DOI: 10.1148/rg.25si055518
RadioGraphics 2005;25:S119-S132
© RSNA, 2005
Imaging Manifestations of Complications Associated with Uterine Artery Embolization1
Yuri Kitamura, MD2,
Susan M. Ascher, MD,
Cirrelda Cooper, MD,
Sandra J. Allison, MD,
Reena C. Jha, MD,
Pamela A. Flick, MD and
James B. Spies, MD
1 From the Department of Radiology, Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC 20007. Presented as an education exhibit at the 2004 RSNA Scientific Assembly. Received May 18, 2005; revision requested May 31 and received June 30; accepted July 12. J.B.S. is a research support consultant for Boston Scientific and Biosphere Medical; all remaining authors have no financial relationships to disclose.
Address correspondence to S.M.A. (e-mail: aschers{at}gunet.georgetown.edu).
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Abstract
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Uterine artery embolization (UAE) is an increasingly performed, minimally invasive alternative to hysterectomy or myomectomy for women with symptomatic uterine fibroids. A growing body of literature documents symptomatic improvement in the majority of women who undergo UAE. Although UAE is usually safe and effective, there are a number of known complications associated with the procedure. Major complications include fibroid passage, infectious disease (endometritis, pelvic inflammatory disease–tubo-ovarian abscess, pyomyoma), deep venous thrombosis, pulmonary embolism, inadvertent embolization of a malignant leiomyosarcoma, ovarian dysfunction, fibroid regrowth, uterine necrosis, and even death. Minor complications include hematoma, urinary tract infection, retention of urine, transient pain, and vessel or nerve injury at the puncture site. As UAE takes its place in the treatment arsenal for women with symptomatic fibroids, radiologists need to be familiar with UAE-associated complications, which may require further treatment and may even be life threatening in some cases. Knowledge of these complications and their imaging features should lead to prompt diagnosis and appropriate treatment.
© RSNA, 2005
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LEARNING OBJECTIVES FOR TEST 3
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After reading this article and taking the test, the reader will be able to:
- Discuss potential complications of UAE.
- Identify the appropriate imaging studies for UAE patients with suspected complications.
- Describe the imaging features of UAE-associated complications.
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Introduction
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Uterine artery embolization (UAE) is a minimally invasive alternative to hysterectomy and myomectomy. Since 1995, when the initial report of UAE as a treatment for symptomatic fibroids was published, more than 25,000 procedures have been performed worldwide (1–3). The goal of performing UAE is to produce hemorrhagic infarction of fibroids while maintaining endometrial and myometrial perfusion (4). Postprocedural studies have documented a significant decrease in uterine and fibroid volumes with a concomitant decrease in bleeding and bulk-related symptoms (1,2,5–9). As with any interventional procedure, complications do occur. The largest series to date found an overall 8.5% short-term complication rate and a 1.25% serious complication rate (7). These complications must be recognized and treated appropriately. There are several classification schemes for complications of interventional procedures in general and of hysterectomy or myomectomy in particular. In this article, we focus on the evaluation and imaging manifestations of UAE-associated complications that require additional therapy beyond over-the-counter analgesics (major complications). Thus, we do not adhere strictly to any of the aforementioned classification schemes for complications. We also briefly mention some complications that typically resolve spontaneously (minor complications).
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Major Complications
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Fibroid Passage
One of most common complications of UAE is passage of a fibroid, occurring in 2.5% of cases (2,7). In some cases, fibroid passage is associated with severe pain, infection, or recurrent bleeding (4,10). Fibroids in contact with the endometrial surface, including submucosal fibroids or intramural fibroids with a submucosal component, pose an increased risk for fibroid passage (4,11,12). In most instances, an infarcted fibroid, with increased signal intensity on T1-weighted magnetic resonance (MR) images, decreased signal intensity on T2-weighted images, and no enhancement on contrast material–enhanced T1-weighted images, distends the endometrial canal and migrates toward the cervix or vagina (10–13). MR imaging is well suited to documenting the migration of the fibroid and can demonstrate any viable attachment to the uterine wall (11,14) with contrast-enhanced sequences. In some instances, the infarcted fibroid is expelled spontaneously (Fig 1) (15). Hysteroscopic resection is reserved for cases in which (a) the patient is symptomatic (Fig 2) or (b) the fibroid is only partially infarcted and is still firmly attached to the uterine wall (Fig 3) (4,11,13).
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Figure 1a. Spontaneous fibroid passage. (a, b) Sagittal single-shot fast spin-echo (SE) T2-weighted (repetition time msec/echo time msec = 4.4/64) (a) and gadolinium-enhanced fat-suppressed three-dimensional (3D) T1-weighted volumetric interpolated breath-hold examination (VIBE) (4.5/1.9, 15° flip angle) (b) MR images obtained 2 months after UAE show an infarcted fibroid (*) in the endometrial canal. (c, d) On sagittal single-shot fast SE T2-weighted (4.4/64) (c) and gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE (4.5/1.9, 15° flip angle) (d) MR images obtained 1 year after UAE, the fibroid is no longer seen. The patient, who reported that the fibroid had been expelled spontaneously without complication, did not require treatment.
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Figure 1b. Spontaneous fibroid passage. (a, b) Sagittal single-shot fast spin-echo (SE) T2-weighted (repetition time msec/echo time msec = 4.4/64) (a) and gadolinium-enhanced fat-suppressed three-dimensional (3D) T1-weighted volumetric interpolated breath-hold examination (VIBE) (4.5/1.9, 15° flip angle) (b) MR images obtained 2 months after UAE show an infarcted fibroid (*) in the endometrial canal. (c, d) On sagittal single-shot fast SE T2-weighted (4.4/64) (c) and gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE (4.5/1.9, 15° flip angle) (d) MR images obtained 1 year after UAE, the fibroid is no longer seen. The patient, who reported that the fibroid had been expelled spontaneously without complication, did not require treatment.
