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Recovery after Uterine Artery Embolization: Understanding and Managing Short-term Outcomes James B. Spies, MD J Vasc Interv Radiol 2003; 14:1219 –1222 Abbreviation: PVA polyvinyl alcohol IN the years since the introduction of uterine artery embolization (UAE) for the treatment of uterine fibroids, the published studies on the procedure have shown that it results in signifi- cant improvement in symptom status and a high degree of patient satisfac- tion (1–7). What has been missing is a more detailed analysis of other aspects of the outcome from embolization. In this issue of JVIR, Pron and colleagues have reported a study that gives us insight into short-term recovery (8). With this work, we have a clearer un- derstanding of the periprocedural re- covery and, in particular, the “tolera- bility” of the procedure. We come to this subject with rela- tively little experience in this type of analysis. Most interventional proce- dures are not painful during recovery, other than the healing of a small inci- sion or the body adjusting to the place- ment of a drainage catheter. With the development and use of embolo- therapy, we have discovered that isch- emic pain is a side effect of the proce- dures that requires recognition and management. Uterine embolization has brought this issue into sharp fo- cus. Here, rather than treating desper- ately ill patients with cancer or se- verely traumatized patients, we are treating young and otherwise healthy women. Many of these patients have never undergone any significant med- ical therapy and this procedure is their introduction to hospital care. From the first reports, it was clear that short- term pain is a normal side effect of the procedure, and the degree of pain is widely variable. In a study early in our uterine embolization experience (9), we could identify no baseline vari- ables that predicted the severity of postprocedure pain, nor did the sever- ity of pain predict outcome. In that analysis, neither the baseline uterine size nor the size of the largest fibroid predicted pain severity. There was no correlation between narcotic dose used in the first 24 hours and the per- ceived pain. Moreover, the degree of pain did not appear to impact the im- aging or symptomatic outcome. Pa- tients with no pain or minor pain were just as likely to have a favorable out- come as were those with severe pain. Because this analysis was early in our experience, the impact of variation in the technique of embolization was not tested. In the current study by Pron and colleagues, a large cohort of patients was enrolled in a prospective outcome study, and the authors presented the details of recovery from the procedure (8). Each patient was interviewed at 2 weeks and 3 months after treatment. The primary focus was on pain and its severity occurring during and after the procedure. Complications that may have occurred during the hospitaliza- tion or in the initial recovery period were also analyzed. The study authors reported the midterm outcomes from this group of patients earlier (10), and they were similar to those reported in other large published series (4,7,11). However, in reviewing the short- term outcome and aspects of the re- covery, there has been some variabil- ity. For example, in the Pron et al. study, 12.3% of the patients had a length of stay greater than one night and 10% of patients had a return visit to the emergency room. By compari- son, in our recent summary of compli- cations in 400 consecutive patients with a minimum of 3 months of fol- low-up (12), 1.25% of patients had pro- longed or recurrent pain requiring hospitalization, and 3.5% of patients had emergency room visits. Of our first 200 of these patients, only 3% stayed in the hospital more than 1 night (11). If one compares the pain experi- enced after the procedure, the recent series of Walker and Pelage (7) was similar to the Canadian experience. For 35% of their patients, the pain after this procedure was the equal of labor pain or worse. However, when com- paring the Canadian study group to the more recently treated Fibroid Reg- istry patients, as the authors acknowl- edge, the pain experienced by their patients was greater than that seen in the Fibroid Registry (7). The peak pain score on the 11-point numeric rating scale was a mean of 5.6 in the Fibroid From the Department of Radiology, Georgetown University Hospital, 3800 Reservoir Road NW, CG201, Washington, DC 20007-2197. Address corre- spondence to J.B.S.; E-mail: spiesj@gunet. georgetown.edu J.B.S. is a consultant for Biosphere Medical and Bos- ton Scientific. © SIR, 2003 DOI: 10.1097/01.RVI.0000092661.72261.A5 Commentary 1219

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Recovery after Uterine Artery Embolization:Understanding and Managing Short-termOutcomesJames B. Spies, MD

J Vasc Interv Radiol 2003; 14:1219–1222

Abbreviation: PVA � polyvinyl alcohol

IN the years since the introduction ofuterine artery embolization (UAE) forthe treatment of uterine fibroids, thepublished studies on the procedurehave shown that it results in signifi-cant improvement in symptom statusand a high degree of patient satisfac-tion (1–7). What has been missing is amore detailed analysis of other aspectsof the outcome from embolization. Inthis issue of JVIR, Pron and colleagueshave reported a study that gives usinsight into short-term recovery (8).With this work, we have a clearer un-derstanding of the periprocedural re-covery and, in particular, the “tolera-bility” of the procedure.

