Embolization of uterine arteries( EMA) in uterine myomas - Causes, symptoms and treatment. MF.
Embolization of the uterine arteries is a minimally invasive intervention, during which, through the puncture of the artery on the thigh, particles of special medical plastic - polyvinyl alcohol( PVA) are injected into the vessels feeding the myoma, completely stopping the blood flow in them. The embolization preparation used is absolutely safe, biologically inert and can not cause allergic reactions. In addition, for EMA, a paltry amount of the preparation, usually not more than 500 mg, is necessary.
Embolization does not exert practically no effect on the vessels of a healthy myometrium, which is related to the peculiarities of their structure( the blood supply of the nodes is made from the so-called peri-fibroid plexus - the vasculature surrounding the peripheral myoma) and the technique of the intervention itself. After the termination of the blood supply, the muscle cells forming the myoma die. Within a few weeks, their replacement with connective tissue( fibrosis), which leads to a significant decrease and / or disappearance of fibroids and its manifestations. Thus, soon after the EMA, the myoma as such does not remain - only the connective tissue remains in its place. Then, during the process of "resorption" of this tissue, there is a significant decrease and / or complete disappearance of the nodes, and the symptoms of myoma pass.
In most cases( about 98%) after embolization, no additional treatment for uterine myoma is required.
Pros and Cons of EMA
- EMA is a minimally invasive and rather safe method of treatment that does not require anesthesia.
- Intervention is highly effective and the probability of myoma recurrence is minimal( in contrast to myomectomy, for which the probability of recurrence reaches 30-40%). .
- Immediate symptom improvement occurs.
- It does not take long to stay in the hospital, usually a one-day hospitalization.
- Low probability of complications provided a good surgeon's qualification. According to comparative studies, the risk of any complications is 20 times lower than for any variant of surgical treatment of fibroids.
- The uterus is not removed.
- Preserved fertility.
BUT: unlike the equipment needed for laparoscopic surgery, angiographic devices are very expensive, so not every clinic can afford them. In addition, in Russia there are very few experienced endovascular surgeons, and doctors of other specialties can not conduct EMA.
Another disadvantage is that X-rays are used during the EMA.However, the feature of modern autographic devices is the use of low doses of radiation. On average, the radiation dose received by the patient during embolization does not exceed the dose obtained in diagnostic fluorography( chest X-ray).
And one more drawback of the method. If you can always take a biopsy of the tissue that you are removing and examine it with an open surgery, unfortunately, this is not possible with embolization. However, this deficiency is leveled by the performance of diagnostic angiographic research before therapeutic manipulation. Benign and malignant education have a different vascular picture. Therefore, based on diagnostic angiographic data, the doctor can decide what is involved.
Preparation for EMA
Typically, embolization is performed on the day of hospitalization. On this day it is recommended to refrain from breakfast, as well as before any surgical intervention. During the procedure, the artery is punctured in the upper part of the right thigh, so it is necessary to shave the thigh and the groin on the right beforehand. Before the procedure, an injection of a sedative is prescribed. On both feet the doctor will apply elastic bandages. After the procedure, elastic bandages will need to be worn for 5-7 days. Then, accompanied by a gynecologist, the patient goes to the department of X-ray surgery on foot or on a gurney.
Embolization of uterine arteries is performed in a specially equipped X-ray room. This operating room is equipped with an angiographic device that allows the surgeon to monitor the manipulations inside the blood vessels in the X-ray mode. Endovascular surgeons perform embolization - they are specialists possessing high qualification of vascular surgeons and extensive experience in working with complex angiographic equipment.
Before the operation, the endovascular surgeon asks the patient a few questions( about the individual tolerability of medications, etc.).The patient is placed on a special angiographic table. In a vein on the inside of the arm, a thin catheter is installed for the dropper and medication. Before the procedure begins, the endovascular surgeon will treat the right thigh and abdomen with a special antiseptic and cover with sterile sheets. Further local anesthesia with a solution of novocaine or lidocaine for painless puncture of the right common femoral artery is performed. Through a small( 1.5 mm) puncture of the skin in the upper part of the thigh, a thin catheter( 1.2 mm) is inserted into the artery, which is guided directly into the uterine arteries under the control of the X-ray machine.
Then, just under the control of fluoroscopy, tiny particles of the embolization preparation are inserted through the catheter, which cover the vessels feeding the myoma. Embolization particles, as a rule, are introduced alternately into the right and left uterine arteries.
