When to say “no” to uterine artery embolization

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For interventional radiologists carrying out uterine artery embolization, there is every reason to proclaim its benefits widely, share its proven success rates and take pride in the body of evidence that supports the use of this procedure. Uterine artery embolization is one of the few procedures in the interventional field which has been tested by many randomised trials and is backed by strong level I evidence. However, sometimes, it is equally important to be able to recognise that this procedure is not for everyone. It is good to know when to say “no”, Jafar Golzarian, professor of Radiology and Surgery and director of the Division of Interventional Radiology & Vascular Imaging, Minneapolis, USA, tells Interventional News

So when is uterine artery embolization absolutely contraindicated?

 

There are a few absolute contraindications including infection, any gynecological cancers and pregnancy.

 

What about relative contraindications?

 

These are more debatable. Endometritis is one of the relative contraindications. In my view, in such a situation, a patient needs antibiotics before considering uterine artery embolization. For patients with post-menopausal bleeding, which happens with persistent fibroids, one should first rule out malignancy before considering uterine artery embolization. It is important to remember that patients with additional diseases or conditions such as endometriosis, endometrial hyperplasia etc may need more workup before determining if they could benefit from uterine artery embolization. 

 

Are there some types of fibroids that do not respond well to uterine artery embolization? What is the evidence to back this?

 

We used to not offer uterine fibroid embolization to patients with narrow stalk or to patients with endocavitary fibroids. New reports show that embolization is effective in those patients. It seems that cervical fibroids do not respond well to embolization. In other types, such as infarcted fibroids, the expected benefit is also low as the goal of uterine artery embolization is precisely to provoke fibroid infarction. However, we have no strong evidence to back this, but this is based on personal experience and others’ experiences. 

 

Can you define the types of patient for whom you would say “no” to uterine artery embolization?

 

 

Two types of patients come to my mind. I would say “no” to embolization in a patient who has an intracavitary fibroid which is less than 3cm. Such a patient could benefit from a hysteroscopic removal. The second type is a patient with menorrhagia who has fibroids, but also a polyp. I would propose treating the polyp first and then re-evaluating the patient for the embolization if the patient is still symptomatic.

 

What is the current understanding on how uterine artery embolization impacts fertility?

 

There are now more studies demonstrating successful pregnancy after uterine artery embolization. A recent paper published by Pisco et al has shown the same outcome after uterine artery embolization and surgery in terms of the number of pregnancies. However, the only paper which can be classified as level one evidence, by Mara et al, favours myomectomy over embolization. 

 

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