We come to this subject with rela-tively little experience in this type ofanalysis. Most interventional proce-dures are not painful during recovery,other than the healing of a small inci-sion or the body adjusting to the place-ment of a drainage catheter. With thedevelopment and use of embolo-therapy, we have discovered that isch-emic pain is a side effect of the proce-dures that requires recognition andmanagement. Uterine embolizationhas brought this issue into sharp fo-

cus. Here, rather than treating desper-ately ill patients with cancer or se-verely traumatized patients, we aretreating young and otherwise healthywomen. Many of these patients havenever undergone any significant med-ical therapy and this procedure is theirintroduction to hospital care. From thefirst reports, it was clear that short-term pain is a normal side effect of theprocedure, and the degree of pain iswidely variable. In a study early in ouruterine embolization experience (9),we could identify no baseline vari-ables that predicted the severity ofpostprocedure pain, nor did the sever-ity of pain predict outcome. In thatanalysis, neither the baseline uterinesize nor the size of the largest fibroidpredicted pain severity. There was nocorrelation between narcotic doseused in the first 24 hours and the per-ceived pain. Moreover, the degree ofpain did not appear to impact the im-aging or symptomatic outcome. Pa-tients with no pain or minor pain werejust as likely to have a favorable out-come as were those with severe pain.Because this analysis was early in ourexperience, the impact of variation inthe technique of embolization was nottested.

In the current study by Pron andcolleagues, a large cohort of patientswas enrolled in a prospective outcomestudy, and the authors presented thedetails of recovery from the procedure(8). Each patient was interviewed at 2weeks and 3 months after treatment.The primary focus was on pain and itsseverity occurring during and after the

procedure. Complications that mayhave occurred during the hospitaliza-tion or in the initial recovery periodwere also analyzed. The study authorsreported the midterm outcomes fromthis group of patients earlier (10), andthey were similar to those reported inother large published series (4,7,11).

However, in reviewing the short-term outcome and aspects of the re-covery, there has been some variabil-ity. For example, in the Pron et al.study, 12.3% of the patients had alength of stay greater than one nightand 10% of patients had a return visitto the emergency room. By compari-son, in our recent summary of compli-cations in 400 consecutive patientswith a minimum of 3 months of fol-low-up (12), 1.25% of patients had pro-longed or recurrent pain requiringhospitalization, and 3.5% of patientshad emergency room visits. Of ourfirst 200 of these patients, only 3%stayed in the hospital more than 1night (11).

If one compares the pain experi-enced after the procedure, the recentseries of Walker and Pelage (7) wassimilar to the Canadian experience.For 35% of their patients, the pain afterthis procedure was the equal of laborpain or worse. However, when com-paring the Canadian study group tothe more recently treated Fibroid Reg-istry patients, as the authors acknowl-edge, the pain experienced by theirpatients was greater than that seen inthe Fibroid Registry (7). The peak painscore on the 11-point numeric ratingscale was a mean of 5.6 in the Fibroid

From the Department of Radiology, GeorgetownUniversity Hospital, 3800 Reservoir Road NW,CG201, Washington, DC 20007-2197. Address corre-spondence to J.B.S.; E-mail: [email protected]

J.B.S. is a consultant for Biosphere Medical and Bos-ton Scientific.

© SIR, 2003

DOI: 10.1097/01.RVI.0000092661.72261.A5

Commentary

1219

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Registry versus 7.0 for the Canadianstudy, with higher numbers indicatinggreater pain.

Another measure of recovery is thenumber of days to return to normalactivity or work. In the Canadiangroup, it took patients an average of13.1 days to return to work and 19% ofpatients required more than 2 weeksto recover. The patients of Walker andPelage (7) had a recovery similar tothat of the Canadian group, with amean of 13.6 days to return to normalactivities and 16.6 days to return towork. In our report on patient out-come in 200 patients, a mean of 8 dayswas required for return to work (11).

