Uterine Artery Embolization for Leiomyomas and Adenomyosis: A Pictorial Essay Based on Our Experience from 1300 Cases

Abstract

Since its introduction in 1995, uterine artery embolization (UAE) has become an established option for the treatment of leiomyomas. Identification of a leiomyoma using arteriography improves the ability to perform effective UAE. UAE is not contraindicated in a pedunculated subserosal leiomyoma. UAE in a cervical leiomyoma remains a challenging procedure. A leiomyoma with high signal intensity on T2-weighted imaging responds well to UAE, but a malignancy with similar radiological features should not be misdiagnosed as a leiomyoma. Administration of gonadotropin-releasing hormone agonists before UAE is useful in selected patients and is not a contraindication for the procedure. The risk of subsequent re-intervention 5 years after UAE is approximately 10%, which represents an acceptable profile. UAE for adenomyosis is challenging; initial embolization using small particles can achieve better success than that by using larger particles. An intravenous injection of dexamethasone prior to UAE, followed by a patient-controlled analgesia pump and intra-arterial administration of lidocaine after the procedure, are useful techniques to control pain. Dexmedetomidine is an excellent supplemental sedative, showing a fentanyl-sparing effect without causing respiratory depression. UAE for symptomatic leiomyoma is safe and can be an alternative to surgery in most patients with a low risk of re-intervention.

Keywords: Adenomyosis; Leiomyoma; MRI; Uterine artery embolization; Uterus.

Fig. 1. 44-year-old woman presenting with heavy bleeding due to cervical leiomyoma.

A. Sagittal T2WI MRI shows 7-cm cervical leiomyoma (arrows). B. Uterine arteriography reveals hypovascular leiomyoma (arrows). C. One month after UAE, patient presented with vaginal expulsion of leiomyoma, which was partially infarcted and viable (arrows) on contrast-enhanced MRI. D. Hysteroscopic resection was performed under general anesthesia. T2WI = T2-weighted imaging, UAE = uterine artery embolization

Fig. 2. Leiomyoma with high SI on T2WI.

A. 41-year-old woman with leiomyoma with high SI on T2WI (arrows). B. Patient underwent failed HiFU. UAE was performed, and 3-month follow-up MRI showed complete necrosis of leiomyoma (asterisk). HiFU = high-intensity focused ultrasound, SI = signal intensity

Fig. 3. UAE for malignant tumors misdiagnosed as leiomyomas.

31-year-old woman underwent myomectomy at another hospital 4 months prior, and histopathological examination revealed leiomyoma.A. MRI showed tumor 7 cm in size (arrows) with high SI; thus, leiomyoma was diagnosed based on pathologic report. B. 3-month follow-up MRI after UAE revealed exacerbation of uterine tumor with peritoneal seeding (arrows) as well as seeding along incision scar. Spindle cell sarcoma of uterus was confirmed.

Fig. 4. GnRH agonists for large leiomyoma prior to UAE.

A. 46-year-old woman presented with voiding difficulty. MRI revealed 10-cm large leiomyoma (arrows). B. After two doses of GnRH agonists, leiomyoma reduced to 4.7 cm in size (arrowheads), 85% volume reductio. C. Left uterine arteriography demonstrated leiomyoma (arrows). D. Complete infarction of leiomyoma (asterisk) was seen on 3-month follow-up MRI. GnRH = gonadotropin-releasing hormone

Fig. 5. 44-year-old woman presenting with recurrent leiomyoma after HiFU.

Serial MRI revealed complete regrowth of leiomyoma (arrows) 26 months after HiFU. Patient underwent UAE, and 3-month follow-up MRI revealed complete infarction of leiomyoma (arrowheads). mo = month

Fig. 6. Pulmonary embolism after UAE for adenomyosis.

40-year-old woman with adenomyosis who was taking oral contraceptive pills for 3 weeks underwent UAE. Ten days after UAE, patient experienced dyspnea, and CT (A) revealed multiple pulmonary emboli (arrows) and thrombosis (arrow) of right common femoral vein (B). (Courtesy of Dr. Yeon Jaewoo at Bundang Jaeseng General Hospital).

Fig. 7. Identification of DVT before UAE.

50-year-old woman with adenomyosis and leiomyoma presented with uterine bleeding. She had been treated with oral contraceptives for 2 weeks. D-dimer level was 1143 ng/mL (normal range: 0–243 ng/mL), and CT scan of her lower extremities revealed venous thrombosis (arrow) in left lower leg. Renal cell carcinoma was detected incidentally (not shown). Partial nephrectomy was performed. One-month follow-up CT scan demonstrated complete occlusion of inferior vena cava filter and progression of thrombosis along both common iliac veins (not shown). DVT = deep vein thrombosis

Fig. 8. Identification of leiomyoma in angiography.

Uterine arteriography reveals leiomyoma (arrows). Right ovary (asterisk) is seen, representing example of Type III utero-ovarian anastomosis based on Razavi's classification.

Fig. 9. Leiomyoma receiving blood flow from unilateral uterine artery.

43-year-old woman underwent kidney transplantation 15 years prior. A. Abdominal aortography showed total occlusion of right internal iliac artery with reconstitution of right uterine artery (arrow) via collaterals. B. On selective uterine arteriography on left side, leiomyoma (arrows) received blood flow exclusively from left uterine artery. C. Complete devascularization of leiomyoma (arrows) is noted at 3-month follow-up contrast-enhanced ultrasound scan. Contrast-enhanced ultrasound instead of MRI was used due to end-stage renal disease.

Fig. 10. Ovarian artery collateral to leiomyoma in uterine fundus.

44-year-old woman presented with multiple leiomyomas. A. MR angiography revealed hypertrophy of both uterine and ovarian (arrows) arteries. B. Leiomyoma on uterine fundus was supplied by left ovarian artery (Type II anastomosis). MR = magnetic resonance

Fig. 11. Aplasia of right uterine artery.

MR angiography revealed presence of only left uterine artery (arrow). Patient required right ovarian artery embolization.

Fig. 12. Leiomyoma becoming endocavitary after UAE.

52-year-old woman had dysfunctional uterine bleeding. A. Sagittal T2WI revealed 7-cm pedunculated submucosal leiomyoma (arrows). B. One month after UAE, patient presented with cramping abdominal pain. Gadolinium-enhanced MRI revealed complete necrosis of submucosal leiomyoma (asterisk), which had become endocavitary, along with widening of cervix, suggesting ongoing expulsion. Three cervical dilatation and curettage procedures were needed to completely remove necrotic leiomyoma.

Fig. 13. Repeated UAE.

43-year-old woman who had undergone UAE for leiomyomas 8 years prior presented with evidence of recurrent leiomyomas.A. Aortography revealed total occlusion of right uterine artery and hypertrophied right ovarian artery (arrows). B. Left uterine artery was partially recanalized, but multiple fine collaterals (arrows) supplied leiomyoma and uterus. Follow-up MRI performed after repeated UAE showed that procedure was ineffective (not shown).

Fig. 14. 38-year-old woman with adenomyosis presenting with vaginal bleeding and pain during menstruation.

A. MRI revealed focal adenomyosis (arrows) with homogeneous, continuous, junctional zone thickening from endometrium. B. After embolization using small polyvinyl alcohol particles (1-2-3 protocol), complete necrosis of adenomyosis (arrows) was seen on 3-month follow-up MRI. Patient's status has been stable for 5 years.