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Figure 1c. Spontaneous fibroid passage. (a, b) Sagittal single-shot fast spin-echo (SE) T2-weighted (repetition time msec/echo time msec = 4.4/64) (a) and gadolinium-enhanced fat-suppressed three-dimensional (3D) T1-weighted volumetric interpolated breath-hold examination (VIBE) (4.5/1.9, 15° flip angle) (b) MR images obtained 2 months after UAE show an infarcted fibroid (*) in the endometrial canal. (c, d) On sagittal single-shot fast SE T2-weighted (4.4/64) (c) and gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE (4.5/1.9, 15° flip angle) (d) MR images obtained 1 year after UAE, the fibroid is no longer seen. The patient, who reported that the fibroid had been expelled spontaneously without complication, did not require treatment.
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Figure 1d. Spontaneous fibroid passage. (a, b) Sagittal single-shot fast spin-echo (SE) T2-weighted (repetition time msec/echo time msec = 4.4/64) (a) and gadolinium-enhanced fat-suppressed three-dimensional (3D) T1-weighted volumetric interpolated breath-hold examination (VIBE) (4.5/1.9, 15° flip angle) (b) MR images obtained 2 months after UAE show an infarcted fibroid (*) in the endometrial canal. (c, d) On sagittal single-shot fast SE T2-weighted (4.4/64) (c) and gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE (4.5/1.9, 15° flip angle) (d) MR images obtained 1 year after UAE, the fibroid is no longer seen. The patient, who reported that the fibroid had been expelled spontaneously without complication, did not require treatment.
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Figure 2a. Fibroid passage requiring hysteroscopic intervention in a patient who complained of severe pain 3 months after undergoing UAE. Sagittal single-shot fast SE T2-weighted (4.4/64) (a) and gadolinium-enhanced fat-suppressed 3D gradient-echo T1-weighted (193/4.76, 70° flip angle) (b) MR images show an infarcted fibroid (*) distending the endometrial canal and extending to the level of the internal os. Hysteroscopic resection of the fibroid was successfully performed and provided symptomatic relief.
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Figure 2b. Fibroid passage requiring hysteroscopic intervention in a patient who complained of severe pain 3 months after undergoing UAE. Sagittal single-shot fast SE T2-weighted (4.4/64) (a) and gadolinium-enhanced fat-suppressed 3D gradient-echo T1-weighted (193/4.76, 70° flip angle) (b) MR images show an infarcted fibroid (*) distending the endometrial canal and extending to the level of the internal os. Hysteroscopic resection of the fibroid was successfully performed and provided symptomatic relief.
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Figure 3a. Fibroid passage requiring hysteroscopic resection. (a, b) Sagittal single-shot fast SE T2-weighted (4.4/64) (a) and gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE (4.5/1.9, 15° flip angle) (b) MR images obtained prior to UAE show a dominant fibroid in the center of the uterus that is mostly sub-mucosal. Note the heterogeneous enhancement of the fibroid in b. (c) On a sagittal gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE MR image (4.5/1.9, 15° flip angle) obtained 27 days after UAE, the dominant fibroid is heterogeneous and enhances less than the adjacent myometrium. The fibroid has prolapsed through the open cervix into the vaginal fornix, with its stalk attached to the posterior uterine wall (arrow). (d) Follow-up sagittal gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE MR image (4.5/1.9, 15° flip angle) obtained 2 days after hysteroscopic removal of the prolapsing fibroid shows residual tissue at the site of attachment (arrow). Note that both the endocervical and endovaginal canals have returned to their native configurations.
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Figure 3b. Fibroid passage requiring hysteroscopic resection. (a, b) Sagittal single-shot fast SE T2-weighted (4.4/64) (a) and gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE (4.5/1.9, 15° flip angle) (b) MR images obtained prior to UAE show a dominant fibroid in the center of the uterus that is mostly sub-mucosal. Note the heterogeneous enhancement of the fibroid in b. (c) On a sagittal gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE MR image (4.5/1.9, 15° flip angle) obtained 27 days after UAE, the dominant fibroid is heterogeneous and enhances less than the adjacent myometrium. The fibroid has prolapsed through the open cervix into the vaginal fornix, with its stalk attached to the posterior uterine wall (arrow). (d) Follow-up sagittal gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE MR image (4.5/1.9, 15° flip angle) obtained 2 days after hysteroscopic removal of the prolapsing fibroid shows residual tissue at the site of attachment (arrow). Note that both the endocervical and endovaginal canals have returned to their native configurations.
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Figure 3c. Fibroid passage requiring hysteroscopic resection. (a, b) Sagittal single-shot fast SE T2-weighted (4.4/64) (a) and gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE (4.5/1.9, 15° flip angle) (b) MR images obtained prior to UAE show a dominant fibroid in the center of the uterus that is mostly sub-mucosal. Note the heterogeneous enhancement of the fibroid in b. (c) On a sagittal gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE MR image (4.5/1.9, 15° flip angle) obtained 27 days after UAE, the dominant fibroid is heterogeneous and enhances less than the adjacent myometrium. The fibroid has prolapsed through the open cervix into the vaginal fornix, with its stalk attached to the posterior uterine wall (arrow). (d) Follow-up sagittal gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE MR image (4.5/1.9, 15° flip angle) obtained 2 days after hysteroscopic removal of the prolapsing fibroid shows residual tissue at the site of attachment (arrow). Note that both the endocervical and endovaginal canals have returned to their native configurations.