Whether these apparent differencesare real is not clear. The methods ofassessing recovery after this procedurevaried from study to study, and thesedifferences alone could account forany apparent discrepancy. The painmanagement used in these studiesvaried considerably and, in the case ofthe Fibroid Registry, included somepatients treated with epidural or spi-nal analgesia. Further, Fibroid Regis-try patients were treated at more than80 different centers and the Canadianpatients were treated in one of 11 cen-ters. There were differences in hospitalpain management and there was justas great a variability in outpatient painmanagement during recovery. Theremay also be social, cultural, or eco-nomic factors that could account forthe differences. In contrast to theUnited States, Canada and the UnitedKingdom have universal health caresystems that may have different fac-tors that influence length of stay, treat-ment regimens, emergency room vis-its, and readmission. Therefore, thereis a hazard in attempting to draw anydistinctions between outcomes in suchsettings.

With that disclaimer, there are atleast two areas that might influencethe severity of the ischemic pain afterthis procedure: the embolization end-point and the pain management planafter treatment.

All the patients in the Canadianstudy were embolized to complete oc-clusion, described as a “standing col-umn of contrast material,” with ap-proximately half the patients receivinga supplemental embolic material ofgelatin sponge pledgets or a coil.Walker and Pelage (7) used polyvinylalcohol (PVA) followed by coils in all

patients. The endpoint used in the pa-tients in our study (12) was “near sta-sis” with slight residual forward flow.No supplemental embolic materialswere used in our group. Whether thisdifference in the degree of emboliza-tion can explain a difference in painafter embolization is not known. Mostinvestigators believe that ischemia inthe normal myometrium is the pri-mary source of pain immediately afterthe procedure, and, with recanaliza-tion of the PVA occlusion over severalhours, the pain is eventually relieved(13). It is speculated that complete oc-clusion may lead to greater ischemicpain than a less-extensive occlusion.

In recent years, there has been apronounced trend toward less-exten-sive embolization, and this has re-sulted in a trend toward less-severepain after embolization. Most physi-cians who have performed this proce-dure for several years and who haveexperienced the transition toward less-extensive occlusion have noted thatthe pain patients experience is less se-vere on average that in earlier days.

The change in philosophy regard-ing endpoint of embolization cameabout in part as a result of the initialexperience with tris-acryl gelatinmicrospheres (Embosphere Micro-spheres; Biosphere Medical, Rockland,MA). The necessary endpoint for suc-cessful embolization is occlusion of theperifibroid vessels, but with a patentuterine artery and patent proximalportions of the major branches (thepruned-tree appearance), with resid-ual sluggish forward flow in the ves-sels (14). This endpoint with use ofmicrospheres has proved to be effec-tive in infarcting fibroids and in pro-viding symptom improvement com-parable to that in patients treated withPVA (15). The success of this endpointin treating fibroids has led many toreduce the extent of occlusion evenwhen using PVA. Because PVA mayocclude more abruptly than micro-spheres, most operators continue em-bolization until there is a greater de-gree of occlusion, with slight residualflow (near-stasis). They then rely onpartial recanalization over the courseof several hours to prevent myome-trial ischemic injury and to relievepain. The ischemia may also be re-lieved by collateral flow from theovarian vessels or serosal or cervicalcollaterals. Even with relatively minor

changes in the extent of embolization,many physicians believe that the post-procedural pain is less severe than inthe past.

What is missing from all these the-ories are data from properly designedstudies to support them. We are near-ing completion of a study we hopewill test the effect of embolic materialon recovery from the procedure. It is arandomized comparison of PVA ver-sus tris-acryl microspheres, with out-come measures of pain, duration ofrecovery, short-term complications,and effectiveness of embolization asmeasured by the rate of fibroidinfarction.

While we await data, how shouldwe proceed? What should be the end-point of embolization? Based on ourown results to date, there appears tobe no advantage to the use of supple-mental embolic materials, and theycertainly have never been shown to benecessary. They merely ensure a fur-ther decrease in perfusion to theuterus and may result in the perma-nent occlusion of the vessel. Not onlyis this likely to be more painful, butalso, in a small proportion of cases, itmay result in persisting ischemic pain,myometrial injury, or endometrial in-jury. None of these benefit the patient.It is also important to consider the po-tential need for repeat embolization.Some fibroids do not infarct com-pletely (even with complete occlusionas an endpoint), and the residual via-ble tissue can regrow, causing recur-rent symptoms (16). In addition, wehave now performed repeat treatmentin three patients who developed newfibroids 4–6 years after the initial em-bolization. This should not be surpris-ing given the frequency at which pa-tients develop new fibroids aftersuccessful myomectomy. If the uterinearteries are occluded, repeat treatmentwill be possible only via the ovarianarteries, potentially putting ovarianfunction at risk.

