Resorbable Microspheres versus Trisacryl Gelatin Microspheres for Uterine Artery Embolization: A Randomized Controlled Trial.

Background There are insufficient data comparing resorbable microspheres (RMs) with permanent trisacryl gelatin microspheres (TAGMs) for uterine artery embolization (UAE). Purpose To compare therapeutic efficacy and clinical outcomes in participants with symptomatic fibroids after UAE with RMs or TAGMs. Materials and Methods This randomized controlled trial included participants undergoing UAE for symptomatic fibroids at a single institution (from May 2021 to May 2023). Participants were randomized one-to-one to undergo UAE with either RMs or TAGMs. Numeric rating scale pain scores and cumulative fentanyl consumption were assessed for 24 hours after undergoing UAE. Anti-Mullerian hormone was measured to assess effects of UAE on ovarian function. MRI was performed before and 3 months after UAE to evaluate fibroid necrosis and uterine artery recanalization. Repeated variables such as pain were analyzed using Mann-Whitney U test with post hoc Bonferroni correction. Results Sixty female participants (mean age, 45.7 years ± 3.6 [SD]) completed the study, with 30 in each group. No evidence of a difference in pain scores was observed between groups (P > .99). Moreover, there was no evidence of a difference in the total fentanyl consumption at 24 hours after UAE between groups (median: RMs, 423 [IQR, 330-530] vs TAGMs, 562 [IQR, 437-780]; P = .15). Serum anti-Mullerian hormone 3 months after UAE showed no evidence of a difference between groups (RMs vs TAGMs, 0.71 ng/mL ± 0.73 vs 0.49 ng/mL ± 0.45, respectively; P = .09). No evidence of a difference in the rate of complete necrosis of the dominant fibroid was observed between groups (97% [29 of 30] for both groups; P > .99). The rate of uterine artery recanalization was higher in RM versus TAGM groups (70% [21 of 30] vs 17% [five of 30], respectively; P < .001). Conclusion UAE with RMs, compared with UAE with TAGMs, showed no evidence of a difference in terms of therapeutic effectiveness or postprocedural pain scores in participants with symptomatic fibroids. Clinical trial registration no. NCT05086770 © RSNA, 2024 See also the editorial by Spies in this issue.

Uterine artery embolization vs myomectomy for the management of women with uterine leiomyomas: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to investigate whether uterine artery embolization offers a better quality of life than myomectomy in premenopausal women diagnosed with leiomyomas of the uterus. DATA SOURCES: A literature search was performed using the electronic databases of PubMed and Cochrane Central Register of Controlled Trials from inception to January 2023. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials comparing uterine artery embolization with myomectomy in women of premenopausal age suffering from uterine leiomyomas were considered. METHODS: The primary outcome was quality of life. The secondary outcomes were reintervention rate and timing, successful pregnancy, stillbirth and miscarriage, cesarean delivery on delivery, and perioperative morbidity. Moreover, time-to-event and standard pairwise meta-analyses were performed, as appropriate. The certainty of the evidence was assessed in line with the Grading of Recommendations, Assessment, Development, and Evaluations methodology. RESULTS: A total of 6 randomized controlled trials met our inclusion criteria. The meta-analysis suggested little to no difference in terms of quality of life between uterine artery embolization and myomectomy (standard mean difference, 0.05; 95% confidence interval, -0.38 to 0.48; I2=92%; very low certainty of evidence). Sensitivity analysis, including randomized controlled trials, which included solely myomectomy procedures in the control arm, demonstrated better quality of life for women treated with myomectomy (standard mean difference, -0.32; 95% confidence interval, -0.49 to -0.15; I2=15%). Concerning reintervention, myomectomy was likely associated with a decreased risk of future reintervention (risk ratio, 0.32; 95% confidence interval, 0.15-0.69; I2=60%; low certainty of evidence) and a more prolonged time interval since a potential reintervention because of recurrence than uterine artery embolization (hazard ratio, 0.41; 95% confidence interval, 0.22-0.77; I2=77%; low certainty of evidence). No difference was found between the 2 interventions concerning severe perioperative adverse events (relative risk, 4.13; 95% confidence interval, 0.44-39.20; I2=0%; low certainty of evidence). CONCLUSION: Uterine artery embolization is likely associated with increased reintervention rates and less time to reintervention compared with myomectomy in premenopausal women diagnosed with uterine leiomyomas. Evidence suggests no difference between the 2 interventions regarding perioperative morbidity. Uterine artery embolization may exert no effect on quality of life and successful pregnancy; however, the evidence is very uncertain.

