Uterine artery embolization (UAE) preserved fertility in “at least 75% of patients with acquired uterine arteriovenous malformations,” according to a recent single centre study presented at the virtual 2020 Global Embolization and Cancer Symposium Technologies (GEST) meeting (4–6 September). Dmitry Akinfiev (National Medical Research Center for Obstetrics, Gynecology and Perinatology, Kulakov, Russia) presented the clinical and reproductive findings of his research group to the live, global audience.
“In our work, the clinical effectiveness of UAE in acquired uterine arteriovenous malformations is 86.2%,” he shared.
Akinfiev and his team conducted a retrospective, single centre study involving 29 patients, with a mean age of 29.1 years—“rather low”, in the presenter’s words, with the oldest patient included in the study being 43 years old. “All [patients included in the study] were fertile,” Akinfiev informed delegates. The study investigators performed 34 UAE procedures, and the mean patient follow-up was 2.5 years (range: one to six years).
Uterine arteriovenous malformations are rare, the GEST audience were told. “Speaking of risk factors for acquired uterine arteriovenous malformations,” Akinfiev said, “in 80% of cases, the malformation was associated with curettage [19 patients had curettage following a miscarriage; four patients had a normal pregnancy and underwent curettage; one patient had a diagnostic curettage and no pregnancy]. Also, we had one patient with arteriovenous malformation after vacuum aspiration [following a normal pregnancy].” A further two patients developed uterine arteriovenous malformations due to gestational trophoblastic disease, and two patients acquired malformations for unknown reasons.
The team from Russia used irregular uterine bleeding as the primary indication for embolization. Eight patients (27%) needed a blood transfusion prior to UAE, and 10 procedures of 34 (29%) were emergency UAEs.
All patients underwent ultrasound and computed tomography (CT)-angiography before and after the procedure. “Those were our main diagnostic instruments,” Akinfiev divulged. “Importantly, we performed CT-angio from the diaphragm to the bottom of [the] pelvis.”
Detailing the procedures themselves, Akinfiev told the GEST attendees that 10 of the 34 procedures were expanded by embolizing additional arteries: branches of the internal iliacs, ovarian arteries, and superior mesenteric artery branches. Twenty-seven (80%) of the procedures were performed via the radial approach, and embolizations were performed with gelfoam and non-spherical polyvinyl acetate (PVA) particles under 500µm. “I prefer to use gelfoam in cubes,” Akinfiev opined.
The evaluation parameters for the study were the elimination of abnormal uterine bleeding, and the absence or significant reduction of arteriovenous shunting on CT-angio.
Of the 29 patients, 25 (86%) experienced clinical success after one procedure. Of the four who underwent a second procedure, the clinical success rate was 75%, with one patient having to have a third embolization. This third UAE was a clinical success.
There was a significant correlation between the clinical findings and the diagnostic findings, as presented on CT-angio. Twenty-seven of the 34 procedures were both clinically successful, and diagnostic imaging revealed a reduction or absence of arteriovenous shunting following UAE. In two cases, the interventionalists reported a clinical success, but diagnostic imaging showed the presence of arteriovenous shunting post-procedurally. All five clinical failures showed arteriovenous shunting on CT-angio. “There were no patients with CT-angio success and clinical failure,” Akinfiev said.
Next, he turned to reproductive outcomes. Of the 29 patients included in the study, 12 (41%) desired pregnancy, and 17 (59%) did not. In the desiring pregnancy subgroup, nine (75%) women did become pregnant, and all nine have since given birth, “a rather encouraging result,” according to Akinfiev.
“We had only one patient with a comorbidity during pregnancy,” he continued, “a patient with placental presentation. Our obstetricians had to perform a caesarean section in the 35th week of gestation due to threatening bleeding.”
Fielding a question from the audience concerning pulmonary embolisms, Akinfiev answered: “In this group, we did not see any sign of pulmonary embolism in our patients, but when we performed our procedures, we always tried to use the gelfoam first prior to PVA, as the cubic gelfoam particles are larger, and this way we try to prevent pulmonary embolism. Generally, we did not see any significant complications in this group except for one strange point, I cannot call it a complication, but about half of them demonstrated a very high temperature, higher than 38°C, on the second or third day after the procedure. I think it is because of using gelfoam.”
Another questioner asked if any of the 29 patients were given hormonal drugs prior to UAE, but Akinfiev replied that they did not use any form of systemic therapy ahead of embolization, “so zero,” he replied.