Physicians and the public have grown more aware of the role IR can play in the treatment of uterine fibroids. However, there are many other areas of women’s health and gynecological catheter-based techniques that IRs can employ to improve patient outcomes.
In yesterday’s “Gyn catheter-based techniques beyond uterine fibroids” presenters covered several of these techniques, providing the clinical aspects, treatment options and case reviews.
PPH
One area where catheter-based therapies can be crucial is with postpartum hemorrhaging (PPH), according to Lisa Walker, MD. According to Dr. Walker, PPH accounts for 8% of maternal deaths in developed regions of the world, and 20% in developing regions. In the United States, PPH is associated with 11% of maternal deaths.
While most PPH cases occur within the first 24 hours after delivery, up to 2% of cases can manifest up to 12 weeks later. PPH causes severe blood loss that can be difficult to manage and has historically been managed via hysterectomies. While this procedure is needed in some cases, Dr. Walker says, it comes with substantial impact to the patient.
Dr. Walker discussed the causes, clinical assessment and risk factors associated with PPH, and walked through various types of management beyond hysterectomy, such as bimanual uterine massage to induce uterine contractions, blood transfusions, mechanical management, uterine artery embolization or hysterectomy.
While hysterectomy is effective, UAE offers a minimally invasive alternative for hemodynamically stable patients that preserves fertility. And though uterine artery ligation has also been shown to be effective, Dr. Walker said, UAE is preferred as it avoids laparotomy. And if it is done before UAE, it can make the subsequent procedure very difficult.
Dr. Walker also discussed the use of prophylactic balloon artery occlusion in a planned hysterectomy prior to c-section, which will reduce intraoperative bleeding, or if the patient wants to preserve fertility. She reviewed the techniques for balloon occlusion in the bilateral internal iliac and distal abdominal aorta, but also cautioned that existing literature on the procedure is limited and conflicting, and that there is a need for multidisciplinary discussion and strong collaboration.
AVM and AVF
IRs can also play a role in the treatment of uterine arteriovenous malformation (AVM), according to Andrew C. Picel, MD.
Uterine AVM is a rare condition, Dr. Picel said, that is likely underreported, even as incidence increases. Accurate diagnosis is critical, he said, because bleeding can be worsened and even become life-threatening if patients undergo certain procedures like dilation and curettage.
There are two types of uterine AVM: congenital and acquired, typically due to endometrial or myometrial trauma. Dr. Picel noted that acquired uterine AVM is often also referred to as arteriovenous fistula, traumatic uterine arteriovenous malformation or arteriovenous shunt.
Dr. Picel reviewed the diagnostic markers for various types of imaging modalities, such as transvaginal ultrasound, MRI and angiography, with examples of each. Once diagnosed, patients have several treatment options. Conservative management is considered for select patients, as is medical management—though the latter option has varying consensus on efficacy. According to Dr. Picel, transcatheter arterial embolization (TAE) is a safe and effective alternative to surgical hysterectomy.
He presented several case studies to describe treatment steps utilizing TAE and weighed the merits of various embolic materials. While there is no consensus on the best agent, Dr. Picel said that particles, liquid embolics and gelatin are generally preferred.
PAS
There are also opportunities for prophylactic management, especially in the area of placenta accreta spectrum (PAS), said Jessica K. Stewart, MD. PAS is an invasive placental disease wherein the placenta abnormally attaches to the uterine wall. In a normal pregnancy, the placenta will attach to a temporary layer in the uterus that is shed during delivery, but in PAS, chorionic villi will adhere, invade or even penetrate the myometrium.
According to Dr. Stewart, incidence of PAS has increased 60 times since 1960s, likely due to increased instrumentation. It can be indicated by certain risk factors such as previous uterine surgery, placenta previa, multiparty or history of retained placenta. It can result in maternal hemorrhage, postpartum infection or uterine rupture.
Early diagnosis is crucial, Dr. Stewart said, but imaging doesn’t always line up, which makes it challenging. She presented several imaging examples, to show what PAS can look like on different modalities.