Crucial factors for implementing treatment strategies in intractable atonic postpartum haemorrhage: early phase contrast medium extravasation on dynamic CT.

AIM: To identify the relationship between contrast medium extravasation (CME) on dynamic contrast-enhanced computed tomography (DCT) and clinical information in intractable atonic postpartum haemorrhage (PPH) and its relevance to treatment with uterine artery embolisation (UAE). MATERIALS AND METHODS: Of 90 patients who underwent DCT to diagnose PPH, 60 diagnosed with intractable atonic PPH were investigated retrospectively. Maternal background and clinical indicators were analysed to compare the positive and negative factors of early phase CME. Regression analysis was used to investigate the factors associated with CME. The sensitivity, specificity, and positive and negative predictive values of early phase CME for predicting UAE were calculated. Clinical outcomes were compared between the two groups according to the timing of the decision to undergo UAE. RESULTS: Of the 60 patients with intractable atonic PPH, 21 underwent UAE, 20 of whom had early phase CME on DCT. Pre-DCT clinical parameters and clinical indices were not significantly different in presence of early phase CME. Early phase CME was associated with UAE performance, with a sensitivity of 95%, specificity of 87%, positive predictive value of 80%, and negative predictive value of 97%. In cases where UAE was performed after conservative management, there was a significant increase in blood loss and transfusion volume. CONCLUSION: Early phase CME is not indicated by background factors or clinical findings. UAE is not required when CME cannot be detected in the uterine cavity. If early phase CME is present, UAE should be considered immediately.

Surgical evacuation combined with Shirodkar cervical suture and selective uterine artery embolization: A fertility preserving treatment for 10-15 weeks' live cesarean scar ectopic pregnancies.

INTRODUCTION: Cesarean scar ectopic pregnancies (CSEPs) are associated with significant maternal morbidity and termination is often recommended in the early first trimester. Management of more advanced cases is challenging due to higher risks of major intraoperative hemorrhage. Hysterectomy is currently the intervention of choice for advanced cases. This study aimed to investigate if advanced live CSEPs could be managed effectively conservatively using suction curettage and interventional radiology. MATERIAL AND METHODS: A retrospective single-center cohort study was performed. A total of 371 women diagnosed with CSEP were identified between January 2008 and January 2023. A total of 6% (22/371) women had an advanced live CSEP with crown-rump length (CRL) of ≥40 mm (≥10 weeks' gestation). Of these, 77% (17/22) opted for surgical intervention, whilst the remaining five continued their pregnancies. A preoperative ultrasound was performed in each patient. All women underwent suction curettage under ultrasound guidance and insertion of Shirodkar cervical suture as a primary hemostatic measure combined with uterine artery embolization (UAE) if required. The primary outcome was rate of blood transfusion. Secondary outcomes were estimated intraoperative blood loss, UAE, intensive care unit admission, reintervention, hysterectomy, hospitalization duration and rate of retained products of conception. Descriptive statistics were used to describe these variables. RESULTS: Median CRL of the 17 patients included was 54.1 mm (range: 40.0-85.7) and median gestational age based on CRL was 12 + 3 weeks (range: 10 + 6-15 + 0). On preoperative ultrasound scan placental lacunae were recorded in 76% (13/17) of patients and color Doppler score was ≥3 in 67% (10/15) of patients. At surgery, Shirodkar cervical suture was used in all cases. It was successful in achieving hemostasis by tamponade in 76% (13/17) of patients. In the remaining 24% (4/17) patients tamponade failed to achieve complete hemostasis and UAE was performed to stop persistent arterial bleeding into the uterine cavity. Median intraoperative blood loss was 800 mL (range: 250-2500) and 41% (7/17) women lost >1000 mL. 35% (6/17) needed blood transfusion. No women required hysterectomy. CONCLUSIONS: Surgical evacuation with Shirodkar cervical suture and selective UAE is an effective treatment for advanced live CSEPs.

Advances in Treating Cesarean Scar Pregnancy: A Comprehensive Review of Techniques, Clinical Outcomes, and Fertility Preservation.