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Figure 3d. Fibroid passage requiring hysteroscopic resection. (a, b) Sagittal single-shot fast SE T2-weighted (4.4/64) (a) and gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE (4.5/1.9, 15° flip angle) (b) MR images obtained prior to UAE show a dominant fibroid in the center of the uterus that is mostly sub-mucosal. Note the heterogeneous enhancement of the fibroid in b. (c) On a sagittal gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE MR image (4.5/1.9, 15° flip angle) obtained 27 days after UAE, the dominant fibroid is heterogeneous and enhances less than the adjacent myometrium. The fibroid has prolapsed through the open cervix into the vaginal fornix, with its stalk attached to the posterior uterine wall (arrow). (d) Follow-up sagittal gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE MR image (4.5/1.9, 15° flip angle) obtained 2 days after hysteroscopic removal of the prolapsing fibroid shows residual tissue at the site of attachment (arrow). Note that both the endocervical and endovaginal canals have returned to their native configurations.
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Infectious Disease
Endometritis.—
Endometritis is an infection of the endometrium that is often seen following gynecologic interventions, including 0.5% of UAEs (4,6,7,16). Most patients with endometritis respond well to antibiotics. If left untreated or refractory to antibiotics, endometritis can result in fever, pelvic pain, or septicemia. Hysterectomy is curative in these instances (7). Although the uterus and endometrium can appear normal at ultrasonography (US) (17), findings that are suggestive of endometritis include uterine enlargement; a thickened, heterogeneous endometrium; intracavitary fluid (simple or complex); and intra-uterine gas (16). At MR imaging, endometritis may manifest as uterine enlargement with intra-cavitary hematoma, typically with high signal intensity on T1-weighted images. Associated gas appears as a signal void with both T1- and T2-weighted sequences (Fig 4).
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Figure 4a. Endometritis in a patient who presented with complaints of pain, vaginal discharge, and fever 2 months after undergoing UAE. Sagittal (a) and axial (b) fast SE T2-weighted MR images (4.4/64), sagittal gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE MR image (4.5/1.9, 15° flip angle) (c), and axial fat-suppressed gradient-echo T1-weighted MR image (193/4.76, 70° flip angle) (d) demonstrate an infarcted intramural fibroid whose inferior aspect is contiguous with the endometrial canal and that is beginning to pass into the endometrial canal. Note the punctate foci of signal void representing air, findings that can be associated with necrosis and superinfection. (Reprinted, with permission, from reference 18.)
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Figure 4b. Endometritis in a patient who presented with complaints of pain, vaginal discharge, and fever 2 months after undergoing UAE. Sagittal (a) and axial (b) fast SE T2-weighted MR images (4.4/64), sagittal gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE MR image (4.5/1.9, 15° flip angle) (c), and axial fat-suppressed gradient-echo T1-weighted MR image (193/4.76, 70° flip angle) (d) demonstrate an infarcted intramural fibroid whose inferior aspect is contiguous with the endometrial canal and that is beginning to pass into the endometrial canal. Note the punctate foci of signal void representing air, findings that can be associated with necrosis and superinfection. (Reprinted, with permission, from reference 18.)
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Figure 4c. Endometritis in a patient who presented with complaints of pain, vaginal discharge, and fever 2 months after undergoing UAE. Sagittal (a) and axial (b) fast SE T2-weighted MR images (4.4/64), sagittal gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE MR image (4.5/1.9, 15° flip angle) (c), and axial fat-suppressed gradient-echo T1-weighted MR image (193/4.76, 70° flip angle) (d) demonstrate an infarcted intramural fibroid whose inferior aspect is contiguous with the endometrial canal and that is beginning to pass into the endometrial canal. Note the punctate foci of signal void representing air, findings that can be associated with necrosis and superinfection. (Reprinted, with permission, from reference 18.)
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Figure 4d. Endometritis in a patient who presented with complaints of pain, vaginal discharge, and fever 2 months after undergoing UAE. Sagittal (a) and axial (b) fast SE T2-weighted MR images (4.4/64), sagittal gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE MR image (4.5/1.9, 15° flip angle) (c), and axial fat-suppressed gradient-echo T1-weighted MR image (193/4.76, 70° flip angle) (d) demonstrate an infarcted intramural fibroid whose inferior aspect is contiguous with the endometrial canal and that is beginning to pass into the endometrial canal. Note the punctate foci of signal void representing air, findings that can be associated with necrosis and superinfection. (Reprinted, with permission, from reference 18.)
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Contrast-enhanced MR images increase the conspicuity of intracavitary fluid collections—that is, the collections will stand out as low-signal-intensity areas adjacent to enhancing endometrium and myometrium.
Pelvic Inflammatory Disease–Tubo-ovarian Abscess.—
Pelvic inflammatory disease (PID)–tubo-ovarian abscess (TOA) is a rare complication of UAE (19) and should be considered as a possible diagnosis in patients with prolonged or recurrent pain accompanied by fever. Recognition of PID-TOA is important, since affected patients who are refractory to medical therapy require aggressive treatment with antibiotics and drainage procedures. The diagnosis is often made on the basis of history, physical examination results, and laboratory data. In problematic cases, transvaginal US is often the initial imaging modality (20). Imaging findings that suggest PID-TOA include (a) a unilocular or multilocular, complex, thick-walled cystic adnexal mass; (b) associated fallopian tube involvement with a hydrosalpinx or pyosalpinx ("cogwheel sign," representing incomplete septa or projections within a fluid-filled tubular structure) (Fig 5 ); and (c) hyperemia of the adnexal region at color Doppler US (17). If there is diagnostic uncertainty, MR imaging may be helpful in determining the location, extent, and character of the process (20–22). PID-TOA may have signal intensities that parallel those of simple fluid (ie, hypointensity on T1-weighted MR images, hyperintensity on T2-weighted images) or may have proteinaceous contents with intermediate signal intensity on T1-weighted images and variable signal intensity on T2-weighted images (20). The abscess rim is at least 3 mm thick and has low to intermediate signal intensity on T1-weighted MR images and intermediate to high signal intensity on T2-weighted images. Intravenously administered gadolinium chelates increase the conspicuity of PID-TOA. Computed tomography (CT) can also be performed if transvaginal US findings are equivocal and is the modality of choice for transabdominal and transgluteal percutaneous drainage procedures (23). The CT features of PID-TOA are similar to its MR imaging features and include a multilocular complex cystic adnexal mass with or without fallopian tube involvement (24).
