Uterine Necrosis after Uterine Artery Embolization for Symptomatic Fibroids

Abstract

Introduction Uterine artery embolization (UAE) is a minimally invasive intervention that is used in the treatment of fibroids. UAE can lead to complications including postembolization syndrome, postprocedure pain, infection, endometrial atrophy leading to secondary amenorrhea, and uterine necrosis. Uterine necrosis after UAE is very rare and hence poses a clinical dilemma for any clinician in its identification and management. We document a case of uterine necrosis after UAE and conduct a literature review on its causation, clinical features, and management principles. Case A patient presented one month after UAE with abdominal pain and abdominal vaginal discharge. Her work-up revealed features of possible uterine necrosis with sepsis and she was scheduled for a laparotomy and a subtotal hysterectomy was performed. She was subsequently managed with broad spectrum antibiotic and recovered well. Conclusion Uterine necrosis after UAE is a rare occurrence and we hope the documentation of this case will add to the body of knowledge around it. Theories that explain its occurrence include the use of small particles at embolization, the use of Contour-SE a spherical poly-vinyl alcohol, and lack of collateral supply to the uterus. Its symptoms may be nonspecific but unremitting abdominal pain is invariably present. Finally although conservative management may be successful at times, surgical management with hysterectomy will be required in some cases. The prognosis is good after diagnosis and surgical management.

The Contribution of Uterine Artery Embolization as a Safe Treatment Option for Uterine Fibroids

“…UAE is a minimally invasive procedure which improves symptoms by interrupting the blood flow uterine vessel branches to fibroids after bilateral (from right and left) hyper-selective catheterization of the myometric feeder arteries and embossing of pistons induceing irreversible ischemic damage and degeneration/ shrinkage in the fibroids. [65,[75][76][77][78][79][80] According to bibliography, therapy success rate during menorrhagia, was is 80-100% and at? pressure phenomena 60-100%.…”

“…The reported deaths following UAE are extremely rare (approximately 1: 1600) and are mainly related to pulmonary embolism, which may be due to the effect of necrotic tissue on activation of the coagulation mechanism and on inflammation. The complications of catheterization are rare (<1%), such as hematoma, allergy to contrast media and pseudo-aneurysm or vascular separation [75,76,[87][88][89][90]. Elimination of uterine fibroids occurs in 5% of cases and can cause inflammation requiring scanning or hysterectomy.…”

“…The necrotic tissue, if not removed in time, can become infected and the condition becomes severe. Cases with submucosal fibroids should be treated hysteroscopically [75,76,[87][88][89][90]. Ischemia may cause endometritis, pelvic inflammation and pyometra with poor outcome if hysterectomy does not occur.…”

“…Ischemia may cause endometritis, pelvic inflammation and pyometra with poor outcome if hysterectomy does not occur. According to the literature, menorrhagia is successfully treated in 91-100% of cases, while symptoms such as flatulence, pressure on organs of the pelvis and loss of urine are reduced to 92-100% [67,75,76,[87][88][89][90]. Uterine size does not appear to be a determinant, as remission of symptoms is also common in patients with a uterus greater than 24 weeks gestation.…”

“…In Table 1 are summarized the complications in our participants and according to international literature with the maximally respectively referred complications rate. The first column of the table refers to our results in the time from 2008 to 2020 while in the second column are shown the respective values of the examinated parameters in average concerning to international literature [72][73][74][75][76].…”