Cesarean scar pregnancy (CSP) is a rare but potentially dangerous condition that occurs when an embryo implants and develops within the scar tissue from a previous cesarean section. Treatment of cesarean scar pregnancy depends on several factors, including the gestational age of the pregnancy, the presence of complications, and the individual patient's circumstances. We performed a systematic review of the published literature on management of cesarean scar pregnancy and the outcomes, complications, and effects on fertility. A systematic review of recent scientific literature published up to April 2023 in the databases PubMed, Google Scholar, and Web of Science was performed according to the PRISMA guidelines. We used the search keywords "cesarean scar pregnancy," "methotrexate," "systemic," "chemoembolization," and "uterine artery embolization." The baseline search resulted in 413 articles. After the exclusion of 342 irrelevant articles, the abstracts and titles of the remaining 71 articles were read for potential inclusion, resulting in exclusion of a further 16 articles. Therefore, the full texts of 55 articles were investigated. Finally, 42 papers were included in the study. The main finding was that chemoembolization is more successful than systemic methotrexate therapy, and is associated with less blood loss and shorter hospital stay. Transarterial chemoembolization appears to be safe and effective method of treatment in patients with CSP and should thus be considered during multidisciplinary evaluation of these patients.

Efficacy of intra-arterial lidocaine administration on pain and inflammatory response after uterine artery embolization for symptomatic fibroids.

BACKGROUND: There have been conflicting outcomes regarding the use of lidocaine to reduce pain after uterine artery embolization (UAE). PURPOSE: To investigate the efficacy of intra-arterial lidocaine injection for pain and inflammatory response control within 24 h of UAE for symptomatic uterine fibroids. MATERIAL AND METHODS: Of 1530 patients who underwent UAE for uterine fibroids in 2007-2021, 5 mL of 1% lidocaine was injected into each uterine artery immediately after UAE in 23 patients. A disease-matched control group (n = 23) who did not receive intra-arterial lidocaine was generated from the same registry. The pain score, white blood cell (WBC) count, C-reactive protein (CRP), neutrophil/lymphocyte ratio (NLR), and fentanyl consumption were compared before and after UAE. Complete infarction of the dominant fibroid was assessed using magnetic resonance imaging. RESULTS: Significantly lower WBC count, CRP level, and NLR were noted 24 h after UAE in the lidocaine group. No statistically significant difference was noted in the pain score between groups at 0-24 h. The cumulative fentanyl dose administered during the first 24 h after UAE was not significantly different. After embolization, fibroid-related symptoms resolved in all patients. No significant difference was observed in the rate of complete infarction of the dominant fibroid. CONCLUSION: Lidocaine administration immediately after UAE resulted in a significant reduction in the inflammatory response. However, such a difference in the inflammatory reaction did not contribute to significant reductions in pain scores or fentanyl consumption.

Clinical outcomes and future fertility after uterine artery embolization for postpartum and post-abortion hemorrhage.

BACKGROUND: Postpartum hemorrhage (PPH) and post-abortion hemorrhage (PAH) are life-threatening conditions. PURPOSE: To evaluate the efficacy and safety of uterine arterial embolization (UAE) for PPH and PAH and to investigate future fertility after UAE. MATERIAL AND METHODS: This study included 57 consecutive patients (mean age = 34 years) who underwent UAE for PPH (n = 46) and PAH (n = 11) at our institution between January 2011 and December 2022. Technical success, non-visualization of the peripheral portion of bilateral uterine arteries on angiography, and clinical success, complete hemostasis after UAE, were assessed. UAE-associated complications and factors related to clinical success were analyzed. Pregnancy outcomes after UAE and complications during subsequent pregnancy were investigated in 16 patients who desired fertility and were followed up for >1 year. RESULTS: The technical and clinical success rates were 100% and 84.2%, respectively. Sepsis (n = 1) and uterine empyema (n = 1) were observed as severe complications. Placental disorder, bleeding within 24 h after delivery or abortion, ≥1.5 shock index, ≥6 units of transfusion erythrocytes, and ≥8 obstetrical disseminated intravascular coagulation score were significantly associated with unfavorable clinical outcomes. In total, 16 pregnancies were observed in 12 patients after UAE, three of which were miscarriages and 13 were successful live births. During pregnancy, uterine rupture (n = 1) and accreta (n = 1) were observed. CONCLUSION: UAE is an effective treatment for PPH and PAH. Although UAE could preserve future fertility, careful attention should be paid to perinatal management for unusual complications.

Factors associated with dysmenorrhoea and menorrhagia improvement in patients with adenomyosis after uterine artery embolisation.