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Figure 5a. PID. (a) On a US image, the left fallopian tube is dilated with echogenic debris (arrows), a finding that is consistent with pyosalpinx. The left ovary (LO) is relatively spared. (b) US image shows incomplete septa projecting into a fluid-filled tubular structure (arrow), findings that help distinguish hydrosalpinx and pyosalpinx from other adnexal conditions.
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Figure 5b. PID. (a) On a US image, the left fallopian tube is dilated with echogenic debris (arrows), a finding that is consistent with pyosalpinx. The left ovary (LO) is relatively spared. (b) US image shows incomplete septa projecting into a fluid-filled tubular structure (arrow), findings that help distinguish hydrosalpinx and pyosalpinx from other adnexal conditions.
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Pyomyoma (Suppurative Leiomyoma).—
Pyomyoma is a rare and potentially fatal condition. Fewer than 100 cases have been described in the literature, the majority having been reported prior to 1945, when antibiotics first became widely available. Pyomyoma is most often encountered as a complication of pregnancy, although sporadic idiopathic cases in postmenopausal women have also been documented. In pregnant women, three routes of infection leading to pyomyoma have been implicated: contiguous spread from the endometrial cavity, direct spread from adnexa or bowel, and hematogenous or lymphatic spread from a remote site of infection. In postmenopausal women, ischemia secondary to hypertension, diabetes, or atherosclerosis may be a predisposing factor. Pyomyoma following UAE has been reported (Fig 6) (6); in fact, a case of post-UAE pyomyoma recently occurred at our institution in a patient with diabetes milletus (Spies JB, personal communication, 2005). Hysterectomy is the definitive treatment; myomectomy with antibiotics represents a less common alternative. The few US case reports cite nonspecific findings. Internal echoes and reverberation artifact secondary to gas can be seen in suppurative leiomyomas. A CT case report described the presence of gas in a uterine leiomyoma as diagnostic for pyomyoma; however, gas can be a normal post-UAE finding (25). The diagnosis of pyomyoma should be reserved for patients with associated clinical symptomatology.
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Figure 6. Pyomyoma in a patient with sepsis who had undergone UAE 10 days earlier. CT scan of the pelvis obtained with use of oral and rectal contrast material shows an increased volume of gas within both an infarcted fibroid and the surrounding myometrium compared with prior CT scans (not shown). Pyomyoma was found at hysterectomy.
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Deep Venous Thrombosis
Deep venous thrombosis is a known complication of uterine fibroids that occurs when an enlarged uterus compresses the main pelvic veins. The subsequent venous stasis leads to thrombus formation. Patients are also at risk for deep venous thrombosis after undergoing UAE (0.25% of cases) (Fig 7). Specifically, inflammation of the major pelvic veins may result in deep venous thrombosis, especially if the patient is immobile. Color duplex US is the first-line modality for diagnosis (26,27). A complete or partial thrombus expands the vein with variable echogenicity, limits vessel compressibility, and dampens or diminishes flow augmentation.
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Figure 7a. Deep venous thrombosis. US images of the right (a) and left (b) common femoral veins obtained without (left side) and with (right side) compression 16 days after UAE show bilateral thrombi (V). Noncompressible, hypoechoic, nonocclusive thrombus is seen in the lumina of both veins (arrows).
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Figure 7b. Deep venous thrombosis. US images of the right (a) and left (b) common femoral veins obtained without (left side) and with (right side) compression 16 days after UAE show bilateral thrombi (V). Noncompressible, hypoechoic, nonocclusive thrombus is seen in the lumina of both veins (arrows).
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The standard treatment for deep venous thrombosis has been inpatient anticoagulation therapy with continuous intravenous injection of heparin followed by outpatient oral anticoagulation therapy (26). Recently, low-molecular-weight heparin has been used instead of conventional heparin (26). In some instances, thrombolytic drugs, an inferior vena cava filter, or elastic compression stockings may be used.
Pulmonary Embolism
Pulmonary embolism is a rare, potentially life-threatening complication of UAE (0.25% of cases). Patients may present with chest discomfort or pain immediately or even weeks or months after UAE. Conventional angiography has been the standard of reference in diagnosing pulmonary embolism; however, dynamic contrast-enhanced (multi–detector row) CT is the preferred noninvasive alternative at most centers (28–30). CT features of emboli include filling defects in the major pulmonary arteries or their branches (Fig 8). If the use of iodinated contrast material is contraindicated, 3D MR angiography with postprocessing is a noninvasive alternative to both CT and conventional angiography (31). If a pulmonary embolus is detected, thrombolytic treatment is instituted immediately.
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Figure 8a. Pulmonary embolism. (a, b) Contrast-enhanced CT scans of the thorax obtained 4 days after UAE (b obtained at a higher level than a) show a discrete filling defect (arrow) in a pulmonary artery branch to the right lower lobe. (c) Three-dimensional multiplanar reformatted image from contrast-enhanced CT data shows the filling defect expanding a pulmonary artery that supplies the right lower lobe (arrow), a finding that is diagnostic for a pulmonary embolus.
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Figure 8b. Pulmonary embolism. (a, b) Contrast-enhanced CT scans of the thorax obtained 4 days after UAE (b obtained at a higher level than a) show a discrete filling defect (arrow) in a pulmonary artery branch to the right lower lobe. (c) Three-dimensional multiplanar reformatted image from contrast-enhanced CT data shows the filling defect expanding a pulmonary artery that supplies the right lower lobe (arrow), a finding that is diagnostic for a pulmonary embolus.
