DOI: 10.1148/rg.255045019
Uterine Artery Embolization for Leiomyomas: Pre- and Postprocedural Evaluation with US1
Sangeet Ghai, MD,
Dheeraj K. Rajan, MD, FRCPC, FSIR,
Matthew S. Benjamin, MD,
Murray R. Asch, MD, FRCPC and
Sandeep Ghai, MD
1 From the Divisions of Vascular and Interventional Radiology (S.G., D.K.R., M.S.B., M.R.A.) and Women’s Imaging (S.G.), Department of Medical Imaging, Toronto General Hospital, University Health Network–Mount Sinai Hospital, University of Toronto, 585 University Ave, NCSB 1C-553, Toronto, Ontario, Canada M5G 2N2. Presented as an education exhibit at the 2003 RSNA Annual Meeting. Received February 16, 2004; revision requested June 17 and received January 3, 2005; accepted January 10. All authors have no financial relationships to disclose.
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Figure 1. Drawing illustrates the different locations of fibroids. (Courtesy of James B. Spies, MD, and David Klemm, Georgetown University Medical Center, Washington, DC.)
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Figure 2a. (a, b) Submucosal fibroid. Transverse transvaginal US image (a) and sonohysterogram (b) depict a large submucosal fibroid (F). (c) Subserosal pedunculated fibroids. Axial transabdominal US image shows subserosal pedunculated fibroids (F). UT = uterus.
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Figure 2b. (a, b) Submucosal fibroid. Transverse transvaginal US image (a) and sonohysterogram (b) depict a large submucosal fibroid (F). (c) Subserosal pedunculated fibroids. Axial transabdominal US image shows subserosal pedunculated fibroids (F). UT = uterus.
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Figure 2c. (a, b) Submucosal fibroid. Transverse transvaginal US image (a) and sonohysterogram (b) depict a large submucosal fibroid (F). (c) Subserosal pedunculated fibroids. Axial transabdominal US image shows subserosal pedunculated fibroids (F). UT = uterus.
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Figure 3a. Adenomyosis in a 34-year-old woman with infertility. Sagittal (a) and coronal (b) T2-weighted MR images of the uterus show indistinct zonal anatomy with widening of the junctional zone (arrows).
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Figure 3b. Adenomyosis in a 34-year-old woman with infertility. Sagittal (a) and coronal (b) T2-weighted MR images of the uterus show indistinct zonal anatomy with widening of the junctional zone (arrows).
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Figure 4a. Adenomyosis in a 47-year-old woman with menorrhagia and pelvic pain. (a) Sagittal transvaginal US image demonstrates an enlarged, globular, diffusely heterogeneous uterus (cursors), a finding that is consistent with adenomyosis. (b, c) Axial T1-weighted (b) and T2-weighted (c) MR images show multiple punctate foci of high signal intensity within the myometrium (arrow), findings that are also consistent with adenomyosis.
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Figure 4b. Adenomyosis in a 47-year-old woman with menorrhagia and pelvic pain. (a) Sagittal transvaginal US image demonstrates an enlarged, globular, diffusely heterogeneous uterus (cursors), a finding that is consistent with adenomyosis. (b, c) Axial T1-weighted (b) and T2-weighted (c) MR images show multiple punctate foci of high signal intensity within the myometrium (arrow), findings that are also consistent with adenomyosis.
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Figure 4c. Adenomyosis in a 47-year-old woman with menorrhagia and pelvic pain. (a) Sagittal transvaginal US image demonstrates an enlarged, globular, diffusely heterogeneous uterus (cursors), a finding that is consistent with adenomyosis. (b, c) Axial T1-weighted (b) and T2-weighted (c) MR images show multiple punctate foci of high signal intensity within the myometrium (arrow), findings that are also consistent with adenomyosis.
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Figure 5a. Endometrioma in a 39-year-old woman with infertility and pelvic pain. (a) Transverse transvaginal US image demonstrates the typical appearance of an endometrioma: a unilocular cyst (C) with low-level echoes, which in this case obscures the right ovary. UT = uterus. (b) Axial T1-weighted MR image of the pelvis shows a high-signal-intensity right adnexal mass (C), a finding that is consistent with an endometrioma. Note also the large simple cyst arising from the left ovary (*).
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Figure 5b. Endometrioma in a 39-year-old woman with infertility and pelvic pain. (a) Transverse transvaginal US image demonstrates the typical appearance of an endometrioma: a unilocular cyst (C) with low-level echoes, which in this case obscures the right ovary. UT = uterus. (b) Axial T1-weighted MR image of the pelvis shows a high-signal-intensity right adnexal mass (C), a finding that is consistent with an endometrioma. Note also the large simple cyst arising from the left ovary (*).
