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Indications & Contraindications
Patient selection, symptom criteria, exclusions
Indications
- Heavy menstrual bleeding (menorrhagia) — most common indication; ~90% report improvement post-UFE
- Bulk symptoms — pelvic pressure/pain, urinary frequency, abdominal distention
- Failed or intolerant of medical therapy (hormonal, GnRH agonists)
- Desire for uterine preservation as alternative to myomectomy or hysterectomy
- Multiple fibroids (treats all fibroids simultaneously, unlike myomectomy)
Contraindications
- Pregnancy
- Active pelvic infection / endometritis
- Pedunculated subserosal fibroid with stalk <50% of fibroid diameter (risk of detachment and peritonitis)
- Known or suspected gynecologic malignancy
- IUD in place (remove prior to procedure)
- Relative: Desire for future fertility — myomectomy generally preferred; limited data on pregnancy outcomes post-UFE
- Relative: Very large fibroid uterus extending above umbilicus (may have suboptimal response)
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Pre-Procedure Planning
Imaging, labs, GYN clearance, pain management setup
Imaging & Labs
- MRI pelvis with and without contrast — map fibroid number, size, location; exclude adenomyosis and malignancy; assess vascularity and enhancement pattern
- Labs: CBC, BMP, coagulation panel (PT/INR, PTT)
- Pregnancy test (serum beta-hCG) — mandatory
- TSH if menorrhagia workup (exclude thyroid cause)
- Type & screen not routinely required
Patient Preparation
- GYN clearance — gynecologist evaluation and agreement on management plan; recent Pap smear; endometrial biopsy if indicated
- NPO per institutional protocol (moderate sedation)
- Pain management plan: arrange PCA pump (morphine or hydromorphone), ketorolac 30 mg IV, ondansetron 4 mg IV
- Discuss overnight admission vs same-day discharge based on institutional protocol
MRI reviewed. Fibroid map completed: number, size, location, enhancement. Adenomyosis and malignancy excluded. Ovarian artery collateral supply assessed.
Labs confirmed. CBC, BMP, coags within acceptable limits. Pregnancy test negative.
GYN clearance obtained. Gynecologist agrees with UFE plan. Recent Pap and endometrial evaluation documented.
Consent obtained. Risks discussed: post-embolization syndrome (pain, fever, nausea × 5–7 days), fibroid expulsion (~5%), premature menopause risk (1% if <45yo, higher if >45yo), infection, amenorrhea, need for further procedures.
Pain protocol arranged. PCA pump ordered. Ketorolac 30 mg IV + ondansetron 4 mg IV available. Nursing aware of post-procedure pain management plan.
IUD removed (if applicable). Confirmed no intrauterine device in place.
Antibiotics: Cefazolin 1g IV ordered for pre-procedure administration.
UFE Periprocedural Pain Management Protocol
Home Prescriptions — Start 1–3 Days Before
Ketorolac 10 mg PO q8h × 3 days — do not skip; set alarm
Cyclobenzaprine (Flexeril) 5–10 mg PO TID with meals × 5 days
Ondansetron (Zofran) 4 mg ODT SL 30 min before meal PRN nausea
Colace 100 mg PO BID × 30 days
Oxycodone/acetaminophen (Percocet) 5/325 mg PO q8h PRN moderate–severe pain × 5 days
Ibuprofen (Motrin) 800 mg PO q8h × 7 days — start only after ketorolac course is complete
Day of Procedure — Pre-Procedure Care Area (PPCA)
Scopolamine patch 1.5 mg — apply behind ear (if not applied at home)
Acetaminophen (Tylenol) 975 mg PO with sip of water
Ketorolac (Toradol) 30 mg IV × 1 — give in PPCA
