Embolization of uterine arteries

Embolization of uterine arteries is a microsurgical low-traumatic method of treatment of nodal uterine myoma. The essence of the technique consists in the artificial "clogging" of arteries feeding the myomatous nodes, in order to reduce their size and prevent further growth.

The method of embolization of uterine arteries is gaining popularity in our country, but in the practice of foreign specialists it has long( since the 70s) taken a worthy leading place. The increasing interest in this technique is explained by the increase in the number of patients with uterine myoma. According to some experts, uterine fibroids are recorded in every fourth woman aged 16-45 years. However, such statistics are most likely connected with the appearance of good diagnostic equipment in conjunction with the increased quality of preventive examinations.

The increasing popularity of the uterine artery embolization technique explains the increased interest in this method. Like any medical innovation, around embolization there are many rumors, fears and wrong theories, and sometimes this method is elevated to the rank of panacea. Meanwhile, the method of embolization of uterine arteries has clear indications and contraindications, is not suitable for every clinical case, has its pros and cons.

To get a clear idea of ​​how and why they treat myoma with embolization, it's worth recalling the very disease - the uterine myome. Myoma of the uterus is a formation of benign origin that forms in the muscle layer of the uterine wall. Contrary to the prevalent opinion among women, myoma is not a true tumor, but it has several similar signs. Significant differences of myomas from tumors are its connection with quantitative oscillations of estrogens and a unique ability for independent regression.

Myoma more often has the form of a node with irregular contours. It originates in the muscular uterine layer( myometrium), therefore, smooth muscle and connective tissue elements prevail in its composition. With multiple myomas, the nodes have different sizes and are at different stages of formation.

Not all fibroids grow in the same way. Formed in the thickness of the myometrium, the myomatous node, as it grows, can "move" towards the uterine cavity and form "protrusions" under the mucous layer( submucous node).If the growth of the node is directed to the opposite side of the uterus, it is found under the outer, serous, membrane of the uterine wall( subserosal node).Some nodes do not tend to move to adjacent layers and continue to develop "on the spot" - in the muscle layer( interstitial node).

Small, Iterstitial myomatous nodes are more often present in the uterus asymptomatic and are diagnosed accidentally. Sometimes a re-examination of such nodes does not reveal, or notes a significant decrease in their number and size.

Submucous location of myoma is considered to be the most unfavorable for the clinic and consequences, such nodes deform the uterine cavity and disrupt the correct operation of the uterine muscles. An asymptomatic submucous node exists in the uterus very briefly, and then causes uterine bleeding and severe menstrual pain.

More than half of all diagnostic sites are subserous. They rarely reach large sizes, but can provoke serious consequences. A distinctive feature of the subserous node is its weak connection with the muscle layer. Sometimes the main growth of a knot occurs in such a way that, as it moves forward, it leaves behind a thin, long formation( leg) that connects it to the myometrium. As a result, the subserosal node becomes mobile.

Simultaneous presence of myomatous nodes of different localization complicates myoma therapy.

It is possible to cure myoma, but the success of any therapy depends on the specific clinical situation, namely:

- on the patient's age( in the menopause, fibroids regress more often);

- from the presence of concomitant gynecological and extragenital pathology;

- on the size and number of nodes;

- from the localization and growth rate of fibroids;

When choosing a treatment method, the patient's desire to have children in the future is always taken into account, after all, often fibroids become the culprits of infertility.

The opinion that the myoma is always surgically removed is not true. Small fibroids without serious complications are treated conservatively, and only in the absence of the proper effect resort to surgical treatment.

Embolization of uterine arteries is a qualitative alternative to the surgical removal of fibroids, which allows to save the organ and restore its original functions.

Embolization of uterine arteries in myoma

If any biological tissue is deprived of the ability to "eat", it stops developing, and then dies. Nutrition for all tissues and organs is provided by the circulatory system, so the cessation of blood supply leads to their death. This is the essence of the procedure for uterine artery embolization.

The uterus is supplied with two pairs of large arteries: right / left uterine and right / left ovarian. Myomatous nodes surround the periphybroid vascular plexus, which connects only to the uterine arteries and is not related to the arteries of the ovaries. If the blood flow is stopped in the uterine arteries, the uterus will begin to receive blood from the arteries of the ovaries, and the myoma will remain without blood supply. As a result, muscle cells of myoma gradually begin to die.

To stop access of blood to the nodes of fibroids, it is necessary to artificially create a mechanical obstacle to the blood flow, such is embol - a microscopic( less than 500 mg) piece of special medical plastic - polyvinyl alcohol( PVA) artificially introduced into the blood vessel. Also as an embolus are sometimes used particles of gelatin sponge or "Embosphere" microspheres, golden balls.

