of obstetric hemorrhage: a five-year experience. Am J Obstet Gynecol 1999; 180:1454.
- Salomon LJ, deTayrac R, Castaigne-Meary V, et al. Fertility and pregnancy outcome following pelvic arterial embolization for severe post-partum haemorrhage. A cohort study. Hum Reprod 2003; 18:849.
- Kirby JM, Kachura JR, Rajan DK, et al. Arterial embolization for primary postpartum hemorrhage. J Vasc Interv Radiol 2009; 20:1036.
- Villella J, Garry D, Levine G, et al. Postpartum angiographic embolization for vulvovaginal hematoma. A report of two cases. J Reprod Med 2001; 46:65.
- Heffner LJ, Mennuti MT, Rudoff JC, McLean GK. Primary management of postpartum vulvovaginal hematomas by angiographic embolization. Am J Perinatol 1985; 2:204.
- Chin HG, Scott DR, Resnik R, et al. Angiographic embolization of intractable puerperal hematomas. Am J Obstet Gynecol 1989; 160:434.
- Hsu YR, Wan YL. Successful management of intractable puerperal hematoma and severe postpartum hemorrhage with DIC through transcatheter arterial embolization--two cases. Acta Obstet Gynecol Scand 1998; 77:129.
- Mason BA. Postpartum hemorrhage and arterial embolization. Curr Opin Obstet Gynecol 1998; 10:475.
- Vedantham S, Goodwin SC, McLucas B, Mohr G. Uterine artery embolization: an underused method of controlling pelvic hemorrhage. Am J Obstet Gynecol 1997; 176:938.
- Sentilhes L, Gromez A, Clavier E, et al. Predictors of failed pelvic arterial embolization for severe postpartum hemorrhage. Obstet Gynecol 2009; 113:992.
- Bischofberger A, Savoldelli GL, Irion O. [Multidisciplinary management of post-partum hemorrhage: new strategies]. Rev Med Suisse 2011; 7:334.
- Badawy SZ, Etman A, Singh M, et al. Uterine artery embolization: the role in obstetrics and gynecology. Clin Imaging 2001; 25:288.
- Oei SG, Kho SN, ten Broeke ED, Brölmann HA. Arterial balloon occlusion of the hypogastric arteries: a life-saving procedure for severe obstetric hemorrhage. Am J Obstet Gynecol 2001; 185:1255.
- Alvarez M, Lockwood CJ, Ghidini A, et al. Prophylactic and emergent arterial catheterization for selective embolization in obstetric hemorrhage. Am J Perinatol 1992; 9:441.
- Ganguli S, Stecker MS, Pyne D, et al. Uterine artery embolization in the treatment of postpartum uterine hemorrhage. J Vasc Interv Radiol 2011; 22:169.
- Pelage JP, Le Dref O, Jacob D, et al. Selective arterial embolization of the uterine arteries in the management of intractable post-partum hemorrhage. Acta Obstet Gynecol Scand 1999; 78:698.
- Ornan D, White R, Pollak J, Tal M. Pelvic embolization for intractable postpartum hemorrhage: long-term follow-up and implications for fertility. Obstet Gynecol 2003; 102:904.
- Chauleur C, Fanget C, Tourne G, et al. Serious primary post-partum hemorrhage, arterial embolization and future fertility: a retrospective study of 46 cases. Hum Reprod 2008; 23:1553.
- Cordonnier C, Ha-Vien DE, Depret S, et al. Foetal growth restriction in the next pregnancy after uterine artery embolisation for post-partum haemorrhage. Eur J Obstet Gynecol Reprod Biol 2002; 103:183.