Ondansetron (Zofran) 4 mg IV × 1 — give in PPCA
Cefazolin (Ancef) 2 g IV — on call to suite, within 1 hr of start time
IV fluids: NS 0.9%, D5½NS, or LR at 75–100 mL/hr
Intra-Procedure
After left uterine artery endpoint: preservative-free lidocaine 1% 10 mL IA into left uterine artery + Ketorolac 15 mg IV
After right uterine artery endpoint: preservative-free lidocaine 1% 10 mL IA into right uterine artery + Ketorolac 15 mg IV
Superior hypogastric nerve block (SHNB) if performed: bupivacaine 0.25% 20 mL ± triamcinolone 40 mg at anterior lower ⅓ of L5 — add levofloxacin 500 mg PO daily × 5–7 days post-procedure
Recovery (4–6 hrs)
Hydromorphone (Dilaudid) 0.5 mg IV q30 min PRN pain — alt: morphine 2 mg IV q1h PRN
Ondansetron (Zofran) 4 mg IV q4h PRN nausea
IV fluids at 100 mL/hr
Discharge Criteria — The “3 Ps”
Pain controlled with PO medications (not requiring IV/PCA)
Puking (nausea/vomiting) controlled; tolerating oral intake
Peeing — able to void spontaneously
Discharge Medications
Ketorolac 10 mg PO q8h — complete remaining days of course
Ibuprofen (Motrin) 800 mg PO q8h × 7 days — start after ketorolac complete
Cyclobenzaprine (Flexeril) 5–10 mg PO TID × 5 days
Colace 100 mg PO BID × 30 days
Oxycodone/acetaminophen (Percocet) 5/325 mg PO q8h PRN moderate–severe pain × 5 days
Ondansetron (Zofran) 4 mg ODT PRN nausea
Scopolamine patch 1.5 mg — leave in place for 3 days
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Relevant Anatomy
Uterine artery origin, cervicovaginal branch, ovarian anastomoses, variants
Uterine Artery
- Arises from the anterior division of the internal iliac artery (IIA)
- Courses medially along the pelvic floor, crossing over the ureter (“water under the bridge”) before reaching the lateral aspect of the uterus
- Gives off the cervicovaginal branch (supplies cervix and upper vagina) before ascending along the lateral uterine body
- Ascending segment gives fibroid branches and ultimately anastomoses with the ovarian artery at the uterine fundus (ovarian-uterine anastomosis)
- The horizontal segment of the uterine artery is the target for catheterization — embolize PAST the cervicovaginal branch takeoff
Variant Anatomy & Collaterals
- Variant origin: uterine artery may arise from the external iliac artery or share a common trunk with the obturator artery
- Ovarian artery supply: 4–8% of patients have significant collateral supply to fibroids via the ovarian arteries (from the aorta); may require additional embolization from an aortic approach
- Utero-ovarian anastomosis types (Razavi classification): Type I — intramyometrial, Type II — tubal, Type III — through ovarian parenchyma; Types Ib and III have higher risk of non-target ovarian embolization
- Bilateral embolization is required — unilateral embolization produces suboptimal results due to cross-collateral supply
Key Angiographic Relationships
On selective internal iliac artery angiography, the uterine artery is identified as a medially coursing branch from the anterior division. The cervicovaginal branch arises early from the uterine artery and courses inferiorly toward the cervix. Microcatheter position must be confirmed distal to this branch before embolization to avoid cervical necrosis. At the fundus, look for the ascending uterine artery anastomosing with the descending ovarian artery — if this is prominent, particle size selection is critical to avoid retrograde ovarian embolization.
