Part One | Part TwoPart 2
By: Jean Johnson for Fibroids1
Part one of this series focused on insights of how uterine fibroid embolization and fibroids patients have enabled the field of interventional radiology to come into its own. In part two of the series, John Kaufman, M.D., interventional radiologist and professor at Oregon Health and Science University, expands on his initial remarks to weigh in on state-of-the-art technology.
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To get less traumatic, effective healthcare, women who have the following conditions may want to ask about Interventional Radiology:
Uterine fibroids
Infertility due to blocked fallopian tubes
Fertility Control (with image-guide tubal occlusion)
Pelvic Pain due to congested uterine veins
Breast masses requiring image-guided biopsy
Nipple discharges requiring ductograms (injection of X-ray dye in to the duct
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Fibroids Treatment Leads Interventional Radiology to New Areas of Women’s Health Armed with anatomical knowledge, it’s only been natural for interventional radiologists like John Kaufman to investigate new ways in which they can treat problems related to the female anatomy.
“Yes. Embolization has opened up people’s minds to other potential avenues for image-guided interventions in women’s health: Treating infertility by opening up blocked fallopian tubes, tubal sterilization for those who don’t want any more children, and pelvic pain – we’re thinking more about these patients. Also for people who are thinking globally about women’s health there are breast biopsies and ductograms.”
As a result of these investigations, Kaufman explains that interventional radiology is now maturing to the point that it is starting to develop sub-specialties.
“We are moving toward focusing on groups of diseases or patient populations, such as women’s health. Just like general surgeons used to do everything until over time it became clear that they needed to focus on specific organ systems or groups of patients. It’s a natural trend that comes when a field has matured, and we’re seeing the beginnings of that now in interventional radiology – this natural evolution in which people are focusing primarily on peripheral arteries, veins, cancer, musculoskeletal and spine, or women’s health.
“It’s exciting personally to be around at a time when you’re seeing your specialty go to the next level,” Kaufman confided. “We’re beyond proving we are legitimate, which is what we had to do during the first 30 or 40 years. Now the field of interventional radiology (IR) is accepted, and we’re entering the next phase where specialists within IR are starting to emerge in areas such as women’s health.”
Uterine Fibroid Embolization in Extreme Cases
How successful is cutting off the blood supply to fibroids by using an image-guided catheter to deliver tiny beads that block off arteries? According to Kaufman the reliability of the procedure is high enough that interventional radiologists are comfortable using it even in extreme cases. First, though, he explains that uterine fibroid embolization, which in many cases can replace a hysterectomy, has done much to elevate women’s healthcare.
“It’s gratifying that you can help someone that others have not always taken seriously,” said Kaufman. “In the past when women went in for help they would hear things like ‘Well, what do you need the uterus for anyway? We’ll just take that organ out.’ Now we are trying to be more sensitive to a patient’s overall concerns.”
Particularly in the case of a 12-year-old girl, of course, losing a uterus would be devastating.
“During her second period ever, this young patient developed massive bleeding that did not respond to transfusion, medication, or other procedures. This is extremely rare, but her gynecologist was at the point of performing a hysterectomy as a life-saving measure. The gynecologist, Dr. Margaret O’Reilly, and I have worked together in the past on patients with fibroids. Dr. O’Reilly turned to us and asked if we thought we could safely embolize the uterus of such a young patient. We did and were successful. Now she’s gone on to have normal periods,” said Kaufman. “To me this was a huge save since she might have just had a hysterectomy if it had not been known that IR is involved in women’s health.”
On the other end of the age spectrum, “we (IRs) used to think that post-menopausal women should never undergo embolization because fibroids in this population were likely to be malignant. However, when post-menopausal women have fibroids that do not shrink naturally and are causing only pressure symptoms, embolization may provide the best results of anybody. The fibroids decrease in size, one of the potential risks of the procedure – ovarian failure – is not a concern, and they feel better.” Kaufman was careful to point out that women with enlarging fibroids or vaginal bleeding after menopause should undergo a complete evaluation for malignancy and usually a treatment other than embolization.
But for women whose fibroids stay stable or shrink only a little after menopause and have symptoms related to the size of the fibroid, uterine artery embolization may now be an option. “It’s a population that would have been turned away four or five years ago as the thinking was that since these women no longer have hormonal cycles, the fibroid should have shrunk on its own – and if it didn’t it was abnormal and should be removed surgically. There was some rigidity in thinking on our part,” Kaufman said. “But it turns out that if you embolize these people, they have a great result. And they avoid major surgery – because at that point the surgical recommendation will usually be a hysterectomy, and women don’t want that.”
From the Physician’s Side of The Uterine Fibroid Embolization Drape
During the procedure, “You’re looking at a two-dimensional image on a black-and-white monitor, so it’s very visually driven. You need to have a very clear mental picture of the three-dimensional anatomy to really understand what you are seeing on the screen,” he added. “While a surgeon looks directly into the patient at the tip of the scalpel in their hand, we look up at a screen and watch the tip of a 160 cm wire move through the arteries to the fibroid while we control it with our hand outside of the (patient's) body.”
The angio-room, or procedure room, where uterine fibroid embolization takes place is different from a surgical suite because of the imaging equipment. Special high-resolution, low-radiation, computer-enhanced X-ray machines are used for uterine artery embolization. These are very different than X-ray machines used for CAT scans, chest-X-rays, or even heart angiograms. In addition, most IR procedures are performed with the patient awake but sedated, without general anesthesia.
“We take a team approach – doctors, nurses, X-ray technicians, and the patient. The patient is awake for the entire procedure. She is under drapes and heated blankets and all that is exposed from the neck down is a small circle of skin where we are entering the artery at the crease of the groin,” Kaufman said. “We use local anesthetic to numb the skin where the catheter enters the body and intravenous sedation to relax the patient, but we talk to the patient the whole time and explain what’s going on.
“In a nutshell, I feel like I have the best job in the hospital. It still amazes me that I get paid for what I do,” Kaufman said. “It’s all very high-tech and the procedure requires a lot of hand-eye coordination and three-dimensional thinking.”
