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OB/Gyn Grand Rounds: What Can the Interventionalist Do for Your Patients. Thea Moran, MD Asst Professor Louisiana State University New Orleans, LA. Disclosures. I have no disclosures to make. What can the IR do for the OB/Gyn service?. 1. Uterine fibroid embolization

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ob gyn grand rounds what can the interventionalist do for your patients

OB/Gyn Grand Rounds: What Can the Interventionalist Do for Your Patients

Thea Moran, MD

Asst Professor

Louisiana State University

New Orleans, LA

  • I have no disclosures to make
what can the ir do for the ob gyn service
What can the IR do for the OB/Gyn service?
  • 1. Uterine fibroid embolization
  • 2. Nonfibroid uterine artery embolization
  • 3. Prepartum uterine artery embolization
  • 4. Pelvic congestion syndrome
  • 5. Fallopian tube recanalization
  • 6. Endovenous ablation of varicose veins
1 uterine fibroid embolization
1. Uterine fibroid embolization
  • Fibroids, or leiomyomas, are benign smooth muscle tumors of the uterus occurring in reproductive age women.
  • Most common benign tumors of the female genital tract although many are without symptoms
  • Fibroids are most frequent in 30-40 year olds and involute after menopause
    • Goal of UFE is selective infarction of symptomatic fibroids
  • Menstrual abnormalities
    • Menorrhagia
      • Most frequent indication
      • Symptom most responsive
      • DDX: adenomyosis, endometrial polyps, endometrial hyperplasia, endometrial CA
    • Menometrorrhagia
    • Worsening of menstrual cramps
  • Pressure symptoms
    • Pressure sx related to the bladder, ureter, bowel, or nerves
    • DDX: ovarian and abdominal masses, infection, endometriosis, adenomyosis; fibroid torsion, degeneration or prolapse; PID, endometriosis, adenomyosis, pelvic congestion syndrome, GU/MSK/GI causes
  • Dyspareunia
  • Increasing pelvic or abdominal girth
  • Needed premyomectomy, hysterectomy for fibroids
  • Infertility or miscarriages with no other discernible cause
    • Controversial
  • Severe anaphylactoid reaction to contrast
  • Uncorrectable coagulopathy
  • Severe renal insufficiency
  • Pregnancy
  • Gynecological malignancy
  • Active pelvic infection/inflammatory disease
  • Prior pelvic radiation
  • Microvascular disease
  • Pedunculated or mucosal fibroids
    • Expulsion, cervical impaction
uterine artery anatomy
Uterine artery anatomy
  • First branch of anterior division of internal iliac artery
  • 3 segments
  • Descending segment goes along pelvic wall
  • Transverse segment goes to the midline
  • Ascending segment along the uterus
uterine artery anatomy9
Uterine artery anatomy
  • Cervicovaginal artery
  • Perforating arteries, terminal branches to the fallopian tubes and ovaries
  • Inferior vesicle artery has common origin
  • Can have completely or partially absent uterine artery which can be bilateral
ovarian artery anatomy
Ovarian artery anatomy
  • 1 ovarian artery per ovary
  • Originate from aorta a few cms below renal artery origins
  • 4% of women have ovaries supplied 100% by the uterine artery
    • Nikhil C Patel, Interventional Radiology Secrets.
ovarian artery anatomy12
Ovarian artery anatomy
  • 46% have uterine-ovarian artery anastomoses *
  • 5-10% have angio vis anastomoses *
    • Ovarian blush
    • Avoid nontarget embolization
  • Normal diameter: 1 mm
  • * Nikhil C Patel, Interventional Radiology Secrets
preoperative work up
Preoperative work up
  • History, pelvic exam, informed consent
  • CBC, FSH (day 3), chem 7, PT/PTT/INR
  • Pelvic US
    • Usually for screening and sufficient
    • Uterine and fibroid volumes, fibroid position
  • Pelvic MRI
    • Better definition of fibroids, uterus c/w US, evaluate for adenomyosis and other pathology
    • CE MRA help planning of UFE
      • Demonstrates vascular supply to fibroids
  • PAP smear
    • R/o cervical CA
preop work up
Preop work up
  • Endometrial biopsy
    • R/o endometrial cancer
    • US and MRI can’t definitively evaluate endometrial thickness
    • Intermenstrual or irregular bleeding, postmenopausal women with vaginal bleeding
    • All women over 40 yo with menorrhagia
  • D/c GnRH analogues several weeks preop
    • Fibroids enlarge
patient consultation
Patient consultation
  • Does the patient desire future childbearing?