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Technique
Access, catheterization, embolic selection, endpoints
Access & Catheters
- Right common femoral artery (CFA) access — single puncture, bilateral catheterization
- 5F vascular sheath
- 5F Cobra (C2) catheter or Roberts uterine catheter for IIA selection
- Microcatheter 2.4–2.8F (e.g., Progreat, Renegade) for superselective uterine artery catheterization
- 0.035” Glidewire and 0.018” microwire
Embolic Agents
- Tris-acryl gelatin microspheres (Embosphere) — preferred; calibrated, predictable penetration
- Size: 500–700 µm or 700–900 µm
- PVA particles (500–710 µm) — acceptable alternative
- Avoid particles <500 µm — risk of deep penetration into ovarian branches and non-target embolization
- Mix with contrast (50:50 with saline/contrast) for fluoroscopic visualization during injection
Medications
- Cefazolin 1g IV pre-procedure
- Moderate sedation (midazolam + fentanyl) or PCA pump
- Ketorolac 30 mg IV (at start of procedure)
- Ondansetron 4 mg IV PRN nausea
- Nitroglycerin 100–200 µg IA (available for uterine artery spasm)
- Heparin per institutional protocol (optional)
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Arterial Access
Ultrasound-guided right CFA access with micropuncture technique. Place 5F vascular sheath. Flush with heparinized saline.
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Contralateral IIA Catheterization (Left Side First)
Using 5F Cobra or Roberts catheter, select the contralateral (left) internal iliac artery first. Perform IIA angiogram to identify the uterine artery arising from the anterior division. Map the cervicovaginal branch and uterine artery course.
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Superselective Microcatheter Placement
Advance microcatheter (2.4–2.8F) coaxially into the uterine artery. Position the tip in the horizontal segment of the uterine artery, PAST the cervicovaginal branch. Confirm position with selective angiogram. The catheter tip should be distal to the cervicovaginal takeoff but proximal to the ascending uterine segment.
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Embolization — Left Uterine Artery
Slowly inject embolic particles (500–700 µm or 700–900 µm Embosphere or PVA) mixed with contrast under continuous fluoroscopy. Inject in pulsatile fashion, allowing antegrade flow between injections. Monitor for reflux. Endpoint: “near stasis” — sluggish antegrade flow with “pruned tree” appearance of distal vasculature. Do NOT reflux embolic material into the IIA.
▶ Left uterine artery catheterization
Left uterine artery catheterization: superselective microcatheter beyond the cervicovaginal branch with fibroid supply opacified.
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Ipsilateral IIA Catheterization — Waltman Loop Technique
After embolizing the contralateral (left) uterine artery, the catheter must be reformed to select the ipsilateral (right) IIA without exchanging the sheath. Two reliable methods:
Option A — Waltman Loop (preferred):
Option B — RUC "Push into Aorta, Rotate & Pull":
Once the ipsilateral IIA is selected: obtain selective angiogram, identify right uterine artery, advance microcatheter past the cervicovaginal branch.
Option A — Waltman Loop (preferred):
- Retract the Cobra/RUC to just above the aortic bifurcation with the tip pointing cephalad.
- Advance the catheter forward while applying gentle clockwise torque — the tip encounters the opposite aortic wall and begins to buckle, forming a reverse-curve (the "loop").
- Continue advancing until a stable J-shaped loop is formed in the distal aorta, with the tip now pointing caudally toward the ipsilateral iliac.
- Pull back slowly on the catheter — in reverse-curve configuration, traction causes the tip to advance distally (paradoxical motion). The loop "walks" down into the ipsilateral IIA.
- Confirm stable IIA position with a hand injection of contrast. Steep ipsilateral oblique (30–45°) to separate anterior and posterior divisions.
Option B — RUC "Push into Aorta, Rotate & Pull":
- Advance a stiff 0.035″ wire deep into the contralateral external iliac to anchor the system.
- Push the catheter body deep into the contralateral iliac, gaining slack in the aortic segment.
- Retract the wire back to the aorta; the catheter tip will prolapse off the bifurcation.
- With clockwise torque, redirect the tip into the ipsilateral common iliac → advance into IIA.
Once the ipsilateral IIA is selected: obtain selective angiogram, identify right uterine artery, advance microcatheter past the cervicovaginal branch.
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Embolization — Right Uterine Artery
Repeat embolization with same technique and endpoint as left side. Same embolic agent and particle size. Achieve near stasis with pruned tree appearance. Confirm no reflux into IIA on completion angiogram.