The duration of the EMA procedure is from 10 minutes to 2.5 hours, depending on the variant of the uterine artery and the surgeon's experience. But as a rule, its duration does not exceed 20 minutes.
Puncture of an artery, thanks to anesthesia, does not cause practically any sensations. In the process of performing the EMA procedure, it is possible to periodically experience a feeling of warmth, a slight burning sensation in the lower abdomen, a lower back is the action of the contrast medium, which the surgeon introduces to visualize the vessels.
After the end of embolization, the doctor removes the catheter from the femoral artery and presses the fingers to the puncture site for 15-25 minutes to avoid the formation of a bruise( hematoma).Then, a pressure bandage is applied to the right thigh. From this moment, within 10-12 hours, you can not bend your right leg. Pressing the bandage is removed after 2-3 hours.
After EMA( postembolization period)
After embolization, you are transported back to the ward on a gurney. On the puncture site, ice will be applied for one hour. Maybe a dropper will be installed for several hours. In 1-2 hours after the procedure there are quite strong pulling pains in the lower abdomen. These sensations are a consequence of ischemia( starvation) of myoma cells. Painful sensations last for several hours and are adequately suppressed by anesthetics.
In addition, in the first days after the EMA, the temperature may rise to subfibril figures - 37-37.5.Possible weakness, malaise, nausea. Nevertheless, all these symptoms, known as postembolization syndrome, go away quickly, do not pose a threat to health and do not relate to complications of EMA.
These symptoms usually last the next day. Typically, 1-3 days after EMA patients are discharged home. Another 7-10 days after this, it is recommended to avoid physical activity. An extract is possible the next day after the procedure.
Embolization of uterine arteries
The most rapid decrease in fibroids continues in the first 6 months after EMA, but in the future the dynamics remain to decrease. On average, to 1 year after EMA, myomas decrease by 4 times, and the size of the uterus normalizes. In some cases, some myomatous nodes( especially located close to the uterine cavity) are separated from the uterine wall and come out naturally( the myoma's "expulsion" takes place).This is a favorable phenomenon, leading to a rapid restoration of the structure of the uterus. In 99% of patients, menstruation normalizes, and the volume of menstrual bleeding decreases. Symptoms of compression are reduced and disappear in 92-97% of patients soon after the EMA procedure.
The absence of risk of recurrence of the disease after intervention is an important feature of EMA.This is due to the fact that with EMA, the impact occurs on all nodes, regardless of their size. In general, more than 98% of patients after EMA do not need additional treatment for uterine fibroids, even in the long-term.
Side effects and complications of uterine artery embolization
Embolization of uterine fibroids is a fairly safe procedure, the risk of complications is tens of times lower than after surgical treatment. Unfortunately, some gynecologists who do not have the opportunity to use any other methods of treatment for uterine myomas, in addition to surgery, often scare patients with more complications after embolization. This is fundamentally wrong and is a conscious misrepresentation of the patients.
The most common problem after EMA is the formation of a bruise( bruise) on the thigh at the artery puncture site. This complication usually does not require additional treatment and lasts for 1-2 weeks.
No more than 3% of patients in the first 3-6 months after embolization of uterine fibroids may have irregularity of the menstrual cycle or transient( temporary) amenorrhea.
A more unpleasant complication of EMA is an infection. This occurs in no more than one patient out of 200. Infection is usually successfully treated with antibiotics, but in rare cases may require the performance of a hysterectomy.
And another theoretically possible complication of EMA is the ingress of embolizing particles into other vascular pools, which is extremely unacceptable and threatens the patient's life.
At the same time, the probability of developing complications that may require a return to surgical treatment does not exceed one case for 600-800 EMA.
EMA and pregnancy
Embolization does not deprive women of fertility. Obviously, after a hysterectomy about childbearing speech does not go, but even after a myomectomy, there is often infertility associated with the formation of adhesions in the uterus and around it. Therefore, EMA is the method of choice for women with fibroid, planning pregnancy.
It is possible to conceive a pregnancy after embolization of uterine arteries, but the risk of termination of pregnancy in this case is very large at any time. And during labor, in the postpartum period, these are certain complications.
It is not recommended to plan pregnancy in terms of up to a year after embolization - there is a decrease in the nodes and a decrease in the uterus. High risk of miscarriage.