  • Weigh treatment options
  • Severity of symptoms severe enough physically and/or psychologically to warrant invasive therapy especially since most fibroids involute after menopause
treatment options
Treatment options
  • Medical
      • Mild symptoms
    • GnRH
      • Moderate symptoms
      • Decreases estrogen which causes fibroid degeneration after 3 months of therapy
      • Noninvasive, short term relief of symptoms, good for perimenopausal women, adjuvant therapy preoperatively
      • Not to be given indefinitely
  • Surgical
    • Severe symptoms
    • Open, laparoscopic or hysteroscopic techniques
      • Hysterectomy
        • Complete cure, r/o possibility of future neoplasm, facilitates postmenopausal HRT, invasive
treatments options
Treatments options
      • Myomectomy
        • Preserves uterus and future childbearing
        • Bleeding c/o if multiple fibroids
        • High recurrence rate (20-25%)
          • Nikhil C Patel, Interventional Radiology Secrets.
  • UFE
    • Severe symptoms
    • Uterus retained, all myoma treated at once, noninvasive
    • Postembolization syndrome, potential for contrast reaction, possibility of no symptom relieve and lack of comparative data
    • No conclusive data on the effect of this treatment on fertility
patient preparation
Patient preparation
  • Usually needs at least a 23 hr admit
  • Serum pregnancy test
  • Foley catheter
  • Vigorous hydration
  • Prophylactic antibiotics
    • Cefazolin 1 g; if PCN allergic – vancomycin 1 g IV
  • Antiemetic and pain meds given
  • PCA pump instructions given
  • Have intraprocedural meds available
    • Conscious sedation, toradol, zofran
  • Both groins prepped with CFA access
  • Pelvic angiogram with catheter inferior to the renal artery
  • Selective uterine artery angiogram
  • Superselective angiogram with catheter tip in the transverse portion of the uterine artery past the cervicovaginal branch
  • Embolic agent injected
    • Ivalon/PVA/Biospheres 700 um
    • Inject until stasis w/o hypervascularity
    • Avoid reflux, nontarget embolization
    • Preserve flow in the main uterine and ovarian arteries
    • +/- f/u with Gelfoam plug in uterine artery
      • More consistently associated with preserved fertility
  • Control angiogram
  • Repeat procedure on opposite side followed by pelvic angiogram
postprocedure management
Postprocedure management
  • Pain management!
    • Severe for 12-24 hrs with gradual decrease over 7 d
    • Usually needs a PCA pump initially
    • Antipyretics, antiinflammatory meds and antiemetics
  • Vigorous hydration until po intake is adequate
  • OK to d/c patient when po intake adequate and pain control via po meds
    • Nothing in vagina for 3 wks
    • Call MD if F/C, foul smelling d/c, worsening pain, other signs of infection
  • Less blood loss, shorter hospital stay, fewer major complications
  • Technical success rate 98% *
  • 90% need no further treatment *
  • 85% improvement in bleeding symptoms *
  • 90% improvement in mass effect symptoms *
  • 40% decreased in fibroid and uterine size *
  • * Nikhil C Patel, Interventional Radiology Secrets.
  • Postembolization syndrome
    • Most frequent complication (15-30%)
      • Nikhil C Patel, Interventional Radiology Secrets.