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Figure 6a. Fibroid size reduction following UAE in a 41-year-old woman. (a) Sagittal transabdominal US image obtained prior to UAE shows an 11-cm posterior intramural uterine fibroid (cursors). (b) On a follow-up sagittal transabdominal US image obtained 3 months after UAE, the fibroid measures 9 cm (cursors). (c) On a follow-up axial transabdominal US image obtained 7 months after UAE, the fibroid measures 4 cm (cursors).
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Figure 6b. Fibroid size reduction following UAE in a 41-year-old woman. (a) Sagittal transabdominal US image obtained prior to UAE shows an 11-cm posterior intramural uterine fibroid (cursors). (b) On a follow-up sagittal transabdominal US image obtained 3 months after UAE, the fibroid measures 9 cm (cursors). (c) On a follow-up axial transabdominal US image obtained 7 months after UAE, the fibroid measures 4 cm (cursors).
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Figure 6c. Fibroid size reduction following UAE in a 41-year-old woman. (a) Sagittal transabdominal US image obtained prior to UAE shows an 11-cm posterior intramural uterine fibroid (cursors). (b) On a follow-up sagittal transabdominal US image obtained 3 months after UAE, the fibroid measures 9 cm (cursors). (c) On a follow-up axial transabdominal US image obtained 7 months after UAE, the fibroid measures 4 cm (cursors).
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Figure 7a. Peripheral fibroid calcification following UAE in a 50-year-old woman. (a, b) Axial transabdominal US images obtained prior to UAE demonstrate multiple intramural (M) and subserosal (S) fibroids in different locations (cursors). (c, d) On US images obtained 3 years after UAE, the fibroids are hypoechoic with decreased volumes (cursors in c). Note also the hyperechoic rim around the involuted fibroids with distal shadowing (arrows), findings that are consistent with calcification and that mimic the appearance of a fetal head.
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Figure 7b. Peripheral fibroid calcification following UAE in a 50-year-old woman. (a, b) Axial transabdominal US images obtained prior to UAE demonstrate multiple intramural (M) and subserosal (S) fibroids in different locations (cursors). (c, d) On US images obtained 3 years after UAE, the fibroids are hypoechoic with decreased volumes (cursors in c). Note also the hyperechoic rim around the involuted fibroids with distal shadowing (arrows), findings that are consistent with calcification and that mimic the appearance of a fetal head.
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Figure 7c. Peripheral fibroid calcification following UAE in a 50-year-old woman. (a, b) Axial transabdominal US images obtained prior to UAE demonstrate multiple intramural (M) and subserosal (S) fibroids in different locations (cursors). (c, d) On US images obtained 3 years after UAE, the fibroids are hypoechoic with decreased volumes (cursors in c). Note also the hyperechoic rim around the involuted fibroids with distal shadowing (arrows), findings that are consistent with calcification and that mimic the appearance of a fetal head.
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Figure 7d. Peripheral fibroid calcification following UAE in a 50-year-old woman. (a, b) Axial transabdominal US images obtained prior to UAE demonstrate multiple intramural (M) and subserosal (S) fibroids in different locations (cursors). (c, d) On US images obtained 3 years after UAE, the fibroids are hypoechoic with decreased volumes (cursors in c). Note also the hyperechoic rim around the involuted fibroids with distal shadowing (arrows), findings that are consistent with calcification and that mimic the appearance of a fetal head.
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Figure 8a. Peripheral fibroid calcification following UAE in a 47-year-old woman. (a) Axial transabdominal US image obtained prior to UAE shows a 3.2-cm subserosal fibroid (cursors). (b) Axial US image obtained 7 months after UAE shows a decrease in the volume of the fibroid (cursors), which is now involuted and measures 1.9 cm, with a hyperechoic calcific rim at the margin (arrow).
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Figure 8b. Peripheral fibroid calcification following UAE in a 47-year-old woman. (a) Axial transabdominal US image obtained prior to UAE shows a 3.2-cm subserosal fibroid (cursors). (b) Axial US image obtained 7 months after UAE shows a decrease in the volume of the fibroid (cursors), which is now involuted and measures 1.9 cm, with a hyperechoic calcific rim at the margin (arrow).
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Figure 9a. Intraparenchymal gas within a fibroid following UAE. (a, b) Axial transabdominal US image obtained prior to UAE (a) reveals a large, 11-cm intramural fibroid (cursors). Follow-up sagittal transvaginal US image obtained 4 months after UAE (b) shows a decrease in the size of the fibroid (cursors), which now measures 7 cm. Note also the multiple focal bright areas (arrows) with reverberation artifacts representing intraparenchymal gas. The patient was asymptomatic. (c) Computed tomographic (CT) scan of the pelvis obtained 2 months after UAE in a different patient demonstrates large cavitating fibroids (F). Note the air within the fibroids (arrows), a finding that is consistent with necrosis.