▶ Right uterine artery catheterization
Right uterine artery catheterization via Waltman loop: microcatheter positioned distal to cervicovaginal branch with fibroid blush confirmed.
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Completion & Closure
Perform final bilateral IIA angiograms to document embolization result. Remove catheters and sheath. Achieve hemostasis with manual compression or closure device. Begin post-procedure pain protocol immediately (PCA pump + ketorolac + ondansetron).
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Angiographic Landmarks
Key identification points on IIA angiography
Uterine Artery Identification
- IIA angiogram: uterine artery courses medially from the anterior division toward the midline pelvis
- Characteristic “hook” or “U-turn” as it crosses over the ureter and turns superiorly along the lateral uterus
- Fibroids demonstrate a dense vascular blush on arterial phase — confirms fibroid vascularity and supply from this uterine artery
- Small or spastic uterine artery may be difficult to identify — use nitroglycerin IA if needed
Critical Branch Points
- Cervicovaginal branch takeoff: arises from the uterine artery early in its course; supplies cervix and upper vagina; must embolize DISTAL to this branch
- Ovarian artery collateral supply: look for retrograde filling of ovarian artery at the fundus on late-phase images; if prominent, consider aortogram to evaluate for accessory ovarian artery supply requiring separate embolization
- Anastomotic arcade: ascending uterine artery connects with descending ovarian artery at the fundus — this is the route for potential non-target ovarian embolization
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Troubleshooting
Intraoperative problems and solutions
Can’t Identify Uterine Artery
Small or Spastic Uterine Artery Not Visible on IIA Angiogram
Administer nitroglycerin 100–200 µg IA directly into the anterior division of the IIA. Wait 30–60 seconds and repeat angiogram. If still not visible, try a more selective anterior division injection. Consider variant anatomy — the uterine artery may arise from the external iliac or share a trunk with the obturator artery. Review pre-procedure MRA if available.
Ovarian Artery Supply
Fibroids Receiving Significant Collateral Supply from Ovarian Arteries
If prominent ovarian artery supply is identified on pre-procedure MRA or on angiography (retrograde filling at fundus), selective catheterization of the ovarian artery from the aorta is required for complete embolization. Use a Cobra or SOS catheter from the femoral approach to select the ovarian artery origin from the anterior aorta (typically at L2 level, below the renal arteries). Embolize with same particles. Be cautious to avoid reflux into ovarian branches.
Unilateral Embolization Only
Unable to Catheterize One Uterine Artery
Unilateral embolization is suboptimal but may be acceptable in select cases. The un-embolized side will continue to supply the fibroids via cross-midline collaterals. Options: (1) attempt from contralateral femoral access, (2) attempt radial approach, (3) accept unilateral result and plan for potential repeat procedure. Document clinical rationale. Outcomes with unilateral embolization are inferior to bilateral.
Severe Vasospasm
Uterine Artery Spasm During Catheterization or Embolization
Administer nitroglycerin 100–200 µg IA through the microcatheter. Wait 1–2 minutes. Avoid aggressive catheter manipulation. If spasm persists, pull microcatheter back slightly and wait. Warm saline flush may help. If spasm is recalcitrant, consider completing embolization from a more proximal position (still distal to cervicovaginal branch) or aborting that side and reattempting at a later date.
Reflux Into IIA
Embolic Material Refluxing Proximal to Uterine Artery Origin
Stop injection immediately. The endpoint has been reached or exceeded. Non-target embolization of IIA branches (gluteal, internal pudendal) can cause buttock pain or ischemia. Allow time for flow to re-establish. Confirm on angiogram that no major IIA branches are occluded. Document and monitor for buttock/perineal symptoms post-procedure.