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Figure 8c. Pulmonary embolism. (a, b) Contrast-enhanced CT scans of the thorax obtained 4 days after UAE (b obtained at a higher level than a) show a discrete filling defect (arrow) in a pulmonary artery branch to the right lower lobe. (c) Three-dimensional multiplanar reformatted image from contrast-enhanced CT data shows the filling defect expanding a pulmonary artery that supplies the right lower lobe (arrow), a finding that is diagnostic for a pulmonary embolus.
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Malignant Leiomyosarcoma
The prevalence of sarcomatous degeneration in patients with fibroids is less than 1% (8,32,33). To our knowledge, no large series to date have published imaging criteria to reliably help distinguish sarcomatous degeneration from other types of degeneration. A recent study of 12 patients by Tanaka et al (34) suggests that leiomyosarcoma and smooth muscle tumors of uncertain malignant potential should be considered as possible diagnoses if more than 50% of a fibroid demonstrates high signal intensity on T2-weighted MR images or any small high-signal-intensity areas on T1-weighted images and there are avascular pocket-like areas after contrast material administration. In the clinical setting, leiomyosarcoma should be considered when there is rapid fibroid growth in a postmenopausal woman (32). This approach should also be used in UAE candidates (Fig 9). Unfortunately, in some cases leiomyosarcomas will be inadvertently embolized. In these cases, the goal of imaging should be to identify patients who do not respond predictably to UAE despite its technical success and to aggressively evaluate these patients.
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Figure 9a. Malignant leiomyosarcoma. (a, b) Pre-UAE single-shot fast SE T2-weighted (4.4/64) (a) and gadolinium-enhanced 3D T1-weighted VIBE (4.5/1.9, 15° flip angle) (b) MR images show a heterogeneous fibroid with degeneration. UAE was technically successful. (c, d) Single-shot fast SE T2-weighted (4.4/64) (c) and gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE (4.5/1.9, 15° flip angle) (d) MR images obtained 4 months later show growing residual viable tissue. (e, f ) MR images (same parameters as c and d) obtained 11 months after UAE and recurrent symptoms show rapid regrowth of the fibroid. A diagnosis of malignant transformation was considered. (g) CT scan obtained 2 years after UAE shows multiple lung nodules, which were presumed to be metastases. Although rare, malignant transformation can occur and underscores the need for careful clinical and imaging follow-up.
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Figure 9b. Malignant leiomyosarcoma. (a, b) Pre-UAE single-shot fast SE T2-weighted (4.4/64) (a) and gadolinium-enhanced 3D T1-weighted VIBE (4.5/1.9, 15° flip angle) (b) MR images show a heterogeneous fibroid with degeneration. UAE was technically successful. (c, d) Single-shot fast SE T2-weighted (4.4/64) (c) and gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE (4.5/1.9, 15° flip angle) (d) MR images obtained 4 months later show growing residual viable tissue. (e, f ) MR images (same parameters as c and d) obtained 11 months after UAE and recurrent symptoms show rapid regrowth of the fibroid. A diagnosis of malignant transformation was considered. (g) CT scan obtained 2 years after UAE shows multiple lung nodules, which were presumed to be metastases. Although rare, malignant transformation can occur and underscores the need for careful clinical and imaging follow-up.
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Figure 9c. Malignant leiomyosarcoma. (a, b) Pre-UAE single-shot fast SE T2-weighted (4.4/64) (a) and gadolinium-enhanced 3D T1-weighted VIBE (4.5/1.9, 15° flip angle) (b) MR images show a heterogeneous fibroid with degeneration. UAE was technically successful. (c, d) Single-shot fast SE T2-weighted (4.4/64) (c) and gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE (4.5/1.9, 15° flip angle) (d) MR images obtained 4 months later show growing residual viable tissue. (e, f ) MR images (same parameters as c and d) obtained 11 months after UAE and recurrent symptoms show rapid regrowth of the fibroid. A diagnosis of malignant transformation was considered. (g) CT scan obtained 2 years after UAE shows multiple lung nodules, which were presumed to be metastases. Although rare, malignant transformation can occur and underscores the need for careful clinical and imaging follow-up.
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Figure 9d. Malignant leiomyosarcoma. (a, b) Pre-UAE single-shot fast SE T2-weighted (4.4/64) (a) and gadolinium-enhanced 3D T1-weighted VIBE (4.5/1.9, 15° flip angle) (b) MR images show a heterogeneous fibroid with degeneration. UAE was technically successful. (c, d) Single-shot fast SE T2-weighted (4.4/64) (c) and gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE (4.5/1.9, 15° flip angle) (d) MR images obtained 4 months later show growing residual viable tissue. (e, f ) MR images (same parameters as c and d) obtained 11 months after UAE and recurrent symptoms show rapid regrowth of the fibroid. A diagnosis of malignant transformation was considered. (g) CT scan obtained 2 years after UAE shows multiple lung nodules, which were presumed to be metastases. Although rare, malignant transformation can occur and underscores the need for careful clinical and imaging follow-up.
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Figure 9e. Malignant leiomyosarcoma. (a, b) Pre-UAE single-shot fast SE T2-weighted (4.4/64) (a) and gadolinium-enhanced 3D T1-weighted VIBE (4.5/1.9, 15° flip angle) (b) MR images show a heterogeneous fibroid with degeneration. UAE was technically successful. (c, d) Single-shot fast SE T2-weighted (4.4/64) (c) and gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE (4.5/1.9, 15° flip angle) (d) MR images obtained 4 months later show growing residual viable tissue. (e, f ) MR images (same parameters as c and d) obtained 11 months after UAE and recurrent symptoms show rapid regrowth of the fibroid. A diagnosis of malignant transformation was considered. (g) CT scan obtained 2 years after UAE shows multiple lung nodules, which were presumed to be metastases. Although rare, malignant transformation can occur and underscores the need for careful clinical and imaging follow-up.