    • Pain, fever, N/V, malaise, leukocytosis
    • Clinically differentiated from infection
      • Infection: vaginal d/c or if fever, pain, malaise are progressive
        • Broad spectrum antibiotics, blood cultures
    • Acetominophen, hydration
  • Ovarian failure
    • >45 yrs
  • Fibroid expulsion with vaginal impaction
    • Submucosal fibroid
    • May need D&C
  • Inadvertent sarcoma embolization
    • More likely to be incomplete infarction
      • Tumor continues to grow
      • No change in prognosis with 3-6 month delay
  • Radiation risks are minimal
  • PE, pain with rehospitalization, failure of procedure to correct sx
  • Sepsis, severe ischemia, fibroid necrosis
    • Most dreaded complication
    • Persistent fever, progressive or unrelenting abdominal pain, purulent d/c
    • Risk of uterine rupture
    • May need emergent hysterectomy
  • Death
  • Percocet with toradol
    • Analgesia, antiinflammatory, antipyretic
  • Compazine
    • Antiemetic
  • Stool softener
    • Analgesics constipate
  • Serum FSH 3 days after 1st period
    • If periods do not resume, random FSH
  • GYN f/u
    • 1-4 wks and 6 mos
  • Pelvic US
    • 3, 6 and 12 mos
  • +/- f/u MRI at 6 mos
2 nonfibroid uae
2. Nonfibroid UAE
  • Pelvic angiogram with selective internal iliac artery angiogram pre and post embolization
  • Postop ie hysterectomy arterial bleeding
    • Extravasation, pseudoaneurysm or AVF
    • If localized - coil
  • Postpartum and tumor bleeding
    • Do not see extravasation or pseudoaneurysm
    • Tumors may appear relatively avascular
      • Particulates sized 3-500 um
    • Uterine atony
      • Gelfoam uterine arteries
3 prepartum uterine artery embolization
3. Prepartum uterine artery embolization
  • Lessens blood loss in patients with placenta previa or accreta or an atonic uterus
  • Occlusion balloon catheters (Boston Scientific 8.5-11 mm) placed into each internal iliac artery from each groin predelivery on the day of the delivery
    • Syringe with predetermined amount of saline attached
    • Epidural placed beforehand
  • Catheter length protruding outside of patient is marked
  • Patient transferred to delivery room
  • Infant delivered
  • Balloons inflated
  • Placenta delivered
4 pelvic congestion syndrome
4. Pelvic congestion syndrome
  • Female equivalent of testicular varicocele
  • Dilated gonadal and periuterine veins with symptoms
    • Dyspareunia, menstrual abnormalities, vulvar varices, LE varicose veins
    • Sx worse late in the day, when upright, with sexual arousal and during menstruation.
  • Condition of childbearing age
  • Reflux of blood into the gonadal veins
  • More common on the left
  • Predisposing conditions
    • Prior pregnancy, nutcracker syndrome, tubal ligation, IUD
  • Indications:
    • Chronic pelvic symptoms with o/w negative w/u
    • Pelvic varicosities with appropriate symptoms
    • Lower extremity varicose veins recurrent immediately after adequate surgical treatment
    • Severe labial/perineal varicosities
  • Contraindications:
    • Severe anaphylactoid reaction to contrast
    • Uncorrectable coagulopathy
    • Severe renal insufficiency
    • Phobia to medical implants
    • Inadequately treated pelvic pain of other cause
preprocedural preparation assessment
Preprocedural preparation - Assessment
  • Detailed clinical assessment by gynecologist
  • Diagnostic testing
    • Diagnostic laparoscopy, pelvic US, CT and/or MRI
    • Dilated gonadal and pelvic veins may be underestimated if patient is supine
      • Normal diameter of gonadal veins is <or= 5 mm
      • Diameter can easily >10 mm when abnormal
  • Clinical assessment by vascular specialist if varicose veins are the 1ary problem
patient education
Patient education
  • Pelvic congestion syndrome is controversial
  • Often see dilated veins in parous women w/o sx and no dilated veins in women with sx
  • Not all patients respond to embolization or may take up to 6 months to respond
  • Most women treated with embolization experience some relief if rigorous clinical and imaging screening is employed
gonadal vein anatomy
Gonadal vein anatomy
  • L gonadal vein empties into LRV
  • R gonadal vein empties into the IVC inferior to the RRV