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Complications
Expected side effects and true complications
Common / Expected
- Post-embolization syndrome (virtually universal) — pain, low-grade fever, nausea, malaise lasting 5–7 days; manage with PCA, ketorolac, ondansetron, and supportive care
- Pelvic cramping / pain — most significant in first 24–48 hours; can be severe; adequate pain protocol is essential
- Vaginal discharge — common in weeks following procedure; usually resolves spontaneously
- Transient amenorrhea — may last 1–3 months; menses typically return
Serious Complications
- Fibroid expulsion (~5%) — submucosal fibroids may undergo transcervical passage; can present with pain, bleeding, discharge weeks to months post-procedure; may require GYN intervention
- Infection / endometritis (<2%) — fever >101.5°F persisting beyond 1 week, purulent discharge, elevated WBC; requires antibiotics, possible hospitalization
- Premature ovarian failure — ~1% if <45yo; higher risk if >45yo; due to non-target embolization of ovarian branches via utero-ovarian anastomosis; presents as amenorrhea with elevated FSH
- Amenorrhea (permanent) — rare in patients <40; more common in perimenopausal patients
- Non-target embolization — ovarian artery (premature menopause), gluteal branches (buttock pain/claudication), cervical necrosis (if embolized proximal to cervicovaginal branch)
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Pearls & Pitfalls
Critical tips for procedural success and complication avoidance
✦
ALWAYS bilateral embolization. Unilateral embolization leads to suboptimal results because of cross-collateral supply from the contralateral uterine artery. Both sides must be treated for adequate fibroid devascularization.
✦
Embolize PAST the cervicovaginal branch. Microcatheter tip must be positioned distal to the cervicovaginal branch in the horizontal segment of the uterine artery. Embolizing proximal to this branch risks cervical necrosis.
✦
Particle size matters. Use 500–700 µm or 700–900 µm particles. Particles that are too small (<500 µm) penetrate too distally and increase risk of ovarian damage via the utero-ovarian anastomosis. Tris-acryl gelatin microspheres (Embosphere) are preferred over irregular PVA for more predictable penetration.
✦
MRI at 6 months. Follow-up MRI demonstrates ~40–60% dominant fibroid volume reduction. Correlate with symptom improvement. Persistent enhancement of fibroids suggests incomplete embolization.
✦
Post-procedure pain is SIGNIFICANT. Have a robust pain management protocol in place before the procedure: PCA pump (morphine or hydromorphone) + ketorolac 30 mg IV + ondansetron 4 mg IV. Inadequate pain control is the most common reason for readmission.
✖
Do NOT reflux into the IIA. The embolization endpoint is “near stasis” with sluggish antegrade flow (pruned tree). Pushing embolic beyond this risks non-target embolization of gluteal, pudendal, or other IIA branches.
✖
Do NOT embolize pedunculated subserosal fibroids with narrow stalks (<50% fibroid diameter). Devascularization may cause detachment into the peritoneal cavity, resulting in peritonitis or bowel obstruction.
✖
Counsel patients >45yo carefully about the elevated risk of premature ovarian failure. The risk increases significantly with age and may be unacceptable for patients who have not completed their fertility plans.
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References & Resources
Primary sources and landmark trials
Primary References
- Spies JB, et al. The EMMY Trial: long-term results of uterine artery embolization vs hysterectomy for treatment of symptomatic uterine fibroids. Am J Obstet Gynecol. 2005;193:1618–1629.
- Goodwin SC, Spies JB, et al. Uterine artery embolization for treatment of leiomyomata: long-term outcomes from the FIBROID Registry. J Vasc Interv Radiol (JVIR). 2008;112:1301–1309.
- Popovic M, et al. Uterine artery embolization for the treatment of symptomatic fibroids: current evidence and future directions. Cardiovasc Intervent Radiol. 2020;43:897–903.
- Stewart JK. Uterine artery embolization for uterine fibroids: a closer look at misperceptions and challenges. Tech Vasc Interventional Rad. 2021;24:100725.
- White AM, Spies JB. Uterine fibroid embolization: update on reported outcomes. Tech Vasc Interventional Rad. 2006;9:2–6.
- Razavi MK, et al. Angiographic classification of ovarian artery-to-uterine artery anastomoses: initial observations in uterine fibroid embolization. Radiology. 2002;224:707–712.