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Figure 9f. Malignant leiomyosarcoma. (a, b) Pre-UAE single-shot fast SE T2-weighted (4.4/64) (a) and gadolinium-enhanced 3D T1-weighted VIBE (4.5/1.9, 15° flip angle) (b) MR images show a heterogeneous fibroid with degeneration. UAE was technically successful. (c, d) Single-shot fast SE T2-weighted (4.4/64) (c) and gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE (4.5/1.9, 15° flip angle) (d) MR images obtained 4 months later show growing residual viable tissue. (e, f ) MR images (same parameters as c and d) obtained 11 months after UAE and recurrent symptoms show rapid regrowth of the fibroid. A diagnosis of malignant transformation was considered. (g) CT scan obtained 2 years after UAE shows multiple lung nodules, which were presumed to be metastases. Although rare, malignant transformation can occur and underscores the need for careful clinical and imaging follow-up.
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Figure 9g. Malignant leiomyosarcoma. (a, b) Pre-UAE single-shot fast SE T2-weighted (4.4/64) (a) and gadolinium-enhanced 3D T1-weighted VIBE (4.5/1.9, 15° flip angle) (b) MR images show a heterogeneous fibroid with degeneration. UAE was technically successful. (c, d) Single-shot fast SE T2-weighted (4.4/64) (c) and gadolinium-enhanced fat-suppressed 3D T1-weighted VIBE (4.5/1.9, 15° flip angle) (d) MR images obtained 4 months later show growing residual viable tissue. (e, f ) MR images (same parameters as c and d) obtained 11 months after UAE and recurrent symptoms show rapid regrowth of the fibroid. A diagnosis of malignant transformation was considered. (g) CT scan obtained 2 years after UAE shows multiple lung nodules, which were presumed to be metastases. Although rare, malignant transformation can occur and underscores the need for careful clinical and imaging follow-up.
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Ovarian Dysfunction
Ovarian dysfunction has also been reported to occur after UAE (6,35–38). The exact mechanism is unknown, but several reports have suggested that arterial communication between ovarian and uterine arteries may lead to inadvertent embolization of the ovaries. Some studies have found uterine-ovarian arterial anastomoses (39). When these anastomoses are bilateral, their presence portends a higher risk for ovarian embolization and subsequent premature menopause. Women over 45 years of age are at increased risk for ovarian dysfunction after UAE because they have a higher prevalence of uterine-ovarian arterial anastomoses (43% of cases) compared with women under 45 years of age (<5%) (6,35). MR angiography, especially with thin maximum-intensity-projection reformatted images, may delineate significant ovarian arterial supply to the uterus in candidates for UAE (Fig 10). The ovarian arteries are paired and originate from the infrarenal aorta (14,40), course inferiorly, and have a corkscrew appearance. In patients without significant ovarian arterial supply to the uterus, the ovarian arteries can rarely be distinguished individually. Visualization of ovarian arteries at MR angiography suggests a significant contribution to the uterine circulation. In these instances, UAE candidates may benefit from discussion about the increased likelihood of ovarian dysfunction or fibroid regrowth (14,40).
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Figure 10. Ovarian dysfunction. Gadolinium-enhanced 3D maximum-intensity-projection T1-weighted VIBE MR image (4.5/1.9, 15° flip angle) clearly depicts dilated bilateral ovarian arterial collateral vessels (arrows). The presence of ovarian arterial collateral vessels to the uterus in patients with uterine fibroids may increase the risk for both premature menopause by means of inadvertent ovarian embolization-infarction and fibroid regrowth after UAE. (Reprinted, with permission, from reference 18.)
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Fibroid Regrowth
Regrowth of fibroids after UAE is not a complication in the strictest sense. However, when re-growth is encountered during follow-up (Fig 11), it warrants attention. Some investigators consider fibroid regrowth to be a type of late failure of UAE. Most symptomatic recurrences occur 2 years after UAE. Some investigators recommend follow-up at 20 months to assess fibroid regrowth (41). The reasons why fibroids regrow or recur are not well understood but may be related to (a) particle size and shape and (b) preservation of normal myometrium (41). Particle size and shape may allow particle redistribution after a technically successful UAE procedure, thereby restoring flow to a fibroid. It is also possible that large particles may occlude proximal vessels and permit collateral vessels to bypass the occlusion. In successful UAE, embolic particles preferentially lodge in the terminal arteries supplying the fibroids and spare the normal myometrium. New fibroids may develop in areas of viable myometrium (41,42).
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Figure 11a. Fibroid regrowth. (a, b) Sagittal single-shot fast SE T2-weighted (4.4/64) (a) and gadolinium-enhanced gradient-echo T1-weighted (160/4.1, 80° flip angle) (b) MR images obtained prior to UAE show a dominant intramural fibroid within the anterior uterine body. (c, d) On sagittal single-shot fast SE T2-weighted (4.4/64) (c) and gadolinium-enhanced gradient-echo T1-weighted (160/4.1, 80° flip angle) (d) MR images obtained 5 months after UAE, the dominant fibroid has decreased in size and vascularity. A nidus of enhancement in the fibroid continued to grow at 1-, 2-, and 3-year intervals after UAE. (e–g) Axial (e) and sagittal (f ) single-shot fast SE T2-weighted MR images (4.4/64) and a sagittal gadolinium-enhanced 3D T1-weighted VIBE MR image (4.5/1.9, 15° flip angle) (g) obtained 4 years after UAE show regrowth of the dominant fibroid without areas of infarction.
