Interventional Radiology: Fibroids and Uterine Artery Embolization
Guest: Dr. Bayne Selby – Radiology, MUSC
Host: Dr. Linda Austin – Psychiatry, MUSC
Dr. Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. Bayne Selby, who is Professor of Radiology and an interventional radiologist here at the MUSC. Dr. Selby, you’ve been working with a very interesting new procedure: uterine artery embolization. Tell us about that procedure.
Dr. Bayne Selby: Well, that’s been one of the nice additions to our field; procedures that we do in interventional radiology, in about the last 15 years. I guess I have to clarify that. Actually, the procedure isn’t an addition. It’s what we do the procedure for. And what we’re specifically talking about here is doing uterine artery embolization for fibroids. Fibroids are benign tumors of the uterus that are very common in women, particularly in African-American women. So, here in South Carolina, we see a lot of women that have them.
Many women will remain asymptomatic; they won’t have any symptoms, but many will. And, usually, when they get into their forties, they [fibroids] can cause problems of excessive bleeding, or pain, or pressure, or other problems with urination, and they’ll need a treatment. Now, the treatment used to be hysterectomy; still a good treatment, which is, of course, surgical removal of the uterus. But that’s a fairly big operation. And, many people think it was one of those operations that was, maybe, a little overdone during most of the twentieth century. So, people have been looking for some less invasive alternatives.
There was a doctor in Paris, in about 1990, who was a gynecologist. He was working with his interventional radiologist and said: maybe if you blocked up the blood vessels to the uterus before I did a hysterectomy for fibroids, I’d have less bleeding at the time of surgery. And it was one of those little serendipitous incidents. When they blocked the blood vessels to the uterus; to the fibroids, a lot of the women said, you know, I don’t think I need that surgery anymore; it seems like all my symptoms are better.
I sort of got a little ahead of the game. The reason I say uterine artery embolization isn’t new is because we’ve been doing that for quite awhile. Usually, when new procedures come along, there’s something truly new about it. Somebody has invented a new medical device, or we’ve figured out a new way to do things. But, actually, blocking the arteries going to the uterus with little particles is something we’ve been doing this since the mid 1970s. When we first did it, however, we would do it for serious acute bleeding episodes, for instance, a woman who had just had a baby and was still bleeding; at that point, it’s very difficult to operate to stop the bleeding, or woman who has just had a hysterectomy and is still bleeding. We would be asked to go in and block the blood vessels.
We do this by putting a little tube into the blood vessels; thread it up into the arteries going to the uterus, and inject little particles. We’ve been doing this for over 30 years now; blocking up people who were, really, bleeding to death. We were doing it as a life-saving procedure.
And then when these folks over in France realized, hey, we can use it just to take care of these benign tumors as well, immediately there was interest. A number of centers started investigating this. The investigation period was during most of the 1990s, and it showed it was a good procedure. And we started doing it here, probably, in about 1999. And we’ve been doing it ever since.
Dr. Linda Austin: So, it decreases bleeding by, what, a fraction, or 100 percent? What percent would you estimate, typically?
Dr. Bayne Selby: When we talk to women who are considering this alternative to hysterectomy, their most common symptom is excessive bleeding; usually during their cycle. We give them a couple sets of numbers. The first one: What is our technical success? And that means, at the time we finish the procedure, we say that everything went well. And because we’ve been doing this for a long time; although it requires training, it’s essentially 100 percent. We’re able to get in there and block these blood vessels.
Then, we use a term we call clinical success rate, which is really the question you asked, which is: how many women say, well, that was great; I don’t need a hysterectomy, or anything else? And that’s about 90 percent. So, about ten percent of the women still have some symptoms. Now, it doesn’t mean that their symptoms are bad enough to require a hysterectomy. But about ten percent of the women will still say that they have some symptoms; not always bleeding. It may be just that they have to go to the bathroom frequently, and they might think that’s still because of a fibroid.
In fact, when we do this procedure, we take the blood supply away from the fibroid so that they die right where they are, and they shrink down. But they don’t go away completely. So, they’ll shrink to about 50 percent by volume. We get very good results with stopping the bleeding, because fibroids not only take up space, they function. So, once we’ve taken away their blood supply, they don’t contribute to the bleeding anymore. However, they shrink about 50 by volume, so you still have a little residual mass that’s in there that could, potentially, cause some symptoms. So, bottom line, 90 percent of the people say it’s a good procedure.
Dr. Linda Austin: Now, I’ve never seen this done, and I’ve always been curious. When you talk about this, you make it sound very easy. You just thread up a little catheter, or little scope, and it goes up into the blood vessel, and then you just kind of hook it into the uterine artery. How do you actually navigate that though? How do you get the tip to go in the artery and make the right bends as you’re going along?
