Uterine artery embolisation for symptomatic adenomyosis--mid-term results.

PURPOSE: To evaluate the role of uterine artery embolisation (UAE) in the treatment of adenomyosis. MATERIALS AND METHODS: 27 women with symptomatic adenomyosis diagnosed on magnetic resonance imaging (MRI) underwent UAE between 1998 and 2004. Clinical evaluation using a standardised questionnaire was made at regular intervals after embolisation to assess patient outcome. RESULTS: The diagnosis of adenomyosis was confirmed histologically by transvaginal biopsy in 5 women. There were 14 women with associated uterine fibroids. Diffuse adenomyosis was identified in 18 women. A focal adenomyoma was present in another 8 women. In 1 patient adenomyosis was not classified. All patients except one underwent bilateral uterine artery embolisation. There was an initial favourable clinical response, with improvement of menorrhagia in 79% (13/16) of patients at 12 months. Follow-up data was available on a total of 14 patients at 2 and 3 years after embolisation. 45.5% (5/11) reported a deterioration in menorrhagia symptoms at 2 years. CONCLUSION: UAE for symptomatic adenomyosis is effective in the short-term but there is a high rate of recurrence of clinical symptoms 2 year following treatment.

Outcomes after unilateral uterine artery embolization: a retrospective review.

PURPOSE: Bilateral uterine artery embolization (UAE) is considered necessary to provide effective treatment for symptomatic uterine fibroids. Occasionally, only unilateral embolization is performed, and this study evaluates these outcomes. MATERIALS AND METHODS: As part of a prospective observational study of more than 1600 patients treated with UAE since 1996, there have been 48 patients in whom unilateral embolization has been performed. This study retrospectively reviews clinical response as assessed by our standard questionnaire and radiological response assessed by either magnetic resonance imaging or ultrasound. RESULTS: Two principal groups emerged: the largest, where only the dominant unilateral arterial supply was electively embolized (30 patients); and the second, where there was technical failure to catheterize the second uterine artery as a result of anatomical constraints (12 patients). Favorable clinical response with a reduction in menorrhagia at 1 year was seen in 85.7% (18/21) of those patients with a dominant arterial supply to the fibroid(s). In contrast, in those patients where there was technical failure to embolize one uterine artery, there was a high rate of clinical failure requiring further intervention in 58.3% (7/12). Comparison of the technical failure group with the dominant uterine artery group demonstrated a statistically significant (Fisher's exact test) difference in the proportion of patients with evidence of persistent fibroid vascularity (p < 0.001) and requiring repeat intervention (p < 0.01). CONCLUSION: We conclude that unilateral UAE can achieve a positive clinical result in the group of patients where there is a dominant unilateral artery supplying the fibroid(s), in contrast to the poor results seen following technical failure.

Long-term follow up of uterine artery embolisation--an effective alternative in the treatment of fibroids.

OBJECTIVES: To evaluate the long-term efficacy and complications of uterine artery embolisation (UAE) for treatment of symptomatic uterine fibroids. DESIGN: A prospective observational study. SETTING: A district general hospital and two private hospitals in the southeast of England. POPULATION: Women with symptomatic fibroids who had been offered surgical options for treatment. METHODS: Postal questionnaire follow up at 5-7 years to assess long-term clinical effects among women who had undergone UAE. MAIN OUTCOME MEASURES: The questionnaire was subdivided into sections dealing with menstrual flow, amenorrhoea and menopause, fibroid-related symptoms, fertility, vaginal discharge, sexual function, subsequent treatments for fibroids and satisfaction with the procedure. RESULTS: A total of 258 women were identified as being between 5 and 7 years post-UAE and suitable for long-term follow up in October 2004. One hundred seventy-two completed questionnaires were analysed (67% response rate). Seventy-five percent of women still had either a return to normal or an improvement in menstrual flow compared with how they were prior to UAE. More than 80% of fibroid-related symptoms were still resolved or improved. Sixteen percent of women required further treatment for fibroids. Premature menopause directly following UAE occurred in only one woman in the study group. Eighty-eight percent of women were satisfied with the outcome of the procedure at 5-7 years and would choose it again or recommend it to others. CONCLUSIONS: These findings show that UAE is of benefit to women wishing to avoid hysterectomy and it carries a low risk of complications.

Pregnancy following uterine artery embolisation for symptomatic fibroids: a series of 26 completed pregnancies.

