Training standards for physicians performing uterine artery embolization for leiomyomata: consensus statement developed by the Task Force on Uterine Artery Embolization and the standards division of the Society of Cardiovascular & Interventional Radiology--August 2000

Medical historical notes on myoma treatment by uterine artery embolization on the occasion of its introduction 30 years ago

BACKGROUND

 Since its development, uterine artery embolization (UAE) for the treatment of symptomatic fibroids has become an established minimally invasive alternative to surgical myoma treatment. Currently, more than 25,000 myoma patients worldwide are likely to be treated with UAE annually.

METHOD

 Thirty years ago, Jacques-Henri Ravina (b. 1930) and his Paris team first performed this therapy as a "substitute" for gynecologic surgery. We contacted him as part of the preparation of the present review. In addition, we performed a literature search with the aim of summarizing the current literature and data in addition to a historical account of the development of UAE.

RESULTS AND CONCLUSION

 On the occasion of this anniversary, we would like to recall the interdisciplinary roots and some facets of the history of the development of this relatively young myoma treatment method.

KEY POINTS

  · UAE is an established minimally invasive alternative to surgical myoma treatment.. · UAE was first developed 30 years ago.. · UAE has continuously increased in importance in recent years..

CITATION FORMAT

· Psilopatis I, Fleckenstein FN, Gebauer B et al. Medical historical notes on myoma treatment by uterine artery embolization on the occasion of its introduction 30 years ago. Fortschr Röntgenstr 2023; 195: 890 - 895.

Unique Learning System for Uterine Artery Embolization for Symptomatic Myoma and Adenomyosis for Obstetrician-Gynecologists in Cooperation with Interventional Radiologists: Evaluation of UAE From the Point of View of Gynecologists Who Perform UAE

STUDY OBJECTIVE

To evaluate a unique learning system for uterine artery embolization (UAE) and examine its feasibility and clinical outcomes for the treatment of symptomatic uterine leiomyomas and adenomyosis when performed by obstetrician-gynecologists in cooperation with interventional radiologists (IVRs).

DESIGN

Retrospective study (Canadian Task Force classification II-2).

SETTING

University hospital.

PATIENTS

One hundred seventy-three patients who underwent UAE for symptomatic leiomyomas and adenomyosis.

INTERVENTIONS

We examined the medical records of patients who underwent UAE for symptomatic uterine leiomyomas and adenomyosis at our department between 2003 and 2012 using our learning system for UAE for obstetrician-gynecologists in cooperation with IVRs. The charts of all patients were reviewed, and data on etiologic factors, past medical history of leiomyomas and adenomyosis, symptoms, details of UAE, and clinical outcomes after UAE were extracted.

MEASUREMENTS AND MAIN RESULTS

A total of 173 patients who underwent 177 UAEs were identified, including 4 patients who underwent embolization twice because of primary treatment failure or symptom recurrence. During the study period, 2 gynecologists successfully acquired endovascular skills. The technical success rate was 97.7% (174 of 177). The duration of fluoroscopy in procedures performed by obstetrician-gynecologists who acquired endovascular skills was not significantly different from that in procedures performed by IVRs at our institution; however, this duration was significantly longer in procedures performed by obstetrician-gynecologists who did not have sufficient experience with our learning protocol for UAE because of inadequate live observation of UAEs performed by skilled IVRs. Complications that necessitated discontinuation of the procedure occurred in 2.3% of cases (4 of 177). The clinical outcomes were similar to those reported in previous studies. Adverse events after UAE included myeloid passages in 7.0% (11 of 158), infections in 2.5% (4 of 158), vaginal discharge in 2.5% of patients with leiomyomas (4 of 158), and vaginal discharge in 7.1% of patients with adenomyosis (1 of 14). All the adverse events were adequately treated by the obstetrician-gynecologists themselves. The timing of hysterectomy due to complications or recurrence of symptoms after UAE varied widely.