Dr. Bayne Selby: There are really two parts to that, I think. The most important thing, and the reason that we’re interventional radiologists, is that we use imaging guidance for every procedure we do. So, we can see where we’re going. So, they puncture into a blood vessel; we don’t need an x-ray for that, but once we start to thread out little catheter through the blood vessels, we have to see where we’re going, and we can use a fluoroscope, which is real time x-ray. And for other procedures, we use other, different, kinds of imaging guidance. Without the imaging guidance, we couldn’t do what we do.
The second part of your question is one that I don’t quite know how to answer, but I think about it a lot. When we tell people that the procedure is fairly simple and we can have 100 percent technical success in doing it, we still want to be humble. We say: we can do that, and it’s not that difficult for us. But, of course, it’s not that difficult for us because we undergo many years of training to do this. So, it’s pretty much like anything else. If people weren’t trained to do this procedure, they would think it’s impossible. But if you’re trained to do the procedure, you find it to be fairly straight forward.
Dr. Linda Austin: So, is the tip of the catheter curved, and do you actually turn it so that the curve goes in the direction you want it to? What is the technique itself?
Dr. Bayne Selby: Probably the underlying principle of how we get around is a coaxial system, which consists of the catheter; the tube, and a little guidewire, so we can get through. Anyone who that has a procedure, or watched us do a procedure, what you would really see is us continually using many differently shaped catheters and many different, specially shaped; with differing degrees of stiffness, guidewires, which allow us to go to different places.
Dr. Linda Austin: Do you continually pull the guidewire out and put something in that will go in the direction you want it to? Is that what happens?
Dr. Bayne Selby: Pretty much. It’s basically a repeating process. We will gain access to the blood vessel by sliding a little wire into it. Then, we’ll slide our tube over it, take the wire out, and inject some contrast material. Then, we can see the outline of the blood vessel, and we’ll see where we are. If we’re where we want to be, we do whatever next step we’re going to do. If we need to go further, we inject some more contrast, see where the branches are, then put a guidewire back in and feed the guidewire. We can steer the catheter and the guidewires.
If you came to one of our rooms, you would find hundreds of these catheters, or tubes; all with different shapes and thicknesses, and other attributes. But, basically, it’s just a continuous catheter and guidewire exchange until we get to where we want to go. Once we get to where we want to go, we take the wire out. And then we can do whatever procedure we’re doing. Sometimes we’re opening up blood vessels, and we use a special catheter, or tube, that has a balloon on it, or stint. But here, we’re trying to close up a blood vessel, so we inject these tiny particles through it once we have it in the right place, and it just blocks the small arteries that go to the fibroids.
Dr. Linda Austin: Tell us about the recovery following uterine artery embolization.
Dr. Bayne Selby: Well, the first thing is that it’s a lot simpler than major surgery. The thing that we say immediately after that is: it isn’t a simple little outpatient procedure. And that’s not because of the way we poke into the artery, but because of what we’ve actually done, which is that we’ve taken the blood supply away from the fibroids. And fibroids don’t like that; just like most other parts of your body don’t like it when they get their blood supply taken away. So, you get a lot of cramping.
When people first started doing this procedure, they would try to do it as an outpatient. And some women, who were pretty stoic, were able to get through it at home, but others came back and said, you know, I think you need to help me through this. So, we now have that pretty well worked out. If we did the procedure here, we would go ahead and do the procedure and start you on some pain medication; hook you up to a little pain pump immediately after the procedure that you could control. And that initial crampy period only lasts for about 8 to 12 hours. So, we admit everybody, overnight, into the hospital, and then you can go home the next day. And by that time, you’re doing pretty well and you don’t need pain medication anymore. Of course, we give people prescriptions if they do need anything. And, I would say, we’re probably discharging 99.9 percent of all the people we do the next day.
Like all procedures, there are possible adverse outcomes. Even though we know exactly what we’re doing, you just never know how the body is going to react to things. So, for this particular procedure, it has less to do with a complication of putting the catheter in the wrong place, or some other technical error. That really doesn’t happen very frequently, if at all. What’s more likely is that different women will respond in different ways. There’s a small percentage of women who won’t get all the relief that they need, or they may develop an infection afterwards. So, about one to two percent of the women that have this procedure elect, ultimately, to go on and have a hysterectomy, which is sort of what they were trying to avoid in the first place. So, we kind of hate it when that happens. But it’s a very small percentage of the women that need to do that.
Dr. Linda Austin: Dr. Selby, thanks so much for talking with us today.
Dr. Bayne Selby: Thanks for having me.
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