Journal of Vascular and Interventional Radiology

Fibroids and Health Equity: Proceedings from the Society of Interventional Radiology Foundation Research Consensus Panel

While known health care disparities among patients with fibroids exist, there is a lack of research on health equity in this specific population and how it affects patients seeking care and the treatment options offered or ultimately the selection they make. Subject matter experts from interventional radiology, obstetrics and gynecology, epidemiology, public health, and patient advocacy participated in a Society of Interventional Radiology Foundation Research Consensus Panel to discuss and to prioritize critical research topics focusing on health equity in patients with uterine fibroids. After topic presentations and discussion of research ideas, the panelists prioritized the following topics: (a) a prospective study evaluating whether the introduction of a standard educational program to patients with low health literacy regarding fibroids improves their scores on standardized patient-reported outcome measures; (b) evaluation of whether a digital-based technology can be effectively used to improve health education and awareness of fibroids; and (c) performance of surveys of patients to understand their barriers to accessing fibroid care and their motivations for selecting different fibroid treatments.

Hysterectomy and Myomectomy versus Uterine Artery Embolization for Symptomatic Fibroids and Adenomyosis: National and Regional Trends and Adverse Events in 70,000 Patients

To compare patient characteristics, regional utilization, and postoperative outcomes among uterine artery embolization (UAE), myomectomy, and hysterectomy for fibroids and adenomyosis and assess whether postoperative adverse events were more common after hysterectomy. This observational study identified all women who underwent UAE, myomectomy, or hysterectomy for fibroids or adenomyosis from 2016 to 2019 in the United States, using TriNetX, a multi-institution database of anonymous health records, yielding 78,758 patients, (UAE, 2,505; hysterectomy, 60,333; myomectomy, 15,920). Regional procedure utilization was assessed. Length of stay (LOS), reintervention, and postprocedural adverse events including pelvic floor prolapse and intestinal obstruction were compared. Pregnancy and miscarriage rates after UAE and myomectomy were evaluated. Compared with UAE, hysterectomy was associated with longer LOS (5 days vs 1 day; P < .01), more blood transfusions (1.8% vs 0.7%; P < .01), increased pelvic floor prolapse (7.1% vs 1.7%; P < .01) and intestinal obstruction (3.4% vs 1.2%; P < .01), and decreased reintervention (0% vs 15.5%; P < .01) within 5 years; myomectomy was associated with more blood transfusions (2.0% vs 0.7%; P < .01), fewer emergency department visits within 1 month (2.9% vs 6.8%; P = .01), and similar reintervention rates (17.0% vs 15.5%; P = .06). Pregnancy occurred in 92 of 2,505 patients who underwent UAE (3.6%) and 2,744 of 15,920 patients who underwent myomectomy (17.2%), with 18% and 11% miscarriage rates, respectively (P = .07). UAE utilization was similar across U.S. regions. Despite increased adverse events including intestinal obstruction and pelvic floor prolapse, hysterectomy was the most common intervention in women with uterine fibroids and adenomyosis. Reintervention occurred in 15%-20% of patients after UAE or myomectomy.

A Decade Long Analysis of Healthcare Disparities and Uterine Artery Embolization: An Exploration of Social Determinants of Health

To determine the extent of impact that social determinants of health have on uterine artery embolization (UAE) utilization for treatment of symptomatic uterine fibroids. In this institutional review board (IRB)-exempt study, data from the 2011-2020 National Inpatient Sample were used to identify patients with International Classification of Diseases, 9th and 10th editions, codes of uterine fibroids who underwent UAE. Data collected included patient demographics (race/ethnicity, income, and insurance status) and procedure location (geographic region and hospital setting). Results are presented in percentage (UAE procedures per variable) and were analyzed using chi-square test. UAE utilization by race/ethnicity demonstrated the following distribution: 45.6% non-Hispanic Blacks, 28.1% non-Hispanic Whites, 14.2% Hispanics, and 5.7% Asians. The lowest quartile for income experienced no change in utilization (27.8%), while the highest quartile gradually decreased across the decade (2011, 26.7%; 2020, 19.0%; P = .01). The Northeast region of the United States (49.0% in 2011) was superseded by the South (34.8% in 2020) as the dominant geographic region for UAE. The main insurance statuses were private (55.5%) and Medicaid (26.2%), with Medicaid rates increasing throughout the decade (2011, 18.2%; 2020, 28.6%; P < .001). Urban teaching hospitals accounted for the highest rates of total UAE (82.3%) compared with urban nonteaching (16.0%) and rural hospitals (1.2%). Over the past decade, UAE has been performed in a relatively equitable fashion on the basis of income level, with improved utilization within the Medicaid population and throughout the geographic regions of the United States. When accounting for U.S. population representation and unequal disease burden, non-Hispanic Blacks demonstrated a greater-than-expected utilization of UAE compared with lower-than-expected rates among non-Hispanic Whites.

