uterine artery embolization


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uterine artery embolization

The injection of particles into the uterine artery to block its blood supply. Uterine artery embolization is used as an alternative to hysterectomy in the management of uterine fibroids and, occasionally, postpartum bleeding. Complications from the procedure include pelvic pain, cramping, fever, nausea, vomiting, or occasionally uterine injury that necessitates surgical removal of the uterus.
See: embolotherapy
See also: embolization

Uterine Fibroid Embolization

Synonym/acronym: UFE; uterine artery embolization.

Common use

A less invasive modality used to assist in treating fibroid tumors found in the uterine lining, heavy menstrual bleeding, and pelvic pain.

Area of application

Uterus.

Contrast

IV iodine based.

Description

Uterine fibroid embolization (UFE) is a way of treating fibroid tumors of the uterus. Fibroid tumors, also known as myomas, are masses of fibrous and muscle tissue in the uterine wall that are benign but that may cause heavy menstrual bleeding, pain in the pelvic region, or pressure on the bladder or bowel. Using angiographic methods, a catheter is placed in each of the two uterine arteries, and small particles are injected to block the arterial branches that supply blood to the fibroids. The fibroid tissue dies, the mass shrinks, and the symptoms are relieved. This procedure, which is done under local anesthesia, is less invasive than open surgery done to remove uterine fibroids. Because the effects of uterine fibroid embolization on fertility are not yet known, the ideal candidate is a premenopausal woman with symptoms from fibroid tumors who no longer wishes to become pregnant. This technique is an alternative for women who do not want to receive blood transfusions or do not wish to receive general anesthesia. This procedure may be used to halt severe bleeding following childbirth or caused by gynecological tumors.

This procedure is contraindicated for

  • high alert Patients who are pregnant or suspected of being pregnant, unless the potential benefits of a procedure using radiation far outweigh the risk of radiation exposure to the fetus and mother.
  • high alert Patients with conditions associated with adverse reactions to contrast medium (e.g., asthma, food allergies, or allergy to contrast medium). Although patients are still asked specifically if they have a known allergy to iodine or shellfish, it has been well established that the reaction is not to iodine, in fact an actual iodine allergy would be very problematic because iodine is required for the production of thyroid hormones. In the case of shellfish, the reaction is to a muscle protein called tropomyosin; in the case of iodinated contrast medium, the reaction is to the noniodinated part of the contrast molecule. Patients with a known hypersensitivity to the medium may benefit from premedication with corticosteroids and diphenhydramine; the use of nonionic contrast or an alternative noncontrast imaging study, if available, may be considered for patients who have severe asthma or who have experienced moderate to severe reactions to ionic contrast medium.
  • high alert Patients with conditions associated with preexisting renal insufficiency (e.g., renal failure, single kidney transplant, nephrectomy, diabetes, multiple myeloma, treatment with aminoglycosides and NSAIDs) because iodinated contrast is nephrotoxic.
  • high alert Elderly and compromised patients who are chronically dehydrated before the test because of their risk of contrast-induced renal failure.
  • high alert Patients with bleeding disorders because the puncture site may not stop bleeding.
  • high alert Patients in whom cancer is a possibility or who have inflammation or infection in the pelvis.

Indications

  • Treatment for anemia from chronic blood loss
  • Treatment of fibroid tumors and tumor vascularity, for both single and multiple tumors
  • Treatment of tumors in lieu of surgical resection

Potential diagnosis

Normal findings

  • Decrease in uterine bleeding
  • Decrease of pelvic pain or fullness

Abnormal findings related to

  • No reduction in size of fibroid

Critical findings

    N/A

Interfering factors

  • Factors that may impair clear imaging

    • Gas or feces in the gastrointestinal tract resulting from inadequate cleansing or failure to restrict food intake before the study.
    • Retained barium from a previous radiological procedure.
    • Metallic objects (e.g., jewelry, body rings) within the examination field, which may inhibit organ visualization and cause unclear images.
  • Other considerations

    • The procedure may be terminated if chest pain or severe cardiac arrhythmias occur.
    • Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status, may interfere with the test results.
    • Failure to follow dietary restrictions before the procedure may cause the procedure to be canceled or repeated.
    • Consultation with a health-care provider (HCP) should occur before the procedure for radiation safety concerns regarding younger patients or patients who are lactating. Pediatric & Geriatric Imaging Children and geriatric patients are at risk for receiving a higher radiation dose than necessary if settings are not adjusted for their small size. Pediatric Imaging Information on the Image Gently Campaign can be found at the Alliance for Radiation Safety in Pediatric Imaging (www.pedrad.org/associations/5364/ig/).
    • Risks associated with radiation overexposure can result from frequent x-ray procedures. Personnel in the room with the patient should wear a protective lead apron, stand behind a shield, or leave the area while the examination is being done. Personnel working in the examination area should wear badges to record their level of radiation exposure.
    • A small percentage of women may pass a small piece of fibroid tissue after the procedure. Women with this problem may require a procedure called a D & C (dilatation and curettage).
    • Some women may experience menopause shortly after the procedure.