OBJECTIVES: To evaluate the outcome of pregnancies after uterine artery embolisation for uterine fibroids. DESIGN: Retrospective analysis of pregnancy subsequent to uterine artery embolisation by one interventional radiologist. SETTING: A UK District General Hospital. POPULATION: Twenty-nine pregnancies in 671 women who had undergone uterine artery embolisation. METHODS: Cases were identified by screening questionnaire and from the study database. Detailed information was collected by questionnaires, direct conversations with women and, when necessary, from hospital records. MAIN OUTCOME MEASURES: Pregnancy outcome, complications and neonatal outcomes. RESULTS: Of 26 completed pregnancies, detailed information was available for 24 and limited information for 2. Seven (27%) ended in miscarriage, there were two terminations and one ectopic pregnancy. Of 16 deliveries after 24 weeks, first and second trimester bleeding occurred in 40% and 33%, respectively, 4 (25%) had preterm deliveries and the caesarean section rate was 88%. Two (13%) women developed proteinuric hypertension and two others had preterm spontaneous rupture of the membranes. Fourteen of 16 cases were delivered by caesarean section. The rate of primary postpartum haemorrhage was 3/15 (20%). The mean birthweight of term babies was 3.39 kg (SD 0.64) and none required admission to neonatal intensive care. There was one (6.7%) case of fetal growth restriction. CONCLUSION: Although this study is relatively small, there is an increase in delivery by caesarean section. There does not appear to be any other major excess obstetric associated risk when the demographics of the population in question is considered.

Ovarian artery: angiographic appearance, embolization and relevance to uterine fibroid embolization.

PURPOSE: To describe the angiographic appearance of the ovarian artery and its main variations that may be relevant to uterine fibroid embolization. METHODS: The flush aortograms of 294 women who had been treated by uterine artery embolization for fibroids were reviewed. Significant arterial supply to the fibroid, and the origin and diameter of identified ovarian arteries were recorded. In patients with additional embolization of the ovarian artery, the follow-up evaluation also included hormonal levels and Doppler imaging of the ovaries. RESULTS: A total of 75 ovarian arteries were identified in 59 women (bilaterally in 16 women and unilaterally in 43 women). All ovarian arteries originated from the aorta below the level of the renal arteries with a characteristic tortuous course. Fifteen women had at least one enlarged ovarian artery supplying the fibroids. Fourteen women (14/15, 93%) presented at least one of the following factors: prior pelvic surgery, tubo-ovarian pathology or large fundal fibroids. CONCLUSION: We advocate the use of flush aortography in women with prior tubo-ovarian pathology or surgery or in cases of large fundal fibroids. In the case of an ovarian artery supply to the fibroids, superselective catheterization and embolization of the ovarian artery should be considered.

Estimation of effective vaccination rate: pertussis in New Zealand as a case study.

In some cases vaccination is unreliable. For example vaccination against pertussis has comparatively high level of primary and secondary failures. To evaluate efficiency of vaccination we introduce the idea of effective vaccination rate and suggest an approach to estimate it. We consider pertussis in New Zealand as a case study. The results indicate that the level of immunity failure for pertussis is considerably higher than was anticipated.

Uterine artery embolisation for symptomatic fibroids: clinical results in 400 women with imaging follow up.

OBJECTIVE: To evaluate the mid-term efficacy and complications of uterine artery embolisation in women with symptomatic fibroids. To assess reduction in uterine and dominant fibroid volumes using ultrasound and magnetic resonance imaging. DESIGN: Prospective observational single-centre study. SETTING: A district general hospital in Surrey and a private hospital in London. METHODS: Four hundred consecutive women were treated between December 1996 and February 2001. Indications for treatment were menorrhagia, menstrual pain, abdominal swelling or bloating and other pressure effects. Uterine artery embolisation was performed using polyvinyl alcohol particles and platinum coils. MAIN OUTCOME MEASURES: Imaging was performed before embolisation and at regular intervals thereafter. Clinical evaluation was made at regular intervals after embolisation to assess patient outcome. RESULTS: Bilateral uterine artery embolisation was achieved in 395 women, while 5 women had a unilateral procedure. With a mean clinical follow up of 16.7 months, menstrual bleeding was improved in 84% of women and menstrual pain was improved in 79%. Using ultrasound, the median uterine and dominant fibroid volumes before embolisation were 608 and 112 cc, respectively, and after embolisation 255 and 19 cc, respectively (P = .0001). Three (1%) infective complications requiring emergency hysterectomy occurred. Twenty-three (6%) patients had clinical failure or recurrence. Of these, nine (2%) had a hysterectomy. Twenty-six (7%) women had permanent amenorrhoea after embolisation including four patients under the age of 45 (2%). Of these, amenorrhea started between 4 and 18 months after embolisation, and only three had elevated follicle stimulating hormone levels when amenorrhea developed. Thirteen (4%) women had chronic vaginal discharge considered as a major irritant. Thirteen pregnancies occurred in 12 patients. Ninety-seven percent of women were pleased with the outcome and would recommend this treatment to others. CONCLUSIONS: Uterine artery embolisation is associated with a high clinical success rate and good fibroid volume reduction. Infective complications requiring hysterectomy, amenorrhoea under the age of 45 and chronic vaginal discharge may complicate the procedure.

