July 7, 2015
CIRSE Publishes Standard of Practice Guidelines for Uterine Artery Embolization
July 8, 2015—The Cardiovascular and Interventional Radiological Society of Europe (CIRSE) Standard of Practice guidelines for transcatheter uterine artery embolization (UAE) for symptomatic leiomyomata have been published by Hans van Overhagen, MD, and Jim A. Reekers, MD, in the society’s official journal, Cardiovascular and Interventional Radiology (2015;38:536–542).
The document, which provides quality assurance guidelines regarding UAE for the treatment of symptomatic uterine fibroids, addresses pretreatment imaging, patient preparation, equipment specifications, stand materials, procedural strategy and techniques, medication and periprocedural care, postprocedural care and follow-up, outcomes and effectiveness, and complications.
The CIRSE Standard of Practice guideline conclusions are:
• UAE is a true alternative to hysterectomy in women who want to preserve their uterus (level 1 evidence).
• The 5-year outcome in quality-of-life is equal in both groups with no difference in major complications (level 1).
• A 15%–20% hysterectomy rate has to be expected during follow-up after successful UAE (level 1).
• In the short-term, UAE had lower blood loss, shorter hospital stay, and quicker resumption of work compared with hysterectomy (level 1).
• The risk for ovarian dysfunction after UAE seems overestimated in women < 40 years of age.
• Every symptomatic patient with uterine myoma should be offered UAE as alternative treatment to hysterectomy/myomectomy.
• UAE should be incorporated in national gynecological guidelines.
According to the guidelines, UAE is indicated for uterine fibroids causing significant lifestyle-altering symptoms, specifically heavy menstrual bleeding, severe dysmenorrhea, or anemia (level 1). UAE is also indicated in fibroids that cause pain or a mass effect on the bladder or intestines (level 3).
Contraindications for UAE include a viable pregnancy, active infection of the uterus, and malignancy of the uterus or the ovaries unless the procedure is being performed for palliation or as an adjunct to surgery.
Relative contraindications for UAE specifically include the desire to maintain childbearing potential because preservation of fertility is not assured in the current literature. However, uncomplicated pregnancies and normal deliveries have been reported after UAE. Thus, this procedure may be considered for women who are not candidates for myomectomy, but not as a first-choice option.
The guidelines state that UAE has been used traditionally to treat fibroids with relatively small diameters after anecdotal reports of limited results and increased complications in larger (> 8 cm) fibroids. However, two recent studies showed no different clinical results or complication rates after UAE of large (> 10 cm) fibroids in a total of 100 patients (level 3).
The presence of pedunculated subserosal fibroids, defined as a uterine fibroid tumor, with a stalk diameter at least 50% narrower than the diameter of the tumor is considered a relative contraindication because this might cause torsion of the stalk, ischemic necrosis of the tumor, or separation of the tumor from the uterus. There are a few cases in the literature reporting complications due to septic pedunculated subserosal leiomyoma requiring surgery, but the exact incidence of complications after embolization of such lesions is unknown. There are a few reports in the literature that support the use of UAE for pedunculated subserosal fibroids, but these are limited. At present, the embolization of pedunculated (tumor stalk at least 50% narrower than the tumor itself) subserosal uterine fibroids remains controversial (level 3).
Additionally, the guidelines advised that a contraindication for UAE is the presence of a common arterial supply of the uterus and (one or both of) the ovaries in those cases where the uterus cannot be embolized selectively. Embolization of the ovaries can lead to premature menopause especially in women > 45 years of age (level 5).
Finally the presence of an intrauterine device (IUD) has traditionally been considered a contraindication for uterine embolization, but a recent series of 20 women who were accidentally embolized with an IUD in situ did not show any infectious side effects (level 4).
Relative contraindications to any endovascular intervention include coagulopathy, contrast material allergy. and impaired renal function, which can be treated before embolization, noted the guidelines in Cardiovascular and Interventional Radiology.