  • Many variations in anatomy and confluences
  • Ascend on psoas with ureters and gonadal arteries
alternative treatments
Alternative treatments
  • Medical management
    • GnRH analogs, birth control pills, pain medicines
  • Surgical management
    • Ligate ovarian veins via laparoscope
    • Hysterectomy
patient preparation36
Patient preparation
  • Timing of the procedure with respect to menstrual or pain cycle is unimportant
  • Outpatient
  • Informed consent
  • Peripheral IV
  • Conscious sedation
invasive diagnostics
Invasive diagnostics
  • Venography is the definitive diagnostic imaging modality
  • Jugular>femoral and basilic vein access
  • 5-7 F sheath
  • Catheter into peripheral left renal vein
  • Table tilted upright to 45 degrees
  • Contrast hand injected
    • Reflux, identify collaterals, renal vein pathology, variant anatomy
  • Positive study
    • Patulous, easy to select vein orifices
    • Retrograde flow into the pelvis and uterine plexus
    • Slow contrast washout
  • Move to the opposite gonadal vein
  • If the ovarian venograms are negative - B internal iliac venograms
  • Control injection in the renal vein after embolization
  • Coils are the best known and most documented
    • Embolize as distal as possible to within 2 cm from the renal vein
    • Coils placed during Valsalva and are slightly larger than the diameter of the gonadal vein
    • Be aware of anatomic variants and collaterals
    • Spasm, coil migration, vessel perforation
  • Other possible agents
    • Detachable balloons, glue, sotradecol, hot contrast
postprocedure management39
Postprocedure management
  • Observe at bed rest for >60 mins
  • Consider f/u CXR
  • D/c to responsible party
  • Acetominophen/codeine for 3 days enough
results and complications
Results and complications
  • Technical success up to 100% *
  • 70-90% with some improvement *
  • Postembolization syndrome in up to 90% *
    • N/V, fever, pain
    • Can be confused for infection
  • Transient pelvic pressure or pain
    • Pelvic venous thrombosis
  • * Lindsay Machan, Handbook of Interventional Radiologic Procedures, 3rd edition.
5 fallopian tube recanalization
5. Fallopian tube recanalization
  • Relieve obstruction(s) in the internal female reproductive tract causing infertility.
  • Infertility: inability to conceive after 1 yr of unprotected intercourse (6 mos if pt >35 yo).
    • 15-20% of reproductive age couples *
    • Female factors alone account for 35%; female with male factors account for another 20% *
      • 20-40% of female infertility due to fallopian tube disease
        • Lindsay Machan, Handbook of Interventional Radiologic Procedures, 3rd edition.
  • Supported by the American Fertility Society
    • 1st line treatment in patients with confirmed proximal tubal obstruction
      • Amy S Thurmond, RadioGraphics 2000;20:1759-176.
  • * Elizabeth E Puscheck, emedicine: Infertility.
  • Proximal unilateral or bilateral fallopian tube occlusion confirmed by HSG, selective salpingography or laparoscopy
    • Needs evaluation by infertility specialists and gynecologist
  • Reocclusion after surgical reversal of tubal ligation
  • Active PID
  • Severe tubal or peritubal pathology not amenable to laparoscopic or open repair
  • Severe uterine deformity or large masses making catheterization difficult
  • Distal tubal occlusion
  • Intrauterine adhesions (severe)
  • Severe anaphylactoid reactions to contrast media
preprocedure evaluation by ir
Preprocedure evaluation by IR
  • Review imaging/surgical studies
  • Patient education
    • Patient’s partner present
    • R/o other contributing male or female factors
    • State procedure is nonoperative alternative or adjunct to surgery or assisted fertility procedures
    • Discuss possible procedural complications ie tubal perforation, infection
    • F/u after missed period or positive pregnancy test
      • Ectopic pregnancy risk
alternative treatments45
Alternative treatments
  • Microsurgery
    • Has been the treatment of choice for tubal occlusion
    • High cost and morbidity
  • In vitro fertilization
    • High cost, time consuming
    • Pregnancy rate 10-15%
      • Amy S Thurmond, RadioGraphics 2000;20:1759-176.