Fibroid embolization.

The most common surgical treatment for fibroids is hysterectomy and approximately 30,000 are carried out annually in the UK for this condition. The operation, however, carries a significant complication rate. Since the first case was carried out in 1989 there has been increasing interest in the interventional radiological procedure called fibroid embolization where angiographic techniques are used to occlude the vascular supply of fibroids. This article is a review of the world experience of fibroid embolization, its development, techniques, indications, results and complications. So far evidence indicates very promising mid-term results but more long-term comprehensive data is needed from large trials.

Uterine artery embolisation for the treatment of symptomatic fibroids in 114 women: reduction in size of the fibroids and women's views of the success of the treatment.

OBJECTIVE: To assess the reduction in size of fibroids following uterine artery embolisation and to analyse women's views of the success of treatment. DESIGN: An uncontrolled case series of 114 consecutive women who underwent uterine artery embolisation for the treatment of fibroids over two years. SETTING: The Diagnostic and Interventional Radiology Department at The Royal Surrey County Hospital, Guildford, UK. METHODS: Bilateral uterine artery embolisation was performed for the treatment of symptomatic fibroids. Magnetic resonance imaging was carried out before and six months following embolisation. Women completed outcome questionnaires following their treatment. MAIN OUTCOME MEASURES: The sites. imaging signal characteristics and percentage reduction in the volume of three dominant fibroids were determined from the magnetic resonance scans. Outcome was measured by questionnaire. Women were asked whether their symptoms resolved completely, improved, remained unchanged or deteriorated. RESULTS: One hundred and sixty-five fibroids of 114 women (mean age 42) were analysed. Forty-five percent of women had complex fibroid masses and 50% had fibroids > or =8.5cm in diameter. The median reduction in the fibroid volume was 58%. The median reduction of the volume of complex fibroid masses, submucous fibroids, fibroids > or =8.5cm and fibroids with high and low signal on T2 weighted sequences were 58%, 63%, 50%, 62% and 51%, respectively. Ninety-one percent of the women's symptoms had resolved or improved following embolisation. DISCUSSION: The majority of women were satisfied with their outcome. We have shown that uterine artery embolisation is a successful treatment for symptomatic fibroids of all types, sizes and signal characteristics.

Pathologic features of uterine leiomyomas following uterine artery embolization.

Bilateral uterine artery embolization has recently been employed as an alternative to operational treatment of uterine leiomyomas. The pathologic features induced by uterine artery embolization have not been previously described in detail. Usually patients experience symptomatic improvement with a reduction in size of the leiomyomas. This report describes the pathologic features in a series of 10 uterine leiomyomas where tissue was available for histologic examination following uterine artery embolization. Characteristic histologic features within the leiomyomas included massive necrosis, sometimes with dystrophic calcification, vascular thrombosis, and intravascular foreign material that elicited a histiocytic and foreign-body giant cell reaction. In some cases, intravascular foreign material was present elsewhere in the myometrium, the cervix, or paraovarian region. In occasional cases, there were foci of myometrial necrosis and microabscess formation beyond the confines of the leiomyomas. Foci of extrauterine inflammation were also occasionally identified. Histopathologists should be aware of these findings because the use of uterine artery embolization will possibly become more widespread in the future.

The potential contribution of urban runoff to surface sediments of the Passaic River: sources and chemical characteristics.

