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A uterine wall defect after uterine artery embolization for symptomatic myomas

2002; Elsevier BV; Volume: 77; Issue: 1 Linguagem: Inglês

10.1016/s0015-0282(01)02953-3

1556-5653

Pierandrea De Iaco, Giuseppe Muzzupapa, Rita Golfieri, M. Ceccarini, Brunilde Roset, S Baroncini,

Gynecological conditions and treatments

Uterine artery embolization is becoming a relatively common treatment for uterine myomas and has a low risk of severe complications (1Spies J.B. Scialli A.R. Jha R.C. Imaoka I. Ascher S.M. Fraga V.M. et al.Initial results from uterine fibroid embolization for symptomatic leiomyomata.J Vasc Interv Radiol. 1999; 10: 1149-1157Abstract Full Text PDF PubMed Scopus (259) Google Scholar, 2Goodwin S.C. Walker W.J. Uterine artery embolization for the treatment of uterine fibroids.Current Opinion Obstet Gynecol. 1998; 10: 315-320Crossref PubMed Scopus (129) Google Scholar). Data about fertility after embolization are scarce, and some physicians reserve the procedure for women who do not want to bear any more children (1Spies J.B. Scialli A.R. Jha R.C. Imaoka I. Ascher S.M. Fraga V.M. et al.Initial results from uterine fibroid embolization for symptomatic leiomyomata.J Vasc Interv Radiol. 1999; 10: 1149-1157Abstract Full Text PDF PubMed Scopus (259) Google Scholar).The histopathologic features of the uterine wall after uterine artery embolization are unknown; in one prior study, the pathologic features of the uterus were analyzed after ischemic complications following hysterectomy (3Ravina J.H. Bouret J.M. Ciraru-Vigneron N. Repiqet D. Herbreteau D. Aymard A. et al.Application of particulate arterial embolization in the treatment of uterine fibromyomata.Bull Acad National Med. 1997; 181: 233-243PubMed Google Scholar).A 54-year-old G1 presented with a history of pelvic pain and intermenstrual bleeding. A pelvic ultrasonogram showed four intramural 3.3–7 cm fibroids. The patient was treated with bilateral uterine artery embolization; the procedure was uneventful. The patient was asymptomatic 6 weeks after the treatment, and at 12 months, a pelvic scan demonstrated a 30% shrinkage of the largest fibroid.Fourteen months after the embolization, she presented with metrorrhagia; a CO2 diagnostic hysteroscopy demonstrated a defect 2 cm wide and 2 cm deep with regular, well-defined borders in the right uterine wall, covered by smooth irregular yellow tissue containing hard yellowish fibroid remnants covered by a film of clear secretion (FIGURE 1, FIGURE 2, FIGURE 3). The defect was limited to the internal myometrium and did not lead to the peritoneal cavity. It opened into the uterine cavity through a 1.5-cm fistula of endometrium and myometrium. The uterine cavity was regular elsewhere and had a regular mucosa.FIGURE 2Hysteroscopic image taken from the internal uterine os showing a 2-cm cavity with regular, well-defined borders on the middle third of the right uterine wall. Fundus and uterine tubal ostia are covered by CO2 gas bubbles. The cavity is partially covered by a yellowish material (A = uterine fundus; B = anterior uterine wall; C = newly formed cavity in the depth of the myometrium).Show full captionDe Iaco. Uterine wall defect after uterine artery embolization. Fertil Steril 2002.View Large Image Figure ViewerDownload (PPT)FIGURE 3Close-up view from the internal os of the fistula of a newly formed cavity resulting from fibroid shrinkage in the myometrium depth. The cavity is covered by smooth, irregular yellow tissue and contains yellowish fibroid remnants covered by a film of clear secretion on the right side (A = os of the cavity; B = fibroid remnants; C = lateral wall of the cavity).Show full captionDe Iaco. Uterine wall defect after uterine artery embolization. Fertil Steril 2002.View Large Image Figure ViewerDownload (PPT)It has been reported that the use of uterine artery embolization results in a 40%–80% reduction in fibroid size at 6 months (2Goodwin S.C. Walker W.J. Uterine artery embolization for the treatment of uterine fibroids.Current Opinion Obstet Gynecol. 