CONCLUSION

UAE performed by obstetrician-gynecologists in cooperation with radiologists can be achieved safely and successfully with acceptable clinical outcomes. Live observation of the procedure performed by skilled IVRs is essential to improving the skills and reducing the fluoroscopic time of obstetrician-gynecologists.

Retrospective study of the impact of fellowship training on two quality and safety measures in uterine artery embolization

RATIONALE AND OBJECTIVES

To measure the impact of 1-year interventional fellowship training on fluoroscopic time and contrast media utilization in uterine artery embolization (UAE).

MATERIALS AND METHODS

Retrospective single institution analysis of 323 consecutive UAEs performed by 12 interventional fellows using a standardized protocol. Fluoroscopy time and contrast media volume were recorded for each patient and correlated with stage of fellowship training. Preprocedure uterine volume (using MRI or ultrasound) was used as a measure of procedural complexity. Regression analysis was conducted per trainee factoring in duration of training, procedure number, supervising radiologist, uterine volume, and outcome variables of fluoroscopy time and contrast media volume.

RESULTS

Median number of patients treated per trainee was 27 (range, 16-43) with mean fluoroscopic time 24.5 minutes (range, 4-90 min) and mean contrast volume 190 mL (range, 50-320 mL). Increasing uterine volume had no significant effect (P > .05) on fluoroscopic time but significantly increased (P < .001) contrast media volume. Significant training effect was identified with decrease in fluoroscopic time (P < .001) and decrease in contrast volume (P = .02) over training. Over the course of a 1-year fellowship, these summed to a decrease of 12 minutes in UAE fluoroscopy time and 17 mL less contrast.

CONCLUSION

A significant (P < .05) training effect that is clinically relevant was demonstrated over the course of a yearlong interventional radiology fellowship program in performance of a standardized protocol for UAE. This data supports fellowship training as a basis for UAE credentialing and privileging.

Uterine artery embolization: optimization with preprocedural prediction of the best tube angle obliquity by using 3D-reconstructed contrast-enhanced MR angiography

PURPOSE

To evaluate the effect of preprocedural prediction of the best tube angle obliquity for visualization of the uterine artery origin by using three-dimensional (3D)-reconstructed contrast material-enhanced magnetic resonance (MR) angiography on the radiation dose, fluoroscopy time, and contrast medium volume during uterine artery embolization (UAE).

MATERIALS AND METHODS

The study was approved by the institutional review board. Informed consent was obtained. The prospective study included 20 consecutive prospective patients (age range, 37-56 years) for whom preprocedural prediction of the best tube angle obliquity was determined by using 3D-reconstructed contrast-enhanced MR angiography; the best tube angle obliquity was provided to the interventionist. Three-dimensional reconstruction was performed by using an application of the angiographic unit. The radiation dose, fluoroscopy time, and contrast medium volume for those patients were compared with those data in 20 retrospectively assessed control patients (age range, 39-56 years) from the prior 20 procedures performed by the same interventionist.

RESULTS

Tube angle prediction resulted in a significant reduction in the radiation dose utilized (P < .001), fluoroscopy time (P = .002), and contrast medium volume (P < .001) for the sample patients compared with those for the control patients. Overall radiation dose was reduced from a mean of 11 044 microGy per square meter to a mean of 4172.5 microGy per square meter. Fluoroscopy time was reduced from a mean of 15 minutes 30 seconds to 8 minutes 49 seconds. Contrast medium volume was reduced from a mean of 135 mL to 75 mL.

CONCLUSION

Preprocedural prediction of the best tube angle obliquity for visualization of the origin of the uterine artery by using 3D-reconstructed contrast-enhanced MR angiography results in significant reductions in radiation dose, fluoroscopy time, and contrast medium volume during UAE.

Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids: 2 years' outcome from the randomized EMMY trial

OBJECTIVE

The purpose of this study was to compare the 2 years' efficiency of uterine artery embolization (UAE) with hysterectomy in the treatment of menorrhagia caused by uterine fibroids in a randomized controlled trial.

STUDY DESIGN

Twenty-eight Dutch hospitals recruited patients with uterine fibroids and menorrhagia, who were eligible for hysterectomy. Patients were randomized to UAE or hysterectomy. The primary endpoint was if UAE could avoid a subsequent hysterectomy in at least 75% of cases. Secondary endpoints were changes in pain, bulk-related complaints, and uterine and dominant fibroid volume reduction.

RESULTS

One hundred seventy-seven patients were randomized to UAE (n = 88) or hysterectomy (n = 89). Two years after treatment 23.5% of UAE patients had undergone a hysterectomy. There were no significant differences in improvement compared to baseline in pain and bulk-related complaints. Uterine and dominant fibroid volume reduction in UAE patients was 48.2% and 60.5%, respectively.

CONCLUSION

UAE is a valuable alternative treatment for symptomatic uterine fibroids. Nevertheless, when patients seek for certainty on the cessation of bleeding problems, a hysterectomy remains the treatment of choice.

Endovascular training for obstetrician-gynecologists: Suggestions for credentialing

This article suggests guidelines for training and credentialing of obstetrician-gynecologists to perform endovascular procedures. It concentrates on the performance of uterine artery embolization for symptomatic myomata. Comparison is made between other recommended case numbers for credentialing of surgeons, radiologists, and cardiologists. Educational courses are discussed, as are the credits obtained for a typical uterine artery embolization. Two paradigms of endovascular credentialing are appropriate for comparison: Cardiology standards for coronary artery interventions and vascular surgery standards for endovascular stent placement. Both require a course including laboratory and participation in 100 cases, 50 of which as primary operator. In addition, many countries require a certificate of fluoroscopy safety. A credentialing board will be created to verify both the standards and completion of course requirement and proctored cases. Credentialing will benefit both patients and obstetrician gynecologists who will be able to provide continuity of care not currently available. The gynecologist will be able to manage all complications, including myomata, which cannot be done under current circumstances.

Technical results and effects of operator experience on uterine artery embolization for fibroids: the Ontario Uterine Fibroid Embolization Trial

PURPOSE

To document the technical results and spectrum of practice of uterine artery embolization (UAE) for fibroids in the health care setting in Canada. The effects of interventional radiologist's (IR's) experience with UAE on procedure and fluoroscopy time were also investigated.

MATERIALS AND METHODS

The study involved a multicenter prospective single-arm clinical treatment trial and included the practices of 11 IRs at eight university-affiliated teaching and community hospitals. Vascular access with percutaneous femoral artery approach was followed by transcatheter delivery of polyvinyl alcohol (PVA) particles into uterine arteries with fluoroscopic guidance. Technical success, complications, procedural time, fluoroscopy time, and effects of operator experience were outcomes analyzed.

RESULTS

Between November 1998 and November 2000, 570 embolization procedures were performed in 555 patients. UAE was bilaterally successful in 97% (95% CI: 95%-98%). Variant anatomy was the most common reason for failure to embolize bilaterally. The procedural complication rate was 5.3% (95% CI: 3.6%-7.4%). Of the 30 events, three involved major complications (one seizure and two allergic reactions) that resulted in additional care or extended hospital stay. Procedure time and fluoroscopy time averaged 61 minutes (95% CI; 58-63 minutes) and 18.9 minutes (95% CI; 18-19.8) and varied significantly among IRs (P <.001; P <.001). The average 27% reduction in procedure time (20 minutes; P <.001) and 24% reduction in fluoroscopy time (5.1 minutes; P <.001) with increasing UAE experience were significant.

CONCLUSIONS

A high level of technical success with few complications was obtained with a variety of operators in diverse practice settings. Increased experience in UAE significantly reduced procedure and fluoroscopy time.