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Figure 9b. Intraparenchymal gas within a fibroid following UAE. (a, b) Axial transabdominal US image obtained prior to UAE (a) reveals a large, 11-cm intramural fibroid (cursors). Follow-up sagittal transvaginal US image obtained 4 months after UAE (b) shows a decrease in the size of the fibroid (cursors), which now measures 7 cm. Note also the multiple focal bright areas (arrows) with reverberation artifacts representing intraparenchymal gas. The patient was asymptomatic. (c) Computed tomographic (CT) scan of the pelvis obtained 2 months after UAE in a different patient demonstrates large cavitating fibroids (F). Note the air within the fibroids (arrows), a finding that is consistent with necrosis.
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Figure 9c. Intraparenchymal gas within a fibroid following UAE. (a, b) Axial transabdominal US image obtained prior to UAE (a) reveals a large, 11-cm intramural fibroid (cursors). Follow-up sagittal transvaginal US image obtained 4 months after UAE (b) shows a decrease in the size of the fibroid (cursors), which now measures 7 cm. Note also the multiple focal bright areas (arrows) with reverberation artifacts representing intraparenchymal gas. The patient was asymptomatic. (c) Computed tomographic (CT) scan of the pelvis obtained 2 months after UAE in a different patient demonstrates large cavitating fibroids (F). Note the air within the fibroids (arrows), a finding that is consistent with necrosis.
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Figure 10a. Embolic particles and organized clot within the uterine arteries. (a) Follow-up sagittal transabdominal US image obtained 6 months after UAE in a 51-year-old woman shows a stagnant echogenic column within a tortuous uterine artery (arrow). (b) Follow-up sagittal transvaginal US image obtained 4 months after UAE in a 40-year-old woman shows a similar-appearing echogenic column within a uterine artery (arrow).
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Figure 10b. Embolic particles and organized clot within the uterine arteries. (a) Follow-up sagittal transabdominal US image obtained 6 months after UAE in a 51-year-old woman shows a stagnant echogenic column within a tortuous uterine artery (arrow). (b) Follow-up sagittal transvaginal US image obtained 4 months after UAE in a 40-year-old woman shows a similar-appearing echogenic column within a uterine artery (arrow).
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Figure 11. Absence of intrafibroid vascularity following UAE in a 35-year-old woman. Transverse transvaginal color Doppler US image obtained 6 months after UAE shows an intramural fibroid (F). Note the absence of intrafibroid vascularity, with persistence of flow within the perifibroid vessels.
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Figure 12. Persistence of intrafibroid and perifibroid vessels following UAE in a 47-year-old woman. Transverse transvaginal duplex color power Doppler US image obtained 2 months after UAE shows persistent perifibroid and intrafibroid vessels. However, the fibroid had decreased in volume compared with its preembolization size.
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Figure 13a. Fibroid expulsion in a 48-year-old woman. (a, b) Transverse (a) and sagittal (b) transvaginal US images obtained prior to UAE show a large intramural fibroid (cursors) with a submucosal component and a normal cervical canal (C). Two months after undergoing UAE, the patient presented with complaints of pain and vaginal bleeding. (c, d) Sagittal transvaginal US images demonstrate the large fibroid (arrows) to be partially expulsed and now present within the endocervical canal. (e) Sagittal transvaginal US image obtained 6 months after UAE demonstrates a normal-appearing uterus with no fibroid in an intramural-submucosal location or within the endocervical canal. The patient provided a history of passing tissue per vaginum shortly after the previous US study.
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Figure 13b. Fibroid expulsion in a 48-year-old woman. (a, b) Transverse (a) and sagittal (b) transvaginal US images obtained prior to UAE show a large intramural fibroid (cursors) with a submucosal component and a normal cervical canal (C). Two months after undergoing UAE, the patient presented with complaints of pain and vaginal bleeding. (c, d) Sagittal transvaginal US images demonstrate the large fibroid (arrows) to be partially expulsed and now present within the endocervical canal. (e) Sagittal transvaginal US image obtained 6 months after UAE demonstrates a normal-appearing uterus with no fibroid in an intramural-submucosal location or within the endocervical canal. The patient provided a history of passing tissue per vaginum shortly after the previous US study.
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Figure 13c. Fibroid expulsion in a 48-year-old woman. (a, b) Transverse (a) and sagittal (b) transvaginal US images obtained prior to UAE show a large intramural fibroid (cursors) with a submucosal component and a normal cervical canal (C). Two months after undergoing UAE, the patient presented with complaints of pain and vaginal bleeding. (c, d) Sagittal transvaginal US images demonstrate the large fibroid (arrows) to be partially expulsed and now present within the endocervical canal. (e) Sagittal transvaginal US image obtained 6 months after UAE demonstrates a normal-appearing uterus with no fibroid in an intramural-submucosal location or within the endocervical canal. The patient provided a history of passing tissue per vaginum shortly after the previous US study.