Urban runoff has been reported as the second most frequent cause of surface water pollution in the United States. Due to the incidence of runoff in urban areas, it was of interest to estimate the impact runoff may have to recent sediment quality within the lower reaches of the Passaic River. Study objectives included i) review of recent urban runoff studies to determine the occurrence and pattern of distribution of chemicals in runoff; ii)comparison of the "fingerprints" from urban runoff studies to the contaminant distributions in surface sediments from the River; and iii) estimation of mass loadings to the surface sediments using surrogate data. The analyses showed that metals and PAH distributions in the sediments were similar to those observed in runoff from diverse locations, suggesting that urban runoff composition within the Passaic watershed is similar to other urban areas. Mass loading calculations demonstrated that urban runoff is a significant source of the metals observed in the sediments, and that PAH and DDT sediment loadings could, in some cases, be accounted for by urban runoff. Observed sediment loads for PCBs, however, were significantly higher than were estimated from urban runoff.

Uterine artery embolization for the treatment of uterine fibroids.

The first reported cases of uterine artery embolization in obstetric and gynaecological practice were carried out in the late 1970s. Recently, bilateral uterine artery embolization was used as a primary treatment for fibroids. Meticulous preoperative assessment is essential. The technique of uterine artery embolization involves the catheterization of both uterine arteries and the installation of tiny micro particles of polyvinyl alcohol. Following the procedure, post-procedural pain occurs within the first 24 h and most patients are advised to rest for 1 week. In the UCLA and RSCH series, three infective complications occurred leading to hysterectomy and some patients developed amenorrhoea. Average shrinkage of fibroids in the UCLA, RSCH and French series were 40%, 64% and 70%, respectively, with most patients losing their symptoms and being satisfied with the procedure. Meticulous pre-operative assessment is essential. At UCLA, 140 patients, and at RSCH, 96 patients have been embolized. To date in the UK, US and French series, fibroid growth has been arrested and new fibroids have not formed. However, long-term follow-up on a larger number of cases will be required before the role of uterine artery embolization in the gynaecologic therapeutic armamentarium can be fully defined.

Measles epidemics 1949-91: the impact of mass immunisation in New Zealand.

AIMS: Mass immunisation of children against measles was introduced in New Zealand in 1969. Although measles is not a notifiable illness in this country accurate hospital discharge data stratified by age and diagnosis are available. These were used to examine the impact of mass vaccination on measles epidemics. METHODS: Official public hospital discharge tables for the period 1949-92 were analysed. RESULTS: There were seven epidemics in the 20 year period from 1949-69 yielding an average interepidemic period of 2.86 years. Since 1969 epidemics have been separated by 3, 5, 3, 5 and 6 years. There has been no significant change in the number of patients discharged from hospitals in epidemic years since 1969. However, there has been a significant shift in their age distribution. Prior to 1969, in epidemic years, the proportion of patients with a discharge diagnosis of measles aged under 10 was 0.823, and aged 10-19 was 0.084. In 1991, the year of the last epidemic the corresponding figures were 0.643 and 0.28. CONCLUSION: These results are predictable from standard compartment models. From these models a simple equilibrium relationship is derived between the interepidemic period (Ti) and a change in the vaccination rate (Pi). This is T2 = T1 (1-p1)/(1-p2) and it is consistent with the New Zealand data. It is noted that measles epidemics could be prevented by periodic boosters or population based revaccination campaigns that prevented the number of susceptibles ever attaining the epidemic threshold.

Long-term results of a single protocol for thrombolysis in acute lower-limb ischaemia.

In a prospective study, 78 of 157 patients with acute lower-limb ischaemia were considered suitable for thrombolysis. The immediate and 4-year results of 52 patients managed by a single protocol are reported. Of 34 patients alive at 4 years, 23 had limb salvage. Initial treatment produced effective lysis in 38 patients (73 per cent) with significant benefit in 35 (67 per cent); that benefit was sustained for a minimum of 4 years in 30 patients (58 per cent). Seven of the 18 deaths by 4 years occurred within 30 days. Amputation was carried out in six patients within 30 days and in five during the next 4 years. Delayed amputation followed persistent distal occlusion or progression of distal disease. No death or amputation was caused by complication of treatment. In selected patients the risks of thrombolysis can be reduced to an acceptable level by personal supervision and a strict protocol. In survivors, limb salvage is generally sustained for at least 4 years.