BACKGROUND: This study examined the improvement of dysmenorrhoea and menorrhagia after uterine artery embolisation (UAE) in women with symptomatic adenomyosis and identified factors that could predict the improvement of dysmenorrhoea and menorrhagia. METHODS: This retrospective study included women with adenomyosis who underwent bilateral UAE between December 2014 and December 2016. The percentage of the volume of the absence of contrast enhancement on T1-weighted images was evaluated 5-7 days after UAE. A receiver operating characteristic (ROC) analysis was used to determine a cut-off point and predict the improvement of dysmenorrhoea and menorrhagia. RESULTS: Forty-eight patients were included. At 24 and 36 months after UAE, the improvement rates for dysmenorrhoea and menorrhagia were 60.4% (29/48) and 85.7% (30/35), and the recurrence rates were 19.4% (7/36) and 9.1% (3/33), respectively. Only the percentage of the volume of the absence of contrast enhancement on T1-weighted images was associated with the improvement of dysmenorrhoea (p = 0.001, OR = 1.051; 95% CI: 1.02-1.08) and menorrhagia (p = 0.006, OR = 1.077; 95% CI: 1.021-1.136). When the cut-off value of the ROC analysis was 73.1%, sensitivity, specificity, positive predictive value, and negative predictive value for the improvement of dysmenorrhoea were 58.6%, 94.7%, 94.4%, and 60%, while they were 58.9%, 80%, 100%, 100%, and 45.5% for the improvement of dysmenorrhoea. CONCLUSION: Bilateral UAE for symptomatic adenomyosis led to good improvement of dysmenorrhoea and menorrhagia. The percentage of the volume of the absence of contrast enhancement on T1-weighted images of the uterus in postoperative magnetic resonance imaging might be associated with the improvement of dysmenorrhoea and menorrhagia.

This study examined the improvement of dysmenorrhoea and menorrhagia after uterine artery embolisation in women with symptomatic adenomyosis and identified factors that could predict the improvement of dysmenorrhoea and menorrhagia. This retrospective study included women with adenomyosis who underwent uterine artery embolisation. A total of 48 patients were included. Only the percentage of the volume of the absence of contrast enhancement on T1-weighted images was associated with improvement of dysmenorrhoea and menorrhagia. Bilateral uterine artery embolisation for symptomatic adenomyosis led to good improvement. The percentage of the volume of the absence of contrast enhancement on images in postoperative T1-weighted magnetic resonance imaging of the uterus might be associated with the improvement of dysmenorrhoea and menorrhagia.

Uterine Fibroid Embolization Survey in Canada: Challenges, Opportunities, and Differences in Practices Across the Country.

Purpose: To assess the current practices surrounding Uterine Fibroid Embolization (UFE) in Canada. Methods: An online survey was sent to Canadian Association for Interventional Radiology (CAIR) members. It included questions on symptoms prompting UFE, patient awareness, investigation, UFE settings, the number of UFE procedures, and post-UFE care. The findings were discussed at CAIR's 2023 annual meeting by an expert panel. Results: Out of 792 surveys sent, 87 were filled (11%). Menorrhagia is the most common indication for UFE (87%). Women's awareness of UFE as a treatment option for fibroids is viewed as poor or average by 94% of our survey respondents. Most respondents see patients in clinics (92%) before the procedure and evaluate fibroids with MRI pre-UFE (76%). There is variability in care post-UFE, with 33% of procedures being performed as day surgery while 67% lead to overnight stay. For pain management, intravenous analgesia (including patient-controlled analgesia) is used in 76% (63/83) of cases while 19% (16/83) of respondents mentioned using epidural analgesia. Finally, there is an even split between embolic agent used; non-spherical polyvinyl alcohol (50%) and spherical particles (50%). Conclusion: Respondents believe patients in Canada still have limited awareness of UFE. Interventional radiologists are increasingly involved in the entire patient care trajectory, overseeing pre-and post-procedure care and hospitalizing patients. For pain management after UFE, it is observed that while epidural analgesia has been demonstrated more effective than alternatives, it is not widely used as the primary method.

Currently Available Treatment Modalities for Uterine Fibroids.

Uterine fibroids (leiomyomas and myomas) are the most common benign gynecological condition in patients presenting with abnormal uterine bleeding, pelvic masses causing pressure or pain, infertility and obstetric complications. Almost a third of women with fibroids need treatment due to symptoms. OBJECTIVES: In this review we present all currently available treatment modalities for uterine fibroids. METHODS: An extensive search for the available data regarding surgical, medical and other treatment options for uterine fibroids was conducted. REVIEW: Nowadays, treatment for fibroids is intended to control symptoms while preserving future fertility. The choice of treatment depends on the patient's age and fertility and the number, size and location of the fibroids. Current management strategies mainly involve surgical interventions (hysterectomy and myomectomy hysteroscopy, laparoscopy or laparotomy). Other surgical and non-surgical minimally invasive techniques include interventions performed under radiologic or ultrasound guidance (uterine artery embolization and occlusion, myolysis, magnetic resonance-guided focused ultrasound surgery, radiofrequency ablation of fibroids and endometrial ablation). Medical treatment options for fibroids are still restricted and available medications (progestogens, combined oral contraceptives andgonadotropin-releasing hormone agonists and antagonists) are generally used for short-term treatment of fibroid-induced bleeding. Recently, it was shown that SPRMs could be administered intermittently long-term with good results on bleeding and fibroid size reduction. Novel medical treatments are still under investigation but with promising results. CONCLUSIONS: Treatment of fibroids must be individualized based on the presence and severity of symptoms and the patient's desire for definitive treatment or fertility preservation.