Any used embolus is absolutely safe, does not cause allergic reactions and is biologically compatible with surrounding tissues. Getting into the uterine artery, the embol moves along it with the blood flow, blocks the lumen, stops the blood flow to the organ and, accordingly, to the myome. The uterus continues to supply blood from the arteries of the ovary, and the fibroids in the absence of food gradually die off.

After the procedure of embolization of the uterine arteries, for several weeks the dying muscle elements of the myoma are replaced by connective tissue( fibrosis), which is subsequently also "absorbed".

In most( 98%) cases after embolization of uterine arteries, the size of myomatous nodes decreases significantly, or their complete disappearance occurs. As a rule, no additional medical measures after successful embolization are required.

In recent years, more and more often for the treatment of myomas in young patients, embolization of uterine arteries is used. The price of this service, unfortunately, remains high. This method requires the availability of complex, expensive equipment and qualified specialists, which only a few large clinics or paid centers can afford. Therefore, the cost of embolization of uterine arteries is always determined by a specific medical institution. It should be noted that not only the embolization of uterine arteries is paid for by patients. The price of the service is formed taking into account the preliminary examination and examination, the costs for postoperative procedures are also taken into account: hospital stay, examinations, bandages, control examinations and others.

Meanwhile, if the cost of embolization of uterine arteries does not allow the patient to agree to it, the doctor can always offer no less effective alternative therapies that do not require large financial costs.

Myoma of the uterus is more often diagnosed in young patients with infertility, at the reception they often ask the question - is pregnancy possible after uterine artery embolization? This procedure does not have a negative effect on the reproductive function, but affects it indirectly. If the source of infertility is myoma, with its elimination, infertility is eliminated, and embolization of uterine arteries is recommended for women with fibroids who want to become pregnant. However, all aspects of the effect of embolization on the reproductive function have not been studied thoroughly, since this method for domestic gynecology is relatively new.

Trying to endure pregnancy after embolization of the uterine arteries in the first year and a half is unsafe, as the recovery process takes place in the uterine wall, and there is a threat of premature birth.

It should be noted that any fibroids have causes. Even the most successful and qualified removal of nodes is not equivalent to eliminating the cause of their development, therefore myomatous nodes can sometimes be formed again in other parts of the uterus.

How uterine artery embolization is performed

The procedure for embolization of uterine arteries begins when there are results of a complete examination of the patient. The procedure is possible only with full compliance with indications in the absence of inflammation and malignant neoplasms.

Embolization of uterine arteries is never performed without prior examination of the vessels feeding the uterus. With the help of angiography, the configuration of the vasculature and its features are studied.

For embolization, the patient should be placed in a hospital, and the procedure itself is usually performed by vascular surgeons. Preparation for embolization of the motor arteries is carried out for five days. During this period, the patient must take antibacterial drugs and adjust the existing chronic extragenital ailments. On the day of embolization( no later than 2 hours), an intravenous infusion of the antibiotic Ceftriaxone( or analog) is administered to prevent infectious complications.

Uterine artery embolization, in contrast to surgical treatment, is performed without incisions and direct access to the uterus. The whole procedure is performed with mandatory local anesthesia. To introduce embolus into the uterine artery, the surgeon performs a puncture in the upper part of the right thigh and inserts a vascular( 1.5 mm in diameter) tubing - a catheter - into the resulting opening. Through the catheter, the embolus is carefully inserted into the uterine artery, which clogs only this vessel, and all other arteries are not affected.

The procedure requires a high qualification of the surgeon, his ability to handle complex anigraphic equipment and precise execution of all stages of the "operation".Since embolization requires visual control over where the catheter is being directed, and how the embolus is "emptied", the entire procedure is monitored by an arteriogram - an X-ray study of blood vessels. In order for the vessels to be clearly visible on the roentgenogram, a special contrasting( coloring) substance is introduced into the catheter. Embolisms are introduced alternately in both, right and left, uterine arteries. They do not enter the myoma cell, as the fibroids have a smaller diameter than the uterine artery lumen size.

Procedure of uterine artery embolization, as a rule, does not last long. On average, a qualified surgeon, with good equipment, has to spend no more than 35 minutes on it. However, in the presence of anatomical features of the location of the vasculature and atypical location of fibroids, embolization may last longer.

Properly performed procedure of embolization of uterine arteries does not provoke severe pain, as it is done with preliminary anesthesia and does not last long. The exception is women with low pain threshold and pronounced lability of the nervous system, when fear of the procedure provokes the appearance of more severe pain. As a rule, such patients are prescribed additional painkillers and sedatives.