Even without supplemental em-bolic materials, embolization to the ex-tent of complete occlusion (no flow) isprobably unnecessary for effectivetreatment, even when using PVA.Complete occlusion with tris-acryl mi-crospheres is not only unnecessary butmay be dangerous. Because micro-spheres pack more tightly than PVAdoes, it leaves less room for recanali-zation and, as a result, overemboliza-

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tion with microspheres may result inuterine injury. Regardless of whichembolic agent we use, we always leaveat least slight forward flow. In our ex-perience, it is effective and results inonly moderately intense pain in mostpatients for 2–8 hours after the proce-dure, at which time it begins tosubside.

If incomplete occlusion is used, it isimportant to avoid underembolizationClearly, if one expects some degree ofrecanalization and collateral flow toprevent severe pain, then the emboli-zation must be sufficient to ensure oc-clusion of the fibroid-feeding branchesand to prevent their reopening. Asmentioned in an earlier commentary(17), avoiding a false endpoint may beaided by slowing the rate of emboliza-tion, avoiding spasm by the routineuse of microcatheters, and waiting 5minutes at the apparent conclusion ofthe embolization to be certain thatearly recanalization does not occur.

Beyond limiting the extent of theembolization, effective pain manage-ment is the key to a tolerable recovery.Without pain management, surgerywould be very painful as well. Thereare a wide variety of approaches topain management after embolization.A full discussion is beyond the scopeof this commentary, but all successfulplans have several things in common.First, the pain protocol must be clearlydefined (preferably written), and allthe involved personnel must betrained so that each understands his orher role in it. This is particularly im-portant for nursing personnel on thepostprocedure care unit. Even in ourinstitution, where we have consider-able experience, pain control will oftendeteriorate with an inexperiencednurse or on a unit on which the per-sonnel are not accustomed to caringfor these patients. The protocol shouldinclude the routine plan for parenteralanalgesics, the transition to oral med-ication, and the outpatient regimen.Second, the pain protocol must be inplace and ready to implement at theconclusion of the procedure. In fact,many physicians begin giving painmedications at the beginning of theprocedure. Third, the protocol musthave flexibility, and a qualified pro-vider (physician, physician’s assistant,or nurse practitioner) must be avail-able in the first several hours to inter-vene and increase or change the med-

ications if pain control is not adequate.Fourth, the plan must include provi-sions for nausea control, which, in ourown practice, has been as much of aproblem as pain. Finally, a set of writ-ten discharge instructions that explainin detail the expected course duringthe first 7–10 postoperative days is es-sential. It should include the protocolfor taking the medications, potentialside effects, activity and dietary re-strictions, and common problems thatmay occur. A qualified provider mustbe available by pager to respond topatient problems and questions.

Some groups use epidural or spinalanalgesia for in-hospital pain manage-ment. With the move toward less-ex-tensive embolization, we and othershave abandoned that approach anduse a combination of intravenous nar-cotics and nonsteroidal antiinflamma-tory drugs for the first 24 hours. Ifintravenous narcotics are used, it isvery important that they be providedby a patient-controlled analgesiapump, which has been demonstratedto provide superior pain control com-pared with nurse-administered medi-cations. Most practices that hospitalizepatients overnight switch to oral med-ications the morning after the proce-dure. Most prescribe oral nonsteroidalantiinflammatory drugs around theclock for several days after discharge,with oral narcotics on an as-neededbasis. We provide our patients with anoral antinausea medication as well.There are some practices that havesuccessfully implemented outpatientprograms without overnight hospital-ization (18), and even some that haveused an all-oral medication regimen.

Regardless of the details of theplan, it must adapt to the experience ofyour patients if you are to succeed.Careful technique of embolization andclose attention to the needs of the pa-tient during the entire course of recov-ery is the only path to a “tolerable”procedure. Uterine embolizationgained the reputation as a painful pro-cedure at a time when these issueswere not addressed. That reputationdoes not reflect the experience of mostpatients when they are treated basedon our current knowledge of this ther-apy. With appropriate understandingof the physiology of embolization, wecan provide a safe, effective, and verytolerable procedure for our patients.