Risk Factors Associated with Clinical Failure of Uterine Artery Embolization for Postpartum Hemorrhage.

PURPOSE: To identify risk factors for clinical failure of uterine artery embolization (UAE) for postpartum hemorrhage (PPH), with particular attention to the uterine artery diameter. MATERIALS AND METHODS: This retrospective study included 47 patients who underwent UAE for PPH between January 1, 2010, and January 31, 2021. Technical success was defined as the completion of embolization of the arteries thought to be the cause of the bleeding. Clinical success was defined as no recurrent bleeding or need for additional therapeutic interventions. Univariate and multivariate analyses were performed to examine the risk factors associated with clinical failure of UAE. RESULTS: Of the 47 patients, 6 had recurrent bleeding. Of the 6 patients, 4 underwent hysterectomy, and 2 underwent repeat embolization. The clinical success rate was 87.2% (41/47), with no major adverse events such as uterine infarction or death. In univariate analysis, there were slight differences in multiparity (P = .115) and placental abruption (P = .128) and a significant difference in the findings of a narrow uterine artery on digital subtraction angiography (DSA) (P = .005). In multivariate analysis, only a narrow uterine artery on DSA was a significant factor (odds ratio, 18.5; 95% confidence interval, 2.5-134.8; P = .004). CONCLUSIONS: A narrow uterine artery on DSA was a risk factor for clinically unsuccessful UAE for PPH. It may be prudent to conclude the procedure only after it is ensured that vasospasm has been relieved.

Superior Hypogastric Nerve Blockade for Uterine Artery Embolization: A Systematic Review.

Superior hypogastric nerve block (SHNB) has potential to reduce pain following uterine artery embolization (UAE). However, existing studies are limited by design, sample size, or conflicting results. A systematic review of the literature was performed. Outcomes included technical success, time to complete SHNB, time under fluoroscopy, procedure time, time to recovery, needle repositioning, same-day discharge, readmission, pain, analgesic consumption, and adverse events. Of 15 included studies, the same-day discharge rate was 98.8%, and readmission rate was 6.9%. The mean pain score was 3.4 in patients who received SHNB compared to 4.3 among controls. Of patients who received SHNB, 46.7% did not require further pain medication. Major adverse events occurred in 0.4% of patients. Early clinical studies suggest that SHNB appears to reduce pain and analgesic consumption in patients undergoing UAE. Additional randomized trials are needed to confirm these findings.

Is High-intensity Focused Ultrasound Superior to Uterine Artery Embolization in Cesarean Scar Pregnancy and Subsequent Pregnancy Outcomes? A Meta-analysis of the Chinese Population.

OBJECTIVE: High-intensity focused ultrasound (HIFU) followed by curettage or uterine artery embolization (UAE) followed by curettage are relatively effective methods for cesarean scar pregnancy (CSP), which can provide a high success rate and repregnancy while reducing blood loss and adverse events. Therefore, we conducted this meta-analysis to evaluate the efficacy, safety, and pregnancy outcomes of HIFU groups versus UAE groups with CSP. DATA SOURCES: The PubMed, EMBASE, Cochrane, China National Knowledge Infrastructure, and Wanfang databases were systematically searched to find studies that compared the therapeutic effects of HIFU groups versus UAE groups. METHODS OF STUDY SELECTION: Our primary end points were blood loss, adverse events, success rate, and repregnancy. We implemented random-effects models or fixed-effects models to evaluate the pooled data. TABULATION, INTEGRATION, AND RESULTS: Thirty-four eligible items were included in studies. The blood loss was significantly reduced in HIFU groups compared with UAE groups (standardized mean difference = -1.45, 95% confidence interval [CI], 2.21 to -0.68; p <.001). Significantly fewer adverse events occurred in the HIFU groups than in UAE groups (odds ratio [OR] = 0.36, 95% CI, 0.23-0.57; p <.001). The success rate of HIFU groups was higher than that of UAE groups (OR = 1.56, 95% CI, 1.05-2.32; p = .03). There were more pregnancies in HIFU groups than in UAE groups (OR = 1.64, 95% CI, 1.28-2.11; p <.001). CONCLUSION: In the CSP, the effect of HIFU groups was better than that of UAE groups: less blood loss, high success rate, fewer adverse events, and favorable fertility protection. Thus, it is a promising therapeutic method for patients.