Like many gynecological complications, there are multiple approaches to management, from conservative treatments that preserve fertility like UAE to surgical hysterectomy. While utilization of IR is variable at every institution, Dr. Stewart said, many patients with PAS will undergo C-section delivery at 34–36 weeks and there is an opportunity for IR to be involved in planning this. Occlusion balloon catheters can be placed before delivery, she said, in attempt to reduce blood flow and blood loss. According to a recent meta-analysis that compared occlusion balloons in the internal iliac arteries or the abdominal aorta, or UAE, outcomes indicated that aortic balloon occlusion had the greatest effect on reducing estimated blood loss and hysterectomy rates in patients with PAS.
Dr. Stewart detailed the technique and approach for occlusion balloon placement and UAE at various stages before and after hysterectomy, aided by several case examples.
“There is an ongoing discussion around when to utilized IR for PAS, due to potential complications surrounding arterial occlusion,” Dr. Stewart said. “There is a clear opportunity for IR to become involved in the early stages of these patients to avoid emergent embolization for massive PPH.”
Adenomyosis
Not all interventions involve pregnancy complications, however. Eisen Liang, MBBS, presented on the unmet needs in the management of adenomyosis, which occurs when endometrial issue grows into the muscular wall of the uterus. In addition to bleeding and pain, adenomyosis can have a negative impact on fertility and pregnancy and have a detrimental effect on IVF outcomes.
According to Dr. Liang, clinical diagnosis doesn’t match the occurrence rate of adenomyosis. In his clinic, Dr. Liang said he sees many unsatisfied patients who have not received resolutions for their bleeding or extreme period pain, despite seeing previous providers.
This is due to differences in imaging modalities and their ability to pick up adenomyosis, he says. Dr. Liang believes that MRI is preferred imaging modality, as adenomyosis can be very subtle when viewed via ultrasound.
He showed examples of adenomyosis imaged via MRI and TVUS to showcase this and added that adenomyosis can sometimes be mistaken as a fibroid when viewed on TVUS. While adenomyosis does commonly co-exist with fibroids, if they are managed like a fibroid or receive endometrial ablation, it can cause the patient even more pain.
“Adenomyosis should never be a surgical case,” said Dr. Liang. “It’s like trying to remove chocolate from a muffin. It’s just not possible.”
Hysterectomy can be considered as a cure, but according to Dr. Liang, “It’s the 21st Century. We can do better.”
Because medical therapy isn’t an effective long-term solution for a progressive disease, and progesterone-releasing IUDs may impact quality of life or be conditional on the size of the uterus, Dr. Liang advocates using UAE, alongside a robust pain management scheme.
UAE has a 90% success rate, and can result in pain reduction, lighter periods, and even occasionally help with the ability to carry to term, Dr. Liang said.
It’s important to take ownership of these patients, Dr. Liang said, sharing his post-UAE treatment plan, which involves follow-up imaging, managing expectations, and medical or surgical management as needed.
“UAE fills a treatment gap and can help many women unsatisfied with medical therapy or IUD management, yet trying to avoid a hysterectomy” he said.
Malignancy
“We often think about catheter-based techniques in terms of fibroids or adenomyosis,” said Claire Kaufman, MD. “But with malignancy, there are a lot things we can do.”
Dr. Kaufman presented a series of patient cases involving catheter-based interventions for gynecological malignancies and masses including bleeding, arterial injury, and venous disease.
Case examples of embolization performed urgently in the setting of bleeding pelvic masses were shown with clinical outcomes, including resolution of bleeding and correct diagnosis and management. Dr. Kaufman also discussed bleeding cervical cancer, which historically was managed with surgical ligation of the hypogastric artery, now more commonly embolization.
But cervical cancer can be more than just uncontrolled pelvic bleeding, she said. In one case, a woman with cervical cancer presented with hematuria and anemia. She had a history of chemotherapy and brachytherapy and had diverting nephrostomies after failed uretic stents. On imaging, physicians saw a uretero-arterial fistula. After covered arterial stent placement they were able to remove the uretic stents, and her hematuria resolved.
Dr. Kaufman also discussed chemoembolization, delivered locally for advanced cervical cancer. Though there is limited data to date, she said that early experiences with intra-arterial chemotherapy infusion have used varied chemotherapy regimens with mixed outcomes. Case examples of venous interventions in the settling of compression and DVT were shown. Many malignancies and especially ovarian cancer create a pro-thrombotic state.
“There are many opportunities in which IR can play a critical role in the care of gyn patients beyond fibroids,” Dr. Kaufman said.