patient preparation46
Patient preparation
  • Schedule as outpatient during the follicular phase
    • After1st 3-5 days after bleeding has stopped
      • Avoids refluxing blood into the tubes or peritoneum
    • Before day 14 of her cycle
      • Ensures patient is not pregnant
  • Doxycycline 100 mg BID started 1-2 days prior and continued for 5 days after the procedure
  • Informed consent
  • Peripheral IV
  • Conscious sedation
    • Atropine 0.5 mg IM optional to prevent vasovagal sx
  • Lithotomy position with pelvis elevated
  • Sterilely prepare the perineum
  • Insert speculum and clean the cervix
  • HSG with H2O soluble contrast
  • Positive HSG
    • 5 F catheter selects the occluded ostium
    • Contrast injected through the introducing catheter
      • May be enough to restore patency
  • Proximal tubal occlusion further confirmed
    • 3 F catheter inserted coaxially through the 5 F catheter and obstruction is probed with an 0.018 wire
  • 3 F catheter advanced over the wire through the obstruction
  • Inject to confirm distal tube patency
  • If patency restored, remove 3 F system and inject through 5 F catheter to confirm patency
  • Manipulations are then done on the opposite side if appropriate
  • Final HSG through 5 F catheter with tip in the uterus
    • If the 1st tube opened is not patent, probably spasm, not indication to reopen
  • Average radiation dose to ovaries same as for a BE or IVP
Steps in salpingography and fallopian tube recanalization courtesy of Imaging.consult.com (2008 Elsevier).
Steps in salpingography and fallopian tube recanalization courtesy of Imaging.consult.com (2008 Elsevier).
postprocedure management51
Postprocedure management
  • Observe for 60 mins
  • Vaginal cramping and spotting for 1-2 d
  • Avoid intercourse for 1 day
  • Use pads for the next cycle
  • Consult infertility specialist for treatment of other infertility d/o
tubal patency results
Tubal patency results
  • Tubal patency results
    • Technical success in 71%-92%
      • Amy S Thurmond, RadioGraphics 2000;20:1759-176.
    • Up to 100% success in idiopathic proximal tubal obstruction *
    • 44-77% success in occluded tubes after tubal ligation *
    • 77-82% success with SIN but technically more difficult *
  • Pregnancy results
    • Variable
    • Average reported pregnancy rate is 30% (9-47%) *
      • Reflects other factors contributing to infertility ie associated distal tubal disease, d/o of ovulation or sperm production
      • Most occur within the 1st 6 mos
      • Compare favorably with those of microsurgery
  • * Lindsay Machan, Handbook of Interventional Radiologic Procedures, 3rd edition.
complications and follow up
Complications and Follow Up
  • Complications
    • Tubal perforation – 2% *
      • Usually those with h/o proximal tubal surgery or severe SIN
      • No clinical sequelae
    • Ectopic pregnancy 1-5% *
    • Pelvic infection
    • Radiation exposure
  • Follow up
    • Reevaluation and reopening if not pregnant by 6 mos
      • 25% of reopened tubes reocclude by this time *
  • * Lindsay Machan, Handbook of Interventional Radiologic Procedures, 3rd edition.
6 endovenous ablation of varicose veins
6. Endovenous ablation of varicose veins
  • In 1994, half the adult population had minor stigmata of venous disease with 50-55% being women and fewer than half of the adult population have visible varicose veins with 20-25% of these being women
    • Wesley K Law et al, emedicine: Varicose Veins.