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Figure 11b. Fibroid regrowth. (a, b) Sagittal single-shot fast SE T2-weighted (4.4/64) (a) and gadolinium-enhanced gradient-echo T1-weighted (160/4.1, 80° flip angle) (b) MR images obtained prior to UAE show a dominant intramural fibroid within the anterior uterine body. (c, d) On sagittal single-shot fast SE T2-weighted (4.4/64) (c) and gadolinium-enhanced gradient-echo T1-weighted (160/4.1, 80° flip angle) (d) MR images obtained 5 months after UAE, the dominant fibroid has decreased in size and vascularity. A nidus of enhancement in the fibroid continued to grow at 1-, 2-, and 3-year intervals after UAE. (e–g) Axial (e) and sagittal (f ) single-shot fast SE T2-weighted MR images (4.4/64) and a sagittal gadolinium-enhanced 3D T1-weighted VIBE MR image (4.5/1.9, 15° flip angle) (g) obtained 4 years after UAE show regrowth of the dominant fibroid without areas of infarction.
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Figure 11c. Fibroid regrowth. (a, b) Sagittal single-shot fast SE T2-weighted (4.4/64) (a) and gadolinium-enhanced gradient-echo T1-weighted (160/4.1, 80° flip angle) (b) MR images obtained prior to UAE show a dominant intramural fibroid within the anterior uterine body. (c, d) On sagittal single-shot fast SE T2-weighted (4.4/64) (c) and gadolinium-enhanced gradient-echo T1-weighted (160/4.1, 80° flip angle) (d) MR images obtained 5 months after UAE, the dominant fibroid has decreased in size and vascularity. A nidus of enhancement in the fibroid continued to grow at 1-, 2-, and 3-year intervals after UAE. (e–g) Axial (e) and sagittal (f ) single-shot fast SE T2-weighted MR images (4.4/64) and a sagittal gadolinium-enhanced 3D T1-weighted VIBE MR image (4.5/1.9, 15° flip angle) (g) obtained 4 years after UAE show regrowth of the dominant fibroid without areas of infarction.
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Figure 11d. Fibroid regrowth. (a, b) Sagittal single-shot fast SE T2-weighted (4.4/64) (a) and gadolinium-enhanced gradient-echo T1-weighted (160/4.1, 80° flip angle) (b) MR images obtained prior to UAE show a dominant intramural fibroid within the anterior uterine body. (c, d) On sagittal single-shot fast SE T2-weighted (4.4/64) (c) and gadolinium-enhanced gradient-echo T1-weighted (160/4.1, 80° flip angle) (d) MR images obtained 5 months after UAE, the dominant fibroid has decreased in size and vascularity. A nidus of enhancement in the fibroid continued to grow at 1-, 2-, and 3-year intervals after UAE. (e–g) Axial (e) and sagittal (f ) single-shot fast SE T2-weighted MR images (4.4/64) and a sagittal gadolinium-enhanced 3D T1-weighted VIBE MR image (4.5/1.9, 15° flip angle) (g) obtained 4 years after UAE show regrowth of the dominant fibroid without areas of infarction.
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Figure 11e. Fibroid regrowth. (a, b) Sagittal single-shot fast SE T2-weighted (4.4/64) (a) and gadolinium-enhanced gradient-echo T1-weighted (160/4.1, 80° flip angle) (b) MR images obtained prior to UAE show a dominant intramural fibroid within the anterior uterine body. (c, d) On sagittal single-shot fast SE T2-weighted (4.4/64) (c) and gadolinium-enhanced gradient-echo T1-weighted (160/4.1, 80° flip angle) (d) MR images obtained 5 months after UAE, the dominant fibroid has decreased in size and vascularity. A nidus of enhancement in the fibroid continued to grow at 1-, 2-, and 3-year intervals after UAE. (e–g) Axial (e) and sagittal (f ) single-shot fast SE T2-weighted MR images (4.4/64) and a sagittal gadolinium-enhanced 3D T1-weighted VIBE MR image (4.5/1.9, 15° flip angle) (g) obtained 4 years after UAE show regrowth of the dominant fibroid without areas of infarction.
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Figure 11f. Fibroid regrowth. (a, b) Sagittal single-shot fast SE T2-weighted (4.4/64) (a) and gadolinium-enhanced gradient-echo T1-weighted (160/4.1, 80° flip angle) (b) MR images obtained prior to UAE show a dominant intramural fibroid within the anterior uterine body. (c, d) On sagittal single-shot fast SE T2-weighted (4.4/64) (c) and gadolinium-enhanced gradient-echo T1-weighted (160/4.1, 80° flip angle) (d) MR images obtained 5 months after UAE, the dominant fibroid has decreased in size and vascularity. A nidus of enhancement in the fibroid continued to grow at 1-, 2-, and 3-year intervals after UAE. (e–g) Axial (e) and sagittal (f ) single-shot fast SE T2-weighted MR images (4.4/64) and a sagittal gadolinium-enhanced 3D T1-weighted VIBE MR image (4.5/1.9, 15° flip angle) (g) obtained 4 years after UAE show regrowth of the dominant fibroid without areas of infarction.
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Figure 11g. Fibroid regrowth. (a, b) Sagittal single-shot fast SE T2-weighted (4.4/64) (a) and gadolinium-enhanced gradient-echo T1-weighted (160/4.1, 80° flip angle) (b) MR images obtained prior to UAE show a dominant intramural fibroid within the anterior uterine body. (c, d) On sagittal single-shot fast SE T2-weighted (4.4/64) (c) and gadolinium-enhanced gradient-echo T1-weighted (160/4.1, 80° flip angle) (d) MR images obtained 5 months after UAE, the dominant fibroid has decreased in size and vascularity. A nidus of enhancement in the fibroid continued to grow at 1-, 2-, and 3-year intervals after UAE. (e–g) Axial (e) and sagittal (f ) single-shot fast SE T2-weighted MR images (4.4/64) and a sagittal gadolinium-enhanced 3D T1-weighted VIBE MR image (4.5/1.9, 15° flip angle) (g) obtained 4 years after UAE show regrowth of the dominant fibroid without areas of infarction.