References1. Andersen PE, Lund N, Justesen P,

Munk T, Elle B, Floridon C. Uterineartery embolization for symptomaticuterine fibroids: initial success andshort-term results. Acta Radiol 2001;42:234–238.

2. Brunereau L, Herbreteau D, Gallas S, etal. Uterine artery embolization in theprimary treatment of uterine leiomyo-mas: technical features and prospectivefollow-up with clinical and sono-graphic examination in 58 patients.AJR Am J Roentgenol 2000; 175:1267–1272.

3. Goodwin S, McLucas B, Lee M, et al.Uterine artery embolization for thetreatment of uterine leiomyomata:midterm results. J Vasc Interv Radiol1999; 10:1159–1165.

4. Hutchins F, Worthington-Kirsch R,Berkowitz R. Selective uterine arteryembolization as primary treatment forsymptomatic leiomyomata uteri. J AmAssoc Gynecol Laparosc 1999; 6:279–284.

5. Pelage J, LeDref O, Soyer P, et al. Fi-broid-related menorrhagia: treatmentwith superselective embolization of theuterine arteries and midterm follow-up. Radiology 2000; 215:428–431.

6. Ravina J, Ciraru-Vigneron N, AymardA, Ledreff O, Herbreteau D, Merland J.Arterial embolization of uterine myo-mata: results of 184 cases. Presented atthe Society of Minimally Invasive Ther-apy; September 4, 1998; London, En-gland.

7. Walker WJ, Pelage J. Uterine arteryembolisation for symptomatic fibroids:clinical results in 400 women with im-aging follow up. Br J Obstet Gynaecol2002; 109:1262–1272.

8. Pron G, Mocarski E, Bennett J, et al.Tolerance, hospital stay, and recoveryafter uterine artery embolization for fi-broids: The Ontario Uterine FibroidEmbolization Trial. J Vasc Interv Ra-diol 2003; 14:1243–1250.

9. Roth A, Spies J, Walsh S, Wood B, Go-mez-Jorge J, Levy E. Pain after uter-ine artery embolization for leiomyoma-ta: can its severity be predicted anddoes the severity predict outcome? JVasc Interv Radiol 2000; 11:1047–1052.

10. Pron G, Bennett J, Common A, Wall J,Asch M, Sniderman K. The OntarioUterine Fibroid Embolization Trial.Part 2: uterine fibroid reduction andsymptom relief after uterine artery em-bolization for fibroids. Fertil Steril2003; 79:120–127.

11. Spies J, Ascher SA, Roth AR, Kim J,Levy EB, Gomez-Jorge J. Uterine ar-tery embolization for leiomyomata.Obstet Gynecol 2001; 98:29–34.

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12. Spies J, Spector A, Roth A, Baker C,Mauro L, Murphy-Skryzniarz K.Complications after uterine artery em-bolization for leiomyomata. Obstet Gy-necol 2002; 100:873–880.

13. Siskin G, Englander M, Stainken B,Ahn J, Dowling K, Dolen E. Embolicagents used for uterine fibroid emboli-zation. AJR Am J Roentgenol 2000; 175:767–773.

14. Spies J, Benenati J, Worthington-KirschR, Pelage J. Initial US. Experience us-

ing tris-acryl gelatin microspheres foruterine artery embolization for leiomy-omata. J Vasc Interv Radiol 2001; 12:1059–1063.

15. Banovac F, Ascher S, Jones D, Black M,Smith J, Spies JB. MR imaging out-come after uterine artery embolizationfor leiomyomata using tris-acryl gela-tin microspheres. J Vasc Interv Radiol2002; 13:681–687.

16. Pelage J, Gouou N, Jha R, Ascher S,Spies J. Long-term imaging outcome

after uterine embolization for fibroids.Radiology 2003 (in press).

17. Spies J. Commentary: uterine arteryembolization for fibroids: understand-ing the technical causes of failure. JVasc Interv Radiol 2003;14:11–14.

18. Siskin G, Stainken B, Dowling K, MeoP, Ahn J, Dolen E. Outpatient uterineartery embolization for symptomaticuterine fibroids: experience in 49 pa-tients. J Vasc Interv Radiol 2000; 11:305–311.

1222 • Commentary: Short-term Outcomes and Recovery after UAE October 2003 JVIR