Thirty-Day Healthcare Encounters after Elective Uterine Artery Embolization for Fibroids with and without Superior Hypogastric Nerve Block

To evaluate how the implementation of superior hypogastric nerve block (SHNB) during uterine artery embolization (UAE) for uterine fibroids impacts same-day discharge and healthcare encounters (HCEs) within 30 days. A total of 240 patients who underwent successful UAE for fibroids between January 2018 and December 2022 were retrospectively reviewed. HCEs within 30 days, including emergency department and urgent care visits, admissions, and readmissions, were categorized as early (0-7 days of discharge) and late (8-30 days of discharge) and related or unrelated to interventional radiology (IR) care. Factors associated with same-day discharge and HCE were identified using univariate analyses. Rates of HCE based on SHNB status were compared using the chi-square tests. The mean age of the patients was 46 years (SD ± 5); 125 patients received UAE with SHNB. Patients who underwent SHNB were significantly more likely to undergo same-day discharge (113/125, 90%) than those without SHNB (55/115, 48%) (P < .001). No factors were associated with rates of all-cause 30-day HCE, including SHNB status (SHNB, 17% [21/125], versus no SHNB, 10% [12/115]; P = .20). A majority of HCEs were due to an IR-related cause (26/33, 79%), including abdominal or pelvic pain (22/33, 67%); nausea, vomiting, or poor oral intake (18/33, 55%); and vaginal bleeding (4/33, 12%). Comparison of patients who underwent SHNB with those without SHNB showed no difference in the proportion of IR-related HCE (17/21 [81%] versus 9/12 [75%], P = .69). UAE with SHNB was associated with significantly higher rates of same-day discharge but similar rates of 30-day HCEs compared with UAE alone.

Reproductive Outcomes of Patients Undergoing Uterine Artery Embolization for Uterine Fibroids: Proceedings from The Dr. James B. Spies Summit for Uterine Fibroid Research—A Society of Interventional Radiology Foundation Research Consensus Panel

Reproductive outcomes after uterine artery embolization (UAE) for the treatment of uterine fibroids are challenging to study, leaving several unanswered questions surrounding the future fertility of patients undergoing the procedure. Subject matter experts from interventional radiology, diagnostic radiology, obstetrics and gynecology, and reproductive medicine participated in a Society of Interventional Radiology (SIR) Foundation Research Consensus Panel to discuss and prioritize critical research topics focusing on fertility and reproductive outcomes in patients undergoing UAE for symptomatic uterine fibroids. After presentations and discussion of research ideas, the panelists prioritized the following topics for further investigation: (a) a prospective study of factors that influence implantation and gene expression in patients undergoing UAE or myomectomy over 1 year; (b) refinement of a classification system for uterine fibroids that can allow for more focused study design, which may include burden of fibroid disease; and (c) conjoint analysis/discrete choice experiments to better characterize those patients for whom fertility preservation is a high priority.