1998; 10: 315-320Crossref PubMed Scopus (129) Google Scholar, 3Ravina J.H. Bouret J.M. Ciraru-Vigneron N. Repiqet D. Herbreteau D. Aymard A. et al.Application of particulate arterial embolization in the treatment of uterine fibromyomata.Bull Acad National Med. 1997; 181: 233-243PubMed Google Scholar), with extensive hyaline necrosis and degeneration of the fibroids (4Stancato-Pasik A, Katz R, Mitty HA. Uterine artery embolization of myomas: preliminary results of gelatin sponge pledgets as the embolic agent [abstract]. SMIT/CIMIT 11th Annual Scientific Meeting, Boston, Sept. 1999.Google Scholar). The concomitant modification in the architecture and structure of the uterine wall has not yet been studied.This image shows severe disruption of the architecture of the uterine wall in a patient who underwent bilateral embolization of the uterine arteries. On the basis of this experience, it is necessary to be extremely careful when offering this procedure to women who want to bear children in the future. Uterine artery embolization is becoming a relatively common treatment for uterine myomas and has a low risk of severe complications (1Spies J.B. Scialli A.R. Jha R.C. Imaoka I. Ascher S.M. Fraga V.M. et al.Initial results from uterine fibroid embolization for symptomatic leiomyomata.J Vasc Interv Radiol. 1999; 10: 1149-1157Abstract Full Text PDF PubMed Scopus (259) Google Scholar, 2Goodwin S.C. Walker W.J. Uterine artery embolization for the treatment of uterine fibroids.Current Opinion Obstet Gynecol. 1998; 10: 315-320Crossref PubMed Scopus (129) Google Scholar). Data about fertility after embolization are scarce, and some physicians reserve the procedure for women who do not want to bear any more children (1Spies J.B. Scialli A.R. Jha R.C. Imaoka I. Ascher S.M. Fraga V.M. et al.Initial results from uterine fibroid embolization for symptomatic leiomyomata.J Vasc Interv Radiol. 1999; 10: 1149-1157Abstract Full Text PDF PubMed Scopus (259) Google Scholar). The histopathologic features of the uterine wall after uterine artery embolization are unknown; in one prior study, the pathologic features of the uterus were analyzed after ischemic complications following hysterectomy (3Ravina J.H. Bouret J.M. Ciraru-Vigneron N. Repiqet D. Herbreteau D. Aymard A. et al.Application of particulate arterial embolization in the treatment of uterine fibromyomata.Bull Acad National Med. 1997; 181: 233-243PubMed Google Scholar). A 54-year-old G1 presented with a history of pelvic pain and intermenstrual bleeding. A pelvic ultrasonogram showed four intramural 3.3–7 cm fibroids. The patient was treated with bilateral uterine artery embolization; the procedure was uneventful. The patient was asymptomatic 6 weeks after the treatment, and at 12 months, a pelvic scan demonstrated a 30% shrinkage of the largest fibroid. Fourteen months after the embolization, she presented with metrorrhagia; a CO2 diagnostic hysteroscopy demonstrated a defect 2 cm wide and 2 cm deep with regular, well-defined borders in the right uterine wall, covered by smooth irregular yellow tissue containing hard yellowish fibroid remnants covered by a film of clear secretion (FIGURE 1, FIGURE 2, FIGURE 3). The defect was limited to the internal myometrium and did not lead to the peritoneal cavity. It opened into the uterine cavity through a 1.5-cm fistula of endometrium and myometrium. The uterine cavity was regular elsewhere and had a regular mucosa. De Iaco. Uterine wall defect after uterine artery embolization. Fertil Steril 2002. De Iaco. Uterine wall defect after uterine artery embolization. Fertil Steril 2002. It has been reported that the use of uterine artery embolization results in a 40%–80% reduction in fibroid size at 6 months (2Goodwin S.C. Walker W.J. Uterine artery embolization for the treatment of uterine fibroids.Current Opinion Obstet Gynecol. 1998; 10: 315-320Crossref PubMed Scopus (129) Google Scholar, 3Ravina J.H. Bouret J.M. Ciraru-Vigneron N. Repiqet D. Herbreteau D. Aymard A. et al.Application of particulate arterial embolization in the treatment of uterine fibromyomata.Bull Acad National Med. 1997; 181: 233-243PubMed Google Scholar), with extensive hyaline necrosis and degeneration of the fibroids (4Stancato-Pasik A, Katz R, Mitty HA. Uterine artery embolization of myomas: preliminary results of gelatin sponge pledgets as the embolic agent [abstract]. SMIT/CIMIT 11th Annual Scientific Meeting, Boston, Sept. 1999.Google Scholar). The concomitant modification in the architecture and structure of the uterine wall has not yet been studied. This image shows severe disruption of the architecture of the uterine wall in a patient who underwent bilateral embolization of the uterine arteries. On the basis of this experience, it is necessary to be extremely careful when offering this procedure to women who want to bear children in the future.