During the embolization process, the patient experiences a feeling of warmth, burning and tingling in the projection of the uterus and in the lumbar region, which is caused by a contrast agent moving along the vessels.

The final stage requires a control angiogram and ultrasound. If they confirm the success of the procedure( lack of blood flow in the zone of fibroids), the surgeon removes the catheter and puts a "pressing" bandage on the thigh. It can be removed after three hours, but it is forbidden to bend the leg for six hours.

Recovery after embolization of uterine arteries

The procedure of embolization allows the patient to return to normal life relatively quickly. The first few hours( more often until the morning of the next day) after embolization of the uterine arteries, it is necessary to observe bed rest and keep the bandaged thigh in a horizontal position. At the point of artery puncture in the first two hours, ice is applied to reduce swelling and avoid inflammation. It is possible that the nurse will connect a dropper at the direction of the doctor.

After the blood flow stops in the uterine arteries, myoma cells begin to experience oxygen starvation( ischemia), that is, they actually develop a heart attack. Gradually the myoma develops total death( necrosis) of the muscular structures. The consequence of all these processes are intense pains of the pulling character in the lower abdomen. They can last several hours and respond very well to pain medications.

In addition to pain during the first hours, other consequences of uterine artery embolization may appear: mild fever, weakness, nausea and / or vomiting, malaise and others. These clinical manifestations are called postembolization syndrome and are considered physiological, as they mean the period of adaptation of the organism and do not cause harm to health. They are well-stopped with the help of medications, continue for a short time and completely disappear without a trace.

The stay in the hospital in the absence of complications is limited to three days, and then the patient returns home. Before releasing the patient from the clinic, the doctor performs a control ultrasound and appoints a time for repeated examinations, usually they are carried out after 2 weeks, and then repeat after 3, 6 and 12 months. Also, the patient is explained how to reverse the symptoms of postembolization syndrome on her own.

The most active period of regression of myomatous nodes is the first six months after embolization. On average, the size of myoma nodes decreases 4 times in a year, and the size of the uterus returns to normal values. The nature and speed of regression of myomatous nodes is affected by their size and localization. The nodes of myoma located on the posterior wall regress to a lesser extent. Submucosal nodes located very close to the uterine cavity can independently "break away" and exit( "expulsion").

Intermenstrual bloody discharge after embolization of uterine arteries should not frighten the patient if they are temporary and do not tend to worsen. The menstrual cycle returns to the previous state three months after the procedure.

Negative consequences of embolization of uterine arteries are more often associated with errors in its execution. If the procedure is performed by a competent surgeon using appropriate equipment, the complication rate is very small( 2%).

Advantages, indications and contraindications for embolization

Like any other method of treatment, uterine artery embolization has strict indications and contraindications.

Indications for embolization of uterine arteries are:

- the size of the uterus is correlated with a 9-week pregnancy and more;

- single or multiple myomatous nodes of different size and location, provided that their dimensions do not exceed 8 cm;

- menometrorrhagia( very ample monthly) against the background of fibroids;

- strongly the patient's desire to carry out the procedure and her categorical rejection of alternative therapies.

It should be noted that sometimes embolization of uterine arteries is performed as a preliminary procedure before a conservative myomectomy. This is the case when patients have multiple large( more than 8 cm) nodes or subserous multiple nodes. The procedure is carried out to reduce the size of the nodes and to disturb their nutrition before removal.

Embolization is not performed if the following contraindications are available:

- giant fibroids that increase the size of the uterus to 20 or more weeks of pregnancy with a multitude of nodes of different sizes;

- single subserosity nodes on a thin stem;

- intramural nodes of large dimensions( 10 cm and more);

- abnormal blood supply of myoma nodes;

- intolerance of the contrast medium necessary for angiography;

- infectious-inflammatory processes of the pelvic region;

- malignant processes;

- pregnancy.

Complications after embolization are rare. Sometimes a puncture of the femoral artery forms a hematoma. In some women, the postembolization syndrome is more severe. In patients over 45 years old, the ovarian function may be impaired.

Some of the patients note that menstrual discharge after embolization of the uterine arteries becomes more scarce. Some experts argue that embolization in rare cases provokes an earlier onset of menopause.

Embolization of uterine arteries has much more advantages than disadvantages. The probability of serious complications in this method in comparison with others remains very low.

The most significant advantages of this technique are:

- minimally invasive and safe;

- no need for general anesthesia;

- low percentage of relapses;

- preservation of the body and, as a consequence, the opportunity to give birth;

- short-term hospitalization;

is a rapid therapeutic effect.

If embolization of uterine arteries is impossible, an alternative procedure is performed - laparoscopic occlusion of the uterine arteries.