  • Risk factors: heredity, h/o DVT, female, parity, standing, hormones, aging, obesity, constipation, leg trauma
  • Sx: swelling, pain, cramps, fatigue, heaviness
  • Can progress to pigmentation changes, dermatitis and/or venous hypertension
  • Indications for treatment: cosmesis, aching, leg heaviness or fatigue, superficial thrombophlebitis, external bleeding, edema, skin changes
  • Result from valvular incompetence
    • Valvular incompetence cannot be reversed
    • Best treatments: control sx or remove the veins
treatment options56
Treatment options
  • Conservative treatment: compression stockings, avoid standing, exercise
  • Surgery is the traditional tx
    • Ligation/stripping
      • Best known
    • Stab phlebectomy
    • Endoscopic powered phlebectomy or perforator ligation
    • Valvuloplasty, valve transplantation or transposition
  • Transcutaneous laser and high intensity pulsed light
    • Superficial telangiectasias
  • Percutaneous options
    • Endovenous ablation and US guided sclerotherapy
endovenous ablation
Endovenous ablation
  • Thermal energy causes contraction of vessel wall collagen and/or fibrotic obliteration of the vessel lumen
  • Laser and RFA are thermal modalities
  • Goals: eliminate highest point of reflux, ablate incompetent venous segment
  • Contraindications: arterial disease, infection, active venous ulceration, central venous obstruction, hypercoagulable syndromes, occluded/absent deep veins, lymphedema, nonambulatory patient, poor general health, venous thromboembolism
  • Greater saphenous vein is vein most often treated
  • Careful patient selection and evaluation needed
  • Preprocedure US
      • Superficial varicosites mapped
        • Patency/competency of the GSV, LSV, major superficial draining veins, perforators, deep venous system
  • GSV accessed at the knee
  • Long vascular sheath advanced to the saphenofemoral junction
  • Tumescent anesthesia
    • Dilute (0.25-0.5%) lidocaine along GSV course in the fascial sheath
  • Ablation device through sheath until below saphenofemoral junction with device protruding out the end of the sheath 2 cm below SFJ
  • Device withdrawn through vein from SFJ to access site
    • Laser
      • Thin optical fiber causes steam bubbles which indirectly causes vein injury
      • Various laser energies available
      • Sheath and fiber pulled back at an average rate of 2 mm/s to deliver 70 J/cm
      • Average length of time to treat 45 cm vein segment using 810 nm laser: 3-5 min; 7.5 mins for 1320 nm laser *
    • RFA
      • Electrodes through catheter directly contact the vein wall and heat the vein to 85-90 degrees
      • Impedance and hence maintenance of temperature, dictates how rapidly the catheter is withdrawn
      • Average length of time to treat 45 cm vein segment: 18-24 mins *
  • Ablation device turned off before removing through skin
  • * http://www.closurefast.com/howitworks/
postprocedure management60
Postprocedure management
  • Compression stockings (30-40 mm Hg) for 1 wk
  • Immediate ambulation, avoid vigorous activity
  • US at 3-7 d
    • Confirms closed vein
  • US at 4-6 wks
    • Clinical and sonographic resolution
    • Residual venous tributaries treated with sclerotherapy
results and complications61
Results and complications
  • Initial closure successful in 95-100%
    • Steven E Zimmel et al, emedicine: Varicose Vein Treatment with Endovenous Laser Therapy.
  • Initial closure successful in 83.5-88.2 % of RFA patients with the initial VNUS Closure system *
  • Initial closure successful in 100% of RFA patients with VNUSClosureFAST system *
    • Has shortened RFA procedure time to that comparable to laser
  • * Helane S. Fronek, The Fundamentals of Phlebology: Venous Disease for Clinicians, 2nd edition.
  • Symptoms post tx:
    • Common
    • Access site bruising, moderate LE discomfort, tightness/pulling peaking in 5-7 d
    • Resolves in 1-3 wks
  • Complications:
    • Overall rare
    • Superficial thrombophlebitis, nerve injury, burns, DVT
  • Telangiectasias, reticular veins and varicosities
  • Follow up to invasive venous therapy
  • Contraindications: unable to ambulate, at risk for or concurrently have a DVT, hypercoagulable states, allergic reaction to sclerosants, difficulty ambulating, deep venous outflow obstruction, severe systemic illness, peripheral arterial insufficiency
  • Small syringe injects 0.5-1 cc sclerosant via 25 G needle
  • Agents: hypertonics or osmotics, detergents and toxins
    • Sodium tetradecyl sulfate is the most common agent in the US
    • Foamed detergents: easier US vis, less dilution, lower concentration, fewer side effects
  • Compression stockings (20-40 mm Hg) for 3-14 d, low level lower extremity exercise
  • Potential complications: swelling, pain, hyperpigmentation, DVT, thrombophlebitis skin necrosis, nerve injury and anaphylaxis