Nursing Implications and Procedure

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this procedure can assist in assessing and treating the uterus.
  • Obtain a history of the patient’s complaints or clinical symptoms, including a list of known allergens, especially allergies or sensitivities to latex, anesthetics, contrast medium, or sedatives.
  • Obtain a history of the patient’s reproductive system, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Note any recent procedures that can interfere with test results; include examinations utilizing barium- or iodine-based contrast medium.
  • Record the date of the last menstrual period and determine the possibility of pregnancy in perimenopausal women.
  • Obtain a list of the patient’s current medications, including anticoagulants, aspirin and other salicylates, herbs, nutritional supplements, and nutraceuticals, especially those known to affect coagulation (see Effects of Natural Products on Laboratory Values online at DavisPlus). Such products should be discontinued by medical direction for the appropriate number of days prior to a surgical procedure. Note the last time and dose of medication taken.
  • Note that if iodinated contrast medium is scheduled to be used in patients receiving metformin (Glucophage) for non-insulin-dependent (type 2) diabetes, the drug should be discontinued on the day of the test and continue to be withheld for 48 hr after the test. Iodinated contrast can temporarily impair kidney function, and failure to withhold metformin may indirectly result in drug-induced lactic acidosis, a dangerous and sometimes fatal side effect of metformin related to renal impairment that does not support sufficient excretion of metformin.
  • Review the procedure with the patient. Address concerns about pain and explain that there may be moments of discomfort and some pain experienced during the test. Explain that a sedative and/or anesthetic may be administered before the procedure to promote relaxation. Inform the patient that the procedure is performed in a radiology or vascular department by an HCP, with support staff, and takes approximately 30 to 120 min.
  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
  • Explain that an IV line may be inserted to allow infusion of IV fluids such as normal saline, anesthetics, sedatives, or emergency medications. Explain that the contrast medium will be injected, by catheter, at a separate site from the IV line.
  • Inform the patient that a burning and flushing sensation may be felt throughout the body during injection of the contrast medium. After injection of the contrast medium, the patient may experience an urge to cough, flushing, nausea, or a salty or metallic taste.
  • Instruct the patient to remove jewelry and other metallic objects from the area to be examined prior to the procedure.
  • Instruct the patient to fast and restrict fluids for 8 hr prior to the procedure. Instruct the patient to avoid taking anticoagulant medication or to reduce dosage as ordered prior to the procedure. Protocols may vary among facilities.
  • Make sure a written and informed consent has been signed prior to the procedure and before administering any medications.
  • This procedure may be terminated if chest pain, severe cardiac arrhythmias, or signs of a cerebrovascular accident occur.

Intratest

  • Potential complications:
  • Establishing an IV site and injecting contrast medium by catheter are invasive procedures. Complications are rare but do include risk for allergic reaction (related to contrast reaction); bleeding (related to a bleeding disorder, or the effects of natural products and medications known to act as blood thinners; postprocedural bleeding from the site is rare because at the conclusion of the procedure a resorbable device, composed of non-latex-containing arterial anchor, collagen plug, and suture, is deployed to seal the puncture site); blood clot formation (related to thrombus formation on the tip of the catheter sheath surface or in the lumen of the catheter; the use of a heparinized saline flush during the procedure decreases the risk of emboli); cardiac arrhythmias; hematoma (related to blood leakage into the tissue following insertion of the catheter); infection (which might occur if bacteria from the skin surface is introduced during catheter insertion); tissue damage (related to extravasation of the contrast during injection); nerve injury or damage to a nearby organ (which might occur if the catheter strikes a nerve or perforates an organ); detachment of small pieces of fibroid tissue during UFE which will pass, but a D & C may be required to verify that all material is removed to prevent further bleeding or infection; and the occurrence of menopause following UFE, which is generally experienced in women older than 45 yr of age.

  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient.
  • Ensure the patient has complied with dietary, fluid, and medication restrictions for 8 hr prior to the procedure.
  • Ensure the patient has removed all external metallic objects from the area to be examined prior to the procedure.
  • Administer ordered prophylactic steroids or antihistamines before the procedure if the patient has a history of allergic reactions to any substance or drug. Use nonionic contrast medium for the procedure.
  • Avoid the use of equipment containing latex if the patient has a history of allergic reaction to latex.
  • Have emergency equipment readily available.
  • Instruct the patient to void prior to the procedure and to change into the gown, robe, and foot coverings provided.
  • Instruct the patient to cooperate fully and to follow directions. Instruct the patient to remain still throughout the procedure because movement produces unreliable results.
  • Record baseline vital signs and assess neurological status. Protocols may vary among facilities.
  • Establish an IV fluid line for the injection of saline, sedatives, or emergency medications.
  • Administer an antianxiety agent, as ordered, if the patient has claustrophobia. Administer a sedative to an uncooperative adult, as ordered.
  • Place electrocardiographic electrodes on the patient for cardiac monitoring. Establish baseline rhythm; determine if the patient has ventricular arrhythmias.
  • Using a pen, mark the site of the patient’s peripheral pulses before angiography; this allows for quicker and more consistent assessment of the pulses after the procedure.
  • Place the patient in the supine position on an examination table. Cleanse the selected area, and cover with a sterile drape.
  • The contrast medium is injected, and a rapid series of images is taken during and after the filling of the vessels to be examined. Delayed images may be taken to examine the vessels after a time and to monitor the venous phase of the procedure.
  • Ask the patient to inhale deeply and hold her breath while the x-ray images are taken, and then to exhale after the images are taken.
  • Instruct the patient to take slow, deep breaths if nausea occurs during the procedure. Monitor and administer an antiemetic agent if ordered. Ready an emesis basin for use.
  • Particles are injected through the catheter to block the blood flow to the fibroids. The particles include polyvinyl alcohol, gelatin sponge (Gelfoam), and micospheres.
  • The needle or catheter is removed, and a pressure dressing is applied over the puncture site.
  • Monitor the patient for complications related to the procedure (e.g., allergic reaction, anaphylaxis, bronchospasm).
  • Observe/assess the needle/catheter insertion site for bleeding, inflammation, or hematoma formation.