Rectouterine Fistula and Fibroid Expulsion after Uterine Artery Embolization

An Evaluation of Ultrasound-Guided Percutaneous Microwave Ablation for the Treatment of Symptomatic Uterine Fibroids

To evaluate the feasibility and effectiveness of ultrasound-guided percutaneous microwave ablation (MWA) for the treatment of symptomatic uterine fibroids. A single-center retrospective study was conducted on 17 patients, mean age 37.5 years (SD ± 7.3; range 19-47 years) with symptomatic uterine fibroid who underwent MWA between September 2018 and December 2022. Outcomes included volume reduction of uterine fibroids, hemoglobin levels, uterine fibroid symptoms, and health-related quality-of-life questionnaire scores before and 12 months after ablation. Preoperative fibroid diameter was a mean of 6.7 cm (SD ± 1.1; range 5-9 cm), and volume was a mean of 101.9 cm The application of MWA as a standalone treatment method might provide an effective, minimally invasive option for Federation of Gynecology and Obstetrics Types 1-6 symptomatic uterine fibroids with the potential to enhance patients' quality of life.

Safety and Efficacy of Arterially Directed Liver Therapies in the Treatment of Hepatic Metastatic Ovarian Cancer: A Retrospective Single-Institution Study

To evaluate the safety and efficacy of 2 locoregional therapies (LRTs) including hepatic artery embolization (HAE) and transarterial radioembolization (TARE) in the treatment of patients with metastatic ovarian cancer to the liver. From October 2010 to May 2019, the data of 15 consecutive patients (median age, 54 years ± 9.8; range, 35-78 years) with hepatic metastatic ovarian cancer who were treated with either HAE (n = 6; 40%) or TARE (n = 9; 60%) were reviewed. The most common histopathologic type was epithelial ovarian carcinoma (80%). The most common chemotherapy regimens used prior to embolization included carboplatin, paclitaxel, cisplatin, and bevacizumab. Patients received a mean of 4 lines ± 3 (range, 1-9) of chemotherapy. All patients with serous carcinoma were resistant to platinum at the time of embolization. Indications for embolization were progression of disease to the liver while receiving chemotherapy in 14 (93.3%) patients and palliative pain control in 1 patient. The overall response rates at 1, 3, and 6 months were 92.4%, 85.6%, and 70%, respectively. Median overall survival from the time of LRT was 9 (95% confidence interval [CI], 4-14) months. Median local tumor progression was 6.4 months ± 5.03 (95% CI, 3.3-9.5). No grade 3-5 adverse events were detected in either group. HAE and TARE were well tolerated in patients with metastatic ovarian cancer to the liver and possibly ensured prolonged disease control in heavily treated, predominantly in patients resistant to platinum. Larger numbers are needed to verify these data.

Uterine Artery Embolization for Mixed Adenomyosis and Fibroids: Outcomes According to Initial Particle Sizes

To characterize the effect of embolic particle size on outcomes of uterine artery embolization (UAE) for mixed adenomyosis/fibroids. A single-center retrospective database was compiled of all patients with mixed adenomyosis/fibroids who underwent UAE with microspheres (Embosphere [Merit Medical, South Jordan, Utah] and Embozene [Varian, Palo Alto, California]) from September 2015 to May 2022 (n = 76; mean age, 46.7 years [standard deviation {SD} ± 5.7]). Demographic, clinical, imaging, procedural, and follow-up data were collected. Intraprocedurally, initial particle size was chosen according to proceduralist judgment and subsequently upsized as needed until near-stasis was achieved. Initial particle size was categorized as either small (Embosphere 300-500 μm and Embozene 500 μm) or large (Embosphere 500-700 μm and Embozene 700 μm). The effect of initial particle size on patient-reported symptomatic improvement was assessed with logistic regression, with preprocedural uterine volume, presence of focal adenomyoma, and total number of vials of embolic material as regression covariates. Preprocedural symptoms included menorrhagia (89.5%), pelvic pain (53.9%), and bulk symptoms (60.5%). The baseline mean uterine volume was 748.5 mL (SD ± 543.9). Postprocedurally, 89.1%, 92.3%, and 97.4% reported improvement in menorrhagia, pelvic pain, and bulk symptoms, respectively. Initial embolic particle sizing was not significantly associated with patient-reported improvement in menorrhagia (P = .134), pelvic pain (P = .598), or bulk symptoms (P = .151), when controlling for covariates. When controlling for covariates, smaller-calibrated microspheres had similar postprocedural pain outcomes as larger particles, with similar target outcomes in UAE for mixed adenomyosis/fibroids.