Efficacy and Safety of High-intensity Focused Ultrasound Compared with Uterine Artery Embolization in Cesarean Section Pregnancy: A Meta-analysis.

OBJECTIVE: To investigate the efficacy and safety of high-intensity focused ultrasound (HIFU) compared with uterine artery embolization (UAE) in cesarean section pregnancy (CSP) and to calculate the success rate of HIFU. DATA SOURCES: We searched PubMed, Cochrane, Scopus, Web of Science, and Embase on September 30, 2022, and the related studies were independently reviewed by 2 researchers. METHODS OF STUDY SELECTION: Medical subject headings and relevant terms from other articles were used for the database search. Patients with CSP who underwent HIFU were included in this analysis. The following results were recorded: success rate, intraoperative blood loss, time for serum beta-human chorionic gonadotropin (beta-HCG) normalization and menstruation recovery, adverse events, hospitalization time, and hospitalization expenses. We used the Newcastle-Ottawa Scale scoring system and the methodological index for nonrandomized studies system to evaluate the quality of the studies. TABULATION, INTEGRATION, AND RESULTS: Data from 6 studies were used to compare the efficacy and safety of UAE and HIFU. We pooled the success rate of HIFU by including 10 studies. No data overlap between the 10 studies. Success rate was higher in the HIFU group (odds ratio [OR] = 1.90; 95% confidence interval [CI] 1.06-3.41; p = .03; I2 = 0). We performed the meta-analysis of single rate in R 4.2.0 software, and the success rate of HIFU group was 0.94 (95% CI 0.92-0.96; p = .04; I2 = 48%). Intraoperative blood loss (mean difference [MD]= -21.94 mL; 95% CI -67.34 to 23.47; p = .34; I2 = 99%) and time for serum beta-HCG normalization (MD = 3.13 days; 95% CI 0.02-6.25; p = .05; I2 = 70%) were not significantly different. Time to menstruation recovery (MD = 2.72 days; 95% CI 1.32-4.12; p = .0001; I2 = 0) in the UAE group was shorter than that in the HIFU group. Adverse events were not significantly different between the 2 groups (OR = 0.53; 95% CI 0.22-1.29; p = .16; I2 = 81%). Hospitalization time was not significantly different between the HIFU and UAE groups (MD = -0.41 days; 95% CI -1.14 to 0.31; p = .26; I2 = 55%). Hospitalization expenses of the HIFU group were lower than those of the UAE group (MD = -7488.49 yuan; 95% CI -8460.13 to -6516.84; p <.000; I2 = 0). Heterogeneity of the time for beta-HCG normalization, adverse events, and hospitalization time were improved after excluding one study, and HIFU showed better results in the sensitivity analysis of adverse events and hospitalization time. CONCLUSION: According to our analysis, HIFU demonstrated satisfactory treatment success, accompanied by similar intraoperative blood loss, slower normalization of beta-HCG levels, and menstruation recovery, but potentially shorter hospitalization time, lower adverse events and lower costs than UAE. Therefore, HIFU is an effective, safe, and economical treatment for patients with CSP. These conclusions should be interpreted with caution because of the significant heterogeneity. However, large and strictly designed clinical trials are required to verify these conclusions.

Uterine artery embolization for postpartum hemorrhage with placenta accreta spectrum.

BACKGROUND: The reported success rate of uterine artery embolization (UAE) for postpartum hemorrhage (PPH) differs by the cause of bleeding; in some reports, UAE shows less successful results in patients with placenta accreta spectrum (PAS). PURPOSE: To evaluate the outcome of UAE for treating PPH associated with PAS. MATERIAL AND METHODS: From September 2011 to September 2021, 227 patients (mean age = 34.67±4.06 years; age range = 19-47 years) underwent UAE for managing intractable PPH. Patients were divided into two groups: those with PAS (n = 46) and those without PAS (n = 181). Delivery details, embolization details, and procedure-related outcomes were compared between the two groups. P values <0.05 were considered statistically significant. RESULTS: The technical success rate was 96.9% (n = 222) and the clinical success rate was 93.8% (n = 215). There were no significant differences in outcome of UAE between the two patient groups. The technical success rate was 95.7% (n = 44) in patients with PAS and 98.3% (n = 178) in patients without PAS (P = 0.267). The clinical success rate was 91.3% (n = 42) in patients with PAS and 95.6% (n = 173) in patients without PAS (P = 0.269). There were 24 cases of immediate complications, including pelvic pain (n = 20), urticaria (n = 3), and puncture site hematoma (n = 1). No major complication was reported. CONCLUSION: UAE is a safe and effective method to control intractable PPH for patients with or without PAS.