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
  • Instruct the patient to resume usual diet, fluids, medications, or activity, as directed by the HCP. Renal function should be assessed before metformin is resumed.
  • Monitor vital signs and neurological status every 15 min for 1 hr, then every 2 hr for 4 hr, and then as ordered by the HCP. Take temperature every 4 hr for 24 hr. Monitor intake and output at least every 8 hr. Compare with baseline values. Notify the HCP if temperature is elevated. Protocols may vary among facilities.
  • Observe for delayed allergic reactions, such as rash, urticaria, tachycardia, hyperpnea, hypertension, palpitations, nausea, or vomiting.
  • Instruct the patient to immediately report symptoms such as fast heart rate, difficulty breathing, skin rash, itching, chest pain, persistent right shoulder pain, or abdominal pain. Immediately report symptoms to the appropriate HCP.
  • Inform the patient that she may experience pelvic cramps for several days after the procedure and possible mild nausea and fever.
  • Assess extremities for signs of ischemia or absence of distal pulse caused by a catheter-induced thrombus.
  • Instruct the patient in the care and assessment of the injection site.
  • Instruct the patient to apply cold compresses to the puncture site as needed, to reduce discomfort or edema.
  • Recognize anxiety related to test results, and be supportive of impaired activity related to genitourinary system. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. Educate the patient regarding access to counseling services.
  • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP. Answer any questions or address any concerns voiced by the patient or family.
  • Instruct the patient in the use of any ordered medications. Explain the importance of adhering to the therapy regimen. As appropriate, instruct the patient in significant side effects and systemic reactions associated with the prescribed medication. Encourage her to review corresponding literature provided by a pharmacist.
  • Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.

Related Monographs

  • Related tests include CBC, CT angiography, CT pelvis, hysterosalpingography, laparoscopy, MRA, MRI pelvis, PT/INR, and US pelvis.
  • Refer to the Reproductive System table at the end of the book for related tests by body system.
References in periodicals archive ?
The findings suggest that for women who desire a future pregnancy, uterine artery embolization (UAE) may offer advantages over myomectomy, Dr.
Gathering a team to perform uterine artery embolization often takes 1 to 4 hours; in this setting, a Bakri balloon is a useful temporizing step that reduces bleeding while the IR team is assembled.
ExAblate lifetime treatment costs were less than a myomectomy or uterine artery embolization, but more than hysterectomy, the most invasive of all procedures.
When outcomes were compared based on the type of arterial occlusion used, the differences between the 26 patients who underwent uterine artery embolization and the 24 patients with no arterial occlusion remained statistically significant, but no significant differences were seen between the 13 who underwent hypogastric balloon inflation and those with no occlusion, Dr.
Uterine artery embolization in the primary treatment of uterine leiomyomas: technical features and prospective follow up with clinical and sonographic examination in 58 patients.
SEATTLE -- Short-term data collected in a multicenter registry suggest that uterine artery embolization is comparable in safety with other treatment approaches for fibroids, Dr.
Publication in the July 2008 issue of the Journal of Vascular and Interventional Radiology of a study entitled: "Economic Evaluation of Uterine Artery Embolization versus Hysterectomy in the Treatment of Symptomatic Uterine Fibroids: Results from the Randomized EMMY Trial," where the authors concluded that "the 24-month cumulative cost of uterine artery embolization (UAE) is lower than that of hysterectomy.
Hysterectomy is not the only treatment option; alternatives include medical therapy, the progesterone-releasing intrauterine system, endometrial ablation, myomectomy (hysteroscopic, laparoscopic, or abdominal), uterine artery embolization (UAE), and focused ultrasound.
Cosponsored by the Society of Interventional Radiology and the Cardiovascular and Interventional Radiology Research and Education Foundation, the Uterine Artery Embolization Fibroid Registry for Outcomes Data (FIBROID) began enrolling patients in late 2000 to assess the procedure's durability and impact on fertility and quality of life.
The mean hemoglobin level was also lower--although not significantly so--upon presentation in those who eventually underwent a uterine artery embolization.
This dynamic may be particularly appropriate when considering alternatives to hysterectomy for the treatment of fibroids, such as uterine fibroid embolization (UFE), also called uterine artery embolization (UAE).