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Uterine Necrosis
Uterine necrosis (Fig 12) is a rare life-threatening complication following UAE. Proposed causes include poor collateral circulation, superinfection, large-diameter leiomyoma, or small polyvinyl alcohol particles that occlude distal arterial branches and impede collateral vessel formation. Regardless of mechanism, prompt treatment with antibiotics and hysterectomy is mandatory to prevent bacteremia, sepsis, and death. Because uterine necrosis is rare, there are few descriptions of the associated imaging findings. In a recent MR imaging case report, UAE-associated necrosis demonstrated intermediate to high signal intensity on T1-weighted images and high signal intensity on T2-weighted images, with no enhancement following intravenous administration of gadolinium chelates (43). Absence of endometrial enhancement suggests endometrial necrosis (Fig 12). Viable peripheral areas of spared myometrium are believed to be due to superficial uteropelvic collateral blood supply. As in endometritis, gas (when present) manifests as foci of signal void with all sequences.
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Figure 12a. Uterine necrosis. (a) Sagittal fast SE T2-weighted MR image (5700/81) obtained prior to UAE shows low-signal-intensity fibroids (F) embedded within the myometrium. (b) On an axial gadolinium-enhanced fat-suppressed gradient-echo T1-weighted MR image (180/1.5, 90° flip angle) obtained prior to UAE, both the index fibroid (F) and the adjacent myometrium (M) demonstrate enhancement. (c) On a sagittal fast SE T2-weighted MR image (6000/85) obtained 4 days after UAE, the myometrium has diffusely higher signal intensity than the index fibroid (F). (d) Delayed sagittal gadolinium-enhanced fat-suppressed gradient-echo T1-weighted MR image (195/1.6, 90° flip angle) shows no enhancement of the fibroids, endometrium, or myometrium, a finding that is consistent with uterine necrosis (N). Note the peripheral area of enhancement (arrow), a finding that is thought to represent a serosal rim of viable myometrium. (Reprinted, with permission, from reference 43.)
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Figure 12b. Uterine necrosis. (a) Sagittal fast SE T2-weighted MR image (5700/81) obtained prior to UAE shows low-signal-intensity fibroids (F) embedded within the myometrium. (b) On an axial gadolinium-enhanced fat-suppressed gradient-echo T1-weighted MR image (180/1.5, 90° flip angle) obtained prior to UAE, both the index fibroid (F) and the adjacent myometrium (M) demonstrate enhancement. (c) On a sagittal fast SE T2-weighted MR image (6000/85) obtained 4 days after UAE, the myometrium has diffusely higher signal intensity than the index fibroid (F). (d) Delayed sagittal gadolinium-enhanced fat-suppressed gradient-echo T1-weighted MR image (195/1.6, 90° flip angle) shows no enhancement of the fibroids, endometrium, or myometrium, a finding that is consistent with uterine necrosis (N). Note the peripheral area of enhancement (arrow), a finding that is thought to represent a serosal rim of viable myometrium. (Reprinted, with permission, from reference 43.)
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Figure 12c. Uterine necrosis. (a) Sagittal fast SE T2-weighted MR image (5700/81) obtained prior to UAE shows low-signal-intensity fibroids (F) embedded within the myometrium. (b) On an axial gadolinium-enhanced fat-suppressed gradient-echo T1-weighted MR image (180/1.5, 90° flip angle) obtained prior to UAE, both the index fibroid (F) and the adjacent myometrium (M) demonstrate enhancement. (c) On a sagittal fast SE T2-weighted MR image (6000/85) obtained 4 days after UAE, the myometrium has diffusely higher signal intensity than the index fibroid (F). (d) Delayed sagittal gadolinium-enhanced fat-suppressed gradient-echo T1-weighted MR image (195/1.6, 90° flip angle) shows no enhancement of the fibroids, endometrium, or myometrium, a finding that is consistent with uterine necrosis (N). Note the peripheral area of enhancement (arrow), a finding that is thought to represent a serosal rim of viable myometrium. (Reprinted, with permission, from reference 43.)
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Figure 12d. Uterine necrosis. (a) Sagittal fast SE T2-weighted MR image (5700/81) obtained prior to UAE shows low-signal-intensity fibroids (F) embedded within the myometrium. (b) On an axial gadolinium-enhanced fat-suppressed gradient-echo T1-weighted MR image (180/1.5, 90° flip angle) obtained prior to UAE, both the index fibroid (F) and the adjacent myometrium (M) demonstrate enhancement. (c) On a sagittal fast SE T2-weighted MR image (6000/85) obtained 4 days after UAE, the myometrium has diffusely higher signal intensity than the index fibroid (F). (d) Delayed sagittal gadolinium-enhanced fat-suppressed gradient-echo T1-weighted MR image (195/1.6, 90° flip angle) shows no enhancement of the fibroids, endometrium, or myometrium, a finding that is consistent with uterine necrosis (N). Note the peripheral area of enhancement (arrow), a finding that is thought to represent a serosal rim of viable myometrium. (Reprinted, with permission, from reference 43.)
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Death
Two deaths following UAE have been reported, one caused by septicemia (44,45) and the other by a pulmonary embolus (46).
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Minor Complications
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Hematoma, urinary tract infection, retention of urine, transient pain, and vessel or nerve injury at the puncture site sometimes occur during or after UAE. Most of these patients need only mild supportive care such as medication or careful observation.
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Conclusions
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As UAE takes its place in the treatment arsenal for women with symptomatic fibroids, radiologists need to be familiar with UAE-associated complications. Knowledge of these complications and their imaging features should lead to prompt diagnosis and appropriate treatment.
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Footnotes
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Abbreviations: PID = pelvic inflammatory disease, SE =
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Abstract
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