Association of normalization of postoperative carbohydrate antigen 125 levels with treatment failure following uterine artery embolization for adenomyosis.

OBJECTIVE: To investigate the association between carbohydrate antigen 125 (CA125) level and adenomyosis treatment failure (TF) after uterine artery embolization (UAE). METHODS: We evaluated 224 patients with symptomatic adenomyosis who underwent UAE between January 2016 and December 2020. Improvements in dysmenorrhea and menorrhagia were assessed on the basis of symptom relief criteria. The factors associated with TF were investigated using a multivariate logistic regression model. Patients were analyzed for preoperative CA125 levels, postoperative CA125 levels, and the normalization of postoperative CA125 levels. Long-term symptom relief and quality of life after UAE were compared between the groups. RESULTS: During the 24-month follow-up, 50 patients (22.3%) experienced TF. Compared to patients in the non-TF group, those in the TF group had significantly higher preoperative and postoperative CA125 levels (p < 0.05). Multivariate analysis revealed that failure to normalize postoperative CA125 levels was independently associated with an increased risk of TF (34.7% vs. 8.5%, p < 0.001; hazard ratio 3.953, 95% confidence interval 1.567-9.973, p = 0.004). After a 3-month follow-up period, patients who normalized their CA125 levels were more likely to achieve complete necrosis on magnetic resonance imaging than those who did not (82.1% vs. 56.8%, p < 0.001). Normalization of postoperative CA125 levels was significantly associated with fewer symptoms and better quality of life 12 months after UAE (p < 0.05). CONCLUSIONS: Following UAE, normalization of postoperative CA125 levels, rather than absolute values, was the strongest predictive marker of TF.

Uterine Artery Embolization for Symptomatic Adenomyosis: Proceedings from a Society of Interventional Radiology Foundation Research Consensus Panel.

Adenomyosis poses an important diagnostic and therapeutic challenge in women's health because of a variety of clinical/imaging presentations and frequent coexistence with other benign gynecologic conditions. In recent years, uterine artery embolization (UAE) for the treatment of adenomyosis has shown encouraging and favorable outcomes and long-term symptom improvement. To expand the current understanding of adenomyosis pathophysiology, imaging diagnostic criteria, and treatment outcomes, the Society of Interventional Radiology Foundation gathered a multidisciplinary Research Consensus Panel with experts from diverse backgrounds. The topics addressed were centered around the following: (i) the clinical presentation and imaging findings to diagnose adenomyosis; (ii) the currently available medical, interventional, and surgical treatment options; and (iii) existing literature for and experiences with UAE in symptomatic disease. The panel acknowledged that before the pursuit of a clinical trial, it would be necessary to first evaluate the imaging criteria for adenomyosis and correlate them with pathology and symptoms to establish a noninvasive imaging classification system. Second priority was given to the development of a quality of life questionnaire to assess patient outcomes following treatment. The third priority was the performance of a prospective clinical trial comparing UAE with medical therapy, which would help establish UAE in the treatment algorithm and societal guidelines for symptomatic adenomyosis.

Management of Symptomatic Vascularized Retained Products of Conception by Proximal Uterine Artery Embolization with Gelatin Sponge Torpedoes.