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Figure 13d. Fibroid expulsion in a 48-year-old woman. (a, b) Transverse (a) and sagittal (b) transvaginal US images obtained prior to UAE show a large intramural fibroid (cursors) with a submucosal component and a normal cervical canal (C). Two months after undergoing UAE, the patient presented with complaints of pain and vaginal bleeding. (c, d) Sagittal transvaginal US images demonstrate the large fibroid (arrows) to be partially expulsed and now present within the endocervical canal. (e) Sagittal transvaginal US image obtained 6 months after UAE demonstrates a normal-appearing uterus with no fibroid in an intramural-submucosal location or within the endocervical canal. The patient provided a history of passing tissue per vaginum shortly after the previous US study.
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Figure 13e. Fibroid expulsion in a 48-year-old woman. (a, b) Transverse (a) and sagittal (b) transvaginal US images obtained prior to UAE show a large intramural fibroid (cursors) with a submucosal component and a normal cervical canal (C). Two months after undergoing UAE, the patient presented with complaints of pain and vaginal bleeding. (c, d) Sagittal transvaginal US images demonstrate the large fibroid (arrows) to be partially expulsed and now present within the endocervical canal. (e) Sagittal transvaginal US image obtained 6 months after UAE demonstrates a normal-appearing uterus with no fibroid in an intramural-submucosal location or within the endocervical canal. The patient provided a history of passing tissue per vaginum shortly after the previous US study.
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Figure 14a. Endometritis in a 35-year-old woman who presented with fever and vaginal discharge 4 weeks after undergoing UAE. Sagittal transabdominal (a) and transvaginal (b) US images show multiple echogenic foci (arrows) with reverberation artifacts, findings that represent gas within a thickened endometrium.
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Figure 14b. Endometritis in a 35-year-old woman who presented with fever and vaginal discharge 4 weeks after undergoing UAE. Sagittal transabdominal (a) and transvaginal (b) US images show multiple echogenic foci (arrows) with reverberation artifacts, findings that represent gas within a thickened endometrium.
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Figure 15a. Uterine abscess in a 51-year-old woman with septicemia. The patient had undergone UAE 3 months earlier. (a) Axial transabdominal US image of the uterus shows a large uterine abscess (cursors) with diffuse hyperechoic foci (arrow), findings that are consistent with gas. (b, c) CT scans obtained at different levels through the uterus help confirm a large uterine abscess with an air-fluid level (arrow in b). The patient subsequently underwent hysterectomy.
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Figure 15b. Uterine abscess in a 51-year-old woman with septicemia. The patient had undergone UAE 3 months earlier. (a) Axial transabdominal US image of the uterus shows a large uterine abscess (cursors) with diffuse hyperechoic foci (arrow), findings that are consistent with gas. (b, c) CT scans obtained at different levels through the uterus help confirm a large uterine abscess with an air-fluid level (arrow in b). The patient subsequently underwent hysterectomy.
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Figure 15c. Uterine abscess in a 51-year-old woman with septicemia. The patient had undergone UAE 3 months earlier. (a) Axial transabdominal US image of the uterus shows a large uterine abscess (cursors) with diffuse hyperechoic foci (arrow), findings that are consistent with gas. (b, c) CT scans obtained at different levels through the uterus help confirm a large uterine abscess with an air-fluid level (arrow in b). The patient subsequently underwent hysterectomy.
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Figure 16a. Deep venous thrombosis in a 52-year-old woman with a history of acute unilateral limb swelling since undergoing UAE 4 days earlier. (a) Longitudinal color Doppler US image shows an occlusive homogeneous thrombus within a noncompressible right common femoral vein (V). (b) Longitudinal gray-scale US image shows the thrombus in the common femoral vein (CFV) and extending into the greater saphenous vein (GSV).
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Figure 16b. Deep venous thrombosis in a 52-year-old woman with a history of acute unilateral limb swelling since undergoing UAE 4 days earlier. (a) Longitudinal color Doppler US image shows an occlusive homogeneous thrombus within a noncompressible right common femoral vein (V). (b) Longitudinal gray-scale US image shows the thrombus in the common femoral vein (CFV) and extending into the greater saphenous vein (GSV).
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Figure 17. Pseudoaneurysm at the arterial puncture site in a 52-year-old woman who had undergone UAE. Duplex color Doppler US image demonstrates a heterogeneous, echogenic swirling mass adjacent to the common femoral artery (CFA) at the puncture site with arterial flow. A narrow "neck" (arrow) is identified in the pseudoaneurysm.
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Copyright © 2005 by the Radiological Society of North America.