PURPOSE: To evaluate the effectiveness and safety of temporary proximal uterine artery embolization (UAE) for the treatment of highly vascularized retained products of conception (RPOCs). MATERIALS AND METHODS: This retrospective analysis included women who underwent treatment for vaginal bleeding after abortion, miscarriage, or delivery, with highly vascularized RPOCs detected by Doppler ultrasound (US) (ie, presence of an enhanced myometrial vascularity, a low resistance index of <0.5, and a peak systolic velocity of ≥0.7 m/s). A unilateral or bilateral embolization with torpedoes of gelatin foam was performed. From November 2017 to January 2021, 24 women with a median age of 30 years (interquartile range, 26.0-34.5 years) with symptomatic highly vascularized RPOCs were included. Clinical success was defined as bleeding arrest between the UAE and 1-month follow-up. Technical success was defined as the complete obstruction of at least 1 uterine artery supplying vascular abnormalities. The safety of the procedure according to the classification of the Society of Interventional Radiology and evolution of lesions on US were also reported. RESULTS: Technical success was achieved in all 24 (100%) patients, with bilateral arterial embolization in 19 (79%) patients and unilateral embolization in 5 (21%) patients. Clinical success was achieved in all 24 (100%) patients. Five patients still had uterine retention at the 1-month follow-up, including 2 patients with highly vascularized RPOCs. Two patients benefited from hysteroscopy, and 3 had noninvasive management. Four minor adverse events were reported (1 patient had infectious endometritis and 3 patients had a postembolization syndrome). CONCLUSIONS: Proximal UAE with torpedoes of gelatin foam is safe and effective for the management of symptomatic highly vascularized RPOCs.

Management of Acquired Uterine Arteriovenous Malformations Associated with Retained Products of Conception.

PURPOSE: To evaluate the efficacy and safety of different treatments for acquired uterine arteriovenous malformations associated with retained products of conception (UAVM-RPOC) and to investigate the role of uterine artery embolization (UAE) in acquired UAVM-RPOC. MATERIALS AND METHODS: This was a retrospective study of consecutive patients who were diagnosed with uterine arteriovenous malformation by ultrasound after recently terminated pregnancy. Forty-eight patients were included in this study and were divided into 2 groups (major and minor bleeding groups) according to vaginal bleeding. The treatments were analyzed between groups. Technical and clinical success rates of UAE were analyzed. RESULTS: Of the 48 patients, 11 patients were in the massive bleeding group and 37 were in the minor bleeding group. Five patients were referred for UAE in each group and UAE was a priority for patients with unstable hemodynamics (chi-square value = 5.524, P =.022). Conservative management, dilation and curettage (D&C), operative hysteroscopy, and UAE were performed in 16 (33%), 18 (38%), 7 (15%), and 13 (27%) patients, respectively. Two patients with ectopic pregnancies suffered uncontrollable bleeding during D&C and required emergent UAE. Three patients underwent UAE before surgery to prevent hemorrhage. The technical and clinical success rates of UAE were 100%. No complications or recurrences occurred. CONCLUSIONS: UAE is a safe and effective treatment for UAVM-RPOC and a priority for patients with unstable hemodynamics. Conservative management, D&C, and hysteroscopy are safe and effective for patients with UAVM-RPOC with stable hemodynamics. However, UAVM-RPOC following ectopic pregnancy may have high risks of massive hemorrhage during procedures.

Potential benefit of GnRH-agonist treatment before uterine artery embolization for large fibroids: MRI prediction of fibroid volume reduction.

BACKGROUND: Signal intensity (SI) of predominant fibroid (F1) on T2-weighted (T2W) images is useful for predicting the volume reduction response after gonadotropin-releasing hormone (GnRH)-agonist treatment. Few studies have been published regarding when and how to use GnRH agonist before UAE. PURPOSE: To investigate magnetic resonance imaging (MRI) prediction of volume reduction rate (VRR) of large fibroids after GnRH-agonist treatment before uterine artery embolization (UAE) as well as the efficacy of UAE based on MRI. MATERIAL AND METHODS: Data from 30 patients with a large fibroid and MRI results both before and after GnRH-agonist treatment were retrospectively analyzed. Indications for GnRH-agonist treatment are fibroids with a maximum diameter ≥10 cm or pedunculated submucosal fibroids ≥8 cm. GnRH agonist (3.75 mg leuprolide acetate) was administered subcutaneously once per month 2-6 times. SI of F1 on T2W imaging was measured: the SI was referenced to the SI of the rectus abdominis muscle (F/R). RESULTS: Mean maximum fibroid diameter was 11.1 ± 1.9 cm (range = 8.0-15.5 cm). Mean number of GnRH-agonist injections before UAE was 2.8 (range = 2-6). For predicting VRR ≥50% and <30%, the optimal cut-off values of F/R were 2.58 (sensitivity 80%, specificity 80%) and 1.69 (sensitivity 100%, specificity 70%), respectively. Of the 30 patients, fibroid infarction was complete in 29 (96.7%). CONCLUSION: SI of F1 on T2W imaging is useful for predicting the volume reduction response after GnRH-agonist treatment. After GnRH-agonist treatment for large fibroids, UAE is effective to achieve complete infarction of fibroids.